A 19-year-old woman with anorexia nervosa (BMI 13.8 kg/m²) is started on nutritional rehabilitation. Which of the following is the most appropriate initial caloric prescription to minimize the risk of refeeding syndrome?
- A Starting at 5-10 kcal/kg/day and advancing slowly ✓
- B Starting at 30-40 kcal/kg/day with rapid advancement
- C Starting at 15-20 kcal/kg/day and advancing slowly
- D Starting at 50 kcal/kg/day from day 1
Correct answer: A. Starting at 5-10 kcal/kg/day and advancing slowly
Explanation
In severely malnourished patients with anorexia nervosa at high risk for refeeding syndrome, initial caloric intake should start low at approximately 5-10 kcal/kg/day and be advanced slowly over several days. This cautious approach allows metabolic adaptation and minimizes the risk of dangerous electrolyte shifts. Close monitoring of phosphate, magnesium, potassium, and cardiac function is essential. More aggressive refeeding in severely malnourished patients increases mortality risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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