side effects and complications while fasting
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Possible side effects and complications during fasting therapy and indications for its stopping
 


Ketoacidosis (non-compensated) with heavy growing complications.

It happens in 2-5% of the patients, usually, during the first fast. It accompanied by vertigo, sickness, vomiting, general weakness. In this case alkaline mineral water should be prescribed or sodium hydrocarbonate (2-3 g every 2-3 hours). If there is no effect during 12-24 hours fasting should be dropped. Sodium hydrocarbonate must be taken, oxygen inhalations and re-feeding nutrition. But if the patient is strongly willing to continue fasting, the fasting could be continued in 2-3 days (fractional fasting method).


Ortostatical collapse (syncope)

More often this undergo in patients suffering from hypotonia (AP is under 90/60 mm). If it occurs, patient should be in horizontal position with his legs up, flow of fresh air should be ensured, a tampon with liquid ammonia is under his nose, (in rare cases inject caffeine or cordiamine). If syncope repeats fasting should be dropped. As prophylactic measures it is recommended to avoid sharp movements, getting up from the bed quickly.


Malignant arrhythmia, unstable angina

Is very rare to happen and show as extracistolia. In its base lays hypocaligistia, caused by ketoacidosis and breach of activity of K+-Na+-AT Phase. If the patients complains on tachycardia, aches in the heart area, urgent electrocardiographia should be hold. Preparations of potassium (panangin, asparkam, etc) and ??-adrenoblocks (obzidan) should be prescribed. If there is no positive result within 12-24 hours fasting should be stopped. Prophylactic measures consist of do not alowing persons that suffers from breach of cardiac rhythm in anamnes to go long-term fast. In this case fractional fasting method could be implemented (1-2-3 days of fasting).


Kidney and bilious colic

Could be at patient with nephro-stone and gall-stone diseases. If colic begin, fasting should be dropped, spasmolitics and analgetics in normal therapeutic doses should be prescribed. Prophylactic measures: adequate drinking regimen in the process of fasting (no less then 1- 1,5 l per day).


Acute erosive-ulcerous changes of gastroduodenal zone

Happens rarely (in 2-5 %). In case of stable epigastral aches, heart burning, eructation, phibrogastroduodenoscopy should be hold. Presence of acute erosive-ulcerous changes of mucous membrane of the stomach and duodenum is an indication to discontinue fast. Antacides should be prescribed (Almagel, Vikalin) or Venter (Surralfat), As usual, epitelisation of the ulcer and erosion happens within 10-14 days of fasting.


Convulsions

Is very rare to happen, usually at long terms of fasting (over 20-30 days). Tonic convulsion of calf muscles, finger and chewing muscles are developing. The reason is water-electrolit shifts. For internal use 1% solution of sodium chloride 20-30 ml 4-5 times per day.


Syndrome of "food overload"

Occurs during first 3-5 days of refeeding period if prescribed regimen of nutrition (overeating) and ration are broken. It causes sickness, vomiting, overloading in epigastry, disorder with stool. It is necessary to lavage the stomach, to give salted laxative, and to recommend food abstinence for 1-2 days (full fasting). Prophylactic measures: keeping the dietetic regimen of the refeeding period of fasting therapy.


"Salt" oedema

Happens during refeeding period if the diet is not kept (use of salt, herring, butter, cheese, etc). It causes oedema under eyes, headache, weakness, increase of mass of the body (up to 1,5-2 kg). Oedema passes independently within 1-3 days if the diet does not contains salt. Diuretics (hypotiazide, etc) or laxatives help to vanish oedema. Prophylactic: absolute exclusion of salt and saltcontaining products for all rehabilitation period (3-4 weeks).


Indications for discontinuance of fasting:

categorical rejection of patients to continue fast
heavy process of ketoacidose, that cannot be treated by bi-carbonates
repeated ortostatical scollapse
stable disorder of cardiac rhythm
symptoms of growing insufficiency of circulation of the blood
stable sinusoid tachicardia (110-120 beats /min and more)
atacks of kidney and bilious colic
marked bradicardia (50 beats/min and less)
increase of content in the blood AlAT, AsAT and/or direct bilirubin 2 times beyond the norm
acute erosive-ulcerous changes of gastroduodenal area.


Clinical studies:


Risk of symptomatic gallstones and cholecystectomy after a very-low-calorie diet or low-calorie diet in a commercial weight loss program: 1-year matched cohort study.
Int J Obes (Lond). 2014 Feb;38(2):279-84. doi: 10.1038/ijo.2013.83. Epub 2013 May 22.Johansson K1, Sundström J2, Marcus C3, Hemmingsson E4, Neovius M1.

BACKGROUND:
Concern exists regarding gallstones as an adverse event of very-low-calorie diets (VLCDs; <800 kcal per day).

OBJECTIVE:
To assess the risk of symptomatic gallstones requiring hospital care and/or cholecystectomy in a commercial weight loss program using VLCD or low-calorie diet (LCD).

DESIGN:
A 1-year matched cohort study of consecutively enrolled adults in a commercial weight loss program conducted at 28 Swedish centers between 2006 and 2009. A 3-month weight loss phase of VLCD (500 kcal per day) or LCD (1200-1500 kcal per day) was followed by a 9-month weight maintenance phase. Matching (1:1) was performed by age, sex, body mass index, waist circumference and gallstone history (n=3320:3320). Gallstone and cholecystectomy data were retrieved from the Swedish National Patient Register.

RESULTS: 
One-year weight loss was greater in the VLCD than in the LCD group (-11.1 versus -8.1 kg; adjusted difference, -2.8 kg, 95% CI -3.1 to -2.4; P<0.001). During 6361 person-years, 48 and 14 gallstones requiring hospital care occurred in the VLCD and LCD groups, respectively, (152 versus 44/10 000 person-years; hazard ratio, 3.4, 95% CI 1.8-6.3; P<0.001; number-needed-to-harm, 92, 95% CI 63-168; P<0.001). Of the 62 gallstone events, 38 (61%) resulted in cholecystectomy (29 versus 9; hazard ratio, 3.2, 95% CI 1.5-6.8; P=0.003; number-needed-to-harm, 151, 95% CI 94-377; P<0.001). Adjusting for 3-month weight loss attenuated the hazard ratios, but the risk remained higher with VLCD than LCD for gallstones (2.5, 95% CI 1.3-5.1; P=0.009) and became borderline for cholecystectomy (2.2, 95% CI 0.9-5.2; P=0.08).

CONCLUSION:
The risk of symptomatic gallstones requiring hospitalization or cholecystectomy, albeit low, was 3-fold greater with VLCD than LCD during the 1-year commercial weight loss program.


Liver and gallbladder disease before and after very-low-calorie diets.
Am J Clin Nutr. 1992 Jul;56(1 Suppl):235S-239S.
Andersen T.
Department of Medical Gastroenterology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.
Hepatobiliary characteristics of untreated obese patients and those of patients reducing weight through very-low-calorie diets (VLCDs) are reviewed. In untreated obesity, hepatobiliary abnormalities are prevalent. Fatty change is common and may be related to insulin resistance. Moreover, portal inflammation and fibrosis are prevalent findings, also in the absence of alcohol abuse. The liver plays a key role in the hyperinsulinism and hyperlipidemia, and hepatic drug metabolism is influenced by enhanced glucuronidation and sulphatation. Predisposition to gallstone formation can be ascribed to increased biliary cholesterol secretion in concert with changed nucleating factors and altered gallbladder motility. Weight loss by VLCD reduces fatty change but may induce slight portal inflammation and fibrosis. Insulin resistance and pharmacokinetic abnormalities regress. During VLCD the risk of gallstone formation is markedly increased. The deleterious effects described of a rapid weight loss should draw some attention to the liver and biliary tract during VLCD treatment.

Nonphysician supervision of a very-low-calorie diet. Results in over 200 cases.
Int J Obes. 1981;5(3):237-41.
Atkinson RL, Kaiser DL.
Nonphysician nutritional therapists treated 234 obese patients with a 12-week behavioral modification, nutrition education program followed by up to 12 weeks on a very-low-calorie diet (VLCD). Mean weight decreased from 104.5 kg to 85.8 kg after 12 weeks on VLCD. Mean maximal weight loss for all patients was 17.2 kg. Blood pressure decreased from 133/86 to a low of 111/70 during VLCD. In 91 hypertensive patients, blood pressure fell from 145/95 to 128/81 after 12 weeks of VLCD. No serious side effects of VLCD were noted, although two patients developed mild cases of gout and one patient was taken off the fast when premature ventricular contractions were noted on ECG. Cost analysis reveals that physician care is almost three times as expensive as care by non-physician nutritional therapists. We conclude that the treatment of obesity should be performed by nutritional therapists under physician supervision using a comprehensive program of behavioral modification and VLCD.

Obesity and risk of gallstone development on a 1200 kcal/d (5025 Kj/d) regular food diet
Heshka S, Spitz A, Nuñez C, Fittante AM, Heymsfield SB, Pi-Sunyer FX.
Int J Obes Relat Metab Disord. 1996 May;20(5):450-4.

Gallstone formation and weight loss.
Weinsier RL, Ullmann DO.
Obes Res. 1993 Jan;1(1):51-6. Review.

Gallstone formation during weight-reduction dieting.
Liddle RA, Goldstein RB, Saxton J.
Arch Intern Med. 1989 Aug;149(8):1750-3.

 

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