Water for Health. Hydration Best Practice Toolkit for Hospitals and Healthcare. part of the. campaign

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1 Water for Heath Hydration Best Practice Tookit for Hospitas and Heathcare

2 "Water is a basic nutrient of the human body and is critica to human ife" Word Heath Organization - Water Sanitation and Heath (WSH) This tookit has been created as a resource within the Roya Coege of Nursing Nutrition Now. It aims to assist nurses, heathcare workers, caterers and other service providers to introduce good hydration and to impement the heath benefits of drinking enough water. This tookit contains factsheets, checkists and advice to enabe you to improve water consumption with patients and hospita staff. It contains: 1 Introduction to the tookit 2 The heath and economic benefits of providing water 3 Wise up on water! Medica evidence for the heath benefits of hydration 4 Frequenty asked questions 5 Did you know? Facts about water as a nutrient 6 Practica tips for encouraging water consumption 7 Sampe menu for providing adequate fuids within heathcare 8 Hospita guidance and standards 9 How good are your water faciities? 10 Try the hydration awareness quiz 11 Hydration best practice - hospita water audit For the sake of simpicity, we wi use the word patient throughout this tookit to mean patients, cients, service users and residents. To protect their heath, staff, famiies and friends shoud aso observe the principes of good hydration. This tookit is supported by websites that contain the information incuded here, pus extra fact sheets, advice, supporting statements and additiona advice on achieving hydration best practice. Visit: "Where cinicay appropriate, patients shoud have access to fresh drinking water, at the correct temperature, at a times. It is recommended that patients are given assistance with their drinking whie the water is at the correct Evidence is avaiabe of the temperature" positive impact that good hydration can have on genera heath, we being and quaity of ife. The Water for Heath Aiance

3 Hospita Hydration Best Practice Tookit The heath and economic benefits of providing water Hospita Hydration Best Practice Tookit 1 Introduction to the tookit Dear Coeague Water is essentia to heath, and is one of the six basic nutrients (aong with carbohydrates, fats, vitamins, proteins and mineras), but is often overooked. This can resut in vunerabe individuas missing out on the support they need to hep maintain a heathy eve of hydration. This tookit has been deveoped to hep protect the we-being and safety of patients by encouraging hydration best practice in the hospita environment. It provides practica advice on how to minimize the risk and potentia harm that poor hydration can cause, and offers soutions to improving the provision of water to patients in hospitas Strong evidence on drinking water Evidence from the Nationa Patient Safety Agency s (NPSA) Nationa Reporting and Learning System has identified dehydration as a patient safety issue - medica evidence shows that good hydration can assist in the management of diabetes and hep prevent pressure ucers, constipation, urinary tract infections and incontinence, kidney stones, heart disease, ow bood pressure, cognitive impairment, fas, poor ora heath, skin conditions and many other inesses. A fundamenta aspect of nutritiona care The Roya Coege of Nursing (RCN) and the NPSA beieve that if we are to make hydration a top priority, everybody in the hospita environment, from the catering staff through to the chief executive, needs to pay a part. We are working with heathcare staff to continue to raise awareness of the importance of water and hydration to patient heath, and ensure that the provision of water is a fundamenta aspect of nutritiona care. continued over August 2007

4 Hospita Hydration Best Practice Tookit The heath and economic benefits of providing water This tookit, which buids on the RCN principes for Nutrition and Hydration, has been deveoped through partnership working with nurses, patient groups and key stakehoders. We hope that you find it usefu, and woud wecome your comments; pease send these to nutritionnow Geradine Cunningham Head of Institute Roya Coege of Nursing Martin Fetcher Chief Executive Nationa Patient Safety Agency August 2007

5 Hospita Hydration Best Practice Tookit The heath and economic benefits of providing water Hospita Hydration Best Practice Tookit 2 The heath and economic benefits of providing water Heath benefits Water is we known for its revitaising properties. Yet even though it is essentia to heath, it frequenty gets overooked as one of the six basic nutrients, aong with carbohydrates, fats, vitamins, proteins and mineras. This can resut in vunerabe individuas missing out on the support and guidance they need to hep maintain a heathy eve of hydration. The medica evidence for good hydration shows that it can assist in preventing or treating aiments such as: pressure ucers urinary infections and incontinence heart disease diabetes (management of) dizziness and confusion eading to fas skin conditions constipation kidney stones ow bood pressure cognitive impairment poor ora heath Furthermore, dehydration has been shown to increase by two-fod the mortaity of patients admitted to hospita with a stroke and to increase the ength of hospita stay for patients with communityacquired pneumonia. Improving hydration brings we-being and better quaity of ife for patients. It can aow reduced use of medication and prevent iness. It is good heathcare and dietary practice and the right thing to do. Providing fresh water aso demonstrates care of patients in a way that reatives and friends can see and enjoy. continued over August 2007

6 Hospita Hydration Best Practice Tookit The heath and economic benefits of providing water Economic benefits Encouraging the drinking of fresh water makes good economic sense for heathcare professionas on tight budgets. By heping to reduce incidences of some of the more common aiments, better hydration improves we-being and can reduce the voumes of medicines that are required. It can aso take away many hours of extra care time associated with inesses and remove some of the higher cost professiona invovement needed to prescribe and administer treatment. Drinking more water may indeed encourage patients to go to the toiet more often, but the investment in staff time can be regained through patients achieving a heathy toiet function, fewer soiing incidents, prevention of urinary tract infections, ess need for time-consuming enemas and ess need for axative products. The medicines that remain are proven to work more effectivey when the patient is propery hydrated. It is not often that a heathy option proves to be a cheaper soution, but taking drinking water from the tap is highy cost-effective. Avaiabe at around one tenth of a penny for each itre, tap water is as much as one thousand times cheaper than ess heathy sugary and caffeinated drink options. Where patients can be encouraged to choose the heathy option and consume fresh water, hospitas can save directy on the costs of purchasing, storing and suppying more expensive drinks. Tap water in the UK is of the highest quaity and is safe to drink. The costs of impementing good hydration and nutritiona practice are more than baanced by the ower maintenance costs of heathier peope. August 2007

7 Wise up on water! Hydration and heathy ageing

8 Introduction Water is we known for its revitaising properties. Yet even though it is vita to heath, it frequenty gets overooked as an essentia nutrient. This can resut in vunerabe individuas missing out on the support and guidance they need to maintain a heathy eve of hydration. Oder peope are a diverse group with individua needs, desires, and aspirations, which incude maintaining their own heath and fitness. As we get oder our body s needs and heath concerns change due to an increasing susceptibiity to degenerative disease. 1 Water can make a vauabe contribution to heath in od age. Water requirements Oder peope have very simiar water requirements to those of younger aduts. Athough there is currenty no agreed recommended daiy intake eve for water in the UK, estimates range from approximatey 1.2 itres 2 to 3.1 itres per day. 3 A conservative estimate for oder aduts is that daiy intake of fuids shoud not be ess than 1.6 itres per day. 4 Unfortunatey, many oder peope do not drink adequate amounts of water. A recent survey of water provision in UK care homes for the edery found that most residents ony consumed 2-4 gasses of water per day ( m). 5 Age as a factor in poor hydration The two dietary sources of water are food and drink. About 80 per cent comes from drinks and 20 per cent is contained in food. 3 Some oder peope, however, have diminished appetites or poor nutrition and may miss out on the vauabe component of their fuid intake contained in food. 6 The kidneys pay a vita roe in reguating the amount of fuid in the body, but their function deteriorates with age. Age-reated changes, such as aterations in hormone eves, aso mean that water baance takes onger to be restored even after a drink has been consumed. 7 Athough fuid baance can usuay be maintained under norma circumstances, dehydration can occur as a resut of: cognitive impairment changes in functiona abiity medication such as axatives, diuretics or hypnotics iness, or stress arising from other factors. 8 In addition, thirst, the body s natura response to dehydration, has been shown to be impaired in oder peope. 9 Patients with stroke or those who are suffering from Azheimer s disease may be particuary insensitive to thirst. 10

9 'Tis a itte thing To give a cup of water; yet its draught Of coo refreshment, drain'd by fever'd ips, May give a shock of peasure to the frame More exquisite than when nectarean juice Renews the ife of joy in happiest hours. Sir Thomas Noon Tafourd (Engish dramatist, poet and jurist ( ), Ion (act I, sc. 2), (Sonnet III)

10 Benefits of good hydration Some of the medica evidence for the benefits of good hydration in oder peope is summarised beow. Pressure ucers: Poory hydrated individuas are twice as ikey to deveop pressure ucers because dehydration reduces the padding over bony points. 11 Fuid intake to correct impaired hydration, increases eves of tissue oxygen and enhances ucer heaing. 12 Constipation: Inadequate fuid intake is one of the most frequent causes of chronic constipation. 13 It is more frequent in incapacitated or institutionaised oder peope, affecting some 42 per cent of patients admitted to geriatric wards. 14 In individuas who are not adequatey hydrated, drinking more water can increase stoo frequency and enhance the beneficia effect of daiy dietary fibre intake. 15 Urinary infections and continence: Water heps maintain a heathy urinary tract and kidneys. Maintaining adequate hydration eves, rather than high fuid intake, per se, is important in the prevention of urinary tract infection. 16 Many oder peope are oath to drink during the evening to eiminate the need to go to the toiet during the night. Evidence shows, however, that the restriction of overa fuid intake does not reduce urinary incontinence frequency or severity. 17 Kidney and gastones: Good hydration can reduce the risk of kidney stone formation by 39 per cent because diute urine heps to prevent crystaization of stone-forming sats. 18 Consumption of water at reguar intervas can aso hep by diuting bie and stimuating gabadder emptying, which in turn heps to prevent gastone formation. 19 Heart disease: Adequate hydration reduces the risk of coronary heart disease by 46 per cent in men and 59 per cent in women. It aso protects against bood cot formation by decreasing bood viscosity. 20 Low bood pressure: Many oder peope suffer a drop in bood pressure on standing, which sometimes causes them to pass out. Drinking a gass of water five minutes before standing heps stabiise bood pressure, and prevents fainting. 21 Diabetes: Water is an essentia dietary management of diabetes since dehydration can worsen diabetic contro. 3 In poory controed diabetic individuas, high urine output can increase the risk of dehydration. 22 Good hydration eves aso hep to sow down the deveopment of diabetic ketoacidosis during insuin deficiency in Type 1 diabetes, and hep maintain heathy bood sugar eves. 23 Cognitive impairment: Dehydration adversey affects menta performance. Symptoms of mid dehydration incude ight-headedness, dizziness, headaches and tiredness, 24 as we as reduced aertness and abiity to concentrate. 25,26 Once thirst is fet (0.8-2 per cent dehydration 24 ), menta function may be affected by as much as 10 per cent. 25 Menta performance deteriorates progressivey as the degree of dehydration increases. In oder peope this impacts on cognitive function eading to increasing fraity, functiona decine, and a reduction in the quaity of ife. 27

11 Fas: The risk of fas increases with age and in oder peope this can resut in injury and fractures. A broken hip, for exampe, can ead to a reduced quaity of ife, over and above the trauma and hurt. Such individuas rarey get back to the same degree of independent iving as they enjoyed before they fe. 28 Dehydration has been identified as one of the risk factors for fas in oder peope, since it can ead to a deterioration in menta state, and increase the risk of dizziness and fainting. The maintenance of adequate eves of hydration in oder peope coud be effective in preventing fas, particuary as part of a mutifactora fas prevention strategy. 29 In addition, in hard water areas, tap water provides a significant proportion of dietary cacium, which is essentia for good bone minera density and the prevention of osteoporosis and fractures. 30 Hospitaisation in oder peope: Dehydration has been shown to increase by two-fod the mortaity of patients admitted to hospita with stroke. It aso increases the ength of hospita stay for patients with community-acquired pneumonia. 31 Skin: Being we hydrated is a good way to keep skin heathy and young-ooking. The skin acts as a water reservoir and participates in fuid reguation for the whoe body. Mid dehydration causes skin to appear fushed, dry and oose, with a oss of easticity, which makes it ook oder than it is. The effects of dehydration on the skin are more noticeabe on the face, than on the ower imbs. 24,32,33 The roe of carers Carers have a vita roe in supporting oder, more dependent, individuas to maintain heathy hydration eves. They can do this by ensuring that fuids are freey avaiabe and physicay accessibe both day and night as we as with meas. They shoud be aware of the individua s need for fuid and encourage them to drink. Many types of foods contain a substantia amount of water. If an oder person finds it difficut to increase the amount of fuid drunk, it may be possibe to hep maintain adequate hydration eves by increasing the amount of moisture consumed in foods, such as fruit and vegetabes which are about per cent water. 6 Further information can be obtained from: Water UK, Water for Heath, Ask about Written by Hiary J Forrester, Independent Researcher and Senior Poicy Executive, Science & Education, BMA

12 1 British Medica Association. Heath profies of oder peope. In: Heath and ageing web resource. London: BMA Food Standards Agency. Eat we, be we. Drinking enough? drinks/drinkingenough/#eem Dietary Reference Intakes for Water, Potassium, Sodium, Choride and Sufate (2004) Institute of Medicine of the Nationa Academies. Washington DC: The Nationa Academies Press. 4 Hodgkinson B, Evans D, and Wood J. Maintaining ora hydration in oder aduts: a systematic review. Internationa Journa of Nursing Practice 2003;9:S Water Provision in Care Homes For the Edery. A survey by the Roya Society for the Promotion of Heath, in cooperation with the Water for Heath Aiance. October Roya Institute of Pubic Heath. Eating for Heath in Care Homes - A practica nutrition handbook. London: RIPH Luckey Ad, Parsa CJ. Fuid and eectroytes in the aged. Archives of Surgery 2003;138: Stout NR, Kenny RA, Bayis PH. A review of water baance in ageing in heath and disease. Gerontoogy 1999;45: Kenney WL, Chiu P. Infuence of age on thirst and fuid intake. Medicine and Science in Sports and Exercise 2001;33: Abert SG, Nakra BR, Grossberg GT, Carmina Er. Drinking behaviour and vasopressin responses to hyperosmoarity in Azheimer's disease. Internationa Psychogeriatrics 1994;6: Casimiro C, Garcia-de-Lorenzo A, Usan L. Prevaence of decubitus ucer and associated risk factors in an institutionazed Spanish edery popuation. Nutrition 2002;18: Stotts NA, Hopf HW. The ink between tissue oxygen and hydration in nursing home residents with pressure ucers: preiminary data. Journa of Wound, Ostomy & Continence Nursing 2003;30: Kauser AG, Beck A, Schindbeck NE, Muer-Lissner SA. Low fuid intake owers stoo output in heathy mae vounteers. Zeitschrift fur Gastroenteroogie 1990;28: Read NW, Abouzekry L, Read MG, Howe RP, PtteweD and Donney TC. Anorecta function in edery patients with feca impaction. Gastroenteroogy 1985;89: Anti M, Pignataro G, Armuzzi A, Vaenti A, Iascone E, Marmo R, Lamaszza A, Pretaroi AR, Pace V, Leo P, Castei A, Gasbarrini G. Water suppementation enhances the effect of high-fibre diet on stoo frequency and axative consumption in adut patients with function constipation. Hepato-Gastroenteroogy 1998;45: Eckford SD, Keane DP, Lamond E, Jackson SR, Abrams P. Hydration monitoring in the prevention of idiopathic urinary tract infections in premenopausa women. British Journa of Uroogy 1995;76: Gray M, Krissovich M. Does fuid intake infuence the risk for urinary incontinence, urinary tract infection, and badder cancer? Journa of wound ostomy and continence nursing 2003;30: Curhan GC, Wiett WC, Speizer FE, Spiegeman D, Stampfer MJ. Comparison of dietary cacium with suppementa cacium and other nutrients as factors affecting the risk for kidney stones in women. Annas of Interna Medicine 1997;126: Math MV, Rampa PM, Faure XR and Demont JP. Gabadder emptying after drinking water and its possibe roe in prevention of gastone formation. Singapore Medica Journa 1986;27: Chan J, Knutsen SF, Bix GG, Lee JW, Fraser GE. Water, other fuids, and fata coronary heart disease. American Journa of Epidemioogy 2002;155: Lu CC, Diedrich A, Tng CS, Parajape SY, Harris PA, Byrne DW, Jordan J, Robertson D. Water ingestion as a prophyaxis against syncope. Circuation 2003;108: The kidney at a gance. Eds C O Caaghan and BM Brenner. London: Backwe Science Burge MR, Garcia N, Quais CR, Schade DS. Differentia effects of fasting and dehydration in the pathogenesis of diabetic ketoacidosis. Metaboism 2001;50: Keiner SM. Water: An essentia but overooked nutrient. Journa of the American Dietetic Association 1999:99: Rogers PJ, Kainth A, Smit HJ. A drink of water can improve or impair menta performance depending on sma differences in thirst. Appetite 2001;36: Sherriffs SM, unpubished data, as quoted in Maughan RJ. Impact of mid dehydration on weness and on exercise performance. European Journa of Cinica Nutrition 2003;57 (Supp 2):S Wison M-MG and Morey JE. Impaired cognitive function and menta performance in mid dehydration. European Journa of Cinica Nutrition 2003;57 (Supp 2):S24-S29 28 Cacium and vitamin D for preventing hip fractures. Bandoier 1997; American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons Pane on Fas Prevention. Guideines for the prevention of fas in oder persons. Journa of the American Geriatrics Society 2001;49: Expert Group on Vitamins and Mineras. Review of cacium. Food Standards Agency. EVM/01/12.REVISEDMAR Thomas DR, Tariq SH, Makhdomm S, Haddad R, Moinuddin A. Physician misdiagnosis of dehydration in oder aduts. Journa of the American Medica Directors Association 2004;5:S Eisenbeiss C, Weze J, Eicher W and Kotz K. Infuence of body water distribution on skin thickness: measurements using high-frequency utrasound. British Journa of Dermatoogy 2001;144: Katayama S. Aging mechanism associated with a function of biowater. Physioogica Chemistry & Physics & Medica NMR 1992;24:43-50 Water UK represents UK water and wastewater service suppiers at nationa and European eve. Water UK, 1 Queen Anne s Gate, London SW1H 9BT, Teephone: Web:

13 Wise up on water! Water and cancer prevention

14 Introduction Next time you fee thirsty - have a drink of water. Not ony wi you be quenching your thirst, but you wi aso be heping to protect yoursef against three of the biggest kier cancers. During our ifetime one in three of us wi be diagnosed with cancer and one in four wi die from cancer. Of the many different types of cancer, the four most common are cancer of the breast, ung, arge bowe and prostate. These four aone account for over haf of a cases diagnosed. They are aso refected in the most common causes of cancer death. In 2002, 22 per cent of a cancer deaths were from ung cancer, foowed by cancer of the arge bowe (10 per cent), breast cancer (8 per cent), and prostate cancer (6 per cent). 1 Research suggests that drinking enough water every day, coud reduce your risk of deveoping cancer of the arge bowe, breast and prostate. Cancer of the arge bowe Large bowe cancer, or coorecta cancer, is the third most common cancer in men, and the second most common cancer in women in the UK. Every year there are 18,500 new cases of coorecta cancer in men, and over 16,000 cases in women. 2 Water pays a major roe in digestion and gut function and yet it is frequenty overooked in studies considering diet and the risk of cancer of the arge bowe. Three studies in which the effect of water was considered, found that peope who maintained good eves of hydration had a reduced risk of arge bowe cancer compared with peope whose water intake was ow. The extent to which the cancer risk was reduced varied between the studies. In one study, the risk of coon cancer was reduced by 45 per cent in women and 32 per cent in men who drank four or five gasses of water per day, compared to those who drank ony two or ess gasses per day. 3 In the other two studies the protective effect was found to be greatest for men, with risk reductions for recta cancer of 92 per cent 4 and for coorecta cancer 42 per cent. 5 The studies support the potentia beneficia effect of adequate water intake in reducing coorecta cancer risk. One expanation as to why good hydration protects against arge bowe cancer is that water may hep to diute toxic compounds in the bowe and speed up the passage of stoos so that any harmfu substances (carcinogens) spend ess time in contact with the bowe ining. The cancer-protective benefits do not appear to be due to the source of water consumed, but it is possibe that other unidentified ifestye or dietary factors are reevant. 6 Breast cancer Breast cancer caims the ives of over 13,000 women a year 8,000 pre-menopausa women are diagnosed, of which 15 per cent are from the age group. 7 Most women woud wecome any opportunity to reduce their chances of deveoping breast cancer. Drinking

15 Ten Tips for drinking more water On a sedentary day, try to drink around two itres of water. Start by drinking a gass of fresh water when you get up in the morning. If you are not used to drinking water reguary, try initiay repacing just one of your other drinks a day with fresh water, increasing your consumption as the weeks go by. Ask for a gass of tap water to go with your coffee and tea in cafes. Drink a gass of water before and during each mea. Hot water with a piece of fruit in - ike emon, ime, orange etc.- often heps those who want a hot drink. Carry a botte fied with chied tap water with you whenever you eave the house. During exercise, drink at 10 to 15 minute intervas or think of it as a fu gass every 30 minutes - drink sowy and drink eary, it s physicay easier to do this when you are sti feeing fresh. Keep a check on your urine. As a genera guide to hydration, it shoud be pentifu, pae in coour and odouress. Ask for a jug of iced tap water with your mea when in restaurants and with your acoho when in bars good estabishments wi be happy to provide this. A reevant medica practice and care guidance must be observed before considering these suggestions. In concusion The benefits of good hydration to protect against cancer have not been we studied and the current findings are considered to be inconcusive. 6 More research is urgenty needed in this area. The evidence that does currenty exist, suggests that good hydration makes good sense as part of a heathy ifestye. Most of us woud agree that any opportunity to protect ourseves against three of the biggest cancer kiers woud be we worth taking.

16 enough water coud be one easy way of doing just that. Good hydration can reduce the risk of breast cancer by 33 per cent for premenopausa women and 79 per cent for postmenopausa women. This evidence is, however, based on data from one sma piot study and more research is needed to confirm these findings. One of the reasons why water may hep to protect against breast cancer is because ces need to adequatey hydrated in order to function propery. When ces are dehydrated, their interna functions become impaired and they may be ess abe to remove harmfu substances, such as those that cause cancer. 8 Prostate and urinary tract cancer Prostate cancer has now overtaken ung cancer to become the most commony diagnosed cancer in UK men, with around 30,000 cases diagnosed each year. 9 It accounts for around 12 per cent of a mae deaths from cancer. 10 Peope with ow fuid intake (ess than 2.4 itres per day) are more ikey to deveop urinary tract cancers (incuding prostate, badder, kidney, and testicuar cancer) than those who are better hydrated. 11 In women, the risk of urinary tract cancer (badder, rena pevis, ureter) has been shown to decine in proportion to the tota amount of fuid consumed, with tap water having the strongest protective effect. 12 Maintaining good hydration can aso reduce the risk of badder cancer in men. Again, water has the biggest protective effect, compared with other fuids. For exampe, in one study the consumption of more than 2.5 itres of water per day was associated with a 51 per cent reduction in badder cancer risk, compared to the consumption of other fuids, which were associated with ony a 37 per cent risk reduction. The researchers noted that for every additiona 240m of water drunk per day, badder cancer risk was reduced by 11 per cent. 13 The evidence of a protective effect for increased fuid intake and badder cancer is controversia, and other studies have found no association between tota fuid intake and the risk of badder cancer, 14,15 or even a sighty increased risk. 16 These findings may arise because the cause of badder cancer is not we understood. One expanation is that higher eves of fuid consumption may reduce contact between the badder and carcinogens by diuting the urine and increasing the frequency of urination. 13 But, if the fuids taken in contain substances that are carcinogenic to the badder, any increase in the tota consumption of such drinks woud aso increase the amount of carcinogens to which the badder was exposed. 16 Coffee and acoho are exampes of substances that can increase the risk of badder cancer. 17,18 There has been some concern that ong-term exposure to chorinated water may increase the risk of badder cancer. Chorine is used to disinfect drinking water. The amount of chorine in water eaving treatment works is safe and we within the Word Heath Organisation guideines for drinking-water quaity. 19 Where there is evidence of an association between chorinated water and badder cancer, the increased risk, compared to individuas with no exposure, appears to be sma. 13 Further information can be obtained from: Water UK, Water for Heath, Ask about Written by Hiary J Forrester, Independent Researcher and Senior Poicy Executive, Science & Education, BMA

17 1 Cancer statistics from: Cancer research UK: Office for Nationa Statistics: Breast cancer care: 2 Cancer research UK. Specific cancers. Bowe (coorecta) cancer. Page updated 20/12/ Shannon J, White E, Shattuck AL, Potter JD. Reationship of food groups and water intake to coon cancer risk. Cancer Epidemioogy, Biomarkers & Prevention 1996;5: Tang R, Wang J-Y, Lo S-K and H L-L. Physica activity, water intake and risk of coorecta cancer in Taiwan: a hospita-based casecontro study. Internationa Journa of Cancer 1999;82: Sattery ML, Caan BJ, Anderson KE and Potter JD. Intake of fuids and methyxanthine-containing beverages: association with coon cancer. Internationa Journa of Cancer 1999;81: Atieri A, La Vecchia C and Negri E. Fuid intake and risk of badder and other cancers. European Journa of Cinica Nutrition 2003;57 (Supp 2):S59-S68 7 Breast Cancer Care. Breast Cancer Facts and Statistics. Statistics updated October Stookey JD, Bederson PE, Russe JM, Barker ME. Correspondence re: J. Shannon et a. Reationship of food groups and water intake to coon cancer risk. Cancer Epidemioogy, Biomarkers & Prevention 1997;6: Cancer research UK. Specific cancers. Prostate cancer. Page updated 20/12/ Cancer research UK. Statistics. Mortaity. Page updated 12/01/ Bitterman WA, Farhadian H, Abu S-C, Lerner D, Amoun H, Krapf D, Makov UK. Environmenta and nutritiona factors significanty associated with cancer of the urinary tract among different ethnic groups. Uroogic Cinic of North America 1991;18: Wikens LR, Kadir MM, Koone LN, Nomura AM, Hankin JH. Risk factors for ower urinary tract cancer: the roe of tota fuid consumption, nitrites and nitrosamines, and seected foods. Cancer Epidemioogy, Biomarkers & Prevention 1996;5: Michaud DS, Spiegemann D, Cinton SK, Rimm EB, Curham GC, Wiett WC. Fuid intake and the risk of badder cancer in men. New Engand Journa of Medicine 1999;340: Risch HA, Burch JD, Mier AD, Hi GB, Steee R, Howe GR. Dietary factors and the incidence of cancer of the urinary badder. American Journa of Epidemioogy 1988;127: Bruemmer B, White E, Vaughn TL, Cheney CL. Fuid intake and the incidence of badder cancer among midde-aged men and women in a three-county area of western Washington. Nutrition and Cancer 1997;29: Geoffroy-Perez B, Cordier S. Fuid consumption and the risk of badder cancer: resuts of a muticenter case-contro study. Internationa Journa of Cancer 2001;93: Cave J, Cordier S. Coffee consumption and badder cancer risk. Internationa Journa of Cancer 1991;47: Kunze E, Chang-Caude J and Frentze-Beyme R. Life stye and occupationa risk factors for badder cancer in Germany. A casecontro study. Cancer 1992;69: Drinking Water Inspectorate. Information eafets. Chorine, sme, taste. Updated 10 Juy

18 Water UK represents UK water and wastewater service suppiers at nationa and European eve. Water UK, 1 Queen Anne s Gate, London SW1H 9BT, Teephone: Web:

19 Wise up on water! Water in the workpace

20 Introduction Water is a vita nutrient for ife, but in a busy working environment it is easy to overook the importance of good hydration for our daiy heath. Everybody wants to be heathy at work and a heathier workforce eads to improved productivity and ower sickness absence. Figures from the CBI show that sickness absence costs UK empoyers 12bn a year, with 168 miion working days ost in Good hydration contributes to workers heath and safety. Even mid eves of dehydration adversey affect both physica and menta performance, but these effects can be made worse by the physica demands of the job, a hot working environment, intake of caffeinated drinks, or the need to wear protective cothing. 1 Good hydration aso has many ong-term heath benefits, making it an essentia part of any heathy ifestye. What is good hydration? There is currenty no agreement about how much water we shoud drink each day. 2 Some estimates do exist and these range from 1.2 itres, 3 to 3 itres (for men) or 2.2 itres (for women). These amounts represent about 81 per cent of our tota daiy water requirement, since on average about 19 per cent of the water we need comes from the food we eat. 4 Dehydration is defined as a 1 per cent or greater oss of body weight as a resut of fuid oss. We usuay fee thirsty when dehydration reaches per cent. 5 This means that you can t rey on thirst to te you when it is time to have a drink, because by the time you fee thirsty, you are aready sighty dehydrated. The key is to keep topping up with water throughout the day. 6 Look out for some of the eary signs of dehydration which incude ight-headedness, dizziness, tiredness, irritabiity, headache, sunken features (particuary the eyes), fushed skin, heat intoerance, dry mouth, throat and eyes, and skin that is oose and acks easticity. There may be a burning sensation in the stomach, urine output wi be reduced, and may appear darker than usua. 7,8,9,10 Water is mainy ost from the body as urine, but we aso ose water through evaporation from our ungs and skin when we breathe and sweat. A sma amount of water is ost in faeces. In hot weather, or when we are active, the body oses more water and so we need more to drink. In order to remain heathy, water gains and osses must be baanced this is what constitutes good hydration. Our bodies are very efficient at reguating daiy water baance provided adequate food and the right fuids are avaiabe. Benefits of good hydration Preventing and reieving headaches Getting a headache is one of the eary signs of dehydration, together with feeings of tiredness and ight headedness. 5 Headaches resuting from mid dehydration can often be reieved quicky (within 30 minutes) by drinking between 200m and 1.5 itres of water. 12 Drinking an extra itre of water per day, has been shown to hep reduce headache duration and intensity in individuas who are susceptibe to headache, or migraine. 13 Concentration and menta performance Mid dehydration adversey affects menta performance, reduces aertness, and increases feeings of tiredness and perceived effort. 14,2 Once thirst is fet, menta performance can decrease by about 10 per cent. 15 The functions affected incude memory, attention, concentration and reaction time. As the degree of dehydration increases, menta

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