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The role of healthy hydration in obesity prevention

By Prof. David Haslam, 25 February 2011

European Food Safety Authority (EFSA) opinion recognises that adequate hydration is essential for health and what we drink can contribute to calorie intake. As such, EFSA promotes drinking more energy-free beverages such as water.1 While obesity and type 2 diabetes guidelines cover changes in physical activity and diet, most dietary recommendations focus on food content.2-4 There’s often little or no advice on the importance of healthier hydration practices.2-4 Common sense dictates that it’s time to remedy this with some simple patient advice. Here’s my perspective.

Overweight and obesity

The rapid rise in overweight and obesity with associated CV risk factors is a serious challenge in many places around the world.5

In a 2006 TED talk, Dr Dean Ornish, clinical professor at UCSF and founder of the Preventive Medicine Research Institute, highlighted that this may be the first generation in which children lead a shorter life span than their parents. He reports that with the global uptake of a western diet, cardiovascular disease now kills more people than everything else combined.6 His good news is that it’s mostly preventable or reversible with simple changes in diet and lifestyle – that’s the ‘power of low-tech and low-cost interventions’.

The simple fact is, the primary causes of overweight and obesity are considered to be a combination of reduced physical exercise and increased consumption of energy-dense foods that are high in sugars and fats.5,7 So how does what we drink fit into all of this?

Sugar-sweetened beverages and fruit juice

During the last 30 years, there has been a noticeable increase in sugar-sweetened beverage (SSB) consumption worldwide.8 Although some observational studies support the hypothesis that SSB produce weight gain, causality is still under debate.9,10

Of course, occasional or moderate consumption of SSB in addition to a healthy, balanced diet is not an issue but it’s important that everyone is aware of the potentially harmful effects of excessive or habitual consumption on long-term health, particularly in children and adolescents, described in current literature.11 Perhaps less obvious is that while fruit juice has a role as an integral part of a healthy balanced diet, excessive consumption may contribute to weight gain and an increased risk of diabetes.12,13 (And, let’s not forget that sweetened fruit juice may contain even more sugar than a carbonated SSB).

Obesity in children: The increasing increase

Have you noticed the increase in overweight and obesity in children?14,15 Around 22 million children under 5 years old are now estimated to be overweight worldwide.5 In parts of Europe, the prevalence of overweight or obesity in school-age children has risen to about 35% – and the increase itself continues to increase.16

The health risks of obesity in children are the same as in adults.17,18 In Europe, over 20,000 obese children have type 2 diabetes and more than a million have CV risk factors.19 Equally disturbing is that it’s not restricted to developed, industrialised countries: a number of developing countries including Brazil, Mexico, Pakistan, India and China have reported rapid increases in prevalence.20, 21

What should we do about it?

Recent studies have shown that increasing water intake and reducing carbonated SSB consumption is effective at preventing excessive weight gain in schoolchildren.22-24

While results in the school setting are positive, public health and healthcare professionals need to step up.
Fortunately, this is exactly what’s happening. In anticipation of the potential benefits of healthy hydration advice, some countries such as Mexico and Indonesia have proposed public-health models and initiated healthy hydration guidance.25-27 I hope to report on the progress of other countries in future blogs.

Addressing the general public’s misconceptions and current lack of information is a way forward and we owe it to our children to make a commitment to put healthy hydration into practice. So if we communicate only one thing about healthy hydration to our patients, young and old, it should be this:

A simple and decisive step towards a healthier lifestyle is to drink plenty of fluids ensuring that water represents the bulk of your daily intake.


Click here to view references
  1. EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA); Scientific Opinion on Dietary reference values for water. EFSA Journal 2010; 8(3):1459. [48 pp.]. doi:10.2903/j.efsa.2010.1459. Available at: http://www.efsa.europa.eu/en/efsajournal/pub/1459.htm. Accessed January 2011.
  2. International Diabetes Federation (IDF). Global guideline for type 2 diabetes. 2005. Available at: http://www.idf.org/webdata/docs/IDF%20GGT2D.pdf. Accessed January 2011.
  3. National Institutes of Health (NIH): North American Association for the Study of Obesity (NAASO)/National Heart, Lung and Blood Institute (NHLBI). The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 2000. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm. Accessed January 2011.
  4. National Institute for Health and Clinical Excellence (NICE)/National Collaborating Centre for Primary Care (NCCPC). Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. 2006. Available at: http://www.nice.org.uk/CG043 Accessed January 2011.
  5. World Health Organization (WHO). Obesity and Overweight. Global Strategy on Diet, Physical Activity and Health. Available at: http://www.who.int/dietphysicalactivity. Accessed January 2011.
  6. http://www.ted.com/talks/dean_ornish_on_the_world_s_killer_diet.html
  7. James WP. The epidemiology of obesity: the size of the problem. J Intern Med 2008;263;336-352.
  8. Malik VS, Popkin BM, Bray GA, Després JP, Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010;121:1356-64.
  9. Drewnowski A, Bellisle F. Liquid calories, sugar, and body weight. Am J Clin Nutr. 2007;85:651-61.
  10. Wolff E, Dansinger ML. Soft drinks and weight gain: how strong is the link? Medscape J Med. 2008;10:189.
  11. Popkin BM, D'Anci KE, Rosenberg IH. Water, hydration, and health. Nutr Rev. 2010;68:439-58.
  12. Schulze MB, Manson JE, Ludwig DS, Colditz GA, Stampfer MJ, Willett WC, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA 2004;292:927-34.
  13. Bazzano LA, Li TY, Joshipura KJ, Hu FB. Intake of fruit, vegetables, and fruit juices and risk of diabetes in women. Diabetes Care 2008;31:1311-17.
  14. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357:505-8.
  15. Dehghan M, Akhtar-Danesh N, Merchant AT. Childhood obesity, prevalence and prevention. Nutr J. 2005 Sep 2;4:24.
  16. Jackson-Leach R, Lobstein T. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 1. The increase in the prevalence of child obesity in Europe is itself increasing. Int J Pediatr Obes 2006;1:26-32.
  17. Kahn SE, Hull RL, Utzschneider KM. Mechanisms linking obesity to insulin resistance and type 2 diabetes. Nature. 2006;444:840-6.
  18. Van Gaal LF, Mertens IL, De Block CE. Mechanisms linking obesity with cardiovascular disease. Nature. 2006;444:875-80.
  19. Lobstein T, Jackson-Leach R. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 2. Numbers of children with indicators of obesity-related disease. Int J Pediatr Obes 2006;1:33-41.
  20. Popkin BM. An overview on the nutrition transition and its health implications: the Bellagio meeting. Public Health Nutr. 2002;5:93-103.
  21. Kelishadi R. Childhood overweight, obesity, and the metabolic syndrome in developing countries. Epidemiol Rev. 2007;29:62-76.
  22. James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004;328:1237.
  23. Muckelbauer R, Libuda L, Clausen K, Toschke AM, Reinehr T, Kersting M. Promotion and Provision of Drinking Water in Schools for Overweight Prevention: Randomized, Controlled Cluster Trial Pediatrics 2009;123:e661-e667.
  24. Sichieri R, Paula Trotte A, de Souza RA, Veiga GV. School randomised trial on prevention of excessive weight gain by discouraging students from drinking sodas. Public Health Nutr. 2009;12:197-202.
  25. Rivera JA, Muñoz-Hernández O, Rosas-Peralta M, Aguilar-Salinas CA, Popkin BM, Willett WC. Beverage consumption for a healthy life: recommendations for the Mexican population. Salud Publica Mex. 2008;50:173-95.
  26. Mexican Ministry of Health. 5 Pasos pur tu salud para Vivor Mejor 2009-2012. Available at: http://5pasos.org.mx/5p/index.php. Accessed January 2011.
  27. Hardinsyah. Air komponen utama dalam gizi seimbang (Water is a major component in the balanced diet). Makalah disajikan pada Kongres IAKMI (Paper presented at the Indonesian Public Health Association National Conference, 2010, Bandung, Indonesia).

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  • Professor J Ritchie Wrote:

    Excessive consumption of SSB seems to impact on almost every aspect of our health. A study published in Hypertension has now shown drinking too many SSBs appears to increase the risk of hypertension.

    The data on over 2,500 people show blood pressure goes up incrementally for every extra can of SSB consumed per day, with more than 355ml a day of sugar-sweetened fruit juice or carbonated drink being enough to upset the balance.

    Participants aged 40-59 years old from the UK and the US recorded what they had eaten in the preceding 24 hours on four separate occasions. They also provided a urine sample and had their blood pressure measured.

    The researchers found that sugar intake was highest in those consuming more than one sugar-sweetened beverage daily and that they consumed around 397 more calories a day than those who didn’t consume sugary drinks.

    Overall, the people who consumed a lot of SSB appeared to also have less healthy diets and were more likely to be overweight. And, even after adjusting for factors such as weight and height, for every extra can of sugary drink consumed per day, participants on average had a 0.8mmHg higher DBP and a 1.6mmHg higher SBP.

    While WHO recommends that added sugars represent no more than 10% of total energy intake, I prefer the simpler advice from the AHA which says people should drink no more than three 355ml cans of SSB a week.

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    March 11th, 2011 - 11:52
  • Lucas Wrote:

    Q: Are there any plans to introduce hydration into the various dietary and lifestyle modification guidelines listed?

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    February 28th, 2011 - 10:16
  • Dr Lowell Wrote:

    In terms of holistic advice, the low-tech, low-cost approach is not something our patients always appreciate.

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    February 28th, 2011 - 10:13

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