This question was asked with the intention of verifying that the stakeholder is not new to the job and has spent a significant amount of time with the subject and therefore can be considered an expert on the problem who can justify its validity.

"For almost eight years, I’ve been practicing."

• REFLECTION: The stakeholder is a veritable source on subjects concerning nutrition because she has actively been working as a nutritionist for a while, and hydration is a nutrition-related problem, so she can be considered an expert on it.

How much experience do you have in the area of hydration? 

To further qualify the stakeholder as an expert in the specific area of hydration, this question asked for the stakeholder’s experience with it so that their expertise and the validity of their comments could be supported by their experience.

"So, it is my opinion that all dieticians are experts in hydration no matter what their specialty is because, you know, we deal with the digestive system, and a huge part of digestion, absorption, and metabolism is your hydration status."

• REFLECTION: Hydration is an important part of many parts of life, especially with health, and dieticians, including the stakeholder, are all experts in hydration no matter what their specialty is because it is so important to every area of health.

"I specifically am board certified in obesity and weight management, so I work with people that are struggling with morbid obesity, and I work for the bariatric program at the hospital, which, if you don't know what bariatrics is, is like weight loss surgery, and in the case of weight loss surgery, especially for the first few weeks and into the first few months after surgery, it is very, very difficult for the patient to drink fluids. They have to take teeny tiny little sips at a time, so it poses a big issue and it's a huge concern, and pretty much all we focus on is making sure that the patient stays hydrated, so that is a huge part of my job and what I have been doing for the last eight years."

• REFLECTION: The stakeholder is certified in an area of health that has her working with the issue of hydration often, and many of her patients have problems with hydration for a variety of reasons, so this is a field in which the stakeholder is experienced.

Compared to other problems concerning health, how important is hydration?

Wanting to justify the importance of the problem in the area of hydration, this question was asked to get the stakeholder’s opinion on the importance of hydration in relation to other problems concerning health.

"It is extremely important and essential to our survival. We can go up to three weeks without food, but we can only survive up to three days without water and being adequately hydrated. All systems of the body, all functions of our body, require the adequate amount of hydration."

• REFLECTION: Other things that are important to life, such as food, are not nearly as important as water because people can last for much longer without them than without water, which is required in adequate portions by all functions of the body.

Would you say that staying hydrated is a health problem a lot of people face? 

With the intention of getting an idea of how much of a problem to health staying hydrated is for most people, this question was asked for information regarding the stakeholder’s thoughts on whether patients struggle with hydration.

"I think about a lot of different populations, especially here in South Florida for a lot of reasons, mainly because it's hot all the time. When we are sweating a lot more and we are expelling more fluids, we need to replenish our body."

• REFLECTION: Especially in places where it is hot, it is important for people to get enough water because in the heat, people sweat and water needs to be consumed to replace the water that is lost in other activities.

"Also, South Florida is, you know, kind of known for a very high percentage of elderly people, and the older that we get, the less our brain tells us to drink and that we're thirsty, so it is a big problem, especially among the elderly population that as they age, they are less likely to feel thirsty. They also can struggle, of course, with memory issues, and so they don't necessarily remember to drink so they can go really long periods of time without drinking at all and then become dehydrated really, really quickly."

• REFLECTION: As people get older, hydration can be a bigger problem because as people get older, their brains become less functional, and older people tend to have more difficulty remembering that they need to drink.

"Also, people that work outside a majority of the day, especially down here (house painters or construction workers or people like that in like warehouses and stuff), are basically sweating all day long. Athletes, of course, are training, so there's a lot of different kinds of subsections of people that do struggle with keeping up with their hydration status for sure."

• REFLECTION: People can also be influenced to drink more or less water based on other factors in their life such as other activities they are a part of that could be a hindrance or the encouragement to drink more water, and it is necessary that they get this water.

What are the greatest problems people face when trying to stay hydrated?

Building on the question of whether many people struggle with hydration or not, this question aims to narrow down the criteria and identify the problems the stakeholder has seen that prevent people from drinking enough water.

"I think some people just are not big fluid drinkers, and so when they go from not drinking a whole lot to trying to drink more – maybe a doctor told them they need to be drinking more fluids or whatever – it can kind of be annoying because they are trying to remember to be drinking throughout the day."

• REFLECTION: People who are trying to go from not drinking enough to drinking enough might find it annoying to try making that transition quickly without falling back because it is such a big change and cannot be expected to just happen.

"Also, when your body is not used to drinking that much, you can end up having to go to the bathroom a lot more, and that can be annoying for people. People who work and have really demanding jobs have to be “go, go, go, go, go” all day long. They do not want to have to be taking breaks constantly, so they can purposely not be drinking a lot because they don't want to have to go to the bathroom, and so there are a lot of different issues that can come up where people would struggle to get enough."

• REFLECTION: People who are busy might also not get enough water because drinking enough water would mean they would have to use the restroom more often, and for busy people, wasting that time to use the restroom is not worth it.

"Also, you know, especially for athletes and people who are really expelling a lot or sweating a lot, you are losing so much that you would literally have to be just constantly drinking throughout the day to really stay on top of it, and so that can be a struggle when you're trying to work and then have to stop and be chugging fluids throughout the day."

• REFLECTION:  It is especially important for people such as those who sweat a lot to remain hydrated because water is lost doing those activities, and it needs to be replaced by drinking more water.

How much water should people be drinking every day to stay healthy?

The question of how much water people should be drinking is dependent on the person, but this question was intended to get the stakeholder’s expert opinion on a good amount for most people to get to stay healthy.

"So that is kind of a loaded question because everybody is different, so there is not a black-and-white blanket answer, but, for the most part, a generally healthy adult person we typically start at that old eight eight-ounce glasses, which would be approximately 64 ounces a day as a good place to start. Most people I would say require more than that."

• REFLECTION: There is no definite answer that works for every person to determine how much water they should be drinking, but for most healthy people, half of a gallon is approximately how much water people should be getting, but most need more.

"Part of my job is doing a full assessment of the person to get an idea of what their activity status is and what their life looks like and if they require a lot more than that or maybe a little bit more than that, or maybe 64 ounces is pretty good, but typically, to maintain a good hydration status, really no less than 48 ounces, and 64 is a great place for a jumping off point to start there."

• REFLECTION: To stay healthy and hydrated, people should definitely not be getting less than forty-eight ounces every day with sixty-four being a good place to start for most people trying to stay hydrated.

"Unless the person is on a fluid restriction (there are certain kidney and cardiac issues that could lead a physician to want them to restrict their fluid intake), if they have not been diagnosed with anything like that and they're generally healthy, 64 ounces is like a nice guideline to start at."

• REFLECTION: Some people might have certain medical conditions that may cause doctors to require that they restrict the amount of water they get, but for the most part, people do not have this problem and should be drinking about a half-gallon every day.

What are some health problems that result from not drinking enough water?

Not only was it important to determine that hydration is a problem, but it is also important to see if it is a problem for health, so this question was asked to hear the stakeholder’s take on what health problems result from dehydration.

"Well, like I said, it's kind of important to all functions of the body. There are a lot of different things that can happen with consistent dehydration like a couple of days here and there."

• REFLECTION: It is important for people to be getting enough water consistently because, since it is so important to all functions of the body, consistent dehydration can result in many different problems that result from a lack of water.

"If you're not really needing, that's not going to make that big of a difference, but consistently, over time, being either underhydrated or truly dehydrated can absolutely affect kidney function. It can cause kidney stones and different types of kidney disease."

• REFLECTION: Although it may not be obvious, over time many types of kidney problems and diseases can affect kidney function negatively due to being consistently underhydrated, including kidney stones.

"Metabolic function is affected, so for people who are trying to lose weight or be healthy, you can eat whatever would be considered the picture of a perfectly healthy diet, but if you're not adequately hydrated, then that will keep you from seeing the results that you want to see on the scale and will keep you from truly getting to that point of being overall healthy."

• REFLECTION: People can do everything else they need to do to stay healthy and do them perfectly, but unless they stay hydrated, they will never achieve the goals that might have them trying to remain healthy in the first place.

"Hair, skin, and nails can be affected. You can have brittle hair and nails."

• REFLECTION: Other areas that can impact a person’s appearance are also negatively affected by dehydration, so it is important for people to get enough water so that they can be as healthy and look as healthy as they can be.

"Constipation is huge. A lot of people suffer from constipation, and a majority of the time those people are not getting enough fluid because fluid is really kind of what is processing everything out of our bodies."

• REFLECTION: Not getting an adequate amount of water can also cause other digestive issues such as constipation because it is so important to process everything in people’s bodies, and so without it, people can’t function as well as they should.

"They can suffer from fluid retention where you are really bloated because when your body's not getting enough fluids, it hangs on to whatever you have there, so you can be super bloated and holding onto those fluids."

• REFLECTION: Another result of dehydration is that someone’s body may start to store the fluids they do take in so that they might have enough for the things their body needs them for, but this can make people bloated because they are holding onto all the fluids.

"There can be blood pressure issues like different cardiac or heart markers are affected. Endurance is affected."

• REFLECTION: Water is very important for blood, and many cardiovascular issues can result from not getting enough water including heart problems or even decreased endurance as a result of dehydration.

"Pretty much everything within our body can be negatively affected by consistent dehydration. True dehydration can lead to death. Being dehydrated and not getting any water ultimately can lead to actual death, but all those other things would be what starts to happen when you are consistently under."

• REFLECTION: Dehydration is a serious issue, and it even has the potential to lead to death if someone is truly dehydrated because water is necessary for everything peoples’ bodies do, and so not getting the necessary water can cause things to stop functioning.

How can people be encouraged to drink more water?

For this question, the goal was to receive feedback from the stakeholder that would be helpful when developing a solution by getting the stakeholder’s opinion on what does or does not work to encourage people to drink more water and stay hydrated.

"So, I think that we try to change the world overnight all the time, and for someone that is only drinking maybe a glass or two of water a day, to tell them to try to drink eight glasses a day is kind of unrealistic, and it seems overwhelming and impossible. So, really with any kind of nutrition recommendations that I'm working with patients on, we start really slow, and I think it's a lot more realistic and doable to tell a person that is only drinking two glasses a day to, for the next two or three weeks, try to aim for three glasses a day and get them more used to just drinking that, and, once they're used to the three glasses, then we can increase it again."

• REFLECTION: It is very important when trying to help people to stay hydrated to take it slow because an overnight change from consistently not getting enough water to getting enough may be unreasonable for some people.

"Also you can jazz it up a little bit because a lot of people just don't like the taste of plain water, and that's okay. There are a lot of different ways that they can add in or squeeze in some natural fruit like lemon juice or lime juice or even muddle some fruit into it. There are infusion bottles that make it really easy to put fresh fruit in, and it just infuses into the water."

• REFLECTION: Many people just don’t like the taste of water, so another method that could be used to get people to stay hydrated is to make the taste more interesting by adding flavors by adding juice or infusing fruit in the water.

"Even things like Crystal Light or MiO, which are a little bit controversial just because of the artificial sweeteners, but for me, if someone is not hydrated, that is way worse than the potential negative of a little bit of Crystal Light in their water. So, if it gets them to drink more water, then by all means, I'm fine with the patient adding in some Crystal Light."

• REFLECTION: Other flavors such as artificial sweeteners can also be helpful for people to get water, and although they have a lot of sugar, the consequences of the excess sugar are less than the consequences of dehydration, so it is still worth it if necessary.

"Things like popsicles, like no sugar added fruit popsicles, are considered fluids, so that would be fine. There are a lot of fruits that are mainly water. If they eat a little bit more fruit, they can get more fluids that way."

• REFLECTION: Popsicles and many regular fruits also have lots of water in them, so they can also be used as an alternative source of hydration if drinking pure water all the time is not desirable.

"There are tons of different electrolyte drinks that can help. I think though that's kind of gotten trendy, and people are drinking them kind of excessively, and a lot of them have a ton of added sugar to them, so it kind of takes away from the benefit of the electrolytes when you're pouring in all of this unnecessary sugar as well, so I'm very cautious about how I recommend the electrolyte drinks, but they can absolutely be hugely beneficial and helpful to some people. Sometimes drinking like a Gatorade Zero or Pedialyte without the sugar in it tastes better than plain water, so that would be more motivating for the patient to drink rather than just trying to drink plain water."

• REFLECTION: Electrolyte drinks can also encourage people to drink more water, but they do have an extremely large amount of sugar that can be harmful to health to get a lot of, so if electrolyte drinks are to be a source of water, it is best to get no-sugar variants.

"Sometimes adding bubbles to it like a seltzer water or something like that is still getting water in, so if that helps them to make it more exciting, I guess, I encourage people always to, no matter what they're doing, where they are, always have a bottle of water with them whenever they're going anywhere so that it is not like, well, I was out running errands for six hours, so I didn't have anything to drink. You always want to take your fluids with you wherever you are going so that it is easily accessible."

• REFLECTION: Carbonating the water is another way that can make drinking water more interesting and encourage people to hydrate, and it is important that people always have water with them to drink no matter what method is used to ensure this.

"It is kind of funny, but straws sometimes are helpful and can be motivating for the patient. I'm not really sure of the science behind that, but I just know that a lot of patients do a lot better and drink a lot more when they are drinking out of straws versus just trying to drink straight out of the bottle, so that can be a recommendation that I make. It really just depends on the patient. There are a lot of options out there that can get people to get more fluids in."

• REFLECTION: Another thing that can make drinking water interesting for people is using straws because, for some reason, it is motivating for people to drink through straws as opposed to drinking directly out of a bottle or cup.

Do you have any additional comments on the issue of hydration?

We asked him this in order to see if he was qualified.

"I’ve been in athletics training since 2002."

• Reflection: The stakeholder is a veritable source on subjects concerning athletics because he has actively been working as a sports coach for twenty years, and hydration and athletics go together, so he can be considered an expert on it.  

What are your qualifications?

We asked him this in order to see if he was qualified.

"I went through a training program in college. After you complete the program, you go through the National Board and then I went to Florida for a license degree. I received a master's in sports medicine and taught athletic training for 10 years."

• Reflection: The stakeholder is a qualified source on subjects concerning athletics because of the fact he received his master's in sports medicine and that he taught athletic training for 10 years.  

How much experience do you have in the area of hydration?

We asked this in order to see his experience with hydration.

"I learned about hydration in the program, learned what contributes to hydration and dehydration, and developed experience in dealing with hydration and saw how people deal with it."

• Reflection: The stakeholder is a valid source on subjects concerning hydration because he has actively been working in the area of hydration for a while, and because of the amount of experience he has in this area he could be known as an expert.   

Would you say that people, especially athletes, don't stay hydrated enough?

We asked him this in order to see his experience with hydration.

"Regarding athletes, not drinking enough water could create problems."

• Reflection: The stakeholder is important in his opinion because he has a lot of knowledge regarding this certain subject of hydration. Therefore, his opinion on why people don't drink enough water is very important.   

How important is hydration to health, especially concerning athletes?

We asked this in order to gain his opinion regarding health and the dangers of dehydration.

"Hydration is extremely important because it allows the athletes to perform."

• Reflection: The stakeholder is a valid source on subjects concerning hydration therefore he understands that having enough liquid in your system is the best way to prevent any injuries or overheating.  

How often and how much should athletes drink during the day, and what habits are best for athletes to stay hydrated?

We asked this because we wanted to see his opinion regarding how much water we should drink.

"Drink consistently throughout the day regarding athletes half a gallon and a gallon of water a day."

• Reflection: The stakeholder is a valid source on the subject concerning how much water athletes should drink a day so that athletes themselves could get a better idea of how much they should be drinking from a professional.  

What are some of the dangers of dehydration?