ORIGINAL ARTICLE

Influence of water drinking on resting energy

expenditure in overweight children
G Dubnov-Raz
1,5
, NW Constantini
2,5
, H Yariv
3
, S Nice
2
and N Shapira
4
1
Exercise, Nutrition and Lifestyle Clinic, The Edmond and Lily Safra Childrens Hospital, Sheba Medical Center,
Tel Hashomer, Israel;
2
Hadassah Optimal Sport Medicine Center, Department of Orthopedic Surgery, Hadassah-
Hebrew University Medical Center, Jerusalem, Israel;
3
School of Nutritional Sciences, The Robert H Smith Faculty of
Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot, Israel and
4
Center for Nutritional
Research, Beilinson Campus, Rabin Medical Center, Petah-Tikva, Israel
Background: It was previously demonstrated that drinking water significantly elevates the resting energy expenditure (REE) in
adults, and that low water intake is associated with obesity and lesser success in weight reduction. This study addressed the
potential of water drinking to increase the REE in children, as an additional tool for weight management.
Objective: To examine the effect of drinking water on the REE of overweight children.
Design: A total of 21 overweight, otherwise-healthy children (age 9.91.4 years, 11 males) drank 10ml kg
1
cold water (41C).
REE was measured before and after water ingestion, for 66min. The main outcome measure was the change in mean REE from
baseline values.
Results: Immediately after drinking water, there was a transient decrease in REE, from a baseline value of 3.32

1.15kilojoule
(kJ) per min to 2.560.66kJ per min at minute 3 (P 0.005). A subsequent rise in REE was then observed, which was
significantly higher than baseline after 24min (3.89

0.78kJ/min (P 0.021)), and at most time points thereafter. Maximal

mean REE values were seen at 57min after water drinking (4.16

1.43 kJ per min (P 0.004)), which were 25% higher than

baseline. REE was significantly correlated with age, height, weight and fat-free mass; the correlations with maximal REE values
after water drinking were stronger than with baseline REE values.
Conclusions: This study demonstrated an increase of up to 25% in REE following the drinking of 10ml kg
1
of cold water in
overweight children, lasting for over 40min. Consuming the recommended daily amount of water for children could result in an
energy expenditure equivalent to an additional weight loss of about 1.2kg per year. These findings reinforce the concept of
water-induced REE elevation shown in adults, suggesting that water drinking could assist overweight children in weight loss or
maintenance, and may warrant emphasis in dietary guidelines against the obesity epidemic.
International Journal of Obesity advance online publication, 12 July 2011; doi:10.1038/ijo.2011.130
Keywords: energy expenditure; fluids; metabolic rate; pediatrics
Introduction
Reducing the consumption of sugar-sweetened beverages
and drinking water is a justified and repeated recommenda-
tion found in many pediatric obesity prevention and
treatment guidelines.
13
Therefore, drinking water is an
obvious alternative for the consumption of sweetened
beverages for obesity prevention and treatment. Sugar-
sweetened beverages might contribute an average of 224kcal
per day (936 kJ per day) to a childs energy intake, which
could correspond to over 10% of the total daily energy
intake.
4
Replacing sugar-sweetened beverages with water
could result in an average reduction of 235kcal per day
(987 kJ per day) in children and adolescents.
5
In a recent
study of a school-based intervention promoting water
consumption for overweight prevention, a 31% reduction
in the prevalence of overweight among study participants
was noted.
6
An intriguing mechanism by which water drinking may
assist in reducing weight, is water-induced thermo-
genesis.
7,8
Related studies conducted in adults demonstrated
that drinking water could significantly elevate the resting
energy expenditure (REE). In the first study, drinking 500 ml Received 14 September 2010; revised 4 April 2011; accepted 31 May 2011
Correspondence: Dr G Dubnov-Raz, Exercise, Nutrition and Lifestyle Clinic,
The Edmond and Lily Safra Childrens Hospital, Sheba Medical Center,
Tel Hashomer, Israel.
E-mail: gal.dubnov-raz@sheba.health.gov.il
5
These authors contributed equally to this paper.
International Journal of Obesity (2011) 16
& 2011 Macmillan Publishers Limited All rights reserved 0307-0565/11
www.nature.com/ijo
of water (temperature 221C), elicited an increase in REE
within 10min, reaching a maximum after 3040min of 30%
higher than baseline. This increase in REE was diminished
when a beta-adrenoreceptor blocker was given, indicating
that the sympathetic system was responsible for this rise in
energy expenditure. In a second study, ingesting 500ml
of water increased energy expenditure over the course of
60min after intake, again by a significant magnitude of 24%
above baseline values, while administration of 500 ml saline
or 50ml water had no effect. This finding suggested that the
REE-increasing effect is osmosensitive, and not related
merely to gastric distension.
Surprisingly, a second research group was not able to
replicate these findings.
9
In this study, eight healthy normal-
weight volunteers from both sexes drank 7.5ml kg
1
body
weight (B518 ml) of distilled water, 0.9% saline or a 7%
sucrose solution (as a positive control). REE, measured from
30min before until 90min after the drinks, was not
increased after drinking either distilled water or 0.9% saline.
Drinking distilled water at 31C caused a small increase in
energy expenditure, of 4.5%, over 60min. This study
introduced some uncertainty regarding the concept of
water-induced thermogenesis. A possible explanation for
the differences between these studies is differences in REE
measurement techniques or other methodological issues.
Additional study is therefore needed to establish the effect
of water drinking on energy expenditure. Further, the
extension of water-induced thermogenesis to the pediatric
population has not been tested.
The aim of this study was to examine the effect of drinking
cold water on the REE of overweight children.
Methods
Participants were 21 overweight and obese children (11 boys,
10 girls; body mass index X85th percentile for age and sex
1
)
aged 712 years (mean 9.9

1.4 years), from the pediatric

obesity treatment program of a tertiary care center in
Jerusalem, Israel. Exclusion criteria were the presence of
any additional chronic medical condition, or the use of
chronic medications. The study was approved by the
Institutional Review Board of the Hadassah- Hebrew
University Medical Center, and performed in accordance
with the Declaration of Helsinki. Written informed consent
was obtained from a parent following the childs agreement
to participate.
Children came to the research facility in the morning,
after at least 12 h of physical inactivity and complete
overnight fasting, during which no water drinking was
allowed. Height and weight were measured for body mass
index calculation and determination of the amount of water
to be consumed. After an explanation of the methods,
participants lay in bed and were covered with a ventilated
hood connected to a portable metabolic cart
10
(COSMED
K4b2, Rome, Italy) for breath-by-breath respiratory gas
exchange measurements. Baseline measurements lasted for
20min; the mean REE of the final 10 minutes was defined as
the baseline REE.
11
During REE measurements, the children
watched a non-action movie of their choice, in order to
reduce impatience and large movements. It was previously
shown that television watching does not affect the REE of
children;
12,13
this was also verified in our setting with a pilot
study of three children, which lasted for 60min (data not
shown). After determination of the baseline REE, children
drank 10ml kg
1
body weight of commercially available
natural mineral water (Mey Eden (Eden Springs) Mineral
Water Company (Bnei Brak, Israel). Total dissolved solids
240 mg l
1
, sodium concentration 1.4 mmol l
1
). Mineral
water was preferred over tap water so as to control for solute
concentrations. Water temperature was 4 1C, measured by a
thermometer with an accuracy of 0.1 1C (ME-03-HA-003,
HANNA Instruments Inc., Woonsocket, RI, USA). Water
drinking took 23min, after which the children resumed
their lying position under the ventilated hood, and con-
tinued to watch the movie. The primary outcome measure
was the REE after water drinking, which was measured for
another 66min. In our pilot study of three children, rising
and lying down again for 60min did not affect the REE (data
not shown).
After termination of the metabolic measurements, body
fat percentage was measured by bioimpedance analysis
(Tanita BC-418 Segmental Body Composition Analyzer,
Tanita Corp., Tokyo, Japan).
Statistical analysis
REE values after water drinking were analyzed using means
of 3-minute segments, in order to reduce the number of
measurements but maintain sensitivity. Repeated measures
analysis of variance was used to compare the REE in each
time point against baseline values, and a t-test was used to
compare respiratory data between baseline and the time
point of maximal REE. The net change in energy expenditure
was calculated as the area under the curve of the mean REE
during the study duration, by adding the sum of trapezoids.
Spearmans correlation coefficient was used to assess the
relationship between maximal REEs obtained after water
drinking and the childs age, sex, height, weight, body mass
index, fat mass percentage, lean body mass and amount of
water consumed. Po0.05 was considered to be statistically
significant. Statistical analysis was carried out using the
PASW Statistics program, version 17.0.3 (SPSS Inc., Chicago,
IL, USA).
The sample size was calculated based on previous studies
7,8
showing an REE elevation of 2430%. Using a conservative
expected elevation of 20% after water drinking, it was
calculated that 19 children would be needed to demonstrate
such a difference with a power of 80% and a0.05.
Water drinking and energy expenditure in children
G Dubnov-Raz et al
2
International Journal of Obesity
Results
Clinical characteristics of study participants are summarized
in Table 1. All children were overweight, as per inclusion
criteria. All drank the determined amount of water in the
specified duration, and all completed the study.
Figure 1 shows the mean changes in REE after water
drinking. We noticed a significant drop in REE immediately
after water drinking, from 3.321.15kJ per min at baseline,
to 2.56

0.66kJ per min at minute 3 (P0.005), with a

subsequent rise in energy expenditure. The REE was
significantly higher than baseline values at 24min after
water ingestion, 3.89

0.78kJ per min (P0.021), and at

most time points thereafter (Figure 1). The highest mean REE
value was observed at 57min after water drinking,
4.161.43kJ per min (P0.004). This corresponds to a
maximal REE elevation of 25% from baseline. VO
2
value at
this time point was 26% higher than baseline (19686ml
per min vs 15653ml per min, Po0.001) and VCO
2
value at
this time point was 20% higher (172

56ml per min vs

144

48ml per min, P0.017). There was no significant

change in the respiratory quotient between these two time
points (0.88

0.8 vs 0.88

0.5, P0.76). No significant

difference was found in REE elevations between males and
females (P0.88). The net accumulated change in total
energy expenditure from baseline to the end of measurement
after 66min, using the mean REE of each time point, was
26 kJ, with individual variability ranging from 13.4 to 84kJ.
Table 2 presents the relationships between the various
clinical characteristics of the participants, and both baseline
and maximal REE values. REE was significantly correlated
with age, height and weight, as well as with fat-free mass,
with a much stronger relationship with the maximal REE
than with baseline REE. body mass index correlated
significantly only with the maximal REE value, while neither
REE values correlated with fat percentage. Both baseline and
maximal REE values also correlated with the volume of water
consumed.
Discussion
This study, conducted among 21 overweight and obese
children from both sexes, demonstrated a 25% increase in
REE following the drinking of 10ml kg
1
cold water (41C).
This increase was apparent from 24min after water drinking,
and lasted for at least 66min. The unique effect of water-
induced thermogenesis is a negative caloric effect, that is, a
net increase in energy expenditure, with no added energy
intake. This effect is especially important for overweight and
obese individuals seeking weight loss or maintenance.
An interesting finding was the large yet transient decrease
in REE following the ingestion of cold water. A technical
issue is unlikely, as this drop was not seen during baseline
REE measurements (data not shown). We presume that this
decrease occurred due to the rapid cooling of the upper
gastrointestinal tract, which perhaps resulted in an adrener-
gic-related or other neural response. Although systemic cold
exposure is well known to elevate the metabolic rate,
14,15
internal cold exposure by cold water drinking produces a
different type of stimulus. The fact that previous studies did
not report on this initial reduction in REE may raise the
question regarding the generalizability of this phenomenon,
Table 1 Clinical characteristics of study participants
Means.d. Range
Age (years) 9.9

1.4 7.012.0
Height (cm) 144.1

10.1 124.0160.5
Weight (kg) 53.9

13.4 34.379.8
BMI (kgm
2
) 25.5

3.5 20.433.5
BMI percentiles (%) 96.83.3 86.999.4
Fat percentage (%) 37.78.1 27.062.4
Fat-free mass index (kgm
2
) 15.71.2 12.617.4
Fat mass index (kgm
2
) 9.9

3.6 5.520.9
Abbreviation: BMI, body mass index.
Figure 1 REE following drinking of 10ml kg
1
of cold water (41C). Water
drinking at time point 0 is marked by a vertical arrow. Data points are mean
values of the 3min before each time point, and error bars represent the
standard error. Values that significantly differ from baseline are marked by an
asterisk.
Table 2 Spearmans correlation coefficients between clinical variables and
resting energy expenditure at baseline (REE
0
) and at its maximal value
(REE
max
)
REE
0
REE
max
Correlation
coefficient
P Correlation
coefficient
P
Age (years) 0.514 0.017 0.574 0.007
Height (cm) 0.541 0.011 0.582 0.006
Weight (kg) 0.445 0.043 0.614 0.003
BMI (kgm
2
) 0.218 0.342 0.463 0.034
Fat percentage (%) 0.245 0.284 0.336 0.136
Fat-free mass (kg) 0.453 0.039 0.732 o0.001
Volume of water (ml) 0.429 0.052 0.607 0.004
Abbreviations: BMI, body mass index; REE, resting energy expenditure.
Water drinking and energy expenditure in children
G Dubnov-Raz et al
3
International Journal of Obesity
for example, if it is dependent on age, overweight status,
water volume or body/ambient temperature. The use of
10-min averaging of REE, as performed in previous studies,
might cause this transient effect to be overlooked. Never-
theless, this REE reduction was short-term, and throughout
most of the post-intervention observation period, REE was
higher than baseline values. A previous study of cold water
ingestion in adults (41C, 900 ml) showed a reduction in
rectal temperature and heart rate during both rest and
exercise, with improved exercise capacity.
16
Together with
our findings, these studies demonstrate that drinking
cold water affects energy metabolism in both resting and
exercise conditions. This effect can partially explain previous
clinical observations in adults, that drinking water assists in
weight loss.
1719
The timing, duration and relative magnitude of the REE
increase seen in our study are very similar to those found
previously.
7,8
In addition, we demonstrated that the venti-
lated hood system can be used to demonstrate water-induced
thermogenesis in children, which until now was only shown
by using a respiratory chamber and in adults. The mechan-
isms by which drinking cold water elevates the metabolic
rate are incompletely understood. They have been suggested
to involve the sympathetic nervous system,
7
as well as gastric
osmoreceptors.
8
Gastric distention and gut hypo-osmolarity
increase neural sympathetic activity, eliciting both a pressure
response and the elevation of energy expenditure.
20
Infusing
a stomach with distilled water showed a twofold greater
increase in blood pressure compared with isotonic saline,
suggesting the role of hypo-osmolarity, possibly detected by
hepatic osmoreceptors.
20
In humans, distilled water, but not
saline, increased heart rate and peripheral vascular resis-
tance.
21
This provided further evidence of an elevated
sympathetic activity in response to the hypo-osmolar state.
Recent research has identified molecular transduction
mechanisms and channels involved in sensing hypo-osmotic
signals and affecting blood pressure and metabolic rate.
20
Water temperature could also have a role in REE elevation: in
the study by Brown et al.,
9
where no increase in REE after
drinking distilled water or 0.9% saline was found, a small
(4.5%) increase in energy expenditure was found after
drinking distilled water at 31C. Though water at 371C also
elevated the REE in a previous study,
7
it was calculated that
only 3040% of the excess energy expenditure after drinking
water at 221C, was used for warming it to body temperature.
The precise mechanism of the increased REE after water
consumption remains to be identified.
The magnitude of REE elevation found in our participating
children ( 26 kJ during 66min, mean 0.39kJ per min) is
half of that seen in adults ( 70kJ during 90min, mean
0.78kJ per min).
7
This smaller absolute increase can be
partially explained by the 3050% lower mean baseline REE
found in our children, as compared with findings from the
adult studies.
7,8
Nevertheless, the relative increase, expressed as percentage
of baseline, was similar. Hence, despite the low absolute REE
in obese children compared with adults, water drinking was
able to increase the REE by a similar proportion. Regarding
the long-term effect of water drinking, it should be noted
that the recommended amount for the average child at this
age is 1800ml per day.
22
Should the observed effect of a
single drink occur repeatedly, then consuming the recom-
mended daily amount of water would result in a mean
energy expenditure of more than 34000kJ (over 8100kcal)
per year; this could translate into an additional weight loss of
about 1.2kg per year, just by adhering to general water
drinking recommendations for children. In a study on older
adults, drinking 500 ml of water before each meal increased
weight loss by 2kg over a 12-week period, explained only
in part by a reduction in the energy intake of the meal;
19
water-induced thermogenesis could have also assisted in the
observed weight loss with pre-meal drinking. In another
study in adults, an absolute increase in drinking water to
X1l per day was associated with B2kg weight loss over 12
months,
18
the effect being significantly larger than drinking
non-caloric beverages. This disparity can be explained by the
previous observation of Boschmann et al.,
8
that water-
induced thermogenesis is osmosensitive, as drinking salt
water did not elevate the REE while plain water did.
Collectively, these studies provide evidence that water
drinking may independently assist weight loss.
Regarding the associations between various clinical mea-
sures and REE (Table 2), it was expected that all measures of
body size would correlate with REE, especially fat-free
mass.
23
These positive and strong associations reinforce the
validity of our measurements, as fat-free mass is the main
determinant of the REE. Interestingly, most correlations
between body size indices and REE were stronger or became
statistically significant with maximal compared with
baseline REE values. A possible explanation for this is the
effect of rehydration of muscle tissue by water ingestion
following the overnight fasting state. The water content of
muscle from obese adults was previously found to be 15%
lower than that of adults of normal weight.
24
Therefore, in
addition to the osmosensitive and neural mechanisms of REE
elevation suggested above, it is possible that the under-
hydrated muscle tissue of the obese children became more
metabolically active following its rehydration.
Our findings have two important clinical implications.
Primarily, this study identified an additional benefit of water
drinking by overweight childrenFincreased energy expen-
diture. The high rate of overweight and obesity among
children, reaching nearly 32% in the US,
25
draws great
attention even from the highest governmental levels.
26
Obese children were found to have a lower REE per kg of
fat-free mass as compared with normal-weight children,
27
so
any means to elevate their energy expenditure is welcome.
Drinking water could therefore assist in weight reduction/
maintenance in two complementary ways: by reducing
energy intake as a substitute for sugar-sweetened beverages,
and by increasing energy output through associated thermo-
genesis. Secondly, as current protocols for measuring the
Water drinking and energy expenditure in children
G Dubnov-Raz et al
4
International Journal of Obesity
resting metabolic rate do not prohibit water drinking,
28
the
thermogenic effect of water should be taken into account.
From our findings and those of the previous studies in
adults,
7,8
it appears that drinking water within at least
90min before REE measurements should be disallowed.
This study has several limitations. Firstly, our baseline
testing did not last as long as the post-drinking measure-
ments. Having the children lie still for over 2h seemed
unrealistic. Therefore, REE values after water drinking are
compared with baseline values (as done in the previous
studies in adults), and not to a corresponding time frame of
no-drinking conditions. Nevertheless, we did not identify a
spontaneous elevation of REE during 60min of rest in our
pilot studies. In previous studies where REE was measured in
obese children for 30min or more, no spontaneous elevation
of REE was reported.
23,2931
We therefore have no reason to
believe that such an effect might have confounded our
results. We also acknowledge that because we did not
compare different types of water, or incorporate a broader
range of subject characteristics, our findings may be limited
to the specific temperature, volume and solute properties of
the water used, as well as to overweight children from this
specific age group. However, similar results shown in
previous studies on adults with water at room temperature
strongly suggest the generality of this phenomenon. Addi-
tional studies using water of different volumes and tempera-
ture, in the presence of beta-blockade, or in other pediatric
populations, could help to elucidate the mechanism behind
water-induced thermogenesis in children. The potential
contribution of water drinking to metabolic balance could
further help in the battle against the obesity epidemic,
especially in children.
In conclusion, we found that drinking 10ml kg
1
of cold
water resulted in an elevation of REE up to 25% from
baseline values in overweight children. Consuming the
recommended daily amount of water for children could
result in an energy expenditure equivalent to an additional
weight loss of about 1.2 kg per year. Water-induced thermo-
genesis may therefore assist in weight loss and weight
maintenance, in children as in adults.
Conflict of interest
The ventilating hood used in this study was purchased using
funding from Mey Eden (Eden Springs) Mineral Water
Company (Bnei Brak, Israel). Hadas Yariv was employed by
Mey Eden (Eden Springs) Mineral Water Company at the
time of the study and this work was part of her Masters
thesis. All other authors declare no conflict of interest.
Acknowledgements
We wish to thank Dr Nira Koren-Morag for the statistical
analysis.
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