Hunger Strike Basic Guidelines

Considerations and Guidelines for Strikers and Support Team

I compiled this basic information to share with students, faculty, and staff who wish to participate in the Hunger Strike for Gaza and their support team. Please share specific health considerations carefully with your local medical support crew. I hope this education will lead to everyone making informed choices about their health and wellbeing, so they can engage in ways that are careful and considered.

Special Considerations:

• Hunger Strikes are most effective with coordination between Strikers and a support team who can advance strategy, coordinate tactics and ensure the safety and wellbeing of all participants.

• Everyone who participates in a Hunger Strike should have clearance from their therapist if they are actively or recently treated for anxiety, depression or eating disorder.

• People with any underlying medical condition should make their condition clear to the Hunger Strike support team and to the medical team. If it is deemed unsafe to participate, those teams will inform the participant. Diabetes and anorexia are absolute contraindications to participation.

• Each person on Hunger Strike needs one support person who is not on the strike who can liaise directly with the medical team and Hunger Strike support team. This person should report to the support team daily.

• After 5 to 7 days of Hunger Strike, the support people and strategy team should be making all key decisions and work to minimize friction and conflict between Hunger Strikers. People tend to become emotionally labile around this time and can wax and wane in their ability to participate in intense executive tasks.

• Everyone must fill out an informed consent/advance directive prior to participating in the Hunger Strike. It is important to clarify what you would want a medical team to do for you regarding refeeding and resuscitation, in case you become incapable of communicating your choices.

Effects of Starvation/Prolonged Fasting: Adaptive changes in metabolism which could lead to change in cellular function, depletion of specific electrolytes and micronutrients.

• Vitamin deficiency B1 → Wernicke-Korsakoff Syndrome

• Electrolyte imbalance (Ca, Mg, K, Phos) → Cardiac arrest

• Inadequate hydration → Kidney failure

• Ketone metabolism → Severe weight loss

• Decreased protein synthesis → Impaired wound healing and immunosuppression

Over two weeks of complete fasting (zero calories, but adequate water intake) can lead to lasting damage to musculoskeletal, renal, neurological and cardiovascular systems. These impacts show up in different people differently and this outline is a guideline for most common things we see, not an exact map of how each person will experience the effects of starvation.

A well-nourished and otherwise healthy person on a complete fast taking adequate fluids doing a complete fast (zero calories) can live 6 weeks, after which risk of death is higher. On a complete fast, however, even a healthy person who is well nourished will start to feel the impacts in 3 days. If a malnourished person becomes sick from another event (infection, for example), after three weeks of complete fasting, their risk of death from infection becomes much higher. An absolute fast (with no food and no liquids), the average survival is on the order of days.

In general the first week of a Hunger Strike is well tolerated by young well-nourished people with no underlying medical conditions. Hunger pangs and stomach spasms dissipate within a few days, blood sugar can drop but reestablishes equilibrium within a few days. In the second week, there is more emotional lability, low energy, headaches and some dizziness. After the second week, lethargy can become more pronounced. In general, at day 40 is where most young otherwise healthy and previously well-nourished people start to get seriously ill.

The phases of energy recruitment explain where the symptoms are felt as prolonged fasting continues.

→ Initial Phase: The first days of a Hunger Strike, the body mobilizes stored glucose from the liver, and blood glucose levels can drop but shortly regain equilibrium.

→ Ketosis Phase: After liver stores are depleted, the body enters ketosis and starts to mobilize energy from fats. The brain can use ketones as an alternate energy source to glucose. This phase lasts about one to several weeks, depending on reserves.

→ Starvation Phase: When fat stores are depleted, the body mobilizes muscle for energy.. This is a more severe phase and can be fatal if prolonged. Protein is mobilized from the heart, muscles around the eyes and around other critical organs, which can lead to irreversible changes and organ failure.

A well-nourished and otherwise healthy person on a complete fast taking adequate fluids doing a complete fast (zero calories) can live 6 weeks, after which risk of death is higher. On a complete fast, however, even a healthy person who is well nourished will start to feel the impacts in 3 days. If a malnourished person becomes sick from another event (infection, for example), after three weeks of complete fasting, their risk of death from infection becomes much higher. An absolute fast (with no food and no liquids), the average survival is on the order of days.

Key Management Strategies:

Fluid Intake 1.5-2L /day, make sure your urine is clear

Daily Weight and BMI calculation

Daily blood pressure, pulse, respiratory rate and oxygen saturation of respiratory rate is abnormal

Physical examination as indicated by symptoms

Thiamine at least 300mg daily, as 150mg twice a day. A recent case report showed that with prolonged fast of >200 days, oral thiamine may be insufficient and IV thiamine infusion may be necessary as prophylaxis.

Minerals: Ca 1000mg daily, Magnesium 400mg daily, Na 500mg daily, K 1000-3500mg daily. Additional electrolyte supplementation if derangements (start weekly labs at week 2 if no other medical issues)

Thrombosis prevention if prolonged bed rest.

Other specific needs: Iron and Vit D3 supplementation.

If a participant is under the care of a mental health specialist, they should inform their provider of participation and schedule regular visits (once or twice a week) during the Hunger Strike.

Indications for Hospitalization:

Weight loss >10% (can tolerate more if more reserves at beginning of fast)

BMI <16.5–18 kg/m2 (15 kg/m2)

Severe hypothermia (T <35.5 °C)

Neurologic signs (lethargy, seizures, double vision, limb paralysis)

Severe electrolyte disturbances or signs of kidney impairment

Severe bradycardia (heart rate <40) or irregular heartbeat

Begin refeeding protocol with close management (labs/hospitalization) if fasting >14 days or weight loss >10%. There is a risk of dangerously low levels of potassium, phosphate and magnesium, which could trigger neurologic and cardiovascular complications in patients with weight loss of >15%. Care must be managed to not reintroduce carbohydrates too quickly and thiamine must be continued throughout the refeeding process. For 1 week of Hunger Strke, convalescence is a matter of days. For 3 weeks of Hunger Strike, convalescence can take up to 2-3 months.

To Prepare for Hunger Strike

Gradually decrease caloric intake over the span of 3-5 days while maintaining hydration.

Eliminate all alcohol, caffeine and ultra-processed foods.

Engage in any practices that will offer grounding from a mental/emotional/spiritual and physical place. All of these aspects will be challenged in a Hunger Strike.

References and Further Reading

Chalela, Julio A., and J. Ivan Lopez. "Medical management of hunger strikers." Nutrition in Clinical Practice 28.1 (2013): 128-135.

Eichelberger, Markus, et al. "Management of patients during hunger strike and refeeding phase." Nutrition 30.11-12 (2014): 1372-1378.

Clinical care of hunger strikers. Lancet. 2008 Sep 6;372(9641):777. doi: 10.1016/S0140-6736(08)61313-6. PMID: 18774401.

Fessler, Daniel MT. "The implications of starvation induced psychological changes for the ethical treatment of hunger strikers." Journal of medical ethics 29.4 (2003): 243-247.

Irmak, Nurbay. "Professional ethics in extreme circumstances: responsibilities of attending physicians and healthcare providers in hunger strikes." Theoretical Medicine and Bioethics 36 (2015): 249-263.