An investigation into equations for estimating water requirements and the development of new equations for predicting total water intake

The primary purpose of this study was to investigate agreement among five equations by which clinicians estimate water requirements (EWR) and to determine how well these equations predict total water intake (TWI). The Institute of Medicine has used TWI as a measure of water requirements. A secondary goal of this study was to develop practical equations to predict TWI. These equations could then be considered accurate predictors of an individual’s water requirement. ^ Regressions were performed to determine agreement between the five equations and between the five equations and TWI using NHANES 1999–2004. The criteria for agreement was (1) strong correlation coefficients between all comparisons and (2) regression line that was not significantly different when compared to the line of equality (x=y) i.e., the 95% CI of the slope and intercept must include one and zero, respectively. Correlations were performed to determine association between fat-free mass (FFM) and TWI. Clinically significant variables were selected to build equations for predicting TWI. All analyses were performed with SAS software and were weighted to account for the complex survey design and for oversampling. ^ Results showed that the five EWR equations were strongly correlated but did not agree with each other. Further, the EWR equations were all weakly associated to TWI and lacked agreement with TWI. The strongest agreement between the NRC equation and TWI explained only 8.1% of the variability of TWI. Fat-free mass was positively correlated to TWI. Two models were created to predict TWI. Both models included the variables, race/ethnicity, kcals, age, and height, but one model also included FFM and gender. The other model included BMI and osmolality. Neither model accounted for more than 28% of the variability of TWI. These results provide evidence that estimates of water requirements would vary depending upon which EWR equation was selected by the clinician. None of the existing EWR equations predicted TWI, nor could a prediction equation be created which explained a satisfactory amount of variance in TWI. A good estimate of water requirements may not be predicted by TWI. Future research should focus on using more valid measures to predict water requirements.^

Stressors, mediators, and health care outcomes of home enteral nutrition in family caregivers and their older adult care recipients

Family caregivers manage home enteral nutrition (HEN) for over 77% of an estimated 1 of every 400 Medicare recipients. Increasing usage of HEN in older adults combined with reliance on family caregivers raises concerns for the quality, outcomes, and costs of care. These concerns are relevant in light of Medicare limitations on nursing assistance and non-reimbursement for nutrition services, despite annual costs of over $600 million. This study applied stress process theories to assess stressor, mediator, and outcome variables salient to HEN and caregiving. In-home structured interviews occurred with a multi-ethnic sample of 30 caregiving dyads at 1–3 months after discharge on HEN. Care recipients were aged ≥60 (M = 68.4 years) and did not have dementia. Caregivers were aged ≥21, unpaid, and lived within 45 minutes of care recipients. Caregivers performed an average of 19.7 tasks daily for 61.9 hours weekly. Training needs were identified for 33 functional, care management, technical, and nutritional tasks. Preparedness scores were low (M = 1.73/4.0), and positively correlated with competence, self-rated quality of care and positive feelings, and negatively with overload, role captivity, and negative feelings (Ps < .05). Caregivers had multiple changes in lifestyle and dietary behaviors. Lifestyle changes positively correlated with overload, and negatively with preparedness and positive feelings. Dietary changes positively correlated with number of tasks, overload, role captivity and negative feelings, and negatively with preparedness (Ps < .01). Fifty-seven percent of caregivers aged >50 were at nutrition risk. Care recipients fared worse. Average weight change was −4.35 pounds (P < .001). Physical complications interrupted daily enteral infusions. Water intake was half of fluid need and associated with signs of dehydration (P < .001). Physical and social function was poor, with older subjects more impaired ( P < .04). Those with better prepared or less overloaded caregivers had higher functionality and QOL (P < .002). Complications, type of feeding tube, and caregiver preparedness correlated with frequency of health care utilization (Ps < .05). Efficacy of HEN in older adults requires specialized caregiver training, attention to caregivers' needs, and frequent monitoring from a highly skilled multidisciplinary team including dietitians. ^