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So as discussed in my last post one of the most consistent presentations along with alcohol abuse and dependence is malnutrition and the risk of refeeding syndrome.
There are many reasons for malnutrition associated with alcohol abuse from the very deliberate drunkorexia which I wrote about here to making choices that preferences spending money on alcohol rather than food or in the case of alcohol dependence having no choice to drink as a priority to eating. If we consume no nutrients the body will break down muscle to provide energy as seen in the top picture above creating wasted limbs.
As described here: Alcohol contains only empty calories and has no nutritional value. It can often contribute to malnutrition because the high levels of calories in most alcoholic drinks can account for a large percentage of your daily energy requirements. Even one alcoholic drink a day can contribute to malnutrition.
Your body can't store alcohol, so it must metabolize it right away. When you drink alcohol, your body makes metabolizing it a priority over all other metabolic processes. Your body sends alcohol to the liver, which produces the enzymes necessary for the oxidation and metabolism of alcohol.
Not only does alcohol not contain any nutrients of its own, but it can impair your body's ability to absorb nutrients and vitamins from the food you eat. Alcohol irritates your gastrointestinal tract, and can damage your body's ability to absorb nutrients, vitamins and minerals from the food you eat.
This becomes very serious in alcohol dependence as introducing food can create the risk of refeeding syndrome:
Refeeding syndrome has been defined as the “potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients”. The most important word to note here is ‘malnourished’. The key clinical marker of this is hypophosphatemia – very low phosphorus levels in the blood. However, lowered potassium, calcium, and magnesium in the blood may also play a role. Calcium, phosphorus and magnesium are all primarily intra-cellular ions – that is, they are kept inside the cells and blood levels (which are outside of cells) tend to be quite low compared with concentrations inside cells.
Refeeding problems can happen once food is given, particularly carbohydrate-containing foods. During the refeeding period, insulin and other hormones are activated. This causes the movement of the major intracellular ions (phosphorus, potassium, calcium and magnesium) into the cells. However, due to overall depletion of body stores, this becomes excessive and too little of these ions are left in the blood. This is what causes the major symptoms of the refeeding syndrome, some of which are rarely fatal.
Vitamin deficiencies have also been described, again mostly with prolonged malnutrition. The most important is thiamine, which is an essential coenzyme in carbohydrate metabolism. Typically, this has been described in alcoholics with the syndromes of Wernicke’s encephalopathy (ataxia, confusion, visual disturbances) and Korsakoff’s syndrome (memory loss and confabulation). Confabulation is a symptom whereby people have a complete lack of short-term memory. They therefore ‘make up’ everything when they are talking because they have no memory. There is no intent to deceive.
All our patients that we consider at risk of alcohol related malnutrition are commenced on thiamine in ED preferably intravenous which has to be given before any food particularly carbohydrate such as a sandwich. This is because a carbohydrate load in the presence of thiamine deficiency risks precipitating Wernicke's Encephalopathy. They are also assessed for evidence of refeeding syndrome and electrolyte imbalances are corrected as they occur. Then they will be on thiamine 3 times a day for 7 days during admission given before food as well as a multi-vitamin.
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