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Do small differences in hydration status affect mood and mental

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Article  in  Nutrition Reviews · September 2015

DOI: 10.1093/nutrit/nuv045

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Supplement Article

Do small differences in hydration status affect mood and

mental performance?
David Benton and Hayley A. Young

Although it has been suggested that many in the general population are
dehydrated to the extent that mood and cognition are disrupted, there has been lit-
tle research investigating mild levels of dehydration. When dehydration reduces
body mass by more than 2%, it has been consistently reported that mood is influ-
enced, fatigue is greater, and alertness is lower. In contrast, the effects on cognition
have been less consistent. Only a few studies have looked at females and these
studies made little attempt to consider hormones that influence kidney functioning.
In particular, there has been virtually no attempt to look at changes in hydration
status in the range that occurs in individuals with a sedentary lifestyle in a temper-
ate climate. There is a consequent need to study individuals who have lost up to
1% of body mass due to dehydration. While 4 intervention trials have found that
the cognition of children improved in response to water consumption, the effects of
water consumption on cognition in older adults, another high-risk group, have
been largely ignored.

INTRODUCTION disrupted by low intake of fluid? In healthy adults in the

Although water is an essential nutrient, the influence of
small variations in its provision has been little studied
in free-living members of the population. Researchers
often assume that thirst and homeostatic mechanisms
have developed to the extent that the hydration status of
those living in temperate climates and whose lifestyle
does not include prolonged activity is likely to be in the
normal range most of the time. Yet, a review of the lim-
ited evidence concluded that “being dehydrated by just
2% impairs performance in tasks that require attention,
psychomotor, and immediate memory and working
memory tasks, as well as assessment of the subjective
state.”1 The following questions then arise. In everyday
life, to what degree is bodily fluid lost? Does a 2% loss
of body mass occur often? What degree of dehydration
disrupts the functioning of the brain? Can it be <2%?
Are there high-risk groups, such as children and older
adults, whose psychological functioning is commonly
general population, how consistent is the evidence that
mood and cognition are influenced by the variations in
hydration status that occur in the course of daily living?
The point at which water loss affects performance
is not yet clearly established. However, given the funda-
mental importance of water for the body, dehydration
will inevitably disrupt functioning at some point. The
impact of dehydration on athletic performance has
been widely studied, and a meta-analysis established
that dehydration amounting to 5% or more of body
mass impairs both VO2max and exercise performance.2
The evidence was, however, insufficient to conclude
that smaller degrees of dehydration affected perfor-
mance. It was noted that interpretation was often diffi-
cult, as the means of inducing dehydration introduced
potentially confounding variables, such as the effects of
exercise, increased body temperature, changes in sub-
strate availability, and the acid–base status. If there is
this degree of uncertainty with the relatively large

Affiliation: D. Benton and H. Young are with the Department of Psychology, Swansea University, Swansea, Wales, UK.
Correspondence: D. Benton, Department of Psychology, Swansea University, Swansea SA2 8PP, Wales, UK. E-mail d.benton@swansea.ac.uk.
Phone: þþ44-1792-295607.
Key words: children, cognition, dehydration, hydration, mild dehydration, mood.
C The Author(s) 2015. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For
V
Permissions, please e-mail: journals.permissions@oup.com.

doi: 10.1093/nutrit/nuv045
Nutrition ReviewsV Vol. 73(S2):83–96
R
83
changes in hydration associated with exercise, what evi-
dence is there that the degree of fluid loss experienced
during a normal day has the potential to be disruptive?
Although there are suggestions that a loss of as little as
1%–2% of body mass may reduce psychological func-
tioning, is there evidence that changes of this magni-
tude occur regularly? Alternatively, could a smaller loss
of body mass be established as disruptive when an ap-
propriate experimental design and sensitive measures
are used? Table 13–32 briefly summarizes studies that
have varied hydration status and examined the effects
on mood and cognition. Rather than discussing each
study in turn in the present review, various generaliza-
tions are made and considered.
Changes in psychological functioning
One major impression created by examining the studies
collectively is that it is easier to observe changes in
mood than in cognition. All 21 studies that reported
ratings of mood found that it was adversely influenced
by dehydration. Specifically, people were less alert and
more fatigued. In contrast, only 13 of the 25 cognition
studies reported at least 1 significant result. Another
impression is that the sample sizes used in many of the
studies reflect those that are commonly used in exercise
studies rather than a considered intention to look for
changes in psychological functioning. There is a clear
need to use power statistics to indicate the necessary
sample size. Human behavior is extremely variable,
both between individuals and within an individual. As
behavior reflects a multitude of factors, it is probable
that the manipulation of any single variable is going to
make, at the most, a small difference. Clearly, when de-
hydration is extreme, the impact will be greater and will
be picked up in small-scale studies. However, if minor
changes in hydration status are sought, like those that
occur in everyday life, only large samples will produce
the needed statistical power. An obvious hypothesis is
that the relatively frequent failure to find changes in
cognitive functioning may reflect a lack of statistical
power.
In considering future research, a first step is to ask
what effect size is likely to occur. There have been many
attempts to find a perceived improvement, using qual-
ity-of-life measures to compute the minimum differ-
ence needed following a medical intervention. One
review that considered changes in quality of life con-
cluded that such improvements have been found to be
consistently in the order of half of a standard deviation;
this possibly reflects a limit in the ability to discriminate
that is about half of a standard deviation.33 Cohen34 de-
fined a medium effect size as a difference of half of a
standard deviation, a difference that power statistics
84
indicate would need 2 samples of 63 in a parallel design
to have a power of 0.80 at the 0.05 level of significance.
Table 1 suggests that a difference in mood effected by
hydration status occurred repeatedly with much smaller
sample sizes, suggesting that a larger effect was being
studied. It seems, however, that the effect of hydration
on aspects of cognition is less robust; assuming there is
an effect, larger samples than used to date should be
considered.
If a typical sample size used in this area is put into
context and compared, for example a sample of 10 who
were dehydrated compared with another 10 who were
euhydrated, it would be possible, with 0.80 power and
0.05 significance, to distinguish a difference amounting
to 1.25 standard deviations. Cohen defines a large effect
size as 0.8 of a standard deviation. A priori it might be
expected that minor changes in hydration status are not
going to have such an obvious influence on cognitive
function. Naturally, testing the same individuals under
different conditions would decrease the sample size re-
quired, but such a repeated measures design often
causes problems when psychological tests are consid-
ered. The second time a test is taken, learning will have
taken place, strategies may have been developed, and
the motivation created by novelty may have passed. At
the very least, individuals should be tested so that the
order of treatment is sometimes AB and at other times
it is BA. This does not control for the order of testing,
and this variable will need to be added to the analysis.
Unfortunately, it is not uncommon to find an interac-
tion between the order of testing and the treatment,
making the data difficult, if not impossible, to interpret.
Any expectation that minor levels of dehydration
will cause only small cognitive differences raises various
possible reactions. One is that although statistical signif-
icance may be achieved with increased power, little of
practical importance may be gained. This response
could easily become a reason for despair, as it is in the
nature of human behavior that a vast range of factors all
have a small influence. It is unrealistic to expect that a
small change in a single variable is going to have a ma-
jor impact on everyday behavior. As such, any single in-
tervention by itself may have little chance of success,
although it may still be of use when it is part of a more
widespread coordinated program of intervention.
Another response is that, in sport, where small margins
make the difference, the philosophy of looking for
many “marginal gains” can bring success. From this
perspective, considering even small differences in hy-
dration status offers another opportunity for a marginal
gain. A third reaction is the need to consider individual
differences, such that although, on average, the effects
may be small, for some individuals, they are larger and
more important.
Nutrition ReviewsV Vol. 73(S2):83–96
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 Table 1 Summary of studies investigating the effects of dehydration on mood and cognition
Reference Study design Participants Age (y)a Ambient Body mass Mood Cognition
temperature
Sharma et al.3 4 h at raised temperature followed M ¼ 25 20–35 25, 29.6, 32.2, Alertness ; Card sorting ;
by exercise 33.3 C with dry or Vigilance ;

R
humid heat Associative learning ;
for 4 h
Sharma et al.4 Heat þ exercise M¼8 21–24 45 C, 30% humidity 1%, 2%, 3% Symbol substitution n.s.
39 C, 60% humidity Working memory
1% n.s., 2%, 3% ;
Psychomotor

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1% n.s., 2%, 3% ;
Gopinathan et al.5 Water restriction and exercise in heat M ¼ 11 20  25 45 C 1%, 2%, 3%, Arithmetic ;
4% Memory ;
Visuomotor tracking ;
Cian et al.6 1.5 h and 3.5 h at 25 C with or without M¼8 27 25 C 2.8% Fatigue : Discrimination ;
fluid and exercise Psychomotor
memory ;
Cian et al.7 Heat þ exercise M¼7 25 45 C, 70% humidity 2.8% Fatigue : Working memory ;
50 C, 20% humidity Perceptual discrimination ;
Reaction times n.s.
Long-term memory n.s.
Tracking n.s.
Neave et al.8 No drinking from 2400 to 1100 6 300 mL M ¼ 12 20 Calmness ; Cognitive battery:
water F ¼ 12 Alertness ; all dimensions n.s.
Rogers et al.9 No drinking for 2 h prior to a M ¼ 30 26 Alertness : at 2 min When thirsty, drink increased
2-h test during which water was drunk F ¼ 30 but not 25 or sustained attention; when not
50 min thirsty, drink decreased
performance
Shirreffs et al.10 Fluid restriction for 13, 24, and 37 h M¼9 30 2.7% at Concentration ;
Comparison of serum at 24 h F¼6 37 h Alertness ;
290 mOsmol/kg with control of Tiredness :
281 mOsmol/kg
Patel et al.11 Comparison of fluid restriction þ M ¼ 24 22 2.5% Fatigue : Memory ;
exercise vs Concussive symptoms :
euhydration Reaction times n.s.
Comparison of urine Speed of processing n.s.
1.025 mOsmol/kg H2O with Working memory n.s.
1.010 mOsmol/kg H2O Postural stability n.s.
Szinnai et al.12 24 h fluid restriction M¼8 28 2.6% Tiredness : Addition n.s.
Comparison of serum 288 mOsmol/kg F¼8 25 Perceived effort : Reaction times n.s.
H2O with 295 mOsmol/kg H2O Alertness ; Tracking n.s.
Comparison of urine 567 mOsmol/kg H2O Stroop task n.s.
with 967
mOsmol/kg H2O
(continued)

85
86
Table 1 Continued
Reference Study design Participants Age (y)a Ambient Body mass Mood Cognition
temperature
Lieberman et al.13 Monitoring of soldiers for 53 h during M ¼ 31 31 5.0% Vigor ; Vigilance ;
training in heat with little sleep Fatigue : Reaction times ;
Confusion: Memory ;
Depression : Reasoning ;
Grego et al.14 3 h cycling 6 M¼8 31 2.2% or Critical flicker fusion n.s.
fluid ingestion 4.1% Map recognition n.s.
Serwah et al.15 Exercise with 100%, 50%, or 0% of fluid M¼8 24 31 C 1.0% or Reaction times n.s.
lost consumed 1.7%
Petri et al.16 24 h without M ¼ 10 25 Energy ; Battery tests of perception,
fluid thinking, and memory took
longer when dehydrated
Tomporowski et al.17 Cycling for 120 min with or without fluid M ¼ 11 26 0.7 with fluid Reaction times n.s
replacement and 3.7% Memory n.s.
without Executive task n.s.
Edwards et al.18 Cycling þ soccer game 6 fluid M ¼ 11 24 0.7% with fluid Perceived Concentration n.s.
2.4% exertion :
no fluid
Backhouse et al.19 90 min run at M ¼ 15 21 1.4% Ratings of
70% VO2max þ fluid pleasure ;
6water 2.7%
fluid
Baker et al.20 Interval walking for 3 h M ¼ 11 21 40 C, 20% humidity 1% to 3% Lightheadedness : Vigilance ;
20% humidity Fatigue :
Adam et al.21 Soldiers studied without or without M¼6 24 2 or 20 C 3.0% Vigilance n.s.
being at 45 C for 8 hours F¼2 Simulated sentry duty n.s.
D’Anci et al.22 Comparison of athletes M ¼ 16 20 23 C, 45–55% M, 2.0% Anger : Vigilance ;
with F ¼ 15 humidity F, 1.65% Fatigue : Digit span :
and without Depression : Memory n.s.
fluid intake Tension : Spatial memory n.s.
Confusion :
Badelow et al.23 Comparison of soccer players before and M ¼ 20 20 34 C, 62–65% Up to Finger tapping n.s
after soccer match relative to humidity 2.5% Visual sensitivity n.s
fluid availability Working memory n.s
Ganio et al.24 Exercise-induced M ¼ 26 20 27.7 C, 42% 0.01% Fatigue : Vigilance ;
dehydration humidity 1.59% Anxiety : Working memory ;
Depression n.s.
Anger n.s.

R
Confusion n.s.
Armstrong et al.25 Exercise and diuretic-induced F ¼ 25 23 Exercised at 27.6 C 1.36% Anger : Vigilance n.s.
dehydration and 49.4% Fatigue : Reaction times n.s.
Comparison of plasma humidity Vigor ; Reasoning n.s.
3.5 mOsm/kg with 10.1 mOsm/kg Working memory n.s.
(continued)

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 Table 1 Continued
Reference Study design Participants Age (y)a Ambient Body mass Mood Cognition

R
temperature
Streitbuerger et al.26 Water intake of 3–4 L over 10-h period, M¼3 25 þ1.2% Tower of London n.s.
then 150 mL per day for 2 days F¼3 2.5%
Edmond et al.27 Comparison of water intake vs no water M ¼ 12 29 Fear n.s. Reaction timec
intake first thing in the morning F ¼ 25 Confusionb: Associate learning n.s.
Sadnessb : Memory n.s.

Nutrition ReviewsV Vol. 73(S2):83–96

Anger n.s. Dimensional set shiftc
Energy n.s. Vigilancec
Tiredness n.s. Choice reaction time n.s.
Happiness n.s.
Tensionb :
Pross et al.28 No drink allowed F ¼ 20 25 Fatigue :
for 23–24 h Alertness ;
Comparison of plasma Confusion :
297 mOsm/kg with 302 Sleepiness :
mOsm/kg
Ely et al.29 Exercise þ heat M ¼ 32 22 50 C, 20% humidity 4.0% Fatigue : Psychomotor n.s.
exposure Confusion : Reaction times n.s.
Anger : Matching to sample n.s.
Depression : Reasoning n.s.
Vigor n.s.
Anxiety n.s.
Lindseth et al.30 Restricted fluid M ¼ 40 20 1 to 3% Working memory n.s.
intake for 2 weeks Spatial orientation ;
Flight performance ;
Shirreffs et al.31 Euhydrated or M¼9 30 Concentration ;
restricted intake for 37 h F¼6 Tiredness :
Alertness ;
Pross et al.32 Increased fluid consumption in tradition- M ¼ 11 25 With low intake:
ally low-level fluid consumers vs re- F ¼ 41 Fatigue ;
stricted fluid consumption in Confusion ;
traditionally high-level fluid consumers With high intake:
Content
Contentedness ;
Positive emotion ;
Vigor ;
a
Age expressed as range or mean
b
First test only
c
Interaction with order of testing
Abbreviations: ;, less than control; :, more than control; F, female; M, male; n.s., not significant,

87
Sex differences
Most of the studies listed in Table 1 were conducted
with males rather than females. Since it cannot be as-
sumed that the sexes respond in an identical manner,
more studies should be performed with both males and
females in order to make direct comparisons. It is sur-
prising that there have been few attempts to relate hy-
dration status and fluid needs to the stages of the
menstrual cycle, as fluid retention is a frequently men-
tioned premenstrual symptom and estrogen, the level of
which is high in the follicular stage of the cycle, are
known to influence kidney function.35
The American College of Sports Medicine has
noted that high levels of estrogen, such as occurs toward
the middle of the menstrual cycle, during pregnancy,
and when taking some types of oral contraceptives, are
associated with water retention, leading to expansion of
plasma volume. Throughout the menstrual cycle,
changes in the level of antidiuretic hormone parallel
those of estrogen and also rise when estrogen is given to
postmenopausal women. In a high-estrogen state, a
combination of increased fluid intake and greater fluid
retention increases total body water. Prasha et al.36
found that urine production was lower and sodium re-
lease greater in the postmenstrual phase; these changes
were not related to the rate of glomerular filtration. In
those taking an oral contraceptive, the excretion of wa-
ter and minerals and creatinine were lower. Female sex
hormones cause renal vasodilation and decrease the
proportion of fluid that, after reaching the kidneys,
passes into the renal tubules.37 A major symptom of
premenstrual syndrome, a time when the levels of pro-
gesterone are high, is water retention, although athletes
find this to be less of a problem.38 There is also a com-
mon belief that taking an oral contraceptive is associ-
ated with weight gain39 to the extent that a concern
about gaining weight is a frequent reason for stopping
the pill.40 Thus, in the context of dehydration, there is a
need to compare males and females, and there is a need
to consider the stage of the menstrual cycle and the use
of oral contraceptives. A minority of the studies listed
in Table 13–32 considered both males and females.
Body temperature
To date, a majority of studies on dehydration have been
orientated toward individuals engaging in sports and
exercise or those in the military, looking to see if judg-
ment is disrupted as hydration is reduced. Typically, de-
hydration was induced by either, or both, exercise and a
high ambient temperature. Immediately, confounding
variables such as physical fatigue and an increased body
temperature are introduced, making it impossible to
88
conclude that any disruption is due to a lack of fluid. A
raised body temperature, in particular, has been sug-
gested to influence both mood and cognitive function-
ing. In 1938, Kleitman et al.41 suggested for the first
time that body temperature regulates performance,
commenting that “there are two interpretations of the
relationship between temperature and reaction time
possible: either a, mental processes represent chemical
reactions in themselves, or b, the speed of thinking de-
pends upon the level of metabolic activity of the cells of
the cerebral cortex, and by the raising of the latter
through an increase in body temperature we indirectly
speed up the thought process.” When body temperature
was raised to 38.80 C–39.05 C by immersion in wa-
ter,42 the increase in core temperature resulted in an in-
crease in the speed of performance on a series of tests,
reduced alertness, and increased irritability. It has been
suggested that performance is better when body tem-
perature is at its circadian peak and poorer at the low
point of the cycle. Body temperature rises from a nadir
in the early morning to a zenith in the early evening,
with a variation of about 0.5 C. Wright et al.,43 in a
study that uncoupled temperature from other physio-
logical parameters, found that working memory, alert-
ness, and attention were better at the stage of the cycle
when body temperature was at its highest. Another rea-
son for taking circadian changes into account when
considering hydration is that urine production varies
systematically over the 24-hour period, being lowest at
night.44
Such data suggest that those wishing to exclusively
consider the influence of dehydration need to distin-
guish any impact from changes in body temperature. In
addition, if body temperature is important, then the
time of day may prove to be critical. It would be ex-
pected that any increase in temperature would prove to
be more beneficial earlier in the day, before circadian
changes reach maximum levels. Although the findings
primarily showed that dehydration was disruptive
(Table 1) and the above studies found that a raised tem-
perature was beneficial, the possibility should be con-
sidered that a response to temperature changes is
masking an adverse response to reduced fluid levels.
Fluid replacement
Many of the studies listed in Table 13–32 simply reflect
correlations such that causality cannot be demon-
strated. Dehydration was induced and performance de-
clined, but why? A potentially better design is to induce
dehydration and then rehydrate some individuals, ide-
ally using a dose–response paradigm. Cian et al.7 dehy-
drated individuals by subjecting them to heat and
exercise (2.8% body mass) and then gave beverages
Nutrition ReviewsV Vol. 73(S2):83–96
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with or without glucose and salt. After 2 hours, no ben-
eficial effects on cognitive measures were found.
Although Neave et al.8 did not report any indication of
the extent of dehydration, they found no positive re-
sponse to water consumption after 12 hours without
fluid. A study of military personnel induced dehydra-
tion (3.0% body mass) and then either did or did not
rehydrate.21 No cognitive measures differed in those
who were euhydrated compared with those who were
hypohydrated. Such findings raise questions as they im-
ply that any changes are not related precisely to hydra-
tion status as such. Future research is needed to
establish whether dehydration instigates changes that
are not rapidly reversed by fluid intake.
Degree of dehydration
The European Hydration Institute comments that “fluid
losses of more than 1% of body weight can lead succes-
sively to a reduction in exercise performance and in the
ability to control body temperature. With fluid deficits
of 4% and more, severe performance decrements may
be observed as well as difficulties in concentration,
headaches, irritability and sleepiness, and increases in
body temperature and in respiratory rates. Dehydration
that causes a loss of 10% or more of body weight can be
fatal.” If there is concern, not with athletes whose exer-
tions will lead inevitably to the loss of fluid, but rather
with normal variations in the general population who
do not exercise, is there reason to suggest that relatively
minor differences in hydration status influence psycho-
logical functioning?
There are marked individual differences in the rate
at which dehydration develops when individuals are
subjected to the same environmental conditions.
Benton et al.45 found that when individuals spent 4 h at
30 C, although there was, on average, a 0.6% loss of
body mass, there were substantial individual differ-
ences, with the losses varying from 0.24% to 2.39%.
When faced with such individual differences, the small
sample sizes used in this area have the potential to hide
genuine effects, i.e., the variance added by individual
differences will prevent statistical significance in small-
scale studies.
During daylight hours in the month of Ramadan,
Muslims are not to consume food or liquid. Inevitably,
there will be a progressive loss of body water that
amounts typically to about 1% of body mass by sunset.46
In one study, when individuals did not drink for 37 h, a
loss of 1% of body mass was reported after 13 h, 1.7%
body mass at 24 h, and 2.7% after 37 h.31 It is, however,
unlikely that many in temperate climates will experience
even this degree of dehydration, because the temperature
will be lower and most will drink at some stage.
Nutrition ReviewsV Vol. 73(S2):83–96
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For 2 weeks during which individuals weighed
themselves twice a day while consuming various bever-
ages, weight declined by between 0.15% and 0.43%.47
Even in warmer countries, fluid is likely to be con-
sumed regularly to reduce the extent of dehydration.
When body mass and water balance were monitored for
6 days in Dar es Salaam, Tanzania, it was found that the
coefficient of variation in body weight varied from
0.54% to 0.86%, with an average of 0.7%; the changes
were accounted for by minor differences in the con-
sumption and excretion of water.48 In 1947, Adolph49
wrote about the physiology of individuals living in a de-
sert and suggested that water balance was closely regu-
lated and that body mass was typically kept within
61%; this generalization seems to have withstood the
passage of time.
In fact, little is known about the impact of differ-
ences in the habitual level of fluid intake on physiology.
Perrier et al.50 compared those with different habitual
levels of fluid consumption and related them to bio-
markers related to hydration status. Those who drank
<1.2 L/day or between 2 and 4 L/day were contrasted.
Although the specific gravity, osmolality, and color of
urine differed, plasma osmolality was similar, suggest-
ing the efficiency of mechanisms that preserve plasma
osmolality when fluid intake is low.
It is clear from such data that for differences in hy-
dration status to impact psychological functioning in
free-living individuals who have access to beverages,
one must consider changes that represent <1% of body
mass. The studies listed in Table 13–32 present no rele-
vant evidence. Such findings put into context comments
such as “being dehydrated by just 2% impairs perfor-
mance.”1 A 2% loss is unlikely to occur except when
physically active for a prolonged period without con-
suming fluid. Environmental conditions are rarely go-
ing to induce a 2% loss of body mass. The studies listed
in Table 13–32 give little support for adverse conse-
quences when there is, at most, a 1% loss of body mass.
In fact, very few studies have considered such small
changes. Although Sharma et al.4 found an adverse ef-
fect of losing 3% of body mass, this was not found with
a 1% decline, although arguably the small sample size
could not have demonstrated the significance of any
likely change. Is any suggestion that there is widespread
underhydration in the general population simply
wrong? Alternatively, can evidence be found of an influ-
ence when dehydration is <2%?
Brain volume
The brain is enveloped by 3 layers of tissue called the
meninges. The outer layer is the dura mater, the next is
the arachnoid mater, with the pia mater lying on the
89
 brain’s surface. One role of the meninges is to fix the

Brain: 0.55% after 16 h

Tower of London task

position of the brain and, therefore, reduce collisions

Ventricles increased 3.3% with Dehydration increased

Rehydration: þ0.72%

blood flow during

with the skull. In the subarachnoid space, the arachnoid
mater contains a pool of cerebrospinal fluid (CSF) that
Cognition/mood

surrounds and cushions the brain. In the center of the

brain, there are fluid-filled cavities, known as the cere-
bral ventricles, which communicate with the subarach-
noid space. The choroid plexus, which is found in the
loss body mass and ventricle : ventricles, secretes about 450 mL of CSF per day.51 As
Ventricle: 6.73 mL dehydrated;

lated with decline in body

dehydration; effect corre-
the volume of the ventricles is about 25 mL,52 the CSF
in the ventricles is renewed about 18 times a day.

loss of body mass and

0–25 Hounsfield units

Correlation between
14.29 mL hydrated

Dehydration decreases the volume of blood (hypo-

volemia) and may, therefore, reduce the amount of in-
Body mass, % Brain volume

Ventricle n.s.

tracerebral blood. Dehydration also increases plasma

Correlation

Ventricle :

ventricle :
Whole n.s.

osmolarity, which changes the volume of the brain53

Brain n.s.

mass
1.56

and leads to fluid being drawn from cells. Both of these

effects are compensated by changes in the volume of
CSF in the ventricles and the subarachnoid space.
When the capacity of the choroid plexus is insufficient
2.31

to replace the lost volume, CSF is drawn from the spinal

2.2

1.6

cord into the cranium54 until the choroid plexus is able

Table 2 Summary of studies investigating the influence of dehydration on the volume of cerebral ventricles

to replace any deficiency.

480 mOsm/kg and 499 mOsm/kg

Thus, although the associations between brain vol-

Plasma: 280 mmOsmol/L when

osmolarity was similar in the

hydrated; 290 mmOsmol/L

ume and the levels of intracranial blood and CSF are

19 C (61), 40% Urine: Prior to dehydration,
Serum: 294–340 nmol/kg
Urine: 223–512 nmol/kg

complex, there are good reasons to suggest that dehy-

dration influences the structure of the brain, with the
when dehydrated

possibility that its functioning will be compromised.

Dehydration can be expected to reduce brain volume, a
2 groups:
Osmolarity

consequence of increased serum osmolality that causes

Abbreviations: :, significantly positive correlation; F, female; M, male; n.s., not significant,

cells to shrink with an inevitable enlargement of the

ventricles.
This topic has been the subject of limited study, but
31 C (61), 40%

20 C (61), 45%

the few that have been performed are summarized in

temperature

humidity

humidity

humidity

Table 2.55–59 With dehydration, the expected increase in

(62%)

(65%)

(65%)
Participants Mean age (y) Ambient

the size of the ventricles has been found consistently.

Although Dickson et al.56 did not find an overall change
in volume, they did find that the loss in body mass cor-
related significantly with an increased size of the ventri-
cles. The procedures used induced changes of between
19.8

23.8

16.8

1.5% and 2.5 % of body mass. Kempton et al.59 similarly

27

reported a significant association between changes in

9 M 11 F

the volume of the lateral ventricle and body mass; those

5M5F

who lost about 2% of body mass had lateral ventricles

1M

6M

7M

that were 7% larger. In contrast, in those who lost about

for 90 min 6heavy

for 60 min 6heavy

þ 40 mg frusemide

1.3% of body mass, the volume of the ventricles did not

1 h before exercise

1 h before exercise
24 h dehydration

16 h dehydration

change.
Before/after 1 h
Study design

Streitburger et al.26 asked participants to drink

500 mL H2O

500 mL H2O
exercise

clothes

clothes

3–4 L of water over a 10-h period and found that the

size of the ventricles reduced by, on average, 3.5%. The
average difference in ventricular volume between indi-
Reveley55

viduals who were dehydrated and those who were

Reference

Kempton

Kempton
Mellanby

et al.56

et al.57

et al.58

et al.59
Dickson

hyperhydrated was 6.2%. Whether there is commonly a

Duning
and

minor degree of dehydration, such that many would

benefit from consuming more fluid, is uncertain.

90 Nutrition ReviewsV Vol. 73(S2):83–96

R
The consequences of increasing the volume of the brain
is unclear since, at some stage, there will be an adverse
effect; normally, there is a concentration gradient such
that an excess of water outside a cell draws sodium
from the cell into serum. Hyponatremia is associated
with a lower-than-usual level of sodium in plasma so
that water enters the cells of the brain, causing them to
swell. In extreme cases, this causes hyponatremic en-
cephalopathy, which is potentially damaging as the
brain is confined inside the rigid bones of the skull.
Whether there is a benefit from a minor increase in the
level of hydration, bringing with it cognitive benefits,
could be considered. Although clearly the volumes of
water consumed in the study of Streitbuerger et al.26 are
in excess of what is consumed regularly, whether bever-
ages of different compositions are more or less able to
hydrate the brain, without compromising the electrolyte
levels, could be considered.
It would, nevertheless, be premature to conclude
that there are no implications for brain functioning be-
cause the ventricles were not enlarged when there was a
decline in body mass of <1%. A measurement of
changes in the size of the ventricles is an extremely
crude index of the status of the brain. It is reasonable to
view any change in the size of the brain as a substantial
insult, such that more minor changes could also prove
to be disruptive and more likely to be demonstrated us-
ing functional rather than structural imaging. To date,
only 1 study has used this approach to relate psychologi-
cal functioning to dehydration-induced changes in
brain functioning. Kempton et al.59 employed the
Tower of London task that monitors executive function-
ing, i.e., planning carried out by the frontal lobes of the
cerebral cortex. Dehydration did not change the ability
of individuals to perform the task; however, when dehy-
drated, functional magnetic resonance imaging showed
greater blood flow to the frontal cortex. It appeared that
dehydration had placed demands on the brain such that
greater resources were required to achieve the same level
of output. A related study used electroencephalography
to monitor brain activity while various cognitive tasks
were performed by participants who had been kept at
25 C or 35 C to increase core body temperature.60
Evoked potentials showed an increase in amplitude and
a decrease in latency, findings that are consistent with a
need for increased neural activity to obtain the same
level of performance when core temperature was raised.
It is an obvious suggestion that the use of functional im-
aging techniques may offer a method that is sensitive
enough to demonstrate the consequences of a relatively
small degree of dehydration.
The magnitude of these changes is put in context by
the report that a 1 year follow-up found that ventricular
volume was increased by 5%–16% in Alzheimer’s
Nutrition ReviewsV Vol. 73(S2):83–96
R
patients and 3.5% in those with mild cognitive impair-
ment.61 In adults, the skull is of a fixed size, with a vol-
ume equivalent to the size of the brain and the volume
of CSF and blood. However, the volumes of these 3
compartments can change, with implications for the
susceptibility to brain damage that results from head in-
jury. More specifically, studies of neurodegeneration in-
creasingly use brain imaging to detect the progression of
disease, with consequences for early diagnosis and the
evaluation of therapeutic interventions. Given that such
techniques can pick up changes that amount to as little
as 0.2% of brain volume,62 even mild dehydration, if it
has consequences for the volume of the brain, will inevi-
tably have an adverse influence on the accuracy of such
assessments. It has been found that in healthy adults
there is an annual expansion of the ventricles of between
1.5% and 3.0%.63 It is easy to suggest that with a disor-
der such as Alzheimer’s disease, a failure to remember
to drink regularly could result in brain shrinkage that, if
not controlled, could be confused with brain atrophy.
As such, there is an obvious need to establish the impact,
if any, of even minor degrees of dehydration.
Thus, at the very least, hydration status has the abil-
ity to add error when using brain imaging to monitor
the progression of disease. In addition, dehydration
may potentially exacerbate existing problems. In sum-
mary, there is clear evidence that dehydration of the
level that occurs during some sports causes shrinkage of
the brain. As yet, whether more limited dehydration has
implications for the brain and, consequently, psycho-
logical functioning is unclear.
Older adults
The studies listed in Table 1 almost exclusively investi-
gated individuals between the ages of 20 and 30 years,
such that little can be said about older or younger age
groups (see Table 3). In fact, most studies have consid-
ered fit young individuals, and it may be that the find-
ings do not readily generalize to those who are older or
to those without a history of regular exercise. For a vari-
ety of reasons, older adults are likely to be more suscep-
tible to dehydration than younger adults; in fact, higher
mortality rates and readmission to the hospital have
been associated with low fluid intake.64 In addition to
the physiological changes associated with aging, disabil-
ity may reduce access to fluids, and the use of diuretics
and other drugs may decrease hydration status.
In older adults, a lower level of lean body mass re-
sults in an increased ratio of extracellular to intracellular
mass65; in fact, the bodies of older rather than younger
adults can contain from 10% to 15% less water. There is
also less renal mass with age, reflecting glomerular scle-
rosis and glomerular loss,66,67 with a consequent reduced
91
 Table 3 Summary of studies investigating the influence of water consumption on cognitive test performance in children
Reference Study design No. of participants, Cognition/mood test Outcome
age, climatea
Bar-David et al.76 Comparison of urine N ¼ 58 10.112.4 y, Hidden figures Hydration status did not influence perfor-
osmolarity in the warm climate Number span mance in morning
morning vs the Making groups Number span poorer in afternoon if
afternoon Verbal analogies dehydrated
Addition Other tests n.s.
Benton and Comparison of water N ¼ 40, 8.7 y Memory Results of both tests better when water
Burgess77 intake vs no water Sustained attention had been drunk
intake
Edmonds and Comparison of children N ¼ 58, 79 y Memory Visual attention tasks (letter cancellation
Burford78 who did or did not Letter cancellation and spot the difference) better after
drink water Spot the difference drinking water
Tracking Memory and tracking n.s.
Edmonds and Comparison of children N ¼ 23, 7.3 y Visual attention Visual attention and visual search better
Jeffes79 who had and had not Visual search in those who had drunk water
drunk water Memory Rated themselves happier with water
Motor performance intake
Memory and motor performance n.s.
Benton80 Comparison of 6 testing N ¼ 22, 9 y Activity sampling used When water had been drunk more time
periods; 3 when water to establish the time was spent concentrating on school
had been drunk and 3 spent in school work
when it had not concentrating on
their work
Fadda et al.81 Comparison of children N ¼ 168, 9  11, y Selective attention Better hydration status correlated with
who did or did not warm climate Addition better working memory (number span)
drink water Number span Other cognitive measures n.s.
Verbal analogies Better hydration associated with higher
Spatial ability ratings of vigor but the rating of fatigue
Mood scale was n.s.

a
Ages expressed as ranges or means; climate included when specified

ability to control the balance of both sodium and water,
resulting in an increased incidence of dehydration. An
impaired thirst mechanism resulting from hormonal
changes may also play a role in the reduction of fluid in-
take.68,69 The above changes are only a few of many
mechanisms that result in a reduced ability to maintain
an adequate level of hydration with age. Water intake
from food and beverages has been found to be lower in
American men aged 70–79 years than those aged 40–49
years. Similarly, older males produce a greater volume of
urine.70 Individual differences in both the intake of wa-
ter and urine production were found, and it was con-
cluded that water turnover is highly variable, with these
differences being little explained by anthropometric pa-
rameters. Although such problems are widely acknowl-
edged, there have been surprisingly few attempts to
relate hydration status to mood and cognition in older
individuals.
Suhr et al.71 compared 2 groups that either had or
had not been asked to abstain from eating and drinking
after their evening meal. The following day, bioelectrical
impedance was used to estimate body fluid; changes in
the ratio of total body water to body weight approached
statistical significance. In this sample of individuals be-
tween the ages of 50 and 82 years, poorer hydration was
associated with slower psychomotor processing speed,
poorer attention, and poorer memory. However, in the
absence of evidence that any detriment in functioning
responded to rehydration, it cannot be concluded that
the lack of fluid intake was the causal mechanism. A
later study by the same group looked at postmenopausal
women, with a mean age of 60 years, who lived in the
community.72 Again, the ratio of total body water to
weight was used as an index of hydration status and was
found to relate to memory. However, when diastolic
blood pressure was included in the analysis, the rela-
tionship between hydration status and cognition de-
clined. As hydration is known to influence blood
pressure, it appears that it needs to be included in future
considerations of hydration before it can be concluded
that a difference in fluid levels is the mechanism. In a
study of older adults with an average age of 72 years,
21.3% of a sample with chronic hyponatremia had been
admitted to hospital after falling; this figure compared
with only 5.3% of a control group without hyponatre-
mia. Performance on a test of attention was poorer in
those with hyponatremia.73 However, studies that con-
sider existing dehydration status and relate it to cogni-
tion produce no more than correlations that cannot
demonstrate whether a lack of fluid is necessarily a

92 Nutrition ReviewsV Vol. 73(S2):83–96

R
problem. The occurrence of dehydration may involve
more than a simple lack of fluid intake. There may also
be, for example, a reduced food intake such that one
can never be certain that hydration is responsible for
any differences found.
The influence of hydration status on older adults is
clearly an underresearched topic. Given the many rea-
sons for believing that older adults are at a high risk of
dehydration, it is strange that the possibility that im-
proving hydration status might improve cognitive func-
tioning has not been systematically examined. Although
dehydration can be induced in deprivation studies and
related to aspects of cognition, there is a remaining
need to demonstrate that the findings generalize to in-
dividuals living freely in the community. Having as-
sessed preexisting hydration status, evidence that
rehydration was beneficial would be instructive and
studies of free-living individuals are needed. That age
may be an important variable is illustrated by a study
that examined those who subjected themselves to 10
days of strenuous hill walking. In an older group, but
not a younger group, an increase in urine osmolality
was related to a decline in the speed of reaction times.74
Children
Children are another group said to be at high risk of be-
coming dehydrated as they are relatively active, have a
greater surface to mass area, and are often reliant on
others to ask if they are thirsty and to provide a drink.
Yet again, there is limited literature on this topic.
However, in this instance, there is evidence of a positive
response to the provision of fluid. A 2006 review75 of
the association between hydration status and the cogni-
tion of children could not find any intervention studies.
In fact, there was only 1 study and it took a correla-
tional approach.76 Table 376–81 lists the studies per-
formed to date.
In a school in the Israeli desert, where the outside
temperature was 35 C, the scores of 5 tests of cognition,
which were taken in the morning, did not depend on
whether, as judged by urine osmolarity, the 10-year-old
children tested were or were not dehydrated.76
However, in the afternoon, the performance on 1 of 5
tests was better in those who were better hydrated. In
Sicily, an association was found between urinary osmo-
larity and digit span, which is a measure of working
memory. Those who were more dehydrated had poorer
memories and rated themselves as less happy.81 More
recently, there have been several intervention studies
that are important because the findings suggest a causal
relationship between fluid intake and cognitive func-
tioning. If consumption of fluid enhances performance,
this suggests that a deficiency existed, although it should
Nutrition ReviewsV Vol. 73(S2):83–96
R
be kept in mind that those given a drink inevitably
know that this is the case and a placebo effect cannot be
excluded.
In 8-year-old children, the consumption of water
in the afternoon resulted in better memory and sus-
tained attention.77 Similarly in 7- to 9-year-olds, visual
attention and memory were better after water was con-
sumed, although a visuo-motor tracking task was not
influenced.78 A third group of 7-year-olds rated them-
selves as happier after drinking water, and visual atten-
tion and visual search performance were better,
although memory and psycho-motor performance were
unchanged.79 Finally, 9-year-olds who did and did not
drink water were observed and those who drank water
spent more time on their school work.80
Thus, 4 studies have reported that water consump-
tion benefitted aspects of children’s cognition. As nei-
ther physical exercise nor subjection to heat was a part
of these studies, the findings are consistent with these
children being dehydrated even though they lived in a
temperate climate. There was a degree of consistency in
the outcomes; attention improved on 4 occasions77–80
and memory was better on 2 of 3 occasions. In the fu-
ture, the nature of the cognitive problems that are com-
promised, the effects of different ambient temperatures,
the optimal fluid intake, and the pattern of consump-
tion need to be established.
DISCUSSION
Attempts to relate minor changes in hydration status to
mood and cognition are characterized by a series of
methodological problems that make it difficult to draw
conclusions. For example, it is impossible to keep par-
ticipants blind as to whether they have or have not been
able to drink. Given the known major influence of
placebo responses, any differences in performance asso-
ciated with dehydration may, in part at least, reflect as-
sociated expectations or a response to symptoms such
as thirst or a dry mouth. Thus, studies that find a posi-
tive response when water is consumed may potentially
reflect either rehydration or a psychological response to
being allowed to drink. That psychological expectancies
are important is illustrated by a study in which both
consuming caffeine and having the false belief that caf-
feine had been consumed improved both attention and
motor speed.82 However, Edmonds et al.83 gave water
to groups who were and were not given information
about the benefits of its consumption for cognitive per-
formance. It was found that water consumption, not
raised expectations, had a beneficial effect on thirst and
letter cancellation, although digit span and reaction
times were not influenced. One solution to these prob-
lems is to consider not differences between groups but
93
rather differences within groups. Benton et al.45 found a
4-fold difference in the tendency to lose body mass in
individuals subjected to an identical raised temperature.
Given that there is, at best, a limited ability of individ-
uals to appreciate their precise hydration status, relating
objective changes of hydration to changes in psycholog-
ical functioning may largely prevent a placebo response
from having a differential effect.
The widespread use of either exercise and/or expo-
sure to heat to induce dehydration makes it difficult to
distinguish the effect of hydration status from that of
physical fatigue or changes in core temperature.
However, Cian et al.6,7 compared dehydration induced
by passive exposure to heat or exercise and reported
similar decrements in cognition, memory, and percep-
tual discrimination. Thus, neither heat nor exercise was
necessary to disrupt functioning, although dehydration
was a common factor. These studies did, however, in-
duce a loss of more than 2.5% of body mass and, so, are
not representative of the more moderate changes that
occur under everyday conditions. An intriguing finding
was that memory was impaired after dehydration as
well as when dehydration had been prevented by con-
suming water. The impairment of memory, however,
disappeared after 3 h irrespective of whether the partici-
pants had been rehydrated. Such studies in which dehy-
dration is prevented by water consumption are
instructive. Either dehydration is not the mechanism,
or the consumption of water takes time to replace lost
bodily fluid. When water is lost, it is unclear to what ex-
tent it is intra- or extracellular in origin and the extent
to which attempts at rehydration succeed in replacing
the former rather than the latter. It remains to be con-
clusively demonstrated whether any disruption is
caused by dehydration rather than other mechanisms.
One study found that after overnight fasting, reac-
tion times were faster when water was consumed.83 In
addition, they reported that thirst affected the speed of
responding. Responses were slower when no water had
been consumed, but only in those reporting high sub-
jective thirst. The responses of those who did not report
feeling thirsty were not affected by water consumption.
It was suggested that rather than affecting dehydration
as such, any benefit of water supplementation may re-
flect alleviation of the demands placed on central pro-
cessing by the subjective sensation of thirst. It should be
remembered, however, that this was the only significant
finding after taking a long test battery. The finding,
however, supports the view of Cohen84 that subjective
thirst is the mechanism by which dehydration nega-
tively affects cognition, by directing attention away
from performance. The underlying model is that atten-
tion has finite capacity, such that the demands placed
on it by a process such as thirst will inevitably result in
94
less capacity for other activities.85 It has been found that
the effect of water consumption on thirsty individuals
was beneficial, while the effect in the absence of thirst
was detrimental.9 Water consumption, however, in-
creased alertness irrespective of the initial level of thirst.
A later study failed to find that the level of initial thirst
influenced the response to water of those who had not
eaten or drank overnight.8 It is clear that the possibility
that thirst might influence the response to drinking
needs to be further considered as it has been little stud-
ied and the findings are inconsistent.
A key question is how often a reduced hydration
status impacts either mood or cognition in those going
about their everyday lives? Although definitions are ar-
bitrary, mild dehydration has been defined as a fluid
loss of 1% of body mass. Although there are reasonably
consistent reports that a loss of 2% has negative conse-
quences (Table 1), findings to date do not allow a simi-
lar conclusion to be made for a decline of 1% or less of
body mass. There are, however, marked differences in
the tendency to become dehydrated when exposed to
the same environmental conditions.45 There may well
be much to be gained by considering individual differ-
ences so that those with a greater or lesser tendency to
lose body fluid can be distinguished and such differ-
ences related to changes in psychological functioning.
Benton et al.45 has developed a questionnaire that corre-
lates with various consequences of the response to heat.
An issue that has been little considered is the influ-
ence of the habitual level of fluid intake. Does adapta-
tion to the habitual level of intake occur such that any
deviation from that pattern has adverse consequences?
One report indicates this may be the case, although the
phenomenon needs to be examined further.32 In that
study, Pross et al.32 compared those whose habitual in-
take of water was low (<1.2 L/d) or high (2–4 L/d) and
asked them to, respectively, increase or decrease their
daily intake of water. Initially the 2 groups differed little
in their mood. However, restricting the level of intake
of those who were used to a high level of consumption
decreased contentedness, calmness, positive emotions,
and vigor. In contrast, increasing the water consump-
tion of those who were accustomed to a low intake de-
creased fatigue and confusion. Thus, increasing intake
was beneficial in those with a low intake whereas reduc-
ing intake had a negative impact on those with a habitu-
ally higher intake. The extent to which it is necessary to
establish existing levels of fluid intake when carrying
out studies in this area needs to be established.
Another perspective is to consider changes in the
effort required when performing a task, as it is usual for
there to be an element of cognitive reserve, i.e., the ca-
pacity of the brain is not fully used, allowing perfor-
mance to be maintained by working harder. The
Nutrition ReviewsV Vol. 73(S2):83–96
R
hypothesis should be considered that a degree of dehy-
dration may reduce neural capacity such that even if the
performance of a task is similar when euhydrated and
under a minor degree of dehydration, the brain may
need to work harder to achieve a similar performance.
The use of brain imaging is one way to consider this
proposal. To date, 1 study has used this approach and
found that the brain did need to work harder when it
was dehydrated, although the participants experienced
up to a 2.5% loss of body mass.59 If this finding is repli-
cated, the nature of the tests used in this area will need
to be considered, as they will need to generate great
cognitive demands. It should, however, be recognized
that changes in blood flow in brain imaging studies
could be influenced by both a reduction in blood vol-
ume induced by dehydration, as well as an increase in
blood flow induced by the activity of particular areas of
the brain. Experimental designs will need to assess pa-
rameters of both of these potential changes.
Typically, performance has been measured over a
relatively short period of time, whereas if dehydration
requires the brain to work harder to produce the same
output, then perhaps it is the ability to maintain perfor-
mance over a longer period that should be considered.
Consistent with this suggestion was the conclusion of
Grandjean and Grandjean,86 who noted that when an
association was reported between dehydration and cog-
nition, it tended to involve complex tasks that, it was
reasonable to assume, demanded more processing ca-
pacity. The fact that cognitive reserve declines with
age87 is another reason to consider samples of older
adults who also are at risk of reduced kidney efficiency.
CONCLUSION
Although it has been suggested that many in the general
population are dehydrated to the extent that mood and
cognition are disrupted, the influence of a reduced hy-
dration status, at the degree that will occur in those who
have not exercised, has been subject to little study. In
particular, there has been virtually no attempt to look at
changes in hydration status in the range that occurs in
those leading a sedentary life in a temperate climate.
When dehydration reduces body mass by more than 2%
due to the experience of a high ambient temperature or
exercise, there are consistent reports that mood is influ-
enced, fatigue is greater, and alertness is lower. The ef-
fects on cognition, however, have been less consistent.
There consequently remains a need for studies of indi-
viduals losing up to 1% of body mass. In addition, only
a few studies have looked at females and there has been
little attempt to consider the effect of hormones on kid-
ney function. High-risk groups also need to be exam-
ined. Four intervention trials have found that the
Nutrition ReviewsV Vol. 73(S2):83–96
R
cognition of children improved in response to water
consumption. Although there are good reasons to be-
lieve that older adults are a high-risk group, they have
been largely ignored.
Acknowledgments
Funding. D.B. was contracted and funded by the
European Hydration Institute. He received financial re-
imbursement for travel and accommodation expenses
and an honorarium from the European Hydration
Institute for his participation in the conference and for
writing this manuscript.
Declaration of interest. The authors have no relevant in-
terests to declare.
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