FLUID REPLACEMENT AND HEAT STRESS

Committee on Military Nutrition Research

Food and Nutrition Board

Institute of Medicine

Bernadette M. Marriott, Editor

Third Printing

NATIONAL ACADEMY PRESS
Washington, D.C.1994



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FLUID REPLACEMENT AND HEAT STRESS FLUID REPLACEMENT AND HEAT STRESS Committee on Military Nutrition Research Food and Nutrition Board Institute of Medicine Bernadette M. Marriott, Editor Third Printing NATIONAL ACADEMY PRESS Washington, D.C.1994

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FLUID REPLACEMENT AND HEAT STRESS National Academy Press • 2101 Constitution Avenue, N.W. • Washington, D.C.20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. Chapter 1 of this report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was established in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This report was produced under grants DAMD17-86-G-6036/R and DAMD17-92-J-2003 between the National Academy of Sciences and the U.S. Army Medical Research and Development Command. The views, opinions, and/or findings contained in chapter 2, chapter 3, chapter 4, chapter 5, chapter 6, chapter 7, chapter 8, chapter 9, chapter 10, chapter 11, chapter 12, chapter 13, chapter 14, chapter 15 through chapter 16 that are authored by U.S. Army personnel are those of the authors and should not be construed as official Department of the Army positions, policies, or decisions, unless so designated by other official documentation. Human subjects who participated in studies described in those chapters gave their free and informed voluntary consent. Investigators adhered to U.S. Army regulation 70-25 and United States Army Medical Research and Development Command regulation 70-25 on use of volunteers in research. Citations of commercial organizations and trade names in this report do not constitute an official Department of the Army endorsement or approval of the products or services of these organizations. Chapter 2, Chapter 3, Chapter 4, Chapter 5, Chapter 6, Chapter 7, Chapter 8, Chapter 9, Chapter 10, Chapter 11, Chapter 12, Chapter 13, Chapter 14, Chapter 15 through Chapter 16 are approved for public release; distribution is unlimited. Library of Congress Catalog Card Number 93-87411 Additional copies of this report are available from: Food and Nutrition Board Institute of Medicine 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Copyright 1994 by the National Academy of Sciences, third printing. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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FLUID REPLACEMENT AND HEAT STRESS COMMITTEE ON MILITARY NUTRITION RESEARCH (at the time of the first printing) ROBERT O. NESHEIM (Chairman), Advanced Health Care, Inc., Monterey, California RICHARD L. ATKINSON, VA Medical Center, Hampton, Virginia ANDRE BENSADOUN, Division of Nutrition Science, Cornell University, Ithaca, New York WILLIAM J. EVANS, USDA Human Nutrition Center on Aging, Tufts University, Boston, Massachusett JOEL A. GRINKER, School of Public Health, University of Michigan, Ann Arbor, Michigan EDWARD S. HORTON, Department of Medicine, University of Vermont, Burlington, Vermont G. RICHARD JANSEN, Department of Food Science and Human Nutrition, Colorado State University, Fort Collins, Colorado JANET C. KING, Department of Nutrition Science, University of California, Berkeley, California JOHN E. KINSELLA, Department of Food Science, Cornell University, Ithaca, New York GILBERT A. LEVEILLE, Nabisco Brands Inc., RMS Technology Center, East Hanover, New Jersey JOHN E. VANDERVEEN, Food and Drug Administration, Washington, D.C. Staff SUSAN E. BERKOW, Program Officer through 1989 BERNADETTE M. MARRIOTT, Program Officer beginning April 1990 ELSIE STURGIS, Senior Secretary, through March 1990 NANCY J. FOX, Interim Senior Secretary beginning April 1990

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FLUID REPLACEMENT AND HEAT STRESS COMMITTEE ON MILITARY NUTRITION RESEARCH (current) ROBERT O. NESHEIM (Chair), Monterey, California RICHARD L. ATKINSON, Department of Internal Medicine, Veterans Affairs Medical Center, Hampton, Virginia WILLIAM R. BEISEL, Department of Immunology and Infectious Diseases, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland JOEL A. GRINKER, Program in Human Nutrition, School of Public Health, University of Michigan, Ann Arbor EDWARD S. HORTON, Department of Medicine, University of Vermont, College of Medicine, Burlington G. RICHARD JANSEN, Department of Food Science and Human utrition, Colorado State University, Fort Collins GILBERT A. LEVEILLE, Nabisco Brands Incorporated, East Hanover, New Jersey JOHN A. MILNER, Department of Nutrition, Pennsylvania State University, State College JAMES G. PENLAND, U.S. Department of Agriculture Research Service, Grand Forks Human Nutrition Research Center, Grand Forks, North Dakota JOHN E. VANDERVEEN, Division of Nutrition, Food and Drug Administration, Washington, D.C. ALLISON A. YATES, College of Health and Human Sciences, University of Southern Mississippi, Hattiesburg Food and Nutrition Board Liaison JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital, Boston, Massachusetts Committee on Military Nutrition Research U.S. Army Grant Officer Representative COL. ELDON W. ASKEW, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts Staff BERNADETTE M. MARRIOTT, Program Director VALERIE McCADDON BREEN, Research Assistant DONNA F. ALLEN, Project Assistant

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FLUID REPLACEMENT AND HEAT STRESS FOOD AND NUTRITION BOARD (at the time of the first printing) RICHARD J. HAVEL, (Chairman), Cardiovascular Research Institute, University of California School of Medicine, San Francisco, California DONALD B. McCORMICK, (Vice Chairman), Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia EDWIN L. BIERMAN, Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, Washington EDWARD J. CALABRESE, Environmental Health Program, Division of Public Health, University of Massachusetts, Amherst, Massachusetts DORIS H. CALLOWAY, Department of Nutritional Sciences, University of California, Berkeley, California DEWITT GOODMAN, Institute of Human Nutrition, Columbia University, New York, New York M. R. C. GREENWOOD, Department of Nutrition, University of California, Davis, California JOAN D. GUSSOW, Department of Nutrition Education, Teachers College, Columbia University, New York, New York JOHN E. KINSELLA, Department of Food Science, Cornell University, Ithaca, New York LAURENCE N. KOLONEL, Cancer Center of Hawaii, University of Hawaii, Honolulu, Hawaii REYNALDO MARTORELL, Food Research Institute, Stanford University, Stanford, California WALTER MERTZ, Human Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, Beltsville, Maryland MALDEN C. NESHEIM, Planning and Budgeting, Cornell University, Ithaca, New York JOHN LISTON, Ex Officio, Division of Food Science, College of Ocean and Fishery Sciences, University of Washington ARNO G. MOTULSKY, Ex Officio, Center for Inherited Diseases, University of Washington, Seattle, Washington ROY M. PITKIN, Ex Officio, Department of Obstetrics and Gynecology, School of Medicine, University of California, Los Angeles, California Institute of Medicine, Food and Nutrition Board Staff SUSHMA PALMER, Director (through August 1989) CATHERINE E. WOTEKI, Director (from April 1990) FRANCES PETER, Deputy Director (through October 1990)

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FLUID REPLACEMENT AND HEAT STRESS FOOD AND NUTRITION BOARD (current) M.R.C. GREENWOOD (Chair), Office of Graduate Studies, University of California, Davis (through November 1993) EDWIN L. BIERMAN, M.D. (Vice Chair), University of Washington School of Medicine, Seattle PERRY L. ADKISSON, Department of Entomology, Texas A&M University, College Station LINDSAY H. ALLEN, Department of Nutrition, University of California, Davis DENNIS M. BIER, Children's Nutrition Research Center, Houston, Texas HECTOR F. DeLUCA, Department of Biochemistry, University of Wisconsin-Madison, Madison MICHAEL P. DOYLE, Department of Food Science and Technology, University of Georgia, Griffin JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital, Boston, Massachusetts JOHN W. ERDMAN, Jr., Division of Nutritional Sciences, University of Illinois, Urbana CUTBERTO GARZA, Division of Nutritional Sciences, Cornell University, Ithaca, New York K. MICHAEL HAMBIDGE, Department of Pediatrics, University of Colorado Medical Center, Denver JANET C. KING, Department of Nutritional Sciences, University of California, Berkeley LAURENCE N. KOLONEL, University of Hawaii, Honolulu SANFORD MILLER, Graduate School of Biomedical Sciences, University of Texas, San Antonio ALFRED SOMMER, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland VERNON R. YOUNG, School of Science, Massachusetts Institute of Technology, Cambridge STEVE L. TAYLOR (Ex Officio), Department of Food Science and Technology, University of Nebraska, Lincoln ARTHUR H. RUBENSTEIN (IOM Liaison), Department of Medicine, University of Chicago, Chicago Staff CATHERINE E. WOTEKI, Director MARCIA S. LEWIS, Administrative Assistant SUSAN M. WYATT, Financial Associate

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FLUID REPLACEMENT AND HEAT STRESS Preface This publication is the third printing of the proceedings of a workshop held in February 1989, on the subject of fluid replacement and military performance. This workshop was organized at the request of the U.S. Army Medical Research and Development Command to explore the question of the potential utility of fluid replacement, including carbohydrate-electrolyte beverages, in enhancing sustained military performance in military operations. Through the Army project officer and the Division of Military Nutrition, U.S. Army Institute of Environmental Medicine (USARIEM), the committee was specifically asked to address twelve questions. Under what conditions, if any, does fluid replacement as water or a fluid replacement product containing electrolytes and a source of carbohydrate enhance performance or endurance with respect to participation in likely military activities? If a fluid replacement beverage is recommended, what is its appropriate composition and how would the composition vary under different military activities and environmental conditions? Under what circumstances is glycogen depletion regarded as a problem, and what types of carbohydrate-containing beverages might be provided to ameliorate such problems? Are there special problems related to maintenance of glycogen stores? If electrolyte-carbohydrate-containing solutions or fluids are recommended, what is appropriate timing for provision of the solutions with

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FLUID REPLACEMENT AND HEAT STRESS respect to performance of the military task or recovery following performance of the task? What are the rates of gastric emptying, intestinal absorption, and the body's utilization of the components of the solution? What are the important considerations in the preparation of hygienic and palatable solutions with respect to safety, quality, and acceptance? What considerations are important for treatment of diarrheal disease and heat casualties? What replacement regimens are regarded as most appropriate for ensuring field duty following minor heat injuries? What important behavioral aspects should be considered relative to thirst, voluntary hypohydration, work-rest cycles, and other factors? Military missions must be performed under different environmental conditions--how do these environmental conditions influence body fluid replacement? Are there specific effects (e.g., hormonal) related to age or gender that should be considered in the use of replacement solutions? What are the major unanswered questions regarding sound replacement beverage practices for the military? The first chapter of the report is an Executive Summary followed by the conclusions and recommendations formulated by the Committee on Military Nutrition Research based on the papers presented at the workshop and on committee members' knowledge and experience. The conclusions and recommendations were developed in executive session of the committee and opinions expressed are those of the committee members and not necessarily those of the authors of the papers. The papers presented at a workshop held in February 1989 make up Part II of the volume. After oral presentation at the workshop, the papers were reviewed by a group of experts other than those on the committee, and authors have been given an opportunity to alter their papers or not in response to reviewers' comments. However, the papers represent the personal opinion of the authors and do not necessarily reflect the committee's views. Prior to the Second Printing in April, 1991, the authors were given the opportunity to review the printed document for typographical errors, spelling and punctuation. Minor changes of this nature were made by the committee staff prior to printing. The third printing is in response to continuing demand for copies of the report and has been reformatted in the book style of the more recent reports of the CMNR providing a uniform filing and shelving option for the publications. The interest in this report is a tribute to the excellence of the

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FLUID REPLACEMENT AND HEAT STRESS contributions of the participants in the workshop and the conclusions and recommendations developed by the Committee on Military Nutrition Research. As chairman of the CMNR, I wish to thank all who participated in the workshop and to recognize in particular E.R. Buskirk and Edward S. Horton who helped organize and co-chaired this workshop. Their assistance was invaluable in providing information and insights into the questions posed by the Army. The contributions of former committee members Alan L. Forbes and Daniel Rudman to the program of the Committee on Military Nutrition Research leading up to this workshop are appreciated. The committee is grateful to the anonymous reviewers of this report for their important contribution. The committee also wishes to acknowledge the assistance of its former staff, Susan Berkow and Elsie Sturgis, who helped make the workshop a success through their skilled and expert work. Also, I recognize on behalf of the members of the CMNR the contribution of Bernadette Marriott, Deputy Director of the Food and Nutrition Board and staff person to the CMNR for working through the editorial revision of the second printing in 1991 and the reformatting of the report in this the third printing. The committee is grateful to Donna F. Allen for her care and precision in assisting with all stages in the development of this third version. I also express my appreciation to all of the members of the CMNR--past and present who have conscientiously contributed their expertise in the development of recommendations in response to issues raised by the Army. Robert Nesheim, Chairman Committee on Military Nutrition Research

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FLUID REPLACEMENT AND HEAT STRESS Contents     PREFACE   vii  I   EXECUTIVE SUMMARY   1     1  Committee Summary and Recommendations   3  II   INVITED PAPERS   9     2  Use of Electrolytes in Fluid Replacement Solutions: What Have We Learned from Intestinal Absorption Studies? Carl V. Gisolfi   11     3  Formulation of Carbohydrate-Electrolyte Beverages David R. Lamb   23     4  Considerations for Replacement Beverages: Fluid-Electrolyte Balance and Heat Illness Lawrence E. Armstrong   37     5  Carbohydrate Supplements During and Immediately Post Exercise John L. Ivy   55     6  Gastric Emptying During Exercise: Influence of Carbohydrate Concentration, Carbohydrate Source, and Exercise Intensity Carl Foster   69     7  Interaction of Water Bioavailability, Thermoregulation, and Exercise Performance Michael N. Sawka and P. Darrell Neufer   85     8  Timing of Carbohydrate Supplementation During Prolonged Strenuous Exercise Edward F. Coyle and Andrew R. Coggan   99     9  Acute Diarrheal Diseases Robert Whang   111     10  Potassium Deficiency as The Result of Training in Hot Weather James P. Knochel   117

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FLUID REPLACEMENT AND HEAT STRESS     11  Shift in Body Fluid Compartments After Dehydration in Humans Hiroshi Nose, Gary W. Mack, Xiangrong Shi, and Ethan R. Nadel   127     12  Role of Osmolality and Plasma Volume During Rehydration in Humans Hiroshi Nose, Gary W. Mack, Xiangrong Shi,and Ethan R. Nadel   143     13  Palatability and Fluid Intake Barbara J. Rolls   161     14  Solute Model or Cellular Energy Model? Practical and Theoretical Aspects of Thirst During Exercise Roger W. Hubbard, Patricia C. Szlyk and Lawrence E. Armstrong   169     15  Environmental Issues That Influence Intake of Replacement Beverages John E. Greenleaf   195     16  Changes in Plasma Volume During Heat Exposure in Young and Older Men Suzanne M. Fortney and Elizabeth Miescher   215     INDEX   229