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A Starving Mom Suddenly Ate 40 Cookies. This Is What Happened To Her Heart.

A starving mom suddenly ate 40 cookies, this is what happened to her heart. MJ is a 35 year old woman, presenting to the emergency room delirious, the paramedics found her on the street lying on the ground, shaking with several
empty boxes of cookies and her children. You see, MJ was a homeless woman who
had been starving for more than a year, she had no legal spouse, didn’t eat very
often, and when she did have food, she’d give it to her kids. A few months ago, she made it to a major city, around this time, she had become
accustomed to not eating much. In fact, the few times she did eat, she would feel dizzy and thirsty afterwards,
her heart rate would increase, she would feel uncomfortable, so she opted
to not eat much; if at all on most days. During this time, MJ had lost a
significant portion of her body weight, at 5′ 5″ tall, she weighed a total of 75 pounds, that’s nearly half of her ideal body weight. Finally, one hot summer day, MJ felt exhausted, she received a few boxes of
cookies late at night from a local bakery, they had past their sell-by date, so it was
typical for the bakery to give the food away. In a strange deviation from her
recent behavior of not eating much, she had a taste of one of the cookies, she enjoyed it, then she had a taste of another,
and another, and another. She looked away, kept eating and
without paying attention in 30 minutes, she had finished a total of 30 cookies by herself. It’s an hour later, her kids are asleep and MJ
feeling lethargic, her vision is blurred, she thinks she feels a little dizzy, but is unsure, she feels that she’s just tired and now that
she’s eating well for the first time in years, she can finally have a good sleep. It’s morning now, MJ wakes up, she didn’t sleep well, she eats 10 more cookies for breakfast. As she walks on the street throughout the day, she feels her heart fluttered, she has a headache, her field of vision
starts to blur and warp, she’s dizzy, collapses on the street and starts seizing. Her kids cry out for help and an ambulance is called where she’s brought to the
emergency room where we are now. Given this past medical history, there’s a few glaring clues as to what’s happening: most immediately, MJ is suffering
from Refeeding Syndrome. The name is intuitive, there’s 40 cookies that she ate, and they’re a form of refeeding, this is the first time, that she’s had a
major oral intake of calories in over a year. “Syndrome” refers to the grouping of symptoms that she’s having related to this refeeding. But how could this be? Even if it was just cookies, eating something
should be better than nothing, right? Well, not quite, and it’s less the fact that cookies are unhealthy for you and more so the changes in MJ’s
physiology since she is gone in starvation. Let’s look at this clinically, first: her body has been malnourished
for a long period of time and this is physically evident. At 5′ 5″ tall, her ideal body weight is 125 pounds, that number is calculated and standardized in humans and we used this in clinic to assess
status and to dose drugs. She weighs 75 pounds 60% of her ideal and this is a problem,
because under 70% is the threshold, where someone would be
at risk for Refeeding Syndrome, and she’s there. On presentation to the emergency
room, she’s hypothermic, meaning her body temperature is
low as she was found shivering, her blood indicates that her liver enzymes are elevated and her kidney function is abnormal, these are typical symptoms for presentation
of a chronically starving patient. She has to some extent compensated
for these losses over time; her baseline heart rate before
refeeding was 35 beats per minute, that could be normal for a well-trained athlete,
but MJ certainly isn’t one at the moment. She should be somewhere between 60 to 100 beats per minute, like most people and at presentation,
she has 70 beats per minute, so she should be okay, right? Actually, no. For patients in starvation,
whether it’s rooted in eating disorder, “dysphagia,” known as an inability to
eat due to difficulty swallowing, or rooted in a different etiology, bradycardia is very typical in patients like MJ. “Brady” meaning slow
and “cardia” referring to heart rate, slow heart rate typically
defined as under 60 beats per minute, in extreme starvation, it can dip
to below 30 beats per minute, meaning one beat every two seconds or longer. Baseline heart rate of 35 now up
to 70 with a sudden refeeding is an extreme change in a short amount of time, educating a major cardiovascular complication, her heart EKG shows that her heart is beating irregularly. But why is this happening? We can start to explain it through
the delirium and the seizure that she suffered when she
arrived to the emergency room, Because she’s been in starvation, she has vitamin deficiencies, the important
one here being thiamine or vitamin B1. Thiamine isn’t produced endogenously, meaning that your body doesn’t produce it by itself, we need to source it from your dietary intake. It’s important in cells, it helps promote the breakdown of sugars and plays a central role in cerebral energy utilization Its deficiency initiates the injury of
brain cells by inhibiting metabolism, causing MJ’s delirium and her seizures. But thiamine isn’t active by itself, it’s usable in your cells in a form known
as thiamine pyrophosphate. Phosphate, that is the root of the problem here, MJ is suffering from hypophosphatemia. “Hypo” meaning low, “phosphate” referring to the important
anion that exists mainly inside of your cells, and “emia” meaning presence in blood. Low phosphate presence in blood. This has severe consequences in
multiple aspects of MJ’s biology, one major contribution to her physical
decay from malnutrition is muscle atrophy. “A” meaning without,
and “trophy” referring to nourishment, her muscles have broken down over
time because she hasn’t been eating. But this isn’t just limited to the muscles
we can see just by looking at her though, what we would call skeletal muscle, the smooth muscle of her stomach and
intestines have atrophied and most importantly, her heart muscle has atrophied. What does this have to do with phosphate? Well, muscle tissue is the prime utilizer of it, in the blood, there’s a few important
electrolytes involved in muscle contraction: sodium and potassium signal for a contraction, calcium commits to a contraction, and phosphate provides the energy for the contraction. You may have heard of it, it’s called ATP, adenosine triphosphate. Adenosine being an adenine molecule,
that’s the a in your genetic information attached to a ribose sugar and triphosphate, three phosphates. That energy provided by ATP is responsible
for almost all movement in your body, whether it’s food through your stomach, blood pumped to your brain,
or you walking on the street. But have you noticed when you walk faster on the street that you start to breathe heavier and deeper? In a state of activity, your muscles need more oxygen to produce
more ATP to meet energy demand and in order to provide that oxygen, the body uses another phosphate-containing compound known as 2,3-Diphosphoglycerate, the name tells you exactly what it is. Glycerate, with two phosphates on
carbons number two and three. 2,3-DPG, in red blood cells
potentiates oxygen dissociation, increasing availability of oxygen to
tissues like the muscle from the blood, that oxygen is used to create more ATP. So all kinds of muscle are very dependent on phosphate to provide energy for contraction. But let’s go back to the name
of MJ’s condition: hypophosphatemia low phosphate presence in blood. Why is the phosphate low? She just ate 40 cookies, so everything in terms of electrolytes and
nutrients should be high in her blood, right? Actually, no. The cookies MJ ate were high in sugar sugar mainly glucose strongly stimulates the pancreas to release a hormone known as insulin, that decreases blood glucose by shifting
it into the body cells from the blood. In a healthy person, insulin release
is highly regulated in very precise, you get exactly what you need. But MJ isn’t healthy, she’s malnourished, 40 cookies totaling 1200 grams
of sugar within 12 hours is a huge shock to her system, her body is sensitive to insulin, meaning small amounts of it will have a greater impact on her
body than if she were healthy. This happened over a long period
of time, as MJ ate less and less, she felt dizzy after eating those cookies, because her blood sugar became
lower than before she ate them, due to this massive insulin response. But it’s not just glucose shifting into her cells, the electrolytes in her blood: sodium, potassium,
calcium, magnesium, and phosphate, they’re all shifting out of the blood and into her cells. Most of these nutrients are literally
getting sucked out of her blood and shoved into her cells, this signals the beginning of MJ’s heart problems. Because the time scale is short, the movement of sodium into all cells of the body, not just the muscle gets detected by the kidney, they respond by reabsorbing the sodium
that would have shown up in the urine, a constant of this is that waterfall
of sodium and is retained in the body. This begins a process of volume overload inside MJ, as more and more fluid begins
to accumulate in her body. Fluid that should have been urinated out, her heart is starting to have difficulty handling it, she exhibited signs of this when her
heart was fluttering in the morning, there’s congestion in her heart. That extra fluid accumulating in her body is more than her heart can handle, and she’s starting to show signs of
acute decompensated heart failure. “Decompensated” means that the heart hasn’t had enough time to adapt to the changes in her body and “acute” meaning an underlying
physiologic change was recent due to an event, in this case, the eating of 40 cookies in
a person who was previously starving. This isn’t a one-dimensional problem,
because her heart muscle has atrophied, it’s not as strong as it would be if she were well fed, because phosphorous is shifting
intracellularly due to high insulin response, the heart muscle has less phosphate
available to it from the blood, meaning less production of ATP for energy and less 2,3-DPG for oxygen
dissociation to produce that ATP. Her heart muscle has a higher workload through an overload in fluid and less energy to provide work to that load, this still isn’t the end of the story. the muscle that draws air into the lungs the diaphragm in MJ’s case, it too has atrophied in her starvation and with less phosphorous
available to it means she has dyspnea. “Dys” meaning abnormal and “pnea” meaning breath, it’s not only harder for her to
provide energy to her muscles, but she also can’t breathe in enough
oxygen with those muscles. This could have been avoided, if MJ ate slowly and didn’t succumb to her appetite. Refeeding Syndrome isn’t new to humans, in 100 A.D., the Jewish Roman scholar, Flavius Josephus, described an epidemic of deaths among Jews who had been entrapped and starved by the Romans, he wrote that those who engorge themselves died, but the ones who restrained their appetite in the face of abundant food were able to survive. In 600 A.D. China, Sun Si Miao, the most influential physician
in East Asia for a thousand years, wrote about Refeeding Syndrome in context of beriberi. The symptoms caused by thiamine deficiency, it was a problem in rural China at the time as peasants were often only allowed to eat white rice and the removal of its husk depleted
its primary source thiamine. And when there wasn’t enough food
due to natural disaster, people starved and faced Refeeding
Syndrome when food was available again. In World War II, prisoners of war were liberated in 1945 and those who were fed paradoxically died after eating. And this was the first modern
description of Refeeding Syndrome, even today, Refeeding Syndrome isn’t well known outside of nutritional support circles in sight clinic. Cancer patients commonly have dysphagia or difficulty swallowing due to their treatments, or stomatitis, a mouth sore and
common side effect of treatment. They typically don’t eat much and
in effect they become malnourished, when hospitalized, they’re typically fed entirely through a tube or parenterally through their veins and
they get a sudden bolus of nutrients that their body isn’t used to, causing insulin response, the intracellular
shift of electrolytes and glucose, causing Refeeding Syndrome. If a person who is previously
starving, refeeds too suddenly, they’re put at an incredible risk of dying inside a decayed form of their own body. For MJ, we treat her underlying
conditions namely her hypophosphatemia, this is easier said than done. Since her levels are extremely low
due to the nature of her Refeeding, we give her intravenous phosphate,
but only up to a limit, because she’s delirious,
oral intake is likely unreliable for her, but IV administration is only for a short amount of time. The reason being is that IV phosphate is very dangerous, as it can form solid salts with the calcium in the blood, which can damage the kidneys causing
renal failure and hypocalcemia, or low calcium presence in blood. Since muscle cells use calcium to commit to a contraction, when it’s low in blood that too can
cause problems in MJ’s heart, we switch to oral repletion of phosphate
when the levels begin to increase. For potassium and magnesium, we replace those intravenously as well, but we do it in a saline solution without dextrose, in some cases, students and residents will want to replete the electrolytes in a 5% dextrose solution, but it’s contraindicated in this case. Dextrose is the D-isomer of glucose, presence of dextrose will stimulate insulin release, which got MJ into the trouble that she’s in right now, by treating the underlying electrolyte
abnormalities and later, thiamine deficiency, MJ was able to resolve her feeding syndrome and subsequent cardiac
dysfunction and encephalopathy. What happened to her and her kids afterwards? Well, that’s a part of the story that you can help write. Thanks so much for watching. Take care of yourself and be well. English CC by Charles Baluyot

100 thoughts on “A Starving Mom Suddenly Ate 40 Cookies. This Is What Happened To Her Heart.

  1. sugar is a drug. when coming off of keto after a year i decided to eat some sweets i couldn’t have, i would have to sit down because i was feel dizzy after a few days i quit eating as much and started having flu symptoms and felt groggy overall

  2. Can someone please explain to me how Matt Stonie eats MASSIVE and lethal doses of sugar and nothing happens to him? I genuinely need to know

  3. Never thought about refeeding syndrome in the United States, wow. Associated it with the Nazi death camp liberation of Europe. Thank you. Also appreciate your last comment that CJ final outcome is something I/we can effect. Imagine watching your parent starving as you live homeless. As always you inspire.

  4. If she hardly eats she would be very skinny and get full quicker, how the hell did she just eat 40 biscuits? She wasn't eating them fast, just grabbing one after the other, how did she not get full?? Omgahd

  5. find your own medical case study coach or consultant who can help you out and make your mental stress lesser for doing other study tasks easily.

  6. 5:22 Atrophy
    A – meaning without, and
    Trophy – referring to trophies🏆

    Being without a trophy for extended periods of time can lead to sadness, frustration and in some cases depression.

  7. Hey, you filmed in Pittsburgh!? I recognized from the garbage can at 0:29 (and then the picture of the city a second later). Giovanni's (the pizza box in the trash) is one of my fave pizza places downtown!

  8. I’m trying to take care of myself and be well, but I need vodka to keep from crying. Everything sucks. Life doesn’t even matter.

  9. CE: So this should be okay, right?
    Me: Please say it's okay for this poor women this time
    CE: Well, not exac-

  10. My mother had an ID photo of herself from the Displaced Person's Camp not long after liberation from Dachau, she looked weird and bloated. She told me everyone who was liberated that survived the first few days of food bloated up like that.

  11. Wow… and my wife used to freak out that she is 5'4" 105lbs. She weird in how sometimes she thought she was "too skinny" but our daily physical activity keeps both our weight stable. With Crohn's Disease, of the two of us, I am the one who HAS to take in 3,000 to 3,500 calories a day to ensure I absorb enough as Crohn's brings with it chronic mal-absorption. So my daily caloric intake is more than twice as much as her's, and while it can be a literal pain, it works. On top of the food she also MAKES me drink at least one Ensure with each meal. I LOVE eating, but only when it's home made food that I or my wife cooks. We RARELY ever have fast food. In fact that last time we had it was because we were on our way home after a VERY long day and were too tired to also cook at home, so we picked up some cheese burgers from a local place. Not nearly as bad as it would be from McDonald's but we were both still a bit uncomfortable after. The last time e had McDonald's was years ago and we both felt like we were dying after. We are just too used to healthy home cooked meals. If we have to keep an eye on MY weight because of the Crohn's Disease, I can't imagine how bad it would have been for the woman in the story. At my worst I was 6'0" and 116lbs when I was 19 years old, and I needed a bowel resection. It worked and I've been 6'2" 185-200lbs ever since. That is a normal range for me, again depending on activity levels.

    Wow. When I was in the best shape of my life from playing a FUCK TON of tennis every day, my resting heart rate was 40bpm, and when I was in the ER with pain related to the Crohn's Disease, every time I would start to fall asleep because I had been awake for too long, the heart monitor would start to go off when my heart rate fell to 35bpm, and every time the damn thing woke me up my heart rate rose to over 40bpm and it would shut the fuck up. It was so fucking annoying because I hadn't slept in two days by that point and they had given me Demerol for the pain so I wanted nothing more than to be able to get some rest. Damn machine.

  12. Yeah… I've starved before. I know what it feels like to get used to that and feel sick when you try to eat again… you have to only eat a little and slowly increase intake daily… Wish people listened to their bodies more. :/

  13. "When no one was looking, a homeless mom ate 40 cookies, she ate 40 cookies, that's as many as 4 tens, and that's unhealthy."

  14. i’ve had refeeding syndrome! when i was put into a hospital for my anorexia, they had to “slowly teach my body how to eat again” is how they explained it. simple terms, i guess.

  15. I wonder how much trial and error it took early humans to figure out that they needed to eat and drink to survive, what they could eat, what they couldn’t eat, how long you can go without eating or drinking before dying, etc. Imagine how many people died 😬

  16. Binge watching all of your videos before my pathophysiology exam. They are well made and very helpful to refresh on the principles. Thank you so much!

  17. she has hypercookieempia
    Hyper meaning high. Cookie meaning cookie.
    Empia meaning presence in blood.
    high cookie presence in blood

  18. You kept referring to the sugar in sweets and other things as "glucose." It isn't. It's sucrose." *Glucose is the form in which sugar is stored in the body. Refined white sugar — sucrose — behaves differently in the body. Please check up on that.

  19. A women ate a human Di## this is what happened to her body here’s a link for more

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