Beverage consumption habits and association with total water and energy intakes in the Spanish population: Findings of the ANIBES study

nutrients Article Beverage Consumption Habits and Association with Total Water and Energy Intakes in the Spanish Population: Findings of the ANIBES Study Mariela Nissensohn 1,2, Almudena Sánchez-Villegas 1,2, Rosa M. Ortega 3, Javier Aranceta-Bartrina 2,4, Ángel Gil 2,5, Marcela González-Gross 2,6, Gregorio Varela-Moreiras 7,8 and Lluis Serra-Majem 1,2,* 1 Research Institute of Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria 35016, Spain; [email protected] (M.N.); [email protected] (A.S.-V.) 2CIBER OBN, Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition, Carlos III Health Institute, Madrid 28029, Spain; [email protected] (J.A.-B.); [email protected] (A.G.); marcela.gonzalez.gr[email protected] (M.G.-G.) 3Department of Nutrition, Faculty of Pharmacy, Madrid Complutense University, Madrid 28040, Spain; [email protected] 4Department of Preventive Medicine and Public Health, University of Navarra, Pamplona 31008, Spain 5Department of Biochemistry and Molecular Biology II and Institute of Nutrition and Food Sciences, University of Granada, Granada 18100, Spain 6 ImFINE Research Group, Department of Health and Human Performance, Technical University of Madrid, Madrid 28040, Spain 7Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, Madrid 28668, Spain; [email protected] 8Spanish Nutrition Foundation (FEN), Madrid 28010, Spain *Correspondence: [email protected]; Tel.: +34-928-453-477; Fax: +34-928-451-416 Received: 28 January 2016; Accepted: 12 April 2016; Published: 20 April 2016 Abstract: Background: Inadequate hydration is a public health issue that imposes a significant economic burden. In Spain, data of total water intake (TWI) are scarce. There is a clear need for a national study that quantifies water and beverage intakes and explores associations between the types of beverages and energy intakes. Methods: The Anthropometry, Intake and Energy Balance Study ANIBES is a national survey of diet and nutrition conducted among a representative sample of 2285 healthy participants aged 9–75 years in Spain. Food and beverage intakes were assessed in a food diary over three days. Day and time of beverage consumption were also recorded. Results: On average, TWI was 1.7 L (SE 21.2) for men and 1.6 L (SE 18.9) for women. More than 75% of participants had inadequate TWI, according to European Food Safety Authority (EFSA) recommendations. Mean total energy intake (EI) was 1810 kcal/day (SE 11.1), of which 12% was provided by beverages. Water was the most consumed beverage, followed by milk. The contribution of alcoholic drinks to the EI was near 3%. For caloric soft drinks, a relatively low contribution to the EI was obtained, only 2%. Of eight different types of beverages, the variety score was positively correlated with TWI (r= 0.39) and EI (r= 0.23), suggesting that beverage variety is an indicator of higher consumption of food and drinks. Conclusions: The present study demonstrates that well-conducted surveys such as the ANIBES study have the potential to yield rich contextual value data that can emphasize the need to undertake appropriate health and nutrition policies to increase the total water intake at the population level promoting a healthy Mediterranean hydration pattern. Keywords: ANIBES; total water intake; energy intake; beverages; Spain Nutrients 2016,8, 232; doi:10.3390/nu8040232 www.mdpi.com/journal/nutrients Nutrients 2016,8, 232 2 of 18 1. Introduction Dehydration occurs when the body loses more water than is taken in. It is often accompanied by disturbances in the body’s mineral salt or electrolyte balance, especially in concentrations of sodium and potassium. Populations at particular risk of hypohydration are children, those engaged in professions where fluid homeostasis is regularly challenged, and older adults [ 1 ]. Limited data are available on the prevalence of hypohydration, but there is evidence to suggest that it may be relatively common among older populations [ 2 ]. The percentage of the population with inadequate water intake varies from 5% to 35% among European countries [ 3 ]. Whereas the burden of disease from inadequate water intake is well known, its consequences in Europe are far from being well understood. Recent research into the risk of disease (from falls and accidents and bowel, metabolic, and kidney diseases), disability (cognitive function, physical performance, and headaches), and death has confirmed the importance of poor hydration with respect to the overall disease burden and quality of life in Europe [ 4 ]. Therefore, the significant economic burden dehydration represents makes it an important public health issue. Depending on the degree or magnitude of dehydration in hospitalized patients, costs may be increased by 7%–8.5%. Dehydration represents a potential target for intervention to reduce healthcare expenditures and improve patient quality of life [5]. On the other hand, scientific literature recognizes that the “adequate intake” value of beverages (AI) is a variable event, in which differences are in part due to the inter-individual variation for water needs in response to different health status, metabolism, and environmental factors such as ambient temperature and humidity, as well as individual factors such as age, body size, and level of physical activity. Furthermore, the water needs also depend partially on overall diet and the water contained in food. About 80% of the required daily intake is provided by drinks, including water; the rest is acquired through solid food. Identifying the variety of drinks consumed and establishing the percentage of energy provided by each beverage to the diet allows us to set the pattern of individual or population-level beverage consumption. Understanding the contribution of each fluid type to the total fluid intake will allow us to draw conclusions about the adequacy of drinking habits. In Spain, the influence of the Mediterranean Diet is widespread. This pattern of consumption also includes the hydration pattern of the population. Traditionally, this pattern included water as a main drink, along with daily but moderate consumption of wine or beer with the principal meal, and the intake of a group of beverages elaborated with fresh vegetables (Gazpacho, Salmorejo, etc.). However, in the last decades [ 6 ], the adherence to the Mediterranean pattern has been decreasing, especially in children and young people. The actual beverage pattern also included the occasional consumption of soft drinks, which was associated with leisure time. Furthermore, total water intake (TWI) data of Spain are scarce. There are no recent epidemiological studies that focus exclusively on beverage intake. Most available hydration data focuses on alcohol consumption. Apart from the Spanish National Survey on Dietary Intake (ENIDE) [ 7 ] in 2011, we are unaware of other research investigating beverage intake among the Spanish population. According to ENIDE data, the average beverage consumption was 1646.5 mL/day, which reflects insufficient fluid intake for that study population. Given the extent of the problem and its poor recognition, there is the clear need for a national study to update the existing data. The aim of this study was to quantify the total water and beverage intake, and to explore associations between the types of beverage consumed and energy intake. The ANIBES study, a national survey of diet and nutrition conducted in 2013 among a representative random sample of 2285 healthy participants aged 9–75 years, provides us the likely best source of detailed information on the diet of normal individuals in Spain. Characteristics of ANIBES include a food and beverages record list (in grams) of each item consumed per participant and a record of the time of consumption. These study attributes provide a rich resource for exploring patterns of consumption according to age and gender, thereby permitting us to reach conclusions about whether or not drinking a variety of beverages helps to increase fluid intake to a level that meets current guidelines. Nutrients 2016,8, 232 3 of 18 2. Materials and Methods The design, protocol, and methodology of the ANIBES study have been described in detail elsewhere [8–10]. 2.1. Sample The ANIBES study is a cross-sectional study conducted using stratified multistage sampling. To guarantee better coverage and representativeness, the fieldwork was performed at 128 sampling points across Spain. The design of the ANIBES study aims to define a sample size that is representative of all individuals living in Spain, aged 9–75 years, and residing in municipalities of at least 2000 inhabitants. The initial potential sample consisted of 2634 individuals. For all analyses, we eliminated participants with anomalous values of energy intake (EI) (men, <800 or >4000 kcal/day; women, <500 or >3500 kcal/day) [ 11 ] to avoid introducing bias to the analysis. The final sample comprised 2007 individuals (1011 men, 50%; 996 women, 50%). In addition, for the youngest age groups (9–12, 13–17, and 18–24 years), an “augment sample” was included to provide at least n= 200 per age group (error ˘ 6.9%). The augment sample is the process of increasing the amount of interviews for a particular subgroup within the population in order to achieve an adequate number of interviews to allow analysis of population subgroups or segments that wouldn ' t normally yield a sufficient number of interviews in a main random survey, without the expense of increasing the sample size for the whole survey. Therefore, the random sample plus augment sample comprised 2285 participants. The sample quotas according to the following variables were: age groups (9–12, 13–17, 18–64, and 65–75 years), gender (men/women), and geographical distribution (Northeast, Levant, Southwest, North–Central, Barcelona, Madrid, Balearic, and Canary Islands). Additionally, other factors for sample adjustment were considered: unemployment rate, percentage of foreigners (immigrant population), physical activity level assessed by The International Physical Activity questionnaire (IPAQ) [ 12 ], tobacco use and education or economic level. Finally, participants’ weight, height, and waist circumference were measured and body mass index was also calculated. The fieldwork for the ANIBES study was conducted from mid-September 2013 to mid-November 2013, and two previous pilot studies were also performed. To equally represent all days of the week, study subjects participated during two weekdays and one weekend day. The final protocol was approved by the Ethical Committee for Clinical Research of the Region of Madrid, Spain [9]. 2.2. Food and Beverage Record Study participants were provided with a tablet device (Samsung Galaxy Tab 2 7.0, Samsung Electronics, Suwon, South Korea) and trained in recording information by taking photos of all food and drinks consumed during the 3 days of the study, both at home and outside the home. Photos were to be taken before beginning to eat and drink, and again after finishing, so as to record the actual intake. Additionally, a brief description of meals, recipes, brands, and other information was recorded using the tablet. Participants who declared or demonstrated that they were unable to use the tablet device were offered other options, such as using a digital camera and paper record and/or telephone interviews. A total 79% of the sample used a tablet, 12% a digital camera, and 9% opted for a telephone interview. As no differences in the percentage of misreporting were found according to the type of device used to assess dietary intake, we used the measurements of the three assessment methods in the analysis. In addition to details of what and how much was eaten, for each eating/drinking event, participants recorded where they were, who they were eating with, and whether they were watching television and/or sitting at a table. After each survey day, participants recorded if their intake was representative for that day (or the reason why if it was not), and details of any dietary supplements taken. The survey also contained a series of questions about participants’ customary eating habits (e.g., the type of milk usually consumed) to facilitate further coding. Food records were returned from the field in real time, to be coded by trained coders who were supervised by dieticians. An ad hoc central Nutrients 2016,8, 232 4 of 18 server software/database was developed for this purpose, to work in parallel with the codification and verification processes. Food, beverage, and energy and nutrient intakes were calculated from food consumption records using VD-FEN 2.1 software, a Dietary Evaluation Program from the Spanish Nutrition Foundation (FEN), Spain, which was newly developed for the ANIBES study by the FEN and is based mainly on Spanish food composition tables [ 13 ], with several expansions and updates. Data obtained from food manufacturers and nutritional information provided on food labels were also included. A food photographic atlas was used to assist in assigning gram weights to portion sizes. The VD-FEN 2.1 software was developed to receive information from field tablets every 2 s, and the database was updated every 30 min. Energy distribution objectives for the Spanish population were used to analyze the overall quality of the diet [9,14]. 2.3. Data Preparation and Analysis The present analysis focused on the TWI of all food and drink, determined from food composition tables with several adaptations and updates [ 13 ]. Metabolic water (water derived from oxidation of substrates) was not included so as to focus on comparisons with dietary water requirements. Beverages were combined into eight categories for further analysis: (1) hot beverages, including hot tea and coffee (iced teas in cans or bottles were considered caloric soft drinks); (2) milk (all types of milk without separation by fat percentage); (3) fruit and vegetable juices (including nectars, juice–milk blends, 100% fruit juices, and some typical Spanish beverages: horchata, gazpacho, salmorejo, and white garlic); (4) caloric soft drinks (including colas, tonic water, sodas, ginger ale, fruit flavored drinks, iced teas in cans or bottles, sports drinks such as isotonic drinks with mineral salts, and caffeinated energy drinks); (5) diet soft drinks (including the same beverages as in the caloric soft drinks group but with artificial sweetener); (6) alcoholic drinks, including two groups: (a) low-alcohol grade (mostly beer, wine, and cider); and (b) high-alcohol grade (including brandies, liqueurs, tequila, vodka, whisky, etc.); (7) water (including tap water and bottled water); and (8) other beverages (including soy-based beverages, non-alcoholic beer and wine, and others). Additionally, a variety score was created as the sum of the different beverages used in our classification with a minimum value of 0 and a maximum value of 8. To investigate daily trends, beverage consumption events were aggregated into six time periods, approximately corresponding to breakfast (up to 10:00 a.m.), mid-morning (10:00 a.m.–1:00 p.m.), lunch (1:00 p.m.–4:00 p.m.), mid-afternoon (4:00 p.m.–7:00 p.m.), dinner (7:00 p.m.–10:00 p.m.), and other times. TWI was compared with the European Food Safety Authority (EFSA) Dietary Reference Values (DRV) for the Adequate Intake (AI) of water for men and women from 14 years of age onward (2.5 L and 2.0 L, respectively), and for boys and girls from 9 to 13 years of age (2.1 L and 1.9 L, respectively) [ 15 ]. Furthermore, Nordic and German-speaking countries take the approach that water intake is considered inadequate when it is less than 1 g per kilocalorie of energy requirement [ 15 ]. Therefore, we used three different approaches to define water intake adequacy to provide a more comprehensive estimate of the proportion of participants who consume low amounts of water [ 16 ]. First, a classification based on the AI value, defined by the EFSA as criterion 1. The second (criterion 2), a ratio between TWI (water from food and beverages in grams) and EI in kcal higher than 1; and the combination of both as final criterion. 2.4. Statistical Analyses Owing to reported differences in water consumption and recommended intakes between male and female individuals, all analyses were carried out separately by gender. Crude differences in TWI and beverage consumption between groups were assessed through an analysis of variance test or t-tests with Bonferroni correction for multiple comparisons. Chi-squared tests were used for categorical variables. All analyses were two-tailed, with statistical significance set at p< 0.05. Partial Correlations between water intake, energy intake, and beverage consumption adjusted for age, gender, body weight, and physical activity were calculated by the use of a variety score. Nutrients 2016,8, 232 5 of 18 Multivariable linear regression models included adjustment for gender, age, weight, and physical activity level. Multiple linear regression models were fitted to assess the effect of varying the type of beverages consumed (caloric vs. non-caloric) on EI while controlling for the effect of confounders (gender, age, weight, and physical activity). The effect of replacing 100 g of caloric beverages with 100 g of non-caloric beverages was estimated by including caloric beverages (as a percentage of total beverage weight) as the main independent variable, with total beverage weight (g) held constant. This necessarily implies an equal and opposite change in other beverages. A further model included energy from food, thus disallowing compensation (reduction in calories from food). Finally, we used within-person daily consumption data to explore the effect of changes in daily beverage consumption, with each person acting as their own control. The independent variables represent the standard deviation of the mean of the three different measurements (3-day records) for each type of beverage collected for each participant. The outcome (change in EI) was derived using the same methodology (deviation from participants’ 3-day mean in energy intake) [16]. 3. Results The ANIBES sample was of 2285 healthy subjects aged 9 to 75 years, of which 50% of the population was men and the other 50% were women. The study sample reflects the distribution of male and female individuals in the general population of Spain [ 17 ] (Statistics National Institute (INE) 2011). A more detailed description of the ANIBES study population is given in Table 1[ 13 ]. There was no statistically significant difference in the education or economic level between men and women. However, men smoked more but engaged in more sport than women. Regarding the measures of overweight and obesity, the data of ANIBES study were representative of the Spanish adult population, according to the Spanish National Health Survey 2011–2012 [ 18 ]: 37% and 32% of men and women, respectively, were overweight, and 21% and 19%, respectively, were obese. Figure 1shows the frequency distribution of TWI (g/day) over a three-day recording period, organized by gender. On average, the TWI was 1.7 L (SE 21.2) for men and 1.6 L (SE 18.9) for women, far less than the EFSA AI recommendations for adults (2.5 L and 2.0 L, respectively). Nutrients 2016,8,2325of17 PartialCorrelationsbetweenwaterintake,energyintake,andbeverageconsumptionadjusted forage,gender,bodyweight,andphysicalactivitywerecalculatedbytheuseofavarietyscore. Multivariablelinearregressionmodelsincludedadjustmentforgender,age,weight,and physicalactivitylevel.Multiplelinearregressionmodelswerefittedtoassesstheeffectofvarying thetypeofbeveragesconsumed(caloricvs.non‐caloric)onEIwhilecontrollingfortheeffectof confounders(gender,age,weight,andphysicalactivity).Theeffectofreplacing100gofcaloric beverageswith100gofnon‐caloricbeverageswasestimatedbyincludingcaloricbeverages(asa percentageoftotalbeverageweight)asthemainindependentvariable,withtotalbeverageweight (g)heldconstant.Thisnecessarilyimpliesanequalandoppositechangeinotherbeverages.A furthermodelincludedenergyfromfood,thusdisallowingcompensation(reductionincalories fromfood).Finally,weusedwithin‐persondailyconsumptiondatatoexploretheeffectofchanges indailybeverageconsumption,witheachpersonactingastheirowncontrol.Theindependent variablesrepresentthestandarddeviationofthemeanofthethreedifferentmeasurements(3‐day records)foreachtypeofbeveragecollectedforeachparticipant.Theoutcome(changeinEI)was derivedusingthesamemethodology(deviationfromparticipants′3‐daymeaninenergyintake) [16]. 3.Results TheANIBESsamplewasof2285healthysubjectsaged9to75years,ofwhich50%ofthe populationwasmenandtheother50%werewomen.Thestudysamplereflectsthedistributionof maleandfemaleindividualsinthegeneralpopulationofSpain[17](StatisticsNationalInstitute (INE)2011).AmoredetaileddescriptionoftheANIBESstudypopulationisgiveninTable1[13]. Therewasnostatisticallysignificantdifferenceintheeducationoreconomiclevelbetweenmen andwomen.However,mensmokedmorebutengagedinmoresportthanwomen.Regardingthe measuresofoverweightandobesity,thedataofANIBESstudywererepresentativeoftheSpanish adultpopulation,accordingtotheSpanishNationalHealthSurvey2011–2012[18]:37%and32%of menandwomen,respectively,wereoverweight,and21%and19%,respectively,wereobese. Figure1showsthefrequencydistributionofTWI(g/day)overathree‐dayrecordingperiod, organizedbygender.Onaverage,theTWIwas1.7L(SE21.2)formenand1.6L(SE18.9)forwomen, farlessthantheEFSAAIrecommendationsforadults(2.5Land2.0L,respectively).  Figure1.Frequencydistributionoftotalwaterintake(g/day)overthreedaysbygender.  Figure 1. Frequency distribution of total water intake (g/day) over three days by gender. Percentages of total weight consumed (g/day), daily EI (kcal/day), and water intake (g/day) are presented in Table 2. Beverages were separated by category, with most consumed in similar amounts Nutrients 2016,8, 232 6 of 18 by participants of both genders. However, men consumed exactly two times more alcoholic beverages than women. The mean total EI was 1809 kcal/day (SE 11.1), and the relative contribution to total EI from beverages was 12% (13% for men, 12% for women). Furthermore, 68% of the TWI came from beverages and 32% from food. Those amounts coincided with EFSA recommendations (70%–80% provided by beverages of all types and the remaining 20%–30% from food). Table 1. Statistical description of the sample ANIBES. Total % Male % Female % Total 2007 100 1011 50.4 996 49.6 Age Group 9–12 Count 100 5 62 6.1 38 3.8 13–17 Count 123 6.1 84 8.3 39 3.9 18–39 Count 777 38.7 387 38.3 390 39.2 40–64 Count 810 40.4 385 38.1 425 42.7 65–75 Count 197 9.8 93 9.2 104 10.4 Unemployed Count 270 13.5 184 18.2 86 8.6 Foreigners (immigrant population) Spanish Count 1933 96.3 975 96.4 958 96.2 Foreign Count 74 3.7 36 3.6 38 3.8 Level of physical activity Inactive Count 884 44.0 389 38.5 495 49.7 Active Count 1123 56.0 622 61.5 501 50.3 Level of education Primary or less Count 743 37.0 378 37.4 365 36.6 Secondary Count 858 42.8 434 42.9 424 42.6 Tertiary or University Count 406 20.2 199 19.7 207 20.8 Economical level 1000 €or less Count 397 19.8 191 18.9 206 20.7 From 1000 to 2000 €Count 795 39.6 393 38.9 402 40.4 Over 2000 €Count 320 15.9 163 16.1 157 15.8 No income Count 7 0.3 4 0.4 3 0.3 No answer Count 488 24.3 260 25.7 228 22.9 Geographical distribution Northwest Count 152 7.6 77 7.6 75 7.5 North Central Count 161 8.0 79 7.8 82 8.2 Northeast + Barcelona AAMM Count 368 18.3 177 17.5 191 19.2 Center + Madrid AAMM Count 455 22.7 240 23.7 215 21.6 Levante Count 335 16.7 176 17.4 159 16.0 South Count 443 22.1 218 21.6 225 22.6 Canarias Count 93 4.6 44 4.4 49 4.9 Tabaco Yes Count 602 30.0 338 33.4 264 26.5 No Count 1182 58.9 527 52.1 655 65.8 Weight (kg) Mean (SE) 72.30 (0.39) 78.40 (0.56) 66.10 (0.46) Height (cm) Mean (SE) 166.20 (0.23) 172.10 (0.31) 160.20 (0.22) Waist Circumference Mean (SE) 87.70 (0.34) 91.90 (0.48) 83.40 (0.45) BMI class (kg/m2) Underweight Count 27 1.34 5 0.5 22 2.2 Normal weight Count 880 43.84 417 41.2 463 46.5 Overweight Count 694 34.57 375 37.1 319 32.0 Obese Count 406 20.22 214 21.2 192 19.3 Nutrients 2016,8, 232 7 of 18 Table 2. Contribution of food and beverages to total water and energy intake. Total Weight Consumed (g/Day) GRAMS Contribution to Energy Intake (kcal/Day) KCAL Contribution to Water Intake (g/Day) WATER Total Men Women Total Men Women Total Men Women Count 2007 1011 996 2007 1011 996 2007 1011 996 All food and drink Mean (SE) 2071.55 2136.35 2005.77 1809.01 1955.68 1660.15 1625.12 1664.19 1585.47 15.87 23.81 20.74 11.15 16.43 13.52 14.22 21.17 18.89 Food only Mean (SE) 45.0% 45.5% 44.6% 87.8% 87.2% 88.4% 32.2% 32.4% 32.1% 0.3% 0.4% 0.4% 0.1% 0.2% 0.2% 0.3% 0.3% 0.4% Beverages only Mean (SE) 55.0% 54.5% 55.4% 12.2% 12.8% 11.6% 67.8% 67.6% 67.9% 0.3% 0.4% 0.4% 0.1% 0.2% 0.2% 0.3% 0.3% 0.4% Hot beverages Mean (SE) 6.1% 5.5% 6.6% 0.4% 0.4% 0.5% 7.7% 7.0% 8.3% 0.1% 0.2% 0.2% 0.0% 0.0% 0.0% 0.2% 0.2% 0.3% Milk Mean (SE) 10.0% 9.5% 10.6% 5.6% 5.1% 6.0% 11.8% 11.3% 12.3% 0.2% 0.2% 0.2% 0.1% 0.1% 0.1% 0.2% 0.3% 0.3% Fruit & Vegetable Juices Mean (SE) 2.4% 2.6% 2.2% 1.3% 1.4% 1.2% 2.8% 3.0% 2.5% 0.1% 0.2% 0.1% 0.1% 0.1% 0.1% 0.1% 0.2% 0.2% Caloric soft drink Mean (SE) 5.1% 5.8% 4.4% 2.2% 2.4% 2.0% 6.1% 6.9% 5.2% 0.2% 0.3% 0.2% 0.1% 0.1% 0.1% 0.2% 0.4% 0.3% Diet soft drink Mean (SE) 1.8% 1.4% 2.1% 0.0% 0.0% 0.0% 2.3% 1.8% 2.7% 0.1% 0.1% 0.2% 0.0% 0.0% 0.0% 0.1% 0.2% 0.2% Alcohol Mean (SE) 4.6% 6.2% 3.0% 2.7% 3.5% 1.9% 5.7% 7.6% 3.7% 0.2% 0.3% 0.2% 0.1% 0.2% 0.1% 0.2% 0.4% 0.2% Water Mean (SE) 24.8% 23.3% 26.3% - - - 31.2% 29.5% 32.9% 0.4% 0.5% 0.5% - - - 0.4% 0.6% 0.6% Other non-alcoholic beverages Mean (SE) 0.2% 0.3% 0.2% 0.0% 0.0% 0.0% 0.3% 0.3% 0.2% 0.0% 0.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.1% 0.0% Nutrients 2016,8, 232 8 of 18 On average, the percentage of total beverage consumption from water over the three-day study period was 46% for women and 41% for men (Figure 2). Water was the most frequently consumed beverage, followed by milk, for both genders. Among men, the decreasing order of consumption was alcoholic drinks, caloric soft drinks, and hot beverages, with similar percentages (11%, 11%, and 10%, respectively). For women, the decreasing order was hot beverages (12%), caloric soft drinks (8%), and alcohol (5%). Fruit and vegetable juices and diet soft drinks were consumed in lower amounts by both genders. Nutrients 2016,8,2328of17 Onaverage,thepercentageoftotalbeverageconsumptionfromwateroverthethree‐daystudy periodwas46%forwomenand41%formen(Figure2).Waterwasthemostfrequentlyconsumed beverage,followedbymilk,forbothgenders.Amongmen,thedecreasingorderofconsumption wasalcoholicdrinks,caloricsoftdrinks,andhotbeverages,withsimilarpercentages(11%,11%,and 10%,respectively).Forwomen,thedecreasingorderwashotbeverages(12%),caloricsoftdrinks (8%),andalcohol(5%).Fruitandvegetablejuicesanddietsoftdrinkswereconsumedinlower amountsbybothgenders.  Figure2.Percentageofbeveragesconsumedoverathree‐dayperiodbygender. Ingeneral(Table3),thecontributionofwaterintakefromfoodincreasedwithage,from434 g/day(SE13.9)amongyoungerparticipants(13–17years)to584g/day(SE24.8)amongolderadults (65–75years).Thisfindingislikelyowingtolowerconsumptionoffruitsandvegetables,whichare richinwater,fortheyoungestparticipants.Thewatercontributionfrombeveragesdeclinedfrom 1202g/day(SE21.6)amongadults(18–64years)to1002g/day(SE44.0)amongolderadults. Foradolescents,themeanconsumptionofcaloricsoftdrinkswas167g/day(SE19.1)formen, and139g/day(SE15.9)forwomen(equivalenttoaboutthreecansperweekforeach).However, consumptionwasloweramongadults,with114g/day(SE6.3)formenand82.1g/day(SE4.6)for women.Consumptionofalcoholicdrinksforadultmenandwomenaveraged160g/day(SE9.0)and 71g/day(SE4.8),respectively.Theintakeofalcoholicdrinksamongtheoldestparticipants(65–75 years)averaged143g/day(SE19.0)formenand53g/day(SE9.8)forwomen. Theprincipalsourcesoftotaldietarywater,bygenderandagegroup,areshowninFigure3. Forbothmenandwomen,themainsourcewaswater,followedbymilk.Childrenandadolescents consumedhigheramountsofwaterfrommilkandjuicesthanadults,forbothgenders;however, adolescentsconsumedlesswaterfromhotbeveragesanddietsoftdrinksthanadults.Adultsand olderadultshadalowerintakeofcaloricsoftdrinksandjuicesbutconsumedgreateramountsofhot beveragesandalcohol,forbothmenandwomen. Figure 2. Percentage of beverages consumed over a three-day period by gender. In general (Table 3), the contribution of water intake from food increased with age, from 434 g/day (SE 13.9) among younger participants (13–17 years) to 584 g/day (SE 24.8) among older adults (65–75 years). This finding is likely owing to lower consumption of fruits and vegetables, which are rich in water, for the youngest participants. The water contribution from beverages declined from 1202 g/day (SE 21.6) among adults (18–64 years) to 1002 g/day (SE 44.0) among older adults. For adolescents, the mean consumption of caloric soft drinks was 167 g/day (SE 19.1) for men, and 139 g/day (SE 15.9) for women (equivalent to about three cans per week for each). However, consumption was lower among adults, with 114 g/day (SE 6.3) for men and 82.1 g/day (SE 4.6) for women. Consumption of alcoholic drinks for adult men and women averaged 160 g/day (SE 9.0) and 71 g/day (SE 4.8), respectively. The intake of alcoholic drinks among the oldest participants (65–75 years) averaged 143 g/day (SE 19.0) for men and 53 g/day (SE 9.8) for women. The principal sources of total dietary water, by gender and age group, are shown in Figure 3. For both men and women, the main source was water, followed by milk. Children and adolescents consumed higher amounts of water from milk and juices than adults, for both genders; however, adolescents consumed less water from hot beverages and diet soft drinks than adults. Adults and older adults had a lower intake of caloric soft drinks and juices but consumed greater amounts of hot beverages and alcohol, for both men and women. Nutrients 2016,8, 232 9 of 18 Table 3. Total water intake and beverage consumption (g/day) by sex and age group (n= 2281). Men Women Age Group p1 Age Group p1 Base 9–12 13–17 18–64 65–75 Base 9–12 13–17 18–64 65–75 (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) Base 1156 125 136 796 99 1125 87 74 857 107 Total Water intake from food & beverage Mean (SE) 1638.63 (19.40) 1440.20 (a) (45.47) 1398.04 (b) (43.29) 1717.49 (24.69) 1585.57 (57.75) <0.001 1559.94 (17.53) 1334.55 (h) (46.58) 1235.51 (f,g) (40.07) 1608.35 (20.97) 1579.77 (48.94) <0.001 Water from Food Mean (SE) 503.90 (6.07) 443.62 (a,c) (13.72) 433.60 (b,d) (13.96) 515.60 (e) (7.41) 583.72 (24.81) <0.001 476.31 (5.67) 440.18 (19.42) 403.67 (g,i) (17.83) 475.75 (j) (6.45) 560.47 (19.59) <0.001 Water from beverages only Mean (SE) 1134.73 (16.74) 997.58 (a) (39.33) 964.44 (b) (36.31) 1201.89 (e) (21.61) 1001.85 (44.03) <0.001 1083.62 (15.55) 894.37 (h) (40.30) 831.84 (f) (33.16) 1132.60 (18.72) 1019.31 (42.33) <0.001 Total beverages Consumption Mean (g/day) (SE) 1181.00 (16.94) 1058.60 (a) (40.39) 1026.43 (b) (37.54) 1244.72 (e) (21.86) 1035.52 (44.79) <0.001 1121.62 (15.65) 943.92 (i) (41.27) 881.93 (f) (33.59) 1169.24 (18.85) 1050.49 (42.78) <0.001 OF WHICH (g/day) Hot beverages Mean (g/day) (SE) 107.14 (3.60) 41.20 (a,c) (4.26) 54.43 (b,d) (7.37) 120.95 (4.55) 151.82 (12.91) <0.001 123.93 (3.96) 41.85 (h,i) (6.12) 37.15 (f,g) (6.81) 134.00 (4.33) 170.00 (19.02) <0.001 Milk Mean (g/day) (SE) 204.48 (4.52) 309.73 (a,c) (12.00) 274.67 (b,d) (16.00) 175.69 (4.94) 206.64 (15.24) <0.001 202.55 (3.85) 249.77 (h) (14.51) 201.86 (15.43) 196.82 (4.28) 210.45 (14.12) 0.003 Fruit & Vegetable Juices Mean (g/day) (SE) 58.22 (3.15) 91.56 (a,c) (11.83) 87.67 (b,d) (11.31) 50.94 (3.51) 34.25 (7.74) <0.001 45.05 (2.42) 91.76 (h,i) (12.08) 93.35 (f,g) (17.17) 37.46 (2.27) 34.42 (6.66) <0.001 Caloric soft drink Mean (g/day) (SE) 112.76 (5.25) 113.02 (c) (14.76) 166.97 (b,d) (19.06) 114.19 (e) (6.32) 26.43 (6.57) <0.001 79.17 (3.86) 67.32 (11.10) 138.94 (g) (15.91) 82.15 (j) (4.59) 23.66 (6.18) <0.001 Diet soft drink Mean (g/day) (SE) 28.81 (2.70) 12.09 (a,c) (3.17) 21.65 (b) (6.41) 35.25 (d) (3.68) 7.98 (3.13) 0.003 40.26 (3.56) 20.90 (6.48) 18.56 (9.28) 46.88 (4.48) 17.91 (6.16) 0.011 Alcohol Mean (g/day) (SE) 122.36 (6.72) - -1.14 (b,d) (1.14) 159.66 (9.05) 143.45 (19.00) <0.001 59.03 (3.88) - -2.93 (2.34) 70.64 (4.85) 52.82 (9.78) <0.001 Water Mean (g/day) (SE) 542.12 (14.81) 491.00 (35.99) 419.88 (b) (33.19) 582.15 (19.15) 452.69 (40.51) <0.001 568.75 (14.17) 472.31 (39.27) 389.14 (f) (34.77) 597.92 (17.03) 537.72 (40.88) <0.001 Other non alcoholic beverages (g/day) (SE) 5.11 (1.11) - - 5.90 (1.49) 12.26 (5.05) 0.034 2.90 (0.55) - - - - 3.347 (0.67) 3.52 (2.14) 0.195 p1value obtained through ANOVA test; (a) BD; (b) CD; (c) BE; (d) CE; (e) DE; (f) HI; (g) HJ; (h) GI; (i) GJ; (j) IJ = Significant. Nutrients 2016,8, 232 16 of 18 Appendix Table A1. Regression model estimating change in energy intake associated with adding caloric beverages in place of non-caloric beverages. Model 1 BpValue 95% Confidence Interval for B Lower Upper (Constant) 1597.476 <0.001 1507.809 1687.144 Gender men 253.295 <0.001 211.937 294.653 Age (years) ´4.715 <0.001 ´5.931 ´3.499 Weight (kg) ´2.722 <0.001 ´3.956 ´1.488 Physical activity active ´34.556 0.092 ´74.704 5.592 Total beverages (100 g/day) 18.191 <0.001 14.541 21.841 5caloricbeverages (100 g) * 49.817 <0.001 42.757 56.877 Model 2: Keeping Food Constant BpValue 95% Confidence Interval for B Lower Upper (Constant) 46.798 <0.001 27.063 66.533 Gender men 22.655 <0.001 15.224 30.085 Age (years) ´0.969 <0.001 ´1.182 ´0.755 Weight (kg) ´0.286 0.009 ´0.502 ´0.070 Physical activity active 3.582 0.316 ´3.424 10.589 Food (Kcal) 1.005 <0.001 0.997 1.012 Total beverages (100 g) ´0.889 <0.008 ´1.542 ´0.235 5caloricbeverages (100 g) * 40.079 <0.001 38.845 41.312 * “5caloricbeverages” = sum of hot beverages, milk, fruit & vegetable juice, caloric soft drinks and alcoholic drinks. Table A2. Within-person change Model: estimated change in energy intake associated with beverage substitution. Model 3: Estimated Effect of Substituting Each Beverage Type * Changes in: BpValue 95% Confidence Interval for B Lower Upper Hot beverages (100 g) ´29.080 0.016 ´52.833 ´5.326 Milk (100 g) 6.539 0.506 ´12.726 25.804 Fruit & vegetable juice (100 g) 47.147 0.030 4.578 89.716 Caloric soft drink (100 g) 17.681 0.155 ´6.706 42.069 Diet soft drink (100 g) ´35.621 0.069 ´73.997 2.755 Alcoholic drinks (100 g) 18.612 0.027 2.128 35.096 Water (100 g) ´34.139 <0.0001 ´42.263 ´26.014 Model 4: Estimated Effect of Caloric Beverages Replacing Non-Caloric Beverages BpValue 95% Confidence Interval for B Lower Upper Change in total beverages (100 g) ´6.083 0.007 ´10.485 ´1.682 Change in caloric beverages (100 g) 43.387 <0.0001 34.702 52.071 Model 5: Estimated Effect of Caloric Beverages Replacing Caloric Beverages, Holding Food Energy Constant BpValue 95% Confidence Interval for B Lower Upper Change in food energy (100 kcal) 103.626 <0.0001 102.587 104.666 Change in total beverages (100 g) ´7.718 <0.0001 ´8.701 ´6.735 Change in caloric beverages (100 g) 34.232 <0.0001 32.292 36.173 * Model 6 is a composite of 7 regressions, one for each beverage, adjusted for change in total beverages. Nutrients 2016,8, 232 17 of 18 References 1. Maughan, R. Impact of mild dehydration on wellness and on exercise performance. Eur. J. Clin. Nutr. 2003 , 57, S19–S23. [CrossRef] [PubMed] 2. Watson, P.; Whale, A.; Mears, S.A.; Reyner, L.A.; Maughan, R.J. Mild hypohydration increases the frequency of driver errors during a prolonged, monotonous driving task. Physiol. Behav. 2015 ,147, 313–318. [CrossRef] [PubMed] 3. Nissensohn, M.; Castro-Quezada, I.; Serra-Majem, L. Beverage and water intake of healthy adults in some European countries. Int. J. Food Sci. Nutr. 2013,64, 801–805. [CrossRef] [PubMed] 4. Serra-Majem, L. Opening remarks: The burden of disease attributable to hydration in Europe. Nutr. Hosp. 2015,32, 10260. [PubMed] 5. Frangeskou, M.; Lopez-Valcarcel, B.; Serra-Majem, L. Dehydration in the Elderly: A Review Focused on Economic Burden. J. Nutr. Health Aging 2015,19, 619–627. [CrossRef] [PubMed] 6. Bach-Faig, A.; Fuentes-Bol, C.; Ramos, D.; Carrasco, J.L.; Roman, B.; Bertomeu, I.F.; Cristià, E.; Geleva, D.; Serra-Majem, L. The Mediterranean diet in Spain: Adherence trends during the past two decades using the Mediterranean Adequacy Index. Public Health Nutr. 2011,14, 622–628. [CrossRef] [PubMed] 7. Spanish Agency for Food Safety and Nutrition (AESAN). ENIDE: Encuesta Nacional de Ingesta Dietética Española 2011. Available online: http://www.aesan.msc.es (accessed on 12 January 2015). 8. Ruiz, E.; Ávila, J.M.; Castillo, A.; Valero, T.; del Pozo, S.; Rodriguez, P.; Aranceta Bartrina, J.; Gil, A.; González-Gross, M.; Ortega, R.M.; et al. The ANIBES study on energy balance in Spain: Design, protocol and methodology. Nutrients 2015,7, 970–998. [CrossRef] [PubMed] 9. Ruiz, E.; Ávila, J.M.; Valero, T.; Del Pozo, S.; Rodriguez, P.; Aranceta-Bartrina, J.; Gil, Á.; González-Gross, M.; Ortega, R.M.; Serra-Majem, L.; et al. Energy intake, profile, and dietary sources in the Spanish population: Findings of the ANIBES study. Nutrients 2015,12, 4739–4762. [CrossRef] [PubMed] 10. Varela Moreiras, G.; Ávila, J.M.; Ruiz, E. Energy Balance, a new paradigm and methodological issues: The ANIBES study in Spain. Nutr. Hosp. 2015,31, 101–112. [PubMed] 11. Willet, W.C. Issues in Analysis and Presentation of Dietary Data. Nutritional Epidemiology, 2nd ed.; Oxford University Press: New York, NY, USA, 1998. 12. Roman-Viñas, B.; Serra-Majem, L.; Hagströmer, M.; Ribas-Barba, L.; Sjöström, M.; Segura-Cardona, R. International physical activity questionnaire: Reliability and validity in a Spanish population. Eur. J. Sport Sci. 2010,10, 297–304. [CrossRef] 13. Moreiras, O.; Carbajal, A.; Cabrera, L.; Cuadrado, C. Tablas de Composición de Alimentos/Guía de Prácticas, 16th ed.; Ediciones Pirámide: Madrid, Spain, 2013. 14. Sociedad Española de Nutrición Comunitaria (SENC). Objetivos nutricionales para la población española. Consenso de la Sociedad Española de Nutrición Comunitaria, 2011. Rev. Esp. Nutr. Comunitaria 2011 ,17, 178–199. 15. EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA). Scientific opinion on dietary reference values for water. EFSA J. 2010,8, 1459. 16. Gibson, S.; Shirreffs, S.M. Beverage consumption habits “24/7” among British adults: Association with total water intake and energy intake. Nutr. J. 2013,10, 9. [CrossRef] [PubMed] 17. INE 2011: Instituto Nacional de Estadística: Censos de Población y Viviendas, 2011. Available online: http://www.ine.es/censos2011_datos/cen11_datos_inicio.htm (accessed on 2 November 2015). 18. Encuesta Nacional de Salud 2011–2012. Available online: http://www.msssi.gob.es/estadEstudios/ estadisticas/encuestaNacional/encuesta2011.htm (accessed on 12 January 2015). 19. Institute of Medicine. Dietary reference intakes for water, potassium, sodium, chloride and sulfate. In Food and Nutrition Board; The National Academies Press: Washington, DC, USA, 2004. 20. WHO/FAO. Diet, Nutrition and the Prevention of Chronic Diseases; Report No. 916; World Health Organization: Geneva, Switzerland, 2002. 21. Drewnowski, A.; Rehm, C.D.; Constant, F. Water and beverage consumption among adults in the United States: Cross-sectional study using data from NHANES 2005–2010. BMC Public Health 2013 ,12, 1068. [CrossRef] [PubMed] 22. Lustig, R.; Schmidt, L.; Brindis, C. The toxic truth about sugar. Nature 2012 ,482, 27–29. [CrossRef] [PubMed] Nutrients 2016,8, 232 18 of 18 23. Johnson, R.J.; Segal, M.S.; Sautin, Y.; Nakagawa, T.; Feig, D.I.; Kang, D.H.; Gersch, M.S.; Benner, S.; Sánchez-Lozada, L.G. Potential role of sugar (fructose) in the epidemic of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and cardiovascular disease. Am. J. Clin. Nutr. 2007 ,86, 899–906. [PubMed] 24. Johnson, R.K.; Appel, L.J.; Brands, M.; Howard, B.V.; Lefevre, M.; Lustig, R.H.; Sacks, F.; Steffen, L.M.; Wylie-Rosett, J. American Heart Association Nutrition Committee of the council on Nutrition, Physical Activity, and Metabolism and the Council on Epidemiology and Prevention. Dietary sugars intake and cardiovascular health: A scientific statement from the American Heart Association. Circulation 2009 ,24, 1011–1020. 25. Malik, V.S.; Popkin, B.M.; Bray, G.A.; Despres, J.P.; Hu, F.B. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation 2010,121, 1356–1364. [CrossRef] [PubMed] 26. Johansson, L.; Solvoli, K.; Gunn-Elin, A.B.; Drevon, C.A. Underand overreporting of energy intake related to weight status and lifestyle in a nationwide sample. Am. J. Clin. Nutr. 1998,68, 266–274. [PubMed] 27. Rasmussen, L.B.; Matthiessen, J.; Biltoft-Jensen, A.; Tetens, I. Characteristics of misreporters of dietary intake and physical activity. Public Health Nutr. 2007,10, 230–237. [CrossRef] [PubMed] 28. Serra-Majem, L.; Bach-Faig, A.; Raidó-Quintana, B. Nutritional and cultural aspects of the Mediterranean diet. Int. J. Vitam. Nutr. Res. 2012,82, 157–162. [CrossRef] [PubMed] © 2016 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/).