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A Randomized Trial To Assess The Potential of Different Beverages To Affect Hydration 2016 (Cafe)
A Randomized Trial To Assess The Potential of Different Beverages To Affect Hydration 2016 (Cafe)
ABSTRACT that body water balance fluctuates over the course of a normal
Background: The identification of beverages that promote longer- day, but generally returns to the same point over a 24-h cycle (1).
term fluid retention and maintenance of fluid balance is of real clinical Consequently, large fluid deficits are uncommon for the majority
and practical benefit in situations in which free access to fluids is of the population, but knowledge of beverages that can maintain
limited or when frequent breaks for urination are not desirable. The hydration status over a longer period may be of interest to those
postingestion diuretic response is likely to be influenced by several who wish to stay hydrated in situations in which free access to
beverage characteristics, including the volume ingested, energy den- fluid is limited or when frequent breaks for urination are not
sity, electrolyte content, and the presence of diuretic agents. desirable (2–5). Although several studies have examined the
Objective: This study investigated the effects of 13 different com- effectiveness of beverages for postexercise rehydration (6), the
monly consumed drinks on urine output and fluid balance when protocols employed do not represent a common situation for
ingested in a euhydrated state, with a view to establishing a beverage the majority of the population. Thus identification of beverages
hydration index (BHI), i.e., the volume of urine produced after that promote longer-term fluid retention and maintenance of
drinking expressed relative to a standard treatment (still water) for fluid balance for prolonged periods under euhydrated conditions
each beverage. would be of real clinical and practical benefit.
Design: Each subject (n = 72, euhydrated and fasted male subjects) Adequate daily water intake is defined in the United States by
ingested 1 L still water or 1 of 3 other commercially available the Institute of Medicine (7) at 3.7 L for men and 3.0 L for women
beverages over a period of 30 min. Urine output was then collected and in Europe by the European Food Safety Authority (8) as 2.5 L
for the subsequent 4 h. The BHI was corrected for the water content for men and 2.0 L for women. The distribution of fluids over the
of drinks and was calculated as the amount of water retained at 2 h
course of the day and their composition, however, also may be
after ingestion relative to that observed after the ingestion of still
important in determining how well an individual is able to
water.
maintain an adequate hydration status. The volume and com-
Results: Total urine masses (mean 6 SD) over 4 h were smaller
position of ingested drinks have a strong influence on the rates at
than the still-water control (1337 6 330 g) after an oral rehydration
which they empty from the stomach and are absorbed in the small
solution (ORS) (1038 6 333 g, P , 0.001), full-fat milk (1052 6
intestine, thus affecting their entry into the body water pool (9).
267 g, P , 0.001), and skimmed milk (1049 6 334 g, P , 0.001).
Beverage components are also metabolized and excreted on
Cumulative urine output at 4 h after ingestion of cola, diet cola, hot
tea, iced tea, coffee, lager, orange juice, sparkling water, and a sports different time scales (9). These various factors are likely to result
drink were not different from the response to water ingestion. The in different hydration status profiles in the first few hours after
mean BHI at 2 h was 1.54 6 0.74 for the ORS, 1.50 6 0.58 for full- ingestion of different beverages. It should therefore be possible to
fat milk, and 1.58 6 0.60 for skimmed milk. assign a beverage hydration index (BHI) to each drink that will
Conclusions: BHI may be a useful measure to identify the short- define the hydration response to any particular drink, in much the
term hydration potential of different beverages when ingested in same way as the glycemic index defines the blood glucose re-
a euhydrated state. This trial was registered at www.isrctn.com as sponse to ingestion of foods (10). In the case of a BHI, the
ISRCTN13014105. Am J Clin Nutr doi: 10.3945/ajcn.115.114769. cumulative volume of urine passed over a fixed period of time is
in effect the AUC for renal water excretion. The urine volume
Keywords: fluid balance, dehydration, rehydration, euhydration, passed relative to a standard treatment (still water) can therefore
electrolytes, macronutrients, gastric emptying, intestinal absorption, be calculated as the BHI of a beverage.
renal excretion, urine
1
Supported by a grant from the European Hydration Institute.
*To whom correspondence should be addressed. E-mail: r.j.maughan@
INTRODUCTION
lboro.ac.uk.
Water intake is episodic, whereas losses are continuous. Under Received May 12, 2015. Accepted for publication November 24, 2015.
normal free-living conditions, homeostatic mechanisms mean doi: 10.3945/ajcn.115.114769.
Am J Clin Nutr doi: 10.3945/ajcn.115.114769. Printed in USA. Ó 2016 American Society for Nutrition 1 of 7
2 of 7 MAUGHAN ET AL.
Therefore, the aim of the present study was to assess fluid cluded. Because body mass was used as an index of euhydration,
balance responses to the ingestion of a fixed volume of commonly those currently undertaking an energy-restricted diet and/or
consumed beverages ingested when in a euhydrated state, with exercise plan also were excluded. Participants were asked to
a view to establishing the feasibility of a BHI. We hypothesized record their diet, including their fluid intake (household mea-
that drinks containing a high electrolyte content or high energy sures technique), as well as any exercise performed, in a diary
content would have greater fluid retention and thus a higher BHI over the 2 d before the first trial and asked to replicate this
than plain water. Conversely, drinks containing nutrients with before their subsequent visits. Participants also were asked not
known diuretic actions, such as alcohol and caffeine, may have to perform any strenuous exercise or consume alcoholic bever-
lower BHI values. ages in the 24 h preceding all trials.
Urine and serum analysis urine osmolality were compared between drinks by repeated-
All urine collected during the study was passed into a 1-L measures ANOVA.
plastic container. The volume of each urine pass was determined The main outcome measure was cumulative urine mass after
by measuring the mass on an electronic balance (to the nearest ingestion of each drink. This was also expressed as a BHI for each
0.1 g), with the mass of the empty plastic container subtracted to beverage by dividing each individual’s cumulative urine mass
enable the estimation of urine volume. From each urine sample, after still water with cumulative urine mass for each other test
a 5-mL aliquot was dispensed into a plain screw-capped tube. drink consumed. Individual hour cumulative urine mass and BHI
This was stored at 48C for the analysis of urine osmolality and of each drink was compared by paired t test to determine which
sodium and potassium concentrations. Urine and serum osmo- drinks differed from still water.
lality was measured in duplicate with the use of the freezing- To assess the practical meaning of the BHI differences ob-
point depression method (either Gonotec Osmomat or Advanced served between still water and each of the test drinks, the dif-
Instruments) within 48 h of collection. Urine sodium and po- ference was compared with the normal variation determined from
tassium concentrations were measured in duplicate with the use a separate repeatability analysis. For this purpose 12 participants
of flame photometry (Corning Flame Photometer) within 5 d of ingested the same drink on 2 occasions. The drinks used for this
collection. Collection, handling, and storage of urine and serum repeatability analysis were the same as those used in the present
were in accordance with the Human Tissues Act. Stored samples study. The repeatability of the BHI was equal to a CV of 18%
were discarded once satisfied analysis was completed. (w180 mL). In addition, the meaningfulness of group differ-
Whole blood in the serum tube was allowed to stand for 1 h at ences was also calculated with the use of Cohen’s d effect size
room temperature to clot before centrifugation (10 min; 48C; (13) and 95% CI of differences between means.
2000–3000 3 g). Serum was then dispensed into an appropriate Although a fixed volume of each of the test drinks was con-
storage tube (e.g., Eppendorf) and stored at 48C for measure- sumed, the presence of other components in some of these drinks
ment of osmolality. means the water content of drinks varied from 88% to 100%
To help ensure consistency in the data analyzed across sites, (Table 2). It might therefore be argued that the BHI should be
7 independently prepared quality control solutions were also corrected for the differences in water intake. If, however, the aim
analyzed in replicates of 10 by each research group. These was to estimate the effects of the different drinks on body water
contained undisclosed concentrations of sodium and potassium content, then the uncorrected values would be more appropriate.
and a measured osmolality. Two-way random-effects intraclass For clarity the data have been expressed both ways.
correlation coefficient analysis suggested good agreement be- All other secondary outcome measures (net fluid balance, BHI
tween the different institutions for osmolality, sodium, and po- corrected for water content, and cumulative urine electrolyte loss)
tassium analysis in which the intraclass correlation coefficients were analyzed by paired t test.
were all $0.999. In addition, Bland-Altman limits of agreement All statistical analyses were completed with the use of
analysis indicated that bias between any 2 institutions was ,2% a computerized statistical software package (GraphPad Prism
for osmolality, ,1% for sodium, and ,2% for potassium. version 6 for Windows). Statistical significance was accepted at
P , 0.05. Data are presented as means 6 SDs.
Data and statistical analysis
Participant characteristics, pretrial participant preparation, and RESULTS
urine responses to the still water trial from each institution were The study was conducted between February and August 2014.
initially compared by an ordinary 1-factor ANOVA. To confirm The study was completed when the target number of participants
that hydration status was similar before each trial, serum and (n = 72) had finished the study, providing n = 17 observations on
4 of 7 MAUGHAN ET AL.
TABLE 3 were ingested, cumulative urine mass was lower and net fluid
Institutional comparison of pretrial standardization and urine output balance was higher for full-fat milk (P , 0.01), skimmed milk
response to a standard drink1 (P , 0.01), and ORS (P , 0.01), but not orange juice (P =
0.06). The effect sizes at 4 h for cumulative urine output com-
Bangor Loughborough Stirling
(n = 24) (n = 24) (n = 24) P pared with still water were 1.04 for full-fat milk, 0.85 for
skimmed milk, and 1.09 for ORS (all large effects), with an
Preingestion of still water effect size of 0.65 for orange juice (a medium effect). The mean
Body mass, kg 76.1 6 12.3 76.7 6 7.3 78.2 6 9.7 0.76 differences in cumulative urine output were 294 g (95% CI: 154,
Serum osmolality, 293 68 291 6 4 295 6 3 0.14
434) for full-fat milk, 339 g (95% CI: 190, 489) for skimmed
mmol/kg
Urine osmolality, 564 6 243 607 6 302 538 6 176 0.62 milk, and 362 g (95% CI: 222, 505) for ORS.
mmol/kg
Postingestion of still water BHI
Urine mass, g 1341 6 360 1337 6 352 1333 6 288 0.99
After 2 h, full-fat milk, skimmed milk, ORS, and orange juice
1
Values are means 6 SDs. P values shown were obtained from a 1-factor had a higher BHI than still water (all differences P , 0.05)
repeated-measures ANOVA. No differences were observed between institu-
(Figure 2). The effect sizes at 2 h were 1.22 for full-fat milk,
tions for body mass, serum osmolality, or urine osmolality immediately
before still-water ingestion or 4-h cumulative urine mass after 1 L still water 1.37 for skimmed milk, 1.03 for ORS, and 0.87 for orange juice
ingestion, suggesting at each institution that participants’ preparation for (all large to very large effects). The higher BHI between still
trials was similar and that participants in the 3 institutions had similar fluid water and full-fat milk, skimmed milk, ORS, and orange juice
regulation. also exceeded twice the CV of the BHI measure. Mean
DEVELOPMENT OF A BEVERAGE HYDRATION INDEX 5 of 7
with positive sodium or potassium balances were typically those
with the highest BHI. That is, ORS had a positive sodium bal-
ance (Figure 4A), whereas orange juice and full-fat and skim-
med milk had positive potassium balances (Figure 4B).
DISCUSSION
Adequate hydration status may be associated with a de-
creased risk of a range of adverse outcomes, including urologic,
gastrointestinal, circulatory, and neurological disorders (14, 15).
In addition, maintenance of euhydration is important for the
preservation of physical and mental function (4, 5, 15, 16).
Consequently, identification of beverages that promote longer-
term fluid retention and maintenance of fluid balance for pro-
longed periods would be of real clinical and practical benefit in
situations in which free access to fluids is limited, or when
frequent breaks for urination are not desirable (2–5). In this
study we propose a novel tool to enable the objective assess-
ment of a beverage’s effectiveness to maintain hydration status
over a period of time after ingestion. The calculated BHI re-
vealed that drinks containing the highest macronutrient and
FIGURE 2 BHIs for 13 commonly consumed and commercially avail-
able drinks. Drinks with different responses to still water were identified by electrolyte contents were the most effective at maintaining
paired t test analysis: *P , 0.05, **P , 0.01. The dashed line represents fluid balance.
twice the CV of the BHI measure. Values are means 6 SDs of n = 17 The differences noted in the urine volume and calculated BHI
observations on each test drink, except for orange juice and diet cola (n = during the monitoring period might be attributed in part to dif-
16) and tea (n = 15). BHI, beverage hydration index.
ferences in the water content of the different drinks. Stahl et al.
(17) recognized that the amount of water present in a fixed
volume of beverage varies because of the presence of other
differences for 2 h BHI values were 0.50 (95% CI: 0.20, 0.80)
nutrients, meaning the amount of water available to influence
for full-fat milk, 0.58 (95% CI: 0.28, 0.89) for skimmed milk,
hydration status can markedly differ, an observation these authors
0.54 (95% CI: 0.16, 0.93) for ORS, and 0.39 (95% CI: 0.05,
termed the “postabsorptive hydration index.” The water content
0.73) for orange juice. Additionally, full-fat milk, skimmed
of the test beverages in the present study ranged from 100% for
milk, ORS, and orange juice BHIs were greater than that for still
water at 3 and 4 h after drink consumption (P , 0.05).