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The Validity of Urine Color as a Hydration Biomarker within the General Adult
Population and Athletes: A Systematic Review

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DOI: 10.1080/07315724.2020.1750073

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The Validity of Urine Color as a Hydration

Biomarker within the General Adult Population
and Athletes: A Systematic Review

Samantha B. Kostelnik, Kevin P. Davy, Valisa E. Hedrick, D. Travis Thomas &

Brenda M. Davy

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Adult Population and Athletes: A Systematic Review, Journal of the American College of Nutrition,
DOI: 10.1080/07315724.2020.1750073

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JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
https://doi.org/10.1080/07315724.2020.1750073

REVIEW

The Validity of Urine Color as a Hydration Biomarker within the General

Adult Population and Athletes: A Systematic Review
Samantha B. Kostelnika, Kevin P. Davya, Valisa E. Hedricka, D. Travis Thomasb, and Brenda M. Davya
a
Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virginia, USA; bDepartment of Athletic Training &
Clinical Nutrition, University of Kentucky, Lexington, Kentucky, USA

ABSTRACT ARTICLE HISTORY

Frequent monitoring of hydration status may help to avoid the adverse effects of dehydration. Received 24 January 2020
Other than urine color assessment, hydration assessment methods are largely impractical for the Accepted 27 March 2020
general population and athletes to implement on a routine basis. Despite its widespread use, the
KEYWORDS
validity of urine color as an indicator of hydration status has not been systematically evaluated.
Hydration status; urine
The objective of this systematic review is to determine the validity of urine color evaluation as a color; adult; validity
hydration status assessment method in the general adult population, older adults, and athletes.
Using the PRISMA guidelines, electronic databases were searched to identify original research
articles of all study design types for inclusion. Of the 424 articles screened, 10 met inclusion
criteria. Most studies compared urine color to either urinary specific gravity or urine osmolality,
and reported significant associations (r) ranging from 0.40 to 0.93. Lower correlations were noted
in studies of adults aged >60 years. Studies generally reported a high sensitivity of urine color as
a diagnostic tool for detecting dehydration and supported the ability of this method to distinguish
across categories of hydration status. Research is needed to determine if clinicians, patients, and
clients can accurately utilize this method in clinical and real-world settings. Future research is also
needed to extend these findings to other populations, such as children.

KEY TEACHING POINTS

Inadequate hydration can lead to impairments in physical performance and cognitive function.

Methods used to assess hydration status include plasma/serum osmolality, urinary specific grav-
ity (USG), urine osmolality (Uosm), change in body weight, urine volume, and urine color.

Urine color assessment is a practical method that is routinely used in clinical, athletic, and other
settings. The validity of this method has not been systemically evaluated.

Available research was limited to 10 articles.

Validity of this method was generally supported; however, research has not investigated the
validity of this method by clinicians, patients and clients.

Introduction Therefore, methods to assess hydration status which can be

Maintaining adequate fluid balance is critical for optimizing
physical and cognitive health (1–3). Mild dehydration (i.e.,
1–2% body water loss) can impair memory and concentra-
tion, and result in headaches and anxiety (4, 5). Body water
losses  2% can lead to more severe impairments in cogni-
tive function, fatigue, cardiovascular strain, and heat-stroke
(1,4,6). Inadequate hydration among individuals engaging
in high-intensity exercise, such as athletes, can lead to
muscle cramps, acute renal failure, and heat illness (4,7).
Dehydration may also impact occupational performance.
El-Sharkawy et al., reported that one-third of doctors and
nurses were dehydrated at the beginning of their shift, which
increased to 50% by the end of their shift; dehydration
adversely impacted short-term memory in this population
(8). Adverse effects of dehydration among pilots include
impairments in spatial cognition and flight performance (9).
feasibly utilized on a daily basis in real-world settings are
needed to help avoid these detrimental effects.
Although serum osmolality (Sosm) is considered the gold
standard method for evaluating hydration status (7), it is
not practical for routine use outside of clinical settings. Less
invasive, pragmatic alternatives include urinary specific grav-
ity (USG), urine osmolality (Uosm), changes in body weight,
urine volume, and urine color (4,10,11). Uosm and USG,
which determine solute particle concentrations, have been
reported to be valid hydration status assessment methods
(12–14). However, these techniques require equipment and
trained assessors, and are thus less feasible for most real-
world settings (11,15). Urine color and volume are cost-
effective approaches which can be self-evaluated (10,16);
these methods have demonstrated (moderate to strong valid-
ity (r ¼ 0.78 and R2¼0.45, respectively) athletes and children

CONTACT Samantha B. Kostelnik samak94@vt.edu Department of Human Nutrition, Foods, and Exercise, Room 229 Wallace Hall, Virginia Tech,
Blacksburg, VA 24061, USA.
ß 2020 American College of Nutrition
2 S. B. KOSTELNIK ET AL.
(10,11,17,18). However, research regarding the validity of
these measures within the general adult population is limited
(11,19–21). Armstrong et al. developed an eight-scale urine
color chart, based upon previous research using urine sam-
ples collected in laboratory and field settings (11,17,18,22).
Colors correspond to a numerical ratings, as follows:
1–3 ¼ well hydrated, 4–6 ¼ moderately dehydrated,
7–8 ¼ severely dehydrated (11). Although this method is
practical and widely utilized, no systematic review of the lit-
erature has been conducted to evaluate the validity of urine
color as a hydration assessment method in the general adult
population, athletes, or older adults. Therefore, the objective
of this systematic review is to determine the validity of urine
color assessment as a method to determine hydration status,
and to identify future research needs.
Materials and methods
Study exclusion and inclusion criteria
Eligibility criteria were developed using the population,
intervention, comparison, outcome, and study design
(PICOS) model, which is presented in Table 1. This review
included randomized controlled trials (RCT), experimental
studies, quasi-experimental studies, observational, cohort,
and cross-sectional studies that were published before May
2019, written in the English language. Meta-analyses, sys-
tematic reviews, and narrative reviews were not included.
A meta-analysis was considered to accompany this sys-
tematic review. Due to the substantial heterogeneity in study
designs and populations, a moderator analysis in a meta-
analysis is warranted. However, in this case a moderator
analysis would be underpowered due to the small number of
studies available. Therefore, a qualitative synthesis of find-
ings was performed.
The “general” adult population was defined as study pop-
ulations that were not defined by chronic diseases or condi-
tions. Studies which recruited individuals with specific
disease conditions known to influence fluid balance or urine
color were excluded. For example, individuals with impaired
renal function may have alterations in urine color due to
the disease process (4,7), and individuals with congestive
heart failure or renal failure may be prescribed fluid restric-
tions. Animal studies and studies conducted in children,
adolescents, and pregnant women were excluded. Studies of
older adults were included, as were studies in athletes, due
to the importance of maintaining hydration to optimize
their physical and cognitive performance and the widespread
use of the urine color assessment method. This review was
registered with PROSPERO (approval pending).
Table 1. PICOS objectives.
Population General adult population (18þ years old), including athletes
Intervention Evaluation of hydration status
Comparison Other validated indicators of hydration status; evaluate the quality of evidence
Outcomes Validity and reliability of urine color as a hydration status indicator
Study design RCT, Quasi-experimental, observational, cross-sectional
Database search strategies
The Preferred Reporting Items for Systematic Review and
Meta-Analyses (PRISMA) guidelines were used to develop
search strategies (23). Databases used for this systematic
review include PubMed from NLM (1946–present); Medline
from ProQuest (1946–present); Cumulative Index of
Nursing and Allied Health Literature (CINAHL) from
EbscoHost (1981–present); Scopus (1800s–present); and
Web of Science Core Collection from Clarivate Analytics
(1900–present). In total, there were 20 search terms and
Boolean search operators used for each database, which are
listed in Table 2. Following the initial search stage, articles
were imported into Endnote and title and abstracts were
reviewed for inclusion/exclusion criteria. The search strategy
and abstract review process was duplicated by a second
reviewer; the two reviewers met to resolve differences in
outcomes of the search and abstract review process. Articles
which appeared to meet the established eligibility require-
ments underwent full-text review (n ¼ 424). Figure 1
presents an overview of the search process, and criteria for
article exclusion. For included articles, article quality ratings
which included risk of bias were performed independently
by two reviewers (S.K. and B.D.) using the Academy of
Nutrition and Dietetics Evidence Analysis Library Quality
Rating Tool (24). Individual quality criteria (e.g., clear study
purpose, risk of bias) were rated as “Yes”, “No”,
“Uncertain”, or “N/A”. “Uncertain” was listed when the art-
icle did not adequately address a quality rating criterion.
Overall article quality rating was listed as Positive (most
answers rated “yes”), Neutral, or Negative ( 6 answers
rated “no”). A Neutral rating suggests that the research was
neither strong nor weak, based upon four of the validity
questions within the Quality Rating Tool (24).
Results
Ten articles were identified for inclusion. Findings are sum-
marized within the text according to method of comparison
with urine color, and described in Table 3 according to
study population. Two articles were included that were not
specifically designed as validation studies. However, urine
color was either compared across categories of hydration
status or across experimental conditions of dehydration vs
hydration, thus these studies provided information which
could be used to evaluate the urine color method’s
validity (25,26).
Urinary specific gravity (USG)
Studies which compared urine color to USG utilized
a variety of testing instruments (i.e., Chemstrip Mini Urine
 JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 3

Analyzer, Bayer’s Multistix, an optical refractometer, hand-held 1.010–1.020 ¼ dehydrated) (10,16). Armstrong et al., reported
refractometer). USG results in the general population are inter- moderate to strong correlations between USG and urine color
preted as follows: 1.013 ¼ over-hydrated or hyper-hydrated; in the athletic population (r ¼ 0.68–0.78), and in college males
l.014–1.029 ¼ euhydrated; 1.030 ¼ dehydrated (11). However, (r ¼ 0.54–0.93) (11). In older adults, correlation coefficients
these categories are different for the athletic population (i.e., between USG and urine color were substantially lower
(Table 3). Therefore, urine color may better reflect hydration
status in younger than older populations.
Table 2. Search term combinations.
Urinary terms Assessment Population
Urine color AND: Validity AND: Adult Urine osmolality (Uosm)
Urine AND: Validation Study AND: Older adult
Urinalysis AND: Reliability AND: Young adult Among urinary indicators of hydration status, Uosm is con-
Urine Osmolality AND: Reproducibility AND: College student
Plasma Osmolality AND: Athlete sidered the most valid technique in athletes and healthy
Fluid Balance AND: adults (27,28). Of the studies reviewed, eight utilized Uosm
Hydration AND:
Hydration Status AND:
as the comparator (Table 3). Moderate to high correlation
Euhydration AND: coefficients (i.e., 0.6–0.9) between urine color and Uosm
Dehydration AND: were reported in college-aged males (11) and young adult
Hypohydration AND:
athletes (15). Urine color demonstrated a high sensitivity for

Figure 1. Flow diagram of the systematic review.

Table 3. Summary of urine color studies in healthy adults (Before May 2019). 4

Study Who Assessed Comparison Biomarker, Validity Sensitivity/

Reference Population, Sample Size Design Urine Color Procedure Urine Color Environmental Conditions (p value) Specificity
Athletes
Armstrong et al. (1994) NCAA D1 Tennis Teams, 8 Cohort Armstrong Urine Color Chart Researcher Usg (spot urine), r ¼ 0.78 (<0.0001)
female, 12 male, 20 ± 2y, 57–71% humidity
race unknown
Armstrong et al. (1998) Male Cyclists n ¼ 9, 23 ± 2y, Cohort Armstrong Urine Color Chart Researcher Uosm r ¼ 0.72 (<0.001)
race unknown Usg (spot urine), 36.7 ± 0.2 C r ¼ 0.68 (<0.001)
Harvey et al. (2007) Premier Division Soccer Pre/Post Adapted Armstrong Urine Color Researcher Sweat Loss (spot urine), Best model included
S. B. KOSTELNIK ET AL.

Athletes n ¼ 13, 22.6 ± 4.9y, Chart; used as a predictor of environmental condition body mass loss þ urine
race unknown sweat loss during a soccer match not reported color change,
(compared to other predictors) r2 ¼ 0.57
Fernandez-Elias Olympic Combat Athletes 244 Cross-Sectional Researcher G1a Uosm (spot urine), r ¼ 0.70 (<0.001)
et al. (2014) male, 101 female, Armstrong Urine Color Chart; environmental condition
22.8 ± 4.1y, race unknown ratings compared across three not reported
b
categories of hydration G2 Uosm r ¼ 0.50 (<0.002)
c
status (G1–G3) G3 Uosm r ¼ 0.40 (<0.004)
Older Adults ( 65 years)
Mentes et al. (2006) Nursing Home Residents Cohort Armstrong Urine Color Chart Researcher Usg (spot urine), environmental r ¼ 0.48 (<0.01)
n ¼ 98, subgroup n ¼ 78, condition not reported
84 ± 8.4y, 98% Caucasian
Hooper et al. (2016) Older Adults in DRIE n ¼ 162, Cross-Sectional Human Hydration LLC; http:// Researcher Sosm (spot urine), ROC AUC ¼ 0.51,
85.8 ± 7.9y, race unknown www.hydrationcheck.com environmental condition  70%
Diagnostic accuracy of not reported
assessing dehydration
College Students
Armstrong et al. (1994) College Males n ¼ 23, 23 ± 2y, Cross-Sectional Armstrong Urine Color Chart Researcher Uosm r ¼ 0.62 (<0.01)
race unknown Usg (spot urine), r ¼ 0.54 (<0.01)
36 ± 3% humidity
College Males n ¼ 11, 23 ± 2y, Cross-Sectional Armstrong Urine Color Chart Researcher Uosm† r ¼ 0.92 (<0.001)
race unknown Usg† (spot urine), r ¼ 0.93 (<0.000001)
32.2 ± 0.4% humidity
Zhang et al. (2017) College Males in China Cross-sectional CIE Methodd (Lab); Diagnostic Researcher (using L Uosm (24-h urine), r¼ 0.56 (<0.0001)
n ¼ 68, 19.1 ± 1.1y accuracy for assessing dehydration a chromatrogram 31–35% humidity
spetrophotometer) b Uosm r ¼ 0.86 (<0.0001) For b:
97.4%/65.5%
a Uosm r¼ 0.35 (<0.0001)
Early et al. (2018) College Students n ¼ 6 male, Randomized Armstrong Urine Color Chart; Participant Experimentally induced short- Day 1: (p ¼ 0.04) Day 2:
10 female, 20.6 ± 1.2y, Cross-over ratings compared on days 1, 2, term (3 d.) hydration vs (p ¼ 0.002) Day
race unknown 3 of each study period dehydration (24-hr urine; 3: (p < 0.001)
not heat acclimated)
General Population
Malisova et al. (2016) Healthy Adults from 3 different Cohort Armstrong Urine Color Chart; Researcher Usg (24-hr urine), winter & p < 0.001
countries n ¼ 573, 39 ± 12y, ratings compared across three summer months
Greek, Spanish, German categories of hydration status
Perrier et al. (2017) Healthy French Adults Cohort Armstrong Urine Color Chart; Participant Uosm (24-hr urine), 87.8%/64.3%
n ¼ 82, 23.6 ± 2.9y Diagnostic accuracy for environmental conditions
assessing Uosm>500mOsm/kg not reported
†
pre-exercise comparison.
a
G1: Group 1 (euhydrated (250–700 mOsm kg H2O1)).
b
G2: Group 2 (dehydrated (700–1.080 mOsm kg H2O1)).
c
G3: Group 3 (severely dehydrated (1.080–1.500 mOsm kg H2O1)).
d
CIE (Commission Internationale de l’Eclarige) Method.
 JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 5

detecting Uosm > 500mOsm/kg in healthy French adults

Overall rating

Positive
Positive
Positive
Positive
Positive
Positive
Positive
Positive
Neutral

Neutral
(using urine color >4), but lower specificity in healthy
French adults (64.3%) (29). Zhang et al. (30) reported a
high sensitivity for detecting dehydration, using a spectro-
photometer-based method to assess three aspects of urine
funding
10. Bias

unlikely

Unclear
due to

color (31).
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Two studies evaluated urine color compared to categories
of hydration status determined using Uosm; one in Olympic
combat athletes (32) and one in healthy adults (25).

Overall rating: Negative (), Neutral (ʘ), Positive (þ). Of 10 criteria: 6 or more questions rated as “no” ¼ (); Most answers including 2,3,6,7 are “yes” ¼ (þ); If 2,3,6,7 are not “yes” ¼ ʘ.
9. Conclusions

Fernandez-Elias et al., utilized three cutpoints based on

supported
by results

Uosm as follows: euhydration (250–700 mOsm kg H2O1),

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
mild dehydration (701–1.080 mOsm kg H2O1), and severe
dehydration (1.081–1.500 mOsm kg H2O1) (32). Stronger
correlations were noted between urine color and Uosm-
determined euhydration and mild dehydration, than severe
8. Statistical

appropriate
analysis

dehydration (Table 3). Malisova et al., assessed the hydration

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

status in the general population of three different countries

over a 7-day period and included the measurement of USG,
Uosm, urine color and other urinary markers (25). Uosm
defined, valid

was used to characterize individuals as euhydrated or dehy-

7. Outcomes

and reliable

drated. Urine color was significantly different (P < 0.001)

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

and consistent with Uosm-classified hydration state across

categories in both females (3.0 ± 1.2, 3.9 ± 1.2, 5.5 ± 1.2,
respectively) and males (3.6 ± 1.4, 4.3 ± 1.1, 5.9 ± 1.0, respect-
to prevent bias described in detail
6. Interventions or

ively). Based upon these findings, urine color may be a use-

exposures

ful diagnostic tool for assessing dehydration or suboptimal

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

hydration in a variety of populations, including athletes and

the general adult population, and for characterizing hydra-
tion status across a range of hydration levels.
5. Blinding used

Unclear

Unclear

Unclear

Unclear
Yes
Yes

Yes

Yes
No

No

Serum osmolality (Sosm)

Although more invasive, Sosm can be used to detect min-
imal changes in hydration status (27). Reference intervals
4. Method of

withdrawals

used to classify hydration status based on Sosm are as fol-

described
handling

Unclear
Unclear

Unclear

Unclear
Unclear

lows: 275 to < 295 mOsm/kg indicates euhydration,

Yes
Yes
Yes

Yes
Yes

295–300 mOsm/kg is mild dehydration, and >300 mOsm/

kg is dehydration (33). Only one study reviewed utilized this
method of comparison (34). In this study of older adults,
comparable

the sensitivity and specificity of urine color for assessing

3. Study

Unclear
groups

hydration was suboptimal at  70% (34) suggesting that

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

urine color may not accurately detect dehydration in older

adults (34).
selection free
2. Participant

from bias

Unclear

Other methods of comparison

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Two studies reviewed utilized other methods of evaluating

urine color as a hydration status indicator. Early et al., con-
ducted a randomized crossover study in college students to
Table 4. Article quality assessment.

clearly stated
1. Research

determine the relationship between hydration status, cardio-

question

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

vascular (CV) function and thermoregulatory response

(Table 3) (26). During the hydration phase, participants
were asked to drink ample amounts of fluids and evaluate
their urine color against the Armstrong urine color chart for
Armstrong, 1998

Armstrong, 1994
Fernandez, 2014

Malisova, 2016

three days (15). The instruction was to maintain urine color

Hooper, 2016
Mentes, 2006
Harvey, 2007

Perrier, 2017
Zhang, 2017
Author, year

Early, 2018

at less than three on the eight scale urine color chart.

During the dehydration phase, participants were asked to
restrict their fluid intake so that their perceived urine color
6 S. B. KOSTELNIK ET AL.
was greater than four on the urine color chart, for three
days. Urine color ratings were reported to be different on
days 1, 2, and 3 of each phase (all p < 0.05).
Harvey et al. evaluated predictors of sweat loss before
and after soccer matches in Premier Division soccer players
(18). Predictors examined included urine color, USG, body
mass, and hematocrit. The best prediction model included
body mass change and urine color change (r2 ¼ 0.57).
Based upon their findings, the investigators concluded that
urine color alone does not adequately assess hydration sta-
tus. Therefore, urine color changes may be a suitable
method for determining hydration status on a day-to-day
basis in young adults, but not pre and post event in athletes.
Article quality assessment
Results of the article quality assessment are provided in
Table 4. There was 100% agreement between reviewers on
article quality rating criteria. Of the individual quality crite-
ria, question 5 of the validity questions which addressed
blinding to reduce risk of bias was most problematic across
studies. Overall study quality was generally positive (8 of 10
studies) (24).
Discussion
The literature reviewed generally supported the validity of
urine color as a measure of hydration status in the healthy
adult population, including athletes. However, the available
research was limited to 10 studies, and very few studies
were available in each population subgroup (i.e., 2–4;
Athletes, 4 studies; Older adults, 2 studies; College students,
3 studies; General population, 2 studies. Of the articles
included, 8 evaluated the validity of urine color compared to
established, validated methods of hydration status. Two
articles identified predictors of urine color and evaluated the
sensitivity to change in urine color based upon manipulation
of fluid intake over 3 days (25,26).
The color chart used was largely consistent across studies,
although investigations utilized a variety of reference meth-
ods. Eight of the studies used the validated urine color chart
developed by Armstrong and colleagues (11), and one study
utilized an adapted version of this urine color chart (18).
Studies which utilized validated urinary indices (i.e., USG
and Uosm) as reference methods reported associations with
urine color assessment ranging from r ¼ 0.40–0.93
(7,11,15,30,32). Those which utilized USG reported moder-
ate to strong correlations (i.e., r ¼ 0.48–0.93) with urine
color (35). All but one of these studies utilized spot urine
samples (vs 24-hour urine samples) for USG assessment.
Five studies utilized Uosm as the reference method (in spot
urine samples, n ¼ 2; in 24-hour urine samples, n ¼ 3), and
reported moderate to strong correlations ranging from
r ¼ 0.40–0.92. Two articles included both USG and Uosm as
reference methods; the magnitude of associations with urine
color was similar between the two reference meth-
ods (11,15).
With regard to differences in urine sampling (i.e., spot vs
24-hour urine collections), the range of associations also
appeared to be similar across studies. Most studies (6/10)
measured spot urine, which has been reported to both over-
and underestimate hydration status, depending on time of
day, relative to 24-hr urine collection (36). Two studies
which utilized 24-hour urine samples to investigate the abil-
ity or urine color assessment to accurately diagnose dehy-
dration reported discrepant findings, which may be
attributed to differences in study population (older vs
younger adults). Although Sosm is considered the gold
standard for assessment of hydration status (4,27,37), only
one study included in this review measured both urine color
and Sosm. However, the validity of urine color was not
assessed using Sosm (34).
Three investigations that compared urine color to another
biomarker utilized different statistical methods such as the
AIC Criterion and sensitivity/specificity (18,29,34). Findings
from these studies indicated that urine color is a valid
hydration status assessment method, although there are limi-
tations to using urine color as a sole hydration indicator
(29,30). A variety of factors can influence urine color—these
include acute changes in body mass (38,39), certain foods,
medications and dietary supplements (40), time of day (16),
environmental conditions (4,16) and menstrual cycle phase
(15,21). Previous research has demonstrated strong associa-
tions between urine color, USG, and Uosm, and concluded
that these methods may all be used to determine hydration
status under normal conditions. However, due to their ease
of administration within real-world settings, USG and urine
color are likely the most feasible (41).
Overall, the evidence supporting the validity of urine
color as a hydration biomarker in the general adult popula-
tion and athletes was relatively consistent and positive in
quality, although the limitations of this method must be
acknowledged. Findings appear less certain in older adults,
given the suboptimal diagnostic accuracy of this method for
detecting dehydration in that study population.
There are several notable strengths of this review. First,
an evidence-based framework was used to develop the
research question (i.e., PICOS) and methodology. Second,
the PRISMA guidelines were utilized, which is the recom-
mended approach for designing, conducting, and reporting
results of systematic reviews. Third, article quality ratings
were included, and performed independently by two evalua-
tors. Lastly, focus of this review is significant in that
although urine color assessment is widely utilized in a var-
iety of settings for hydration status assessment, the validity
of this tool has not yet been systematically evaluated.
Several limitations in this body of literature were identi-
fied. First, a limited number of articles were available for
inclusion. Second, limitations in study methods related to
validation methods across studies were noted. Specifically,
all studies did not assess the validity of the urine color chart
using a validated hydration biomarker, and no studies uti-
lized the gold standard reference method for comparison.
Thus, research is needed to confirm the validity of urine
color assessment using Sosm, across population subgroups.

Third, most studies (9 of 10) relied on research staff for
urine color assessment; therefore, the validity of this method
for self-evaluation of daily hydration status is not known.
Additionally, article quality evaluations indicated that
researcher bias could have influenced urine color ratings.
Fourth, research on urine color’s sensitivity to change in
response to changes in hydration status was limited, which
is necessary when using this method to evaluate the effect-
iveness of interventions aimed at improving hydration sta-
tus. Lastly, only three of ten studies evaluated sensitivity and
specificity. If this method is used for diagnostic purposes,
more research is needed to support its validity particularly
among older adults.
Conclusion
The findings of this review suggest that urine color appears
to be a reasonably valid method for determining hydration
status in the general adult population and athletes. However,
a limited number of studies were available studies in the
population subgroups, particularly in older adults who are
more susceptible to dehydration. Research is also needed
which utilizes the gold standard Sosm as the reference
method (28,42), as well as evaluations of urine color assess-
ment’s sensitivity to change in response to changes in hydra-
tion status. In addition, future research should determine if
clinicians, patients, and clients are able to evaluate hydration
status using this method, and to determine if this method is
valid in other populations such as children.
Acknowledgements
The authors wish to acknowledge Katelyn Barker (K.B.) from Virginia
Tech for her assistance with duplication of the article search and full-
text article screening processes.
Disclosure statement
The authors declare that they have no conflicts of interest.
Funding
The authors declare no funding for this review. SK was supported by
the Water INTERface Interdisciplinary Graduate Education Program
Fellowship through Virginia Tech.
Authors’ contributions
SBK designed the review protocol, conducted the literature search,
wrote the protocol and report, screened eligible studies, extracted and
interpreted the data, screened articles for quality, updated reference
lists, created the summary of findings, and led the development of
the report.
KPD, VEH, DTT, and BMD assisted with designing the review
protocol and data interpretation, provided critical feedback on the
report, contributed to writing the report, and approved the final ver-
sion of the manuscript.
BMD supervised the development of the protocol and report, and
screened articles for quality.
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 7
References
1. Jequier E, Constant F. Water as an essential nutrient: the physio-
logical basis of hydration. Eur J Clin Nutr. 2010;64(2):115–23.
doi:10.1038/ejcn.2009.111.
2. Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration, and
health. Nutr Rev. 2010;68(8):439–58. doi:10.1111/j.1753-4887.
2010.00304.x.
3. Hancock PA, Vasmatzidis I. Effects of heat stress on cognitive
performance: the current state of knowledge. Int J Hyperthermia.
2003;19(3):355–72. doi:10.1080/0265673021000054630.
4. Sawka MN, Burke LM, Eichner ER. American College of Sports
Medicine position stand. Exercise and fluid replacement. Med
Sci Sports Exerc. 2007;39(2):377–90.
5. Spano MK, Thomas DT. Nutrition for sport, exercise and health.
USA: Human Kinetics; 2018.
6. Arnaoutis G, Kavouras SA, Angelopoulou A, et al. Fluid balance
during training in elite young athletes of different sports. J
Strength Cond Res. 2015;29(12):3447–52.
7. Mentes JC, Wakefield B, Culp K. Use of a urine color chart to
monitor hydration status in nursing home residents. Biol Res
Nurs. 2006;7(3):197–203. doi:10.1177/1099800405281607.
8. El-Sharkawy AM, Bragg D, Watson P, Neal K, Sahota O,
Maughan RJ, Lobo DN. Hydration amongst nurses and doctors
on-call (the HANDS on prospective cohort study). Clin Nutr.
2016;35(4):935–42. doi:10.1016/j.clnu.2015.07.007.
9. Lindseth PD, Lindseth GN, Petros TV, Jensen WC, Caspers J.
Effects of hydration on cognitive function of pilots. Mil Med.
2013;178(7):792–8. doi:10.7205/MILMED-D-13-00013.
10. Casa DJ, Armstrong LE, Hillman SK, et al. National athletic
trainers’ association position statement: fluid replacement for
athletes. J Athl Train. 2000;35(2):212–24.
11. Armstrong LE, Maresh CM, Castellani JW, Bergeron MF,
Kenefick RW, LaGasse KE, Riebe D. Urinary indices of hydra-
tion status. Int J Sport Nutr. 1994;4(3):265–79. doi:10.1123/ijsn.4.
3.265.
12. Sommerfield LM, McAnulty SR, McBride JM, et al. Validity of
urine specific gravity when compared with plasma osmolality as
a measure of hydration status in male and female NCAA collegi-
ate athletes. J Strength Cond Res. 2016;30(8):2219–25.
13. Wyness SP, Hunsaker JJH, Snow TM, Genzen JR. Evaluation
and analytical validation of a handheld digital refractometer for
urine specific gravity measurement. Pract Lab Med. 2016;5:
65–74. doi:10.1016/j.plabm.2016.06.001.
14. Armstrong LE. Hydration assessment techniques. Nut Rev. 2005;
63(6 Pt 2):S40–S54. doi:10.1301/nr.2005.jun.S40-S54.
15. Armstrong LE, Soto JA, Hacker FT, Jr., Casa DJ, Kavouras SA,
Maresh CM. Urinary indices during dehydration, exercise, and
rehydration. Int J Sport Nutr. 1998;8(4):345–55. doi:10.1123/ijsn.
8.4.345.
16. Thomas DT, Erdman KA, Burke LM. Position of the Academy
of Nutrition and Dietetics, Dietitians of Canada, and the
American College of Sports Medicine: nutrition and athletic per-
formance. J Acad Nutr Diet. 2016;116(3):501–28. doi:10.1016/j.
jand.2015.12.006.
17. Kavouras SA, Johnson EC, Bougatsas D, Arnaoutis G,
Panagiotakos DB, Perrier E, Klein A. Validation of a urine color
scale for assessment of urine osmolality in healthy children. Eur
J Nutr. 2016;55(3):907–15. doi:10.1007/s00394-015-0905-2.
18. Harvey G, Meir R, Brooks L, Holloway K. The use of body mass
changes as a practical measure of dehydration in team sports. J
Sci Med Sport. 2008;11(6):600–3. doi:10.1016/j.jsams.2007.05.012.
19. Rodrigues S, Silva J, Severo M, In
acio C, Padr~ao P, Lopes C,
Carvalho J, Carmo I, Moreira P. Validation analysis of a geriatric
dehydration screening tool in community-dwelling and institu-
tionalized elderly people. IJERPH. 2015;12(3):2700–17. doi:10.
3390/ijerph120302700.
20. Armstrong LE, Ganio MS, Klau JF, Johnson EC, Casa DJ,
Maresh CM. Novel hydration assessment techniques employing
8 S. B. KOSTELNIK ET AL.
thirst and a water intake challenge in healthy men. Appl Physiol
Nutr Metab. 2014;39(2):138–44. doi:10.1139/apnm-2012-0369.
21. Armstrong LE, Johnson EC, Munoz CX, Swokla B, Le Bellego L,
Jimenez L, Casa DJ, Maresh CM. Hydration biomarkers and
dietary fluid consumption of women. J Acad Nutr Diet. 2012;
112(7):1056–61. doi:10.1016/j.jand.2012.03.036.
22. Culp K, Mentes J, Wakefield B. Hydration and acute confusion
in long-term care residents. West J Nurs Res. 2003;25(3):251–66.
doi:10.1177/0193945902250409.
23. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC,
Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D,
et al. The PRISMA statement for reporting systematic reviews
and meta-analyses of studies that evaluate health care interven-
tions: explanation and elaboration. PLoS Med. 2009;6(7):
e1000100. doi:10.1371/journal.pmed.1000100.
24. Evidence Analysis Manual: Quality Criteria Checklist-Primary
Research. Acad NutrDiet: 339 EAL; 2018.
25. Malisova O, Athanasatou A, Pepa A, Husemann M, Domnik K,
Braun H, Mora-Rodriguez R, Ortega J, Fernandez-Elias V,
Kapsokefalou M, et al. Water intake and hydration indices in
healthy european adults: the european hydration research study
(EHRS). Nutrients. 2016;8(4):204. doi:10.3390/nu8040204.
26. Early KS, Earnest CP, Theall B, Lemoine NP, Harrell B,
Johannsen NM. Free-living, continuous hypo-hydration, and car-
diovascular response to exercise in a heated environment.
Physiol Rep. 2018;6(8):e13672. doi:10.14814/phy2.13672.
27. Popowski LA, Oppliger RA, Patrick Lambert G, Johnson RF,
Kim Johnson A, Gisolf CV. Blood and urinary measures of
hydration status during progressive acute dehydration. Med Sci
Sports Exerc. 2001;33(5):747–53.
28. Shirreffs SM, Maughan RJ. Urine osmolality and conductivity as
indices of hydration status in athletes in the heat. Med Sci
Sports Exerc. 1998;30(11):1598–602.
29. Perrier ET, Bottin JH, Vecchio M, Lemetais G. Criterion values
for urine-specific gravity and urine color representing adequate
water intake in healthy adults. Eur J Clin Nutr. 2017;71(4):
561–3. doi:10.1038/ejcn.2016.269.
30. Zhang N, Du SM, Zheng MQ, et al. Urine color for assessment
of dehydration among college men students in Hebei, China—a
cross-sectional study. Asia Pac J Clin Nutr. 2017;26(5):788–93.
31. Takatsui F, Andrade M. F d, Neisser MP, Barros LAB, Loffredo
L. d C M. CIE Lab: comparison of digital images obtained
photographically by manual and automatic modes. Braz Oral
Res. 2012;26(6):578–83. doi:10.1590/S1806-83242012005000025.
View publication stats
32. Fernandez-Elias VE, Martinez-Abellan A, Lopez-Gullon JM.
Validity of hydration non-invasive indices during the weightcut-
ting and official weigh-in for Olympic combat sports. PloS One.
2014;9(4):e95336.
33. Cheuvront SN, Ely BR, Kenefick RW, Sawka MN. Biological
variation and diagnostic accuracy of dehydration assessment
markers. Am J Clin Nutr. 2010;92(3):565–73. doi:10.3945/ajcn.
2010.29490.
34. Hooper L, Bunn DK, Abdelhamid A, Gillings R, Jennings A,
Maas K, Millar S, Twomlow E, Hunter PR, Shepstone L, et al.
Water-loss (intracellular) dehydration assessed using urinary
tests: how well do they work? Diagnostic accuracy in older peo-
ple. Am J Clin Nutr. 2016;104(1):121–31. doi:10.3945/ajcn.115.
119925.
35. Mukaka MM. Statistics corner: A guide to appropriate use of
correlation coefficient in medical research. Malawi Med J. 2012;
24(3):69–71.
36. Bottin JH, Lemetais G, Poupin M, Jimenez L, Perrier ET.
Equivalence of afternoon spot and 24-h urinary hydration bio-
markers in free-living healthy adults. Eur J Clin Nutr. 2016;
70(8):904–7. doi:10.1038/ejcn.2015.217.
37. Armstrong LE. Assessing hydration status: the elusive gold
standard. J Am Coll Nutr. 2007;26(sup5):575s–84s. doi:10.1080/
07315724.2007.10719661.
38. O’Connell BN, Weinheimer EM, Martin BR, Weaver CM,
Campbell WW. Water turnover assessment in overweight adoles-
cents. Obesity. 2011;19(2):292–7. doi:10.1038/oby.2010.225.
39. Chang T, Ravi N, Plegue MA, Sonneville KR, Davis MM.
Inadequate hydration, BMI, and obesity among US adults:
NHANES 2009–2012. Ann Fam Med. 2016;14(4):320–4. doi:10.
1370/afm.1951.
40. Simerville JA, Maxted WC, Pahira JJ. Urinalysis: a comprehen-
sive review. Am Fam Physician. 2005;71(6):1153–62.
41. Perrier E, Rondeau P, Poupin M, Le Bellego L, Armstrong LE,
Lang F, Stookey J, Tack I, Vergne S, Klein A. Relation between
urinary hydration biomarkers and total fluid intake in healthy
adults. Eur J Clin Nutr. 2013;67(9):939–43. doi:10.1038/ejcn.
2013.93.
42. Hustrini NM, Siregar P, Nainggolan G, Harimurti K. Diagnostic
performance of afternoon urine osmolality to assess optimal
hydration status in an adult healthy population. Acta Medica
Indonesiana. 2017;49(2):112–7.