June 2005: (II)S2–S5
The Importance of Good Hydration for the Prevention of
Chronic Diseases
Friedrich Manz, MD, and Andreas Wentz, MD
There is increasing evidence that mild dehydration
plays a role in the development of various morbidities.
In this review, the effects of hydration status on
chronic diseases are categorized according to the
strength of the evidence. Positive effects of mainte-
nance of good hydration are shown for urolithiasis
(category Ib evidence); constipation, exercise asthma,
hypertonic dehydration in the infant, and hyperglyce-
mia in diabetic ketoacidosis (all category IIb evi-
dence); urinary tract infections, hypertension, fatal
coronary heart disease, venous thromboembolism,
and cerebral infarct (all category III evidence); and
bronchopulmonary disorders (category IV evidence).
For bladder and colon cancer, the evidence is incon-
sistent.
Key words: chronic diseases, mild dehydration, mor-
bidity
© 2005 International Life Sciences Institute
doi: 10.1301/nr.2005.jun.S2–S5
INTRODUCTION
Many chronic diseases have multifactorial origins. In
particular, differences in lifestyle and the impact of
environment are known to be involved and constitute
risk factors that are still being evaluated. Water is quan-
titatively the most important nutrient. In the past, scien-
tific interest with regard to water metabolism was mainly
directed toward the extremes of severe dehydration and
water intoxication. There is increasing evidence, how-
ever, that mild dehydration may also account for many
morbidities. Until recently, there was no “gold standard”
for hydration markers, particularly for mild dehydration.
As a consequence, the effects of mild dehydration on the
development of several disorders and diseases have not
been well documented.
Drs. Manz and Wentz are with the Research Insti-
tute of Child Nutrition, Dortmund, Germany.
Address for correspondence: Dr. Friedrich Manz,
Research Institute of Child Nutrition, Heinstück 11,
D-44225 Dortmund, Germany; Phone: 49-231-792-
2100; Fax: 49-231-711-581; E-mail: manz@fke-do.de.
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In October 2001, the 2nd International Conference
on Hydration throughout Life was held in Dortmund,
Germany, and was devoted to “The Health Effects of
Mild Dehydration.”1 This review describes evidence pre-
sented at this conference regarding long-term health
effects of mild dehydration. A follow-up and more data
based mainly on computer-based literature searches in
Medline focused on the years 2001 to 2004 are given. In
the computer-based literature searches, the following
markers of hydration status were used: a) intake (water
OR fluid), b) urine output (volume OR osmolality), and
c) hydration. Papers were classified according to the
following categories of evidence2:
Ia: Evidence from a meta-analysis of
randomized, controlled trials;
Ib: Evidence from at least one randomized,
controlled trial;
IIa: Evidence from at least one controlled study
without randomization;
IIb: Evidence from at least one other type of
quasi-experimental study;
III: Evidence from descriptive studies, such as
comparative studies, correlation studies,
and case control studies;
IV: Evidence from expert committee reports,
opinions or clinical experience of
respected authorities, or both.
Acute health effects of mild dehydration on exercise
performance, wellness, cognitive function, mental per-
formance, and the course of labor have been reviewed
previously,1 and some of these topics are also discussed
elsewhere in this journal.
HEALTH EFFECTS OF MILD DEHYDRATION
ON CHRONIC DISEASES
Urolithiasis
A sufficient intake of fluids is one of the most important
preventive measures for urinary stone recurrence.3 In a
prospective, randomized study of 199 patients with a first
episode of idiopathic urolithiasis, the intervention group
Nutrition Reviews姞, Vol. 63, No. 6
was instructed to increase fluid intake, while the remain-
ing patients did not receive any therapy.4 During the
5-year follow-up period, patients in the intervention
group displayed a significantly higher urine volume, a
50% lower recurrence rate, and a longer period before
the first recurrence. Thus, there is category Ib evidence
that an increase in urine volume results in a lower stone
recurrence rate.1 In 2004, a prospective study in 25
patients with urolithiasis showed that an increased fluid
intake and limited intake of salt and protein resulted in an
increased urine volume and a decreased number of
stones (category IIb evidence).5 Furthermore, from 2001
to 2004, there were 13 epidemiological reports, 11 of
which showed a significant association between a favor-
able hydration status and a lower stone recurrence rate.
In two reports, no association was observed.
Urinary Tract Infection
No definitive evidence has been found to show that a
susceptibility to urinary tract infection (UTI) is influ-
enced by fluid intake.6 In three reports from 2001 to
2004, UTI was associated with a low fluid intake or low
urine output (category III evidence).7–9 In two prospec-
tive studies in girls, recurrent UTI was associated with
infrequent urine voiding and poor fluid intake.7,8 A study
in adults with urinary catheters showed that low urine
output was significantly related to UTI.9 Several expert
committees recommend a high fluid intake in patients
with UTI.
Bladder and Colon Cancer
The findings of epidemiological studies investigating the
relationship between fluid intake and bladder or colon
cancer are inconsistent.10 Two new reports confirm this
general statement.11,12 A prospective study of fluid in-
take in 267 patients with superficial bladder cancer at
risk for recurrence did not find any association between
fluid intake and tumor recurrence.11 In a case-control
study of 130 newly diagnosed bladder cancer patients,
there was no significant association of total fluid intake
and the risk of bladder cancer, although mineral water
consumption and frequency of urination were identified
as protective factors.12
Constipation
In a few studies, constipation has been shown to be
increased by fluid restriction. The beneficial effect of
increased fluid intake may perhaps be limited to subjects
with dehydration, while fluid overload in euhydrated
subjects may not improve stool consistency (category IIb
evidence).13 In a prospective, randomized study of 21
Nutrition Reviews姞, Vol. 63, No. 6
patients with functional dyspepsia and secondary consti-
pation, the constipation score was decreased after drink-
ing carbonated water but not after drinking tap water.14
Bronchopulmonary Disorders
The basic physiologic mechanisms in lung and airways
demonstrate a critical role of water transport and local
hydration status of mucus. Except for exercise asthma
(category IIb evidence), more research is needed to
confirm or refute chronic mild hypohydration as a risk
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factor for bronchopulmonary disorders.15 Nevertheless,
several expert committees recommend a high fluid intake
in bronchopulmonary disorders (category IV evidence).
In a hospital emergency department, dehydration of ex-
pired air was observed in asthmatic patients compared
with controls.16
Morphological and Functional Changes in the
Kidney
In rats, low hydration with sustained high levels of
vasopressin induces morphological and functional
changes in the kidney, and results particularly in an
increase in the glomerular filtration rate.17 However, in
patients with polycystic kidney disease and chronic renal
failure, sustained high urine volumes with urine osmo-
lalities below plasma osmolality accelerate the decline of
glomerular filtration rate.18
Hypertension
In rats, mild dehydration with sustained high levels of
vasopressin impairs renal sodium excretion.17 In diabetic
patients, lower urine flow and sodium excretion rates are
associated with higher blood pressure during the day and
a reduced fall in blood pressure at night (category III
evidence).19 In a study of 1688 healthy men, a low urine
production day-to-night ratio was not associated with
hypertension.20
Lambs exposed in utero to hypertonicity due to
water restriction demonstrate plasma hypertonicity and
high blood pressure later in life, indicating in utero
programming of an altered set point for systemic osmo-
lality and blood pressure.21 The offspring of prenatally
water-restricted ewes exhibit high hypernatremia and
hypertension.22 In one study, eight male hypertensive
volunteers and eight controls were exercised in a hot
environment with or without water ingestion. In hyper-
tensive men, water ingestion increased exercise-related
differences in their systolic and diastolic blood pres-
sure.23
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Fatal Coronary Heart Disease
In the Adventist Health Study,24 a high intake of water
was associated with a reduced risk of fatal cardiac heart
disease (category III evidence). Another study showed
that Japanese taxi drivers with an increased risk of
cardiac heart disease had increased blood coagulation
and hematocrit, probably due to a low water intake at
night.25
Venous Thromboembolism
A study of patients with high serum osmolality values of
more than 297 mOsm/kg a few days after an acute
ischemic stroke revealed an increased rate of venous
thromboembolism, which was highly independently as-
sociated with this marker of dehydration (category III
evidence).26
Cerebral Infarct
Raised plasma osmolality or hematocrit on admission is
associated with an increased risk of stroke morbidity and
mortality (category III evidence).27,28 In patients with
ischemic stroke, the best discharge outcome is associated
with an initial mid-range hematocrit level.29
Dental Diseases
Salivary excretion is reduced in hypohydration. Al-
though there is considerable circumstantial evidence to
indicate that a link between dehydration and dental
diseases exists, this has not yet been proven.30
Hypertonic Dehydration in Infants
In infants with gastroenteritis, a high urine osmolality
due to a high protein and sodium content of formula and
weaning foods increases the risk of hypertonic dehydra-
tion (category IIb evidence).31
Diabetic Ketoacidosis
In patients with diabetes mellitus, experimental dehydra-
tion favors the development of hyperglycemia, whereas
fasting results in reduced glucose plasma concentrations
(category IIb evidence).32 In a study of children with
diabetic ketoacidosis, serum osmolality level on admis-
sion was the most important predictor of death.33
Gallstone, Mitral Valve Prolapse, and
Glaucoma
In these three diseases, the pathogenic effect of different
states of hydration is highly speculative. Water ingestion
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has been shown to induce gallbladder emptying, and a
high daily water intake could perhaps prevent gallstone
formation.34 In one study, mitral valve prolapse devel-
oped after dehydration in one in 10 healthy men.35
Dehydration has also been shown to reduce intraocular
pressure and elevated colloid osmotic pressure.36 Mean
intraocular pressure was shown to increase 15 minutes
after water ingestion and remain elevated above baseline
for 45 minutes.37
CONCLUSIONS
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There is increasing evidence that mild dehydration may
play a role in various morbidities. Good hydration has
been shown to reduce the risk of urolithiasis (category Ib
evidence), constipation, exercise asthma, hypertonic de-
hydration in the infant, and hyperglycemia in diabetic
ketoacidosis (all category IIb evidence), and is associated
with a reduction in UTIs, hypertension, fatal coronary
heart disease, venous thromboembolism, and cerebral
infarct (all category III evidence). For other conditions
such as bladder or colon cancer, evidence of a preventive
effect of maintaining good hydration is not consistent.
PANEL DISCUSSION
Larry Armstrong: Is there evidence in your data
that there is a difference in any disease at the lower and
upper level of urine concentration?
Friedrich Manz: This is a very important question.
However, I cannot answer it, since up to now, nobody
has looked at the health effects of different levels of
euhydration. I am convinced that this assumption will be
true for urolithiasis. All data we have show that if you
increase the fluid intake, which means that urine output
goes up and urinary osmolality goes down, then the
recurrence rate of urolithiasis decreases. In other disor-
ders I hesitate to speculate. However, this is a large field
for further research and we have now the tools to do this
kind of research.
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