The role of sugar in electrolyte solutions?

[ahimsa]

[Edit - When I say "sugar" I mean either glucose, fructose or sucrose (table sugar) ]

I found a web page that talks about oral rehydration therapy -- http://rehydrate.org/ors/ort-how-it-works.htm

I realize that this web page is describing therapy for people (mostly infants and children) who have dehydration due to diarrhea and vomiting (e.g., cholera). But I wonder if any part of the scientific discussion of rehydration therapy also applies to folks who have either dehydration or low blood volume and have some kind of Orthostatic Intolerance? (POTS, NMH/NCS)

Here's the part where it talks about the difference between plain saline vs. when glucose is added:

Simply giving a saline solution (water plus Na+) by mouth has no beneficial effect because the normal mechanism by which Na+ is absorbed by the healthy intestinal wall is impaired in the diarrhoeal state and if the Na+ is not absorbed neither can the water be absorbed. In fact, excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens.

If glucose (also called dextrose) is added to a saline solution a new mechanism comes into play. The glucose molecules are absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - and in conjunction sodium is carried through by a co-transport coupling mechanism. This occurs in a 1:1 ratio, one molecule of glucose co-transporting one sodium ion (Na+).
...
It should be noted that glucose does not co-transport water - rather it is the now increased relative concentration of Na+ across the intestinal wall which pulls water through after it.

So, is there anyone out there who understands this science and can tell whether this applies to our patient population? I'd love to know if this is why sometimes (not always!) solutions like pedialyte (or generic versions) seem to help me so much more than just water/salt/potassium, without any sugar.

My other thought is maybe sometimes I just need more potassium. One liter of pedialyte has 20 Meq potassium. My daily prescription of Klor-Con has half of that, 10 Meq.

Here's a much longer extract from the web page for those who want to read more:

In deciding the optimal composition of an oral rehydration solution the following considerations must apply:

1. Sodium - losses of sodium in the stool range from 50-60 meg/l to well over 100 meg/l in cholera and in fact total body depletion of sodium may be higher than stool losses alone indicate. For this reason a Na+ concentration of 90 meg/l is considered an optimal figure for replenishing Na+ in dehydration from diarrhoea caused by any etiology and in all age groups from neonates to adults.
   
   For some years there was controversy over optimum concentration of sodium in oral rehydration fluids, which stemmed from the fact that in the early days of its use, particularly in USA, causes of hypernatraemia (excess sodium) occurred fairly frequently in infants given oral rehydration therapy.
   
   The apparently obvious answer was to assume that the sodium concentration in the oral rehydration fluid used was too high and to reduce it (even to as low as 25 or 30 meg/l). Unfortunately, the apparently obvious was not the correct answer - actually nearly all these children were being given high- solute infant formula which tended to make them hypernatraemic to start with and the oral rehydration solution used then contained excess glucose - up to 8% - which was added to provide extra nutritive calories. Unfortunately, the excess glucose caused osmotic diarrhoea which precipitated acute hypernatraemia in these children.
   
   The less obvious but correct answer was to reduce the glucose content - not the sodium. We now recognize that the sodium and glucose should be in a 1:1 ratio in terms of molarity.
   
   Experience has now shown that even hypernatraemic neonates with dehydration can be successfully rehydrated and made normonatraemic using the standard WHO / UNICEF ORS formula (with 90 meg/l Na+) when the water intake is sufficient to ensure normal kidney function and hence physiological regulation of the sodium concentration in the plasma.
   Although ORS with a sodium content of around 50 meq/l is sufficient for maintenance of hydration of a normally will-nourished child with diarrhoea it would be inadequate for rehydration of a patient with a secretary diarrhoea (e.g., cholera) losing considerable sodium in the stool.
2. Glucose should be close to equivalent with the Na+ content - it is 111 mmol/l in the WHO / UNICEF formula, which happens to be exactly 2%. It should be noted that if glucose is present in excess of 3% it will cause further losses of water through osmotic effects, this would also upset the electrolyte balance, since increased water losses will result in hypernatraemia.
3. We have not yet given more than a passing mention to potassium. Although as we saw that 98% of the body's potassium is held within the cells, repeated diarrhoeal attacks over a period of time will cause a chronic loss of potassium. This results in muscular weakness, lethargy and anorexia. The typical distended abdomen of a chronically malnourished child is caused by loss of muscle tone in the abdominal wall largely due to chronic depletion of potassium. The kidneys are unable to conserve potassium as they do sodium, and there is a continuous obligatory loss of potassium of about 10 mmol daily in the urine, in addition to the larger losses in the stool.
   
   Potassium is not involved in any way in the sodium/glucose co-transport mechanism and is absorbed passively. Restoration of potassium levels is therefore achieved more slowly than sodium and water restoration. A potassium concentration of 20 mmol/l is considered optimal for the purpose.
   
   Simple mixtures of sugar , salt and water or starch, salt and water contain no potassium and cannot restore potassium depletion - hence these mixtures are an "incomplete" formula and further potassium supplementation is definitely necessary for a child who suffers repeated attacks of diarrhoea.
   
   A potassium-rich diet including, for example, bananas or coconut water can be helpful but an ORS solution containing potassium is therapeutically more effective. In order to produce a significant effect it is necessary to provide potassium-rich foods in reasonable large quantities over a period of time.
   
   Restoring a potassium deficit promotes a feeling of well-being and stimulates the appetite and activity of the child. If additional food is provided over several weeks an increase in weight gain will occur and the status of the child's health will improve markedly. Dietary intake is needed to achieve this.
4. Electrolyte imbalance and fluid loss also causes metabolic acidosis. These effects are more critical in the case of infants, as their renal function is not fully developed and they have a large surface area in ratio to body weight and a higher metabolic rate. Acidosis is corrected by the addition of bicarbonate (or another base such as citrate) to the ORS formula.

Thanks in advance to any scientist(s) out there who can understand this and can shed some light!

 

[ahimsa]

Here's a link to another page with a recipe for a "mix it yourself" rehydration drink:

http://www.webmd.com/hw-popup/rehydration-drinks?navbar=hw86827

Note that this one also includes sugar. I suppose "sugar" means table sugar (sucrose). It says don't give it to children under 12. I wonder why?

 

[Sea]

Thanks for those links Ahimsa, good information there. I've heard several times that the glucose is a necessary component for the electrolyte mix to be absorbed effectively but I haven't before heard a clear explanation of the process.

I'd say the warning in the second link against giving the home mix to children is either because they need a slightly different ratio or because they'd rather not have you take matters into your own hands with children. Dehydration in children can escalate rapidly into a critical life threatening state.

 

[adreno]

I don't see why this principle wouldn't apply to us? 2 tablespoons of sugar per liter is an awful lot of sugar though...

I have used 1/2 teaspoon sea salt, 1/4 teaspoon sugar, 1/4 teaspoon potassium, but this seems to be too little sugar. On the other hand, if we don't have diarrhea, I believe there must be some glucose present in the GI tract from the foods we eat, so the question is if it really necessary to provide so much in the drinks? Not sure about this.

 

[xchocoholic]

I think it's explained in this article ... tc ... x

http://forums.phoenixrising.me/inde...e-dehydration-malnutrition.12620/#post-214895

 

[ahimsa]

I think it's explained in this article ... tc ... x

http://forums.phoenixrising.me/inde...e-dehydration-malnutrition.12620/#post-214895

Thanks for the link! I tried to read that article but I kind of got lost trying to figure out how it applied to this situation of people with OI (POTS, NMH) who are trying to retain more fluid and which electrolyte drinks are the best choice in this situation.

For example, here's the study conclusion:

Our results indicate that the main routes for water and solute absorption are deficient in celiac disease and may play a role in the onset of malabsorption symptoms.

I think I get the main point here. People with celiac disease have serious problems with absorbing things in their intestines. I'm assuming that this includes sodium?

But what does this mean when it comes to folks with OI choosing electrolyte drinks either with sugar (either glucose, sucrose, or something else) or without sugar? Yes to sugar, in limited amounts, in electrolyte drinks? (e.g., the levels that the WHO uses -- or maybe even less -- NOT Gatorade levels) Or no to sugar? (meaning sugar is not relevant or helpful for us when it comes to absorbability of sodium and potassium )

Maybe the point of the link is that many (most?) folks here have undiagnosed celiac disease? (even those without any diarrhea or other intestinal symptoms?) So, no matter what type of food/drink we take we are not going to absorb sodium (and many other things) properly in the intestines? Or was there some other point being made that I missed?

I'm sorry if these are dumb questions but I don't understand. Thanks!!

 

[LaurelW]

What about people like me who don't tolerate table sugar at all? I've made a home-grown sports drink with sodium chloride, potassium chloride, lime juice and stevia. Seems to help with the OI.

 

[ahimsa]

... On the other hand, if we don't have diarrhea, I believe there must be some glucose present in the GI tract from the foods we eat, so the question is if it really necessary to provide so much in the drinks?

That makes sense...but I also have no idea whether it's true.

 

[ahimsa]

What about people like me who don't tolerate table sugar at all? I've made a home-grown sports drink with sodium chloride, potassium chloride, lime juice and stevia. Seems to help with the OI.

I used the word "sugar" in the title as a catchall category to include options like glucose, fructose or sucrose (table sugar). I didn't mean to use sugar to mean only sucrose.

For example, that first link I included talks about glucose, not sucrose. I know that a lot of the pre-mixed versions (e.g., Pedialyte) use glucose (often labelled as dextrose - it's just a different word for the same chemical formula, C6H12O6).

Most of the homemade recipes that I've seen use fruit juice of some kind. Your recipe has lime juice (I've also seen lemon and orange juice) and any of those options would provide some fructose. I just happened to post a second recipe that uses table sugar. I can't see why one could not substitute glucose or fructose.

Of course, the only reason to add sugar of any kind is if it would actually help with absorption of sodium. And that's what I'm trying to figure out. I'm just too dense to understand the science behind this.

I do think it's true that table sugar is harder to digest for most people than either glucose or fructose. Although one person posted that he/she could not digest glucose (dextrose). Although I wonder if maybe they were thinking of maltodextrin since the word sounds somewhat similar?

 

[xchocoholic]

http://www.ncbi.nlm.nih.gov/pubmed/20415666

CONCLUSIONS:

Our results indicate that the main routes for water and solute absorption are deficient in celiac disease and may play a role in the onset of malabsorption symptoms

I'm not sure if people actually have to have celiac disease to have this problem. This study is just specific for celiacs.

Later in that same PR thread I gave a link for there is another link about how the FDA is defining celiac disease now. Check out the first 8 pages of the FDAs info tho. A dx of celiac disease isn't as cut and dried now as it used to be. At least according to the FDA. There's been a lot of interest in this in the last few years so there's new info that many doctors won't know but our govt does.

I'm not sure if being dehydrated is just an OI thing. Maybe it's just common in chronic illness. For sure it's common for celiacs. There are many different auto immune illnesses associated with celiac disease. Maybe OI is auto immune for some of us.

It's late so I can't read anymore tonight. tc ... x

ps .. great info btw ...

 

[adreno]

Science to the rescue:

J Trop Med Hyg.1981 Oct;84(5):189-94.
Comparison of simple sugar/salt versus glucose/electrolyte oral rehydration solutions in infant diarrhoea.

Clements ML, Levine MM, Cleaves F, Hughes TP, Caceres M, Aleman E, Black RE, Rust J.
Abstract

In a randomized double-blind trial, infants with mild or moderate diarrhoeal dehydration were rehydrated orally either with a simple solution containing table sugar and salt (without potassium or bicarbonate) or with a complete glucose/electrolyte formula. All 32 given glucose/electrolyte solution and 27 (93%) of 29 infants given sugar/salt were successfully rehydrated with similar improvement in metabolic acidosis and rapidity of rehydration. The drawbacks to oral therapy with simple sugar/salt solution were the frequent development of hypokalaemia and greater volume of vomiting during treatment. Carefully prepared sugar/salt solution, if accompanied by adequate potassium supplementation, may be used as an alternative to the preferred glucose/electrolyte formula when the latter is unavailable.
PMID:7029004

 

[adreno]

Cent Afr J Med.1987 Aug;33(8):200-4.
Serum electrolytes in children admitted with diarrhoeal dehydration managed with simple salt sugar solution.

Nathoo KJ, Glyn-Jones R, Nhembe M.
Abstract

PIP:​

Diarrheal diseases constitute a major cause of childhood morbidity and mortality in Zimbabwe. Since 1982, it has been the policy in Zimbabwe to use home-based Salt Sugar Solution (SSS) as standard Oral Rehydration Solution (ORS) therapy for both prevention and management of dehydration. The recommended formula is incomplete, lacking both potassium and bicarbonate. It may not, therefore, be as efficacious as complete ORS for the prevention or correction of hypokalemia and acidosis during diarrhea. For this reason, a study was carried out at Harare Central Hospital to assess the type and prevalence of electrolyte abnormalities in dehydrated children who had previously been managed with oral salt sugar solution for acute gastroenteritis. 121 such referred patients had their serum urea and electrolytes estimated on admission prior to further management in the Unit; .38 (27.5%) cases of hypokalemia, 12 (8.9%) of hypernatremia, 52 (5.5%) of hypoatremia and 65 (45.7%) of severe acidosis (bicarbonate level 10 mmol/1) were documented. It is concluded that simple salt sugar solution is ideal for the prevention of dehydration but in cases of established dehydration the WHO complete formula is more appropriate for combating hypokalemia and severe metabolic acidosis.
PMID:3451801

 

[Dreambirdie]

What about people like me who don't tolerate table sugar at all? I've made a home-grown sports drink with sodium chloride, potassium chloride, lime juice and stevia. Seems to help with the OI.

Hi LaurelW--This is what I've been looking for. How do you make this drink, and what amounts of each ingredient do you use, and how do you store it?

Like you, I do not tolerate sugar. And I don't think it's necessary.

Thanks in advance for your info.

 

[LaurelW]

Somebody here on PR posted the link, I don't remember where now. The recipe is: 1 cup water, 1/8 tsp. sodium chloride, 1/8 tsp. potassium chloride, lime juice to taste, stevia to taste. I make a quart at a time, which is 1 qt. water, 1/2 tsp. of each of the salts. etc.
It was difficult to find plain old potassium chloride. Most of the "Lite" salts these days have a bunch of other crap in them. I ended up buying a pack of six on Amazon. It's called Morton Salt Substitute.

 

[adreno]

It was difficult to find plain old potassium chloride.

http://www.iherb.com/Now-Foods-Potassium-Chloride-Powder-8-oz-227-g/777

 

[Sparrow]

I believe that if your intestines are working well, you should absorb some salt without the glucose/dextrose (or table sugar, which has glucose in it). But with it, you will absorb more. So if you can tolerate some sugar, your drink should be more effective that way.

 

[Dreambirdie]

Thanks LaurelW and adreno Much appreciated.

 

[ahimsa]

I believe that if your intestines are working well, you should absorb some salt without the glucose/dextrose (or table sugar, which has glucose in it). But with it, you will absorb more. So if you can tolerate some sugar, your drink should be more effective that way.

Thanks, that makes sense.

Do you happen to know whether adding some lime juice (e.g., the recipe posted by LaurelW) would help the sodium absorption in the same way as glucose?

 

[Dreambirdie]

Do you happen to know whether adding some fructose (e.g., the lime juice in the recipe posted by LaurelW) would help the sodium absorption in the same way as glucose?

That's actually a good idea. Maybe a squirt from an orange or a Meyer lemon would be a good option?

 

[SOC]

All carbohydrates (fruits, vegetables, grains, sugars) are broken down to glucose, a simple sugar, in the digestive tract. That occurs mostly through the action of enzymes in the mouth and small intestines. Glucose is the small energy storage unit that can move through the intestinal walls and into the bloodstream where it is moved to where it is needed, The majority of our food is converted to glucose. If it wasn't, our bodies wouldn't be able to use it. (We also eat foods that contain fats and proteins which break down into fatty acids, glycerol, and amino acids, but that's not relevent to this discussion.)

If you are digesting any food that is not exclusively fat or protein, you have glucose in your intestines. Infants with diarrhea often are not digesting much of anything -- they are either vomiting it up or passing it through so fast nothing is getting absorbed.

An adult ME/CFS patient without absorption issues is almost certain to have glucose in his/her intestines from the digestion of fruits, vegetables, grains, etc. I don't see that it would be necessary to add the glucose to electrolyte mix for the purpose of improving OI/low blood volume. Dehydration due to vomiting and diarrhea is a different matter.