You Are What You Drink

There is a question that I now ask almost every patient during their initial appointment; it’s one that I never would have predicted would become such a common part of my repertoire and yet the answers that I get to it are often enlightening. No, it’s not the “do you have pain with sex?” question (though I do ask that one pretty frequently as well! It’s even simpler

“How much water and other liquids do you drink in a day?”

I know, I know…you’re thinking, “Yes, Jenn, but you are a pelvic floor therapist. You are dealing with constipated patients or folks with incontinence all day; of course you ask about drinking! How is that relevant to my patients with chronic low back pain or knee pain?

There are multiple reasons to be concerned about fluid intake-only some of which have anything to do with the reasons that may immediately come to mind. Lack of appropriate fluid intake is associated with decreased muscle performance (some studies have found that as little as a 2% drop in hydration is associated with a decrease in physical performance in athletes); decreased cognitive functioning (worst in older adults and children, but present across the lifespan); decrease in metabolic rate, constipation and difficulty controlling electrolyte and other balances in the body; issues with blood pressure regulation; increased risk for headache; increased likelihood of joint pain; and likely increase in symptomatology of chronic disease. The human body is 55-75% composed of water (the precise amount varies across the life span) and water is arguably one of the most important nutrients we consume.

Many prevalence studies suggest that between 60-75% of Americans are chronically, at least slightly dehydrated, but this has been difficult to prove, in part because clear evidence regarding exactly what constitutes adequate hydration is lacking.

Put simply, hydration needs vary significantly based on individual body composition, climate, activity level/sweating, breastfeeding status, and more.

Unfortunately, in light of a lack of clear consensus regarding what exactly constitutes adequate hydration, we are left with clinical signs and experimentation; hardly the most accurate/reproducible option, but a necessary skill for us to develop and hone as care providers of individual people, not statistics.

Signs of dehydration can include dizziness, confusion, lack of short or long term recall, difficulty with word finding, dry mouth, feeling of thirst (though it is important to note that multiple studies have documented a phenomenon in which a chronically dehydrated person’s sense of thirst will be altered to reflect what they usually drink instead of what they need to drink, meaning they can’t necessarily rely on feeling thirsty to stay hydrated), joint pain, muscle cramping, and headache, among others. Obviously all of these symptoms can also be caused by other things, so differential diagnosis and a comprehensive evaluation of the entire person is crucial. In more extreme circumstances, the dehydrated individual might lose the ability to sweat or cry, have a dry appearance to their mucus membranes and lips, and have a loss of turgor in their skin (“tenting”-if you pinch it, the skin will hold that shape for a few seconds before slowly rebounding). One of the signs I find easiest for patients to quantify is the color of their urine.

In a well hydrated person, urine is clear to lightly tinted, whereas a dehydrated person’s urine can range from bright yellow to orange (this is not a good sign) even to brown.

By the way, this is one reason to also ask about incontinence with many of your patients (even ones that are working with you for something other than their pelvic girdle). Many patients logically believe that if they are having difficulty with urine, they can/should drink less and then they will leak less frequently. However, drinking less concentrates the urine, which causes bladder irritation. This can actually lead to increased urgency and frequency, which can lead them to drink less, and the vicious cycle continues. Educating these patients that drinking more will actually probably help them have less frequent urges can be very beneficial!

I actually recently evaluated a lovely older lady with insidious onset of knee pain for about 3 months with no obvious pathologic explanation. Upon observation and examination, I realized that her skin was very dry feeling (truly felt like leather!) and exhibited tenting and that her lips were cracked and dry. She also had difficulty in accurate recall during her evaluation. When I questioned her drinking habits (yes, for knee pain!) she stated that about 3 months ago she had been diagnosed with a disease which impacted the lining of her bladder and which was causing some stress incontinence. She had been put on medication to help her bladder recover, but instead of the typical 6 week course, she was still on it as her bladder lining was still eroding. She had stopped drinking and was limiting herself to no more than 20 ounces (yes, total!!) of fluid in a day in hopes that the leakage would be less. Her knee exam was unremarkable, so we worked on increasing her fluid intake while doing some general strength and conditioning work, and within about 2 weeks her knee pain was eliminated and she was able to get off the medication as her bladder lining had finally healed (the extremely concentrated urine was irritating it enough that it wasn’t able to heal)-unfortunately none of her bladder care providers had discussed appropriate fluid intake with her!

So what if you have a patient who is not drinking adequately-where do you have them start?

Well, one thing to know is that it will probably work better for them (ie they will comply better!) to taper up instead of trying to instantly go from 40 total oz per day to 90, for example. I usually have people increase by 8-10 ounces every 3-4 days until they are at an appropriate amount. While there is truly no data that states an ideal number of ounces per person (in fact, several task forces have stated no such standard is possible due to the absurd number of possible complicating factors), starting with half the person’s body weight in ounces and then titrating up or down depending on urine color and other symptoms is a common recommendation. I also often encourage people to try to “stack” their water consumption in the earlier part of the day-try to have 2/3 of your water for the day down by early afternoon, and then stop drinking significant amounts about 3-4 hours before bedtime to prevent night time waking and urgency. By the way, the myth that beverages that are not water are dehydrating is just that; the amount of caffeine consumed by most people in their day is too low of a dose to cause a diuretic effect. However, acidity in drinks can be a bladder irritant, so it’s helpful to consider that as well. It is true that liquids that are not 100% water do not hydrate as well as water, but they do still hydrate somewhat.

As physical therapists continue to become more and more involved in primary musculoskeletal care (and as physicians’ time is so pressed that they often don’t have or take time to discuss more time consuming topics such as nutrition with their patients), we have a responsibility to be or become educated in other systems that impact the musculoskeletal one. As you can probably tell from this blog post, even something as simple as water intake can actually be rather complex, but can also make a substantial positive impact in patients’ lives and symptoms. People who feel more well are more motivated to move and can move more, and after all, isn’t that the entire purpose of our profession?

I would love to hear what you think-do you discuss this topic with patients? If not, do you leave it unaddressed or do you prefer to refer people to a nutritionist, etc.?


Popkin. Water, Hydration, and Health. Nutritional Review. 2010: 68(8). 439-458.

Dennis et al. Water consumption increases weight loss during a hypocaloric intervention in middle-aged and older adults. Obesity. 2010: 18(2). 300-307.

Armstrong. Challenges of linking chronic dehydration and fluid consumption to health outcomes. Nutritional Review. 2012:70. S12-S17.

Manz. Hydration and Disease. Journal of the American College of Nutrition. 2007: 26(5). S535-S541.


6 responses to “You Are What You Drink

  1. Jessie Podolak says:


    Thanks for this great post! Sometimes we forget to ask the most fundamental questions pertaining to health, and we need reminders of why they are so important. Thanks for doing just that!!


    1. Jennifer Stone says:

      Thanks for reading Jessie!

  2. Great article and, as is typical with this blog, great aha moment created (for me anyway). We do often forget the most fundamental questions pertaining to health and something I often do is perhaps use improper word choice while asking the ones I do remember. I’ll ask someone if there is anything important I missed or that we didn’t cover during the initial evaluation (or with follow up for that matter) but forget to realize that too many things aren’t perceived as “important” by the client. Drinking less water is probably one of those things so perhaps rewording the question would elicit more information.

    1. Jennifer Stone says:

      Great reflection! I have definitely found that if I don’t pay attention it is very easy for me to fall into a routine, especially with my subjective history taking, and forget that people don’t know what they don’t know. The longer I am a therapist the more I see that we are perfectly positioned to help people enhance whole health, and that means taking responsibility for education on multiple body systems. I also have found that far too many people have no idea what an appropriate amount to drink might be, etc. Thanks for being willing to adjust your practice patterns for the health of your patients, you do our profession great credit!

  3. How much to drink and the impact on electrolytes are interesting topics. Much of what many believe and some of what has been cited as resources in this post seems to comes from the sports drink industry. Tim Noakes provides a comprehensive outline in his book “Waterlogged – The Serious Problem of Overhydration in Endurance Sports.” His book also provides reference to and traces (historically) the issues through the primary literature. Noakes demonstrates that marathons are won by the most dehydrated athletes with the greatest % body weight loss that drink the least. How much and when humans need to drink and the impact on electrolytes may not be what you think.

    1. Jennifer Stone says:

      Hi Chris,
      There is certainly a lot of debate out there (as mentioned, there is not currently a standard on what to drink!). It’s another of those interesting human physiology questions that seems to leave us with “it depends.” However, I still think it’s a worthwhile discussion to have with patients (I have certainly met people who swear up and down that all they drink per day is 2 cans of soda)-as in many areas, I think here we are left with a lot of clinical reasoning and education on the information we have while waiting for more clear cut guidelines. Thanks for your input, it’s always great to have more resources to check out, so I appreciate you including that one!

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