research paper on water

A comprehensive review of water quality indices (WQIs): history, models, attempts and perspectives

• Review paper
• Published: 11 March 2023
• Volume 22 , pages 349–395, ( 2023 )

Cite this article

• Sandra Chidiac   ORCID: orcid.org/0000-0002-1822-119X 1 ,
• Paula El Najjar 1 , 2 ,
• Naim Ouaini 1 ,
• Youssef El Rayess 1 &
• Desiree El Azzi 1 , 3  

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Water quality index (WQI) is one of the most used tools to describe water quality. It is based on physical, chemical, and biological factors that are combined into a single value that ranges from 0 to 100 and involves 4 processes: (1) parameter selection, (2) transformation of the raw data into common scale, (3) providing weights and (4) aggregation of sub-index values. The background of WQI is presented in this review study. the stages of development, the progression of the field of study, the various WQIs, the benefits and drawbacks of each approach, and the most recent attempts at WQI studies. In order to grow and elaborate the index in several ways, WQIs should be linked to scientific breakthroughs (example: ecologically). Consequently, a sophisticated WQI that takes into account statistical methods, interactions between parameters, and scientific and technological improvement should be created in order to be used in future investigations.

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1 Introduction

Water is the vital natural resource with social and economic values for human beings (Kumar 2018 ). Without water, existence of man would be threatened (Zhang 2017 ). The most important drinking sources in the world are surface water and groundwater (Paun et al. 2016 ).

Currently, more than 1.1 billion people do not have access to clean drinking water and it is estimated that nearly two-thirds of all nations will experience water stress by the year 2025 (Kumar 2018 ).

With the extensive social and economic growth, such as human factors, climate and hydrology may lead to accumulation of pollutants in the surface water that may result in gradual change of the water source quality (Shan 2011 ).

The optimal quantity and acceptable quality of water is one of the essential needs to survive as mentioned earlier, but the maintenance of an acceptable quality of water is a challenge in the sector of water resources management (Mukate et al. 2019 ). Accordingly, the water quality of water bodies can be tested through changes in physical, chemical and biological characteristics related to anthropogenic or natural phenomena (Britto et al. 2018 ).

Therefore, water quality of any specific water body can be tested using physical, chemical and biological parameters also called variables, by collecting samples and obtaining data at specific locations (Britto et al. 2018 ; Tyagi et al. 2013 ).

To that end, the suitability of water sources for human consumption has been described in terms of Water Quality Index (WQI), which is one of the most effective ways to describe the quality of water, by reducing the bulk of information into a single value ranging between 0 and 100 (Tyagi et al. 2013 ).

Hence, the objective of the study is to review the WQI concept by listing some of the important water quality indices used worldwide for water quality assessment, listing the advantages and disadvantages of the selected indices and finally reviewing some water quality studies worldwide.

2 Water quality index

2.1 history of water quality concept.

In the last decade of the twentieth century, many organizations involved in water control, used the water quality indices for water quality assessment (Paun et al. 2016 ). In the 1960’s, the water quality indices was introduced to assess the water quality in rivers (Hamlat et al. 2017 ).

Horton ( 1965 ), initially developed a system for rating water quality through index numbers, offering a tool for water pollution abatement, since the terms “water quality” and “pollution” are related. The first step to develop an index is to select a list of 10 variables for the index’s construction, which are: sewage treatment, dissolved oxygen (DO), pH, coliforms, electroconductivity (EC), carbon chloroform extract (CCE), alkalinity, chloride, temperature and obvious pollution. The next step is to assign a scale value between zero and 100 for each variable depending on the quality or concentration. The last step, is to designate to each variable is a relative weighting factor to show their importance and influence on the quality index (the higher the assigned weight, the more impact it has on the water quality index, consequently it is more important) (Horton 1965 ).

Later on, Brown et al. ( 1970 ) established a new water quality index (WQI) with nine variables: DO, coliforms, pH, temperature, biochemical oxygen demand (BOD), total phosphate, nitrate concentrations, turbidity and solid content based on a basic arithmetic weighting using arithmetic mean to calculate the rating of each variable. These rates are then converted not temporary weights. Finally, each temporary weight is divided by the sum of all the temporary weights in order to get the final weight of each variable (Kachroud et al. 2019a ; Shah and Joshi 2017 ). In 1973, Brown et al., considered that a geometric aggregation (a way to aggregate variables, and being more sensitive when a variable exceeds the norm) is better than an arithmetic one. The National Sanitation Foundation (NSF) supported this effort (Kachroud et al. 2019a ; Shah and Joshi 2017 ).

Steinhart et al. ( 1982 ) developed a novel environmental quality index (EQI) for the Great Lakes ecosystem in North America. Nine variables were selected for this index: biological, physical, chemical and toxic. These variables were: specific conductance or electroconductivity, chloride, total phosphorus, fecal Coliforms, chlorophyll a , suspended solids, obvious pollution (aesthetic state), toxic inorganic contaminants, and toxic organic contaminants. Raw data were converted to subindex and each subindex was multiplied by a weighting factor (a value of 0.1 for chemical, physical and biological factors but 0.15 for toxic substances). The final score ranged between 0 (poor quality) and 100 (best quality) (Lumb et al. 2011a ; Tirkey et al. 2015 ).

Dinius ( 1987 ), developed a WQI based on multiplicative aggregation having a scale expressed with values as percentage, where 100% expressed a perfect water quality (Shah and Joshi 2017 ).

In the mid 90’s, a new WQI was introduced to Canada by the province of British Columbia, and used as an increasing index to evaluate water quality (Lumb et al. 2011b ; Shah and Joshi 2017 ). A while after, the Water Quality Guidelines Task Group of the Canadian Council of Ministers of the Environment (CCME) modified the original British Columbia Water Quality Index (BCWQI) and endorsed it as the CCME WQI in 2001(Bharti and Katyal 2011 ; Lumb et al. 2011b ).

In 1996, the Watershed Enhancement Program (WEPWQI) was established in Dayton Ohio, including water quality variables, flow measurements and water clarity or turbidity. Taking into consideration pesticide and Polycyclic Aromatic Hydrocarbon (PAH) contamination, is what distinguished this index from the NSFWQI (Kachroud et al. 2019a , b ).

Liou et al. (2003) established a WQI in Taiwan on the Keya River. The index employed thirteen variables: Fecal coliforms, DO, ammonia nitrogen, BOD, suspended solids, turbidity, temperature, pH, toxicity, cadmium (Cd), lead (Pb), copper (Cu) and zinc (Zn). These variables were downsized to nine based on environmental and health significance: Fecal coliforms, DO, ammonia nitrogen, BOD, suspended solids, turbidity, temperature, pH and toxicity. Each variable was converted into an actual value ranging on a scale from 0 to 100 (worst to highest). This index is based on the geometric means (an aggregation function that could eliminate the ambiguous caused from smaller weightings) of the standardized values (Akhtar et al. 2021 ; Liou et al. 2004 ; Uddin et al. 2021 ).

Said et al. ( 2004 ) implemented a new WQI using the logarithmic aggregation applied in streams waterbodies in Florida (USA), based on only 5 variables: DO, total phosphate, turbidity, fecal coliforms and specific conductance. The main idea was to decrease the number of variables and change the aggregation method using the logarithmic aggregation (this function does not require any sub-indices and any standardization of the variables). This index ranged from 0 to 3, the latter being the ideal value (Akhtar et al. 2021 ; Kachroud et al. 2019a , b ; Said et al. 2004 ; Uddin et al. 2021 ).

The Malaysian WQI (MWQI) was carried out in 2007, including six variables: DO, BOD, Chemical Oxygen Demand (COD), Ammonia Nitrogen, suspended solids and pH. For each variable, a curve was established to transform the actual value of the variable into a non-dimensional sub-index value.

The next step is to determine the weighting of the variables by considering the experts panel opinions. The final score is determined using the additive aggregation formula (where sub-indices values and their weightings are summed), extending from 0 (polluted) to 100 (clean) (Uddin et al. 2021 ).

The Hanh and Almeida indices were established respectively in 2010 on surface water in Vietnam and 2012 on the Potrero de los Funes in Argentina, based on 8 (color, suspended solids, DO, BOD, COD, chloride, total coliforms and orthophosphate) and 10 (color, pH, COD, fecal coliforms, total coliforms, total phosphate, nitrates, detergent, enterococci and Escherichia coli .) water quality variables. Both indices were based on rating curve- based sum-indexing system (Uddin et al. 2021 ).

The most recent developed WQI model in the literature was carried out in 2017. This index tried to reduce uncertainty present in other water quality indices. The West Java Water Quality Index (WJWQI) applied in the Java Sea in Indonesia was based on thirteen crucial water quality variables: temperature, suspended solids, COD, DO, nitrite, total phosphate, detergent, phenol, chloride, Zn, Pb, mercury (Hg) and fecal coliforms. Using two screening steps (based on statistical assessment), parameter (variable) redundancy was determined to only 9: temperature, suspended solids, COD, DO, nitrite, total phosphate, detergent, phenol and chloride. Sub-indices were obtained for those nine variables and weights were allocated based on expert opinions, using the same multiplicative aggregation as the NSFWQI. The WJWQI suggested 5 quality classes ranging from poor (5–25) to excellent (90–100) (Uddin et al. 2021 ).

2.2 Phases of WQI development

Mainly, WQI concept is based on many factors as displayed in Fig.  1 and described in the following steps:

Phases of WQI development

Parameter selection for measurement of water quality (Shah and Joshi 2017 ):

The selection is carried out based on the management objectives and the environmental characteristics of the research area (Yan et al. 2015 ). Many variables are recommended, since they have a considerable impact on water quality and derive from 5 classes namely, oxygen level, eutrophication, health aspects, physical characteristics and dissolved substances (Tyagi et al. 2013 ).

Transformation of the raw data parameter into a common scale (Paun et al. 2016 ):

Different statistical approach can be used for transformation, all parameters are transformed from raw data that have different dimensions and units (ppm, saturation, percentage etc.) into a common scale, a non-dimensional scale and sub-indices are generated (Poonam et al. 2013 ; Tirkey et al. 2015 ).

Providing weights to the parameters (Tripathi and Singal 2019 ):

Weights are assigned to each parameter according to their importance and their impact on water quality, expert opinion is needed to assign weights (Tirkey et al. 2015 ). Weightage depends on the permissible limits assigned by International and National agencies in water drinking (Shah and Joshi 2017 ).

Aggregation of sub-index values to obtain the final WQI:

WQI is the sum of rating and weightage of all the parameters (Tripathi and Singal 2019 ).

It is important to note that in some indices, statistical approaches are commonly used such as factor analysis (FA), principal component analysis (PCA), discriminant analysis (DA) and cluster analysis (CA). Using these statistical approaches improves accuracy of the index and reduce subjective assumptions (Tirkey et al. 2015 ).

2.3 Evolution of WQI research

2.3.1 per year.

According to Scopus ( 2022 ), the yearly evolution of WQI's research is illustrated in Fig.  2 (from 1978 till 2022).

Evolution of WQI research per year (Scopus 2022 )

Overall, it is clear that the number of research has grown over time, especially in the most recent years. The number of studies remained shy between 1975 and 1988 (ranging from 1 to 13 research). In 1998, the number improved to 46 studies and increased gradually to 466 publications in 2011.The WQI's studies have grown significantly over the past decade, demonstrating that the WQI has become a significant research topic with the goal of reaching its maximum in 2022 (1316 studies) (Scopus, 2022 ).

2.3.2 Per country

In Fig.  3 , the development of WQI research is depicted visually per country from 1975 to 2022.

Evolution of WQI research per country (Scopus 2022 )

According to Scopus ( 2022 ), the top three countries were China, India and the United States, with 2356, 1678 and 1241 studies, respectively. Iran, Brazil, and Italy occupy the fourth, fifth, and sixth spots, respectively (409, 375 and 336 study). Malaysia and Spain have approximately the same number of studies, respectively 321 and 320 study. The studies in the remaining countries decrease gradually from 303 document in Spain to 210 documents in Turkey. This demonstrates that developing nations, like India, place a high value on the development of water quality protection even though they lack strong economic power, cutting-edge technology, and a top-notch scientific research team. This is because water quality is crucial to the long-term social and economic development of those nations (Zhang 2019 ).

2.4 Different methods for WQI determination

Water quality indices are tools to determine water quality. Those indices demand basic concepts and knowledge about water issues (Singh et al. 2013 ). There are many water quality indices such as the: National Sanitation Foundation Water Quality Index (NSFWQI), Canadian Council of Ministers of Environment Water Quality Index (CCMEWQI), Oregon Water Quality Index (OWQI), and Weight Arithmetic Water Quality Index (WAWQI) (Paun et al. 2016 ).

These water quality indices are applied in particular areas, based on many parameters compared to specific regional standards. Moreover, they are used to illustrate annual cycles, spatio-temporal variations and trends in water quality (Paun et al. 2016 ). That is to say that, these indices reflect the rank of water quality in lakes, streams, rivers, and reservoirs (Kizar 2018 ).

Accordingly, in this section a general review of available worldwide used indices is presented.

2.4.1 National sanitation foundation (NSFWQI)

The NSFWQI was developed in 1970 by the National Sanitation Foundation (NSF) of the United States (Hamlat et al. 2017 ; Samadi et al. 2015 ). This WQI has been widely field tested and is used to calculate and evaluate the WQI of many water bodies (Hamlat et al. 2017 ). However, this index belongs to the public indices group. It represents a general water quality and does not take into account the water’s use capacities, furthermore, it ignores all types of water consumption in the evaluation process (Bharti and Katyal 2011 ; Ewaid 2017 ).

The NSFWQI has been widely applied and accepted in Asian, African and European countries (Singh et al. 2013 ), and is based on the analysis of nine variables or parameters, such as, BOD, DO, Nitrate (NO 3 ), Total Phosphate (PO 4 ), Temperature, Turbidity, Total Solids(TS), pH, and Fecal Coliforms (FC).

Some of the index parameters have different importance, therefore, a weighted mean for each parameter is assigned, based on expert opinion which have grounded their opinions on the environmental significance, the recommended principles and uses of water body and the sum of these weights is equal to 1 (Table 1 ) (Ewaid 2017 ; Uddin et al. 2021 ).

Due to environmental issues, the NSFWQI has changed overtime. The TS parameter was substituted by the Total Dissolved Solids (TDS) or Total Suspended Solids (TSS), the Total Phosphate by orthophosphate, and the FC by E. coli (Oliveira et al. 2019 ).

The mathematical expression of the NSFWQI is given by the following Eq. ( 1 ) (Tyagi et al. 2013 ):

where, Qi is the sub-index for ith water quality parameter. Wi is the weight associated with ith water quality parameter. n is the number of water quality parameters.

This method ranges from 0 to 100, where 100 represents perfect water quality conditions, while zero indicates water that is not suitable for the use and needs further treatment (Samadi et al. 2015 ).

The ratings are defined in the following Table 2 .

In 1972, the Dinius index (DWQI) happened to be the second modified version of the NSF (USA). Expended in 1987 using the Delphi method, the DWQI included twelve parameters (with their assigned weights): Temperature (0.077), color (0.063), pH (0.077), DO (0.109), BOD (0.097), EC (0.079), alkalinity (0.063), chloride (0.074), coliform count (0.090), E. coli (0.116). total hardness (0.065) and nitrate (0.090). Without any conversion process, the DWQI used the measured variable concentrations directly as the sub-index values (Kachroud et al. 2019b ; Uddin et al. 2021 ).

Sukmawati and Rusni assessed in 2018 the water quality in Beratan lake (Bali), choosing five representative stations for water sampling representing each side of the lake, using the NSFWQI. NSFWQI’s nine parameters mentioned above were measured in each station. The findings indicated that the NSFWQI for the Beratan lake was seventy-eight suggesting a good water quality. Despite this, both pH and FC were below the required score (Sukmawati and Rusni 2019 ).

The NSFWQI indicated a good water quality while having an inadequate value for fecal coliforms and pH. For that reason, WQIs must be adapted and developed so that any minor change in the value of any parameter affects the total value of the water quality index.

A study conducted by Zhan et al. ( 2021 ) , concerning the monitoring of water quality and examining WQI trends of raw water in Macao (China) was established from 2002 to 2019 adopting the NSFWQI. NSFWQI's initial model included nine parameters (DO, FC, pH, BOD, temperature, total phosphates, and nitrates), each parameter was given a weight and the parameters used had a significant impact on the WQI calculation outcomes. Two sets of possible parameters were investigated in this study in order to determine the impact of various parameters. The first option was to keep the original 9-parameter model, however, in the second scenario, up to twenty-one parameters were chosen, selected by Principal Component Analysis (PCA).

The latter statistical method was used to learn more about the primary elements that contributed to water quality variations, and to calculate the impact of each attribute on the quality of raw water. Based on the PCA results, the 21-parameter model was chosen. The results showed that the quality of raw water in Macao has been relatively stable in the period of interest and appeared an upward trend overall. Furthermore, the outcome of environmental elements, such as natural events, the region's hydrology and meteorology, can have a significant impact on water quality. On the other hand, Macao's raw water quality met China's Class III water quality requirements and the raw water pollution was relatively low. Consequently, human activities didn’t have a significant impact on water quality due to effective treatment and protection measures (Zhan et al. 2021 ).

Tampo et al. ( 2022 ) undertook a recent study in Adjougba (Togo), in the valley of Zio River. Water samples were collected from the surface water (SW), ground water (GW) and treated wastewater (TWW), intending to compare the water quality of these resources for irrigation and domestic use.

Hence, WQIs, water suitability indicators for irrigation purposes (WSI-IPs) and raw water quality parameters were compared using statistical analysis (factor analysis and Spearman’s correlation).

Moreover, the results proposed that he water resources are suitable for irrigation and domestic use: TWW suitable for irrigation use, GW suitable for domestic use and SW suitable for irrigation use.

The NSFWQI and overall index of pollution (OPI) parameters were tested, and the results demonstrated that the sodium absorption ratio, EC, residual sodium carbonate, Chloride and FC are the most effective parameters for determining if water is suitable for irrigation.

On the other hand, EC, DO, pH, turbidity, COD, hardness, FC, nitrates, national sanitation foundation's water quality index (NSFWQI), and overall index of pollution (OPI) are the most reliable in the detection of water suitability for domestic use (Tampo et al. 2022 ).

Following these studies, it is worth examining the NSFWQI. This index can be used with other WQI models in studies on rivers, lakes etc., since one index can show different results than another index, in view of the fact that some indices might be affected by other variations such as seasonal variation.

Additionally, the NSFWQI should be developed and adapted to each river, so that any change in any value will affect the entire water quality. It is unhelpful to have a good water quality yet a low score of a parameter that can affect human health (case of FC).

2.4.2 Canadian council of ministers of the environment water quality index (CCMEWQI)

The Canadian Water Quality Index adopted the conceptual model of the British Colombia Water Quality Index (BCWQI), based on relative sub-indices (Kizar 2018 ).

The CCMEWQI provides a water quality assessment for the suitability of water bodies, to support aquatic life in specific monitoring sites in Canada (Paun et al. 2016 ). In addition, this index gives information about the water quality for both management and the public. It can furthermore be applied in many water agencies in various countries with slight modification (Tyagi et al. 2013 ).

The CCMEWQI method simplifies the complex and technical data. It tests the multi-variable water quality data and compares the data to benchmarks determined by the user (Tirkey et al. 2015 ). The sampling protocol requires at least four parameters sampled at least four times but does not indicate which ones should be used; the user must decide ( Uddin et al. 2021 ). Yet, the parameters may vary from one station to another (Tyagi et al. 2013 ).

After the water body, the objective and the period of time have been defined the three factors of the CWQI are calculated (Baghapour et al. 2013 ; Canadian Council of Ministers of the Environment 1999 ):

The scope (F1) represents the percentage of variables that failed to meet the objective (above or below the acceptable range of the selected parameter) at least once (failed variables), relative to the total number of variables.

The frequency (F2) represents the percentage of tests which do not meet the objectives (above or below the acceptable range of the selected parameter) (failed tests).

The amplitude represents the amount by which failed tests values did not meet their objectives (above or below the acceptable range of the selected parameter). It is calculated in three steps.

The excursion is termed each time the number of an individual parameter is further than (when the objective is a minimum, less than) the objective and is calculated by two Eqs. ( 4 , 5 ) referring to two cases. In case the test value must not exceed the objective:

For the cases in which the test value must not fall below the objective:

The normalized sum of excursions, or nse , is calculated by summing the excursions of individual tests from their objectives and diving by the total number of tests (both meetings and not meeting their objectives):

F3 is then calculated an asymptotic function that scales the normalized sum of the excursions from objectives (nse) to yield a range between 0 and 100:

Finally, the CMEWQI can be obtained from the following equation, where the index changes in direct proportion to changes in all three factors.

where 1.732 is a scaling factor and normalizes the resultant values to a range between 0 and 100, where 0 refers to the worst quality and one hundred represents the best water quality.

Once the CCME WQI value has been determined, water quality in ranked as shown in Table 3

Ramírez-Morales et al. ( 2021 ) investigated in their study the measuring of pesticides and water quality indices in three agriculturally impacted micro catchments in Costa Rica between 2012 and 2014. Surface water and sediment samples were obtained during the monitoring experiment.

The specifications of the water included: Pesticides, temperature, DO, oxygen saturation, BOD, TP, NO3, sulfate, ammonium, COD, conductivity, pH and TSS.

Sediment parameters included forty-two pesticides with different families including carbamate, triazine, organophosphate, phthalimide, pyrethroid, uracil, benzimidazole, substituted urea, organochlorine, imidazole, oxadiazole, diphenyl ether and bridged diphenyl.

WQIs are effective tools since they combine information from several variables into a broad picture of the water body's state. Two WQIs were calculated using the physicochemical parameters: The Canadian Council of Ministers of the Environment (CCME) WQI and the National Sanitation Foundation (NSF) WQI.

These were chosen since they are both extensively used and use different criteria to determine water quality: The NSF WQI has fixed parameters, weights, and threshold values, whereas the CCME has parameters and threshold values that are customizable.

The assessment of water quality using physico-chemical characteristics and the WQI revealed that the CCME WQI and the NSF WQI have distinct criteria. CCME WQI categorized sampling point as marginal/bad quality, while most sampling locations were categorized as good quality in the NSF WQI. Seemingly, the water quality classifications appeared to be affected by seasonal variations: during the wet season, the majority of the CCME WQI values deteriorated, implying that precipitation and runoff introduced debris into the riverbed. Thus, it’s crucial to compare WQIs because they use various factors, criteria, and threshold values, which might lead to different outcomes (Ramírez-Morales et al. 2021 ).

Yotova et al. ( 2021 ) directed an analysis on the Mesta River located between Greece and Bulgaria. The Bulgarian section of the Mesta River basin, which is under the supervision of the West-Aegean Region Basin Directorate, was being researched. The goal was to evaluate the surface water quality of ten points of the river using a novel approach that combines composite WQI developed by the CCME and Self organizing map (SOM) on the required monitoring data that include: DO, pH, EC, ammonium, nitrite, nitrate, total phosphate, BOD and TSS.

The use of WQI factors in SOM calculations allows for the identification of specific WQI profiles for various object groups and identifying groupings of river basin which have similar sampling conditions. The use of both could reveal and estimate the origin and magnitude of anthropogenic pressure. In addition, it might be determined that untreated residential wastewaters are to blame for deviations from high quality requirements in the Mesta River catchment.

Interestingly, this study reveals that WQI appear more accurate and specific when combined with a statistical test such as the SOM (Yotova et al. 2021 ).

2.4.3 Oregon water quality index (OWQI)

The Oregon Water Quality Index is a single number that creates a score to evaluate the water quality of Oregon’s stream and apply this method in other geographical region (Hamlat et al. 2017 ; Singh et al. 2013 ). The OWQI was widely accepted and applied in Oregon (USA) and Idaho (USA) (Sutadian et al. 2016 ).

Additionally, the OWQI is a variant of the NSFWQI, and is used to assess water quality for swimming and fishing, it is also used to manage major streams (Lumb et al. 2011b ). Since the introduction of the OWQI in 1970, the science of water quality has improved noticeably, and since 1978, index developers have benefited from increasing understanding of stream functionality (Bharti and Katyal 2011 ). The Oregon index belongs to the specific consumption indices group. It is a water classification based on the kind of consumption and application such as drinking, industrial, etc. (Shah and Joshi 2017 ).

The original OWQI dropped off in 1983, due to excessive resources required for calculating and reporting results. However, improvement in software and computer hardware availability, in addition to the desire for an accessible water quality information, renewed interest in the index (Cude 2001 ).

Simplicity, availability of required quality parameters, and the determination of sub-indexes by curve or analytical relations are some advantages of this approach (Darvishi et al. 2016a ). The process combines eight variables including temperature, dissolved oxygen (percent saturation and concentration), biochemical oxygen demand (BOD), pH, total solids, ammonia and nitrate nitrogen, total phosphorous and bacteria (Brown 2019 ). Equal weight parameters were used for this index and has the same effect on the final factor (Darvishi et al. 2016a ; Sutadian et al. 2016 ).

The Oregon index is calculated by the following Eq.  9 (Darvishi et al. 2016a ):

where,n is the number of parameters (n = 8) SI i is the value of parameter i.

Furthermore, the OWQI scores range from 10 for the worse case to 100 as the ideal water quality illustrated in the following Table 4 (Brown 2019 ).

Kareem et al. ( 2021 ) using three water quality indices, attempted to analyze the Euphrates River (Iraq) water quality for irrigation purposes in three different stations: WAWQI, CCMEWQI AND OWQI.

For fifteen parameters, the annual average value was calculated, which included: pH, BOD, Turbidity, orthophosphate, Total Hardness, Sulphate, Nitrate, Alkalinity, Potassium Sodium, Magnesium, Chloride, DO, Calcium and TDS.

The OWQI showed that the river is “very poor”, and since the sub-index of the OWQI does not rely on standard-parameter compliance, there are no differences between the two inclusion and exclusion scenarios, which is not the case in both WAWQI and CCMEWQI (Kareem et al. 2021 ).

Similarly, the OWQI showed a very bad quality category, and it is unfit for human consumption, compared to the NSFWQI and Wilcox indices who both showed a better quality of water in Darvishi et al., study conducted on the Talar River (Iran) (Darvishi et al. 2016b ).

2.4.4 Weighted arithmetic water quality index (WAWQI)

The weighted arithmetic index is used to calculate the treated water quality index, in other terms, this method classifies the water quality according to the degree of purity by using the most commonly measured water quality variables (Kizar 2018 ; Paun et al. 2016 ).This procedure has been widely used by scientists (Singh et al. 2013 ).

Three steps are essential in order to calculate the WAWQI:

Further quality rating or sub-index was calculated using the following equation (Jena et al. 2013 ):

Qn is the quality rating for the nth water quality parameter.

Vn is the observed value of the nth parameter at a given sampling station.

Vo is the ideal value of the nth parameter in a pure water.

Sn is the standard permissible value of the nth parameter.

The quality rating or sub index corresponding to nth parameter is a number reflecting the relative value of this parameter in polluted water with respect to its permissible standard value (Yogendra & Puttaiah 2008 ).

The unit weight was calculated by a value inversely proportional to the recommended standard values (Sn) of the corresponding parameters (Jena et al. 2013 ):

Wn is the unit weight for the nth parameter.

K is the constant of proportionality.

Sn is the standard value of the nth parameter.

The overall WQI is the aggregation of the quality rating (Qn) and the unit weight (Wn) linearly (Jena et al. 2013 ):

After calculating the WQI, the measurement scale classifies the water quality from “unsuitable water” to “excellent water quality” as given in the following Table 5 .

Sarwar et al. ( 2020 ) carried out a study in Chaugachcha and Manirampur Upazila of Jashore District (Bangladesh). The goal of this study was to determine the quality of groundwater and its appropriateness for drinking, using the WAWQI including nine parameters: turbidity, EC, pH, TDS, nitrate, ammonium, sodium, potassium and iron. Many samplings point was taken from Chaugachcha and Manirampur, and WQI differences were indicated (ranging from very poor to excellent). These variations in WQI were very certainly attributable to variances in geographical location. Another possibility could be variations in the parent materials from which the soil was created, which should be confirmed using experimental data. It is worth mentioning that every selected parameter was taken into consideration during calculation. Similarly, the water quality differed in Manirampur due to the elements contained in the water samples that had a big impact on the water quality (Sarwar et al. 2020 ).

In 2021, García-Ávila et al. undertook a comparative study between the CCMEWQI and WAWQI for the purpose of determining the water quality in the city of Azogues (Ecuador). Twelve parameters were analyzed: pH, turbidity, color, total dissolved solids, electrical conductivity, total hardness, alkalinity, nitrates, phosphates, sulfates, chlorides and residual chlorine over 6 months. The average WAWQI value was calculated suggesting that 16.67% of the distribution system was of 'excellent' quality and 83.33% was of 'good' quality, while the CCMEWQI indicated that 100% of the system was of ‘excellent’ quality.

This difference designated that the parameters having a low maximum allowable concentration have an impact on WAWQI and that WAWQI is a valuable tool to determine the quality of drinking water and have a better understanding of it (García-Ávila et al. 2022a , b ).

2.4.5 Additional water quality indices

The earliest WQI was based on a mathematical function that sums up all sub-indices, as detailed in the 2.1. History of water quality concept section (Aljanabi et al. 2021 ). The Dinius index (1972), the OWQI (1980), and the West Java index (2017) were later modified from the Horton index, which served as a paradigm for later WQI development (Banda and Kumarasamy 2020 ).

Based on eleven physical, chemical, organic, and microbiological factors, the Scottish Research Development Department (SRDDWQI) created in 1976 was based on the NSFWQI and Delphi methods used in Iran, Romania, and Portugal. Modified into the Bascaron index (1979) in Spain, which was based on 26 parameters that were unevenly weighted with a subjective representation that allowed an overestimation of the contamination level. The House index (1989) in the UK valued the parameters directly as sub-indices. The altered version was adopted as Croatia's Dalmatian index in 1999.

The Ross WQI (1977) was created in the USA using only 4 parameters and did not develop into any further indices.

In 1982, the Dalmatian and House WQI were used to create the Environmental Quality Index, which is detailed in Sect.  2.1 . This index continues to be difficult to understand and less powerful than other indices (Lumb et al. 2011a ; Uddin et al. 2021 ).

The Smith index (1990), is based on 7 factors and the Delphi technique in New Zealand, attempts to eliminate eclipsing difficulties and does not apply any weighting, raising concerns about the index's accuracy (Aljanabi et al. 2021 ; Banda and Kumarasamy 2020 ; Uddin et al. 2021 ).

The Dojildo index (1994) was based on 26 flexible, unweighted parameters and does not represent the water's total quality.

With the absence of essential parameters, the eclipse problem is a type of fixed-parameter selection. The Liou index (2004) was established in Taiwan to evaluate the Keya River based on 6 water characteristics that were immediately used into sub-index values. Additionally, because of the aggregation function, uncertainty is unrelated to the lowest sub-index ranking (Banda and Kumarasamy 2020 ; Uddin et al. 2021 ).

Said index (2004) assessed water quality using only 4 parameters, which is thought to be a deficient number for accuracy and a comprehensive picture of the water quality. Furthermore, a fixed parameter system prevents the addition of any new parameters.

Later, the Hanh index (2010), which used hybrid aggregation methods and gave an ambiguous final result, was developed from the Said index.

In addition to eliminating hazardous and biological indicators, the Malaysia River WQI (MRWQI developed in the 2.1 section) (2007) was an unfair and closed system that was relied on an expert's judgment, which is seen as being subjective and may produce ambiguous findings (Banda and Kumarasamy 2020 ; Uddin et al. 2021 ).

Table illustrated the main data of the studies published during 2020–2022 on water quality assessments and their major findings:

2.5 Advantages and disadvantages of the selected water quality indices

A comparison of the selected indices is done by listing the advantages and disadvantages of every index listed in the Table 7 below.

2.6 New attempts of WQI studies

Many studies were conducted to test the water quality of rivers, dams, groundwater, etc. using multiple water quality indices throughout the years. Various studies have been portrayed here in.

Massoud ( 2012 ) observed during a 5-year monitoring period, in order to classify the spatial and temporal variability and classify the water quality along a recreational section of the Damour river using a weighted WQI from nine physicochemical parameters measured during dry season. The WWQI scale ranged between “very bad” if the WQI falls in the range 0–25, to “excellent” if it falls in the range 91–100. The results revealed that the water quality of the Damour river if generally affected by the activities taking place along the watershed. The best quality was found in the upper sites and the worst at the estuary, due to recreational activities. If the Damour river is to be utilized it will require treatment prior any utilization (Massoud 2012 ).

Rubio-Arias et al. ( 2012 ) conducted a study in the Luis L. Leon dam located in Mexico. Monthly samples were collected at 10 random points of the dam at different depths, a total of 220 samples were collected and analyzed. Eleven parameters were considered for the WQI calculation, and WQI was calculated using the Weighted WQI equation and could be classified according to the following ranges: < 2.3 poor; from 2.3 to 2.8 good; and > 2.8 excellent. Rubio-Arias et al., remarked that the water could be categorized as good during the entire year. Nonetheless, some water points could be classified as poor due to some anthropogenic activities such as intensive farming, agricultural practices, dynamic urban growth, etc. This study confirms that water quality declined after the rainy season (Rubio-Arias et al. 2012 ).

In the same way, Haydar et al. ( 2014 ) evaluated the physical, chemical and microbiological characteristics of water in the upper and lower Litani basin, as well as in the lake of Qaraaoun. The samples were collected during the seasons of 2011–2012 from the determined sites and analyzed by PCA and the statistical computations of the physico-chemical parameters to extract correlation between variables. Thus, the statistical computations of the physico-chemical parameters showed a correlation between some parameters such as TDS, EC, Ammonium, Nitrate, Potassium and Phosphate. Different seasons revealed the presence of either mineral or anthropogenic or both sources of pollution caused by human interference from municipal wastewater and agricultural purposes discharged into the river. In addition, temporal effects were associated with seasonal variations of river flow, which caused the dilution if pollutants and, hence, variations in water quality (Haydar et al. 2014 ).

Another study conducted by Chaurasia et al., ( 2018 ), proposed a groundwater quality assessment in India using the WAWQI. Twenty-two parameters were taken into consideration for this assessment, however, only eight important parameters were chosen to calculate the WQI. The rating of water quality shows that the ground water in 20% of the study area is not suitable for drinking purpose and pollution load is comparatively high during rainy and summer seasons. Additionally, the study suggests that priority should be given to water quality monitoring and its management to protect the groundwater resource from contamination as well as provide technology to make the groundwater fit for domestic and drinking (Chaurasia et al. 2018 ).

Daou et al. ( 2018 ) evaluated the water quality of four major Lebanese rivers located in the four corners of Lebanon: Damour, Ibrahim, Kadisha and Orontes during the four seasons of the year 2010–2011. The assessment was done through the monitoring of a wide range of physical, chemical and microbiological parameters, these parameters were screened using PCA. PCA was able to discriminate each of the four rivers according to a different trophic state. The Ibrahim River polluted by mineral discharge from marble industries in its surroundings, as well as anthropogenic pollutants, and the Kadisha river polluted by anthropogenic wastes seemed to have the worst water quality. This large-scale evaluation of these four Lebanese rivers can serve as a water mass reference model (Daou et al. 2018 ).

Moreover, some studies compared many WQI methods. Kizar ( 2018 ), carried out a study on Shatt Al-Kufa in Iraq, nine locations and twelve parameters were selected. The water quality was calculated using two methods, the WAWQI and CWQI. The results revealed the same ranking of the river for both methods, in both methods the index decreased in winter and improved in other seasons (Kizar 2018 ).

On the other hand, Zotou et al. ( 2018 ), undertook a research on the Polyphytos Reservoir in Greece, taking into consideration thirteen water parameters and applying 5 WQIs: Prati’s Index of Pollution (developed in 1971, based on thirteen parameter and mathematical functions to convert the pollution concentration into new units. The results of PI classified water quality into medium classes (Gupta and Gupta 2021 ). Bhargava’s WQI (established in 1983, the BWQI categorize the parameters according to their type: bacterial indicators, heavy metals and toxins, physical parameters and organic and inorganic substances. The BWQI tends to classify the water quality into higher quality classes, which is the case in the mentioned study (Gupta and Gupta 2021 ). Oregon WQI, Dinius second index, Weighted Arithmetic WQI, in addition to the NSF and CCMEWQI. The results showed that Bhargava and NSF indices tend to classify the reservoir into superior quality classes, Prati’s and Dinius indices fall mainly into the middle classes of the quality ranking, while CCME and Oregon could be considered as “stricter” since they give results which range steadily between the lower quality classes (Zotou et al. 2018 ).

In their study, Ugochukwu et al. ( 2019 ) investigated the effects of acid mine drainage, waste discharge into the Ekulu River in Nigeria and other anthropogenic activities on the water quality of the river. The study was performed between two seasons, the rainy and dry season. Samples were collected in both seasons, furthermore, the physic-chemistry parameters and the heavy metals were analyzed. WQI procedure was estimated by assigning weights and relative weights to the parameters, ranking from “excellent water” (< 50) to “unsuitable for drinking” (> 300). The results showed the presence of heavy metals such as lead and cadmium deriving from acid mine drainage. In addition, the water quality index for all the locations in both seasons showed that the water ranked from “very poor” to “unsuitable for drinking”, therefore the water should be treated before any consumption, and that enough information to guide new implementations for river protection and public health was provided (Ugochukwu et al. 2019 ).

The latest study in Lebanon related to WQI was carried out by El Najjar et al. ( 2019 ), the purpose of the study was to evaluate the water quality of the Ibrahim River, one of the main Lebanese rivers. The samples were collected during fifteen months, and a total of twenty-eight physico-chemical and microbiological parameters were tested. The parameters were reduced to nine using the Principal Component Analysis (PCA) and Pearson Correlation. The Ibrahim WQI (IWQI) was finally calculated using these nine parameters and ranged between 0 and 25 referring to a “very bad” water quality, and between 91 and 100 referring to an “excellent” water quality. The IWQI showed a seasonal variation, with a medium quality during low -water periods and a good one during high-water periods (El Najjar et al. 2019 ).

3 Conclusion

WQI is a simple tool that gives a single value to water quality taking into consideration a specific number of physical, chemical, and biological parameters also called variables in order to represent water quality in an easy and understandable way. Water quality indices are used to assess water quality of different water bodies, and different sources. Each index is used according to the purpose of the assessment. The study reviewed the most important indices used in water quality, their mathematical forms and composition along with their advantages and disadvantages. These indices utilize parameters and are carried out by experts and government agencies globally. Nevertheless, there is no index so far that can be universally applied by water agencies, users and administrators from different countries, despite the efforts of researchers around the world (Paun et al. 2016 ). The study also reviewed some attempts on different water bodies utilizing different water quality indices, and the main studies performed in Lebanon on Lebanese rivers in order to determine the quality of the rivers (Table 6 ).

As mentioned in the article (Table 7 ); WQIs may undergo some limitations. Some indices could be biased, others are not specific, and they may not get affected by the value of an important parameter. Therefore, there is no interaction between the parameters.

Moreover, many studies exhibited a combination between WQIs and statistical techniques and analysis (such as the PCA, Pearson’s correlation etc.). with a view to obtain the relation between the parameters and which parameter might affect the water quality.

In other research, authors compared many WQIs to check the difference of water quality according to each index. Each index can provide different values depending on the sensitivity of the parameter. For that reason, WQIs should be connected to scientific advancements to develop and elaborate the index in many ways (example: ecologically). Therefore, an advanced WQI should be developed including first statistical techniques, such as Pearson correlation and multivariate statistical approach mainly Principal Component Analysis (PCA) and Cluster Analysis (CA), in order to determine secondly the interactions and correlations between the parameters such as TDS and EC, TDS and total alkalinity, total alkalinity and chloride, temperature and bacteriological parameters, consequently, a single parameter could be selected as representative of others. Finally, scientific and technological advancement for future studies such as GIS techniques, fuzzy logic technology to assess and enhance the water quality indices and cellphone-based sensors for water quality monitoring should be used.

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Chidiac, S., El Najjar, P., Ouaini, N. et al. A comprehensive review of water quality indices (WQIs): history, models, attempts and perspectives. Rev Environ Sci Biotechnol 22 , 349–395 (2023). https://doi.org/10.1007/s11157-023-09650-7

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Title: an elemental ethics for artificial intelligence: water as resistance within ai's value chain.

Abstract: Research and activism have increasingly denounced the problematic environmental record of the infrastructure and value chain underpinning Artificial Intelligence (AI). Water-intensive data centres, polluting mineral extraction and e-waste dumping are incontrovertibly part of AI's footprint. In this article, I turn to areas affected by AI-fuelled environmental harm and identify an ethics of resistance emerging from local activists, which I term 'elemental ethics'. Elemental ethics interrogates the AI value chain's problematic relationship with the elements that make up the world, critiques the undermining of local and ancestral approaches to nature and reveals the vital and quotidian harms engendered by so-called intelligent systems. While this ethics is emerging from grassroots and Indigenous groups, it echoes recent calls from environmental philosophy to reconnect with the environment via the elements. In empirical terms, this article looks at groups in Chile resisting a Google data centre project in Santiago and lithium extraction (used for rechargeable batteries) in Lickan Antay Indigenous territory, Atacama Desert. As I show, elemental ethics can complement top-down, utilitarian and quantitative approaches to AI ethics and sustainable AI as well as interrogate whose lived experience and well-being counts in debates on AI extinction.

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Exploring China's water usage trends and sustainability

by Maximum Academic Press

Against the backdrop of growing global concern over water scarcity, China, has been grappling with the complexities of water dynamics and their impact on economic growth and environmental protection. A study published in the journal Advances in Water Science has shed light on the intricate interplay between China's water usage, demand, and the factors influencing it, which is crucial for understanding the future trajectory of the country's water resources.

Led by Academician of Chinese Academy of Engineering Zhang Jianyun, the research team delved into the concept of water peaking, which refers to the point where water consumption reaches a maximum and then stabilizes or declines. This phenomenon is vital for comprehending the future of China's water resources.

The researchers analyzed China's water usage patterns, identifying three distinct phases : a period of rapid growth, a stable growth phase, and a gradual decline since 2013. However, this decline is attributed to a combination of factors, including stringent water resource management policies, technological advancements in water efficiency, and adjustments in statistical reporting methods.

The study emphasizes that China's current economic and social development indicators, such as GDP per capita, industrial structure, and urbanization levels, do not yet align with those of developed countries that have experienced water peaking. This suggests that China may not have reached its peak water demand, and future water demand remains uncertain.

The study also highlights the urgent issue of water scarcity in China, with significant challenges in agriculture, industry, domestic water use, and ecological conservation. Despite efforts to improve water efficiency and implement water-saving measures, researchers believe there is still considerable room for improvement in water resource management and conservation.

In light of these findings, researchers call for a comprehensive top-level design of China's national water grid, emphasizing the need to enhance the optimization of water resource allocation at various scales. They argue that this is essential for ensuring water security and supporting the country's high-quality development amidst increasing demands and environmental constraints.

As China continues to balance its economic growth with sustainable water resource management, the international community will closely monitor its strategies and their impact on global water resource management. The study serves as a reminder of the critical role water plays in the sustainable development of any country and the importance of proactive planning and management in addressing water-related challenges.

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There is unequivocal evidence that Earth is warming at an unprecedented rate. Human activity is the principal cause.

• While Earth’s climate has changed throughout its history , the current warming is happening at a rate not seen in the past 10,000 years.
• According to the Intergovernmental Panel on Climate Change ( IPCC ), "Since systematic scientific assessments began in the 1970s, the influence of human activity on the warming of the climate system has evolved from theory to established fact." 1
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• From global temperature rise to melting ice sheets, the evidence of a warming planet abounds.

The rate of change since the mid-20th century is unprecedented over millennia.

Earth's climate has changed throughout history. Just in the last 800,000 years, there have been eight cycles of ice ages and warmer periods, with the end of the last ice age about 11,700 years ago marking the beginning of the modern climate era — and of human civilization. Most of these climate changes are attributed to very small variations in Earth’s orbit that change the amount of solar energy our planet receives.

The current warming trend is different because it is clearly the result of human activities since the mid-1800s, and is proceeding at a rate not seen over many recent millennia. 1 It is undeniable that human activities have produced the atmospheric gases that have trapped more of the Sun’s energy in the Earth system. This extra energy has warmed the atmosphere, ocean, and land, and widespread and rapid changes in the atmosphere, ocean, cryosphere, and biosphere have occurred.

Related Reading

Do scientists agree on climate change?

Yes, the vast majority of actively publishing climate scientists – 97 percent – agree that humans are causing global warming and climate change.

Earth-orbiting satellites and new technologies have helped scientists see the big picture, collecting many different types of information about our planet and its climate all over the world. These data, collected over many years, reveal the signs and patterns of a changing climate.

Scientists demonstrated the heat-trapping nature of carbon dioxide and other gases in the mid-19th century. 2 Many of the science instruments NASA uses to study our climate focus on how these gases affect the movement of infrared radiation through the atmosphere. From the measured impacts of increases in these gases, there is no question that increased greenhouse gas levels warm Earth in response.

"Scientific evidence for warming of the climate system is unequivocal." — Intergovernmental Panel on Climate Change

Ice cores drawn from Greenland, Antarctica, and tropical mountain glaciers show that Earth’s climate responds to changes in greenhouse gas levels. Ancient evidence can also be found in tree rings, ocean sediments, coral reefs, and layers of sedimentary rocks. This ancient, or paleoclimate, evidence reveals that current warming is occurring roughly 10 times faster than the average rate of warming after an ice age. Carbon dioxide from human activities is increasing about 250 times faster than it did from natural sources after the last Ice Age. 3

The Evidence for Rapid Climate Change Is Compelling:

Global temperature is rising.

The planet's average surface temperature has risen about 2 degrees Fahrenheit (1 degrees Celsius) since the late 19th century, a change driven largely by increased carbon dioxide emissions into the atmosphere and other human activities. 4 Most of the warming occurred in the past 40 years, with the seven most recent years being the warmest. The years 2016 and 2020 are tied for the warmest year on record. 5

The Ocean Is Getting Warmer

The ocean has absorbed much of this increased heat, with the top 100 meters (about 328 feet) of ocean showing warming of 0.67 degrees Fahrenheit (0.33 degrees Celsius) since 1969. 6 Earth stores 90% of the extra energy in the ocean.

The Ice Sheets Are Shrinking

The Greenland and Antarctic ice sheets have decreased in mass. Data from NASA's Gravity Recovery and Climate Experiment show Greenland lost an average of 279 billion tons of ice per year between 1993 and 2019, while Antarctica lost about 148 billion tons of ice per year. 7

Glaciers Are Retreating

Glaciers are retreating almost everywhere around the world — including in the Alps, Himalayas, Andes, Rockies, Alaska, and Africa. 8

Snow Cover Is Decreasing

Satellite observations reveal that the amount of spring snow cover in the Northern Hemisphere has decreased over the past five decades and the snow is melting earlier. 9

Sea Level Is Rising

Global sea level rose about 8 inches (20 centimeters) in the last century. The rate in the last two decades, however, is nearly double that of the last century and accelerating slightly every year. 10

Arctic Sea Ice Is Declining

Both the extent and thickness of Arctic sea ice has declined rapidly over the last several decades. 11

Extreme Events Are Increasing in Frequency

The number of record high temperature events in the United States has been increasing, while the number of record low temperature events has been decreasing, since 1950. The U.S. has also witnessed increasing numbers of intense rainfall events. 12

Ocean Acidification Is Increasing

Since the beginning of the Industrial Revolution, the acidity of surface ocean waters has increased by about 30%. 13 , 14 This increase is due to humans emitting more carbon dioxide into the atmosphere and hence more being absorbed into the ocean. The ocean has absorbed between 20% and 30% of total anthropogenic carbon dioxide emissions in recent decades (7.2 to 10.8 billion metric tons per year). 1 5 , 16

1. IPCC Sixth Assessment Report, WGI, Technical Summary . B.D. Santer et.al., “A search for human influences on the thermal structure of the atmosphere.” Nature 382 (04 July 1996): 39-46. https://doi.org/10.1038/382039a0. Gabriele C. Hegerl et al., “Detecting Greenhouse-Gas-Induced Climate Change with an Optimal Fingerprint Method.” Journal of Climate 9 (October 1996): 2281-2306. https://doi.org/10.1175/1520-0442(1996)009<2281:DGGICC>2.0.CO;2. V. Ramaswamy, et al., “Anthropogenic and Natural Influences in the Evolution of Lower Stratospheric Cooling.” Science 311 (24 February 2006): 1138-1141. https://doi.org/10.1126/science.1122587. B.D. Santer et al., “Contributions of Anthropogenic and Natural Forcing to Recent Tropopause Height Changes.” Science 301 (25 July 2003): 479-483. https://doi.org/10.1126/science.1084123. T. Westerhold et al., "An astronomically dated record of Earth’s climate and its predictability over the last 66 million years." Science 369 (11 Sept. 2020): 1383-1387. https://doi.org/10.1126/science.1094123

2. In 1824, Joseph Fourier calculated that an Earth-sized planet, at our distance from the Sun, ought to be much colder. He suggested something in the atmosphere must be acting like an insulating blanket. In 1856, Eunice Foote discovered that blanket, showing that carbon dioxide and water vapor in Earth's atmosphere trap escaping infrared (heat) radiation. In the 1860s, physicist John Tyndall recognized Earth's natural greenhouse effect and suggested that slight changes in the atmospheric composition could bring about climatic variations. In 1896, a seminal paper by Swedish scientist Svante Arrhenius first predicted that changes in atmospheric carbon dioxide levels could substantially alter the surface temperature through the greenhouse effect. In 1938, Guy Callendar connected carbon dioxide increases in Earth’s atmosphere to global warming. In 1941, Milutin Milankovic linked ice ages to Earth’s orbital characteristics. Gilbert Plass formulated the Carbon Dioxide Theory of Climate Change in 1956.

3. IPCC Sixth Assessment Report, WG1, Chapter 2 Vostok ice core data; NOAA Mauna Loa CO2 record O. Gaffney, W. Steffen, "The Anthropocene Equation." The Anthropocene Review 4, issue 1 (April 2017): 53-61. https://doi.org/abs/10.1177/2053019616688022.

4. https://www.ncei.noaa.gov/monitoring https://crudata.uea.ac.uk/cru/data/temperature/ http://data.giss.nasa.gov/gistemp

5. https://www.giss.nasa.gov/research/news/20170118/

6. S. Levitus, J. Antonov, T. Boyer, O Baranova, H. Garcia, R. Locarnini, A. Mishonov, J. Reagan, D. Seidov, E. Yarosh, M. Zweng, " NCEI ocean heat content, temperature anomalies, salinity anomalies, thermosteric sea level anomalies, halosteric sea level anomalies, and total steric sea level anomalies from 1955 to present calculated from in situ oceanographic subsurface profile data (NCEI Accession 0164586), Version 4.4. (2017) NOAA National Centers for Environmental Information. https://www.nodc.noaa.gov/OC5/3M_HEAT_CONTENT/index3.html K. von Schuckmann, L. Cheng, L,. D. Palmer, J. Hansen, C. Tassone, V. Aich, S. Adusumilli, H. Beltrami, H., T. Boyer, F. Cuesta-Valero, D. Desbruyeres, C. Domingues, A. Garcia-Garcia, P. Gentine, J. Gilson, M. Gorfer, L. Haimberger, M. Ishii, M., G. Johnson, R. Killick, B. King, G. Kirchengast, N. Kolodziejczyk, J. Lyman, B. Marzeion, M. Mayer, M. Monier, D. Monselesan, S. Purkey, D. Roemmich, A. Schweiger, S. Seneviratne, A. Shepherd, D. Slater, A. Steiner, F. Straneo, M.L. Timmermans, S. Wijffels. "Heat stored in the Earth system: where does the energy go?" Earth System Science Data 12, Issue 3 (07 September 2020): 2013-2041. https://doi.org/10.5194/essd-12-2013-2020.

7. I. Velicogna, Yara Mohajerani, A. Geruo, F. Landerer, J. Mouginot, B. Noel, E. Rignot, T. Sutterly, M. van den Broeke, M. Wessem, D. Wiese, "Continuity of Ice Sheet Mass Loss in Greenland and Antarctica From the GRACE and GRACE Follow-On Missions." Geophysical Research Letters 47, Issue 8 (28 April 2020): e2020GL087291. https://doi.org/10.1029/2020GL087291.

8. National Snow and Ice Data Center World Glacier Monitoring Service

9. National Snow and Ice Data Center D.A. Robinson, D. K. Hall, and T. L. Mote, "MEaSUREs Northern Hemisphere Terrestrial Snow Cover Extent Daily 25km EASE-Grid 2.0, Version 1 (2017). Boulder, Colorado USA. NASA National Snow and Ice Data Center Distributed Active Archive Center. doi: https://doi.org/10.5067/MEASURES/CRYOSPHERE/nsidc-0530.001 . http://nsidc.org/cryosphere/sotc/snow_extent.html Rutgers University Global Snow Lab. Data History

10. R.S. Nerem, B.D. Beckley, J. T. Fasullo, B.D. Hamlington, D. Masters, and G.T. Mitchum, "Climate-change–driven accelerated sea-level rise detected in the altimeter era." PNAS 15, no. 9 (12 Feb. 2018): 2022-2025. https://doi.org/10.1073/pnas.1717312115.

11. https://nsidc.org/cryosphere/sotc/sea_ice.html Pan-Arctic Ice Ocean Modeling and Assimilation System (PIOMAS, Zhang and Rothrock, 2003) http://psc.apl.washington.edu/research/projects/arctic-sea-ice-volume-anomaly/ http://psc.apl.uw.edu/research/projects/projections-of-an-ice-diminished-arctic-ocean/

12. USGCRP, 2017: Climate Science Special Report: Fourth National Climate Assessment, Volume I [Wuebbles, D.J., D.W. Fahey, K.A. Hibbard, D.J. Dokken, B.C. Stewart, and T.K. Maycock (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, 470 pp, https://doi.org/10.7930/j0j964j6 .

13. http://www.pmel.noaa.gov/co2/story/What+is+Ocean+Acidification%3F

14. http://www.pmel.noaa.gov/co2/story/Ocean+Acidification

15. C.L. Sabine, et al., “The Oceanic Sink for Anthropogenic CO2.” Science 305 (16 July 2004): 367-371. https://doi.org/10.1126/science.1097403.

16. Special Report on the Ocean and Cryosphere in a Changing Climate , Technical Summary, Chapter TS.5, Changing Ocean, Marine Ecosystems, and Dependent Communities, Section 5.2.2.3. https://www.ipcc.ch/srocc/chapter/technical-summary/

Header image shows clouds imitating mountains as the sun sets after midnight as seen from Denali's backcountry Unit 13 on June 14, 2019. Credit: NPS/Emily Mesner

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Water, Hydration and Health

Barry m. popkin.

Department of Nutrition, University of North Carolina, Chapel Hill, NC

Kristen E. D’Anci

Department of Psychology, Tufts University, Medford, MA

Irwin H. Rosenberg

Nutrition and Neurocognition Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA

This review attempts to provide some sense of our current knowledge of water including overall patterns of intake and some factors linked with intake, the complex mechanisms behind water homeostasis, the effects of variation in water intake on health and energy intake, weight, and human performance and functioning. Water represents a critical nutrient whose absence will be lethal within days. Water’s importance for prevention of nutrition-related noncommunicable diseases has emerged more recently because of the shift toward large proportions of fluids coming from caloric beverages. Nevertheless, there are major gaps in knowledge related to measurement of total fluid intake, hydration status at the population level, and few longer-term systematic interventions and no published random-controlled longer-term trials. We suggest some ways to examine water requirements as a means to encouraging more dialogue on this important topic.

I. INTRODUCTION

Water is essential for life. From the time that primeval species ventured from the oceans to live on land, a major key to survival has been prevention of dehydration. The critical adaptations cross an array of species, including man. Without water, humans can survive only for days. Water comprises from 75% body weight in infants to 55% in elderly and is essential for cellular homeostasis and life. 1 Nevertheless there are many unanswered questions about this most essential component of our body and our diet. This review attempts to provide some sense of our current knowledge of water including overall patterns of intake and some factors linked with intake, the complex mechanisms behind water homeostasis, the effects of variation in water intake on health and energy intake, weight, and human performance and functioning.

Recent statements on water requirements have been based on retrospective recall of water intake from food and beverages among healthy non-institutionalized individuals. We provide examples of water intake assessment in populations to clarify the need for experimental studies. Beyond these circumstances of dehydration, we do not truly understand how hydration affects health and well-being, even the impact of water intakes on chronic diseases. Recently, Jéquier and Constant addressed this question based on the human physiology. 2 We need to know more about the extent that water intake might be important for disease prevention and health promotion.

As we note later, few countries have developed water requirements and those that do base them on weak population-level measures of water intake and urine osmolality. 3 , 4 The European Food Safety Authority (EFSA) has been recently asked to revise existing recommended intakes of essential substances with a physiological effect including water since this nutrient is essential for life and health. 5

The US Dietary Recommendations for water are based on median water intakes with no use of measurements of dehydration status of the population to assist. One-time collection of blood samples for the analysis of serum osmolality has been used by NHANES. At the population level we have no accepted method of assessing hydration status and one measure some scholars use, hypertonicity, is not even linked with hydration in the same direction for all age groups. 6 Urine indices are used often but reflect recent volume of fluid consumed rather than a state of hydration. 7 Many scholars use urine osmolality to measure recent hydration status. 8 – 12 Deuterium dilution techniques (isotopic dilution with D2O or deuterium oxide) allows measurement of total body water but not water balance status. 13 Currently we feel there are no adequate biomarkers to measure hydration status at the population level.

When we speak of water we are essentially focusing first and foremost on all types of water, be they soft or hard, spring or well, carbonated or distilled water. Furthermore we get water not only directly as a beverage but from food and to a very small extent also from oxidation of macronutrients (metabolic water). The proportion of water that comes from beverages and food varies with the proportion of fruits and vegetables in the diet. We present the ranges of water in various foods ( Table 1 ). In the United States it is estimated that about 22% of water comes from our food intake while it would be much higher in European countries, particularly a country like Greece with its higher intake of fruits and vegetables or South Korea. 3 , 14 , 15 The only in-depth study of water use and water intrinsic to food in the US found a 20.7% contribution from food water; 16 , 17 however as we show later, this research was dependent on poor overall assessment of water intake.

The Water Content Range for Selected Foods

Source: The USDA National Nutrient Database for Standard Reference, Release 21 provided in Altman. 127

This review considers water requirements in the context of recent efforts to assess water intake in US populations. Relationship of water and calorie intake is explored both for insights into the possible displacement of calories from sweetened beverages by water and also to examine the possibility that water requirements would be better expressed in relation to calorie/energy requirements with the dependence of the latter on age, size, gender, and physical activity level. We review current understanding of the exquisitely complex and sensitive system which protects land animals against dehydration and comment on the complications of acute and chronic dehydration in man against which a better expression of water requirements might complement the physiological control of thirst. Indeed, the fine intrinsic regulation of hydration and water intake in individuals mitigates against prevalent underhydration in populations and effects on function and disease.

Regulation of fluid intake

To prevent dehydration reptiles, birds, vertebrates, and all land animals have evolved an exquisitely sensitive network of physiological controls to maintain body water and fluid intake by thirst. Humans may drink for various reasons, particularly for hedonic ones but most of drinking is due to water deficiency which triggers the so called regulatory or physiological thirst. The mechanism of thirst is quite well understood today and the reason non-regulatory drinking is often encountered is related to the large capacity of kidneys to rapidly eliminate excesses of water or reduce urine secretion to temporarily economize on water. 1 But this excretory process can only postpone the necessity for drinking or for stopping drinking an excess of water. Non regulatory drinking is often confusing, particularly in wealthy societies facing highly palatable drinks or fluids that contain other substance that the drinker seeks. The most common of them are sweeteners or alcohol to which water is served as a vehicle. Drinking these beverages isn’t due to excessive thirst or hyperdipsia as it can be shown by offering pure water instead and finding out that the same drinker is in fact hypodipsic (Characterized by abnormally diminished thirst). 1

Fluid balance of the two compartments

Maintaining a constant water and mineral balance requires the coordination of sensitive detectors at different sites in the body linked by neural pathways with integrative centers in the brain that process this information. These centers are also sensitive to humoral factors (neurohormones) produced for the adjustment of diuresis, natriuresis and blood pressure (angiotensin mineralocorticoids, vasopressin, atrial natriuretic factor). Instructions from the integrative centers to the “executive organs” (kidney, sweat glands and salivary glands) and to the part of the brain responsible for corrective actions such as drinking are conveyed by certain nerves in addition to the above mentioned substances. 1

Most of the components of fluid balance are controlled by homeostatic mechanisms responding to the state of body water. These mechanisms are sensitive and precise, and are activated with deficits or excesses of water amounting to only a few hundred milliliters. A water deficit produces an increase in the ionic concentration of the extracellular compartment, which takes water from the intracellular compartment causing cells to shrink. This shrinkage is detected by two types of brain sensors, one controlling drinking and the other controlling the excretion of urine by sending a message to the kidneys mainly via the antidiuretic hormone vasopressin to produce a smaller volume of more concentrated urine. 18 When the body contains an excess of water, the reverse processes occur: the lower ionic concentration of body fluids allows more water to reach the intracellular compartment. The cells imbibe, drinking is inhibited and the kidneys excrete more water.

The kidneys thus play a key role in regulating fluid balance. As discussed later, the kidneys function more efficiently in the presence of an abundant water supply. If the kidneys economize on water, producing a more concentrated urine, these is a greater cost in energy and more wear on their tissues. This is especially likely to occur when the kidneys are under stress, for example when the diet contains excessive amounts of salt or toxic substances that need to be eliminated. Consequently, drinking enough water helps protect this vital organ.

Regulatory drinking

Most drinking obeys signals of water deficit. Apart from urinary excretion, the other main fluid regulatory process is drinking, mediated through the sensation of thirst. There are two distinct mechanisms of physiological thirst: the intracellular and the extracellular mechanisms. When water alone is lost, ionic concentration increases. As a result, the intracellular space yields some of its water to the extracellular compartment. One again, the resulting shrinkage of cells is detected by brain receptors that send hormonal messages to induce drinking. This association with receptors that govern extracellular volume is therefore accompanied by an enhancement of salt appetite. Thus, people who have been sweating copiously prefer drinks that are relatively rich in Na+ salts rather than pure water. As previously mentioned, it is always important to supplement drinks with additional salt when excessive sweating is experienced.

The brain’s decision to start or stop drinking and to choose the appropriate drink is made before the ingested fluid can reach the intra- and extracellular compartments. The taste buds in the mouth send messages to the brain about the nature, and especially the salt of the ingested fluid, and neuronal responses are triggered as if the incoming water had already reached the bloodstream. These are the so-called anticipatory reflexes: they cannot be entirely “cephalic reflexes” because they arise from the gut as well as the mouth. 1

The anterior hypothalamus and pre-optic area are equipped with osmo-receptors related to drinking. Neurons in these regions show enhanced firing when the inner milieu gets hyperosmotic. Their firing decreases when water is loaded in the carotid artery that irrigates the neurons. It is remarkable that the same decrease in firing in the same neurons takes place when the water load is applied on the tongue instead of being injected in the carotid artery. This anticipatory drop in firing is due to a mediation neural pathways departing from the mouth and by converging on to the neurons which simultaneously sense of the inner milieu (blood).

Non-regulatory drinking

Although everyone experiences thirst from time to time, it plays little day-to-day role in the control of water intake in healthy people living in temperate climates. We generally consume fluids not to quench our thirst, but as components of everyday foods (e.g. soup, milk), as beverages used as mild stimulants (tea, coffee) and for pure pleasure. As common example is alcohol consumption which can increase individual pleasure and stimulate social interaction. Drinks are also consumed for their energy content, as in soft drinks and milk, and are used in warm weather for cooling and in cold weather for warming. Such drinking seems also to be mediated through the taste buds, which communicate with the brain in a kind of “reward system” the mechanisms of which are just beginning to be understood. This bias in the way human beings rehydrate themselves may be advantageous because it allows water losses to be replaced before thirst-producing dehydration takes place. Unfortunately, this bias also carries some disadvantages. Drinking fluids other than water can contribute to an intake of caloric nutrients in excess of requirements, or in alcohol consumption that in some people may insidiously bring about dependence. For example, total fluid intake increased from 79 fluid ounces in 1989 to 100 fluid ounces in 2002 among US adults, all from caloric beverages. 19

Effects of aging on fluid intake regulation

The thirst and fluid ingestion responses of older persons to a number of stimuli have been compared to those seen in younger persons. 20 Following water deprivation older persons are less thirsty and drink less fluid compared to younger persons. 21 , 22 The decrease in fluid consumption is predominantly due to a decrease in thirst as the relationship between thirst and fluid intake is the same in young and old persons. Older persons drink insufficient water following fluid deprivation to replenish their body water deficit. 23 When dehydrated older persons are offered a highly palatable selection of drinks, this also failed to result in an increased fluid intake. 23 The effects of increased thirst in response to an osmotic load have yielded variable responses with one group reporting reduced osmotic thirst in older individuals 24 and one failing to find a difference. In a third study, young individuals ingested almost twice as much fluid as old persons, despite the older subjects having a much higher serum osmolality. 25

Overall these studies support small changes in the regulation of thirst and fluid intake with aging. Defects in both osmoreceptors and baroreceptors appear to exist as well as changes in the central regulatory mechanisms mediated by opioid receptors. 26 Because of their low water reserves, it may be prudent for the elderly to learn to drink regularly when not thirsty and to moderately increase their salt intake when they sweat. Better education on these principles may help prevent sudden hypotension and stroke or abnormal fatigue can lead to a vicious circle and eventually hospitalization.

Thermoregulation

Hydration status is critical to the body’s process of temperature control. Body water loss through sweat is an important cooling mechanism in hot climates and in physical activity. Sweat production is dependent upon environmental temperature and humidity, activity levels, and type of clothing worn. Water losses via skin (both insensible perspiration and sweating) can range from 0.3 L/h in sedentary conditions to 2.0 L/h in high activity in the heat and intake requirements range from 2.5 to just over 3 L/d in adults under normal conditions, and can reach 6 L/d with high extremes of heat and activity. 27 , 28 Evaporation of sweat from the body results in cooling of the skin. However, if sweat loss is not compensated for with fluid intake, especially during vigorous physical activity, a hypohydrated state can occur with concomitant increases in core body temperature. Hypohydration from sweating results in a loss in electrolytes, as well as a reduction in plasma volume, and can lead to increased plasma osmolality. During this state of reduced plasma volume and increased plasma osmolality, sweat output becomes insufficient to offset increases in core temperature. When fluids are given to maintain euhydration, sweating remains an effective compensation for increased core temperatures. With repeated exposure to hot environments, the body adapts to heat stress, and cardiac output and stroke volume return to normal, sodium loss is conserved, and the risk for heat-stress related illness is reduced. 29 Increasing water intake during this process of heat acclimatization will not shorten the time needed to adapt to the heat, but mild dehydration during this time may be of concern and is associated with elevations in cortisol, increased sweating, and electrolyte imbalances. 29

Children and the elderly have differing responses to ambient temperature and different thermoregulatory concerns than healthy adults. Children in warm climates may be more susceptible to heat illness than adults due to greater surface area to body mass ratio, lower rate of sweating, and slower rate of acclimatization to the heat. 30 , 31 Children may respond to hypohydration during activity with a higher relative increase in core temperature than adults do, 32 and sweat less, thus losing some of the benefits of evaporative cooling. However, it has been argued that children can dissipate a greater proportion of body heat via dry heat loss, and the concomitant lack of sweating provides a beneficial means of conserving water under heat stress. 30 Elders, in response to cold stress, show impairments in thermoregulatory vasoconstriction and body water is shunted from plasma into the interstitial and intracellular compartments. 33 , 34 With respect to heat stress, water lost through sweating decreases water content of plasma, and the elderly are less able to compensate for increased blood viscosity. 33 Not only do they have a physiological hypodipsia, but this can be exaggerated by central nervous system disease 35 and by dementia 36 . In addition, illness and limitations in activities of daily living can further limit fluid intake. Coupled with reduced fluid intake, with advancing age there is a decrease in total body water. Older individuals have impaired renal fluid conservation mechanisms and, as noted above, have impaired responses to heat and cold stress 33 , 34 . All of these factors contribute to an increased risk of hypohydration and dehydration in the elderly.

II. PHYSIOLOGICAL EFFECTS OF DEHYDRATION

In this section, the role of water in health is generally characterized in terms of deviations from an ideal hydrated state, generally in comparison to dehydration. The concept of dehydration encompasses both the process of losing body water and also the state of dehydration. Much of the research on water and physical or mental functioning compares a euhydrated state, usually achieved by provision of water sufficient to overcome water loss, to a dehydrated state, which is achieved via withholding of fluids over time and during periods of heat stress or high activity. In general, provision of water is beneficial in those with a water deficit, but little research supports the notion that additional water in adequately hydrated individuals confers any benefit.

Physical performance

The role of water and hydration in physical activity, particularly in athletes and in the military, has been of considerable interest and is well-described in the scientific literature. 37 – 39 During challenging athletic events, it is not uncommon for athletes to lose 6–10% of body weight in sweat loss, thus leading to dehydration if fluids have not been replenished. However, decrements in physical performance in athletes have been observed under much lower levels of dehydration, as little as 2%. 38 Under relatively mild levels of dehydration, individuals engaging in rigorous physical activity will experience decrements in performance related to reduced endurance, increased fatigue, altered thermoregulatory capability, reduced motivation, and increased perceived effort. 40 , 41 Rehydration can reverse these deficits, and also reduce oxidative stress induced by exercise and dehydration. 42 Hypohydration appears to have a more significant impact on high-intensity and endurance activity such as tennis 43 and long-distance running 44 than on anaerobic activities 45 such as weight lifting or on shorter-duration activities, such as rowing. 46

During exercise, individuals may not hydrate adequately when allowed to drink according to thirst. 32 After periods of physical exertion, voluntary fluid intake may be inadequate to offset fluid deficits. 1 Thus, mild to moderate dehydration can therefore persist for some hours after the conclusion of physical activity. Research in athletes suggests that, principally at the beginning of the season, they are at particular risk for dehydration due to lack of acclimatization to weather conditions or suddenly increased activity levels. 47 , 48 A number of studies show that performance in temperate and hot climates is affected to a greater degree than performance in cold temperatures. 41 , 49 , 50 Exercise in hot conditions with inadequate fluid replacement is associated with hyperthermia, reduced stroke volume and cardiac output, decreases in blood pressure, and reduced blood flow to muscle. 51

During exercise, children may be at greater risk for voluntary dehydration. Children may not recognize the need to replace lost fluids, and both children as well as coaches need specific guidelines for fluid intake. 52 Additionally, children may require longer acclimation to increases in environmental temperature than do adults. 30 , 31 Recommendations are for child athletes or children in hot climates to begin athletic activities in a well-hydrated state and to drink fluids over and above the thirst threshold.

Cognitive performance

Water, or its lack (dehydration), can influence cognition. Mild levels of dehydration can produce disruptions in mood and cognitive functioning. This may be of special concern in the very young, very old, those in hot climates, and those engaging in vigorous exercise. Mild dehydration produces alterations in a number of important aspects of cognitive function such as concentration, alertness and short-term memory in children (10–12 y), 32 young adults (18–25y) 53 – 56 and in the oldest adults, 50–82y. 57 As with physical functioning, mild to moderate levels of dehydration can impair performance on tasks such as short-term memory, perceptual discrimination, arithmetic ability, visuomotor tracking, and psychomotor skills. 53 – 56 However, mild dehydration does not appear to alter cognitive functioning in a consistent manner. 53 , 54 , 56 , 58 In some cases, cognitive performance was not significantly affected in ranges from 2–2.6% dehydration. 56 , 58 Comparing across studies, performance on similar cognitive tests was divergent under dehydration conditions. 54 , 56 In studies conducted by Cian and colleagues, 53 , 54 participants were dehydrated to approximately 2.8% either through heat exposure or treadmill exercise. In both studies, performance was impaired on tasks examining visual perception, short-term memory, and psychomotor ability. In a series of studies using exercise in conjunction with water restriction as a means of producing dehydration, D’Anci and colleagues 56 observed only mild decrements in cognitive performance in healthy young men and women athletes. In these experiments, the only consistent effect of mild dehydration was significant elevations of subjective mood score, including fatigue, confusion, anger, and vigor. Finally, in a study using water deprivation alone over a 24-h period, no significant decreases in cognitive performance were seen with 2.6% dehydration 58 . It is possible therefore, that heat-stress may play a critical role in the effects of dehydration on cognitive performance.

Reintroduction of fluids under conditions of mild dehydration can reasonably be expected to reverse dehydration-induced cognitive deficits. Few studies have examined how fluid reintroduction may alleviate dehydration’s negative effects on cognitive performance and mood. One study 59 examined how water ingestion affected arousal and cognitive performance in young people following a period of 12-h water restriction. While cognitive performance was not affected by either water restriction or water consumption, water ingestion affected self-reported arousal. Participants reported increased alertness as a function of water intake. Rogers and coworkers 60 observed a similar increase in alertness following water ingestion in both high- and low-thirst participants. Water ingestion, however, had opposite effects on cognitive performance as a function of thirst. High-thirst participants’ performance on a cognitively demanding task improved following water ingestion, but low-thirst participants’ performance declined. In summary, hydration status consistently affected self-reported alertness, but effects on cognition were less consistent.

Several recent studies have examined the utility of providing water to school children on attentiveness and cognitive functioning in children. 61 – 63 In these experiments, children were not fluid restricted prior to cognitive testing, but were allowed to drink as usual. Children were then provided with a drink or no drink 20–45 minutes before the cognitive test sessions. In the absence of fluid restriction and without physiological measures of hydration status, the children in these studies should not be classified as dehydrated. Subjective measures of thirst were reduced in children given water, 62 and voluntary water intake in children varied from 57 ml to 250 ml. In these studies, as in the studies in adults, the findings were divergent and relatively modest. In the research led by Edmonds and colleagues, 61 , 62 children in the groups given water showed improvements in visual attention. However, effects on visual memory were less consistent, with one study showing no effects of drinking water on a spot-the-difference task in 6–7 year old children 61 and the other showing a significant improvement in a similar task in 7–9 year old children 62 In the research described by Benton and Burgess, 63 memory performance was improved by provision of water but sustained attention was not altered with provision of water in the same children.

Taken together these studies indicate that low to moderate dehydration may alter cognitive performance. Rather than indicating that the effects of hydration or water ingestion on cognition are contradictory, many of the studies differ significantly in methodology and in measurement of cognitive behaviors. These variances in methodology underscore the importance of consistency when examining relatively subtle chances in overall cognitive performance. However, in those studies in which dehydration were induced, most combined heat and exercise, thus it is difficult to disentangle the effects of dehydration on cognitive performance in temperate conditions, from the effects of heat and exercise. Additionally, relatively little is known about the mechanism of mild dehydration’s effects on mental performance. It has been proposed that mild dehydration acts as a physiological stressor which competes with and draws attention from cognitive processes 64 . However, research on this hypothesis is limited and merits further exploration.

Dehydration and delirium

Dehydration is a risk factor for delirium and delirium presenting as dementia in the elderly and in the very ill. 65 – 67 Recent work shows that dehydration is one of several predisposing factors in observed confusion in long-term care residents, 67 although in this study daily water intake was used as a proxy measure for dehydration rather than other, more direct clinical assessments such as urine or plasma osmolality. Older people have been reported as having reduced thirst and hypodypsia relative to younger people. In addition, fluid intake and maintenance of water balance can be complicated by factors such as disease, dementia, incontinence, renal insufficiency, restricted mobility, and drug side effects. In response to primary dehydration, older people have less thirst sensation and reduced fluid intakes in comparison to younger people. However, in response to heat stress, while older people still display a reduced thirst threshold, they do ingest comparable amounts of fluid as younger people. 20

Gastrointestinal function

Fluids in the diet are generally absorbed in the proximal small intestine, and absorption rate is determined by the rate of gastric emptying to the small intestine. Therefore, the total volume of fluid consumed will eventually be reflected in water balance, but the rate at which rehydration occurs is dependent upon factors which affect the rate of delivery of fluids to the intestinal mucosa. Gastric emptying rate is generally accelerated by the total volume consumed and slowed by higher energy density and osmolality. 68 In addition to water consumed in food (1 L/d) and beverages (~2–3 L/d), digestive secretions account for a far greater portion of water that passes through and is absorbed by the gastrointestinal tract (~8 L/d). 69 The majority of this water is absorbed by the small intestine, with a capacity of up to 15 L/d with the colon absorbing some 5 L/d. 69

Constipation, characterized by slow gastrointestinal transit, small, hard stools, and difficulty in passing stool, has a number of causes including medication use, inadequate fiber intake, poor diet, and illness. 70 Inadequate fluid consumption is touted as a common culprit in constipation, and increasing fluid intake is a frequently recommended treatment. Evidence suggests, however, that increasing fluids is only of usefulness in individuals in a hypohydrated state, and is of little utility in euhydrated individuals. 70 In young children with chronic constipation, increasing daily water intake by 50% did not affect constipation scores. 71 For Japanese women with low fiber intake, concomitant low water intake in the diet is associated with increased prevalence of constipation. 72 In older individuals, low fluid intake is a predictor for increased levels of acute constipation 73 , 74 with those consuming the least amount of fluid having over twice the frequency of constipation episodes than those consuming the most fluid. In one trial, researchers compared the utility of carbonated mineral water in reducing functional dyspepsia and constipation scores to tap water in individuals with functional dyspepsia. 75 When comparing carbonated mineral water to tap water, participants reported improvements in subjective gastric symptoms, but there were no significant improvements in gastric or intestinal function. The authors indicate that it is not possible to determine to what degree the mineral content of the two waters contributed to perceived symptom relief, as the mineral water contained greater levels of magnesium and calcium than the tap water. The available evidence suggests that increased fluid intake should only be indicated in individuals in a hypohydrated state. 71 , 69

Significant water loss can occur through the gastrointestinal tract, and this can be of great concern in the very young. In developing countries, diarrheal diseases are a leading cause of death in children resulting in approximately 1.5–2.5 million deaths per year. 76 Diarrheal illness results not only in a reduction in body water, but also in potentially lethal electrolyte imbalances. Mortality in such cases can many times be prevented with appropriate oral rehydration therapy, by which simple dilute solutions of salt and sugar in water can replace fluid lost by diarrhea. Many consider application of oral rehydration therapy to be one of the signal public health developments of the last century. 77

Kidney function

As noted above, the kidney is crucial in regulating water balance and blood pressure as well as removing waste from the body. Water metabolism by the kidney can be classified into regulated and obligate. Water regulation is hormonally mediated, with the goal of maintaining a tight range of plasma osmolality between 275 to 290 mOsm/kg. Increases in plasma osmolality, and activation of osmoreceptors (intracellular) and baroreceptors (extracellular) stimulate hypothalamic release of arginine vasopressin (AVP). AVP acts at the kidney to decrease urine volume and promote retention of water, and the urine becomes hypertonic. With decreased plasma osmolality, vasopressin release is inhibited, and the kidney increases hypotonic urinary output.

In addition to regulating fluid balance, the kidneys require water for the filtration of waste from the blood stream and excretion via urine. Water excretion via the kidney removes solutes from the blood, and a minimum obligate urine volume is required to remove the solute load with a maximum output volume of 1 L/h. 78 This obligate volume is not fixed, but is dependent upon the amount of metabolic solutes to be excreted and levels of AVP. Depending on the need for water conservation, basal urine osmolality ranges from 40 mOsm/kg up to a maximum of 1400 mOsm/kg. 78 The ability to both concentrate and dilute urine decreases with age, with a lower value of 92 mOsm/kg and an upper range falling between 500–700 mOsm/kg for individuals over 70. 79 – 81 Under typical conditions, in an average adult, urine volume of 1.5 to 2.0 L/d would be sufficient to clear a solute load of 900 to 1200 mOsm/d. During water conservation and the presence of AVP, this obligate volume can decrease to 0.75–1.0 L/d and during maximal diuresis can require up to 20 L/d to remove the same solute load. 78 , 80 , 81 In cases of water loading, if the volume of water ingested cannot be compensated for with urine output, having overloaded the kidney’s maximal output rate, an individual can enter a hyponatremic state as described above.

Heart function and hemodynamic response

Blood volume, blood pressure, and heart rate are closely linked. Blood volume is normally tightly regulated by matching water intake and water output, as described in the section on kidney function. In healthy individuals, slight changes in heart rate and vasoconstriction act to balance the effect of normal fluctuations in blood volume on blood pressure. 82 Decreases in blood volume can occur, through blood loss (or blood donation), or loss of body water through sweat, as seen with exercise. Blood volume is distributed differently relative to the position of the heart whether supine or upright, and moving from one position to the other can lead to increased heart rate, a fall in blood pressure and, in some cases, lead to syncope. This postural hypotension (or orthostatic hypotension) can be mediated by drinking 300–500 ml of water. 83 , 84 Water intake acutely reduces heart rate and increases blood pressure in both normotensive and hypertensive individuals. 85 These effects of water intake on the pressor effect and heart rate occur within 15–20 minutes of drinking water and can last for up to 60 minutes. Water ingestion is also beneficial in preventing vasovagal reaction with syncope in blood donors at high risk for post-donation syncope. 86 The effect of water drinking in these situations is thought to be due to effects on the sympathetic nervous system rather than to changes in blood volume. 83 , 84 Interestingly, in rare cases, individuals may experience bradycardia and syncope after swallowing cold liquids. 87 – 89 While swallow syncope can be seen with other substances than water, swallow syncope further supports the notion that the result of water ingestion in the pressor effect has both a neural component as well as a cardiac component.

Water deprivation and dehydration can lead to the development of headache. 90 Although this observation is largely unexplored in the medical literature, some observational studies indicate that water deprivation, in addition to impairing concentration and increasing irritability, can serve as a trigger for migraine and also prolong migraine. 91 , 92 In those with water deprivation-induced headache, ingestion of water provided relief from headache in most individuals within 30 min to 3 h. 92 It is proposed that water deprivation-induced headache is the result of intracranial dehydration and total plasma volume. Although provision of water may be useful in relieving dehydration related headache, the utility of increasing water intake for the prevention of headache is less well documented.

The folk wisdom that drinking water can stave off headaches has been relatively unchallenged, and has more traction in the popular press than in the medical literature. Recently, one study examined increased water intake and headache symptoms in headache patients. 93 In this randomized trial, patients with a history of different types of headache, including migraine and tension headache, were either assigned to a placebo condition (a non-drug tablet) or the increased water condition. In the water condition, participants were instructed to consume an additional volume of 1.5 L water/day on top of what they already consumed in foods and fluids. Water intake did not affect number of headache episodes, but was modestly associated with reduction in headache intensity and reduced duration of headache. The data from this study suggest that water is limited as prophylaxis in headache sufferers, and the ability of water to reduce or prevent headache in a broader population remains unknown.

One of the more pervasive myths regarding water intake is the improvement of the skin or complexion. By improvement, it is generally understood that individuals are seeking to have a more “moisturized” look to the surface skin, or to minimize acne or other skin conditions. Numerous lay sources such as beauty and health magazines as well as the Internet suggest that drinking 8–10 glasses of water a day will “flush toxins from the skin” and “give a glowing complexion” despite a general lack of evidence 94 , 95 to support these proposals. The skin, however, is important in maintaining body water levels and preventing water loss into the environment.

The skin contains approximately 30% water, which contributes to plumpness, elasticity, and resiliency. The overlapping cellular structure of the stratum corneum and lipid content of the skin serves as “waterproofing” for the body. 96 Loss of water through sweat is not indiscriminate across the total surface of the skin, but is carried out by eccrine sweat glands, which are evenly distributed over most of the body surface. 97 Skin dryness is usually associated with exposure to dry air, prolonged contact with hot water and scrubbing with soap (both strip oils from the skin), medical conditions and medications. While more serious levels of dehydration can be reflected in reduced skin turgor, 98 , 99 with tenting of the skin as a flag for dehydration, overt skin turgor in individuals with adequate hydration is not altered. Water intake, particularly in individuals with low initial water intake, can improve skin thickness and density as measured by sonogram, 100 and offsets transepidermal water loss, and can improve skin hydration. 101 Adequate skin hydration, however, is not sufficient to prevent wrinkles or other signs of aging, which are related to genetics, and sun and environmental damage. Of more utility to individuals already consuming adequate fluids, the use of topical emollients will improve skin barrier function and improve the look and feel of dry skin. 102 , 103

Hydration and chronic diseases

Many chronic diseases have multifactorial origins. In particular, differences in lifestyle and the impact of environment are known to be involved and constitute risk factors that are still being evaluated. Water is quantitatively the most important nutrient. In the past, scientific interest with regard to water metabolism was mainly directed toward the extremes of severe dehydration and water intoxication. There is evidence, however, that mild dehydration may also account for some morbidities. 4 , 104 There is currently no consensus on a “gold standard” for hydration markers, particularly for mild dehydration. As a consequence, the effects of mild dehydration on the development of several disorders and diseases have not been well documented.

There is strong evidence showing that good hydration reduces the risk of urolithiasis (See Table 2 for evidence categories). Less strong evidence links good hydration with reduced incidence of constipation, exercise asthma, hypertonic dehydration in the infant, and hyperglycemia in diabetic ketoacidosis. Good hydration is associated with a reduction in urinary tract infections, hypertension, fatal coronary heart disease, venous thromboembolism, and cerebral infarct but all these effects need to be confirmed by clinical trials. For other conditions such as bladder or colon cancer, evidence of a preventive effect of maintaining good hydration is not consistent (see Table 3 ).

Categories of evidence in evaluating the quality of reports

Adapted from Manz 104

Hydration Status and Chronic Diseases

III. Water consumption and requirements and relationships to total energy intake

Water consumption, water requirements and energy intake are linked in fairly complex ways. This is partially because physical activity and energy expenditures affect the need for water but also because a large shift in beverage consumption over the past century or more has led to consumption of a significant proportion of our energy intake from caloric beverages. Nonregulatory beverage intake, as noted earlier, has assumed a much greater role for individuals. 19 In this section we first review current patterns of water intake, then refer to a full meta-analysis of the effects of added water on energy intake. This includes adding water to the diet and water replacement for a range of caloric and diet beverages, including sugar-sweetened beverages, juice, milk, and diet beverages. The third component is a discussion of water requirements and suggestions for considering the use of ml water/kcal energy intake as a metric.

A. Patterns and trends of water consumption

Measurement of total fluid water consumption in free-living individuals is fairly new in focus. As a result, the state of the science is poorly developed, data are most likely fairly incomplete, and adequate validation of the measurement techniques used are not available. We first present varying patterns and trends of water intake for the United States over the past three decades and review briefly the work on water intake in Europe.

We have really no information to allow us to assume that consumption of water alone or beverage containing water affects hydration differentially. 3 , 105 Some epidemiological data suggests water might have differential metabolic effects when consumed as water alone rather than water contained in caffeinated or flavored or sweetened beverages but these data are at best suggestive of an issue deserving of exploration. 106 , 107 We do show below from the research of Ershow that beverages not consisting of solely water do contain less than 100% water.

One study in the United States has attempted to examine all the sources of water in our diet. 16 , 17 These data are cited in Table 4 as the Ershow study and were based on National Food Consumption Survey food and fluid intake data from 1977–78. These data are presented in Table 4 for children 2–18 (Panel A) and for adults 19 and older (Panel B). Ershow and colleagues spent a great deal of time working out ways to convert USDA dietary data into water intake, including water absorbed during the cooking process, water in food, and all sources of drinking water. 16 , 17

Beverage Pattern Trends in the United States for Children aged 2–18 and Adults Aged 19 and older, Nationally Representative

Note: The data are age and sex adjusted to 1965; for 1977–78 the 488, 95, and 736 come from the Ershow calculations.

These created a number of categories and used a range of factors measured in other studies to estimate the water categories. The water that is found in food, based on food composition table data, was 393ml for children. The water that was added as a result of cooking (e.g., rice) was 95 ml. That consumed as a beverage directly as water was 624 ml. The water found in other fluids as noted comprised the remainder of the ml with the most water coming from whole fat milk and juices (506 ml). There is a small discrepancy between the Ershow total fluid intake measures for these children and that of the normal USDA figure. That is because USDA does not remove milk fats and solids, fiber and other food constituents found in beverages, particularly, juice and milk.

A key point to be seen in these nationally representative US data is enormous variability in the amount of water consumed between survey waves (see Figure 1 which highlights that large variation in water intake measured in these surveys). Although adult and child water intake moved up and down at the same time, for reasons we cannot explain, the variation is greater among children than adults. This is partly that the questions asked have varied and there has not been detailed probing for water intake as the focus has been on obtaining measures of macro-and micronutrients. Dietary survey methods in the past have focused on obtaining foods and beverages containing nutrient and nonnutritive sweeteners but not on water. Related are the huge differences between the NHANES 1988–1994 and 1999 and later surveys and the USDA surveys. In addition even the NHANES1999–2002 and the 2003–6 surveys differ greatly. This represents a shift in mode of questioning to inclusion of water intake as part of a standard 24-hour recall rather than as standalone questions. Water was not even measured in 1965, and the way the questions have been asked and the limitation on probes for water intake are very clear from a review of the questionnaires plus these data. Essentially in the past people were asked how much water they consumed in a day and now they are asked these questions as part of a 24-hour recall survey. However, unlike other caloric and diet beverages, there are limited probes for water. These must be viewed as crude approximations of total water intake without any strong research to show if they are over- or underestimated. We know from our own research with several studies of water and two on-going random controlled trials that probes that include consideration of all beverages including water as a separate item provide more complete data.

Water Consumption Trends from USDA and NHANES Surveys (ml/day/capita), weighted to be nationally representative

Note: this includes water from fluids only, excluding water in foods. Sources for 1965, 77–78, 89- are USDA. Others are NHANES and 2005–6 is joint USDA and NHANES

Water consumption data for Europe are collected far more selectively than even the crude water intake questions from NHANES. The recent EFSA report provides measures of water consumption from a range of studies in Europe. 4 , 105 , 108 , 109 Essentially what these studies show is that total water intake is lower across Europe than the United States. As with the United States data, none are based on long-term carefully measured or even repeated 24-hour recall measures of water intake from food and beverages. In unpublished work Popkin and Jebb 110 are examining water intake in UK adults in 1986–87 and 2001–2. Their intake increased by 226 ml/d over this time period but still is only 1787 ml/d in the latter period, far below the US figure for 2005–6 of 2793 or earlier figures for comparably aged adults.

There are a few studies in the US and Europe that utilize 24-hour urine and serum osmolality measures to determine total water turnover and this measure of hydration status. These studies suggest that US adults consume over 2100 ml of water per day while those from Europe consume less than a half liter or more. 4 , 111 Data on total urine collection would appear to be another useful measure for examining total water intake. Of course few studies aside from the Donald adolescent cohort in Germany have collected such data on population levels for large samples. 109

B. The effects of water consumption on overall energy intake

There is an extensive literature that focuses on the impact of sugar-sweetened beverages on weight and risk of obesity, diabetes and heart disease; however the perspective of providing more water and its impact on health has not been examined. The water literature does not address portion sizes but rather focuses mainly on water ad libitum or in selected portions compared with other caloric beverages. Elsewhere we have prepared a detailed meta-analysis of the effects of water intake alone (adding additional water), replacing sugar-sweetened beverages, juice, milk and diet beverages. 112

In general, the results of this review suggest that water, when replacing sugar-sweetened beverages, juice and milk is linked with reduced energy intake. This comes mainly from the clinical feeding studies but also from one very good random controlled school intervention and several other epidemiological and intervention studies. Aside from portion sizes, there are issues of timing of the beverage intake and meals (delay time from the beverage to the meal) and types of caloric sweeteners that remain to be considered. However when beverages are consumed in a normal free-living situations where 5–8 eating occasions are the norm, the delay time from the beverage to the meal may matter less. 113 – 115

The literature on children is extremely limited as it relates to water intake. However, the excellent German school intervention with water would suggest the effects of water on overall energy intake of children might be comparable to that of adults. 116 In this German study children were educated on the value of water and provided in school with special filtered drinking fountains and water bottles. The intervention school children increased by 1.1 glasses/day (P<0.001) and reduced their risk of overweight by 31% (OR=0.69, P=0.40).

C. Water requirements: Evaluation of the adequacy of water intake

Classically, water data are examined in terms of milliliters (or some other measure of water volume consumed per capita per day by age group). This measure does not link fluid and caloric intake. Disassociation of fluid and calorie intake difficult for clinicians dealing with an older person who has reduced caloric intake. This ml water measure assumes some mean body size (or surface area) and a mean level of physical activity – both determinants of not only energy expenditure, but also of water balance. Children are dependent on adults for access to water and studies suggest that a larger surface area to volume ratio makes them susceptible to changes in skin temperatures, linked with ambient temperature shifts. 117 One option utilized by some scholars is to explore in ml/kcal of food and beverage intake as was done in the 1989 US RDAs. 4 , 118 This is an option interpretable for clinicians and does incorporate in some sense body size or surface area and activity. It has one disadvantage, namely that water as consumed with caloric beverages, affects both the numerator and denominator; however we do not know a measure that could be independent of this direct effect on body weight and/or total caloric intake.

Despite its critical importance in health and nutrition, as noted earlier, the array of available research that serves as a basis for determining requirements for water or fluid intake, or even rational recommendations for populations, is limited compared to most other nutrients. While this deficit may be partly explained by the highly sensitive set of neurophysiological adaptations and adjustments that occur over a large range of fluid intake to protect body hydration and osmolarity, this deficit remains a challenge for the nutrition and public health community. The latest official effort at recommending water intake for different subpopulations was a part of the Dietary Reference Intake process of the Institute of Medicine of the National Academy of Science’s Report on Dietary Reference Intakes on Water and Electrolytes as reported in 2005. 3 As a graphic acknowledgement of the limited database upon which to express Estimated Average Requirements for water for different population groups, the Committee and the Institute of Medicine were forced to state “While it might appear useful to estimate an average requirement (an EAR) for water, an EAR based on data is not possible”. Given the extreme variability in water needs that are not solely based on differences in metabolism, but also on environmental conditions and activities, there is not a single level of water intake that would assure adequate hydration and optimum health for half of all apparently healthy persons in all environmental conditions. Thus, an Adequate Intake (AI) is established in place of an EAR for water.

The AI for different population groups was set as the median water intake in populations from the National Health and Nutrition Examination Survey, whose intake levels varied greatly based on the survey years (e.g., NHANES 1988–94 vs NHANES 1999–2002) and also were much higher than the USDA surveys (e.g., 1989–91, 1994–98, or 2005–6). If the AI for adults as expressed in Table 5 is taken as a recommended intake, we question the wisdom of the conversion of an AI into recommended water or fluid intake. The first problem is the almost certain inaccuracy of the fluid intake information from the national surveys, even though that problem may also exist for other nutrients. More importantly, from the standpoint of translating an AI into recommended fluid intake for individuals or populations, is the decision in setting the AI to add an additional roughly 20% of water intake, which is derived from some foods in addition to water and beverages. While this may be a legitimate effort to express total water intake as a basis for setting the AI, the recommendations that derive from this IOM report would better be directed at recommendations for water and other fluid intake on the assumption that the water content of foods would be a “passive” addition to total water intake. In this case, the observations of the DRI committee that water intake needs to meet needs imposed by not only metabolism and environmental conditions, but also body size, gender and physical activity. Those are the well studied factors which allow a rather precise measurement and determination of energy intake requirements. It is only logical that those same factors might underlie recommendations to meet water intake needs in the same populations and individuals, and therefore that consideration be given and data gathering be done by experimental and population research, to the possibility that water intake needs would best be expressed relative to the calorie requirements, as is done regularly in the clinical setting.

Water requirements expressed in relation to energy recommendations

AI for total fluids derived from dietary reference intakes for water, potassium, sodium, chloride, and sulfate

Ratios for water intake based on the AI for water in liters/day calculated using EER for each range of physical activity. EER adapted from the Institute of Medicine Dietary Reference Intakes Macronutrients Report, 2002.

It is important to note that only a few countries even include water on the list of nutrients. 119 The European Food Safety Authority is developing a European wide standard. 105 At present only the United States and Germany provide Adequate intake (AI) values but no other country does that. 3 , 120

Another way of considering an approach to the estimation of water requirements beyond the limited usefulness of the AI or estimated mean intake is to express water intake requirements in relation to energy requirements in ml/kcal. An argument for this approach includes the observation that energy requirements are strongly evidence-based in each age and gender group on extensive research which takes into account body size, and activity level which are crucial determinants of energy expenditure which must be met by dietary energy intake. Such measures of expenditure have used highly accurate methods such as doubly-labeled water and thus EERs (Estimated Energy Requirements) have been set based on solid data rather than the compromise inherent in the AIs for water. Those same determinants of energy expenditure and recommended intake are also applicable to water utilization and balance and this provides an argument for pegging water/fluid intake recommendations to the better studied energy recommendations. The extent to which water intake and requirements are determined by energy intake and expenditure is understudied but in the clinical setting it has long been practice to supply 1 ml per kcal administered by tube to patients unable to take in food or fluids. Factors such as fever or other drivers of increased metabolism affect both energy expenditure and fluid loss and are thus linked in clinical practice. This concept may well deserve consideration in the setting of population intake goals.

Finally, for decades there has been discussion of expressing nutrient requirements per 1000 kcal so that a single number would apply reasonable across the spectrum of age groups. This idea, which has never been adopted by the Institute of Medicine (IOM) and National Academy of Science, may lend itself to an improved expression of water/fluid intake requirements which must replace the AIs eventually. Table 5 presents the IOM water requirements and then develops a ratio of ml/kcal based on them. The European Food Safety Agency refers positively to the possibility of expressing water intake recommendations in ml/kcal as a function of energy requirements. 105 Outliers in the adult male categories which reach ratios as high as 1.5 may well be based on American AI data which are above those in the more moderate and likely more accurate European recommendations.

Exploring the topic of utilizing ml/kcal as the way to examine water intake and water gaps, we take the full set of water intake AIs for each age-gender grouping and examine total intake in Table 6 . They suggest a high level of fluid deficiency. Since a large proportion of fluids in the US are based on caloric beverages and this proportion has changed markedly over the past 30 years, fluid intake increases both the numerator and denominator of this ml/kcal relationship. Nevertheless even using 1 ml/kcal as the AI would leave a gap for all children and adolescents. We then utilize the NHANES physical activity data translated into METS/day to categorize all individuals by physical activity level and thus varying caloric requirements. Using these measures show a fairly large fluid gap, particularly for adult males as well as children.

Water intake and water intake gaps based on US Water Adequate Intake Recommendations (based on utilization of water and physical activity data from NHANES 2005–6.

Note: Recommended water intake for actual activity level is the upper end of the range for moderate and active.

IV. DISCUSSION

This review has pointed out a number of issues related to water, hydration and health. As undoubtedly the most important nutrient and the only one whose absence will be lethal within days, understanding of water measurement and requirements are very important. The effects of water on daily performance and short and long-term health are quite clear. There are few negative effects of water intake and the evidence of positive effects is quite clear from the literature.

Little work has been done to measure total fluid intake systematically and there is no understanding of measurement error and best methods of understanding fluid intake. The most definitive US and European documents on total water requirements as based on these extant intake data. 3 , 105 We feel that absence of validation of methods for water consumption intake levels and patterns represents a major gap. Little exploration of even varying methods of probing to collect better water recall data have been conducted.

Of course, the other half of the issue is the need for understanding total hydration status. We have no acceptable biomarkers of hydration status at the population level. Controversy exists about current knowledge of hydration status among older Americans. 6 , 121 This represents a topic understudied at the population level though certainly scholars are focused on attempting to create biomarkers for measurement of hydration status.

As we have noted, the importance of understanding the role of fluid intake on health has emerged as a more important topic partially because of the shift toward large proportions of fluids coming from caloric beverages. We summarized briefly a related systematic review of the clinical, epidemiological and intervention literature on the effects of added water on health. As a replacement for SSB’s, juice, or whole milk there are clear effects in that energy intake is reduced by about 10–13% of total energy intake. However on these topics, there are only a few longer-term systematic interventions and no published random-controlled longer-term trials. There is very minimal evidence on the effects of just adding water to the diet and of replacing water with diet beverages.

Limitations to this review are many. One certainly is the omission of discussions of the issue of potential differences in the metabolic functioning of different types of beverages 122 . There is little basis at this point for delving into this sparse literature. Another is omission of the potential effects of fructose (from all caloric sweeteners) when consumed in caloric beverages on abdominal fat and subsequently all the metabolic conditions directly linked with this (e.g., diabetes). 123 – 126 We do not review in any detail all the array of biomarkers being considered to measure hydration status as there is just no sense in the field today that there is a measurement that covers more than a very short time period except for 24-hour total urine collection.

We suggest some ways to examine water requirements as a means to encouraging more dialogue on this important topic. Given the importance of water to our health and of caloric beverages to our total energy intake and potential risks of nutrition-related non communicable diseases, understanding both the requirements for water related to energy requirements, and the differential effects of water vs. other caloric beverages remain important outstanding issues.

In the end, this review has attempted to provide some sense of the importance of water to our health, its role in relationship to the rapid increases of obesity and other related diseases, and our gaps in understanding measurement and requirements. Water is essential to our survival and to our civilizations’ and we hope this critical role will sharpen our focus on water in human health.

Acknowledgments

Funding was provided by the Nestlé Waters, Issy-les-Moulineaux, France, 5ROI AGI0436 from the National Institute on Aging Physical Frailty Program, and NIH R01- CA109831 and R01-CA121152. We also wish to thank Ms. Frances L. Dancy for administrative assistance, Mr. Tom Swasey for graphics support, Dr. Melissa Daniels for assistance, and Florence Constant (Nestle’s Water Research) for advice and references.

Contributor Information

Barry M. Popkin, Department of Nutrition, University of North Carolina, Chapel Hill, NC.

Kristen E. D’Anci, Department of Psychology, Tufts University, Medford, MA.

Irwin H. Rosenberg, Nutrition and Neurocognition Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA.

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• 22 March 2024

How to achieve safe water access for all: work with local communities

• Farhana Sultana 0 ,
• Tara McAllister 1 ,
• Suparana Katyaini 2 &
• Michael D. Blackstock 3

Farhana Sultana is a professor of geography and the environment at Maxwell School of Citizenship and Public Affairs, Syracuse University, Syracuse, New York, USA.

You can also search for this author in PubMed   Google Scholar

Tara McAllister (Te Aitanga a Māhaki, Ngāti Porou) is a Kairangahau Matua (lead researcher) at Te Wānanga o Aotearoa, New Zealand.

Suparana Katyaini is a programme lead at the Council on Energy, Environment and Water, New Delhi, India.

Michael D. Blackstock of the Gitxsan Nation, whose traditional name is Ama Goodim Gyet, is a poet, artist and independent scholar on cross-cultural perspectives on water, ecology, climate change and conflict resolution.

Women walk across a dried-up lake in Bangladesh to collect water. Credit: Ab Rashid/Solent News/Shutterstock

More than two billion people worldwide lack access to reliable, safe drinking water. Challenges around managing water resources are complex and wide-ranging . They are interlinked with those affecting land and food systems and are exacerbated by the climate crisis . Four scholars propose ways to prompt progress in water governance — and highlight just how crucial it is for local communities to be involved.

Farhana Sultana approaches research on environmental harms and social inequities in tandem. Credit: Wainwright Photos

FARHANA SULTANA : Collaborate to advance water justice

Throughout my childhood in Dhaka, Bangladesh, the frantic call ‘ Pani chole jaitese !’ (‘The water is running out!’) prompted my family, along with the entire neighbourhood, to scramble to fill pots and buckets with water before the taps ran dry. I witnessed women and girls walk long distances to secure this basic necessity for their families, long before water governance became central to my academic career. Amid water insecurity, the opposite extreme was just as familiar — going to school through devastating floods and experiencing the fall-out from disastrous cyclones and storm surges.

Municipal water services in Dhaka also struggled to meet the growing demands of a rapidly urbanizing and unequal megacity. Access to electricity — needed to run water pumps — was sporadic, and there weren’t enough treatment plants to ensure clean water for millions of residents.

These early experiences fuelled my dedication to tackling water injustices. Today, as an interdisciplinary human geographer with expertise in Earth sciences, and with policy experience gained at the United Nations, I approach environmental harms and social inequities in tandem — the root causes that connect both must be addressed for a just and sustainable future. My research also encompasses climate justice, which is inextricably linked with water justice. Climate change intensifies water-security concerns by worsening the unpredictability and severity of hazards, from floods and droughts to sea-level rise and water pollution.

Such events hit marginalized communities the hardest, yet these groups are often excluded from planning and policymaking processes. This is true at the international level — in which a legacy of colonialism shapes geopolitics and limits the influence of many countries in the global south on water and climate issues — and at the national level.

However, collaborative work between affected communities, activists, scholars, journalists and policymakers can change this, as demonstrated by the international loss-and-damage fund set up last year to help vulnerable countries respond to the most serious effects of climate-related disasters. The product of decades of globally concerted efforts, this fund prioritizes compensation for low-income countries, which contribute the least to climate change but often bear the brunt of the disasters.

I also witnessed the value of collaboration and partnership in my research in Dhaka. Community-based groups, non-profit organizations and activists worked with the Dhaka Water Supply and Sewerage Authority to bring supplies of drinking water at subsidized prices to marginalized neighbourhoods, such as Korail, where public infrastructure was missing.

Globally, safe water access for all can be achieved only by involving Indigenous and local communities in water governance and climate planning. People are not voiceless, they simply remain unheard. The way forward is through listening.

Tara McAllister is exploring the interface between Mātauranga Māori (Māori Knowledge) and non-Indigenous science. Credit: Royal Society of New Zealand

TARA MCALLISTER: Let Māori people manage New Zealand’s water

I have always been fascinated by wai (water) and all the creatures that live in it. Similar to many Indigenous peoples around the world, Māori people have a close relationship with nature. Our connection is governed by geneaology and a concept more akin to stewardship rights than to ownership. This enables us to interact with our environment in a sustainable manner, maintaining or improving its state for future generations.

I was privileged to go to university, where I studied marine biology. I then moved to the tribal lands of Ngāi Tahu on Te Waipounamu , the South Island of New Zealand, which triggered my passion for freshwater ecosystems. Intensive agriculture is placing undue pressure on the whenua (land) and rivers there. Urgent work was required. Undertaking a PhD in freshwater ecology, I studied the causes of toxic benthic algal blooms in rivers. For me, there is no better way to work than spending my days outside, with my feet in the water.

A worker fills people’s water containers from a tanker in Kolkata, India. Credit: Rupak De Chowdhuri/Reuters

Having just started a research position at Te Wānanga o Aotearoa , a Māori-led tertiary educational institution, I am now exploring the interface between Mātauranga Māori (Māori Knowledge) and non-Indigenous science, and how these two systems can be used alongside each other in water research. I have also been working on nurturing relationships with mana whenua , the community that has genealogical links to the area where I live, so that I can eventually work in the community’s rivers and help to answer scientific questions that its members are interested in.

Despite a perception that Aotearoa (New Zealand) is ‘clean and green’, many of its freshwater ecosystems are in a dire state. Only about 10% of wetlands remain, and only about half of rivers are suitable for swimming. Water resource management is challenging, because of a change this year to a more right-wing government. The current government seems intent on revoking the National Policy Statement for Freshwater Management, established in 2020.

This policy has been crucial in improving the country’s management of freshwater resources. Although not perfect, it does include Te Mana o te Wai — a concept that posits that the health and well-being of water bodies and ecosystems must be the first priority in such management. It is now in danger of being repealed.

I think that, ultimately, our government’s inability to divulge control and power to Māori people to manage our own whenua and wai is what limits water resource management. More than any change in policy, I would like to see our stolen lands and waters returned.

Suparana Katyaini calls for more policy support for Indigenous-led water management. Credit: Milan George Jacob

SUPARANA KATYAINI: Consider water, food and land together

Growing up in New Delhi, I always had easy access to drinking water — until the summer of 2004, when a weak monsoon triggered a water crisis and the city had to rely on water tankers. I realized then that good management of water resources supports our daily lives in ways we take for granted until we experience scarcity.

My professional journey in research and teaching has been motivated by this experience. During my environmental studies of water poverty in India, I noticed that the field relied largely on quantitative data over qualitative insights — the degree of water-resources availability, access and use are typically assessed through metrics such as the water-availability index or the water-demand index. But in many places, Indigenous and local communities, including farmers and women in any occupation, have collectively developed skills to weather periods of water scarcity. Paying attention to these skills would lead to better water management. For example, the issue of food and nutritional insecurity in water-scarce areas in the state of Odisha, India, is being solved by Bonda people through revival of the crop millet, using varieties that are nutritious, water-efficient and climate-resilient.

But these efforts need more policy support. My current work at the Council on Energy, Environment and Water explores how water, food and land systems are interlinked in India, and how better understanding of these relationships can inform policies. I am looking to identify similarities and differences in objectives of national and regional policies in each sector, as well as exploring whom they affect and their intended impacts. The aim is to move towards unifying water, food and land governance.

Michael Blackstock examines climate change from a water-centred perspective. Credit: Mike Bednar

MICHAEL BLACKSTOCK: Shift attitudes towards water

In 2000, I conducted an ethnographic interview with Indigenous Elder Millie Michell from the Siska Nation in British Columbia, Canada, that transformed my interest in water from intellectual curiosity to passion. She passed a torch to me that fateful day. During our conversation for my research about the Indigenous spiritual and ecological perspective on water, she asked me: “Now that I shared my teachings and worries about water, what are you going to do about it?” She died of a stroke a few hours later.

As an independent Indigenous scholar, I went on to examine climate change from a water-centred perspective — drying rivers, downpours, floods and melting ice caps are all water. This approach, for which I coined the term ‘blue ecology’, interweaves Indigenous and non-Indigenous ways of thinking. It acknowledges water’s essential role in generating, sustaining, receiving and, ultimately, unifying life on Mother Earth. This means changing our collective attitude towards water.

In 2021, I co-founded the Blue Ecology Institute Foundation in Pavilion Lake, Canada, which teaches young people in particular to acknowledge the spiritual role of water in nature and in our lives, instead of taking it for granted as a commodity or ecosystem service. Giving back to nature with gratitude is also crucial. Such restrained consumption — taking only what is needed — would give abused ecosystems time to heal.

A focus on keeping water healthy can help to guide societies towards more sustainable environmental policies and climate-change resilience — and ensure that future generations will survive with dignity. Critics say, ‘Blue ecology is kinda out there.’ In my view, however, ‘here’ is not working.

Nature 627 , 732-734 (2024)

doi: https://doi.org/10.1038/d41586-024-00886-z

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The authors declare no competing interests.

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Bottled Water Contains Hundreds of Thousands of Microscopic Plastic Pieces, Research Shows

• Scientists detected a huge number of nanoplastics in bottled water sold in the United States.
• Nanoplastics, which are about 100,000 times smaller than a sheet of paper is thick, are even smaller and potentially more damaging than microplastics.
• It’s still unclear how plastic impacts human health, but some evidence suggests chemicals used to make plastic could disrupt hormones and even cause cancer.

The bottled water you drink may contain hundreds of thousands of microscopic pieces of plastic, new research shows.

Microplastics—tiny bits of plastic that range in size from 1 nanometer to 5 millimeters in diameter—have been widely studied in recent years and have been found virtually everywhere on Earth, from the far reaches of the Arctic to the lining of human placentas.

One analysis estimated that Americans ingest more than 44,000 microplastic particles every year and inhale more than 46,000. But until recently, scientists couldn’t reliably measure even smaller particles, called nanoplastics.  

Nanoplastics are less than 1 nanometer in size—a sheet of paper is about 100,000 nanometers thick, and a strand of DNA is 2.5 nanometers—and experts believe that if ingested, these bits of plastic can cross the blood-brain barrier, which protects the brain from toxins.

The new study, published in January in the Proceedings of the National Academy of Sciences , estimated a human may consume as many as 370,000 nanoplastic particles in one liter of bottled water.  

“It’s sobering at the very least, if not very concerning,” Pankaj Pasricha, MD, MBBS , chair of the department of medicine at the Mayo Clinic, who was not involved with the new research, told Health . 

Lucas Ottone / Getty Images

Examining the Plastic in Bottled Water

For the new study, researchers tested three brands of bottled water sold in the United States, though the authors did not disclose which brands they included. They found that the water harbored an average of 240,000 pieces of plastic, 90% of which were nanoplastics. The remaining 10% were microplastics, about a thousand times larger than nanoplastics. 

A 2018 study first identified microplastics in 93% of samples taken from 11 types of bottled water sold in nine different countries. The average was more than 300 microplastic particles per liter. However, the new study found a plastic bottle of water may contain more than a thousand times as many nanoplastics.  

“The concern with the nanoplastics in particular is that they have been found in human lungs and blood,” Phoebe Stapleton, PhD , an associate professor of pharmacology and toxicology at Rutgers University who co-authored the new study, told Health . “It means they are able to get through these traditional barriers. Now the questions are how long do they stay there, how do they get back out, and what are they doing when they are there?”

The team identified seven different plastic chemicals in their samples. Some chemicals, including polyethylene terephthalate (PET) and polyethylene (PE), were found in all three brands. The water packaging’s bottles and caps were made from these types of plastic, leading the authors to believe bits of the material shed into the water during packaging and transportation.

Other types, including polyvinyl chloride or vinyl (PVC), polyamide nylon (PA), polypropylene (PP), and polystyrene (PS), which is typically used in plastic foam, were likely introduced to the water before it was packaged since the packaging was not made from these materials.

“Because these nanoplastics are so small, they cannot get filtered out. They may have been in that source water,” said Stapleton, adding that nanoplastics may also have been introduced during the filtration process itself.

Because plastic is so ubiquitous in the environment, and plastic packaging is not the only way nanoplastics appear to get into food and water, the particles are virtually impossible to avoid completely, Pasricha said.

However, “it’s certainly possible that air or water filters could be designed to filter them out, and now that we know how to measure these particles, I am sure a lot of efforts towards that technology will happen,” he said.

Is Plastic Bad for Human Health?

At least 4,000 known chemicals are used to make plastic. Scientists don’t know how the vast majority may or may not impact human health.  

Pasricha said he expects studies like this to be a call to action for the scientific community to better understand how different types of plastic impact human health.

“Scientists have speculated for a long time that these particles, whether inhaled or ingested, have the ability to do significant damage to the body,” he said. “It’s still not fully clear how they do that; they could do that because of their intrinsic toxicity, or they could be carriers of toxic materials even though they themselves are relatively inert.”

Bisphenol A (BPA), a chemical additive used in some plastics, has been found to be a reproductive and developmental toxin. For this reason, the Food and Drug Administration banned BPA in baby bottles and sippy cups in late 2012, but it’s still allowed in food and beverage packaging.

“Cells are able to take in plastics, especially nanoplastics, internalize, and bring them into the cells,” Stapleton told Health . “There has been some evidence of oxidative stress, changes to DNA and inflammation due to those particle-cell interactions.”

Oxidative stress occurs when there is an imbalance between free radicals and antioxidants, which neutralize free radicals. If not kept in check, free radicals react with other chemicals in the body and can damage fatty tissue, DNA, and proteins, leading to diseases such as diabetes and cancer.

Most research into plastic compounds’ effects on health has been conducted on animals, not humans. While some human studies have found phthalates, one of the most common chemicals used to make plastic, may cause more weight gain during pregnancy and increase a woman’s risk for gestational diabetes, these studies have not yet proven cause and effect.

Scientists are concerned that both phthalates and BPA are endocrine disruptors, meaning the chemicals interfere with hormones. This can particularly impact people who are assigned female at birth (AFAB). The Environmental Protection Agency recognizes DEHP, one of the most widely used phthalates, as a probable carcinogen, but its use hasn’t been restricted like BPA’s.  

Most of the current evidence is circumstantial. Still, it isn’t a wide leap to assume ingesting plastic particles can have health impacts in the same way other particles, such as those found in air pollution, have been shown to harm human health, Pasricha said.

“These small particles are potentially of more concern to your health,” he said. “The smaller the particle, the more likely it can get into cells and penetrate the blood-brain barrier, and they are present in everyday sources like bottled water in quantities that appear to be even larger than microplastic particles.”

The Challenges of Studying Plastic

One reason for the lack of information about plastic’s health impacts is that scientists still know little about the material itself.

This was illustrated in a 2019 study examining eight common classes of plastics used in household items, including yogurt cups and sponges. Researchers found that six out of the eight contained toxic chemicals, but of the 1,400 total compounds the products contained, the team could only identify 260 of them.  

“Plastic has the ability to absorb other things, too,” Stapleton said. “If it comes into contact with organic material or metals, it can release those compounds in the body as well.”

Although it’s still unclear exactly how plastics and the chemical additives used to make everyday plastic products may interfere with human health, one thing is certain: Humans are regularly ingesting plastic. 

“We have now seen the extent of exposure, and it’s certainly cause for concern,” Pasricha said.

Environmental Protection Agency. Microplastics research .

Cox KD, Covernton GA, Davies HL, Dower JF, Juanes F, Dudas SE. Human consumption of microplastics . Environ Sci Technol . 2019;53(12):7068-7074. doi:10.1021/acs.est.9b01517

Qian N, Gao X, Lang X, et al. Rapid single-particle chemical imaging of nanoplastics by SRS microscopy . Proc Natl Acad Sci U S A . 2024;121(3):e2300582121. doi:10.1073/pnas.2300582121

Mason SA, Welch VG, Neratko J. Synthetic polymer contamination in bottled water . Front Chem . 2018;6:407. doi:10.3389/fchem.2018.00407

Zimmermann L, Dierkes G, Ternes TA, Völker C, Wagner M. Benchmarking the in vitro toxicity and chemical composition of plastic consumer products . Environ Sci Technol . 2019;53(19):11467-11477. doi:10.1021/acs.est.9b02293

Food and Drug Administration. Bisphenol A (BPA): use in food contact application .

Environmental Protection Agency. Di (2-ethylhexyl) phthalate (DEHP) .

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The intermittent fasting trend may pose risks to your heart

Intermittent fasting — when people only eat at certain times of day — has exploded in popularity in recent years. But now a surprising new study suggests that there might be reason to be cautious: It found that some intermittent fasters were more likely to die of heart disease.

The findings were presented Monday at an American Heart Association meeting in Chicago and focused on a popular version of intermittent fasting that involves eating all your meals in just eight hours or less — resulting in at least a 16-hour daily fast, commonly known as “time-restricted” eating.

The study analyzed data on the dietary habits of 20,000 adults across the United States who were followed from 2003 to 2018. They found that people who adhered to the eight-hour eating plan had a 91 percent higher risk of dying from heart disease compared to people who followed a more traditional dietary pattern of eating their food across 12 to 16 hours each day.

The scientists found that this increased risk also applied to people who were already living with a chronic disease or cancer. People with existing cardiovascular disease who followed a time-restricted eating pattern had a 66 percent higher risk of dying from heart disease or a stroke. Those who had cancer meanwhile were more likely to die of the disease if they followed a time-restricted diet compared to people with cancer who followed an eating duration of at least 16 hours a day.

The study results suggest that people who practice intermittent fasting for long periods of time, particularly those with existing heart conditions or cancer, should be “extremely cautious,” said Victor Wenze Zhong, the lead author and the chair of the department of epidemiology and biostatistics at the Shanghai Jiao Tong University School of Medicine in China.

“Based on the evidence as of now, focusing on what people eat appears to be more important than focusing on the time when they eat,” he added.

Zhong said that he and his colleagues conducted the new study because they wanted to see how eating in a narrow window each day would impact “hard endpoints” such as heart disease and mortality. He said that they were surprised by their findings.

“We had expected that long-term adoption of eight-hour time restricted eating would be associated with a lower risk of cardiovascular death and even all-cause death,” he said.

Losing lean muscle mass

The data didn’t explain why time-restricted eating increased a person’s health risks. But the researchers did find that people who followed a 16:8 time-restricted eating pattern, where they eat during an eight-hour window and fast for 16, had less lean muscle mass compared to people who ate throughout longer periods of the day. That lines up with a previous clinical trial published in JAMA Internal Medicine , which found that people assigned to follow a time-restricted diet for three months lost more muscle than a control group that was not assigned to do intermittent fasting.

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Holding onto muscle as you age is important. It protects you against falls and disability and can boost your metabolic health. Studies have found that having low muscle mass is linked to higher mortality rates, including a higher risk of dying from heart disease, said Zhong.

He stressed that the findings were not definitive. The study uncovered a correlation between time-restricted eating and increased mortality, but it could not show cause and effect. It’s possible for example that people who restricted their food intake to an eight-hour daily window had other habits or risk factors that might explain their increased likelihood of dying from heart disease. The scientists also noted that the study relied on self-reported dietary information. It’s also possible that the participants did not always accurately report their eating durations.

A trendy form of dieting and weight control

Intermittent fasting has been widely touted by celebrities and health experts who say it produces weight loss and a variety of health benefits. Another form of intermittent fasting involves alternating fasting days with days of eating normally. Some people follow the 5:2 diet, in which they eat normally for five days a week and then fast for two days.

But time-restricted eating is generally considered the easiest form of intermittent fasting for people to follow because it doesn’t require full-day fasts. It also typically doesn’t involve excessive food restriction. Adherents often eat or drink whatever they want during the eight-hour eating period — the only rule is that they don’t eat at other times of day.

Some of the earliest studies on time-restricted eating found that it helped prevent mice from developing obesity and metabolic syndrome. These were followed by mostly small clinical trials in humans, some of which showed that time-restricted eating helped people lose weight and improve their blood pressure , blood sugar and cholesterol levels. These studies were largely short-term, typically lasting one to three months, and in some cases showed no benefit .

One of the most rigorous studies of time-restricted eating was published in the New England Journal of Medicine in 2022. It found that people with obesity who were assigned to follow a low-calorie diet and instructed to eat only between the hours of 8 a.m. and 4 p.m. daily lost no more weight than people who ate the same number of calories throughout the day with no restrictions on when they could eat. The two diets had similar effects on blood pressure, blood sugar, cholesterol, and other metabolic markers.

The findings suggest that any benefits of time-restricted eating likely result from eating fewer calories.

More questions about intermittent fasting

Christopher Gardner, the director of nutrition studies at the Stanford Prevention Research Center, said he encouraged people to approach the new study with “healthy skepticism.” He said that while the findings were interesting, he wants to see all the data, including potential demographic differences in the study subjects.

“Did they all have the same level of disposable income and the same level of stress,” he said. “Or is it that the people who ate less than eight hours a day worked three jobs, had very high stress, and didn’t have time to eat?”

Gardner said that studying intermittent fasting can be challenging because there are so many variations of it, and determining its impact on longevity requires closely following people for long periods of time.

But he said that so far, the evidence supporting intermittent fasting for weight loss and other outcomes is mixed at best, with some studies showing short-term benefits and others showing no benefit at all. “I don’t think the data are very strong for intermittent fasting,” he added. “One of the challenges in nutrition is that just because something works really well for a few people doesn’t mean it’s going to work for everyone.”

He said that his biggest complaint with intermittent fasting is that it doesn’t address diet quality. “It doesn’t say anything about choosing poorly when you’re eating,” he said. “What if I have an eight-hour eating window but I’m eating Pop Tarts and Cheetos and drinking Coke in that window? I’m not a fan of that long term. I think that’s potentially problematic.”

Do you have a question about healthy eating? Email [email protected] and we may answer your question in a future column.

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