HUNGER STRIKE

DR ABDUL BASITH ER RESIDENT CSH ALQASSIM

The world medical association (WMA) defines hunger strike as voluntary total fasting (taking only water ,possibly with salt,minerals or sugar added) lasting more than 72 hours by a mentally competent individual as a form of protest or demand.

Intentions and motivations ?

Determined
Some food refusers fast to gain publicity to achieve there goal but no intension of permanently damaging their health hunger strikers who are not prepared to back down unless they have achieved their goal.

"Iron Lady of Manipur" or "Mengoubi"

Irom Sharmila Chanu

Irom Sharmila CIrom Sharmila Chanu hanu Having refused food and water for more than 500 weeks, she has been called "the world's longest hunger striker

Pathophysiology of fasting

Metabolically, early fasting is characterized by a high rate of gluconeogenesis with amino acids as the primary substrates. As fasting continues, progressive ketosis develops due to the mobilization and oxidation of fatty acids. As ketone levels rise they replace glucose as the primary energy source in the central nervous system, thereby decreasing the need for gluconeogenesis and sparing protein catabolism. Several hormonal changes occur during fasting, including a fall in insulin and T3 levels and a rise in glucagon and reverse T3 levels Early in fasting weight loss is rapid, averaging 0.9 kg per day during the first week and slowing to 0.3 kg per day by the third week; early rapid weight loss is primarily due to negative sodium balance.

Elements to be considered in patients of suspect of hunger strike (maximum of 24 hrs after hunger strike announcement)
Exculde (if present ,patient should not be considered as hunger strike) 1. Somatic disease : GI diseses eg:- dyspepsia 2. Psychiatric illness : anorexia,depression,psychotic disorder,personality disorder.

3. Modalities of fasting:
Absolute (no food and liquid intake) Total (only water and abstention from all food stuff) Partial (only some nutrients are not taken)

 Assess/discuss
Complete physical examination Psychiatic disorders (depression,delusions,paranoid disorders) Psychiatri st follow up Remind the need of fluid intake (fasting thirst sensation )

o Laboratory testing (once a week from 3rd week)

CBC,RBS,Ketonuria, Na,K,urea,creatinine,HCO3,

P,Mg,Ca,Uric acid
Creatinine kinase( if myalgia),albumin Thiaminaemia (if refusal of supplement) Transaminases (if liver disorder) Electrocardiogram

Indications of hospitalisation
Weight loss >10%
BMI <16.5-18kg/m2 Co-morbidities ( eg: diabetes mellitus)

Absolute fasting
Severe bradycardia (<35/min or irregular pulse) Severe hypothermia ( temp <35.5c)

Neurological signs
Significant renal or electrolyte disorders (related to fasting) To facilitate the resolution of the conflict

To initiate re-feeding (if fasting >2weeks)

Treatment of hunger strike

Fluid intake (1.5-2litre/day) Minerals:1.5g/day Supplementation in cases of electrolyte disturbances ( K,Ca,Mg) Nacl infusion if no longer able to drink Vitamin B1 /multivitamin supplement Thrombosis prevention if prolonged bed rest

Thanks for listening. Now go eat something.