Our Hostages Are Starving, But Refeeding Them Too Quickly Might Kill Them

Like so many of you, I stared at the images of Or Levy, Eli Sharabi, and Ohad Ben Ami, released as part of phase one of the hostage deal, with horror.

Like so many of you, I found these images so jarring because they looked like Holocaust survivors. If the question “is ‘never again’ happening again, now?” has been in the back of our minds, the starved faces of the returning hostages forced that thought to the forefront. Their release from Hamas captivity reactivated for so many the generational trauma we carry.

But, unlike others, I looked at Or, Eli, and Ohad through a professional lens, too, as a Registered Dietitian with an expertise in rehabilitating malnourished people.

When American GIs liberated concentration camps during World War II, they did what any normal person would do – horrified by the emaciated condition of survivors, they shared their food rations in an attempt to feed them. To their horror, their well-meaning efforts actually hastened the deaths of some survivors. This was due to what we now call ‘refeeding syndrome,’ or a constellation of electrolyte abnormalities that can occur when a malnourished person is refed too quickly with carbohydrates, or sugar. If left untreated, refeeding syndrome can be fatal. Modern medicine only knows this because of what happened to the Jews before us. And now it’s at risk of happening again, in Israel.

As a Registered Dietitian over 6,000 miles away, I am not attempting to speculate on the condition of our returning hostages without their consent. Without knowing more about their clinical condition or receiving patient consent, it is impossible for me to speak to the specific, real-time medical needs of the returning hostages. But our past experience as a people, combined with clinical studies which are used to train dietitians like myself, give some basic understanding of what these men might be facing.

Here is what I see in these images, as a nutrition professional who rehabilitates starving people for a living:

• Cachexia: This is a medical term for severe muscle wasting. Usually seen in patients with late-stage cancer, AIDS, or anorexia, it signifies severe malnutrition and starvation.
• Temporal wasting: All three men had signs of loss of fat and muscle in their faces along their temples, another sign of severe malnutrition.
• Global fat loss: The normal fat pads that insulate organs, provide warmth, and fill out skin are completely depleted. Sharp clavicles protrude from sweatshirts. Collars hang loose around thin necks. You do not have to know what these men looked like before their abduction and captivity to see the depths of their starvation now.
• Protruding bones: without sufficient muscle and fat stores, long depleted over 491 days of captivity, bones have become sharp and prominent.

And that’s just what we can see. Do they have invisible signs of malnutrition, too? Almost surely. Are they dizzy? Are they weak? Recent reports say that some of these men spent nearly 500 days chained up, and were forced to relearn to walk in the days before their release.

How is their digestion? Without regular food intake, the gut atrophies just like any other muscle. Stool volume and frequency can increase, and/or digestion can become sluggish and can remain that way for quite some time. The bacteria that naturally reside in their intestines die, and since that is the immune system’s first line of defense, their immune system becomes compromised, increasing their risk of infection and illness.

To better understand refeeding syndrome, and to understand how to rehabilitate the millions of people at risk for mass famine after World War II, the U.S. government and the University of Minnesota forced conscientious objectors into a starvation study. Over a period of 24 weeks, participants, all young, healthy men, were severely starved, then refed, to study what would happen to them. What researchers found was an increased preoccupation with food, even after nutritional rehabilitation, and the development of disordered eating patterns such as self-imposed food restriction, hoarding food, and binge eating.

As a Jew, I want to feed them. I want to show up, uninvited, with enough aluminum foil trays of bagels, shakshuka, and roast chicken to last weeks, to arrange meal trains, and to never leave them unfed again. So much of Jewish tradition is held in food, especially when we face grief and mourning. That is how we care for each other. But in this moment, we have to fight against that instinct if we are to keep these particular Jews alive.

As a dietitian, I can look at these men and know that they will never be the same again, that the reminders of their starvation will likely linger long after they are refed, even if refeeding is done carefully and under expert supervision. Since we discovered refeeding syndrome after World War II, slow, steady refeeding and cautious observation of blood electrolyte levels is now standard practice to nutritionally rehabilitate malnourished people.

I was in Israel last month to feed hungry Jews and to support Jewish farms. It felt like the most Jewish way to help. But for these particular Jews, given what they have endured, my professional training tells me that their road to recovery will be long, and the impact of their 491 days captivity may last a lifetime.