Water intake, hydration status and 2-year changes in cognitive performance: a prospective cohort study
Authors: Nishi Stephanie K. , Babio Nancy , Paz-Graniel Indira , Serra-Majem Lluís , Vioque Jesús , Fitó Montserrat , Corella Dolores , Pintó Xavier , Bueno-Cavanillas Aurora , Tur Josep A. , Diez-Ricote Laura , Martinez J. Alfredo , Gómez-Martínez Carlos , González-Botella Andrés , Castañer Olga , Alvarez-Sala Andrea , Montesdeoca-Mendoza Cristina , Fanlo-Maresma Marta , Cano-Ibáñez Naomi , Bouzas Cristina , Daimiel Lidia , Zulet María Ángeles , Sievenpiper John L. , Rodriguez Kelly L. , Vázquez-Ruiz Zenaida , Salas-Salvadó Jordi 
Published: March 2023

Abstract
Background
Water intake and hydration status have been suggested to impact cognition; however, longitudinal evidence is limited and often inconsistent. This study aimed to longitudinally assess the association between hydration status and water intake based on current recommendations, with changes in cognition in an older Spanish population at high cardiovascular disease risk.

Methods
A prospective analysis was conducted of a cohort of 1957 adults (aged 55–75) with overweight/obesity (BMI between ≥ 27 and < 40 kg/m2) and metabolic syndrome from the PREDIMED-Plus study. Participants had completed bloodwork and validated, semiquantitative beverage and food frequency questionnaires at baseline, as well as an extensive neuropsychological battery of 8 validated tests at baseline and 2 years of follow-up. Hydration status was determined by serum osmolarity calculation and categorized as < 295 mmol/L (hydrated), 295–299.9 mmol/L (impending dehydration), and ≥ 300 mmol/L (dehydrated). Water intake was assessed as total drinking water intake and total water intake from food and beverages and according to EFSA recommendations. Global cognitive function was determined as a composite z-score summarizing individual participant results from all neuropsychological tests. Multivariable linear regression models were fitted to assess the associations between baseline hydration status and fluid intake, continuously and categorically, with 2-year changes in cognitive performance.

Results
The mean baseline daily total water intake was 2871 ± 676 mL/day (2889 ± 677 mL/day in men; 2854 ± 674 mL/day in women), and 80.2% of participants met the ESFA reference values for an adequate intake. Serum osmolarity (mean 298 ± 24 mmol/L, range 263 to 347 mmol/L) indicated that 56% of participants were physiologically dehydrated. Lower physiological hydration status (i.e., greater serum osmolarity) was associated with a greater decline in global cognitive function z-score over a 2-year period (β: − 0.010; 95% CI − 0.017 to − 0.004, p-value = 0.002). No significant associations were observed between water intake from beverages and/or foods with 2-year changes in global cognitive function.

Conclusions
Reduced physiological hydration status was associated with greater reductions in global cognitive function over a 2-year period in older adults with metabolic syndrome and overweight or obesity. Future research assessing the impact of hydration on cognitive performance over a longer duration is needed.

Trial registration
International Standard Randomized Controlled Trial Registry, ISRCTN89898870. Retrospectively registered on 24 July 2014