 Celebrating National Nutrition Month Estimating Fluid Needs for Obese Patients
Water is the single largest constituent of the human body and is essential for homeostasis and life. Fluid intake is important to health and is considered a critical component of nutrition assessment. As the population in the United States becomes more obese, many dietitians are questioning how to estimate fluid needs in an obese patient. When assessing fluid needs, is it necessary to adjust the IBW for a patient who is classified as obese (BMI>30)? An on-line attempt at a literature review indicates there are virtually no published studies on this topic. However, published nutrition assessment guides currently available indicate that the actual body weight should be used for fluid estimates, not adjusted body weight. As with other nutrition assessment tools, calculation of fluid needs should be used in conjunction with assessment of fluid intake and signs and symptoms for dehydration. The clinical practitioner should use his/her clinical skills to judge if fluid provided is adequate. There is, however, increasing evidence for a relationship between obesity and underhydration. Individuals with an osmolality of 800 or more were considered underhydrated. Inadequately hydrated patients weighted more than adequately hydrated patients. This 2016 research suggests calculating 40-50 ml/kg/day in a healthy population. Formulas that are recommended for fluid estimates (assuming normal renal and cardiac function) include:
Implications for Dietetics PractitionersDietetics practitioners should use actual body weight when calculating fluid needs for obese patients. There are several formulas available for estimating fluid needs; the practitioner should select the method that they are comfortable using. This method should be indicated on the nutrition assessment form so the results can be justified if necessary. Nutrition AssessmentIn nutrition assessment and progress notes, document that fluid needs are estimated and/or provide a range of estimated fluid needs (such as 25-30 cc/kg body weight). Adequate fluids should be made available, preferably in a calorie-free form that will not contribute to excess weight gain in an obese patient. Practitioners can allow for the fact that up to 19% of fluids are provided by foods and the body’s metabolic processes (Dietary Reference Intakes), or up to 700 cc/day (Kobriger) by documenting that the fluids available in foods contribute to the overall fluids available to the patient. Monitoring Hydration StatusHydration status can be monitored by assessing food and beverage intake and urinary output (when available). Abnormal laboratory values such as serum osmolality and electrolytes should be addressed as needed. The patient should be monitored for signs and symptoms of dehydration, including weight loss, poor skin turgor, decreased or concentrated urine, dry skin and mouth, sunken eyes, and decreased functional ability. If dehydration is noted in obese patients, fluids provided should be increased and this should be documented in the patient’s progress notes. References: AND Nutrition Care Manual. Available to subscribers at www.nutritioncaremanual.org. Brummit, P. Dietary Documentation Pocket Guide. Developed as a Joint Project by the Consultant Dietitians in Health Care Facilities DPG and the Dietary Managers Association, 2002. Kobriger, AM. Hydration: Maintenance: Dehydration, Laboratory Values, and Clinical Alterations. Chilton, WI: Kobriger Presents, Inc., 2005. National Academy of Science. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and Sulfate. 2004. Available at http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=4&tax_subject=256&topic_id=1342&level3_id=5141&level4_id=10592. https://pmc.ncbi.nlm.nih.gov/articles/PMC4940461/ Advertisement
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 Weight Plateaus are frightful, bothersome states of metabolic stagnation that occur smack dab in the middle of a successful weight loss plan. Even if expected, plateaus can cause discouragement, feelings of failure, and a desire to “give up.”
No, no need to give up. Let’s look at some game changers for those plateaus. At the bottom of this physiological storm is that of survival. In a plateau, the body is fighting to stay alive, lowering its metabolism to match the calories given to it. Yes, it defeats the purpose but the body is just trying to save its own life by this metabolic shift. The question(s) then become the following:
Plateau Interventions, What Should be in Your Toolbox???? Meal Plan Manipulations Keep the Food/Symptom Diary again if you are not still doing it. Sometimes, as the same old regimen is repeated, boredom slips in. Calories begin to creep back in, portion sizes aren’t watched like they used to be. Go back to the basics: weigh, measure and revisit portion sizes and food choices. Intermittent-Fasting Routine: For this plateau buster, the weight loss is facilitated by moving calories. For 2-3 days either a very low calorie diet (800 calories) or a fast can be chosen to throw the body’s expectations off. Do this for two days then go back on your meal plan for 3 days and then fast or follow a very low calorie diet on an every- other- day basis. There are various renditions of this manipulation. Now, hunger is still a problem with this type of plan unless your fasting days take you into ketosis. Not appropriate for diabetes. Fasting is associated with increased ghrelin and decreased obestatin in the blood circulation. Specifically these naughty hormones are ghrelin and obestatin. Both hormones play intricate roles in playing with our regulation of diet induced thermogenesis. Alternatively, one can increase calories while at the same time kicking up exercise intensity to 70-75% Maximum Heart Rate for one to two days and then drop down to 800 calories and then return to caloric weight loss plan. The idea is to fool your body’s metabolism to break the cycle. Calorie-Restricted Adequate Nutrition (CRAN): This meal plan, originally developed in life- extension research, was found to be effective at keeping the body lean and mean, but it is not practical to live on such small amounts of food with supplementation for extended periods of time. These human studies continue, but now the rage is to look for CRAN mimetics that make life more livable. However, short term use can blast a hole in a plateau! Macronutrient Manipulation: Take your meal plan and flip flop it. For example, low carbohydrate high protein for one month may be different than the high fiber low fat meal plan you may have been following. Some meals will be turned from a meat based to a vegetarian based or from a regular carbohydrate diet to a low glycemic carbohydrate, high protein diet. Again, your body is fooled for a bit. Then, don’t forget the little plateau “busters”: a) drink 8 oz. glass of water or sugar free beverage prior to a meal; b) achieve adequate hydration, but not too much – 1 ml per kcal or 8 glasses per day and consume high water foods such as melons, hot cereals; c) keep your sodium to the recommended level of 2,300 mg. sodium/day or higher if exercise requires it. Exercise and Lifestyle Change Your Workout Routine: Keep your metabolism guessing! Here are some guidelines creating new work-outs for your toolbox. Have fun with the following ideas! Redesign your old work -out program by changing one or more variables – frequency, intensity, duration. FREQUENCY: Change the number of times you do a work out per week. DURATION: Change the length of time you do a specific workout. INTENSITY: Increase your target heart rate for 20 minutes of the cardio portion of the routine. Use Video exercise programs to increase compliance. Try to get fresh air and walk daily! Remember to adjust your fluid and meal intake to the type of sports you are in – professional athlete vs. weekend warrior. Get in touch with your hunger signals again and what that feeling is like. Plan ahead for parties and social events. Thermogenic Aides or Where's The Pill? A pill is not our long-term answer. Short-term like in Breaking a Plateau, it is reasonable. And, our top contenders for Thermogenic Aides are: Green Tea: This herb has been used medicinally for a very long time. Studies have shown that green tea can help reduce obesity when consumed on a daily basis. I seems to work by increasing metabolism after eating. Green tea may also reduce appetite, fat absorption, and storage. To break a plateau, drink 6 0z of caffeinated green tea 3x per day until weight loss is established again. The chemicals responsible for green tea's effect on weight are primarily ECGC, catechins , and polyphenols. Green Tea should be respected as a known adjunct to reducing BMI, body weight, and body fat, reducing overall fat cell generation, decreased fat absorption, and suppressed appetite. Hot, Spicy Foods: Incorporate the use of hot chili peppers and turmeric in meals. These spices cause a slight sweating reaction and a greater response to the food, thus elevating thermogenesis. Resveratrol: Resveratrol has been on the market for many years and has been used medicinally for generations. Controversial human trials continue, but studies have shown that 150 mg of trans-resveratrol will cause weight loss in obese but not normal weight humans. Vitamin D/Calcium: Approximately 90% of our world’s population is deficient in vitamin D. Vitamin D is actually a hormone, and recent reports suggest that our rise in obesity is related, in part, to our lack of Vitamin D and calcium. Bitter Orange, p-Synephrine, Caffeine, Kola Nut: These nutrients/foods- all thermogenic teas-can be used alone or in combination to break the plateau. While controversy exists regarding the use of these products, used judiciously they are safer than weight loss drugs in general and pose few side effects when used as indicated. Vitamin C: Vitamin C is inversely related to body mass. Individuals replete vitamin C and oxidize 30% more fat during moderate exercise than those who are depleted. The dosage should be approximately 100 mg by food (preferably) or supplement. If you smoke, add 35 mg daily to this value. Transformation of our Mindset
In taking an Integrative and Functional Medicine Approach, we must look at our toolbox holistically. Approaching problems from many angles means utilizing the most neglected tools to meet our goals at all levels of the problem. Sources Al-salafi R, Irshad M, Abdulghani. Does green tea help to fight against obesity? An overview of the epidemiological reports. Austin Journal of Clinical Medicine. April, 2014. http://www.researchgate.net/profile/Md_Irshad2/publication/262201112_Does_Green_Tea_Help_to_Fight_against_Obesity_An_Overview_of_the_Epidemiological_Reports/links/54367faa0cf2dc341db352c7.pdf. Accessed 5/21/15. Bradford PG. Curcumin and obesity. Biofactors. 2013; 39 (1):78-87. http://onlinelibrary.wiley.com/enhanced/doi/10.1002/biof.1074 . Accessed 5/22/15. Johnstone A. Fasting for weight loss: an effective strategy or latest dieting trend? International Journal of Obesity. http://www.nature.com/ijo/journal/v39/n5/full/ijo2014214a.html Accessed 5/21/15. Lin L, Lee JH, Bongmba OYN . . . The suppression of ghrelin signaling mitigates age-associated thermogenic impairment. 2014. Aging.6 (12):1019 http://www.impactaging.com/papers/v6/n12/pdf/100706.pdf Assessed 5/21/15. Muceherjee A, Mukherjee S, Biswas J. Phytochemicals in obesity control. International Journal of Current Microbiology and Applied Sciences, 2015 4(4): 558-567 http://www.impactaging.com/papers/v6/n12/pdf/100706.pdf Accessed 5/22/15. Singh R. Significant improvement in obese, grade three male individual with nutrient dense low calorie, moderate to high protein diet. Advances in Obesity, Weight Management and Control2015. 2(2) http://medcraveonline.com/AOWMC/AOWMC-02-00013.pdf Accessed 5/22/15. Stohs SJ, Preuss HG, and Mohd Shara. A review of the human clinical studies involving citrus aurantium (Bitter Orange) Extract and its primary protoalkaloid p-synephrine. International Journal of Medical Sciences 9(7): 527-528. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444973/ Accessed 5/22/15. Timmers S, Konings E, Bilet L, . . .Calorie restriction-like effects of 30 days of resveratrol supplementation on energy metabolism and metabolic profile in obese humans. Cell Metabolism. 14:612-622 http://www.sciencedirect.com/science/article/pii/S155041311100386X Accessed 5/21/15. Wang S, Moustaid-Moussa NM, Chen L.. Novel insights of dietary polyphenols and obesity. J of Nutr Biochemistry. (25): 1 http://www.sciencedirect.com/science/article/pii/S0955286313001617 Accessed 5/21/15. Adapted from the Weight-Loss Program, “Synergetics,” by Kathryn J. Shattler, M.S., RDN  The blame for the obesity epidemic has been placed on everything from genetics to poor eating . . . but is there a darker, unspoken human need that remains unfulfilled and often even unknown even to oneself? Let’s start this part of our transformative inquiry by being honest with ourselves, confronting the sabotages, finding ourselves, and then not losing that person again.
Unmet emotional (and spiritual) longings are recurrently filled by food, yet the longing and emptiness remain. Our mind, in its ultimate judgment, feels empty, lonely, starved for affection or belonging recurrently and unconsciously, even telling our bodies to turn to food to gain some feeling of being “full.” Food eventually becomes a learned substitution for every need in our lives, including how to deal with stress, loss, grief, loneliness, and loss of faith. Stress alone comes with its own sad story of fat hormones and carbohydrate intolerance, which may lead to sleep issues. Lack of adequate sleep, in turn, contributes to “fatness.” Constantly, almost like a mouse on a wheel, we try and try but get nowhere. Miraculously, if goals are met, the weight is lost – think . . . just how permanent is it? Usually, not very. It is because the elephant in the room, our heart, our soul, is still in the room unattended, unfulfilled, and even unrecognized. Is it feasible to expect that with growing awareness of these other barriers to long-term weight-loss success, a separate treatment plan would blossom out of a need for permanent wellness success? Oh, Where to Begin to Find Such Secrets to Be Solved? Both the logical and exercise science points of view determine that obesity is caused by energy input being greater than energy output. Many people’s palates and brains are addicted to high salt, sugar, and fatty food, true. This notion is also consistent with science, but I believe other etiologies with more effective approaches are out there but underutilized, as just discussed. Humans are emotional creatures, and there is no denying basic instincts such as finding community, love, pleasure, and happiness. Unlike our land and sea mammals, which are driven biologically to reproduce and survive, humans have an expansive consciousness with the free will to choose how they want to live. The gift of choice without knowledge sometimes harms our overall balance and well-being. It can be argued that over the years, families have changed, giving birth to an entire generation with prominent negative health behaviors. If a child grows up eating fast food and drinking soda in replacement for water, the child will grow up into an adult who passes these behaviors and unhealthy ways of coping down to his/her family. Simply put, what science and psychology say about obesity is true, and an integrative approach to this problem must be taken globally. No longer can feelings, anger, stress, sexual dysfunctions in marriages or relationships/break-ups – no longer can they be ignored and swept under the rug. The underlying causes of obesity are driven by emotions, which then become akin to an addiction caused by the release of hormones and neurotransmitters in the body. Many food chemists, for example, design food to become addictive, which plays into the role of overeating. It’s a vicious cycle that takes time to retrain the body and brain. This is a huge job and one that is not being done in its entirety in any weight loss program today. Plan For Listening to the Inner Self, Your Emotions, Your Beliefs For many obese people, they have “lost” their power somewhere on their journey in life. Many keep giving their power away to their boss, spouse, children, friends, or anyone who needs their service. Those who have power but still struggle emotionally are stuck in belief systems that they can’t be or look a certain way. This, too, is linked subconsciously to being powerless. Many experience the domino effect. Sometimes it starts with one scenario that leads into other and more complex situations later in life. Many who have been verbally, physically, or sexually abused in the past are likely to fall into negative eating habits. Mostly, with women, there is either an underlying sense of shame or the need to be unattractive to men. I have found this with women who were sexually abused in their upbringing. In fact, they cover and hide any sense of beauty and love that can shine from their power center. People are obese for many reasons, but those who are not emotionally happy often seek fulfillment and validation through overeating. Those who “MUST eat their ice cream every day” have connected a certain food with a certain feeling. Why is this connection to a certain food that important? Questions like these must be asked and answered with a plan for emotional fulfillment without the use of food. A truly balanced person never has a biological urge to “need” a certain daily food for survival. The most important lesson is that power must be balanced. Those who have excess power often abuse their personal strength. Or they use their power to compensate for something else lacking in their life. Not everybody has emotional problems, but for many, the emotion is deeply buried and allows others to control our lives instead of ourselves. Even if a person is religious, he or she may not be spiritually fulfilled and in control of his or her life, choices, and emotions. Start by listening:
©Kathryn Shattler, Synergetics Weight Loss for Life Plan |
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