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The Importance ofHealthy Hydration
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The Importance of Water
Water composition of tissues and organs(% by weight)1
Lungs
Skin
68.3Heart
10.0
75.6
Skeleton (bone)
Intestine
82.7Spleen
83.0
74.8
79.0
72.0
79.2
22.0
74.5
75.8Liver
Adipose tissue
Muscle
Kidney
Blood
Brain
Water is an essential physiological requirement and maintaining hydration is essential for normal body function
Water is an essential componentof all bodily organs
The water content of body parts varies from 10% in adipose tissue to 83% in blood1
Adequate hydration is necessary to ensure healthy organ function, including that of the urinary tract, the heart, the digestive system, and the brain2
1. Pivarnik, J.M. Ed. Hickson, J.F., and Wolinsky, I. Boca Raton, FL: CRC Press, 245-262.2. Manz F. J Am Coll Nutr 2007; 26(5 Suppl):535S-541S
Quantity Quality
Healthy Hydration: Two simple concepts
Quantity Quality
Healthy Hydration: Two simple concepts
Average daily water loss1
Respiratory tract 0.4L
Kidneys 1.5L
Total 2.6L
Gastrointestinal tract 0.2L
Skin 0.5L
Water is continuously lost from the body – even when sedentary
On average, at least 2.6 litresof water are lost through respiration, perspiration,faeces and urine every day1
The kidneys have a particular requirement for good hydration and are highly sensitive to fluctuations in fluid levels2
1. Shirreffs SM. J Sports Med Phys Fitness 2000; 40:80-4.2. Groff JL, et al. In: Advanced Nutrition and Human Nutrition, Second Edition. 1995; pp423-439
Relationship between dehydration and disorders and disease1
Category of EvidenceIa Ib IIa IIb III IV
Acute Systemic Mild DehydrationOligohydramnios XProlonged labour XHypertonic dehydration in infants XCystic fibrosis XRenal toxicity of xenobiotics X
Chronic Systematic Mild DehydrationUrolithiasis XUrinary tract infections XConstipation XHypertension XVenous thromboembolism XCoronary heart disease XStroke XDental Disease XHyperosmolar hyperglycaemic diabetic ketoacidosis X
Gallstones XMitral valve prolapse XGlaucoma X
Local Mild DehydrationBronchopulmonary disorders:
Exercise asthma XCystic fibrosis X
Category of Evidence(Ia) evidence from meta-analysis of randomized controlled trials; (Ib) evidence from at least one randomized controlled trial; (IIa) evidence from at least one controlled study without randomization; (IIb) evidence from at least one other type of quasi-experimental study; (III) evidence from descriptive studies such as comparative, correlation, and case control studies; (IV) evidence from expert committee reports, opinions or clinical experience of respected authorities, or both
Not drinking enough fluid is associatedwith a range of physiological disorders
Dehydration has been linked to increases in risk for several diseases and disorders including1
− Urinary-tract infections
− Dental disease
− Bronchopulmonary disorders
− Constipation
− Kidney stones
− Impaired cognitive function
1. Manz F. J Am Coll Nutr 2007; 26(5 Suppl):535S-541S.
Differences in blood pressure after exercise induced dehydration (EX-DEH) and after rehydration (EX-REH)3
200
0
250
50M
SN
A (
un
it/b
ea
t)
Diastolic blood pressure (mmHg)
150
100
40 50 60 908070
EX-DEH EX-REH
Dehydration also impacts on physical performance
Fluid deficits of >1% of body weight can lead to reductionsin exercise performance and thermoregulation1
Deficits of ≥4% lead to increases in body temperature and in respiratory rate1
Cardiovascular function is increasingly impaired with increasing dehydration, with a rise in heart rate and difficultiesin maintaining blood pressure2,3
1. Grandjean AC, et al. Nutr Rev 2003; 61: 261-71.2. Schroeder C, et al. Circulation 2002; 106:2806-11.3. Charkoudian N, et al. J Physiol 2003; 552:635-44.
1. Howard G, Bartram J. WHO 2003. Available at http://whqlibdoc.who.int/HQ/2003/ WHO_SDE_WSH_03.02.pdf. Accessed June 2009.2. EFSA. Scientific Opinion on Dietary Reference Values for water. Available at: http://www.efsa.europa.eu/en/scdocs/scdoc/1459.htm. Accessed April 2010.
How much should we drink?
The amount of fluid (including water obtained from food) to maintain hydration for average adults in average conditions is:− 2.9 litres/day for men
− 2.2 litres/day for women1
The European Food Safety Authority (EFSA) and the Institute of Medicine (IOM) state that the average food diet provides 20% of the recommended total daily fluid intake2
Based on the EFSA expert opinion for recommended daily consumption,the amount of liquid that should be consumed can be calculated as:− 2.0 litres for men
− 1.6 litres for women2
These figures are calculated on the basis of a normal temperate climate and a sedentary lifestyle. Changes in these and/or other factors (such as pregnancy or lactation) would increase the daily liquid intake requirement
Quantity
Healthy Hydration: Two simple concepts
Quality
Continuous increase in prevalence of diabetes worldwide2
300
250
200
150
0
400
350
50
Nu
mb
er
of
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op
le w
ith
dia
be
tes
(M
illio
ns)
Year
100
1985 2000 2009 2025 Estimated
Obesity and other metabolic disorders have become 21st century health ‘epidemics’
There are now more than 1 billion overweight adults in the world – at least 300 million are considered
to be obese1
− 22 million of the world’s children under 5 years old are overweight1
The number of people with type 2 diabetes is increasing alarmingly:− 150 million in 2000
− 246 million in 2007
− 380 million predicted in 20252
Metabolic syndrome now affects around 25% of the world’s population3
1. World Health Organization. Available at http://www.who.int/dietphysicalactivity/publications/facts/obesity/en/. Accessed April 20102. International Diabetes Federation, Diabetes Atlas Third Edition (2006). Available at: http://www.eatlas.idf.org/. Accessed April 2010.3. Riccardi G, et al. Eur J Nutr 2004; 43(Suppl 2):II7-II46.
Cut-off points for overweight and obesity in European and Asian countries1
The optimum population BMI is considered to be approximately ~21 kg/m2
Overweight and obesity: classification
1. WHO Western Pacific Region, 2000. http://www.who.int/nutrition/publications/obesity/09577082_1_1/en/index.html. 2. James WPT. J Intern Med. 2008; 263:336-52.3. Swinburn BA, et al. Public Health Nutr. 2004; 7:123-46.
Overweight and obesity are caused by:• A sedentary lifestyle
• An excess intake of calories vs. energy burned3
BMI (kg/m2)European
BMI (kg/m2)Asian
Normal 18.5-24.9 18.5-22.9
Overweight (pre-obese) 25-29.9 23-24.9
Obese 30 25
Overweight and obesity are important risk factorsfor cardiometabolic disease
Excess weight – especially intra-abdominal fat – is associated with a number of conditions that are known risk factors for cardiovascular disease, including:1-3
Hypertension
Dyslipidaemia
Insulin resistance
Type 2 diabetes
1. Després JP, et al. J Endocrinol Invest. 2006; 29:77-82. 2. James WPT. J Int Med 2008; 263:335-352.3. WHO. Available at: http://www.who.int/dietphysicalactivity/publications/facts/obesity/en/ Accessed: April 2010.
0
5
10
20
30
35
1975 1980 1995 2000 2005
Ob
es
e (
BM
I ≥
30
kg
/m2 )
(%
)
15
25
1970 1985 1990
The increasing prevalence of obesity is rapidly becoming a global societal problem1
1. James WPT. J Intern Med. 2008; 263:336-52.2. WHO. http://www.who.int/dietphysicalactivity/publications/facts/obesity/en/
The obesity epidemic is not only restricted to Western or industrialised countries
Some Asian and African countries are showing changes in physical activity and diet associated with rapid increases in obesity and type 2 diabetes1,2
Year
USA
EnglandFinland
Australia
BrazilJapan
Cuba
Sweden
Norway
BMI ≥30
1999-20001988-94
USA
20021985Germany
1992-41985-8Hungary
20031993England
19991991Austria
(self report) 1999(self report) 1994Italy
1993-71976-80Netherlands
19921982Denmark
(self report) 2003(self report) 1997France
BMI 25-29.9BMI 25-29.9BMI ≥30
60% 60%40%20%0%20%40%
The prevalence of overweight and obesityis increasing, particularly in men1
1. International obesity task force. March 2005. Available at: http://ec.europa.eu. Accessed: September 3, 2008.
Changes in adult weight and obesity in selected countries
1. International obesity task force 2007. Available at: http://www.iotf.org/database/Childhoodandadolescentoverweightineurope.htm. Accessed: April 2010.
Overweight & obesity in pre-adolescent(7–11 yrs) European girls1
England 2004
Italy 1993-2001
Spain 1998-2000
Ireland (Republic of) 2001/2
Slovakia 1995-99
Greece 2003/4
Portugal 1996
%
Sweden 2001
Russian Fed 1992
Cyprus 1999/2000
5 10 15 20 25 30 35 40
Switzerland 2002
France 2000
Czech Republic 2001
Germany 1995
Poland 1996
Denmark 1996/7
Netherlands 1997
England 2004
Italy 1993-2001
Portugal 2002/3
Russian Fed 1992
Netherlands 1997
Spain 1998-2000
Malta 1992
%
Ireland (Republic of) 2001/2
France 2000
Cyprus 1999/2000
5 10 15 20 25 30 35 40
Sweden 2001
Czech Republic 2001
Switzerland 2002
Poland 2001
Germany 1995
Denmark 1996/7
Slovakia 1995-99
Overweight & obesity in pre-adolescent(7–11 yrs approx) European boys1
The prevalence of overweight and obesity in children is also of concern
Note: some of the data is self-reported and may underestimate prevalence of overweight and obesity
Overweight (inc obesity)Obesity Overweight (inc obesity)Obesity
1. International obesity task force 2007. Available at: http://www.iotf.org/database/Childhoodandadolescentoverweightineurope.htm. Accessed: April 2010.
Overweight & obesity in post-adolescent(14–17 yrs) European girls1
%
England 2004
Italy 1993-2001
Ireland (Republic of) 2001/2
Denmark 1996/7
Netherlands 1997
Spain 1998-2000
Malta (self report 2001)
%
Slovenia (self report) 2001/2
Finland (self report) 1999
Russian Fed 1992
Poland 1996
Hungary 1993-4
Germany 1995
Turkey 2001
Czech Republic 2001
Slovakia 1995-99
Estonia (self report) 2001/2
Overweight & obesity in post-adolescent (14–17 yrs approx) European boys1
Overweight (inc obesity)Obesity
Latvia (self report) 2001/2
Italy 1993-2000
Hungary 1993/4
Malta (self report) 2001
Denmark 1996/7
Latvia (self report) 2001/2
England 2004
Ireland (Republic of) 2001/2
Russian Fed 1992
Spain 1998-2000
Cyprus 1999-2000
Germany 1995
Netherlands 1997
Turkey 2001
Finland (self report) 1999
Poland 1996
Czech Republic 2001
Slovenia (self report) 2001/2
Slovakia 1995/99
Estonia (self report) 2001/2
5 10 15 20 25 30 35 405 10 15 20 25 30 35 40
Note: some of the data is self-reported and may underestimate prevalence of overweight and obesity
Overweight (inc obesity)Obesity
The prevalence of overweight and obesity in adolescents is also of concern
Estimated numbers of obese children in the EUwith obesity-related disorders2
1.000.000
800.000
600.000
400.000
0
1.400.000
1.200.000
Nu
mb
er
of
ch
ild
ren
Type of disorder
200.000
Glucose intolerance CV risk factors Early liver disorder
Childhood obesity has a profound effect on health
The prevalence of overweight among schoolchildren is estimated to be 35% in European regions1
More than 20,000 obese children in the EU alone have type 2 diabetes2
Obesity in childhood is associated with the presence of risk factors for conditions such as diabetes and hypertension and with the early development of these diseases2
1. Jackson-Leach R, Lobstein T. Int J Pediatr Obes 2006; 1:26-32.2. Lobstein T, et al. Int J Pediatr Obes 2006; 1:33-41.
Higher numbers of adipocytes in obese children and adults (open circles) vs. non-obese children and adults (closed circles)2
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Ad
ipo
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Age in years
20
0.3
10
30
1 2-4 6-8 10-12 14-16 18-20 22-24(11)
(8)
(8)
(11)
(12)
(12)
(11)
(14)
(12)
(13)
(13)
(13)
(5)
(8)
Overweight and obese children can become overweight and obese adults
Overweight and obese people have a higher number of adipose cells than individuals of normal weight1,2
The number of fat cells is set during childhood and adolescence1
It is important to note that the consumption of calories during childhood has significant consequences for the amount of fat deposits (e.g. adipocytes) in adult life1-3
1. Spalding KL, et al. 2008; 453:783-7.2. Knittle JL, et al. J Clin Invest 1979; 63:239-46.3. Häger A, et al. Metabolism 1977; 26:607-14.
The relationship between emerging public health issues such as obesity
and beverage consumption
Modern dietary habits are also leading to an increased consumption of liquid calories
In the US, soft drink consumption has increased by 300% in the past 20 years1
Sugar-sweetened beverage (SSB) consumption has increased by 135%in this time2
In 1998, added sugars in food accounted for 15.8% of daily energy intake for children in the US3
To burn off the calories in just onecan of sugar-sweetened soft drink(~150 calories) requires 45 minutes walking or 20 minutes jogging
Consuming an additional 120 kcalper day (about one serving of a SSB) produces a 50 kg (110 pounds) increase in body mass over 10 years1
1. Harrington S. J Sch Nurs 2008; 24:3-12.2. Nielsen SJ, Popkin BM. Am J Prev Med 2004; 27:205-210.3. Drewnowski A, Bellisle F Am J Clin Nutr. 2007; 85:651-61.
Increasing risk of type 2 diabetes with increasing consumption of sugar-sweetened beverages4
Re
lati
ve
ris
k
1.6
1.4
1.2
1
0
2
1.8
0.4
0.8
0.6
0.2
<1/month 4-6/month 2-6/week 1/day
P<0.001 for trend
Excessive consumption of sugar-sweetened drinks has been linked to a range of modern-day health problems
A habitual intake of SSBs has been associated with metabolic disorders and diseases including− Weight gain in children1,2
− Prevalence of metabolic syndrome3
− Type 2 diabetes4,5
Excessive consumption of carbonated soft drinks is suspected to increase the risk of other diseases, such as kidney disease and kidney stones6,7
Number of sweetened beverages consumed
1. Ludwig DS, et al. Lancet 2001; 357:505-508; 2. Troiano RP, et al. Am J Clin Nutr 2000; 72(Suppl. 5):343S-1353S. 3. Yoo S, et al. Am J Clin Nutr 2004; 80:841-848; 4. Schulze MB, et al. JAMA 2004; 292:927-934.5. Bazzano LA, et al. Diabetes Care 2008; 31:1311-1317; 6. Shuster J, et al. J Clin Epidemiol 1992; 45:911-6.7. Saldana TM, et al. Epidemiology 2007; 18:501-506
Effect on weight of regular between-meal consumption of SSBs on children between the ages of 2.5 and 4–5 years old4
Pe
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Excessive consumption of SSBs is positively associated with weight gain, especially in children and adolescents
A prospective observational study conducted in schoolchildren showed that daily consumptionof SSBs increased the risk of obesity by approximately 60%1
SSBs have a high glycaemic index (GI): high GI foods canlead to increased post-prandial insulin, and energy storage, especially in young people2,3
8
4
2
0
16
12
14
10
6
Non SSB consumer SSB consumer
P=Not significant
Regular consumption was ≥4–6 times per week
1. Ludwig DS, et al. Lancet 2001; 357:505-8.2. Harrington S. J Sch Nurs 2008; 24:3-12.3. Ebbeling CB, et al. Lancet 2002; 360:473-82.4. Dubois L, et al. J Am Diet Assoc 2007; 107:924-34.
Increasing risk of type 2 diabetes with greater consumption of fruit juices2
Re
lati
ve
Ha
zard
fo
r T
yp
e 2
Dia
be
tes
1.5
1
0
2.5
2
0.5
Fruit-juice intake (number of cups [8oz])
<1/mo 1/mo-4wk 5-7/wk >4/day2-3/day
There is a lack of information and some misunderstanding regarding consumption of SSBs – particularly fruit juices
It is not always recognised that some fruit-juice drinks contain high amounts of sugar andcan lead to disorders related to high-sugar consumption
In one study, women who consume fruit juice every day were shown to be heavierthan women who consumeit less than once a week1
Another study has shown that excessive consumption of fruit juices has been associatedwith an increased incidenceof type 2 diabetes2
1. Schulze MB, et al. JAMA 2004; 292:927-34.2. Bazzano LA, et al. Diabetes Care 2008; 31:1311-17.
Healthy Hydration: Two simple concepts
Quantity Quality
Drinking more water can be a simple and sustainable steptowards a healthier lifestyle
Maintaining good hydration ensures optimal physical
and cognitive performance
Healthy Hydration: Two simple concepts
Quantity Quality
Water is the only liquidour bodies need to hydrate.
It contains no calories,no additives, no acids
Chan J, et al. Water, Am J Epidemiol 2002; 155:827-33.
This study showed a reduced risk of fatal coronary heart disease for people who drank water rather than other types of fluid1
Re
lati
ve
ris
k
1.5
1
0
3
2
0.5
Water (men)
Water (women)
Other fluids(men)
Other fluids(women)
2.5
Increasing daily water consumption is a simple step towards a healthier lifestyle, and has a number of health benefits
Water contains no calories, no sugar, no additives and is not acidified
Water consumption is not associated with weight gain or metabolic disorders
Water is one of the healthiest beverages for children aged >2 years
Drinking water from an early age helps to maintain healthy dietary practices throughout life
Pe
rce
nt
of
ov
erw
igh
t a
nd
ob
es
e
ch
ild
ren
25
23
22
21
29
27
28
26
24
Control group Intervention group
P=0.04
Reduction in proportion of overweight children after an initiative aimed at promoting water consumption as the sole beverage in school children1
An initiative aimed at promoting water as the sole beverage in German schools, effectively reduced the prevalence of overweight schoolchildren1
A similar UK initiative showedthat reducing carbonated-drink consumption in schoolchildren prevented further increases in overweight and obesity2
Reducing consumption of carbonated drinks leads to increased consumptionof pure water2
Promoting good hydration behaviour and consumingmore water can have a significant impact on weight, particularly in children
1. Muckelbauer R, et al. Pediatrics 2009; 123:e661-e667.2. James J, et al. BMJ 2004; 328(7450):1237.
*National daily intake guidelines vary. For reference, EFSA recommend drinking 2L per day
Conclusions
Healthy hydration practices are often either overlooked or lack emphasisin current public-health recommendations and advice given by healthcare professionals
However, current scientific literature suggests that there are a number of benefits
Excessive consumption of SSBs has been linked to a range of modern-day health problems
Good hydration ensures optimal physical and cognitive performance
Water is the only liquid needed for hydration – when you drink water, you are not consuming any calories or additives.
Drinking plenty* of water each day is a positive behaviourto promote as it is a simple and sustainable
step towards a healthier lifestyle
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