Many people have heard the recommendation to drink 8 glasses of water per day. However, this guideline was never based on solid scientific evidence (Schnirring L. 2004).

Until recently, about the only definitive research regarding fluid intake and health was a study of Seventh Day Adventists that was published in 2002. Researchers at Loma Linda University in California reported that people who drank at least 5 glasses of water per day had a lower risk of a heart attack during the 6-year period than people who drank 2 or fewer glasses per day (Chan J, et al. 2002).

But even this information is not very precise: how much water is "5 glasses" anyway? To establish better guidelines on fluid intake, a panel of experts from the US and Canada was convened on behalf of the Institute of Medicine. Their report was made public in February 2004. Some of the recommendations from this excellent report are listed below:

For healthy sedentary adults living in temperate climates:

• Men: 125 oz (3.7 liters) of water per day from all dietary sources
• Women: 91 oz (2.7 liters) of water per day from all dietary sources

Even though foods supply 20% of our daily fluid intake, stop for a minute and think about how much that remaining 80% really is. The requirement for men is roughly 3 quarts per day. How many of you men out there drink this much water every single day? For women, the requirement is over 2 quarts per day. Do you drink that much? If you are like most adults, you are in a state of mild dehydration.

ATHLETES DON'T DRINK ENOUGH EITHER

Some athletes require even more fluid than what is recommended in the Institute of Medicine report. For example, researchers at West Chester University in Pennsylvania determined that their cross-country runners needed 4.6 liters per day and that football players can require as much as 12.2 liters per day. That's over 3 gallons per day! (Godek SF, et al. 2005).

At these amounts, it shouldn't be surprising that even athletes don't drink enough, even though they may know that dehydration can impair exercise performance.

The same problem exists in young athletes. In one report, 34 boys (average age 13 yrs) and 24 girls (average age 12 yrs) who participated at a 4-day soccer camp in Pennsylvania during July 2003 were studied. Most of the players were dehydrated by the second day of camp; more than half of the girls were seriously dehydrated at this point. By the last day of camp, 59% of boys and 70% of girls were significantly dehydrated. This occured despite the fact that coolers of fluids were available within 25 meters and coaches encouraged players to drink and take frequent rest breaks (Mamula PW. 2004).

THE THIRST RESPONSE IS UNRELIABLE

Part of the problem is that the body's thirst response is not very precise. First, you can lose significant amounts of body water before you begin to feel thirsty. The thirst reflex is even more flawed in the elderly.

Even in elite athletes, the thirst reflex cannot be relied upon to maintain adequate hydration. Studies in soccer players show that athletes often do not drink enough to offset their sweat losses, regardless of whether they train in the heat (Shirreffs SM, et al. 2005) or a cooler environment (Maughan RJ, et al. 2005).

Second, drinking cold water shuts off the drive to drink before enough volume has been consumed. Researchers at Gatorade® have shown that flavoring, sodium content, and temperature (of the beverage) can each affect how much fluid an athlete will drink before he/she feels satisfied.

Determining the correct amount of fluid an athlete needs while exercising or competing is highly variable. Specific formulas exist. Readers are referred to a separate review, Fluids and Electrolytes During Exercise, for a thorough discussion of this.

SPECIFIC TYPES OF BEVERAGES

So far, we've discussed the required amount of fluid that should be consumed daily. Now, what about specific types of beverages?

In March 2006, the American Journal of Clinical Nutrition published a set of guidelines that address this question. The report was developed by the "Beverage Guidance Panel", a group of scientists organized by Barry M. Popkin, PhD, a professor at the School of Public Health, University of North Carolina, Chapel Hill. The mission of this group was to develop dietary guidelines that addressed the persistent obesity epidemic, but their recommendations are relevant for this discussion.

The Panel grouped beverages into 6 categories, and ranked them from most important to least important, and provided recommended daily amounts of each:

• Level 1 (most important): Water: 20-50 fl. oz./day
• Level 2: Tea & Coffee: 0-40 fl. oz./day (can replace an equivalent amount of water); limit caffeine intake to no more than 400 mg/day
• Level 3: Low Fat/Skim Milk and Soy Beverages: 0-16 fl. oz./day
• Level 4: "Non-calorically Sweetened" Beverages (eg., Diet Coke®): 0-32 fl. oz./day
• Level 5: "Caloric Beverages With Some Nutrients" (eg., 100% fruit juices, sports drinks, alcohol): Fruit juices: 0-8 fl. oz./day; Alcohol: 0-1 drinks per day for women; 0-2 drinks per day for men
• Level 6 (least important): "Calorically-Sweetened" Beverages (eg., non-diet soft drinks): 0-8 fl. oz./day

Regarding sports drinks (see Level 5), the Panel recommended that these beverages be consumed "sparingly", except by endurance athletes. Because sports drinks contain sodium, they are preferred over plain water when sweating is profuse or prolonged. This is particularly important when:

• the sweat rate > 8 liters/hour
• strenuous exercise lasts > 60 minutes
• there is a deficiency of sodium or carbohydrates available for consumption

This issue is discussed in greater detail in Sports Drinks and Recovery Drinks.

COMMENTARY

I have several thoughts on these recommendations from the Beverage Guidance Panel:

•Water: The water recommendation of 20-50 fl. oz. per day seems low, particularly if we refer to the Institute of Medicine guidelines which recommend 91-125 oz. per day. 20-50 fl. oz. is only one-half to 1.5 quarts of water per day. And allowing for a reduction if someone drinks a lot of coffee -- which most people do -- reduces it further.

•Milk: The panel recommends a range of 0-16 fl. oz. per day. Setting a lower limit of zero seems unwise. Children and adults do not drink enough milk (USDA data). The most recent dietary guidelines (MyPyramid.gov) recommend 2-3 cups/day, depending on age group. Milk is not only a nutritious drink, but, one study even claims that milk might be an ideal post-exercise sports drink (Karp JR, et al. 2006).

In my opinion, the panel should have written the milk recommendation as "8-16 fl. oz. per day", or even "12-16 fl. oz. per day". Note that some brands of chocolate milk contain high-fructose corn syrup....these brands should be avoided. (see below)

•"Calorically-sweetened" beverages: Almost all non-diet soft drinks in the US are sweetened with 55% high-fructose corn syrup (HFCS) (Bray GA, et al. 2004). There is substantial research showing that HFCS contributes to obesity (Bray GA, et al. 2004) and a worse lipid profile (Krilanovich NJ. 2004). The Center for Science in the Public Interest is so concerned about HFCS that, in 2005, they submitted a petition to the FDA to have this food additive removed from our food supply. In my opinion, the recommended intake of beverages sweetened with HFCS should be zero. Period.

QUESTIONS

Q: Does the use of caffeine, alcohol, or prescription diuretics change these new fluid-intake recommendations?

ANSWER: This question requires three separate answers:

•Caffeine: Most people know that caffeine and alcohol have diuretic-like effects. However, caffeine is a relatively mild diuretic and this effect appears to diminish with daily consumption. Thus, regular caffeine use by non-athletes is probably less of an issue than failure to meet these new fluid-intake recommendations. The kidney can easily reverse the diuretic effect of caffeine once exercise begins (Wemple RD, et al. 1997). So, it would seem that caffeine-drinkers don't need to increase their daily fluid intake beyond the amounts recommended in the 2004 Institute of Medicine (IOM) guidelines.

•Alcohol: Alcohol is a stronger diuretic than caffeine. In addition, it doesn't appear that your body develops a tolerance to the diuretic effects of alcohol like it does for caffeine. Thus, dehydration is just another in a long list of reasons to minimize the amount of alcohol you consume. On days that you might drink too much alcohol, then you definitely want to meet the 2004 IOM recommendations.

•Diuretics: Recommending fluid intake for someone who takes prescription diuretics is much more complicated, and can only be answered by your physician. Diuretics have many medical uses, so we cannot offer one simple answer that might apply to all these possible scenarios.

Q: Is caffeinated water (ie., bottled water with added caffeine) a bad idea?

ANSWER: Not necessarily. But, caffeine is caffeine, whether it comes from coffee or caffeinated water; the effects will be the same. Caffeine is ergogenic (ie., enhances performance) and can get you disqualified from sanctioned competition if concentrations in your urine are too high. But, this is highly unlikely with caffeinated water; the amounts of caffeine in these beverages are too low: an average cup of java contains 75-150 mg caffeine, a 12-oz can of cola contains 40-50 mg, and caffeinated water contains even less than that. (Note that some energy drinks may contain very large amounts of caffeine.)

SUMMARY

For most people, attaining these new goals for fluid intake will require a substantial change in daily routine. However, keep in mind that you don't have to take it all in as water (or other beverages). Roughly 80% of your total daily fluid intake comes from drinks; the other 20% comes from fruits, vegetables, and other foods. Still, consuming this much fluid on a daily basis will require some conscious effort.

Also, these recommendations do not apply to endurance athletes, or anyone else for that matter who exercises and perspires for an extended period of time.

FOR MORE INFORMATION

The Institute of Medicine report mentioned above is available as the book Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulfate. It can be obtained at the National Academies Press web site: www.nap.edu.

The web site MyPyramid.gov contains a lot of nutritional information.

The web site for USA Track and Field (www.usatf.org) provides several excellent papers on the topic of fluid replacement during exercise.

Readers may be interested in the following related stories:

• Alcohol and the Athlete (coming soon)
• Caffeine: Effects on Exercise and Performance (coming soon)
• Fluids and Electrolytes During Exercise
• Sports Drinks and Recovery Drinks

PERSONALIZED FITNESS AND LIFESTYLE COUNSELING

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REFERENCES

Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr 2004;79:537-543. Abstract

Chan J, Knutsen SF, Blix GG, et al. Water, other fluids, and fatal coronary heart disease: the Adventist Health Study. Am J Epidemiol 2002;155:827-833. Abstract

Godek SF, Bartolozzi AR, Godek JJ. Sweat rate and fluid turnover in American football players compared with runners in a hot and humid environment. Br J Sports Med 2005;39:205-211. Abstract

Karp JR, Johnston JD, Tecklenburg S, et al. Chocolate milk as a post-exercise recovery aid. Int J Sport Nutr Exerc Metab 2006;16:78-91. Abstract

Krilanovich NJ. Fructose misuse, the obesity epidemic, the special problems of the child, and a call to action. Am J Clin Nutr 2004;80:1446-1447. Abstract

Mamula PW. Dehydration risk during summer youth sports camps. Phys Sportsmed 2004;32:15. (no abstract)

Maughan RJ, Shirreffs SM, Merson SJ, et al. Fluid and electrolyte balance in elite male football (soccer) players training in a cool environment. J Sports Sci 2005;23:73-79. Abstract

Popkin BM, Armstrong LE, Bray GM, et al. A new proposed guidance system for beverage consumption in the United States. Am J Clin Nutr 2006;83:529-542. Abstract

Schnirring L. Dietary guidelines for water and electrolytes. What role for thirst? Phys Sportsmed 2004;32:12, 41. (no abstract)

Shirreffs SM, Aragon-Vargas LF, Chamorro M, et al. The sweating response of elite professional soccer players to training in the heat. Int J Sports Med 2005;26:90-95. Abstract

Wemple RD, Lamb DR, McKeever KH. Caffeine vs caffeine-free sports drinks: effects on urine production at rest and during prolonged exercise. Int J Sports Med 1997;18:40-46. Abstract

ABOUT THE AUTHOR

Stan Reents, PharmD, is a former healthcare professional. He holds Personal Trainer and Lifestyle Counselor certifications from the American Council on Exercise. He has also been certified as a tennis coach by USTA. He can be reached at: Editor@athleteinme.com.