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ORIGINAL COMMUNICATION
Markers of hydration status
SM Shirreffs1*
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Many indices have been investigated to establish their potential as markers of hydration status. Body mass changes, blood indices, urine indices and bioelectrical impedance analysis have been the most widely investigated. The current evidence and opinion tend to favour urine indices, and in particular urine osmolality, as the most promising marker available.
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patients hydration status. Since this manuscript was published, there has been a large amount of research into some of these measurements, observations and tests, and some of the main ones, along with others, are discussed in the rest of this paper. secretion, urine production or diarrhoea. However, in subjects studied by Francesconi et al (1987), who lost more than 3% of their body mass mainly through sweating, no change in haematocrit or serum osmolality was found, although as described below certain urine parameters did show changes. Similar findings to this were reported by Armstrong et al (1994, 1998). This perhaps suggests that plasma volume is defended in an attempt to maintain cardiovascular stability, and so plasma variables will not be affected by hypohydration until a certain degree of body water loss has occurred. Plasma testosterone, adrenaline and cortisol concentrations were reported by Hoffman et al (1994) not to be influenced by hypohydration to the extent of a body mass loss of up to 5.1% induced by exercise in the heat. In contrast, however, plasma noradrenaline concentration did respond to the hydration changes, which means that it may be possible to use this as a marker of hydration status, at least when induced by exercise in the heat.
Body mass
Acute changes in body mass over a short time period can frequently be assumed to be due to body water loss or gain; 1 ml of water has a mass of 1 g (Lentner, 1981) and therefore changes in body mass can be used to quantify water gain or loss. Over a short time period, no other body component will be lost at such a rate, making this assumption possible. Throughout the exercise literature, changes in body mass over a period of exercise have been used as the main method of quantifying body water losses or gains due to sweating and drinking. Indeed, this method is frequently used as the method to which other methods are compared. Respiratory water loss and water exchange due to substrate oxidation are sometimes calculated and used to correct the sweat loss values, but this is not always done (Mitchell et al, 1972). Examples of such types of calculations are shown in Table 1.
Urine indices
Collection of a urine sample for subsequent analysis has also been investigated and used as a hydration status marker. Measurement of urine osmolality has recently been an extensively studied parameter as a possible hydration status marker. In studies of fluid restriction, urine osmolality has increased to values greater than 900 mosm/kg for the first urine of the day passed in individuals dehydrated by 1.9% of their body mass, as determined by body mass changes (Shirreffs & Maughan, 1998). Armstrong et al (1994) have determined that measures of urine osmolality can be used interchangeably with urine-specific gravity, opening this as another potential marker. Urine colour is determined by the amount of urochrome present in it (Diem, 1962). When large volumes of urine are excreted, the urine is dilute and the solutes are excreted in a large volume. This generally gives the urine a very pale colour. When small volumes of urine are excreted, the urine is concentrated and the solutes are excreted in a small volume. This generally gives the urine a dark colour. Armstrong et al (1998) have investigated the relationship
Blood indices
Collection of a blood sample for subsequent analysis has been both investigated and used as a hydration status marker. Measurement of haemoglobin concentration and haematocrit has the potential to be used as a marker of hydration status or change in hydration status, provided a reliable baseline can be established. In this regard, standardisation of posture for a time prior to blood collection is necessary to distinguish between postural changes in blood volume, and therefore in haemoglobin concentration and haematocrit, which occur (Harrison, 1985) and change due to water loss or gain. Plasma or serum sodium concentration and osmolality will increase when the water loss inducing dehydration is hypotonic with respect to plasma. An increase in these concentrations would be expected, therefore, in many cases of hypohydration, including water loss by sweat
Table 1 Examples of hydration status calculations Pre-exercise Body massa (kg) 70.00 70.00 70.00 Post-exercise Body massa (kg) 68.00 70.00 70.20 Total body mass loss or gaind (ml or g) 2000 0 200 Drinks consumed during exerciseb (ml) 0 500 1000 Urine excreted during exercisec (ml) 200 400 0
Body mass measured nude with dry skin. Drinks consumed any time between the two body mass measurements. c Urine emptied from the bladder any time between the two body mass measurements. d water gain, water loss, 0no change in water balance.
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between urine colour and specific gravity and conductivity. Using a scale of eight colours (Armstrong, 2000), it was concluded that a linear relationship existed between urine colour and both specific gravity and osmolality of the urine, and that urine colour could therefore be used in athletic or industrial settings to estimate hydration status when a high precision may not be needed. Urine indices of hydration status perhaps have their limitation in identifying changes in hydration status during periods of rapid body fluid turnover, as in subjects studied who lost approximately 5% of their body mass with, on average, 62 min of exercise in the heat, then rehydrating by replacing this lost fluid (Popowski et al, 2001). In these subjects, in comparison to measures of plasma osmolality which increased and decreased in an almost linear fashion, urine osmolality and specific gravity were found to be less sensitive and demonstrated a delayed response, lagging behind the plasma osmolality changes.
Conclusions
The body water content of a person is most appropriately determined using tracer methodology with the use of deuterium oxide. The determination of a persons hydration status has received increasing attention over the past 10 years, much of it influenced by body water losses that can occur in a relatively short period of time with physical activity. Blood-borne parameters and urinary markers have been widely studied areas, with a substantial amount of research into the use of BIA also being undertaken. In most cases, acute changes in body mass are used to signify the body water losses or gains to which comparisons are made. However, an arbitrary decision or definition of euhydration must be made before a person is assigned to being in a state of hypohydration or hyperhydration, and this perhaps remains a major issue to be resolved. The choice of hydration status marker will ultimately be determined by the sensitivity and accuracy with which hydration status needs to be established, the technical and time requirements and the expense of the method. However, consideration must also be given to other conditions or complicating factors that may impact on the parameter of measurement. From the studies reviewed above, it seems fair to conclude that urinary measures are more sensitive than the other methods, but they may have a time lag over the short term. It must also be remembered that classification of the state of hypohydration or hyperhydration depends on the physiological definition of euhydration, which is not as simple as giving the dictionary definition.
References
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Other markers
Hydration status has also been investigated by a number of less commonly investigated parameters. For example, alterations in the response of pulse rate and systolic blood pressure to postural change have been demonstrated in clinical settings of dehydration and rehydration (Johnson et al, 1995). The diameter of the inferior cava vein, measured with the subject lying supine, has been used with patients undergoing peritoneal dialysis (Cheriex et al, 1989). European Journal of Clinical Nutrition
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Harrison MH (1985): Effects of thermal stress and exercise on blood volume in humans. Physiol. Rev. 65, 149209. Hoffman JR, Maresh CM, Armstrong LE, Gabaree CL, Bergeron MF, Kenefick RW, Castellani JW, Ahlquist LE & Ward A (1994): Effects of hydration state on plasma testosterone, cortisol, and catecholamine concentrations before and during mild exercise at elevated temperature. Eur. J. Appl. Physiol. 69, 294300. Johnson DR, Douglas D, Hauswald M & Tandberg D (1995): Dehydration and orthostatic vital signs in women with hyperemesis gravidarum. Acad. Emer. Med. 2, 692697. Lentner C (1981): Geigy scientific tables. 8th Edition. Basle: Ciba-Geigy Limited. McArdle WD, Katch FI & Katch VL (1996): Exercise Physiology: Energy, Nutrition, and Human Performance. p 54. Philadelphia: Lippincott Williams & Wilkins. Mitchell JW, Nadel ER & Stolwijk JAJ (1972): Respiratory weight losses during exercise. J. Appl. Physiol. 32, 474476. National Institutes of Health (1994): Bioelectrical impedance analysis in body composition measurement. NIH Technol. Assess. Statement. December 1214, pp 135. Popowski LA, Oppliger RA, Lambert GP, Johnson RF, Johnson AK & Gisolfi CV (2001): Blood and urinary measures of hydration status during progressive acute dehydration. Med. Sci. Sports Exerc. 33, 747753. Saunders MJ, Blevins JE & Broeder CE (1998): Effects of hydration changes on bioelectrical impedance in endurance trained individuals. Med. Sci. Sports Exerc. 30, 885892. Schoeller DA (1996): Hydrometry. In Human Body Composition. eds A Roche, S Heymsfield & T Lohman, pp 2543. Champaign: Human Kinetics. Shirreffs SM & Maughan RJ. (1998): Urine osmolality and conductivity as indices of hydration status in athletes in the heat. Med. Sci. Sport Exerc. 30, 15981902.