June 2005: (II)S40 S54

Hydration Assessment Techniques

Lawrence E. Armstrong, PhD, FACSM
Water in the human body is essential for metabolism, temperature regulation, and numerous other physiological processes that are consistent with good health. Accurate, precise, and reliable methods to assess body uid compartments are needed. This review describes the hydration assessment techniques of isotope dilution, neutron activation analysis, bioelectrical impedance, body mass change, thirst, tracer appearance, hematologic indices, and urinary markers. It also provides guidance for selecting techniques that are appropriate for use with unique individuals and situations. Key words: total body water, extracellular uid, intracellular uid, osmolality
2005 International Life Sciences Institute doi: 10.1301/nr.2005.jun.S40 S54

THE IMPORTANCE OF HYDRATION ASSESSMENT Water serves as the essential solvent for cellular biochemical reactions and facilitates the thermal equilibrium of cells. It comprises about 63% of the entire body mass1 and 80% to 84% of kidney, lung, and skeletal muscle tissues.2 Water must be consumed by humans because the amount lost in metabolism exceeds the amount synthesized by the body. These facts and the following observations emphasize the importance of accurate, precise, and reliable methodologies with which to evaluate hydration: 1. The human body constantly loses water from the lungs, skin, and kidneys. 2. Even when normal hydration exists, uid moves into and out of cells and the circulation.3,4
Dr. Armstrong is with the Human Performance Laboratory, Departments of Kinesiology and Nutritional Sciences, University of Connecticut, Storrs, Connecticut. Address for correspondence: Dr. Lawrence Armstrong, Human Performance Laboratory, Departments of Kinesiology and Nutritional Sciences, University of Connecticut, Unit 1110, 2095 Hillside Road, Storrs, CT 06269-1110; Phone: 860-486-2647; Fax: 860-4861123; E-mail: lawrence.armstrong@uconn.edu.
S40

Strenuous labor, exercise, or environmental heat stress may increase sweat losses to the point that the daily water requirement increases 2 to 6 times above daily living in a mild environment (i.e., up to 15 L/d).5 4. Prior to athletic competition in the sport of wrestling, some athletes purposefully dehydrate to qualify for a weight class and experience increased hemoconcentration that would otherwise be classied as pathological (i.e., mean plasma osmolality of 320 mOsm/kg; n 12).6 5. Various illnesses disrupt whole-body uid and electrolyte balance acutely and chronically. 6. Insufcient or excessive dietary intake of water changes cellular volume and affects a variety of cellular functions, including metabolism, excitation, transport, hormone release, cell proliferation, and cell death.7 7. Some individuals consume too much uid, which dilutes total body water abnormally, and experience the clinical condition known as water intoxication hyponatremia.8 8. Total body water varies across the lifespan9 from childhood10 to adolescence11 to adulthood12 and to elder adulthood.10 9. Increasing the dietary intake of sodium chloride or protein increases the obligatory water requirement for whole-body osmotic equilibrium.13 10. Mild dehydration of 1% or 2% of body mass can reduce exercise performance, cognitive function, and alertness.14,15 This review is designed to describe hydration assessment techniques, provide selection guidelines appropriate to unique individuals and situations, and to highlight recent publications by Shirreffs and Maughan,16 Kavouras,17 Opplinger and Bartok,18 and Manz and Wentz.13 BODY FLUIDS: DEFINITIONS In this review paper, the following denitions1,19,20 will be utilized. Total body water (TBW) is the uid that occupies intracellular and extracellular spaces, comprising about 0.6 L/kg (63.3%) of body mass. Extracellular
Nutrition Reviews, Vol. 63, No. 6

3.

volume (ECV) is all uid outside of cells, including the interstitial uid and plasma water, and comprises about 0.2 L/kg (24.9%) of body mass. Intracellular volume (ICV) is the uid within tissue cells, comprising about 0.4 L/kg (38.4%) of body mass. Plasma volume (PV) is the liquid portion of the blood, which makes up about 5% of body mass. Interstitial uid (ISF) is the uid located in the spaces between tissue cells with a chemical composition similar to that of lymph; it is usually calculated as ECV PV, and makes up about 21% of body mass. An electrolyte is any compound that, in solution, conducts electricity and is decomposed (electrolyzed) by it; i.e., an ionizable substance in solution. Osmolality is the concentration of a solution expressed in milliosmoles of solute particles per kilogram of water. HYDRATION ASSESSMENT TECHNIQUES Dilution Techniques: Fluid Compartment Size Oral or intravenous administration of a tracer substance, before and after sampling a body uid or expired air, enables measurement of human uid compartment size. If the amount of substance is known, and if the baseline and equilibration concentrations are measured, the volume into which the tracer has been diluted can be calculated. Measuring tracer concentration before it has equilibrated throughout the uid space (i.e., less than 3 or 4 hours) is the primary threat to reliability and accuracy. Considering all of the methods in subsequent sections, dilution techniques are considered to be the gold standard for measurements of body uid spaces. TBW is assessed with stable (i.e., non-radioactive) isotopes of hydrogen or oxygen21 that distribute in 3 to 4 hours throughout virtually all body uid compartments (Figure 1). Deuterium (2H), deuterium oxide (2H2O, D2O), and oxygen-18 (18O, which is a constituent of heavy water, H18 2 O) are most commonly used. The ra-

Figure 1. The time required for deuterium oxide (2H2O) to reach all accessible human body water spaces is 3 to 4 hours. This representative graph depicts the increase in plasma 2H2O.
Nutrition Reviews, Vol. 63, No. 6

dioactive isotope tritium (3H) or tritiated water (3H2O) are utilized less frequently in TBW studies. Using these naturally occurring isotopes, the smallest detectable change in TBW is about 0.8 L (L.E. Armstrong, unpublished observations). TBW is regulated tightly by neurohumoral mechanisms, so that it varies only 0.9% to 1.0 % from one day to the next.22 ECV measurements historically involved thiocyanate and isotopes of sodium and chloride (i.e., 22Na, 24 Na, 36Cl), but in recent years bromide has been utilized widely.23,24,25 A corrected bromide space can be calculated from the serum concentration after administration of a known amount of bromide, which is an excellent approximation of ECV. Oral bromide is completely absorbed from the intestine, has a biological half-life of about 12 days, and is lost in urine and feces in insignificant amounts for 2 to 4 hours after an oral dose.24 Thus, ECV can be determined from bromide that is administered either orally or intravenously within a 2- to 4-hour window.25 ICV is calculated as the difference between TBW and ECV.1 Whole-body counters (i.e., neutron activation analysis) providing alternative methods of ECV assessment are described below. During blood volume measurements, a small quantity of radioactive tracer is applied to erythrocytes or a plasma component, which are injected intravenously after a baseline blood sample is drawn. The coefcient of variation of these techniques for repeated measures is 3.0%.26 After allowing ample circulatory mixing time, an equilibrium blood sample is drawn, the radioactivity is counted, and the blood volume is calculated.27 The tracers 51Cr and 125I have been widely used to label erythrocytes and human serum albumin, respectively. Using these techniques, Sawka et al.28 developed algorithms to successfully predict volumes of blood and plasma in healthy young men; lean body mass was the anthropometric characteristic that was most closely correlated with vascular uid volumes. Closely regulated by osmotic and oncotic forces, PV varies only 0.7% from day to day in resting individuals.29 Although human subject review boards at some institutions may voice concerns for subject safety, one dilution technique allows the simultaneous assessment of multiple uid spaces.19 This method incorporates simultaneous dilution of the following radionuclides via intravenous injections: Na51Cr (to assess erythrocyte volume; 3.4% of body mass), human brinogen labeled with 125I (to assess PV; 4.6% of body mass), Na82Br (to assess ECV; 25.7% of body mass), and 3H2O (to assess TBW; 65.3% of body mass). Corrected for the presence of protein, urine loss, and migration of isotopes out of the vascular space, calculations30 also allow determination
S41

of ICV (38.8% of body mass), ISF volume (21.1% of body mass), and blood volume (7.9% of body mass).19 Neutron Activation Analysis: Fluid Compartment Size Neutron activation analysis identies and quanties about 70% of all known elements. A specimen is irradiated in a nuclear reactor, producing specic radionuclides that emit characteristic gamma rays during decay. These emissions allow scientists to identify and measure, via radiation detectors, the amount of a substance that is present. This technique has proven to be useful in forensic investigations, geology, archaeology, and biochemistry. Although this method is considered to be the reference standard for all element identication (with a precision to parts per billion), it requires a nuclear reactor and technical expertise that exist in few laboratories. Total body neutron activation analysis originally was applied to the study of calcium and nitrogen metabolism. Subsequently, analyses of total body chloride, potassium, and sodium were used to calculate ECV, ICV, and total exchangeable extracellular sodium, respectively.31 TBW was calculated as the sum of ECV plus ICV. One whole-body scan thus provided a non-invasive measurement of uid compartment sizes, with the assurance of small error and elemental equilibrium. Bioelectrical Impedance: Fluid Compartment Size Electrical current that ows through the human body (i.e., from hands to feet) is resisted by body tissues and water. Measurements of bioelectrical impedance utilize this property to provide estimates of body composition, including body water. This technique assumes that the human body is a conductor of homogeneous composition, with a xed cross-sectional area throughout and uniform current density. Clearly, the body meets none of these assumptions perfectly.31 Impedance at One to Four Frequencies: TBW Prior to 1990, single-frequency impedance (i.e., at 50 or 100 kHz) was used almost exclusively for estimates of fat mass and fat free mass, as validated by hydrostatic weighing.32,33 Subsequently, single-frequency impedance has been used to estimate TBW in children,10 older adults,35,36 and patients with varied disease states.35 Validation studies (i.e., utilizing dilution procedures, as described above) veried that this method is reliable and valid,10,35,36,37 with a coefcient of variation for repeated measurements of 1.5% to 3.4%10,34,38 in a 70-kg adult. However, it is widely recognized that
S42

several environmental and host factors may reduce the reliability and accuracy of this technique. These factors include electrode site placement,39 skin temperature,3 skin blood ow,38,40 posture,41 recent uid ingestion,38 composition of ingested uids,38 exercise, and changes in plasma osmolality38,42 or plasma sodium concentration.41,42 Bioimpedance Spectroscopy: TBW, ECV, ICV During the 1990s, theoretical principles of physics and technological advancements allowed impedance to be scanned at numerous frequencies (e.g., 50) in rapid succession.43,44 Also, because todays instruments cannot measure impedance reliably at very low (1 kHz) or very high (500 kHz) frequencies, statistical modeling programs have been developed for computers. Bioimpedance spectroscopy (BIS) is a statistical technique that extrapolates values for resistances at very high and very low frequencies from resistance values in the frequency range that is reliable (i.e., 1500 kHz).45 After TBW and ECV have been determined, ICV is calculated as TBW minus ECV. In studies of body uid volumes, this method has caused single-frequency impedance analyzers to be replaced, because spectroscopy offers the potential of measuring TBW, ECV, and ICV separately.46,47 BIS has been validated by using dilution techniques (see above) as the reference standard in elderly individuals,48 women,3,43,49 and healthy males,3,43,50 with statistical correlation (r2) ranging from 0.87 to 0.98.38 Figure 2 presents comparisons of BIS and dilution measurements in resting subjects.1 As is the case with single-frequency methods, the reliability and accuracy of BIS decrease if measurement protocols are not standardized.38 For example, investigations on the effects of uid compartments have shown that postural changes (i.e., raising the arm from the hips to an overhead position),32,41 dehydration, and ingestion of uid with difference tonicities38 invalidate BIS estimates of TBW and ECV. When such factors are controlled, the TBW prediction error (as a percentage of cellular volume) ranges from 3.5% to 6.9%1,37,38,43,49,51 for adults with a body mass of approximately 70 kg. Although this variance likely makes BIS inappropriate for measuring the small changes (1 L) of TBW, ECV, or ICV that occur during uid intake or sweating, BIS is a useful clinical and research tool when the above factors are controlled.1,22 Hematocrit and Hemoglobin: Extracellular Fluid Shifts Harrisons classic review of the effects of exercise and thermal stress on PV4 describes the interactions of
Nutrition Reviews, Vol. 63, No. 6

tion and volume of ingested uid and sweat; (c) adaptations to physical training; and (d) acclimatization to hot or high-altitude environments.5,29 These factors partly explain why PV responses vary within subjects from one experiment to another.4 The rst evidence that environmental heat exposure resulted in hemoconcentration was published in 1878.4 When immersed for 30 to 45 min in 38C water, then wrapped in dry wool for 2 hours, most subjects exhibited an increase in hemoglobin concentration. Approximately 100 years later, awareness of the importance of PV during exercise-heat exposure prompted attempts to quantify hemoconcentration and hemodilution. The rst attempt52 utilized hematocrit measurements to calculate changes in PV, despite acknowledging that the ratio between red cell volume and blood volume (i.e., hematocrit) was not linearly proportional to PV. Two years later, a second publication53 calculated PV changes from hematocrit and hemoglobin concentration. Hemoglobin was included because it resides inside erythrocytes and does not leave the circulation, and because changes in its concentration represent changes in PV. This publication also acknowledged that changes of plasma osmolality affect erythrocyte volume and, in turn, hematocrit. Due to its simplicity and relevance, this technique is widely used today. Between 1994 and 2004, for example, this paper was cited in more than 1300 peer-reviewed scientic publications (Science Citation Index, Thomson Learning, Inc., Florence, KY). Tracer Appearance: Fluid Absorption and Equilibration The rate at which water and nutrients appear in blood is a function of gastric emptying and intestinal absorption. However, the addition of a tracer (e.g., 2H2O) to an ingested uid and collection of timed blood samples provides a tool to assess the integrated effects of gastric emptying and intestinal absorption.54 Because net water uptake in the stomach is negligible, tracking the rate at which deuterium accumulates in blood allows comparisons of different mixtures and uid properties such as temperature and osmolality.55 Objections have been raised regarding the use of 2 H2O because water movement in the intestine is a bidirectional process.54 Nevertheless, the experimental ndings from deuterium tracer studies agree with the known gastric emptying and intestinal absorption characteristics of the solutions involved55 and are quantitatively similar to the triple lumen perfusion technique, which measures net water ux in the proximal intestine.56 Further, Lambert and Maughan57 also reported that the use of 2H2O was reliable in repeated measures performed on different days.
S43

Figure 2. Linear regression comparisons of total body water (TBW, panel A), extracellular volume (ECV, panel B), and intracellular volume (ICV, panel C) as estimated with bioimpedance spectroscopy (BIS). Deuterium oxide dilution (see Figure 1) and bromide dilution (see text) techniques were used as reference standards. Intracellular volume (ICV) was calculated as TBW ECV. (Reprinted from Armstrong et al.1 with permission.)

numerous factors that cause extracellular water to move into or out of the circulation. These include: (a) changes of posture, exercise mode, exercise intensity, sodium chloride balance, and plasma osmolality;29 (b) composiNutrition Reviews, Vol. 63, No. 6

Heavy water (H18 2 O) also has been used as a tracer to assess uid movements during exercise in a hot environment. Analyses utilized an isotope-ratio mass spectrometer and the H2O/CO2 equilibration method. In one investigation,58 healthy male subjects drank 100 mL of 18 H18 O; 84.7% 16O) during 6 hours of heat 2 O (15.3% exposure with intermittent cycling exercise (42.7C air temperature). Samples of saliva, blood, and urine were collected, with the result that the isotopic enrichment in saliva and urine (collected 3 6 hours post-dosing) was similar to that of plasma. These ndings indicated that water transport could be assessed with H18 2 O. 59 A second investigation involved the same exercise and tracer protocol as above, but in 37.1C air temperature. The tracer H18 2 O appeared in body uids rapidly (8 18 min) after consumption. The peak enrichment (post-dose; 18O/16O ratio) occurred at 21 to 28 minutes in plasma and 21 to 45 minutes in sweat, then declined slowly for the remainder of the 6-hour experiment. Interestingly, neither the plasma nor the sweat 18O enrichment plots (i.e., 18O/16O ratio versus time) was altered by exercise intensity or duration. Plasma or Serum Osmolality: Index of Hydration Status Although hematocrit and hemoglobin assess uid movements into and out of the circulation (see above), plasma or serum osmolality is the most widely used hematological index of hydration status, because extracellular uid osmolality stimulates important uid-regulatory mechanisms. Indeed, some investigators consider it to be the only valid index of hydration status.60 For example, an osmolality increase of only 1% initiates the sensation of thirst (i.e., increasing uid consumption) and an increase of arginine vasopressin that exceeds basal values by 100% (i.e., reabsorbing water at renal distal tubules).61,62 The neuroendocrine regulation of osmolality is such that normal values rarely deviate by more than 1% to 2% from a basal mean value of 287 mmol/kg in healthy, well-hydrated individuals.63 Direct laboratory measurements of plasma osmolality are performed with either a freezing point or vapor pressure depression osmometer. A coefcient of variation of less than 0.3% to 0.4 % is desirable and attainable by competent technicians.63 It is important to note that osmolality must be measured directly after a blood sample has been collected and centrifuged, because as storage time in mild or cool laboratories increases (i.e., 0.1 6.0 h), plasma osmolality decreases. This decrease may be due to changes in pH, dissolved CO2, lactic acid concentration, or the binding of electrolytes to protein.63
S44

Body Mass Difference: Hydration Status The measurement of body mass change represents a commonly used, safe technique to assess hydration status, especially during dehydration that occurs over a period of 1 to 4 hours, with or without exercise.17 When an individual is in caloric balance, her/his body mass loss essentially equals water loss (i.e., when corrected for the mass of uid and food intake, urine and fecal losses, sweat evaporation, and sweat absorbed by clothing), because no other body constituent is lost at a similar rate.64 When body mass measurements are made with an interval of more than 4 hours, water exchange due to substrate oxidation and respiratory water loss become large enough that the body mass difference should be corrected for by these factors.64,65 When using body mass to represent water loss, the following three factors should be considered: 1. In clinical and athletic settings, a baseline body mass is required but often not available.17 2. From one day to the next, body mass uctuates 0.51 0.20 kg (mean SD), with a group coefcient of variation for repeated days of 0.66 0.24%. This means that three consecutive measurements provide an accurate assessment of daily body mass variability in active men who replace 100% of sweat lost during exercise.66 3. If body mass measurements are performed over several weeks or months, this technique cannot be interpreted, because the gain or loss of adipose tissue is unknown unless precise whole-body scans are available to interpret changes in fat mass (i.e., dual x-ray absorptiometry). Urinary Indices of Hydration Status As noted above, the body mass of active men uctuates only 0.66% from day to day.66 Unless sweating causes a loss of water that exceeds 3% of body weight, the regulation of whole-body uid-electrolyte balance generally is adequate. Osmoregulation is affected by alterations of renal water and electrolyte excretion under the inuence of arginine vasopressin. TBW volume is associated with water and sodium balance and is controlled by uid regulatory hormones. Given normal renal function, urine is concentrated and scanty when the body is dehydrated and conserving water, or is dilute and plentiful when a temporary excess of body water exists. An obvious question then arises: how accurate are urine variables in assessing hydration? Urine Osmolality Urine osmolality, a measure of total urine solute content, is affected by all dissolved particles in a known
Nutrition Reviews, Vol. 63, No. 6

volume (i.e., mass) of uid. Analyses require an osmometer (as described above for plasma/serum) and a trained laboratory technician and are time-consuming. Because osmolality is the most accurate measurement of total solute concentration, it provides the best measurement of the kidneys concentrating ability.61 However, because urine properties are regulated by several interactive mechanisms, and because water turnover is constantly changing, no universally accepted technique exists to determine whether humans are well hydrated, euhydrated, or hypohydrated.67 For example, urine osmolality may not accurately reect hydration status when used immediately after exercise.68 Further complicating matters, large intercultural differences exist, as evidenced by mean 24-hour values from Germany (860 mOsm/kg) and Poland (392 mOsm/kg).13 Regarding the day-to-day use of urine osmolality within a group, one investigation16 evaluated the hydration status of athletes who trained in a hot environment, and found that hydration status during competition or training in a warm environment can be effectively monitored by measuring urine tonicity. Urine Specic Gravity The specic gravity of urine refers to the density (mass per volume) of a sample in comparison to pure water. Any uid that is denser than water has a specic gravity greater than 1.000. Normal urine specimens usually range from 1.013 to 1.029 in healthy adults.69,70 During dehydration or hypohydration, urine specic gravity exceeds 1.030. When excess water exists, values from 1.001 to 1.012 are typically seen.69,70 Specic gravity can be measured quickly and accurately with a handheld refractometer. A few drops of a urine specimen are placed on the stage of the refractometer and it is pointed toward a light source, which passes through the specimen. Although this device can be used indoors or outdoors, purchasing and using a refractometer may intimidate the average, non-technical adult. One investigation70 involving 34 healthy males demonstrated that urine specic gravity (as measured with a refractometer) and urine osmolality (as measured with an osmometer) may be used interchangeably. The correlation (r2) of these measurements was 0.96. Other techniques are used to measure specic gravity less frequently (i.e., dipsticks);71 their validity and reliability require further validation. Twenty-Four-Hour Urine Volume Urine volume may be used to assess hydration status as compared with normal adults of similar body mass. A healthy woman produces 1.13 0.42 L (mean SD) of
Nutrition Reviews, Vol. 63, No. 6

urine per day, whereas a healthy male produces 1.36 0.44 L/d.72 This means that women and men should produce at least 0.29 and 0.48 L/d of urine, respectively, to avoid being two standard deviations below the mean. Children 10 to 14 years of age will produce proportionately less urine each day (girls, 0.44 0.31 L/d; boys, 0.61 0.30 L/d), as will elderly adults over the age of 90 years (0.85 0.40 L/d).72 Urine Color Attempting to simplify urinalysis, our research group conducted a series of experiments involving the color of urine. We reasoned that virtually anyone could determine when they need to rehydrate if urine color were directly proportional to the level of hydration. Our initial study involved developing a numbered scale that includes colors ranging from very pale yellow (number 1) to brownish green (number 8).69 Those individuals who maintained a pale yellow urine color always were within 1% of their baseline euhydrated body mass. This project demonstrated that urine color did not offer the same precision and accuracy as urine specic gravity or osmolality, but it likely would be effective in athletic and industrial settings that do not require high precision. Our second laboratory investigation evaluated the effects of heavy physical training and large water turnover ( 4% of body weight) on urine color.70 Nine subjects performed strenuous exercise in a hot environment (36.7C), then undertook a 21-hour period of oral rehydration. The change in body mass was the reference standard by which all hydration indices were evaluated, because it represented body water uctuations. Figure 3 illustrates changes of body mass, urine color, urine specic gravity, urine osmolality, total plasma protein concentration, plasma sodium concentration, and plasma osmolality of highly trained cyclists across the ve phases of this study. These graphs demonstrate that urine color, specic gravity, and osmolality followed a pattern similar to that of uid loss. The minor exceptions to this pattern, in urine specic gravity and urine osmolality at phase D, indicate that urine color mimics body water loss as effectively or more effectively than urine specic gravity, urine osmolality, plasma osmolality, plasma total protein concentration, or plasma sodium concentration. Our third investigation observed women as they undertook 6 weeks of physical training and heat acclimation.73 Measurements of urine specic gravity and urine color once per week indicated that these variables can be used interchangeably. The weekly statistical correlation (r2) ranged from 0.77 to 0.96. The above statements should not be interpreted to mean that urinary (or any) hydration indices are foolproof. For example, when a large bolus of pure water or hypotonic
S45

Figure 3. Changes of body mass, plasma, and urinary indices of hydration status during a 41-hour dehydration and rehydration protocol involving highly trained cyclists. B Baseline state before testing; D dehydration ( 4% body mass); E after cycling exercise to exhaustion; 4H 4 hours of ad libitum rehydration; and 21H 21 hours of ad libitum rehydration. (Reprinted from Armstrong et al.70 with permission.)

uid is consumed during a brief period (e.g., 1.5 L/h), the ingested uid rapidly dilutes the blood and the kidneys excrete dilute urine over a range of hydration states.70 This occurs even if dehydration exists,68 because the urine variables mirror the volume of uid consumed rather than the amount of water retained in the body.18 Time Interval Between Measurements

hydration assessment techniques prior to deployment on day 1 compared with the end of long-term residence (day 14) in sub-Arctic conditions74 and in a eld environment (day 44).67 Both research teams concluded that urinary and hematologic techniques could not be used to assess hydration status, in part due to unknown changes in body composition. PERCEPTUAL RATING OF THIRST

Considering the short-term dynamics illustrated in Figures 3 and 4, it would be useful to know if indices of hydration status are valid across days or weeks. Seeking to answer this question, two distinct studies compared
S46

When instrumentation or technical expertise is unavailable, or when an approximation of hydration state is acceptable, the sensation of thirst can be used to anNutrition Reviews, Vol. 63, No. 6

the negative effects of mild dehydration on health and human performance. At only 1% or 2% of body mass, exercise performance capacity, cognitive function, and alertness decline14,15 and physiological strain (i.e., heart rate, tissue heat storage) increases.76 Thirst can be measured with a simple numerical rating scale ranging from 1 (not at all thirsty) to 9 (very, very thirsty), which was developed by Young et al.77 Between a score of 3 (a little thirsty) and 5 (moderately thirsty), an individual can safely assume in most situations that he/she is mildly dehydrated. As a caveat, it is important to acknowledge that numerous host factors may alter the perception of thirst. These include uid palatability, time allowed for uid consumption, gastric distention, older age, gender, and heat acclimation status.62,73,75 Thus, this approach to hydration assessment is at best an approximation, but may serve as a reminder to individuals who anticipate undertaking dehydrating exercise, labor, or dietary restriction. INVESTIGATIONAL DEVICES From 1998 to 2004, research teams evaluated the efcacy of two instruments as hydration monitors. Although still under investigation, these bioengineering devices represent the ongoing quest to nd accurate, precise, and reliableyet practicalmethods to assess hydration status. Urine Conductivity Analyzer Shirreffs and Maughan16 investigated day-to-day hydration status in athletes who trained in a hot environment and lost approximately 2% of body mass via sweating. Urine samples from 60 subjects were analyzed with a conductivity meter that was designed for eld use by athletes. A laboratory osmometer was used as the reference standard technique. This handheld device provided values that were in good agreement with laboratory osmometer data, was portable, and provided rapid feedback to individuals who trained in a warm environment. As with other urinary hydration indices, urine conductivity may not accurately reect hydration status when used within a few minutes of exercise.68
Figure 4. Plasma osmolality, urine osmolality, and urine specic gravity as a function of hydration status. (Reprinted from Popowski et al.78 with permission.)

Arm Radio Frequency Absorption This device consisted of a power source, two antennae, a power sensor, and an open exposure chamber that held the wrist of a test subject. Theoretically, electromagnetic waves interact with tissue water and solutes, but the mode of interaction varies according to the wave frequency. This technique utilized a comparison of attenuation of radio waves by tissue at frequencies ranging
S47

nounce the threshold of hypohydration that affects physiological responses and health. This occurs when the TBW loss reaches 1% or 2% of body mass.62,75 Recognizing that one has attained this level of dehydration is meaningful, because recent publications have reported
Nutrition Reviews, Vol. 63, No. 6

from 450 to 2120 MHz in healthy male subjects who experienced a 1% to 2.5% loss of body mass by exercise and water restriction.60 A statistical correlation (r2) of 0.73 was determined between body mass loss and change in radio frequency absorption pattern. The authors recommended further study and development of this technique. SELECTING AN APPROPRIATE ASSESSMENT TECHNIQUE No infallible method for assessing hydration exists.17 Table 1 compares the techniques described above on the basis of commonly used criteria. The ratings of each characteristic have been designed to make a low score preferable to a high score. Laboratory Assessment The process of selecting an appropriate technique for laboratory use is quite different from selecting one for use during daily activities. Precision, accuracy, and

reliability are the hallmarks of sound laboratory practices. With the appropriate technical expertise, time, and nancial resources, these three criteria are met by isotope dilution techniques, neutron activation analysis, osmometry, and measurements of hematocrit and hemoglobin. Bioelectrical impedance and BIS show promise as techniques, but are not sufciently accurate or reliable to measure TBW when posture or hydration state (i.e., sweat loss or uid ingestion) uctuate.37 If environmental and test subject factors are not controlled carefully, measurements are not valid. Assessment during Daily Activities Exercise enthusiasts, laborers, and military personnel may experience a large water turnover on consecutive days, which eventually may lead to signicant hypohydration. To monitor proper hydration, they should utilize an approach that requires little technical expertise or sophisticated instrumentation. Ideally, this method also should be accurate, safe, and inexpensive. The ratings in Table 1 show that urine specic gravity, urine

Table 1. Comparison of Techniques to Assess Hydration Status

Instrument Cost 3 Time Required Per Analysis 3 Technical Expertise Required 3 Risk to Individual Health 2,3*

Technique Isotope dilution, isotope appearance Neutron activation analysis Plasma and urine osmolality Hematocrit, hemoglobin Bioelectrical impedance and BIS Urine specic gravity Urine conductivity meter Urine color Body mass change Rating of thirst

Purpose Fluid volume

Accuracy 1

Portability 3

Fluid volume, whole body K Fluid concentration % plasma volume change Fluid volume

urine, 1 plasma, 2 2 1

2 2

2 3

3 2

1 2

3 2

Body water change Body water change Body water change Body water change Body water change Key to ratings:

2 2

1 2

1 2

2 2

1 3

1 1

1 1 1 1 small 2 moderate 3 great

1 1 1 1 small 2 moderate 3 great

1 1 1 1 little 2 intermediate 3 much

2 2 3 1 high 2 moderate 3 low

1 1 1 1 portable 2 moderate 3 not portable

1 1 1 1 low 2 moderate 3 high

*Depending on the type of isotope involved (i.e., radioactive, stable, non-radioactive) Bioimpedance spectroscopy Portable, hand-held meters are available16 Using a oor scale
S48 Nutrition Reviews, Vol. 63, No. 6

color, and body mass are the techniques that best meet these requirements (i.e., they have the lowest sum of ratings). Two previous publications13,64 support this rating system, in that urinary indices (i.e., osmolality and specic gravity) were considered to be superior to other hydration assessment techniques. However, disagreement exists regarding the relative efcacy of plasma osmolality versus other hydration indices. One laboratory study70 showed that urinary indices represented body water loss as well as, or better than, plasma osmolality (Figure 3). A subsequent laboratory investigation78 found that plasma osmolality responded to acute dehydration faster than urine indices, purportedly because sweat originates from ISF, which rapidly equilibrates with the circulation (Figure 4). These minor differences of interpretation may be due to the unique dehydration protocols of each study, as well as the timing of blood samples, and may not be signicant in eld settings. During daily activities, it is likely that only body mass measurements will detect small uctuations in hydration (0.5 L) when compared within and across days. Such comparisons require that an individual know her/his baseline body mass. A recent investigation66 determined that, considering daily variability (0.51 0.20 kg), a valid baseline value can be determined by measuring body mass on three consecutive days. Finally, the consensus statements of professional sports medicine organizations and regulations of athletic governing bodies represent state-of-the-art applications of the scientic literature. The National Collegiate Athletic Association is a prime example. When three university wrestlers died during the 1998 season, the NCAA prohibited the use of intentional dehydration to make weight, and included body mass and urine specic gravity measurements as safeguards against harmful weight-reduction practices.77 Similarly, the National Athletic Trainers Association position statement regarding uid replacement80 recommends that three techniques be used to assess the hydration status of athletes: body weight change, urine specic gravity, and urine color. This supports the ratings in Table 1 and demonstrates that these three techniques can be used successfully in clinical settings. ACKNOWLEDGEMENTS This research was funded by the Nestle Research Center, Lausanne, Switzerland. PANEL DISCUSSION Irwin Rosenberg: Can one be condent that we have a gold standard against which to validate hydration assessment techniques, and if so, what would you use as the gold standard?
Nutrition Reviews, Vol. 63, No. 6

Larry Armstrong: The accuracy that I refer to in Table 1 represents whether I believe the technique was validated or not. And with the body water measurements, typically deuterium oxide or some isotope dilution technique was used to validate these. That is how I derived the numbers 1, 2, and 3, which represent high, moderate, and low accuracy. In this case, you will notice that I considered eld-adaptable techniques to be less accurate. For body water, isotope dilution techniques are considered to be the gold standard today. For the elemental content of the body, neutron activation analysis is considered to be the gold standard. Friedrich Manz: An athlete will look at his urine color just before competing to assess his hydration status. At what time during the day should an ordinary subject, who has no specic event or physical exercise to prepare for, look at the urine color to determine if the hydration status is adequate? Larry Armstrong: Debate exists in the scientic literature about the best time of day. Some have recommended using the rst morning void. Others have said, and I have published this based upon our observations, that the rst morning void may not be valid in terms of the total 24-hour losses. Rather than taking one specic time of the day as a gold standard, perhaps a person ought to do this often, just as a matter of habit. My recommendation would be that, if they must do it one time a day, to do it daily at that same time. To date, no evidence veries that one time is better than another. Antonio Dal Canton: Your experience with urine color is really interestingsimple and useful. I would add just a suggestion to this. High grades of color, for example, 7 or 8, in rare circumstances can be misunderstood as high urine concentration when they are actually gross hematuria or bilirubin excretion because of jaundice. So, I would advise: drink water but if the color persists after 12 hours, go to a physician. In some cases, there may be the chance that a change in color is not due to high urine osmolality but to a disease. Larry Armstrong: Yes, indeed that is true and I mentioned the dietary conditions that may affect urine color, although we found in three studies that few of the dietary issues arose, even though these were active people who often took vitamins. I would agree that the average person probably needs the advice to look at their urine. But I dont know that this panel can address exceptions such as hematuria or renal disease. Do you have any suggestions? Antonio Dal Canton: I expect that if urine color has increased because of high urine concentration and then you drink, after some hours the urine will become diluted, and the color will change. However, if the darker color persists, my advice would be to go to a physician. Denis Barclay: If you were advocating the use of a
S49

urine color chart for the general public, apart from those specied by Dr. Dal Canton, what other qualiers would you want to include so that such a chart would not be misused or misinterpreted? Is it possible to have a light urine color and still be dehydrated? Are there false negatives and false positives that we would need to think about if we wanted to use such a color chart for the general public? Larry Armstrong: Yes. A large bolus of water at one time, say 800 to 1000 mL, dietary intake of vitamins, and other compounds can all alter urine color. There are also compounds, even in vegetables, that alter the urine color. Patrick Ritz: There are also some medications that affect urine color. Denis Barclay: So are you saying to monitor urine color over time and look for changes that are taking you to level 7 and above, that this would be a valid way of advocating their use? Larry Armstrong: I think that the key to using it, and again it is not a laboratory technique but a eld expedient, would be to train oneself to look at urine color with each urination. Ive done this with athletes time and again, and they are initially amazed at how dark their urine is. But to understand the concept that drinking more results in a pale urine color, as simple as that may seem, they must intellectually connect uid intake with urine output. With training, people seem to be able to adapt quite readily. Patrick Ritz: And do you have any data showing that those athletes who increased their water consumption in order to ensure that their urine became pale had improved performance? Larry Armstrong: I think the answer to that lies in the large data sets that Dr. Sawka and Dr. Shirreffs showed earlier demonstrating the effects of hydration on performance. Michael Sawka: For urine osmolality and specic gravity, are these effective eld measures in terms of screening, using a threshold, or are they quantitative for individual athletes? Larry Armstrong: In terms of quantitation for eld use, these techniques should require little technical expertise, no sophisticated instrumentation, and should be accurate, safe, and inexpensive. That would eliminate osmolality, unless you utilize a handheld unit. Michael Sawka: So can urine specic gravity be used quantitatively for dehydration, or is it a tool to use in the eld for screening? For example, the American College of Sports Medicine in a consensus statement and others have recommended setting a threshold above or below which you probably are euhydrated or dehydrated, and if you are in between you really dont know. Thats what theyre saying? Larry Armstrong: Does this mean that you do not
S50

accept the common clinical perspective that urine specic gravity is valid? Michael Sawka: Yes, absolutely. I dont think its quantitated. You can go back to the original work of Adolph that shows individual variability, you can go to Popowski and others, who show no signicant correlation with plasma osmolality. I know also that there are a number of things in a normal individual that affect urine ow. For example, physical exercise or just heat stress. There are a number of things that a person can do that will concentrate the urine, so my feeling isand this has been stated by the American College Sports Medicine in a consensus statementthat it certainly is an effective screen; that if the urine specic gravity falls below 1.02 or above 1.03 you can tell when a person is dehydrated or euhydrated. In between, its difcult to quantitate. Larry Armstrong: I think the question is also complicated by the fact that the change in body mass (Figure 3) over this short period of time represents water loss from the body. We nd that these curves are very similar and, at least under these laboratory conditions, urine specic gravity increases when body mass increases. Michael Sawka: I think most people would not argue with that. However, I think the question is, if you are actually going to use it as a measure for hydration status, i.e. if you get a urine specic gravity value of X, is it indicative of dehydration or some level of hydration? Susan Shirreffs: I would use osmolality or specic gravity. If I see a value of urine osmolality of near 900 or 1000, I would say theres a good chance this person is dehydrated, such that we could quantify it to around 2% body mass loss. For values at 700, we couldnt say that they were dehydrated by a specic amount less, and if its 1100, then a specic amount more, I dont think I could use it in that way. When we also look at large numbers of individuals at pre-training, we do see an indication that if you measure their osmolality at that point, that theres a reasonable correlation between that pre-training osmolality and how much they choose to drink voluntarily during training. So that if its higher, suggesting perhaps they are slightly dehydrated, they do voluntarily drink more during training. I think its an indicator, rather than a quantication. Michael Sawka: I would agree with that. Now, I was really interested in your impedance work, Dr. Armstrong, particularly the multi-frequency, because the single impedance has always been shown to be a good rough estimate of TBW. But as you know, when you dehydrate, there are problems that arise in different types of dehydration and a variety of confounding factors, but you seem to think that the multi-frequency with the Cole correction works pretty well. I know that Bartok and Schoeller have recently looked at that, and they found
Nutrition Reviews, Vol. 63, No. 6

that not necessarily TBW but a change in TBW really was unsatisfactory for individual values. What are your thoughts? Larry Armstrong: Both single-frequency and bioimpedance spectroscopy with multiple frequencies, I think are not valid when dehydration or uid shifts occur. Also, changes in skin-blood-ow, skin temperature, or posture might affect these values. There are many things that have to be controlled very carefully. In the studies done by my group, by Long, and by Bartok, at the beginning of the measurements the subjects were well hydrated, stationary, and the conditions of the environment had been controlled carefully. That is very important and I would agree with you. Across time, when there are perturbations in the uid state, I would not trust impedance values. Michael Sawka: So you think impedance has some value as a rough estimate of TBW, but when you start getting into hydration changes, you dont think there is a lot of value there? Larry Armstrong: If you are comparing point A to point B. Patrick Ritz: Im not actually sure that isotopic measurements would provide you with sufcient precision to be able to see a small change. Larry Armstrong: I believe that you are correct. When I was an investigator at USARIEM, in Natick, MA, I observed that the precision of bioimpedance spectroscopy is about 800 mL. Patrick Ritz: And for isotopic techniques the precision is about 1 L, so any change below 2 L is difcult to see with any of these techniques. Michael Sawka: Usually in such studies, they measure TBW; they will be very standardized and then they start using weight changes. Antonio Dal Canton: In my experience, urine specic gravity is a very good surrogate for urine osmolality, because the molecules that contribute to urine osmolality are pretty small (i.e. urea and electrolytes), and their weight and their number rise together with some exceptions. For example, in proteinuria you have very large and heavy molecules and specic gravity will increase, but osmolality of urine will not increase. It may be that you have some problems in measuring specic gravity with a refractometer, because to the layman, it might be quite difcult to use that instrument. But maybe if you use a oating densitometer it is much easier to read and maybe even more reliable. I dont know whether using a refractometer may be misleading or may induce mistakes. Michael Sawka: Yes, I cant really comment on the instrumentation approach. All I can say is that the studies I have seen that have actually compared urine osmolality and urine specic gravity show a good relationship, and
Nutrition Reviews, Vol. 63, No. 6

thats always fairly constant. But what they cant show is the relationship between that and change in plasma osmolality. When you go back and do careful calculation of the body weight changes, as Adolph did in the desert, being very precise, this follows the general trend, but there is a wide scatter. So I certainly would agree with Dr. Armstrong that there are good indices for screening, such as urine color, specic gravity, and osmolality. But I am not so sure how good it is just to take one measure and say this is your hydration level. Larry Armstrong: I think that Dr. Sawkas view as a scientist is exactly right. But the question then becomes, what is the need for research in the laboratory versus eld use? Those uses are different. Michael Sawka: Exactly. When we give advice to soldiers, we dont use the urine color charts, but we tell them to look at their urine volume and the color; that if they are dark and they are not urinating enough, and if it persists, they are probably dehydrated, and certainly we are not going to argue that. Its just translating that into a value. Irwin Rosenberg: Dr. Sawka just mentioned urine volume as well as color. When we talked a little earlier about some of the special considerations with the elderly, and Dr. Dal Canton reminded us that kidney function and concentration capacity are declining with age to some extent, what could we say about the use of color alone, without volume, as a measure of hydration status in a 75-year-old, lets say, who might be excreting greater volume in order to be able to excrete his or her solute load? How would we apply that information, which you derived largely from young athletes, to an assessment of an older population? Larry Armstrong: I dont recall anyone utilizing the urine color chart in an elderly population. However, during a heat stroke study that I did some years ago, we evaluated a military ofcer who was about 45 years old and nearing retirement. We tested him three times over the course of 11 months to see if he was heat tolerant. He had experienced hypo-ltration after a heat stroke, probably because of renal damage due to hyperthermia. We observed that he always had a urine specic gravity of 1.001 to 1.004, representing hypo-ltration. If we lose the ability to lter with age and if it decreases 60% or 70% by the age of 80, as we have heard, then there is likely to be a difference in the use of the urine color chart; it may have a different meaning. Irwin Rosenberg: Obviously, that would require some tests to see what the applicability across populations might be. Larry Armstrong: Yes, and for children as well. Monique Ferry: In elderly people, the main problem is that many are incontinent and it is difcult to obtain urine. Urine volume is quite impossible to obtain,
S51

and just to have urine color is sometimes really difcult. So we try to inform people that it is useful, but it can be difcult to apply. Larry Armstrong: Moreover, individuals who are incontinent often avoid drinking. Monique Ferry: Often, people with a disease who develop fever or other conditions that increase cognitive impairment are incontinent and you cant obtain urine. You have to follow the patient and try to obtain urine, but it is difcult. Patrick Ritz: Assume that you have a very cheap and accurate isotopic measurement of total body extracellular and intracellular water, how would you relate that to hydration? Assume you measure me and you nd 42 L, what does it tell you about my hydration? Larry Armstrong: I would measure TBW over the course of days and weeks to nd a baseline value, and I would work with that baseline value. Patrick Ritz: So you mean youre looking at this as the stability of TBW. Larry Armstrong: Once I have a baseline value, then I would take measurements from time to time, whenever the critical time might be, and I would relate it to that baseline value, realizing of course that there are body composition changes with age and with time. I expect this technique would work best for a period of weeks or months. Then I would re-establish the baseline. Patrick Ritz: I think that one of the difculties we have when faced with an individual subject is to be able to say that this subject is euhydrated, optimally hydrated, dehydrated, or whatever without a reference table of the values for TBW with age, with gender, with body composition, and so on. I cant see how we can assess hydration status punctually from water spaces. I agree that it may work for longitudinal changes, but for punctual measurements I cant see it working. Larry Armstrong: You remind me of a recent study by Cheuvront of Dr. Sawkas group that looked at baseline body weight, not TBW. They attempted to determine how many days were required to establish a valid baseline body weight. It took three measurements over three days. Have I interpreted that study correctly, Dr. Sawka? Michael Sawka: Yes, we usually do it over many days, as well as a variety of other measurements, but if you ask the question what is the minimal amount of time to get a valid measurement?, it comes down to three days. If you do three days and you control, you can get a pretty good estimate. Larry Armstrong: You can use that as an estimate of changes in body water. One thing I always tell people that they seem to remember: a pints a pound the world around. For each pound that they lose, they should consume a pint of uid.
S52

REFERENCES
1. Armstrong LE, Keneck RW, Castellani JW, et al. Bioimpedance spectroscopy technique: intra-, extracellular, and total body water. Med Sci Sports Exerc. 1997;29:16571663. Oser, BL, ed. Hawks Physiological Chemistry. New York: McGraw-Hill, 1965. Gudivaka R, Schoeller D, Kushner RF. Effect of skin temperature on multifrequency bioelectrical impedance analysis. J Appl Physiol. 1996;81:838 845. Harrison M. Effects of thermal stress and exercise on blood volume in humans. Physiol Rev. 1985;65: 149 209. Adolph EF. Physiology of Man in the Desert. New York: Interscience; 1947. Kraemer WJ, Fry A, Rubin M, et al. Physiological and performance responses to tournament wrestling. Med Sci Sports Exerc. 2001;33:13671378. Lang F, Busch GL, Ritter M, et al. Functional significance of cell volume regulatory mechanisms. Physiol Rev. 1998;78:247306. Noakes TD. Overconsumption of uids by athletes. BMJ. 2003;327:113114. Chumlea WC, Guo SS, Zeller CM, Reo NV, Siervogel RM. Total body water data for white adults 18 to 64 years of age: the Fels Longitudinal Study. Kidney Int. 1999;56:244 252. Suprasongsin C, Kalhan S, Arslanian S. Determination of body composition in children and adolescents: validation of bioelectrical impedance with isotope dilution technique. J Pediatr Endocrinol Metab. 1995;8:103109. Novak LP. Changes in total body water during adolescent growth. Hum Biol. 1989;61:407 414. Chumlea W, Guo S, Zeller C, et al. Total body water reference values and prediction equations for adults. Kidney Int. 2001;59:2250 2258. Manz F, Wentz A. 24-h hydration status: parameters, epidemiology and recommendations. Eur J Clin Nutr. 2003;57(suppl 2):S10 S18. Maughan RJ. Impact of mild dehydration on wellness and on exercise performance. Eur J Clin Nutr. 2003;57(suppl 2):S19 S23. Wilson MM, Morley JE. Impaired cognitive function and mental performance in mild dehydration. Eur J Clin Nutr. 2003;57(suppl 2):S24 S29. Shirreffs SM, Maughan RJ. Urine osmolality and conductivity as indices of hydration status in athletes in the heat. Med Sci Sports Exerc. 1998;30: 1598 1602. Kavouras S. Assessing hydration status. Curr Opin Clin Nutr Metab Care. 2002;5:519 524. Oppliger R, Bartok C. Hydration testing of athletes. Sports Med. 2002;32:959 971. Maw GA, Mackenzie IL, Comer DA, Taylor NA. Whole-body hyperhydration in endurance-trained males determined using radionuclide dilution. Med Sci Sports Exerc. 1996;28:1038 1044. Stedmans Concise Medical Dictionary for the Health Professions. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2001. Schoeller DA, Kushner RF, Taylor P, et al. Measurement of total body water: isotope dilution techniques. In: Roche AF, ed. Body Composition AsNutrition Reviews, Vol. 63, No. 6

2. 3.

4.

5. 6.

7.

8. 9.

10.

11. 12.

13.

14.

15.

16.

17. 18. 19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

sessment in Youth and Adults. Columbus, OH: Ross Laboratories; 1985. Bartoli WP, Davis JM, Pate RR, Ward DS, Watson PD. Weekly variability in total body water using 2 H2O dilution in college-age males. Med Sci Sports Exerc. 1993;25:14221428. Lukaski HC. Methods for the assessment of human body composition: traditional and new. Am J Clin Nutr. 1987;46:536 556. Miller ME, Cosgriff JM, Forbes GB. Bromide space determination using anion-exchange chromatography for measurement of bromide. Am J Clin Nutr. 1989;50:168 171. Vaisman N, Pencharz PB, Koren G, Johnson JK. Comparison of oral and intravenous administration of sodium bromide for extracellular water measurements. Am J Clin Nutr. 1987;46:1 4. Fairbanks VF, Klee GG, Wiseman GA, et al. Measurement of blood volume and red cell mass: reexamination of 51Cr and 125I methods. Blood Cells Mol Dis. 1996;22:169 186. Lindberg LH, Nickel K, Pettit JE, et al. Albas Medical Technology, 10th ed. Anaheim, CA: Berkeley Scientic Publications; 1984. Sawka MN, Young AJ, Pandolf KB, Dennis RC, Valeri CR. Erythrocyte, plasma, and blood volume of healthy young men. Med Sci Sports Exerc. 1992;24: 447 453. Greenleaf JE, Convertino VA, Mangseth GR. Plasma volume during stress in man: osmolality and red cell volume. J Appl Physiol. 1979;47:10311038. Chien S, Gregersen MI. Determination of body uid volume. In: Nastuk WL, ed. Physical Techniques in Biological Research. IV. Special Methods. New York: Academic Press; 1962. Yasumura S, Cohn S, Ellis K. Measurement of extracellular space by total body neutron activation. Am J Physiol. 1983;13:R36 R40. Sinning WE, Morgan AL. The effects of body position on bioimpedance spectroscopy. In: Ellis KJ, Eastman JD, eds. Human Body Composition. New York: Plenum Press; 1993. Deurenberg P. International consensus conference on impedance in body composition. Age Nutr. 1994; 5:142145. Boulier A, Thomasset AL, Apfelbaum M. Bioelectrical impedance measurement of body water. Am J Clin Nutr. 1992;55:761762. Ritz P; Source Study. Bioelectrical impedance analysis estimation of water compartments in elderly diseased patients: the source study. J Gerontol. 2001;56:M344 M348. Bussolotto M, Ceccon A, Sergi G, Giantin V, Beninca P, Enzi G. Assessment of body composition in elderly: accuracy of bioelectrical impedance analysis. Gerontology. 1999;45:39 43. Segal KR, Burastero S, Chun A, Coronel P, Pierson RN Jr, Wang J. Estimation of extracellular and total body water by multiple-frequency bioelectrical-impedance measurement. Am J Clin Nutr. 1991;54: 26 29. OBrien C, Young AJ, Sawka MN. Bioelectrical impedance to estimate changes in hydration status. Int J Sports Med. 2002;23:361366. Dunbar CC, Melahrinides E, Michielli DW, Kalinski

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

MI. Effects of small errors in electrode placement on body composition assessment by bioelectrical impedance. Res Q Exerc Sport. 1994;65:291294. Buono MJ, Burke S, Endemann S, et al. The effect of ambient air temperature on whole-body bioelectrical impedance. Physiol Meas. 2004;25:119 123. Roos AN, Westendorp RG, Frolich M, Meinders AE. Tetrapolar body impedance is inuenced by body posture and plasma sodium concentration. Eur J Clin Nutr. 1992;46:53 60. Berneis K, Keller U. Bioelectrical impedance analysis during acute changes of extracellular osmolality in man. Clin Nutr. 2000;19:361366. VanLoan M, Mayclin PL. Use of multi-frequency bioelectrical impedance analysis for the estimation of extracellular uid. Eur J Clin Nutr. 1992;46:117 24. Deurenberg P, Tagliabue A, Schouten FJ. Multifrequency impedance for the prediction of extracellular water and total body water. Br J Nutr. 1995; 73:349 358. van Marken Lichtenbelt WD, Westerterp KR, Wouters L, Luijendijk SC. Validation of bioelectrical-impedance measurements as a method to estimate body-water compartments. Am J Clin Nutr. 1994; 60:159 166. Cole KS, Cole RH. Dispersion and adsorption in dielectrics: I. Alternating current characteristics. J Chem Physiol. 1941;9:341351. Thomasset A. Measurement of the extracellular uid volume by the electro-chemical method. Biophysical signicance of 1 kilocycle impedance of the human body [in French]. Lyon Med. 1965;214:131 143. Visser M, Deurenberg P, van Staveren WA. Multifrequency bioelectrical impedance for assessing total body water and extracellular water in elderly subjects. Eur J Clin Nutr. 1995;49:256 266. Deurenberg P, Schouten F. Loss of total body water and extracellular water assessed by multifrequency impedance. Eur J Clin Nutr. 1992;46:247255. Pioaloux V, Mischler I, Mounier R, et al. Effect of equilibrated hydration changes on total body water estimates by bioelectrical impedance analysis. Br J Nutr. 2004;91:153159. OBrien C, Baker-Fulco CJ, Young AJ, Sawka MN. Bioimpedance assessment of hypohydration. Med Sci Sports Exerc. 1999;31:1466 1471. van Beaumont W. Evaluation of hemoconcentration from hematocrit measurements. J Appl Physiol. 1972;32:712713. Dill DB, Costill DL. Calculation of percentage changes in volumes of blood, plasma, and red cells in dehydration. J Appl Physiol. 1974;37:247248. Lambert CP, Ball D, Leiper JB, Maughan RJ. The use of a deuterium tracer technique to follow the fate of uids ingested by human subjects: effects of drink volume and tracer concentration and content. Exp Physiol. 1999;84:391399. Davis JM, Lamb DR, Burgess WA, Bartoli WP. Accumulation of deuterium oxide in body uids after ingestion of D2O-labeled beverages. J Appl Physiol. 1987;63:2060 2066. Fordtran JS. Measurement of intestinal water abS53

Nutrition Reviews, Vol. 63, No. 6

57.

58.

59.

60.

61.

62.

63.

64. 65.

66.

67.

68.

69.

sorption. Am J Physiol. 1992;262(2 part 1):G377 G378. Lambert CP, Maughan RJ. Accumulation in the blood of a deuterium tracer added to hot and cold beverages. Scand J Med Sci Sports. 1992;2:76 78. Armstrong LE, Hubbard RW, Zeisel SH, Janghor18 bani M. Dynamics of H2 O transport during exercise in a hot environment. Fed Proc. 1987;46:318. Armstrong LE, Hubbard RW, Zeisel SH, Janghor18 bani M. Appearance of ingested H2 O in plasma and sweat during exercise-heat exposure. Med Sci Sports Exerc. 1987;19:S56. Moran D, Heled Y, Margaliot M, et al. Hydration status measurement by radio frequency absorptiometry in young athletesa new method and preliminary results. Physiol Meas. 2004;25:5159. Dufour DR. Osmometry: The Rational Basis for Use of an Underappreciated Diagnostic Tool. New York, NY: Advanced Instruments; 2001. Greenleaf JE, Morimoto T. Mechanisms controlling uid ingestion: thirst and drinking. In: Buskirk ER, Puhl SM, eds. Body Fluid Balance: Exercise and Sport. Boca Raton, FL: CRC Press; 1996. Bohnen N, Terwel D, Markerink M, Ten Haaf JA, Jolles J. Pitfalls in the measurement of plasma osmolality pertinent to research in vasopressin and water metabolism. Clin Chem. 1992;38:2278 2280. Shirreffs SM. Markers of hydration status. Eur J Clin Nutr. 2003;57(suppl 2):S6 S9. Mitchell JW, Nadel ER, Stolwijk JA. Respiratory weight losses during exercise. J Appl Physiol. 1972; 32:474 476. Cheuvront SN, Carter R 3rd, Montain SJ, Sawka MN. Daily body mass variability and stability in active men undergoing exercise-heat stress. Int J Sport Nutr Exerc Metab. 2004;14:532540. Francesconi R, Hubbard R, Szlyk P, et al. Urinary and hematologic indexes of hypohydration. J Appl Physiol. 1987;62:12711276. Kovacs EM, Senden JM, Brouns F. Urine color, osmolality, and specic electrical conductance are not accurate measures of hydration status during post-exercise rehydration. J Sports Med Phys Fitness. 1999;39:4753. Armstrong LE, Maresh CM, Castellani JW, et al.

70.

71.

72. 73.

74.

75.

76.

77.

78.

79. 80.

Urinary indices of hydration status. Int J Sport Nutr. 1994;4:265279. Armstrong LE, Soto JA, Hacker FT Jr, Casa JR, Kavouras SA, Maresh CM. Urinary indices during dehydration, exercise, and rehydration. Int J Sport Nutr. 1998;8:345355. Guthrie RM, Lott JA, Kriesel S, Miller IL. Does the urine dipstick meet medical needs for urine specic gravity? J Fam Pract. 1987;25:512514. Lentner C, ed. Geigy Scientic Tables. vol 1. Basel, Switzerland: CIBA-GEIGY; 1981. Ormerod JK, Elliott TA, Scheett TP, VanHeest JL, Armstrong LE, Maresh CM. Drinking behavior and perception of thirst in untrained women during 6 weeks of heat acclimation and outdoor training. Int J Sport Nutr Exerc Metab. 2003;13:1528. Hackney AC, Coyne JT, Pozos R, Feith S, Seale J. Validity of urine-blood hydrational measures to assess total body water changes during mountaineering in the sub-Arctic. Arctic Med Res. 1995;54:69 77. Hubbard RW, Szlyk PC, Armstrong LE. Inuence of thirst and uid palatability on uid ingestion during exercise. In: Gisol CV, Lamb DR, eds. Perspectives in Exercise Sciences and Sports Medicine. Fluid Homeostasis During Exercise. Indianapolis, IN: Benchmark Press; 1990. Armstrong L, Maresh C, Gabaree C, et al. Thermal and circulatory responses during exercise: effects of hypohydration, dehydration, and water intake. J Appl Physiol. 1997;82:2028 2035. Young AJ, Sawka MN, Epstein Y, Decristofano B, Pandolf KB. Cooling different body surfaces during upper and lower body exercise. J Appl Physiol. 1987;63:1218 1223. Popowski LA, Oppliger RA, Patrick Lambert G, Johnson RF, Kim Johnson A, Gisol CV. Blood and urinary measures of hydration status during progressive acute hydration. Med Sci Sports Exerc. 2001;33:747753. Anonymous. Wrestlers deaths prompt new discussions. Athletic Management. 1998;10.3:8 10. Casa DJ, Armstrong LE, Hillman SK, et al. National Athletic Trainers Association Position Statement: Fluid Replacement for Athletes. J Ath Train. 2000; 35:212224.

S54

Nutrition Reviews, Vol. 63, No. 6