Investigating Water Balance as a Nutritional Determinant in Breastfeeding: A Comparative Study of Water Consumption Patterns and Influencing Factors.

BACKGROUND: Ensuring adequate hydration is critical for breastfeeding women, yet their water consumption patterns and hydration status is poorly understood. This study investigates the water consumption patterns and estimated water balance among women, practicing exclusive, mixed, and no breastfeeding methods. METHODS: 529 healthy women completed the Nursing Water Balanced Questionnaire (N-WBQ). Participants were distributed across breastfeeding groups as follows: exclusive (39.7%), mixed (31.9%), and no breastfeeding (28.4%). RESULTS: Significant differences were noted in water consumption patterns among breastfeeding groups regarding intake from beverages (p < 0.001), juices (p = 0.019), coffee (p < 0.001), and milk (p = 0.015). Water intake from liquids, except for drinking water (p < 0.001), juices (p = 0.024) and coffee (p < 0.001) differed significantly among groups in women with adequate total water intake based on recommendation, with exclusive breastfeeding mothers prioritizing plain water over other beverages. Total water loss (p < 0.001) and estimated water balance (p < 0.001) significantly varied among breastfeeding groups, with exclusive breastfeeding mothers to exhibit the lowest water balance (-475.36 mL/day), indicating potential dehydration risk. Apart from plain water, water from foods, coffee and milk significantly contributed to positive water balance. CONCLUSIONS: Our findings highlight a risk of dehydration in this population, while water consumption patterns are influenced by breastfeeding method, likely affected by varying lactational demands and lifestyle factors. Further research to develop more accurate and individualized methods for assessing water balance in breastfeeding women is needed.

Dietary Intake and Lifestyle Habits of Children Aged 10-12 Years Enrolled in the School Lunch Program in Greece: A Cross Sectional Analysis.

School Lunch programs are a common strategy to address social inequalities in food access among children, especially food insecurity. The aim of this study was to evaluate the dietary intake and lifestyle habits of children aged 10-12 years enrolled in the School Lunch Program in Greece. A cross-sectional survey of fifth and sixth grade students, School Lunch recipients (n = 609) and control subjects (n = 736), collected data on sociodemographic, nutritional and lifestyle habits via self-reported questionnaires during May-October 2019. Despite enrollment in the School Lunch Program children in this group reported consuming less meals during the day (3.47 ± 1.38 vs. 3.65 ± 1.35, p = 0.002). No differences were seen in intakes of energy and macronutrients, however School Lunch recipients reported lower intakes of cereals/potatoes and legumes but higher fruit intake (2.32 ± 1.59 vs. 1.97 ± 1.72, p < 0.05). School Lunch recipients reported 42min/d and 28min/d higher screen-time during weekdays and weekends, respectively. Linear regression highlighted that dietary quality was not associated with School Lunch enrollment but rather sleep duration and screen time had a stronger influence on dietary habits. Enrollment in a School Lunch Program was linked to sustained differences in sedentary lifestyle habits but less so in dietary habits.

Impact of COVID-19 confinement on eating behaviours across 16 European countries: The COVIDiet cross-national study.

We aimed to evaluate the changes in eating behaviours of the adult population across 16 European countries due to the COVID-19 confinement and to evaluate whether these changes were somehow related to the severity of the containment measures applied in each country. An anonymous online self-reported questionnaire on socio-demographic characteristics, validated 14-items Mediterranean diet (MedDiet) Adherence Screener (MEDAS) as a reference of a healthy diet, eating and lifestyle behaviours prior to and during the COVID-19 confinement was used to collect data. The study included an adult population residing in 16 European countries at the time of the survey. Aggregated Stringency Index (SI) score, based on data from the Oxford COVID-19 Government Response Tracker, was calculated for each country at the time the questionnaire was distributed (range: 0-100). A total of 36,185 participants completed the questionnaire (77.6% female, 75.2% with high educational level and 42.7% aged between 21 and 35 years). In comparison to pre-confinement, a significantly higher adherence to the MedDiet during the confinement was observed across all countries (overall MEDAS score prior to- and during confinement: 5.23 ± 2.06 vs. 6.15 ± 2.06; p < 0.001), with the largest increase seen in Greece and North Macedonia. The highest adherence to MedDiet during confinement was found in Spain and Portugal (7.18 ± 1.84 and 7.34 ± 1.95, respectively). Stricter contingency restrictions seemed to lead to a significantly higher increase in the adherence to the MedDiet. The findings from this cross-sectional study could be used to inform current diet-related public health guidelines to ensure optimal nutrition is followed among the population, which in turn would help to alleviate the current public health crisis.

Nutrition Transition in the Post-Economic Crisis of Greece: Assessing the Nutritional Gap of Food-Insecure Individuals. A Cross-Sectional Study.

Food insecurity has risen by 40% in Europe's post-economic crisis, linked to the economic turmoil and austerity. Despite the intensification of efforts to fight all forms of poverty, including the implementation of programs targeted to the most deprived, the study of individuals at risk of food insecurity has been largely neglected. This study aimed to map the nutritional habits and needs of the most deprived in Greece, one of the countries most affected by the economic crisis. Individuals classified as most deprived under the Fund for the European Aid to the Most Deprived (FEAD) criteria (n = 499) from across Greece and an age matched control from the general population (n = 500) were interviewed between December 2017 and December 2019. Participants provided information about demographic characteristics, and self-reported anthropometric measures and nutritional intake of the past month via a food frequency questionnaire (FFQ). Protein and energy malnutrition were defined as daily intake <1.950 kcal and ≤0.75 g/kg body-weight accordingly. Protein and energy malnutrition were high among FEAD recipients (52.3% and 18.6% respectively, p < 0.001), alongside a high prevalence of overweight and obesity (BMI > 25: 68.4% versus 55.1%; p < 0.001). The diet of FEAD recipients included higher amounts of carbohydrates, lower amounts of monounsaturated fat (MUFA) and polyunsaturated fat (PUFA; p < 0.001 compared to control), larger amounts of plant-based proteins (5.81 ± 1.7 versus 4.94 ± 1.3% E respectively, p < 0.001) and very limited intake of fish (0.07 portions/day). Despite being enrolled in a food assistance program, protein and energy malnutrition is prevalent among Greece's most deprived who experience not only lower diet quality but also the double burden of malnutrition.

Fluctuation of Water Intake and of Hydration Indices during the Day in a Sample of Healthy Greek Adults.

Mild dehydration may occur during specific periods of the day because of poor hydration habits and/or limited access to a variety of beverages or foods, for example, in work environments. Measurement of hydration indices in spot or in 24 h urine samples may mask mild dehydration in specific periods of the day. Healthy subjects (n = 164; 74 females; age 38 ± 12 years) living in Athens, Greece were enrolled in the study. Subjects recorded their solid food and drink intakes and recorded and collected all urinations for three consecutive days. Water intake was analyzed in 24 h and 6 h periods from wake-up time and scored for variety. Urine hydration indices (osmolality, volume, color, specific gravity) were analyzed in 24 h samples, in morning urine samples and in samples collected in 6 h periods from wake-up time. Fluctuations during the day were significant for the intake of drinking water, hot beverages, milk, fruit and vegetable juices, and alcoholic drinks and for urine osmolality, volume, color, and specific gravity. The urine volume of the first 6 h period after wake-up time (557 ± 231 mL/day) reflects by 76% the 24 h urine collection (1331 ± 144 mL/day). Water intake from all beverages, with the exception of alcoholic beverages, was greater in the first 6h period (morning period) and decreased throughout the day. Hydration indices changed accordingly. The 6 h timed urine sample collected reflects indices in samples collected over 24 h better than any spot urine sample.

Differing Water Intake and Hydration Status in Three European Countries-A Day-to-Day Analysis.

Adequate hydration is essential for maintaining health and functionality of the human body. Studies assessing both daily water intake and hydration status are lacking. This study explored data from the European Hydration Research Study (EHRS) and focused on total water intake (TWI), 24 h hydration status, and day-to-day variations in a sample of 573 healthy adults. TWI was assessed by food records and hydration status (urine osmolality and urine volume) was measured from 24 urine samples collected over seven consecutive days. On all weekdays, mean TWI was higher (p < 0.001 for all days) for the German subjects compared to the Greek and Spanish participants. In 37% of the male and 22% of the female subjects, the individual mean TWI was below the European Food Safety Authority (EFSA) recommendation, with 16% men (4% women) being below the EFSA recommendation on every testing day. Twenty-four hour urine osmolality was lower in women compared to men (595 ± 261 vs. 681 ± 237 mOsmol/kg; p < 0.001). More men (40%) showed a urine osmolality ≥800 mOsmol/kg at least on four days of the study period compared to women (26%) and more participants from Spain (46%) compared to Greece (29%) and Germany (11%). A large number of individuals showed an inadequate hydration status on several days per week, which may have a negative health and cognitive impact on daily life.

Sodium and Potassium Intake from Food Diaries and 24-h Urine Collections from 7 Days in a Sample of Healthy Greek Adults.

OBJECTIVE: The main objective of the present study was to evaluate sodium and potassium intake, employing 24 h and spot urine samples and food diaries for seven consecutive days. METHODS: For seven consecutive days subjects recorded their food and drink intakes, and recorded and collected all urinations. Food sodium and potassium intake were analyzed in 24- and 6-h intervals from wake-up time. Urine indices were analyzed in first morning, 24- and 6-h intervals samples over the day from wake-up time. The study took place in Agricultural University of Athens, Greece. In total, 163 healthy subjects (age 39 ± 12 years; 74 females) were enrolled in the study. RESULTS: Mean urine sodium excretion was 2,803.3 ± 1,249.0 mg/day (121.9 ± 54.3 mmol/day) and mean urine potassium excretion was 2,152.2 ± 913.3 mg/day (55.2 ± 23.4 mmol/day). The highest potassium concentration was measured in the afternoon, while the lowest sodium concentration was measured in the overnight 6-h interval. Food sodium intake was 1,983.2 ± 814.1 mg/day and food potassium was 2,264.5 ± 653.3 mg/day. The sources that contribute most in food sodium intake are dairy products 24%, breads 22%, and savory snacks 17%. CONCLUSION: Strategies should encourage the Greek population to moderate sodium intake and promote potassium intake, thus adopting a healthier dietary and lifestyle pattern.

Evaluation of water balance in a population of older adults. A case control study.

Older adults are at risk for dehydration and its' potentially life-threatening consequences. Unrecognized dehydration can complicate chronic medical problems and increase morbidity. The objective of the study was to estimate water balance, intake and loss in elderly people living in Greece using the Water Balance Questionnaire (WBQ). WBQ was administered in winter to 108 independents (65-81yrs) (Group A), 94 independents (82-92yrs) (Group B) and 51 hospitalized (65-92yrs) (Group C). A database from previous study of 335 adults (18-65yrs) (Control Group) used for comparison. Mean estimates of water balance, intake and loss were, respectively, for Group A -749 ± 1386 mL/day, 2571 ± 739 mL/day and 3320 ± 1216 mL/day, for Group B -38 ± 933 mL/day, 2571 ± 739 mL/day and 3320 ± 1216 mL/day, for Group C 64 ± 1399 mL/day, 2586 ± 1071 mL/day and 2522 ± 1048 mL/day and for Control Group -253 ± 1495 mL/day, 2912 ± 1025 mL/day and 3492 ± 2099 mL/day. Significant differences were detected in water balance, intake and loss (p < 0.01). Water balance and water intake in Group A was the lowest. For Groups A, B, C and Control, contribution of solid foods to water intake was 36%, 29%, 32%, 25%, of drinking water was 32%, 48%, 45%, 47%, of beverages was 32%, 23%, 23% and 28% respectively. Significant differences observed in the contribution of drinking water and beverages (p < 0.01). Group A had lower water balance and water intake. Groups B and C had lower water intake from beverages.

Water Intake in a Sample of Greek Adults Evaluated with the Water Balance Questionnaire (WBQ) and a Seven-Day Diary.

Awareness on the importance of hydration in health has created an unequivocal need to enrich knowledge on water intake of the general population and on the contribution of beverages to total water intake. We evaluated in the past water intake in a sample of Greek adults using two approaches. In study A, volunteers completed the Water Balance Questionnaire (WBQ), a food frequency questionnaire, designed to evaluate water intake (n = 1092; 48.1% males; 43 ± 18 years). In study B, a different population of volunteers recorded water, beverage, and food intake in seven-day diaries (n = 178; 51.1% males; 37 ± 12 years). Herein, data were reanalyzed with the objective to reveal the contribution of beverages in total water intake with these different methodologies. Beverage recording was grouped in the following categories: Hot beverages; milk; fruit and vegetable juices; caloric soft drinks; diet soft drinks; alcoholic drinks; other beverages; and water. Total water intake and water intake from beverages was 3254 (SE 43) mL/day and 2551 (SE 39) mL/day in study A; and 2349 (SE 59) mL/day and 1832 (SE 56) mL/day in study B. In both studies water had the highest contribution to total water intake, approximately 50% of total water intake, followed by hot beverages (10% of total water intake) and milk (5% of total water intake). These two approaches contribute information on water intake in Greece and highlight the contribution of different beverages; moreover, they point out differences in results obtained from different methodologies attributed to limitations in their use.

Water Intake and Hydration Indices in Healthy European Adults: The European Hydration Research Study (EHRS).

Hydration status is linked with health, wellness, and performance. We evaluated hydration status, water intake, and urine output for seven consecutive days in healthy adults. Volunteers living in Spain, Germany, or Greece (n = 573, 39 ± 12 years (51.1% males), 25.0 ± 4.6 kg/m² BMI) participated in an eight-day study protocol. Total water intake was estimated from seven-day food and drink diaries. Hydration status was measured in urine samples collected over 24 h for seven days and in blood samples collected in fasting state on the mornings of days 1 and 8. Total daily water intake was 2.75 ± 1.01 L, water from beverages 2.10 ± 0.91 L, water from foods 0.66 ± 0.29 L. Urine parameters were: 24 h volume 1.65 ± 0.70 L, 24 h osmolality 631 ± 221 mOsmol/kg Η2Ο, 24 h specific gravity 1.017 ± 0.005, 24 h excretion of sodium 166.9 ± 54.7 mEq, 24 h excretion of potassium 72.4 ± 24.6 mEq, color chart 4.2 ± 1.4. Predictors for urine osmolality were age, country, gender, and BMI. Blood indices were: haemoglobin concentration 14.7 ± 1.7 g/dL, hematocrit 43% ± 4% and serum osmolality 294 ± 9 mOsmol/kg Η2Ο. Daily water intake was higher in summer (2.8 ± 1.02 L) than in winter (2.6 ± 0.98 L) (p = 0.019). Water intake was associated negatively with urine specific gravity, urine color, and urine sodium and potassium concentrations (p < 0.01). Applying urine osmolality cut-offs, approximately 60% of participants were euhydrated and 20% hyperhydrated or dehydrated. Most participants were euhydrated, but a substantial number of people (40%) deviated from a normal hydration level.

Influence of Physical Activity and Ambient Temperature on Hydration: The European Hydration Research Study (EHRS).

This study explored the effects of physical activity (PA) and ambient temperature on water turnover and hydration status. Five-hundred seventy three healthy men and women (aged 20-60 years) from Spain, Greece and Germany self-reported PA, registered all food and beverage intake, and collected 24-h urine during seven consecutive days. Fasting blood samples were collected at the onset and end of the study. Food moisture was assessed using nutritional software to account for all water intake which was subtracted from daily urine volume to allow calculation of non-renal water loss (i.e., mostly sweating). Hydration status was assessed by urine and blood osmolality. A negative association was seen between ambient temperature and PA (r = -0.277; p < 0.001). Lower PA with high temperatures did not prevent increased non-renal water losses (i.e., sweating) and elevated urine and blood osmolality (r = 0.218 to 0.163 all p < 0.001). When summer and winter data were combined PA was negatively associated with urine osmolality (r = -0.153; p = 0.001). Our data suggest that environmental heat acts to reduce voluntary PA but this is not sufficient to prevent moderate dehydration (increased osmolality). On the other hand, increased PA is associated with improved hydration status (i.e., lower urine and blood osmolality).

Evaluation of drinks contribution to energy intake in summer and winter.

All drinks hydrate and most also provide nutrients and energy. Our objective was to evaluate the contribution of drinks to total energy intake in summer and winter. Data were obtained using the Water Balance Questionnaire (WBQ) from a sample of the general population in Athens, Greece (n = 984), 473 individuals (42 ± 18 years) in summer and 511 individuals (38 ± 20 years) in winter stratified by sex and age. The WBQ embeds a semi-quantitative food frequency questionnaire of 58 foods and the Short International Physical Activity Questionnaire. Data were analyzed for the contribution of drinks to total energy intake. In winter, total energy intake was 2082 ± 892 kcal/day; energy intake from drinks was 479 ± 286 kcal/day and energy expenditure 1860 ± 390 kcal/day. In summer, total energy intake was 1890 ± 894 kcal/day, energy intake from drinks 492 ± 499 kcal/day and energy expenditure 1830 ± 491 kcal/day. Energy intake from drinks in summer was higher than in winter (p < 0.001) and in men higher than in women in both seasons (p < 0.001 in summer, p = 0.02 in winter). Coffee, coffee drinks, milk, chocolate milk and alcoholic drinks contributed approximately 75% of energy from drinks. Fruit juice and sugar-sweetened drinks, including soft drinks and fruit juice based drinks, were consumed less frequently contributing up to 25% of drink energy intake. Drinks contribute approximately 1/4 of total energy intake depending on the energy content of the drink and frequency of consumption. Coffee, dairy and alcoholic drinks were the main energy contributors.

Estimations of water balance after validating and administering the water balance questionnaire in pregnant women.

Dehydration during pregnancy may be harmful for the mother and fetus; thus our objective was to understand whether pregnant women balance water intake and loss. The Water Balance Questionnaire (WBQ) was modified to reflect pregnancy (WBQ-P). Validation was performed using 3-day diaries (n = 60) and hydration indices in urine (osmolality, specific gravity, pH and color, n = 40). The WBQ-P was found valid according to Kedhal τ-b coefficient agreement. The WBQ-P was administered to 95, 100 and 97 women per trimester, in Greece. Median (IQR) water balance, intake and loss were, respectively, 203 (-577, 971), 2917 (2187, 3544) and 2658 (2078, 3391) ml/day; these did not differ among the trimesters or between pregnant and non-pregnant women. However, more pregnant women were falling in the higher quartiles of water balance distribution. No differences in sources of water intake were identified except that women in the third trimester had lower water intake from beverages.

The water balance questionnaire: design, reliability and validity of a questionnaire to evaluate water balance in the general population.

There is a need to develop a questionnaire as a research tool for the evaluation of water balance in the general population. The water balance questionnaire (WBQ) was designed to evaluate water intake from fluid and solid foods and drinking water, and water loss from urine, faeces and sweat at sedentary conditions and physical activity. For validation purposes, the WBQ was administrated in 40 apparently healthy participants aged 22-57 years (37.5% males). Hydration indices in urine (24 h volume, osmolality, specific gravity, pH, colour) were measured through established procedures. Furthermore, the questionnaire was administered twice to 175 subjects to evaluate its reliability. Kendall's τ-b and the Bland and Altman method were used to assess the questionnaire's validity and reliability. The proposed WBQ to assess water balance in healthy individuals was found to be valid and reliable, and it could thus be a useful tool in future projects that aim to evaluate water balance.