# Risk of refeeding syndrome: an observational study in primary healthcare

Clément de Begon de Larouzière de Montlosier, Candy Guiguet-Auclair,
Pierre Mély, David Julien, Laurent Gerbaud, Marie Blanquet

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Clément de Begon de Larouzière de Montlosier, Candy Guiguet-Auclair, Pierre Mély, David Julien, Laurent Gerbaud, et al. Risk of refeeding syndrome: an observational study in primary healthcare. Family Practice, 2025, 42 (4), pp.cmaf038. 10.1093/fampra/cmaf038. hal-05120082

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Risk of refeeding syndrome: an observational study in primary health care

Clément de Begon de Larouzière de Montlosier ª, Candy Guiguet-Auclair b, Pierre Mély ª, David
Julien c, Laurent Gerbaud b, Marie Blanquet b

**Corresponding author:** Dr. M. Blanquet

Santé Publique, CHU Clermont-Ferrand, 7 place Henri Dunant, 63000 Clermont-Ferrand, France,
mblanquet@chu-clermontferrand.fr

<footnote>a Maison médicale des Gentianes, Centre médical, Route de Condat, 15400 Riom-ès-Montagnes, France</footnote>

<footnote>b Santé Publique, 7 place Henri Dunant, 63000 Clermont-Ferrand, France ; Université Clermont
Auvergne, CNRS, CHU Clermont-Ferrand, Institut Pascal, F-63000 Clermont-Ferrand, France</footnote>

<footnote>c Cabinet médical, 137 rue Jean Fourcade, 63115 Mur-sur-Allier, France</footnote>
# Risk of refeeding syndrome: an observational study in primary health care

Running title: Risk of refeeding syndrome in primary health care

## Key messages:

* The risk of developing refeeding syndrome in primary care settings is not negligible.

* The risk for refeeding syndrome increase with age and chronic conditions.

* Two third of patients have a high risk of refeeding syndrome if they experience an acute event.
**Abstract**

**Background:** Refeeding syndrome (RFS) is a complex phenomenon associated with increased mortality. However, the prevalence of risk factors for RFS has never been assessed in primary care. Our aim was to assess the prevalence of risk for developing RFS in primary care.

**Methods:** A retrospective observational study was conducted in a general practitioner (GP) surgery in June 2022. The study included older adult patients (aged ≥75 years) or adult patients with chronic disease (aged 18–74 years), living at home and receiving care at home or at the GP’s surgery between January 1 and June 30, 2021. Patients at high risk of developing RFS were identified using the National Institute for Health and Clinical Excellence (NICE) criteria. The risk of RFS was also assessed in patients aged ≥ 70 years using an adaptation of the NICE criterion for body mass index based on the Global Leadership Initiative on Malnutrition guidelines.

**Results:** The prevalence of patients at risk for RFS was 2.8% (95%CI: 1.5%–4.1%) in the full population of 611 patients and 8.8% (95% CI: 6.1% - 6.4%) in the subset of patients aged ≥ 70 years assessed using the adapted NICE criterion. The prevalence of patients at risk for RFS increased with age and chronic conditions. More severe comorbidity and home care were factors associated with higher risk of RFS.

**Conclusion:** The risk of developing RFS in primary care settings is not negligible. GPs should consider this risk in their practice to develop a more comprehensive care programme.

**Keywords:** aged, chronic disease, malnutrition, primary health care, refeeding syndrome, risk assessment.
Introduction

Refeeding syndrome (RFS) is a potentially fatal metabolic complication that can occur after reintroducing nutrition in severely malnourished patients. RFS was first described at the end of the World War II in soldiers and prisoners of war who had been released from concentration camps and in Japanese prisoners of war. Many of the extremely malnourished survivors, who presented cardiovascular and pulmonary disorders, went on to die during refeeding (1,2). RFS is associated with a higher 6-month mortality rate and an increased risk of admission to intensive care (3,4). However, there is no universally accepted definition of RFS, largely due to the complexity of the phenomenon, which encompasses a wide range of symptoms affecting various body systems that can manifest in opposing extremes (e.g. diarrhoea vs. constipation, agitation vs. coma, and hyperglycaemia vs. hypoglycaemia) (5-7).

Early screening of patients at risk for RFS and early diagnosis are important to prevent the development of clinical sequelae. The most widely used criteria for screening high-risk factors for RFS were proposed in the 2006 United Kingdom National Institute for Health and Care Excellence (NICE) guidelines (8,9). In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) published new recommendations for the diagnosis of RFS (10).

Three previous studies have assessed the prevalence of RFS risk in hospitalized patients (11-13). Owers et al. studied a population with a mean age of 65 years old (SD 18) in an acute medicine setting and found a 9% prevalence of RFS risk (11). Henderson et al. studied older adults with a mean age of 83.8 years old (SD 7.5) in a specialist medicine setting and found decreased serum magnesium levels in 23.3% of patients and decreased phosphate levels in 46.5% (12). Marik et al. explored RFS in an intensive care unit and showed that 34% of patients had refeeding hypophosphataemia (13). However, to our knowledge, the prevalence of RFS risk has never been evaluated in primary health care setting. Malnutrition is a significant issue in primary care, and since RFS is associated with malnutrition, health care providers addressing malnutrition should also consider RFS to prevent the adverse effects of refeeding and hospitalization.
The aim of this study was to assess the prevalence of risk for developing RFS in a primary health care setting among community-dwelling older adults (aged ≥75 years) and adult patients with chronic disease (aged 18-74 years) according to the NICE criteria, and to identify factors associated with a high risk of RFS.

# Materials and methods

## Study design, setting, and patients

An observational retrospective study was conducted in a general practitioner's (GP) surgery in south-central France in June 2022. The GP had no role in the study design, data collection, and analysis.

Adult patients aged 18–74 years with one or more chronic diseases (CD), or older adults (aged ≥75 years), living at home and receiving care for CD or medication renewal at home or at the GP's surgery between January 1 and June 30, 2021, were included in the study. Patients were excluded if they were under legal guardianship, receiving end-of-life palliative care, dependent on artificial nutrition, or if they did not consent to the use of their medical data for research purposes. Patients who died before data collection were also excluded, as they could no longer provide consent to participate. Patients lost to follow-up during the study period were subsequently excluded from the analysis.

## Measurements

Data were collected from patients' medical records, computerised prescriptions, and correspondence sent by specialists or hospitals.

Patients at high risk for RFS were identified using the NICE guidelines (Table 1). Patients were considered at high risk for RFS if they met one or more of the following major criteria: body mass index (BMI) <16 kg/m², unintentional weight loss of >15% within the last 3 to 6 months, reduced food intake or fasting >10 days, and low levels of potassium, phosphate or magnesium in blood before refeeding. In addition, patients could also be at high risk for RFS if they met two or more of the
following minor criteria: BMI <18.5 kg/m², unintentional weight loss of >10% within the last 3 to 6 months, reduced food intake or fasting >5 days, and a history of alcohol abuse or medical drugs including insulin, chemotherapy, antacids or diuretics. We screened for all of these criteria except for potassium, phosphate, or magnesium blood levels, as these tests were not routinely performed in practice.

Risk for RFS was also assessed in patients aged ≥70 years using an adaptation of the NICE criteria for BMI based on the Global Leadership Initiative on Malnutrition (GLIM) guidelines, which defined the thresholds as <20 kg/m² for major criteria and <22 kg/m² for minor criteria (14).

Comorbidity level was assessed using the age-adjusted Charlson comorbidity index (a-CCI) (15), which accounts for 18 predefined comorbid conditions, weighted based on their associated adjusted risk of 1-year mortality, combined with age. The a-CCI score was used to categorize comorbidity severity as follows: no comorbidity (a-CCI score: 0); mild comorbidity (a-CCI: 1–2); moderate comorbidity (a-CCI: 3–4); and severe comorbidity (a-CCI ≥5).

Patient age, gender, living situation, occupational status, whether they had a caregiver, and whether they received follow-up care at the GP's surgery or at home were also recorded.

## Statistical analysis

Categorical variables were expressed as numbers and percentages, and continuous variables as mean and standard deviations (SD). Patients were categorised into four groups: patients aged 18–69 years old with one or more chronic diseases (CD), patients aged 70–74 years old with one or more CD, patients aged ≥75 years old with one or more CD, and patients aged ≥75 years old without CD. Descriptive analyses were performed to assess sociodemographic and clinical characteristics of the patients. Prevalence of patients at risk of developing RFS was assessed with a 95% confidence intervals (95% CI) in all patients and in each of the four groups. Patients at risk/not at risk of developing RFS were compared according to their sociodemographic and clinical characteristics using Chi-square or Fisher's exact tests for categorical variables and non-parametric Mann-Whitney tests for continuous variables. Multivariate logistic regression analysis was performed to investigate
which factor was associated with risk for RFS, after adjusting for all factors analysed. Adjusted odds
ratios (OR) with 95% CIs were computed. Two-sided P-values <.05 were considered statistically
significant. All statistical analyses were performed using SAS statistical software package v 9.4 (SAS
Institute Inc., Cary, NC).

**Results**

Patient population

During the period studied, 678 patients were eligible for inclusion and 611 were included in
statistical analysis (Fig. 1). Mean age was 74.4 years old (SD 11.4), half of the patients were women,
63.5% did not live alone, and 71.7% had a caregiver (Table 2). The majority of patients received care
at the GP's surgery (82.5%). According to the a-CCI scores, 44.0% of patients had moderate
comorbidity and 46.6% of patients had severe comorbidity.

The breakdown of the patient groups was as follows: 29.0% 18–69 years old with CD, 13.4%
70–74 years old with CD, 42.5% ≥75 years old with CD, and 15.1% ≥75 years old without CD. One
patient could not be classified into any of these four groups, as his/her CD status could not be
determined (this patient was not included in the group analysis but was included in the overall sample
analysis). Among patients aged ≥75 years, 73.8% had at least one CD. The two groups of patients
aged ≥75 years had significantly more women (P < .001) and patients living alone (P < .001). Home
follow-up was more frequent in patients aged ≥75 years with CD (P < .001), compared to the other
three groups. Severe comorbidity was more frequent in patients aged 18-69 years old with CD and
those aged ≥75 years old with CD (P < .001) than in the other two groups.

Analysis of the NICE criteria found that BMI was <16.0 kg/m² in one patient and <18.5 kg/m²
in five patients. Information on weight loss at 3 and 6 months was available in 47.5% and 66.0% of
patient medical files, respectively. Two patients experienced >10% weight loss or >15% weight loss
over 3-6 months. Reduced food intake or fasting for > 5 days was reported in 2.6% of patients. A
history of alcohol abuse or the use of medical drugs, including insulin, chemotherapy, antacids or diuretics, was found in 66.8% of patients.

## Prevalence of RFS risk

The prevalence of patients at risk of developing RFS was 2.8% (95%CI: 1.5%–4.1%) based on the NICE criteria. Four patients met one major risk criterion for RFS, and 13 met two minor criteria. In addition, 65.1% of the entire sample met at least one minor NICE criterion, with the most common being a history of alcohol abuse or the use of medical drugs, including insulin, chemotherapy, antacids, or diuretics.

The prevalence of RFS risk increased with age in patients with CD, from 1.1% (95%CI: 0%–2.7%) in patients aged <70 years, to 2.4% (95%CI: 0%–5.8%) in patients aged 70–74 years, and to 4.2% (95%CI: 1.8%–6.7%) in patients aged ≥75 years. Among patients aged ≥75 years without CD, the prevalence of RFS risk was 2.2% (95%CI: 0%–5.1%).

For patients aged ≥70 years, the risk for RFS was also assessed using an adaptation of the NICE criterion for BMI. In this older-adult subset, the prevalence of patients at risk of developing RFS was 8.8% (95% CI: 6.1%–6.4%). Specifically, the prevalence was 7.3% (95%CI: 1.7%–13.0%) in patients aged 70–74 years with CD, 8.9% (95%CI: 5.4%–12.3%) in patients aged ≥75 years with CD, and 9.8% (95%CI: 3.7%–15.8%) in patients aged ≥75 years without CD.

## Factors associated with risk for RFS

Follow-up setting (at home vs. at the GP's surgery) and severity of comorbidity were significantly associated with the risk for RFS (Fig. 2). The risk of developing RFS was more prevalent in patients cared for at home (*P* < .001) and those with more severe comorbidity (*P* = .010) compared to patients not at risk. Having a caregiver appeared to be a protective factor, with fewer patients found to be at risk of developing RFS when a caregiver was present (*P* = .052). Risk for RFS was not significantly associated with the four patient groups (*P* = .28), gender (*P* = .47), and living situation (*P* = .54). In multivariate analysis, at-home follow-up alone was significantly associated with an increased likelihood of being at risk of developing RFS (adjusted OR=3.78, 95% CI: 1.21–11.81).
In the subset of patients aged ≥70 years, using the adapted NICE criterion for BMI, the only factor significantly associated with RFS risk was gender (*P* = .011). After adjustment in multivariate analysis, women were at higher risk of developing RFS compared to men (adjusted OR=2.65, 95% CI:1.21–5.80).

**Discussion**

*Summary*

The prevalence of RFS risk in primary health care was 2.8% based on the NICE criteria and increased with age and chronic conditions. Using an adapted BMI value in the NICE criteria, the prevalence of RFS risk increased to 7.3% in patients aged 70–74 years, 8.9% in patients aged ≥75 years with CD, and 9.8% in patients aged ≥75 years without CD. Additionally, 65.1% of the entire sample met at least one minor NICE criterion, primarily a history of alcohol misuse or the use of medical drugs, including insulin, chemotherapy, antacids, or diuretics. This suggests that an acute event could put these patients at increased risk for RFS.

More severe comorbidity and at-home follow-up care were associated with a higher risk of RFS. Analysis using an adapted NICE criterion for BMI found that women aged ≥70 years were at higher risk of developing RFS.

*Strengths and limitations*

This is the first study to assess the prevalence of RFS risk in primary care among community-dwelling patients. Although this was a monocentric study, we evaluated the representativeness of the patient population analysed. Compared to other patients followed by GPs in the same administrative area, the patient population of the practice where the study took place was older (21.5% of patients aged ≥75 years vs. 16.1%, *P* < .001), but had a similar proportion of CDs (34.6% vs. 31.7%, *P* = .11).

Note that the prevalence of RFS risk observed in this study was likely underestimated due to the following reasons: (i) we were unable to screen serum levels of phosphate and/or magnesium (a major criterion), as these tests were not routinely performed; (ii) there was a very high rate of missing
data on weight loss; and (iii) patients who died before data collection may have been more likely to develop RFS. The current organisation of general practice in France is not structured to routinely schedule certain tests, such as monitoring weight loss, when ongoing care is provided at home. As patients with stable chronic conditions typically receive care every 6 months, weight is not measured every 3 months, and therefore weight loss at 3 months is rarely detect. The rates of missing data for weight loss and BMI were higher for patients followed at home, which is a significant issue, as these are the most vulnerable patients at the highest risk for RFS. Furthermore, we were unable to stratify RSF risk (as mild, moderate, or severe) according to the ASPEN guidelines, due to the lack of serum phosphate and magnesium values. It would be valuable to conduct a longitudinal study that systematically records NICE or ASPEN criteria in order to collect more comprehensive data.

*Comparison with existing literature*

To our knowledge, no previous study has measured RFS risk in primary care setting. The prevalence of RFS risk in hospital settings ranges from 9% in young hospitalized patients in acute care to 46.5% in older adults in a specialist medicine settings (11,12). A study in intensive care found a high prevalence of RFS risk in critically ill patients, with 34% developing hypophosphataemia after 48-h of fasting. The authors highlighted the need for a consensus definition of RFS risk (13). The recently published ASPEN guidelines for RFS provide updated criteria on blood ion thresholds and risk stratification, but these criteria have not yet been integrated into French guidelines (10).

*Implications for practice*

GPs need to recognize malnutrition as a significant issue that should be addressed throughout the process, from screening to care. They should also be aware that their patients with CDs may be at risk of RFS and adjust their care accordingly to prevent higher mortality. A rethinking of primary care organisation is needed to systematically include evaluations of nutritional status and RFS criteria in the assessment and management of CDs, implementing comprehensive care as necessary.
Advanced practice nurses could be well-positioned to deliver this solution.
**Conclusion**

This study is the first to assess the prevalence of RFS risk in primary care. Using the NICE criteria, the prevalence of RFS risk was 2.8%, increasing to 4.2% in patients with CDs aged 75 years and older. Using an adapted BMI value in the NICE criteria, based on recent GLIM guidelines for malnutrition, the risk for RFS was significantly higher, approaching 9% in patients aged 75 years and older. Additionally, 65.1% of patients met at least one minor criterion, indicating they would be at increased risk of RFS if they experienced an acute event. More severe comorbidity and home follow-up care were associated with a higher risk of RFS. There is a need to enhance screening for patients at risk of RFS in primary care to guide appropriate comprehensive care, as prevention remains the most effective treatment.

**Author contributions**

Clément de Begon de Larouzière de Montlosier (Conceptualization, Investigation, Project administration, Validation, Writing-review & editing), Candy Guiguet-Auclair (Data curation, Formal analysis, Methodology, Software, Validation, Visualization, Writing-original draft, Writing-review & editing), Pierre Mély (Resources, Writing-review & editing), David Julien (Validation, Writing-review & editing), Laurent Gerbaud (Methodology, Writing-review & editing), and Marie Blanquet (Conceptualization, Methodology, Project administration, Supervision, Validation, Visualization, Writing Methodology, original draft, Writing Methodology, review & editing).

**Conflicts of interest**

None declared.

**Funding**

None declared.
**Data availability**

The data that supports the findings of this study are available from the corresponding author upon
reasonable request.

**Ethical approval**

The study was approved by the French Committee for the Protection of Individuals southeast 6 (reference 2022 / CE38, 31 May 2022) and conducted in accordance with the principles of the Declaration of Helsinki. All patients gave informed consent to participate, i.e. to use of their medical data for the purposes of this study.
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2. Schnitker MA, Mattman PE, Bliss TL. A clinical study of malnutrition in japanese prisoners of war. Ann Intern Med. 1951;35(1):69-96.

3. Bioletto F, Pellegrini M, Ponzo V, Cioffi I, De Francesco A, Ghigo E, et al. Impact of refeeding syndrome on short- and medium-term all-cause mortality: a systematic review and meta-analysis. Am J Med. 2021;134(8):1009-1018.e1.

4. Heuft L, Voigt J, Selig L, Stumvoll M, Schlögl H, Kaiser T. Refeeding syndrome. Dtsch Arztebl Int. 2023;120(7):107-14.

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<table><caption>**Table 1.** NICE criteria for identifying patients at high risk of developing refeeding syndrome.</caption><thead><tr><th>High risk for RFS</th><th>1 or more</th><th>2 or more</th></tr></thead><tbody><tr><td>Body mass index</td><td>&lt;16 kg/m<sup>2</sup></td><td>&lt;18.5 kg/m<sup>2</sup></td></tr><tr><td>Unintentional weight loss over 3-6 months</td><td>&gt;15%</td><td>&gt;10%</td></tr><tr><td>Little/no nutritional intake</td><td>&gt;10 days</td><td>&gt;5 days</td></tr><tr><td>Other</td><td>Low blood potassium, phosphate, or magnesium</td><td>Alcohol abuse, insulin, chemotherapy, antacids, or diuretics</td></tr></tbody></table>

Abbreviation: NICE, National Institute for Health and Clinical Excellence
<table><caption>**Table 2.** Sociodemographic and clinical characteristic of the patient population.</caption><thead><tr><th></th><th>Total</th><th>18-69 years old with CD</th><th>70-74 years old with CD</th><th>≥75 years old with CD</th><th>≥75 years old without CD</th></tr><tr><th></th><th>(n = 611)</th><th>(n = 177)</th><th>(n = 82)</th><th>(n = 259)</th><th>(n = 92)</th></tr></thead><tbody><tr><td>Age (years), mean (SD)</td><td>74.4 (11.4)</td><td>60.2 (8.0)</td><td>71.9 (1.4)</td><td>82.4 (5.5)</td><td>81.4 (4.8)</td></tr><tr><td>Gender, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Women</td><td>307 (50.2)</td><td>73 (41.2)</td><td>29 (35.4)</td><td>140 (54.1)</td><td>64 (69.6)</td></tr><tr><td>Men</td><td>304 (49.8)</td><td>104 (58.8)</td><td>53 (64.6)</td><td>119 (45.9)</td><td>28 (30.4)</td></tr><tr><td>Living situation, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Alone</td><td>221 (36.5)</td><td>43 (24.7)</td><td>22 (27.2)</td><td>114 (44.2)</td><td>41 (45.1)</td></tr><tr><td>With a partner</td><td>314 (51.9)</td><td>105 (60.3)</td><td>58 (71.6)</td><td>107 (41.5)</td><td>44 (47.8)</td></tr><tr><td>With children</td><td>41 (6.8)</td><td>3 (1.7)</td><td>1 (1.2)</td><td>31 (12.0)</td><td>6 (6.6)</td></tr><tr><td>Other<sup>a</sup></td><td>29 (4.8)</td><td>23 (13.2)</td><td>0</td><td>6 (2.3)</td><td>0</td></tr><tr><td>Occupational status, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Employed</td><td>62 (10.2)</td><td>62 (35.2)</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Retired</td><td>529 (86.9)</td><td>97 (55.1)</td><td>81 (98.8)</td><td>258 (100)</td><td>92 (100)</td></tr><tr><td>Other<sup>b</sup></td><td>18 (3.0)</td><td>17 (9.7)</td><td>1 (1.2)</td><td>0</td><td>0</td></tr><tr><td>Having a caregiver, n (%)</td><td>435 (71.7)</td><td>126 (72.4)</td><td>62 (75.6)</td><td>183 (70.7)</td><td>63 (69.2)</td></tr><tr><td>Follow-up, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>At GP surgery</td><td>504 (82.5)</td><td>169 (95.5)</td><td>78 (98.1)</td><td>173 (66.8)</td><td>84 (91.3)</td></tr><tr><td>At home</td><td>107 (17.5)</td><td>8 (4.5)</td><td>4 (4.9)</td><td>86 (33.2)</td><td>8 (8.7)</td></tr><tr><td>Comorbidity severity<sup>c</sup>, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><tbody><tr><td>No comorbidity</td><td>3 (0.5)</td><td>3 (1.7)</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Mild</td><td>54 (8.8)</td><td>52 (29.4)</td><td>0</td><td>2 (0.8)</td><td>0</td></tr><tr><td>Moderate</td><td>269 (44.0)</td><td>102 (57.6)</td><td>41 (50.0)</td><td>62 (23.9)</td><td>63 (68.5)</td></tr><tr><td>Severe</td><td>285 (46.6)</td><td>20 (11.3)</td><td>41 (50.0)</td><td>195 (75.3)</td><td>29 (31.5)</td></tr><tr><td>BMI (kg/m²), mean (SD)</td><td>28.0 ± 5.4</td><td>28.9 ± 5.9</td><td>29.3 ± 5.1</td><td>27.3 ± 5.0</td><td>26.6 ± 4.8</td></tr><tr><td>Weight loss at 3 months, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>118 (40.7)</td><td>42 (51.9)</td><td>22 (40.7)</td><td>36 (31.0)</td><td>18 (46.2)</td></tr><tr><td>&lt;10%</td><td>171 (59.0)</td><td>38 (46.9)</td><td>32 (59.3)</td><td>80 (69.0)</td><td>21 (53.9)</td></tr><tr><td>10–15%</td><td>1 (0.3)</td><td>1 (1.2)</td><td>0</td><td>0</td><td>0</td></tr><tr><td>&gt;15%</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Weight loss at 6 months, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>192 (47.6)</td><td>59 (49.2)</td><td>31 (45.6)</td><td>73 (49.0)</td><td>29 (43.9)</td></tr><tr><td>&lt;10%</td><td>210 (52.1)</td><td>60 (50.0)</td><td>37 (54.4)</td><td>76 (51.0)</td><td>37 (56.1)</td></tr><tr><td>10–15%</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>&gt;15%</td><td>1 (0.2)</td><td>1 (0.8)</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Reduced food intake or fasting, n (%)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>594 (97.4)</td><td>175 (98.9)</td><td>80 (97.6)</td><td>248 (96.1)</td><td>90 (97.8)</td></tr><tr><td>5–9 days</td><td>14 (2.3)</td><td>2 (1.1)</td><td>2 (2.4)</td><td>8 (3.1)</td><td>2 (2.2)</td></tr><tr><td>&gt;10 days</td><td>2 (0.3)</td><td>0</td><td>0</td><td>2 (0.8)</td><td>0</td></tr><tr><td>History of alcohol abuse, n (%)</td><td>119 (19.5)</td><td>48 (27.1)</td><td>19 (23.2)</td><td>42 (16.3)</td><td>10 (10.9)</td></tr><tr><td>Medical drugs</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Insulin, n (%)</td><td>35 (5.7)</td><td>11 (6.2)</td><td>4 (4.9)</td><td>20 (7.7)</td><td>0</td></tr><tr><td>Chemotherapy, n (%)</td><td>7 (1.1)</td><td>2 (1.1)</td><td>1 (1.2)</td><td>4 (1.5)</td><td>0</td></tr></tbody></table>
<table><tr><td>Antacids, n (%)</td><td>220 (36.0)</td><td>61 (34.5)</td><td>25 (30.5)</td><td>110 (42.5)</td><td>24 (26.1)</td></tr><tr><td>Diuretics, n (%)</td><td>214 (35.0)</td><td>37 (20.9)</td><td>28 (34.1)</td><td>118 (45.6)</td><td>31 (33.7)</td></tr></table>

aWith other family members.

bDisability: n=11.

cSeverity of comorbidity was graded into classes based on the age-adjusted Charlson comorbidity index (a-CCI): no comorbidity (a-CCI score: 0), mild (a-CCI:1-2), moderate (a-CCI:3-4), and severe (a-CCI: ≥ 5).

Abbreviations: CD, chronic conditions (one or more chronic diseases); SD, standard deviation.
<figure><img src="image_2.png" /><figcaption>**Figure 1.** Flow diagram.</figcaption></figure>
<caption>**Figure 2.** Factors associated with risk for refeeding syndrome.</caption>

†P < .10. **P < .01. ***P < .001. Comorbidity level was graded into classes based on the age-adjusted Charlson comorbidity index (a-CCI): no comorbidity (a-CCI score: 0), mild (a-CCI: 1–2), moderate (a-CCI: 3–4), and severe (a-CCI: ≥5). CD, chronic conditions (one or more chronic diseases).

<figure><img src="image_3.png" /></figure>