Content uploaded by Ismael San Mauro
Author content
All content in this area was uploaded by Ismael San Mauro on Apr 09, 2018
Content may be subject to copyright.
1
vol. XX no X American Journal of Lifestyle Medicine
Ismael San Mauro Martín, PhD, Elena Garicano Vilar, MSc,
Denisse Aracely Romo Orozco, BSc,Paula Mendive Dubourdieu, MSc,
Victor Paredes Barato, MSc, Mario Rincón Barrado, BSc,
Ana Valente, MSc, Fabiana Bentancor, MSc,
Alexis Daniel Morales Hurtado, BSc, and Cristina Garagarza, MSc
Abstract: Physical activity, adherence
to a healthy diet, and healthy beverage
pattern are considered essential
components of a healthy lifestyle. We
aimed to evaluate the associations
between physical exercise, diet quality,
and total fluid intake, along with fluid
recommendations compliance in a
sample of adults. Data on fluid intake
from different types of beverages were
collected in a cross-sectional study,
in 1161 men and women between 18
and 65 years of age, using a fluid-
specific diary. Exercise was evaluated
with a self-reported questionnaire,
and quality of diet was assessed using
the Healthy Eating Index-2010 (HEI).
Mean volume of water consumed
was 1497.5 mL for men, 1309.5 mL
for women. A total of 37.4% did not
follow the recommendations of the
European Food Safety Agency for total
water intake. There was a statistically
significant difference
( P = .002) between total water intake
and follow-up of recommendations,
as well as for sex ( P < .001). Mean
HEI-2010 score was 65.21. There were
no statistically significant differences
( P = .301) in HEI index among better
or worse hydration. Sport variables
had influence on milliliters of water
consumed ( P < .001). Participants
who engaged in more physical exercise
exhibit a healthier pattern of fluid
intake. Healthy individuals with the
highest scores for HEI-2010 did not
present the healthiest beverage patterns.
Keywords: hydration; exercise; diet;
Healthy Eating Index-2010
Lifestyle is one of the most
important factors conditioning
health. Physical activity and
adherence to a healthy diet, including
adequate hydration and a healthy
beverage pattern, are considered
essential components of a healthy
lifestyle that reduces the risk of several
noncommunicable chronic diseases.1
Although there are several guidelines in
scientific literature and media for
achieving optimal hydration status, there
is no clear consensus about how
much fluid an individual should intake
(Table 1),2 neither sufficient research
regarding the amount of water required
to prevent disease or improve health.3 As
a result, neither upper nor lower
consumption thresholds have been
clearly linked to a specific benefit or risk
for humans.4 As for other fluids, it is
recommended that consumption of
higher energy content beverages, mainly
coming from sugar-sweetened beverages,
should be discouraged.5
The differences in recommendations
may be due, in part, to the wide
individual variation found in response to
hydration needs, as fluid loss is affected
by environmental factors.5-10 But it is
important to evaluate determinant factors
for covering the fluid intake
recommendations other than classical
individual factors (sex, age, body
surface) and environmental conditions.
The percentage of the population with
inadequate water intake varies from 5%
to 35% among European countries.
Recent research regarding the risk of
disease, disability, and death has
confirmed the importance of poor
hydration with respect to the overall
disease burden and quality of life.11
What is more, the benefits of physical
exercise on health and the adverse
effects of sedentary behavior are both
well recognized.12 While more physically
active men and women tend to have a
higher daily fluid intake,13 the beverage
pattern as a whole of individuals with
711906AJLXXX10.1177/1559827617711906American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine
research-article2017
Hydration Status: Influence of
Exercise and Diet Quality
There is no clear consensus
about how much fluid an individual
should intake.
DOI: 10.1177/1559827617711906. From Research Centre in Nutrition and Health, CINUSA Group, Madrid, Spain (ISMM, EGV, VPB); Research Centre in Nutrition and
Health, CINUSA Group, Tucaman, Mexico (DARO, ADMH); Research Centre in Nutrition and Health, CINUSA Group, Montevideo, Uruguay (PMD, FB); Bioinformatic Department,
Research Centre in Nutrition and Health, CINUSA Group, Spain (MRB); and Research Centre in Nutrition and Health, CINUSA Group, Lisbon, Portugal (AV, CG). Address corre-
spondence to: Ismael San Mauro Martin, PhD, Research Centers in Nutrition and Health, Paseo de la Habana, 43, 28036 Madrid, Spain; e-mail: research@grupocinusa.com.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2017 The Author(s)
2
Mon Mon XXXXAmerican Journal of Lifestyle Medicine
different levels of physical exercise has
not been well ascertained yet. Debate
exists regarding the quantity of fluid that
should be consumed during exercise,
especially in children who may be at
greater risk of dehydration. While some
sport authorities recommend that adults
should drink between 400 and 800 mL or
between 600 and 1000 mL of fluid per
hour to optimize exercise performance,
others advise “drinking to thirst” in order
to avoid consuming a very large volume
of water.14
Lifestyle factors such as food habits affect
water intake as well. The promotion of a
healthy diet can improve hydration status
at the population level. In turn, adherence
to a health-conscious diet is associated
with higher beverage consumption as is
physical activity.15 Some studies conducted
on the US population have reported that
increased water consumption was
associated with higher diet quality, better
eating patterns, and even higher levels of
physical activity.16 Among the dietary
patterns are more variety and greater
consumption of vegetables, fruits, whole
grains, and low-fat dairy products. It has
also been associated to the Healthy Eating
Index (HEI).17
Individuals who participate regularly in
recreational sports and/or exercise are
dehydrated during exercise and drink at
a rate according to their perceived thirst,
which barely replaces two thirds of their
fluid losses. However, debate exists
regarding the quantity of fluid that
should be consumed during exercise.16
Awareness of the need for healthy-
hydration advice, within the context of
dietary and lifestyle guidelines for the
management and prevention of existing
public health problems, should be better
emphasized. Occasional or moderate
consumption of sugar-sweetened
beverages in addition to a healthy,
balanced diet is not an issue of
contention. However, public health
systems and health care professionals in
the front line should be aware of the
potential detrimental effects of excessive
or habitual consumption on long-term
health, particularly in children and
adolescents. Health care professionals
are well positioned to identify and
promote behavioral changes that
decrease sugar-sweetened beverage
consumption and encourage water
intake.14
Very few studies have examined the
association between beverage intake
patterns and healthy lifestyle
characteristics. In this sense, it is
important to assess whether lifestyle
determines the percentage of individuals
meeting fluid intake recommendations
established at a population level.1
Objective
The main aim of the present study was
to evaluate the association between
physical exercise practice or high-quality
diet and the total fluid intake, and the
percentage of population covering fluid
recommendations in a sample of adults.
Material and Methods
Design
A cross-sectional cohort study was
designed. A total of 1181 adults aged 18
to 65 years were randomly recruited
from 4 different geographical territories,
Spain, Portugal, Uruguay, and Mexico,
until the quotas were met. Information
on participants’ anthropometric
measures, exercise, diet, and hydration
was collected using validated
questionnaires. Data were collected,
individually, by trained and formed
nutritionists and dieticians, standardizing
the data collection protocol and
monitoring the study. Participants
provided written informed consent.
Minor modifications to wording and
customs were made for Uruguay and
Mexico’s surveys, for a better unification
of the answers in the database.
Study Factors
The following information on
demographics factors was collected: age,
sex, height (m), weight (kg), and
nationality. Physical exercise practice of
more than 30 minutes a day was
evaluated with a nonvalidated self-
reported questionnaire and categorized
as follows: 5 times a week or more, 3 to
4 times a week, between 1 and 2 times a
week, and once every 2 weeks or less.
Type and hours per day of each exercise
performed was also detailed.
Information about the quantity of daily
fluid intake (in milliliters or liters) from
Table 1.
Water Intake Recommendations of Four International Authoritiesa.
European Food Safety
Authority (2010)6
National Health and Medical
Research Council (2006)7
Institute of Medicine
(2004)8
World Health
Organization (2003)9
Men 2.5 liters 3.4 liters 3.7 liters Sedentary: 2.9 liters
Active: 4.5 liters
Women 2.0 liters 2.8 liters 2.7 liters Sedentary: 2.2 liters
Active: 4.5 liters
aReference values for total water intake (food + fluid), liters/day.
3
vol. XX no X American Journal of Lifestyle Medicine
different types of beverages was also
collected, differentiating water from other
beverages (hot beverages; milk and dairy
products; juices; sweet regular beverages:
carbonated soft drinks, noncarbonated
soft drinks, and other sugared soft
drinks; sweet light beverages: diet
carbonated soft drinks, diet
noncarbonated soft drinks, or other diet
soft drinks; and alcoholic drinks). The
questionnaire assessed the moment of
the day when the participants consumed
fluids, and the type and the volumes of
beverages using standard portion sizes.
Total fluid intake is defined as the sum
of all these beverages.
The percentage of individuals who did
not meet the European Food Safety
Agency (EFSA) recommendations was
calculated based on the EFSA
recommendations for total water intake
(water from food and beverages) set at
2.5 and 2 L/day for men and women,
respectively. EFSA takes the assumption
that foods contribute about 20% to total
water intake; therefore, the EFSA
recommendations for total fluid intake
were set at 2 and 1.6 L/day for men and
women, respectively, most of which
should preferably be consumed as
water.18
Diet was evaluated using The Healthy
Eating Index-2010 (HEI-2010). It is a
dietary assessment tool comprising 12
components designed to measure quality
in terms of how well diets meet the
recommendations of the 2010 Dietary
Guidelines for Americans,19 that is, more
vegetables, fruits, whole grains, and
low-fat dairy products and less refined
grains, saturated fatty acids, and added
sugars. Diet quality is assessed from 2
perspectives: 9 components address
nutrient adequacy (dietary components
to increase) and the remaining 3
components assess moderation (dietary
components to decrease).20
For adequacy components, a score of
zero is assigned for “no intake,” and the
scores increase proportionately as
intakes increase up to the standard. For
moderation components, a reverse
scoring is applied, that is, levels of
intakes at the standard get the maximum
score, with scores decreasing as intakes
increase. Component scores can range
from 0 to 5, 0 to 10, or 0 to 20, with a
maximum total score of 100. A score
corresponding to 100% indicates that the
recommendation on average was met or
exceeded. For the adequacy components,
higher scores reflect higher intakes. For
the moderation components, higher
scores reflect lower intakes because
lower intakes are more desirable. For all
the components, a higher percentage
indicates a higher quality diet. “Empty
calories” refers to calories from solid fats
(ie, sources of saturated fats and trans
fatty acids) and added sugars (ie, sugars
not naturally occurring) plus calories
from alcohol beyond a moderate level.21
The components are defined as follows
and described more fully in Table 3.
Guidance on how to use the HEI-2010 in
research, including SAS code and
macros, is available online.22
Inclusion Criteria
Men and women with aged between
18 and 65 years
Sufficient level of understanding to
allow their participation in the study
Acceptance and voluntary
participation after signing an
informed consent
Exclusion Criteria
Nonage
Participants that did not complete the
record correctly
Participants not able to read and write
in the language of the questionnaire
Statistical Analyses
Questionnaire responses were analyzed
using the Statistical Package for the
Social Sciences (SPSS) version 21.0.
Frequency, percentage, and other
descriptive statistics were used to
describe and summarize data.
Data are presented as means and 95%
confidence intervals (CI) for continuous
variables, or as numbers and percentages
for dichotomous variables. We compared
the distribution of the selected
characteristics between groups using 2
tests for categorical variables or Student’s
t tests or analysis of variance (ANOVA),
as appropriate, for continuous variables.
P values <.05 were considered
statistically significant.
Results
Response Rate
A total of 1181 surveys were returned.
Twenty surveys were excluded due to
respondent’s nonage or incongruent
answers. Thus, a total of 1161
participants (439 men and 718 women)
were taken in consideration with a mean
age of 37.9 ± 16.1 years and recruited
from Spain, Portugal, Uruguay, and
Mexico. There were no significant
differences between country and gender
(P = .240), but there were significant
differences when analyzed by age (P <
.05, Kruskal-Wallis). The baseline
characteristics of participants are
summarized in Table 2.
The mean volume of water consumed
(tap water, filtered tap water, natural
mineral water, sparkling mineral water,
flavored water, and fountain water) was
1403.5 mL/day for the whole population
(1497.5 mL for men and 1309.5 mL for
women).
The percentage of individuals who did
not follow the recommendations of the
EFSA for total water intake was
calculated (37.4% of both sexes; 36.7%
men and 38% women; Table 3). There
was a statistically significant difference
(P = .002) between the total water
intake and the follow-up of
recommendations.
The mean quantity of liquid intake
from different types of beverages was
above the EFSA recommendations (2000
mL/day for men and 1600 mL/day for
women), 2222.9 mL/day for men and
1938.1 mL/day for women. There was
statistically significant difference between
total water intake and sex (P < .001) and
country (P < .001); statistically significant
difference was also found for total fluid
intake (P < .001; Figure 1). Meeting the
EFSA recommendations also resulted in
statistically significant difference (P <
.001). Women consumed 20.9% more
total fluid intake than recommended by
the EFSA, while men consumed 10.7%
more. EFSA recommendations were
better met by men.
4
Mon Mon XXXXAmerican Journal of Lifestyle Medicine
Table 2.
Information on Demographics Factors, by Country and Sexa.
Spain (n = 620) Portugal (n = 199) Uruguay (n = 132) Mexico (n = 210) Total (N = 1161)
Male
(n = 253)
Female
(n = 363)
Male
(n = 77)
Female
(n = 122)
Male
(n = 36)
Female
(n = 96)
Male
(n = 73)
Female
(n = 137)
Male
(n = 439)
Female
(n = 718) Both Sexes
Sex (%) 40.8 58.5 38.7 61.3 27.3 72.7 34.8 65.2 37.8 61.8 99.7b
Age (M ± SD) 35.1 ± 15.4 34.5 ± 15.4 49.8 ± 14.2 46.3 ± 12.9 38.8 ± 15.1 43.5 ± 19.6 30.3 ± 13 38.0 ± 14.5 37.2 ± 16 38.4 ± 16.1 37.9 ± 16.1
Height, m (M ± SD) 1.75 ± 0.07 1.63 ± 0.06 1.73 ± 0.08 1.61 ± 0.06 1.76 ± 0.07 1.61 ± 0.08 1.71 ± 0.08 1.59 ± 0.08 1.74 ± 0.07 1.62 ± 0.07 1.66 ± 0.09
Weight, kg (M ± SD) 77.1 ± 11.1 61.2 ± 10.2 77.4 ± 13.8 60.3 ± 9.6 77.8 ± 16.2 63.9 ± 14.2 78.1 ± 15.5 65.6 ± 12.5 77.4 ± 12.8 62.3 ± 11.3 68 ± 14
BMI, kg/m2 (M ± SD) 25.2 ± 3.6 23.1 ± 3.7 25.9 ± 4 23.2 ± 3.6 25.4 ± 4.4 25.1 ± 5.7 26.6 ± 4.7 26 ± 5 25.6 ± 4 23.9 ± 4.4 24.5 ± 4.3
Abbreviations: M, mean; SD, standard deviation; BMI, body mass index.
aData expressed as mean ± standard deviation, sample size (n), or percentage.
bMissing data about the sex of 4 Spanish participants.
5
vol. XX no X American Journal of Lifestyle Medicine
Table 3.
Data About the Knowledge and Follow-up of Hydration Recommendations, by Country and Sexa.
Spain (n = 620) Portugal (n = 199) Uruguay (n = 132) Mexico (n = 210) Total (N = 1161)
Male (n = 253)
Female
(n = 363) Male (n = 77)
Female
(n = 122) Male (n = 36)
Female
(n = 96) Male (n = 73)
Female
(n = 137) Male (n = 439)
Female
(n = 718) Both Sexes
Mean quantity fluid (mL) 2432.5 ± 892.1 2049.9 ±738 1369.5 ± 619.8 1410.2 ± 532.3 2616.7 ± 1171.1 2135.4 ± 892.7 2202.6 ± 673 1973.5 ± 608.9 2222.9 ± 935.4 1938.1 ± 746.9 2049.1 ± 835.8
Mean quantity water (mL) 1608.7 ± 794.9 1372.3 ± 642.9 1013 ± 553.4 1018.4 ± 455.1 1675 ± 819.6 1386.5 ± 729.9 1535.6 ± 640.8 1348.6 ± 523.9 1497.5 ± 767.5 1309.5 ± 619.8 1384.3 ± 685.3
Follow EFSA
recommendations, n (%)
Yes 186 (73.5) 252 (69.4) 16 (20.8) 29 (23.8) 29 (80.6) 62 (64.6) 47 (64.4) 102 (74.5) 278 (63.3) 445 (62) 723 (62.3)
No 67 (26.5) 111 (30.6) 61 (79.2) 93 (76.2) 7 (19.4) 34 (35.4) 26 (35.6) 35 (25.5) 161 (36.7) 273 (38) 434 (37.4)
Abbreviation: EFSA, European Food Safety Agency.
aData expressed as mean ± standard deviation, or sample size (n) and percentage.
6
Mon Mon XXXXAmerican Journal of Lifestyle Medicine
When analyzing total HEI scores and
the compliance of EFSA recommenda-
tions, there were no statistically
significant differences (P = .301) in HEI
index among those who hydrate better
or worse, so it cannot be affirmed that
both groups eat differently.
The mean HEI-2010 score was 65.21
(Table 4). Few people scored very high
or very low on the HEI-2010. Only 1.6%
of the sample had a mean score below
50. Similarly, 3.1% of the sample had a
HEI-2010 score higher than 80.
Any category contributed
disproportionally to the mean score.
Mean components scores were lowest for
seafood and plant proteins (1.23) and
total protein foods (1.29). The
percentage of the sample scoring 0 in a
category was highest for seafood and
plant proteins (23.7%) and whole grains
(10.9%). The ranking in the fatty acids
category has a bimodal distribution, that
is, 26.7% of the sample scored 0 ((PUFAs
+ MUFAs)/SFAs < 1.2) yet 32.8% scored
10 ((PUFAs + MUFAs)/SFAs > 2.5), where
PUFA is polyunsaturated fatty acid,
MUFA is monounsaturated fatty acid, and
SFA is saturated fatty acid. The
moderation group components had a
perfect score of 10 or 20.
A post hoc (Tukey HSD) test revealed
statistically significant differences in total
HEI-2010 score between countries:
Spain-Portugal (P = <.001), Spain-
Uruguay (P = <.001), and Spain-Mexico
(P = <.001).
To see the influence of hydration on
sport, a 2 analysis was performed. In
this case, the analysis was performed
with all the variables related to sport (if
participants exercise or not, days a week,
whether they are active or not, and hours
of exercise a day; see Table 5) and the
variable related to hydration, “participant
meets the EFSA recommendation.” There
were no statistically significant
differences for any of the variables.
On the contrary, all sport variables
have influence on the amount of
milliliters of water consumed (P < .001),
while the HEI index does not have it in
any case.
Discussion
According to ENIDE data,23 the only
research investigating beverage intake
among the Spanish population, the
average beverage consumption was
1646.5 mL/day, which reflects insufficient
fluid intake for that study population.
However, in our study the mean quantity
of liquid intake from different types of
beverages exceeded the EFSA
recommendations (2000 mL/day for men
and 1600 mL/day for women). However,
neither men nor women consumed
sufficient amounts of water (1497.5 mL
for men and 1309.5 mL for women),
according to EFSA reference values.
Contrary to our findings, mean total
water intake in 1724 British adults from
the National Diet and Nutrition Survey
(2000/2001) was nearly identical to the
EFSA reference adequate intake for both
genders.24
The comparison is difficult to do when
we want to compare American and
Spanish populations. The NHANES study,
developed in the United States between
2005 and 2010, used the proposal by the
Institute of Medicine (IOM) of the United
States as reference value, set as 3.7 L/day
for men and 2.7 L/day for women.8 This
leads us to consider the need to
investigate why the recommendations of
the EFSA and the IOM are so different if
both recommendations include the water
from food and beverage sources. The
clarification of this issue deserves further
study.
The HEI-2010 is a mechanism that
allows individuals to assess the overall
quality of their diets, not simply isolated
components. It was developed using the
most current scientific information
available.25
The HEI-2010 reflects the complexity of
dietary patterns; no one single
component drives the index. Having a
good score on only one component does
Figure 1.
Data on mean total fluid intake versus mean total water intake (mL), by country.
7
vol. XX no X American Journal of Lifestyle Medicine
not ensure a high score. A great number
of components contributed to lower than
ideal scores. Respondents were least
likely to achieve a perfect score in
seafood and plant proteins, total protein
foods, greens and beans, and total fruit
and dairy. Only in the moderation
components category did 100% of the
subjects achieve a perfect score of 10 or
20. The HEI-2010 provides important
evidence on the types of dietary
improvements that need to be made to
bring food consumption patterns more in
line with the recommendations.
In our sample, Portuguese subjects
showed a higher total HEI-2010 score
followed by Mexicans, Spanish, and
Uruguayans. Spanish stood out in high
dairy consumption and low fatty acids
ingestion compared to the other 3
countries, while Portuguese did better on
whole fruit consumption and worst in
fatty acids intake. Uruguayans were in
average with other countries except for a
very low consumption of greens and
beans and seafood and plant proteins.
Mexicans showed the highest
consumption of whole grains but a
poorer intake of total fruit and seafood.
Unfortunately, our results are not in
agreement with those reported by other
investigators regarding healthier dietary
patterns related to healthier beverage
patterns.26-28 The statistically significant
difference (P < .001) found between total
water intake and the sex in our study
could be explained by the fact that
women tend to have a healthier lifestyle,
which includes a healthier dietary
pattern including beverages. This fact
may explain why females tend to adhere
more closely to the recommendations.29
In the study by Ferreira-Pêgo etal,1
individuals with greater adherence to the
Mediterranean diet showed a higher
intake of water and wine and a lower
consumption of sweetened regular
beverages.
The relatively low contribution of
caloric soft drinks to the energy intake
could be attributable to the
Mediterranean pattern of consumption
that this society follows. By contrast,
the NHANES study of the United
States30 has the highest contribution to
energy intake from sweetened
beverages.
Table 4.
The Quality of Participant’s Diets, as Measured by the Healthy Eating Index-2010 (HEI)a.
Dietary Component (Maximum
Score)
Spain
Score (%)
Portugal
Score (%)
Uruguay
Score (%)
Mexico
Score (%)
Total
Score (%) P Value
Adequacy (higher score indicates higher consumption)
Total fruit (5) 1.99 (39.8) 2.22 (44.5) 2.09 (41.8) 1.63 (32.5) 1.97 (39.4) <.001*
Whole fruit (5) 3.27 (65.4) 3.87 (77.3) 3.3 (66) 2.69 (53.7) 3.26 (65.2) <.001*
Total vegetables (5) 2.1 (42.1) 2.72 (54.3) 2.93 (58.6) 2.31 (46.2) 2.34 (46.8) <.001*
Greens and beans (5) 1.2 (24.1) 1.46 (29.3) 0.82 (16.3) 2.26 (45.2) 1.4 (28) <.001*
Whole grains (10) 4.6 (46) 5.87 (58.7) 4.32 (43.2) 6.48 (64.8) 5.18 (51.8) <.001*
Dairy (10) 3.95 (39.5) 2.42 (24.2) 2.62 (26.2) 2.11 (21.1) 3.2 (32) <.001*
Total protein foods (5) 1.27 (25.4) 1.29 (25.7) 1.12 (22.4) 1.47 (29.5) 1.29 (25.8) .001*
Seafood and plant proteins (5) 1.45 (28.9) 1.5 (30) 0.39 (7.8) 0.98 (19.5) 1.23 (24.6) <.001*
Fatty acids (10) 4.62 (46.2) 6.61 (66.1) 4.78 (47.8) 6.34 (63.4) 5.29 (52.9) <.001*
Moderation (higher score indicates lower consumption)
Refined grains (10) 10 (100) 10 (100) 10 (100) 10 (100) 10 (100) 1.000
Sodium (10) 10 (100) 10 (100) 10 (100) 10 (100) 10 (100) 1.000
Empty calories (20) 20 (100) 20 (100) 20 (100) 20 (100) 20 (100) 1.000
Total score (100) 64.41 (64.4) 68 (68) 62.52 (62.5) 66.35 (66.3) 65.21 (65) <.001**
aThe component and total scores are presented both as an absolute number and as a percentage of the maximum possible score, by country.
*Statistically significant differences (P < .05) between all countries. **Statistically significant differences (P < .05) in total HEI-2010 score between Spain-
Portugal, Spain-Uruguay, and Spain-Mexico.
8
Mon Mon XXXXAmerican Journal of Lifestyle Medicine
Table 5.
Information on Exercise, by Country and Sexa.
Spain (n = 620) Portugal (n = 199) Uruguay (n = 132) Mexico (n = 210) Total (n = 1161)
Male
(n = 253)
Female
(n = 363)
Male
(n = 77)
Female
(n = 122)
Male
(n = 36)
Female
(n = 96)
Male
(n = 73)
Female
(n = 137)
Male
(n = 439)
Female
(n = 718) Both sexes
Do exercise 207 (81.8) 273 (75.2) 64 (83.1) 89 (72.9) 27 (75) 76 (79.2) 40 (54.8) 80 (58.4) 338 (77) 518 (72.1) 856 (73.7)
Days of exercise
Once every 2 weeks 24 (11.6) 26 (9.5) 12 (18.8) 18 (20.2) 0 (0) 14 (18.4) 5 (12.5) 15 (18.8) 40 (11.8) 73 (14.1) 114 (13.3)
1-2 days/week 45 (21.7) 94 (34.4) 26 (40.6) 38 (42.7) 10 (37) 28 (36.8) 8 (20) 10 (12.5) 89 (26.3) 170 (32.8) 260 (30.4)
3-4 days/week 79 (38.2) 93 (34.1) 22 (34.4) 25 (28.1) 12 (44.4) 18 (23.7) 12 (30) 34 (42.5) 125 (37) 170 (32.8) 296 (34.6)
5 days/week 57 (27.5) 55 (20.1) 4 (6.3) 8 (9) 5 (18.5) 16 (21.1) 15 (37.5) 22 (27.5) 81 (24) 100 (32.8) 183 (21.4)
Hours of exercise
<1 hour/day 51 (24.6) 96 (35.2) 21 (32.8) 37 (41.6) 5 (18.5) 37 (48.7) 7 (17.5) 34 (42.5) 84 (24.9) 204 (39.4) 288 (33.6)
1-2 hours/day 136 (65.7) 161 (59) 34 (53.1) 45 (50.6) 15 (55.5) 35 (46.1) 30 (75) 40 (50) 215 (63.6) 281 (54.2) 499 (58.3)
>2 hours/day 16 (7.7) 11 (4) 7 (10.9) 7 (7.9) 7 (25.9) 3 (3.9) 3 (7.5) 6 (7.5) 33 (9.8) 27 (5.2) 60 (7)
aData expressed as sample size (n) and percentage.
9
vol. XX no X American Journal of Lifestyle Medicine
Participants who engaged in more
physical exercise consumed more water,
milk and milk products, juices, and wine
and less sweetened regular beverages.
Compared to the lowest category, the
possibility of meeting the EFSA
recommendations of total fluid intake
was greater in individuals with 8 or more
points on the Mediterranean diet
adherence questionnaire (odds ratio =
1.94; 95% confidence interval = 1.25-
3.01) and in those who practice physical
exercise 3 times a week or more (odds
ratio = 1.71; 95% confidence interval =
1.22-2.39).1
To the best of our knowledge, the
possible associations between physical
exercise and total fluid intake or different
types of beverages consumption have
not been subject to a great deal of
research among the general populations
to date. In our study, individuals who
engaged in most physical exercise
presented a higher total daily fluid and
water consumption, probably because
they had an increased fluid loss and
consequently a higher demand of fluid
intake. However, this study is not able to
conclude whether these higher intakes
cover the higher intake demand.
Individuals who engaged most in
physical exercise tended to comply
better with the EFSA’s total fluid intake
recommendations as reported previously
by Ferreira-Pêgo etal.31
Similar results were observed in the
Bahia study,32 where participants who
took part in intense physical activity
consumed more fluid daily (2355 mL vs
1988 mL for those with a low physical
activity level) and did so more times per
day (6.46 vs 5.75). In the ASNS 2007,33 a
higher physical activity level was also
associated with a higher water intake.
For individuals who exercised 4 to 6
times per week for at least 30 minutes,
mean water consumption was 1.26 to
0.97 L/day compared with 0.75 to 0.73 L/
day for those who exercised rarely and
0.6 to 0.88 L/day for those who stated
they never exercised.16 This was also
seen in the ASNS 2012, in which men
and women with high physical activity
levels had higher total daily water intakes
than those with low high physical
activity levels (2876 mL vs 2610 mL for
men and 2785 mL vs 2446 mL for
women; P < .015 for women).
In our study, compliance with the EFSA
recommendations for total fluid intake
was not mainly associated with higher
HEI-2010 scores. However, water intake
in the ASNS 200733 differed according to
the participants’ food consumption
pattern, with those on a vegetarian diet
consuming significantly more (P < .01)
tap water than those on a typical
Austrian or even a health-conscious diet
(1.23 L/day vs 0.88 L/day and 1.16 L/day,
respectively; P < .001 between normal
and health-conscious diets). In the ASNS
2012, a high intake of fruit and
vegetables (defined as at least 2 servings
per day of each) was also associated
with a higher intake of water in 333
adults aged 18 to 80 years.15
Limitations
This study is a cross-sectional design,
which provides evidence for association
but not causal relationships.
Conclusion
The present study shows clearly that
neither men nor women consumed
adequate total water intake when
compared with the EFSA reference
values. What is more, there were
differences among the countries included
in this study.
The diet quality of the sample also fell
short of recommendations. The diet
quality scores would be improved by
increasing the intake of fruit, vegetables,
especially dark greens and beans;
replacing refined grains with whole
grains, increasing seafood, meat, and
poultry; and decreasing the intake of
sodium (salt) and empty calories from
solid fats and added sugars.
On the one hand, participants who
adhere more closely to a healthy diet did
not show better compliance with total
fluid intake recommendations. On the
other hand, participants who engage in
more physical exercise have a healthier
fluid intake pattern. Apart from that,
participants with a healthier lifestyle in
general had a greater probability of
complying with EFSA’s total daily fluid
intake. Adequate total fluid intake is
associated with a higher physical
exercise but not with a high quality diet.
These results suggest that there is a
relationship between physical exercise
and a better fluid intake pattern, but not
with a healthier diet. However, future
studies are warranted to confirm our
results and to establish cause-effect
associations in order to design future
public health recommendations.
Declaration of
Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
AJLM
References
1. Ferreira-Pêgo C, Babio N, Salas-Salvadó
J. A higher Mediterranean diet adherence
and exercise practice are associated with
a healthier drinking profile in a healthy
Spanish adult population. Eur J Nutr.
2017;56:739-748.
2. Killer SC, Blannin AK, Jeukendrup AE. No
evidence of dehydration with moderate
daily coffee intake: a counterbalanced
cross-over study in a free-living population.
PLoS One. 2014;9(1):e84154.
3. Palmer SC, Wong G, Iff S, etal.
Fluid intake and all-cause mortality,
cardiovascular mortality and kidney
function: a population-based longitudinal
cohort study. Nephrol Dial Transplant.
2014;29:1377-1384.
4. H4hinitiative. Recommendations for daily
water intake. Available at: http://www.
h4hinitiative.com/recommendations#III.
Accessed October 22, 2015.
5. Martinez H. Fluid intake in Mexican
adults; a cross-sectional study. Nutr Hosp.
2014;29:1179-1187.
6. EFSA Panel on Dietetic Products, Nutrition,
and Allergies (NDA). Scientific opinion on
dietary reference values for water. EFSA J.
2010;8:1459. doi:10.2903/j.efsa.2010.1459.
7. National Health and Medical Research
Council. Water. https://www.nrv.gov.au/
nutrients/water. Accessed October 22,
2015.
8. Institute of Medicine. Dietary Reference
Intakes: Water, Potassium, Sodium,
Chloride, and Sulfate. Washington, DC:
National Academies Press; 2004. http://
10
Mon Mon XXXXAmerican Journal of Lifestyle Medicine
iom.nationalacademies.org/Reports/2004/
Dietary-Reference-Intakes-Water-Potassium-
Sodium-Chloride-and-Sulfate.aspx.
Accessed October 22, 2015.
9. Grandjean A. Water requirements,
impinging factors, and recommended
intakes. http://www.who.int/water_
sanitation_health/dwq/nutwaterrequir.pdf.
Published August 2004. Accessed May 17,
2017.
10. US Department of Agriculture.
Predictions of Daily Water and Sodium
Requirements. https://www.nal.usda.gov/
sites/default/files/fnic_uploads//485-493.
pdf. Accessed May 29, 2017.
11. Nissensohn M, Sánchez-Villegas A, Ortega
RM, etal. Beverage consumption habits
and association with total water and energy
intakes in the Spanish population: findings
of the ANIBES study. Nutrients. 2016;8:232.
12. Mansoubi M, Pearson N, Biddle SJ, Clemes
S. The relationship between sedentary
behaviour and physical activity in adults: a
systematic review. Prev Med. 2014;69:28-35.
13. Mensink GB, Loose N, Oomen CM.
Physical activity and its association with
other lifestyle factors. Eur J Epidemiol.
1997;13:771-778.
14. Armstrong LE, Barquera S, Duhamel JF,
Hardinsyah R, Haslam D, Lafontan M.
Recommendations for healthier hydration:
addressing the public health issues of
obesity and type 2 diabetes. Clin Obes.
2013;2:115-124.
15. Elmadfa I, Meyer AL. Patterns of drinking
and eating across the European Union:
implications for hydration status. Nutr Rev.
2015;73:141-147.
16. Yang M, Chun OK. Consumptions of plain
water, moisture in foods and beverages,
and total water in relation to dietary
micronutrient intakes and serum nutrient
profiles among US adults. Public Health
Nutr. 2015;18:1180-1186.
17. An R, McCaffrey J. Plain water consumption
in relation to energy intake and diet quality
among US adults, 2005-2012. J Hum Nutr
Diet. 2016;29:624-632.
18. Agostoni CV, Bresson JL, Fairweather-
Tait S, etal. Scientific opinion on dietary
reference values for water. EFSA J.
2010;8(3):1459.
19. US Department of Agriculture and US
Department of Health and Human Services.
Dietary Guidelines for Americans, 2010.
7th ed. Washington, DC: US Government
Printing Office; 2010.
20. Guenther PM, Casavale KO, Reedy J, etal.
Update of the Healthy Eating Index: HEI-
2010. J Acad Nutr Diet. 2013;113:569-580.
21. US Department of Agriculture, Center
for Nutrition Policy and Promotion. Diet
quality of children age 2-17 years as
measured by the Healthy Eating Index-
2010. https://www.cnpp.usda.gov/sites/
default/files/nutrition_insights_uploads/
Insight52.pdf. Published July 2013.
Accessed May 17, 2017.
22. National Cancer Institute. Overview and
background of the Health Eating Index.
http://riskfactor.cancer.gov/tools/hei.
Accessed June 16, 2016.
23. Spanish Agency for Food Safety and
Nutrition (AESAN). ENIDE: Encuesta
Nacional de Ingesta Dietética Española
2011. http://www.aesan.msc.es. Accessed
November 24, 2016.
24. Gibson S, Shirreffs SM. Beverage
consumption habits “24/7” among British
adults: association with total water intake
and energy intake. Nutr J. 2013;12:9.
25. Kennedy ET, Ohls J, Carlson S, Fleming
K. The Healthy Eating Index: design and
applications. J Am Diet Assoc. 1995;95:1103-
1108.
26. Sánchez-Villegas A, Toledo E, Bes-
Rastrollo M, Martín-Moreno JM, Tortosa
A, Martínez-González MA. Association
between dietary and beverage
consumption patterns in the SUN
(Seguimiento Universidad de Navarra)
cohort study. Public Health Nutr.
2009;12:351-358.
27. León-Muñoz LM, Galán I, Valencia-Martín
JL, López-García E, Guallar-Castillón
P, Rodríguez-Artalejo F. Is a specific
drinking pattern a consistent feature of
the Mediterranean diet in Spain in the
XXI century? Nutr Metab Cardiovasc Dis.
2014;24:1074-1081.
28. Duffey KJ, Popkin BM. Adults with
healthier dietary patterns have healthier
beverage patterns. J Nutr. 2006;136:2901-
2907.
29. Sánchez-Villegas A, Delgado-Rodríguez M,
Martínez-González MA, De Irala-Estévez
J; Seguimiento Universidad de Navarra
Group. Gender, age, socio demographic
and lifestyle factors associated with major
dietary patterns in the Spanish Project SUN
(Seguimiento Universidad de Navarra). Eur
J Clin Nutr. 2003;57:285-292.
30. Drewnowski A, Rehm CD, Constant F.
Water and beverage consumption among
adults in the United States: cross-sectional
study using data from NHANES 2005-2010.
BMC Public Health. 2013;12:1068.
31. Ferreira-Pêgo C, Babio N, Fenández-Alvira
JM, Iglesia I, Moreno LA, Salas-Salvadó J.
Fluid intake from beverages in Spanish
adults: cross-sectional study. Nutr Hosp.
2014;29:1171-1178.
32. de Francisco AL, Martínez Castelao A;
Grupo Investigador Bahía 2008. Bahia
Study 2008: a hydration barometer of the
Spanish population [in Spanish]. Nefrologia.
2010;30:220-226.
33. Frohler M. Empirical Assessment of the
Importance of Drinking Water in the Diet of
Austrian Adults [PhD dissertation]. Vienna,
Austria: University of Vienna, 2010.
