Nutrición Hospitalaria

Conclusions of the II International and IV Spanish Hydration Congress. Toledo, Spain, 2^nd-4^th December, 2015

Impact of physical activity and sedentarism on hydration status and liquid intake in Spanish older adults: the PHYSMED study

Introduction: Data on hydration status in older adults are scarce and there are very few studies focusing on the impact of physical activity (PA) on drinking behavior. Objective: To assess the impact of physical activity and sedentarism on fluid intake in Spanish elderly. Methods: 433 non-institutionalized Spanish older adults (58% females), aged 55-88 years, volunteered for the PHYSMED study. PA data were obtained by means of the Minnesota and EXERNET questionnaires. Population was divided into four groups: ILS (inactive and low sedentary), IHS (inactive and high sedentary), ALS (active and low sedentary) and AHS (active and high sedentary). Serum from fasting blood samples was analysed for osmolarity. Results: The mean of total liquid intake was 1,751 ± 628 mL/d. Significant differences were observed for total liquid intake between ILS/ALS and IHS/ALS (p < 0.001). ALS subjects consumed a higher amount of beverages such as water, juice, milk, coffee, sport drink, beer, wine and distilled drinks than the other PA groups. There was a significant difference for water intake between PA groups (p < 0.01). Serum osmolarity values were within references ranges in all subjects, and there was a significant difference between PA groups (p < 0.01). Conclusions: Spanish older adults meet the DACH recommendations set by the German, Austrian and Swiss nutrition societies' liquid intake recommendations in the mean independently of PA and sedentary level. All participants are within reference ranges of serum osmolarity. Subjects in the active and low sedentary group consumed higher amounts of water and other beverages than in the other PA groups.

Nutritional differences in malnourished patients according to their liquid-intake habits after hospital discharge

Introduction: Malnutrition is a serious and relatively common problem among hospitalized patients; moreover, it is known that a good hydration state contributes to health and wellbeing. Objective: The aim of this study was to determine the relationship between nutritional status, functional dependency, quality of life and liquid-intake habits in malnourished patients after hospital discharge. Methods: Cross-sectional descriptive study in 91 patients (45 males) who presented malnutrition at hospital discharge. The patients were grouped according to their liquid intake estimated through the Mini Nutritional Assessment questionnaire: 3-5 glasses (n = 42), and > 5 glasses (n = 46); removing from analysis < 3 glasses of liquid intake (n = 3). The body mass index, weight, Malnutrition Universal Screening Tool (MUST), functional dependency (Barthel questionnaire), and quality of life (Short Form 12 Health Survey [SF-12]) were assessed 2-months after discharge. Results: The > 5 glasses liquid intake group showed better nutritional status than the 3-5 glasses intake group, for weight (p < 0.001), body mass index (p = 0.001), and MUST scale (p = 0.020). Additionally, the > 5 glasses liquid intake group significantly scored higher values in the total SF-12 questionnaire (p = 0.013), presenting better self-reported quality of life, and higher functional independency in the Barthel index (p = 0.037) than the 3-5 glasses liquid intake group (p = 0.013). Conclusions: Although further research is needed to elucidate the characteristics of this relationship, descriptive comparisons between groups showed favorable nutritional status, functional independency and quality of life for the > 5 glasses of liquid intake compared with the 3-5 glasses of liquid intake group during a 2-months follow-up.

Urinary hydration biomarkers and water sources in free-living elderly

Introduction: Accurate estimates of water intake and hydration status in populations are essential to identify populations at risk of dehydration and define strategies to improve standards of water intake. Objective: To evaluate the hydration status and the contribution of food and beverages to the total water intake in a sample of free-living physically active Portuguese elderly. Methods: A sample of 74 individuals (28 men), aged 60 to 83 years, were included in this study. A 24 h urine sample was collected; 24 h urine volume and osmolality were quantified in order to estimate the free water reserve (FWR) used to assess the hydration status. A 24 h food recall corresponding to the day of urine collection was obtained. Food and beverages were grouped according to their nutritional composition, namely water content. The contribution of those groups to total water intake and its association with the hydration status were estimated. Urinary markers and food groups' contribution to total water intake were compared between sexes and according to the median FWR, using the t-test and Mann Whitney test. Results: Less than 10% of the participants were classified as hypohydrated/at hypohydration risk. Water from food was nearly half of the total water intake (47% in females and 48% in males, p = 0.757). "Water" (22%) and "foods with reduced water content" (19%) were the groups that contributed the most to the total water intake in women and men, respectively. In men, the contribution of "alcoholic beverages" was significantly higher than that of women (10.5% vs 1.7%, p < 0.001). Conclusions: Even though most of the study participants were classified as euhydrated, the contribution of water-rich and nutritionally dense food, and non-alcoholic beverages, particularly in men, should be promoted.

The association between water intake, body composition and cardiometabolic factors among children: the Cuenca study

Introduction: Beverage consumption and its possible association with current obesity epidemic and metabolic syndrome is under investigation in recent years, however water intake is probably the most underestimated of all beverages and could play an important role. Objective: The aim of this study was to examine the association between water intake, body composition and cardiometabolic factors in a sample of Spanish children. Methods: A cross-sectional study was conducted in 366 schoolchildren (53.5% girls) aged 9-11 years from the province of Cuenca in Spain. Data of anthropometrics, body composition, cardiometabolic risk factors and cardiorespiratory fitness variables were collected. Beverage consumption was assessed using two non-consecutive 24 h dietary recalls. Results: We found an inverse association between the consumption of water (ml)/kg per weight with BMI, body fat, fat-free mass, waist circumference, insulin levels, HOMA-IR (p < 0.001), and with arterial pressure parameters, systolic (p < 0.010) and diastolic blood pressure (p < 0.028), and mean arterial pressure (p < 0.012), as well as direct associations with HDL cholesterol (p < 0.001). In ANCOVA analyses, children who drank less water (ml)/kg per weight, had higher levels of LDL cholesterol (p < 0.050) and lower levels of HDL cholesterol (p < 0.042), and overweight-obesity subjects drank less water (ml)/kg per weight than normal peers (p < 0.011). Besides, children with lower levels of HDL cholesterol and higher levels of triglycerides and blood pressure had less water intake as a beverage. Finally, children who drank less water from beverages had high levels of LDL cholesterol. Conclusions: Higher consumption of water (ml)/kg per weight was negatively associated with BMI, body fat, fat-free mass, waist circumference, insulin levels, HOMA-IR, and positively with HDL cholesterol in children independently of age, sex and cardiorespiratory fitness. In addition, overweight-obese children drank less water (ml)/kg per weight than normoweight ones. Therefore, water consumption is associated with numerous health benefits and its adequate intake could contribute to prevent obesity and metabolic syndrome in childhood.

Comparison of beverage consumption in adult populations from three different countries: do the international reference values allow establishing the adequacy of water and beverage intakes?

Introduction: Recommendations of adequate total water intake (aTWI) have been proposed by the European Food Safety Agency (EFSA) and the Institute of Medicine (IOM) of the United States of America. However, there are differences in the approach used to support them: IOM recommendation is based on average intakes observed in NHANES III (Third National Health and Nutrition Examination Survey) and EFSA recommendation on a combination of observed intakes from 13 different European countries. Despite these recommendations of aTWI, the currently available scientific evidence is not sufficient to establish a cut-off value that would prevent disease, reduce the risk for chronic diseases or improve health status. Objective: To compare the average daily consumption of fluids (water and other beverages) in selective samples of population from Mexico, US and Spain, evaluating the quantity of fluid intake and understanding the contribution of each fluid type to the total fluid intake. We also aim to determine if they reached adequate intake (AI) values, as defined by three different criteria: IOM, EFSA and water density. Methods: Three studies were compared: from Mexico, the National Health and Nutrition Survey conducted in 2012 (NHNS 2012); from US, the NHANES III 2005-2010 and from Spain the ANIBES study leaded in 2013. Different categories of beverages were used to establish the pattern of energy intake for each country. Only adult population was selected. TWI of each study was compared with EFSA and IOM AI recommendations, as well as applying the criterion of water density (mL/kcal). Results: The American study obtained the higher value of total kcal/day from food and beverages (2,437 ± 13). Furthermore, the percentage of daily energy intake coming from beverages was, for American adults, 21%. Mexico was slightly behind with 19% and Spain ANIBES study registered only 12%. ANIBES showed significantly low AI values for the overall population, but even more alarming in the case of males. Only 12% of men, in contrast with 21% of women, do satisfy the EFSA criterion. The IOM criterion reaches even less with higher recommended values for daily intake. In contrast, 60% of the American population reached the recommended intake of the IOM criterion. However, available data did not allow calculating the percentage reached by the EFSA criterion. Data from the Mexican study did not permit conducting comparisons with IOM or with EFSA. However, the water density criteria (mL/kcal) was higher than 1. Conclusion: There is a notable difference between all three populations in terms of TWI. Furthermore, within the same population, values of adequacy of TWI changed significantly when they were assessed using different criteria. More scientific evidence is required for the production of better defined water intake recommendations in the future as well as more studies focusing on beverage consumption patterns in different settings.

Urinary hydration biomarkers and dietary intake in children

Introduction: The importance of hydration is undoubtable but reliable data on hydration status and its relation with diet is lacking. Objectives: We aimed to evaluate the hydration status and its relation to beverages and food intake in children. Methods: A sample of 172 (50% male), 7-11 year-old children was included in this survey. Participants completed a 24 h urine collection; a 24 hours food recall corresponding to the day of urine collection was applied, weight and height were measured and parents/caregivers filled a lifestyle and socio-demographic questionnaire. The free water reserve was used to assess the hydration status. The intakes of food and beverages were compared according to hydration status using the t-test, Mann-Whitney test or unconditional regression models as appropriate. Results: More than half of the participants were classified as hypohydrated or at risk of hypohydration (57% in girls and 58% in boys). Compared to hypohydrated children, a significant higher consumption of water (276.2 ± 208.4 vs 188.2 ± 187.4 g/day) and fruit juices (77.6 ± 139.4 vs 14.4 ± 57.2 g/day) was reported by euhydrated boys and girls, respectively. Lower consumers of water and fruit juices showed a higher risk of hypohydration (OR = 2.16, 95% CI: 1.02-4.58, p = 0.045), adjusting for confounders. Conclusions: Most of the children included in this analysis were classified as at risk of hypohydration and those with higher water and fruit juices consumption showed a better hydration status.

Dietary intake according to hydration status in 9-10 year-old soccer players

Introduction: Children have an increased risk of voluntary dehydration especially during physical activity which may increase the risk of non-compensating water losses. Objectives: The aim of this study was to assess the hydration status and its relation to food intake in a children group of soccer players. Method: A sample of 36 boys aged 9-10 years was included in this study; 30 completed a 24 h urine collection. Participants completed a 24 h urine collection; a 24 hours food recall corresponding to the day of urine collection was applied, weight and height were measured and parents/caregivers filled a lifestyle and socio-demographic questionnaire. The free water reserve (FWR [ml/24 h] = urine volume [ml/24 h] - obligatory urine volume [ml/24 h]) was used to assess the hydration status. Food and beverage groups were created and models of unconditional logistic regression were fitted in order to estimate the magnitude of the association between the hydration status and diet. Results: Forty three per cent of participants were classified as at risk of hypohydration. Children who reported a high fruit and vegetables intake (above the median) were at decreased risk of hypohydration (OR = 0.19, 95% CI 0.04-0.94, p = 0.041), compared to children who reported a low fruit and vegetables intake. Conclusions: Almost half of the children were at risk of hypohydration. Our results suggested that water food sources such as fruit and vegetables may contribute to euhydration.

Fifty years of beverages consumption trends in Spanish households

Objectives: To describe the evolution of non-alcoholic and alcoholic beverages consumption in the Spanish households from the 60's to nowadays. Methods: This study is based on beverages and food consumption in Spanish households; the data sample consisted of consumption and distribution data, obtained from the Household Budget Survey (HBS) since 1964 to 1991 and from the Food Consumption Survey (FCS) since 2000 to 2014, in collaboration with the Spanish Nutrition Foundation (FEN). Results: In 2014 the average consumption of non-alcoholic beverages was 332 g/person/day, whereas alcoholic beverages consumption represented 72.6 g/person/day. Consumption of non-alcoholic beverages has increased 721% (1964: 46 g/person/day; 1991: 96 g/person/day; 2000: 240 g/person/day and 2014: 332 g/person/day), whereas alcoholic beverages consumption has decreased roughly a 50% (1964: 145 g/person/day; 1991: 113 g/person/day; 2000: 78.4 g/person/day and 2014: 72.6 g/person/day). The most consumed alcoholic beverage in 2014 was beer (41.3 g/day), followed by wine (23.0 g/day). Regarding non-alcoholic beverages, the most consumed was water (144 g/day), followed by cola (ordinary: 30.7 g/day and diet: 20.5 g/day). According to Spanish regions, in 2014 non-alcoholic beverages were the most consumed in the islands (Balearic Islands 521 grams/person/day; Canary Islands 515 grams/person/day), as it was in the nineties (Balearic Islands 148 grams/person/day and Canary Islands 281 grams/person/day). However in 1980-81 the largest consumption of alcoholic beverages was that of Galicia, 408 g/person per day, and the lower in the Canary Islands, 63 g/person per day. In 2014, Murcia and Andalucía represented the regions with the highest consumption of alcoholic beverages. In 2014, alcoholic beverages provided roughly 1.89% of the total energy and 1.47% of sugars, whereas non-alcoholic beverages provided 3.28% of energy and 15.72% of sugars and, in 2000, alcoholic beverages contributed 2.29% of the energy and 1.47% of sugars and non-alcoholic drinks provided 3.76% of the energy and 22.7% of sugars. Conclusion: There have been significant changes in the eating patterns at the Spanish homes, especially regarding beverages consumption, over the last five decades. In general, a higher consumption and variety for non-alcoholic drinks has occurred, especially in the islands. In parallel, a decline in alcoholic beverages consumption has been clearly observed.

Macronutrients contribution from beverages according to sex and age: findings from the ANIBES Study in Spain

Methodologies and procedures used in dietary surveys have been widely developed with the aim of evaluating the nutritional status of a population. However, beverages are often either disregarded at national and international assessment of nutrients intake or poorly mentioned. Moreover, there is no standardized questionnaire developed as a research tool for the evaluation of beverages intake in the general population. Moreover, the contribution of different beverages to macronutrients intake is rarely provided. The latter in the context of a continuous expansion and innovation of the beverages market in Spain. Therefore, the main goal of the present study was to evaluate non-alcoholic and alcoholic beverages macronutrients contribution in the ANIBES study in Spain (9-75 years old). As expected, those contributed to dietary macronutrient intake mainly as total carbohydrates and sugar. The contribution to other macronutrients (proteins and lipids) by the beverage groups was of much less importance. For non-alcoholic beverages, contribution to carbohydrates was much higher in younger populations (children: 10.91 ± 9.49%, mean ± SD for boys and 9.46 ± 8.83% for girls; adolescents: 11.97 ± 11.26% for men and 13.77 ± 10.55% in women) than in adults: 9.01 ± 9.84% for men and 7.77 ± 8.73% in women. Finally, a much lower contribution was observed in the elderly: 4.22 ± 6.10% for men and 4.46 ± 6.56% for women. No sex differences, however, across all age groups were found. Results for sugar contribution showed a similar trend: children (23.14 ± 19.00% for boys and 19.77 ± 17.35% for girls); adolescents (28.13 ± 24.17% for men and 29.83 ± 21.82% in women); adults 20.42 ± 20.35% for men and 16.95 ± 17.76% in women, p ≤ 0.01; and elderly: 14.63% ± 9.97 for men and 9.33 ± 12.86% in women. The main contribution corresponded to sugared soft drinks, juices and nectars, more relevant and significant in the younger populations. As for alcoholic beverages, the contribution of macronutrients to the total diet is low for carbohydrates and sugar. The main contribution of this group, as expected, is alcohol, being higher from low alcohol content beverages, and in men vs women (p ≤ 0.001).

Effects of maternal hydration status on the osmolality of maternal milk

Background: It has been demonstrated that human milk osmolality (Mosm) is regulated within an established range, typically 290 to 300 mOsm/kg, and appears to be resistant to effects of maternal dehydration, as reflected by high urinary osmolality (Uosm). Objective: To determine the degree of association between Mosm and Uosm at a common point in time, as well as the reproducibility of both measures over a one-week interval of sampling. Methods: Mosm and Uosm were measured with a Vogel Löser 450 osmometer on samples of the respective biological fluids collected concurrently in 31 lactating women, with infants aged between 30 and 340 days. In the first 15 women recruited, collections were repeated 7 days after the initial ones. Results: The median Mosm for the 46 samples collected was 308 mOsm/kg with a range from 288 to 448 mOsm/kg. The corresponding values for Uosm were 598 mOsm/kg with a range from 93 to 1,678 mOsm/kg. The Spearman rank-order correlation coefficient for within-individual association of Mosm and Uosm was r = 0.214 (p = 0.153). The median Mosm for the 15 repeat-subjects was 309 mOsm/kg on both occasions, with a within-individual Spearman coefficient of r = 0.326 (p = 0.118). By contrast, for the Uosm, the within-subject association was much stronger, with r = 0.699 (p = 0.002). Conclusions: The osmometry technique proved to be a highly stable and reproducible measurement technique. Mosm and Uosm are not significantly associated at a point in time. Intra-subject Mosm varies more across time than intra-subject Uosm.

A new educational tool to learn about hydration: taste workshops for children

Introduction: Nutrition education contributes to children's understanding and practice of healthy lifestyles behaviors. Having a well hydration status is an essential topic, especially since children are a vulnerable population who are much more prone to dehydration than adults are. The approval of the Report on the European Gastronomic Heritage: Cultural and Educational Aspects in 2014 served as starting point to work on innovative audio-visual and multimedia materials for children. The Spanish Nutrition Foundation (FEN) and the Royal Academy of Gastronomy (RAG), in collaboration with the Ministry of Education, Culture and Sport in Spain (MECD), developed educational videos for schoolchildren to learn about food, nutrition and gastronomy, specially, the importance of being hydrated. Objectives: To develop a serial of videos for children between 3 and 9 years old with nutrition and cooking lessons to be used as educational resources in the official curricula. Methods: Fourteen chapters related to food, nutrition, gastronomy, physical activity and hydration to be used to record videos were designed and tested. A nutritionist, a chef and two puppets were the main characters acting in the videos. Results: The chapters were assembled in nine videos that included five sections: introduction, video lesson, recipes -in case of hydration, recipes with different water content foods were recorded-, what have you learnt and check your knowledge. A summary of the new educational material was officially presented at the Spain Pavilion during the Expo Milano 2015. Moreover, they are included as education tool for teachers in the new PANGEI Programme (Food, Nutrition and Gastronomy for Infantile Education) conjointly launched by FEN, RAG and MEDC. Conclusion: Taste workshops are useful as innovative nutrition education tools to reinforce language, listening and motor skills as well as food and nutrition concepts, and specially, the importance of being well hydrated.

The use of moderated mediated analysis to study the influence of hypo-hydration on working memory

Introduction: To date, dehydration has been typically reported to influence psychological parameters when there has been at least a 2% loss of body mass, although there has been little examination of those going about their everyday lives, those who have lost less than 1% of body mass. In such situations factors such as the initial hydration status and individual differences in the response to a reduced fluid intake are likely to be influential. Yet to study the complexity added by such additional variables novel methods of statistical analysis are required. Objectives: The present study describes the use of moderated mediation, an approach that asks various questions: firstly, is drinking influential?; secondly, does a mediator (e.g., thirst) sit between an independent and dependent variable?; and thirdly, does an effect only occur under certain conditions such as initial osmolality?. Method: In the study, 118 subjects were exposed to 30 ºC for four hours during which they half drank 300 ml water. The serial sevens test of working memory was performed before and at the end of the procedure. Results: A 0.6% loss of body mass reduced the efficiency of working memory. Those who consumed water had better working memory; working memory was worse in participants who lost more body mass or became thirstier, but only in those with higher levels of baseline osmolality. Conclusions: Small variations in hydration status influenced cognitive functioning although there were individual differences in the response. The parameters that influence an adverse response to hypo-hydration need to be established to allow giving appropriate advice.