Rationale for Renewed Emphasis on Dietary Water Intake
Armstrong, Lawrence E. PhD, FACSM
Lawrence E. Armstrong, PhD, FACSM, is professor in the Departments of Kinesiology and Nutritional Sciences, Human Performance Laboratory, University of Connecticut, Storrs.
Dr Armstrong has received a research grant and speaker honorarium from Danone Waters R&D. He serves as a consultant member of the Danone Research Scientific Advisory Board and has conducted laboratory research funded by Danone Research.
Correspondence: Lawrence E. Armstrong, PhD, FACSM, Departments of Kinesiology and Nutritional Sciences, Human Performance Laboratory, University of Connecticut, Unit 1110, 2095 Hillside Road, Storrs, CT 06269 (email@example.com).
Human metabolism, nutrient transport, circulation, temperature regulation, contraction of skeletal muscles, nerve impulse transmission, regulation of fluid-electrolyte balance, and waste excretion would be impossible without water because it is the medium for all cellular and systemic processes. Thus, total body water is defended by multiple neuroendocrine mechanisms. But even though water is essential to life and optimal human performance, (a) no scientific or clinical consensus exists regarding precise values for the daily water requirements of men and women,1 and (b) surprisingly, few data exist regarding the hydration status of healthy, free-living, sedentary adults who are not under environmental or physiological stress.2 This dilemma exists, in part, because human body water balance is complex (ie, residing in interconnected intracellular and extracellular fluid compartments) and dynamic (ie, both volume and concentration change in sinusoidal patterns due to fluid and food intake, excretion, metabolism, and respiration).3 Unfortunately, the published data that describe human water requirements contain recognized limitations.4 This means that precise measurements of adult water consumption patterns are needed.
During the past decade, increasing international consumption of sugar-sweetened beverages has sparked debates about the potential negative health consequences of high-calorie beverages. For example, data5 spanning the period 1999 to 2001 indicate that beverages accounted for approximately 21% of all calories consumed in the United States. Schulze and colleagues6 associated a higher consumption of sugar-sweetened beverages with a greater weight gain and an increased risk of type 2 diabetes in women, possibly due to excessive calories and large amounts of rapidly absorbable sugars. The rapid absorption of glucose induces a sequence of metabolic and hormonal changes that promote excessive food intake.7 Other research has emphasized a parallel growth of diabetes and sugar consumption in the United Kingdom and the United States,8 as well as a new hypothesis that excessive fructose intake (ie, in sweetened beverages) and excess uric acid may promote type 2 diabetes. These recent trends prompted one panel of experts to recommend that adults and children should consume fewer sugar-containing beverages and use water as the foundation of a healthy hydration program.9
From a different perspective, investigators have hypothesized that consumption of water, before or during meals, may help overweight individuals manage their body weight by increasing satiety or altering food intake.10,11 One study of women reported that satiety increased during, but not after, a meal if water was consumed before the meal.12 A subsequent study compared energy intake when water, diet cola, regular cola, orange juice, and 1% milk were consumed with the midday meal.11 The total energy intake of this meal was greater (P < .0001; mean, 652 kJ) when a caloric beverage was consumed (vs a noncaloric fluid including water), but satiety ratings were not different among the fluids. Although promising, these studies suggest that further research is required to discern the subtle interactions between water intake, food energy content, and satiety.
Boschmann and colleagues13,14 provide a different focus: water-induced thermogenesis. These investigators measured a 30% increase of metabolic rate after obese men (n = 7) and women (n = 7) consumed 500 mL of water13; this increase (ie, approximately 100 kJ) occurred within 10 minutes and reached a maximum at 30 to 40 minutes. Similarly, a 24% increase of metabolic rate was observed when a different sample of obese men (n = 8) and women (n = 8) consumed 500 mL of water;14 however, no change of metabolic rate was measured when these subjects consumed either 50 mL of water or 500 mL of isotonic saline. These researchers concluded that this inexpensive intervention might be a useful adjunctive treatment for obese individuals, to attain an increase in energy expenditure.13 Although these were short-term studies, a report15 evaluated the effects of drinking water on weight loss, in overweight dieting women, at 3 points across 1 year. Mean daily intakes of water, noncaloric fluids, unsweetened caloric fluids (eg, 100% fruit juice, milk), and sweetened caloric fluids; food energy; and nutrients were tracked using 24-hour diet recalls at 2, 6, and 12 months. Absolute volume (in grams) and relative (percentage of all fluids) increases in drinking water were associated with a significant loss of body weight and fat over time, independent of several other factors that were statistically covaried. The authors concluded that drinking water may promote weight loss in overweight dieting women.
Although confirmatory research is required, a laboratory study16 suggested that water intake (to the point of euhydration) reduced the mean resting heart rate of healthy men who were moderately hypohydrated (3.4 % loss of body mass). Similarly, water consumption reduced their mean resting plasma osmolality (ie, a physiological index of hydration state) from a hypertonic level of 296 mOsm/kg when hypohydrated to a normal level of 287 mOsm/kg when euhydrated. The long-term health effects of chronic mild physiological strain are unknown.
Dehydration also has been shown to have behavioral effects. Studies indicate that degradation of cognitive function and mood begins at a point between 1% and 2% body mass loss.17 Such mild dehydration is experienced by most adults, at some point during their weekly activities,3 but it is unlikely that they are aware of subtle cognitive deficits.
Low dietary water intake has been associated with a number of diseases including coronary heart disease and bladder cancer.18,19 Additionally, the beneficial effects of increased water consumption on colon cancer incidence have been reported independently by 2 research teams, utilizing multivariate statistical analyses.20,21 A strong inverse dose-response relationship was reported. Women who consumed more than 5 glasses of water each day had a 45% decreased risk of colon cancer than those who consumed 2 or fewer glasses per day. Also, epidemiological evidence describes a strong association between increased water intake and a decreased risk of kidney stone formation and recurrence.22,23 For example, a group of investigators, observing 107 men and women with idiopathic calcium oxalate kidney stone disease23 recommended increased water intake to decrease the risk of nephrolithiasis. The underlying goal of this increased water intake was to produce a dilute urine.
The studies above (ie, involving nutrition, metabolism, obesity, epidemiology, physiological responses, and disease) provide ample rationale for renewed emphasis on water consumption, distinct from other beverages. With this in mind, the present supplement to Nutrition Today presents critical reviews and identifies future research directions. The scientific community, across a range of specialty areas, will benefit by considering the important theme of this issue: improving public health by optimizing water intake.
1. Sawka MN, Cheuvront SN, Carter R. Human water needs. Nutr Rev. 2005;63:S3.
2. Grandjean AC, Reimers KJ, Bannick KE, et al. The effect of caffeinated, non-caffeinated, caloric and non-caloric beverages on hydration. J Am Coll Nutr. 2005;19:591-600.
3. Armstrong LE. Assessing hydration status: the elusive gold standard. J Am Coll Nutr. 2007;26:S575-S584.
4. Fulgoni VL. Limitations of data on fluid intake. J Am Coll Nutr. 2007;26:588S-591S.
5. National Center for Health Statistics. The Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). Reference Manuals and Reports [CD-ROM]. Hyattsville, MD: Centers for Disease Control and Prevention; 1996.
6. Schulze MB, Manson JE, Ludwig DS, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA. 2004;292:927-934.
7. Ludwig DS, Majzoub JA, Al-Zahrani A, et al. High glycemic index foods, overeating, and obesity. Pediatrics. 1999;103:E26.
8. Johnson RJ, Perez-Pozo SE, Sautin YY, et al. Could excessive fructose intake and uric acid cause type 2 diabetes? Endocr Rev. 2009;30:96-116.
9. Popkin BM, Armstrong LE, Bray GM, et al. A new proposed guidance system for beverage consumption in the United States. J Am Coll Nutr. 2006;83:529-542.
10. Negoianu D, Goldfarb S. Just add water. J Am Soc Nephrol. 2008;19:1041-1043.
11. DellaValle DM, Roe LS, Rolls BJ. Does the consumption of caloric and non-caloric beverages with a meal affect energy intake? Appetite. 2005;44:187-193.
12. Lappalainen R, Mennen L, van Weert L, et al. Drinking water with a meal: a simple method of coping with feelings of hunger, satiety and desire to eat. Eur J Clin Nutr. 1993;47:815-819.
13. Boschmann M, Steiniger J, Hille U, et al. Water-induced thermogenesis. J Clin Endocrinol Metab. 2003;88:6015-6019.
14. Boschmann M, Steiniger J, Franke G, et al. Water drinking induces thermogenesis through osmosensitive mechanisms. J Clin Endocrinol Metab. 2007;92:3334-3337.
15. Stookey JD, Constant F, Popkin BM, et al. Drinking water is associated with weight loss in overweight dieting women independent of diet and activity. Obesity. 2008;16:2481-2488.
16. Armstrong LE, Maresh CM, Gabaree CV, et al. Thermal and circulatory responses during exercise: effects of hypohydration, dehydration, and water intake. J Appl Physiol. 1997;82:2028-2035.
17. Lieberman HR. Hydration and cognition: a critical review and recommendations for future research. J Am Coll Nutr. 2007;26:S555-S561.
18. Chan J, Knutsen SF, Blix GG, et al. Water, other fluids, and fatal coronary heart disease: the Adventist health study. Am J Epidemiol. 2002;155:827-833.
19. Altieri A, La Vecchia C, Negri E. Fluid intake and risk of bladder and other cancers. Eur J Clin Nutr. 2003;57(suppl 2):S59-S68.
20. Shannon J, White E, Shattuck AL, et al. Relationship of food groups and water intake to colon cancer risk. Cancer Epidemiol Biomarkers Prev. 1996;5:495-502.
21. Tang R, Wang JY, Lo SK, et al. Physical activity, water intake and risk of colorectal cancer in Taiwan: a hospital based case-control study. Int J Cancer. 1999;82:484-489.
22. Borghi L, Meschi R, Amato F, et al. Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. J Urol. 1996;155:839-843.
23. Siener R, Schade N, Nicolay C, et al. The efficacy of dietary intervention on urinary risk factors for stone formation in recurrent calcium oxalate stone patients. J Urol. 2005;173:1601-1605.
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