Effect of water consumption on weight loss: a systematic review

Abstract

Introduction:
Water intake has been proposed for weight loss; however, the evidence of its efficacy is limited. The aim of this study was to systematically review the randomized clinical trials that assessed the effect of water consumption on weight with a follow up ≥ 12 weeks. A systematic query-based search was performed on PubMed, EBSCO, and Cochrane Library to identify eligible records that quantitatively measured body weight change after interventions. This review included six RCTs that reported different strategies for weight loss achievement: increasing daily water intake, replacement of caloric beverages with water, and premeal waterload. All the studies showed a weight loss effect after follow-up, ranged from -0.4 kg to -8.8 kg with a mean percentage of weight loss of 5.15%. The most effective intervention among the studies was the replacement of caloric beverages with water. The quality of the evidence for the primary outcome of weight loss was rated low to moderate. The main limitation of these results is the short-term follow up-period. In conclusion, despite 5.15% of weight loss, the low to moderate quality of evidence and the short term of follow-up are limitations to support evidence-based recommendations of water consumption for weight loss.

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Nutrición
Hospitalaria
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ISSN (electrónico): 1699-5198 - ISSN (papel): 0212-1611 - CODEN NUHOEQ S.V.R. 318
Effect of water consumption on weight loss: a systematic review
Efecto del consumo de agua sobre la pérdida de peso: revisión sistemática
Guillermo Bracamontes Castelo, Montserrat Bacardí Gascón and Arturo Jiménez Cruz
Facultad de Medicina y Psicología. Universidad Autónoma de Baja California. Tijuana, Baja California. Mexico
Key words:
Water consumption.
Weight loss. Non-
nutritive sweeteners.
Obesity. Systematic
review.
Abstract
Water intake has been proposed for weight loss; however, the evidence of its efficacy is limited. The aim of this study was to systematically review
the randomized clinical trials that assessed the effect of water consumption on weight with a follow up ≥ 12 weeks. A systematic query-based
search was performed on PubMed, EBSCO, and Cochrane Library to identify eligible records that quantitatively measured body weight change
after interventions. This review included six RCTs that reported different strategies for weight loss achievement: increasing daily water intake,
replacement of caloric beverages with water, and premeal waterload. All the studies showed a weight loss effect after follow-up, ranged from
-0.4 kg to -8.8 kg with a mean percentage of weight loss of 5.15%. The most effective intervention among the studies was the replacement of
caloric beverages with water. The quality of the evidence for the primary outcome of weight loss was rated low to moderate. The main limitation
of these results is the short-term follow up-period. In conclusion, despite 5.15% of weight loss, the low to moderate quality of evidence and the
short term of follow-up are limitations to support evidence-based recommendations of water consumption for weight loss.
Palabras clave:
Consumo de agua.
Pérdida de peso.
Endulzantes no
nutritivos. Obesidad.
Revisión sistemática.
Resumen
El consumo de agua se ha propuesto como medida para la pérdida de peso; sin embargo, la evidencia de su eficacia es limitada. El objetivo de
este estudio fue revisar sistemáticamente los ensayos clínicos aleatorizados que han evaluado el efecto del consumo de agua en el peso corporal
con un periodo de seguimiento ≥ 12 semanas. Se realizó una búsqueda sistemática en cadena en PubMed, EBSCO y Cochrane Library para
identificar estudios elegibles que midieran cuantitativamente el cambio de peso corporal después de sus intervenciones. Esta revisión incluye seis
ECA que reportan diferentes estrategias para alcanzar la pérdida de peso: incremento del consumo diario de agua, reemplazo de bebidas calóricas
por agua y sobrecarga con agua previa a las comidas. Todos los estudios mostraron un efecto de pérdida de peso después del seguimiento, con
un rango de -0.4 kg a -8.8 kg y con un porcentaje promedio de pérdida de peso del 5.15%. La intervención más efectiva entre los estudios fue
el reemplazo de bebidas calóricas por agua. La calidad de la evidencia para el resultado primario de pérdida de peso fue calificada de baja a
moderada. La principal limitación de estos resultados es el corto periodo de seguimiento. En conclusión, a pesar de encontrarse unapérdida de
peso del 5.15%, la calidad de la evidencia baja a moderada y el corto periodo de seguimiento son limitaciones para sustentar una recomendación
basada en la evidencia sobre el consumo de agua para la pérdida de peso.
Correspondence:
Arturo Jiménez Cruz. Facultad de Medicina y
Psicología. Facultad de Medicina y Psicología.
Tijuana, Baja California. Mexico
e-mail: arturojmenezc@yahoo.com
Bracamontes Castelo G, Bacardí Gascón M, Jiménez Cruz A. Effect of water consumption on weight loss:
a systematic review. Nutr Hosp 2019;36(6):1424-1429
DOI: http://dx.doi.org/10.20960/nh.02746
Received: 19/06/2019 • Accepted: 16/09/2019
©Copyright 2019 SENPE y ©Arán Ediciones S.L. Este es un artículo Open Access bajo la licencia CC BY-NC-SA (http://creativecommons.org/licenses/by-nc-sa/4.0/).

1425EFFECT OF WATER CONSUMPTION ON WEIGHT LOSS: A SYSTEMATIC REVIEW
[Nutr Hosp 2019;36(6):1424-1429]
INTRODUCTION
Over the past 50 years, the prevalence of obesity has increased
to pandemic proportions all over the world (1), representing an
important global health and economic problem (2). It was also
considered, between 1975 and 2014, the most common nutri-
tional disorder in the United States (2). The worldwide prevalence
of obesity (BMI ≥ 30 kg/m²) increased from 3.2% in 1974 to
10.8% in 2014 among adult men, and from 6.4% to 14.9% in
adult women over the same period (1,3).
Excess weight has been reported to be associated with various
negative effects such as cardiovascular disease, hypertension,
diabetes, cancer, and chronic renal disease, among others, and
also with early mortality (2,4).
In response to the growing epidemic of obesity and obesity-relat-
ed chronic diseases, over the last four years numerous guidelines
and position statements have been published (5). Some authors
have indicated that the fundamental goal in the treatment of over-
weight and obesity is weight loss, indicated to individuals with BMI ≥
30 or ≥ 27 kg/m2 in the presence of weight-related comorbidity (6).
Evidence-based treatments for weight loss include lifestyle in-
tervention, pharmacotherapy, and bariatric surgery (6). However,
there are inconsistent results regarding the effectiveness of some
of these strategies (lifestyle intervention, pharmacotherapy) in the
long-term maintenance of weight (7-8).
Water is essential for life (9). It comprises about 60% of human
body weight and is critical for life; without water, humans can sur-
vive for just 2-4 days (10). Beverage consumption recommenda-
tions, motivated by the large increase in unhealthy weight patterns
in the United States over the past 20 years, suggest water as the
gold-standard beverage for optimal health (11).
Increasing water intake has been proposed as an important tool
for reducing weight. However, the evidence of its efficacy is limited
(12-13). Epidemiologic and clinical studies suggest that energy
intake is significantly lower in water drinkers than in non-water
drinkers, which may contribute to weight loss and consequently
to obesity prevention (14-18).
Drinking water has been proposed to increase energy expen-
diture and rates of lipolysis (19-21). Some studies have conclud-
ed that drinking water, compared to intake of caloric beverages,
lowers total energy intake (22-25). Absolute increases in drinking
water may promote weight loss by altering metabolism and by a
slight increase in satiety, thus promoting weight loss. Very few
studies have been conducted to assess the long-term effects of
drinking water on changes in body weight (13, 26).
A previous systematic review that analyzed the effect of water
intake on body weight outcomes in an adult population, pub-
lished in 2013, concluded that studies of individuals dieting for
weight loss or maintenance suggest a weight-reducing effect
of increased water consumption, whereas studies in general
mixed-weight populations yielded inconsistent results (27).
However, the weight loss effect was marked as low evidence
because the quality of the studies was poor. In addition, the
review included only one randomized clinical trial with a follow
up of 12 weeks, one non-randomized trial, and a few more with
observational periods of a few days, several of them cross-sec-
tional in design.
Therefore, the aim of this review was to systematically sum-
marize all the existing evidence from randomized clinical trials
that evaluated the effect of water consumption on weight or body
mass index in adult and adolescent populations with a follow-up
equal or greater than 12 weeks.
Figure 1.
Flow diagram of selected studies.
Records identified through database
searching (n = 2966)
MEDLINE (PubMed) (n = 2537)
EBSCO (n = 334)
Cochrane Library (n = 95)
Additional records identified
through othersources (n = 48)
Records duplicates removed (n = 1745)
Records screened (n = 1745)
Full-text articles assesed for
eligibility (n = 18)
Records excluded by title and abstract (n = 1727)
Full-text articles excluded
(n = 12). Reasons:
- Mean follow up < 12 weeks (n = 7)
- Duplicated patients in other included studies (n = 2)
- Unsuitable outcomes (n = 3)
Studies included in qualitative
synthesis (n = 6)
INCLUDED ELIGIBILITY SCREENING IDENTIFICATION

1426 G. Bracamontes Castelo et al.
[Nutr Hosp 2019;36(6):1424-1429]
MATERIALS AND METHODS
This systematic review was conducted following the PRISMA
guidelines.
IDENTIFICATION OF RECORDS
A systematic query-based PubMed search was performed to iden-
tify eligible records that quantitatively measured body weight change
after interventions regarding water consumption. The search terms
used were the following: (“water consumption OR “water intake” OR
“drinking water” OR “beverages” OR “plain water”) AND (“adults” OR
“adolescents”) AND (“body weight” OR “body mass index” OR “weight
loss” OR “weight outcomes” OR “obesity” OR “overweight”).
Searches using the keywords “water intake,” “obesity,” and
“weight loss” were performed in EBSCO, Web of Science, and
Google Scholar to identify additional publications. To maximize
the number of studies assessing body composition outcomes, we
included all studies found in the literature that met the inclusion
criteria. The last search was conducted on March 8th, 2019.
The article selection process is presented in a flow diagram
in figure 1.
INCLUSION/EXCLUSION CRITERIA
Randomized clinical trials of the effects of water consumption on
body weight were selected, including the following criteria: 1. Any
language full-text articles, adolescent and adult population above
12 years old; 2. Articles with a follow-up of at least 12weeks; 3.
Retention rate of at least 70%; 4. Studies that reported baseline
and post-intervention measurements of body weight or BMI or both;
and 5. Studies that reported the amount of water intake. Studies at-
tending populations with comorbidities were included if these were
related to overweight and obesity. We excluded published letters,
comments, reviews, abstracts only, and duplicated studies.
SCREENING AND ELIGIBILITY
We identified 2,966 articles through the initial database research.
Title screening was performed by one researcher to exclude clear-
ly irrelevant and duplicated studies; 1,221 records were excluded.
Screening on abstract was performed by three researchers, who ex-
cluded 1,727 records. Full-text screening of the remaining 18 records
was initially performed by one researcher, and any eligible records
with uncertain data were discussed with a second researcher. In total,
12 records were excluded. A total of 6 records were included.
DATA EXTRACTION
We used a standard data extraction method to collect the infor-
mation of each study: author, year of publication, country, sample
size, age interval and gender of the participants, mean follow-up,
retention rate, weight loss, and BMI reduction outcomes reported
on each study. Weight outcomes evaluated were body weight loss
and body mass index reduction after intervention.
QUALITY ASSESSMENT
To assess the quality of the evidence, we used the Grading
of Recommendations Assessment, Development and Evaluation
(GRADE) system, which defines the quality of the evidence as
high, moderate, low, or very low. The evidence was evaluated
according to the primary outcome (weight loss).
RESULTS
STUDY CHARACTERISTICS
A total of six eligible publications were included, consisting
of six RCTs. Table I summarizes the major characteristics of the
studies included.
One study had an adolescent population with OW/OB without
comorbidities (12), the other five included mixed (13,28-29)
and only female populations (30-31) with OW/OB, and one of
them included OW/OB with diabetes mellitus in both groups
(31). Fiveof the studies reported statistical power and all stud-
ies reported a retention rate higher than 70% at 12 weeks of
follow-up.
Different strategies to weight loss achievement were used:
five of the studies included a weight loss program with hy-
pocaloric diets, physical activity and/or behavioral programs.
Two studies assessed the effect of increasing daily water intake
(12,29), two the effect of replacing caloric beverages with water
following lunch (30-31), and the remaining two studies evaluat-
ed the effect of 500mL of water preload before all 3 daily meals
and before the main meal (13,28).
All studies reported baseline and post-intervention weight,
and four of them also reported BMI reduction (12,13,30,31).
Other measurements were non-uniformly reported: four stud-
ies reported changes in waist circumference, lipid profile and
fasting glucose (13,29-31); two of them reported A1C and in-
sulin resistance indicators (30,31), and two reported body fat
percentage (12,13).
PARTICIPANTS’ CHARACTERISTICS
A total of 609 participants were included in this study. Total
size samples ranged from 38 to 303 participants. Gender dis-
tribution was reported in all six studies, and there was a greater
proportion of women (78.1%) than men (21.9%). Age at baseline
ranged from 12 to 75 years. Baseline weight ranged from 83.90
to 93.03 kg, and BMI ranged from 32.0 to 34.2 kg/m2.

1427EFFECT OF WATER CONSUMPTION ON WEIGHT LOSS: A SYSTEMATIC REVIEW
[Nutr Hosp 2019;36(6):1424-1429]
CHANGE IN WEIGHT LOSS
Weight loss outcomes in the intervention groups, based on
body weight in kgs, are shown in Table 1. Mean body weight at
baseline and at end of follow-up was 89.33 kg and 84.55 kg,
respectively. After the interventions all the studies showed a
mean weight loss of -4.96 kg, ranging from -0.4 kg to -8.8 kg.
The mean percentage weight loss was 5.15%. The most effec-
tive intervention among the studies was the replacing of caloric
beverages with water, with weight loss ranging between 7.62%
and 9.41% at 24 weeks of follow-up with a significant differ-
ence between groups (31). Interventions involving an increase
in daily water intake were the least effective, with reductions
that ranged from 0.46% to 2.98% at 24 (12) and 52 weeks of
follow-up (29), respectively; differences between groups were
reported only in the 52-week study. Premeal waterload showed
a reduction that ranged from 2.6% to 7.8% at 12 weeks of
follow-up. Both studies found significant differences between
groups (13,28).
The study with the longest follow-up had 52 weeks, and re-
ported a weight loss of 2.98% in the group with higher water
intake (29).
GENERAL CHARACTERISTICS OF THE
STUDIES INCLUDED
A RCT conducted by Dennis (13) studied the effects of water con-
sumption on body weight. Participants were 55-75-year-old adults
and included predominantly white men. The intervention group (IG)
had a hypocaloric diet plus 500mL of bottled water prior to each of
the three daily meals, and the control group (CG) had a hypocaloric
diet alone. After 12 weeks of follow-up a weight reduction of 7.8%
(p<0.001) was found in the IG, which was approximately 2kg
greater in the water group than in the CG. Weekly water intake
compliance was 90%. There were differences in food and bever-
ages energy density within groups but not between groups at the
end of the study. No differences in mean ad libitum breakfast meal
energy intake at the end of follow-up was found. Most male and
white participants were included in the IG. The Institute for Public
Health and Water Research funded the study.
Parretti et al (28) conducted a RCT to assess the efficacy of
water preloading before meals as a weight loss strategy. All races,
a nonspecific wide age range, and participants with comorbidities
were included. The IG had 500mL of water within 30 min prior
to the main meals each day, without any specific diet, plus a
Table I. Study characteristics and weight loss outcomes
Author,
year
(country)
Follow-
up
(weeks)
Retention
rate (%)
Sample
size:
sex (age
range in
years)
Intervention
Weight
change
from
baseline
(kg)
p
BMI
change
from
baseline
(kg/m2)
p
Wong,
2017 (USA) 24 100 38: M/F
(12 to 17)
IG: weight loss diet plus eight cups
per day of water
vs. CG: weight loss diet
IG: -0.4
CG: -0.6 0.90 IG: -0.6
CG: -0.4 0.71
Madjd,
2016 (Iran) 24 80 81: F (18
to 50)
IG: weight loss diet plus post lunch
replacement of DB with water
vs. CG: weight loss diet plus DB
post-lunch daily
IG: -6.4
CG: -5.25 0.006 IG: -2.5
CG: -2.05 0.006
Peters,
2016 (USA) 52 73 303: M/F
(21 to 65)
IG: weight loss behavioral program
plus 710mL of NSS per day
vs. CG: weight loss behavioral
program plus at least 710mL of
water per day
IG: -8.39
CG: -3.39 < 0.001
Madjd,
2015 (Iran) 24 71 62: F (18
to 50)
IG: weight loss diet plus post lunch
replacement of DB with water vs.
CG: weight loss diet plus DB post-
lunch daily
IG: -8.0
CG: -7.6 0.015 IG: -3.3
CG: -2.9 0.002
Parreti,
2015
(England)
12 92.8
84: M/F
(56.5
mean)
IG: no weight loss diet plus
500mL water preload 30 min
before main daily meal
vs. CG: no weight loss diet
IG: -2.4
CG: -1.2 0.028
Dennis,
2010 (USA) 12 85.4 41: M/F
(55 to 75)
IG: weight loss diet plus 500mL
water preload 30 before 3 daily
meals vs. CG: weight loss diet
IG: -0.87
CG: -0.6 < 0.001 IG: -2.6
CG: -1.9
Not
significant
OW: overweight; OB: obese; DM: diabete mellitus; IG: intervention group; CG: control group; DB: diet beverages; CB: caloric beverages; NSS: non-nutritive sweeteners.

1428 G. Bracamontes Castelo et al.
[Nutr Hosp 2019;36(6):1424-1429]
behavioral program. The CG received behavior counseling only.
After 12weeks of follow-up a change of -2.4 ± 3.4 kg was found
in the IG. Twenty-seven percent of the participants lost at least
5% of their body weight; the change in CG was -1.2 ± 2.9 kg; a
difference of -1.3 kg was reported between groups (p=0.028).
The mean difference in weight change between drinking water
three times a day versus no water regimen a day was 3.6 kg (95%
CI -7.0 to 0.2). Private funding was reported.
Madjd et al. (30) conducted a RCT to study the effect of re-
placing diet beverages (DBs) with water during a 24-week weight
loss program with a hypocaloric diet, exercise, and behavioral
support. Participants were 18-50-year-old women without other
comorbidities. Subjects in the IG replaced their usual intake of
DB with 250mL of water after the main meal (lunch), and the CG
was instructed to drink 250mL of DB once a day after lunch, five
times a week, and the resting days only water. In both groups no
water or DBs were allowed during lunch. At the end of follow-up
a weight loss of 8.8 ± 1.9 kg was reported in the IG, and of 7.6
± 2.1 kg in the CG, with a 13.6% greater weight reduction in the
IG (p=0.015) group. A greater improvement in insulin sensitivity
and cardiometabolic risk was found in both groups. The authors
reported no conflicts of interest.
In 2016, Madjd et al. (31) replicated their previous study in
type-2 diabetes female patients. With a larger sample and a re-
tention rate of 80%, they found after 24 weeks of follow-up a
reduction of 7.62% in body weight in the IG, compared to 1.16 kg
in the CG (p=0.006). A greater improvement in fasting plasma
glucose and insulin sensitivity was reported in the IG. There was
a greater reduction in energy intake in the IG compared with the
CG. The authors reported no conflicts of interest.
Peters et al. (29) conducted a RCT to evaluate the effects of
sweetened beverages with non-nutritive sweeteners (NNS) versus
water (WG) in subjects enrolled in a one-year behavioral weight
loss program. The sample consisted on 303 participants aged 21
to 65 years. The NNS group consumed 710mL of NSS per day
and the WG had 710mL of water per day during the 52-week fol-
low-up period. Both the NNS and water treatments were reported
as non-equivalent: the NNS group had greater weight loss, -6.2 ±
7.65 kg (p<0.001) when compared to the WG, with a reduction
of 3.39 ± 6.33 kg. Forty-four percent of the participants in the
NNS group archived a 5% weight reduction, compared to 25.5%
in the WG. This study had the longest follow-up period and the
largest sample. The authors reported private funding for the study.
Wong et al. (12) conducted a RCT in an adolescent population
from 12 to 17 years of age. As an inclusion criterion the participants
had to usually drink ≤ 4 cups of water per day. In addition to a stan-
dardized nutrition and behavioral intervention, the IG was encouraged
to increase water intake to 8 cups per day, referred to as 8×8 (eight
8-oz glasses [1.92 L] of water per day), and the CG received no spe-
cific advice on drinking water but did receive the same nutritional and
behavioral intervention. After 24 weeks of follow-up water intake was
greater in the IG compared with the CG (1.6 cups per day, 95% CI,
-0.2 to -3.0, p=0.03), but the IG did not achieve the 8-cup-per-day
goal. In addition, a significant reduction in BMI z score within groups,
but not between groups, was found. Private funding was declared.
QUALITY OF THE EVIDENCE
The quality of the evidence was evaluated based on study design,
study quality, consistency, directness, precision, and publication
bias. All the studies reported they had calculated statistical power,
retention rates were high, and no imbalance between intervention
and control groups was found. Four studies reported their ran-
domization procedures (12,28,30,31) and allocation concealment
method (12,28,30,31), and followed an intention-to-treat principle
[12,28,29,31]. While all the interventions tested the effect of water
intake on weight reduction, the strategies used were different: two
tested increase in water intake (12,29), two replacement of caloric
beverages (30,31), and two premeal water load (13,28); and all
the studies but one (28) included a weight loss diet. The length of
the studies ranged from 12 to 52 weeks, and for weight loss lon-
ger-term weight assessments are needed. In five out of six studies
the IG lost more weight than the control group. Four out of six stud-
ies had either industry funding or conflicts of interest with royalties
out of a book promoting water intake. The quality of the evidence
for the primary outcome of body weight loss was low to moderate.
DISCUSSION
In this systematic review we found that the overall reduction
of the initial weight after a water consumption intervention in
overweight and obese adults and adolescents was 5.15%, which
ranged from 0.46% to 9.41%. However, the quality of the evi-
dence for the effectiveness of water consumption interventions for
weight loss ranged from low to moderate. Intervention strategies
included increased water intake, replacement of caloric beverag-
es, and premeal water load. Caloric beverage replacement was
the most effective approach to weight loss achievement.
These results are consistent with a previous systematic review
published in 2013, which included observational studies, non-ran-
domized trials, and RCTs with short-term follow-up periods. Ourre-
view limited the studies to RCTs with a retention rate higher than
70% and a follow-up of at least 12 weeks. When compared to
other RCTs assessing diet, physical activity, and pharmacological
interventions, water consumption strategies show a quantitavely
similar effect on weight reduction. However, the period of follow-up
prevents long-term (more than a year) predictions regarding weight
loss. Additionally, heterogeneous samples and low to moderate
quality of the evidence are the main limitations of these results.
Public health programs and RCTs focusing on reducing energy
intake from food usually give little value to fluid consumption, but
the findings of this review indicate that the strength of the evi-
dence for the effect of water intake, water replacement, or water
load is low to moderate.
Among the strengths of this study are that all the studies in-
cluded were well designed, randomized, controlled trials, had a
follow-up of at least 12 weeks, and at least a 70% retention rate.
As for weaknesses, the studies included were heterogeneous,
thus a meta-analysis could not be conducted, and the quality of
the evidence for weight loss ranged from low to moderate. Other

1429EFFECT OF WATER CONSUMPTION ON WEIGHT LOSS: A SYSTEMATIC REVIEW
[Nutr Hosp 2019;36(6):1424-1429]
adiposity indicators were not uniformly reported, and only one
study with one year of follow-up was conducted.
CONCLUSIONS
Water consumption interventions in overweight and obese adults
and adolescents resulted in a reduction of 5.15% of initial body
weight. In this systematic review only six studies were included and
the quality of the evidence for the effectiveness of weight loss ranged
from low to moderate. Further high-quality studies with long-term
follow-up are warranted to assess weight loss during more than one
year.
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