Assessing hydration status
Stavros A. Kavouras
Purpose
Understanding the importance of euhydration in humans in
order to ensure good health in various situations, the purpose of
this review is to examine the available techniques in assessing
hydration status.
Recent findings
During the past 20 years, many indices have been developed to
assess hydration levels accurately in humans. Changes in body
weight, haematological and urine parameters, bioelectrical
impedance, skinfold thickness, heart rate and blood pressure
changes are among these indices. Plasma osmolality, urine
osmolality and urine specific gravity are the most widely used
markers of hydration. However, urine colour has also been used
with reasonable accuracy when laboratory analysis is not
available or when a quick estimate of hydration is necessary.
Some data indicate that urine colour is as good indicator of
hydration as plasma or urine osmolality or urine specific gravity.
Summary
Although there is no `gold standard' for assessment of hydration
status, it appears that changes in body weight, along with urine
osmolality, specific gravity, conductivity and colour are among
the most widely used indices. Furthermore, they provide
reasonable results, especially when the analysis is based on the
first morning urine sample.
Keywords
body water, dehydration, fluid balance, urine colour
Curr Opin Clin Nutr Metab Care 5:519524. # 2002 Lippincott Williams & Wilkins.
Laboratory of Nutrition and Clinical Dietetics, Department of Nutrition and Dietetics,
Harokopio University, Athens, Greece
Correspondence to Stavros A. Kavouras, Harokopio University, Department of
Nutrition and Dietetics, 70 El. Venizelou Avenue, Athens 17671, Greece
Tel: +30 10 9549 173; fax: +30 10 9549 141; e-mail: skav@hua.gr
Current Opinion in Clinical Nutrition and Metabolic Care 2002, 5:519524
Abbreviations
AVP arginine vasopressin
BIA bioelectrical impedance analysis
TBW total body water
USG urine specific gravity
# 2002 Lippincott Williams & Wilkins
1363-1950
Introduction
In a healthy adult 4570% of body weight is water [1],
which serves as a solvent for many organic and inorganic
materials and helps with their transportation from one
place to another. Water is also consumed in greater
quantities than is any other nutrient. In extreme
situations, such as ultra-marathon foot races, it has been
reported that water consumption may equal an athlete's
body weight over a period of 3 consecutive days, while
maintaining weight balance [2]. Although humans can
survive up to 6070 days without food [3], water
deprivation will lead to death within a few days,
especially in a warm environment [4]. For this reason
there are complex regulatory mechanisms that control
body water levels [5]. One of the primary determinants
of body hydration is the kidney, which ultimately affects
water output and inuences other factors that stimulate
water intake [6].
An appreciation of the importance of water balance is
very important in the accurate assessment of hydration
status. At present, there are major methodological
limitations in estimating both the absolute volume of
the body uid and its compartmental distribution, and
thus it is easier to measure changes in these volumes. In
fact, acute changes in body weight appear to represent
equal changes in hydration status. Other methods,
including skinfold thickness [7 .], bioelectrical impe-
dance analysis (BIA) [8] and responses to orthostatic
tolerance tests [9], have also been proposed as markers of
hydration. In addition, measures of blood parameters can
offer signicant information, and urinary indices have
attracted much attention over the past few years because
of their simplicity in terms of sample collection and
analysis.
Body water
Water in an average human accounts for approximately
60% of body weight, varying mainly with degree of
adiposity; for instance, as percentage of body fat
increases, the amount of body water decreases. In
newborns, 75% of body weight is water. The approxi-
mately 600 ml/kg of body weight accounted for by total
body water (TBW) is distributed in intracellular (two-
thirds TBW, 400 ml/kg) and extracellular (one-third
TBW, 200 ml/kg) space. Furthermore, 75% of the extra-
cellular uid is distributed interstitially (150 ml/kg) and
25% intravascularly (50 ml/kg) [10].
Under normal circumstances, when food and water are
freely available and the environment is thermally
519
520 Assessment of nutritional status and analytical methods
comfortable, water ingestion is more a result of
behaviour than thirst. Thirst, as an emergency mechan-
ism for maintenance of uid balance, is controlled by
plasma osmolality and plasma volume. When plasma
osmolality increases or plasma volume decreases, per-
ception of thirst rises [6]. Of those two signals the former
is the main regulator, because just a 23% increase in
plasma osmolality induces a strong increase in perception
of thirst [11], whereas plasma volume must decrease by
approximately 10% to stimulate thirst [12].
Water loss
Water may be lost from the body via several routes,
namely the renal, cutaneous, respiratory and gastro-
intestinal routes.
Renal water excretion
Under normal circumstances the kidneys are the primary
controllers of water balance. They weigh less than 0.5%
of the total body weight, but their blood ow at rest is
approximately 25% of cardiac output. Although the
kidneys lter more than 150 l uid on a daily basis, less
than 1% of that uid is actually secreted into the urine
[10].
Renal water excretion is primarily under the control of
arginine vasopressin (AVP; an antidiuretic hormone) and
the reninangiotensin system. However, other hormones
such as atrial natriuretic peptide (atriopeptin) [13] and
urodilatin [14] also appear to play a role. AVP, the main
uid-regulating hormone, is controlled by osmotic and
pressure signals [15]. AVP levels, like thirst, increase
rapidly with small increases in osmolality, and changes in
plasma volume appear to modulate this osmotic stimula-
tion [1618]. The most common causes of dehydration,
namely exposure to heat, fever, insufcient uid
consumption and physical activity, result in an increase
in osmolality and a decrease in plasma volume (hyper-
osmotic hypovolaemia). In such situations, dehydration
stimulates both thirst and increases in AVP levels. Thirst
results in increased uid ingestion (when available), and
elevated AVP concentrations prevent water losses
through a decrease in urinary output due to increased
tubular water reabsorption in the nephron. As a
consequence of the latter mechanism urine becomes
concentrated, as evidenced by a darker yellowish colour.
It is precisely the AVP response to dehydration, which
manifests as changes in urine colour, urine osmolality
and urine specic gravity (USG), that is used to estimate
levels of hydration [1921].
Cutaneous water loss
Cutaneous water loss, through sweating, plays a major
thermoregulatory role. For every litre of sweat that a
human evaporates, 580 kcal of heat may be dissipated
into the environment [22]. Water losses through
secretion of hypotonic sweat are usually around
500 ml/day. However, such losses increase with fever,
burn, increased metabolism and high ambient tempera-
ture. Cutaneous water loss can increase dramatically
during physical activity. For example, trained athletes
can sweat between 1500 and 2000 ml/h during intense
exercise in a hot environment [23], and there are
individuals who sweat as much as 3700 ml/h [24]. It is
also well documented that athletes with high water
losses through sweating rarely ingest more that 200
500 ml/h in a 2-h race, allowing themselves to dehydrate
by 23 kg water [23]. This phenomenon, described as
both voluntary and involuntary dehydration [25,26],
shows that perception of thirst may not be an accurate
index of hydration [27].
Respiratory water loss
The relatively small amount of water lost through
respiration may be estimated on the basis of ventilatory
volume and the relative humidity of the environment
[28]. However, factors such as exercise, hyperventilation,
fever and low environmental relative humidity induce
greater respiratory water losses. In an average day, with
low to moderate levels of physical activity, respiratory
water loss does not exceed 200 ml/day [29].
Gastrointestinal water loss
A relatively small amount of water (i.e. 100 ml) is
excreted daily through faeces. Most of the ingested uid
that enters the small intestine is reabsorbed there, and
the remainder is absorbed in the colon. In cases of
diarrhoea, vomiting and other gastrointestinal pathology,
water loss can increase signicantly and cause severe
dehydration.
Dehydration
Decrease in body water stores is commonly known as
dehydration. It is usually associated with a decrease in
plasma volume, which negatively impacts on cardiovas-
cular functioning [30]. The decreased plasma volume
can decrease stroke volume, leading to increased heart
rate in order to maintain a constant cardiac output.
Decreased plasma volume also decreases both sweating
and skin blood ow, thus compromising thermoregula-
tion [31]. Dehydration both at rest, and during mild and
intense physical activity increases body temperature to a
greater extent [22], which in turn increases the risk for
developing heat injuries. In addition, mild dehydration,
of 12% of body weight, decreases exercise performance.
In a classic study, Armstrong et al. [32] dehydrated
trained runners by 1.52% of their body weights and
asked them to race for 1500, 5000 and 10 000 m around a
track. When their performance was compared with that
in the euhydrated state, they were slower by 3.1, 6.7 and
6.3% for the 1500, 5000 and 10 000 m distances,
respectively.

Indices of hydration
Various indices have been employed to assess hydration
status, including change in body weight, haematological
indices, urinary indices, BIA and cardiovascular indices.
These are summarized below.
Body weight changes
Changes in body weight have been widely used for
determination of acute changes in hydration status, and
especially for assessment of dehydration as a result of
heat stress with or without exercise over a short period of
a few hours. In this scenario, because a signicant
portion of water loss is due to cutaneous water losses
through sweating or renal excretion by urination, it is
assumed that the specic gravity of sweat and USG is
approximately 1.0, resulting in a one-gram change in
body weight for every millilitre of sweat and urine
output.
In several studies, evaluation of hydration status is based
on changes in body weight over several hours, including
overnight sleep [33,34]. A major disadvantage of this
method is that measures may be altered by factors such
as bowel movement, and food and uid consumption.
Moreover, evaluation of the hydration status using this
technique requires previous knowledge of the baseline
(pre-dehydration) body weight. Changes in body weight
can be used to evaluate dehydration in combination with
other markers, especially in people who do not undergo
signicant uctuations in their body weight. In spite of
these limitations, measuring hydration status through
changes in body weight remains the only quantitative
approach that can safely be used in laboratory/experi-
mental settings.
Haematological indices
Measurements of blood parameters have been widely
used in assessment of hydration status. Changes in the
concentration of haemoglobin and haematocrit may be
used as indicators of hydration status, but in reality these
changes represent changes in plasma volume and not in
TBW. If the baseline (control) values of those two
parameters are known, then the change in plasma volume
can be estimated using the following mathematical
equation (originally developed by Dill and Costill [35].
 
Hbc 1 Hcti
%
PV  1  100
Hbi 1 Hctc
Where c refers to the control blood sample and i refers to
the blood sample at any time after the control sample is
drawn; PV is the plasma volume; Hb is the haemoglobin
concentration; and Hct is the haematocrit concentration.
This technique is very reliable, assuming that baseline
measurements are available and valid. However, these
values may be inuenced by several factors. For
Assessing hydration status Kavouras 521
example, the use of a tourniquet for drawing blood has
been shown to induce changes in haematocrit and
haemoglobin [36], and upright posture for 20 min can
also change signicantly the values of haematocrit and
haemoglobin, and in turn causes changes in plasma
volume [37]. In summary, haematocrit and haemoglobin
may be valid markers of hydration, but reliable baseline
measurements of those parameters are required for
accurate assessment of hydration status.
Levels of plasma osmolality and sodium concentration
have also been used to assess hydration status, in
particular because they are easily measured and rapidly
analysed. During dehydration, especially during hyper-
tonic hypovolaemic dehydration from insufcient uid
intake, both plasma sodium and osmolality are signi-
cantly elevated [38]. In a recent study conducted by
Popowski et al. [39 . .], plasma osmolality rose even with
dehydration as low as 1% of body weight. Both plasma
sodium and osmolality are also the most potent signals
for stimulating plasma AVP, which is the major uid-
regulating hormone. Measurements of uid-regulating
hormones such as AVP, renin, aldosterone and atriopep-
tin also offer signicant information regarding hydration
status [40,41]. For instance, AVP increases linearly with
dehydration and increases in plasma osmolality [42].
Elevated AVP level has a drastic antidiuretic effect on
the kidney that results in a rapid and signicant decrease
in urine output, while increasing urine osmolality and
USG [16].
Urinary indices
Based on the aforementioned relationship between the
AVP and urine osmolality and USG, the latter urinary
parameters are widely used not only because they
provide accurate and rapid information on hydration
status, but also because they are relatively easy to
measure. This is particularly signicant when it is
considered that estimation of AVP in plasma requires a
sophisticated laboratory technique that involves a 3-day
radioimmunoassay. In this regard it has been suggested
that urine colour in most circumstances reects level of
hydration and is closely related to several urinary and
plasma indices of hydration [43], even though it is
inuenced by diet [44], drugs [45,46] and illness [47].
In 1994, Armstrong et al. [20] introduced an 8-level
colour scale to investigate whether hydration status can
reasonably be evaluated on the basis of urine colour.
They took urine samples from 54 males and females that
were well hydrated, euhydrated or hypohydrated
through exercise, and measured urine colour, osmolality
and USG. Those investigators concluded that urine
colour is a reasonable index of hydration, and can be
used in athletic and industrial settings or eld studies,
but that it should not be used in laboratory settings,
522 Assessment of nutritional status and analytical methods
where greater accuracy is required. In a follow-up study,
those investigators [21] studied the validity of urinary
indices, including colour, during dehydration, exercise
and rehydration. They found that urine colour, osmol-
ality and USG were valid indices of hydration status in
healthy individuals. Furthermore, they found that urine
colour was as effective as (or better than) USG, urine
osmolality, urine volume, plasma osmolality, plasma
sodium and total plasma protein.
In another study, Fletcher et al. [48] examined the
validity of urine colour as an index of hydration in 40
critically ill patients. Those investigators reported a weak
but statistically signicant relationship between urine
colour and urine output, as well as between urine colour
and the ratio of urine to plasma sodium. Interestingly,
they did not show correlations between urine colour and
body weight change, plasma osmolality or USG, which
are the three most widely used indices of hydration.
They concluded that urine colour adds little to the
overall assessment of hydration status in such patients.
One important observation regarding that study is that
many of the urine samples had colour beyond level 6,
suggesting that the samples were probably taken from
severely dehydrated patients. A possible explanation for
this nding is that, although AVP concentration and
urine volume and osmolality are linearly related for low
to moderate levels of AVP (15 pg/ml), for higher levels
(4510 pg/ml) the relationship reaches a plateau. This
means that an additional increase in AVP does not
induce a similar increase in antidiuresis, thus further
increasing urine osmolality, USG and urine colour. Thus,
it would be reasonable to suggest that, when high levels
of dehydration exist, the urine indices of hydration may
not accurately describe the degree of dehydration as well
as during mild dehydration.
Recently, Kovacs et al. [49] examined the accuracy of
urine colour, osmolality and specic electrical conduc-
tance for assessing hydration status during rapid ad
libitum postexercise rehydration. For this purpose they
dehydrated the subjects to 3% of their body mass and
then rehydrated them ad libitum for 2 h, and observed
their responses for a total of 6 h. Those investigators
reported that urinary indices of hydration are poor
measures of hydration status. It is well established,
however, that levels of AVP heavily impact on urinary
indices of hydration. During rapid rehydration in
dehydrated individuals, levels of AVP decrease very
rapidly as a result of swallowing because of stimulation of
the oropharyngeal receptors [50]. In the study reported
by Kovacs et al., they did not allow any uids to be
absorbed because all of the ingested uids were
removed using a nasogastric tube. To avoid this prob-
lem when measuring hydration indices, Shirreffs and
Maughan [51] recommended use of the rst morning
urine sample, which gives a better indication of body
hydration. They also recommended that urine osmolality
greater than 900 mOsm/kg can be used as an indication
of hypohydration, and that urine conductivity can also be
used because of its simplicity and ability to provide rapid
information on hydration status.
Based on these observations, it appears reasonable to
conclude that urinary indices of hydration provide an
accurate assessment of hydration status during mild
dehydration, but that there are some situations in which
they may be altered independently of the level of
hydration. These situations include rapid rehydration
[50], alcohol consumption [52], caffeine consumption
[53], intravenous infusion [54], and critical illness [48]
and severe dehydration.
Bioelectrical impedance analysis
During the past decade evidence has been gathered that
supports the use of bioelectrical impedance to monitor
hydration status [8]. In spite of signicant limitations
(e.g. dependence on factors such as skin temperature,
food or drink consumption, and body posture before the
measurement), Piccoli et al. [55] endorse BIA as a
method for assessment of hydration assessment, even
during mountain climbing. BIA is a noninvasive, rapid,
accurate and practical method for assessing TBW in
healthy individuals at rest [56]. However, it appears that
it does not provide accurate estimates of uid compart-
ment volumes [57]. Although BIA is promising as a
potential technique for assessing hydration status,
further investigation is necessary before it may be used
as a diagnostic tool for investigating body water
alterations.
Blood pressure, heart rate and orthostatic tolerance
It is well established that dehydration alone increases
heart rate at rest and during submaximal exercise [30].
Dehydration also appears to induce orthostatic intoler-
ance [58], whereas uid ingestion in dehydrated persons
improved performance on an orthostatic tolerance test
[9]. In fact, blood pressure and heart rate responses to
rapid changes in body posture may be used to provide
additional information in the assessment of hydration
status, even though they are not able to identify uid
imbalances independently of other indices.
Conclusion
Changes in body weight, urinary indices, blood osmol-
ality and hormone concentrations, heart rate, blood
pressure, skinfold thickness and perception of thirst are
among the indices that are used to assess hydration
status. The most widely used are urinary indices, namely
urine osmolality, USG and urine colour. Recently, BIA
has emerged as a promising method for assessing
hydration status, but it is not yet clear whether it is
 Assessing hydration status Kavouras 523

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sensitive information regarding hydration. In the position
statement of the National Athletic Trainers' Association
on uid replacement for athletes published in 2000 [60],
the authors recommended three indices of hydration
status (Table 1): percentage change in body weight,
urine colour [20] and USG. Although controversy persists
in the eld of hydration assessment, it appears that some
of these indices can be used with reasonable results,
even in daily practice [61 .].
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Urinary indices of hydration may be used to ensure good hydration status in
athletes.