Stress & The Effects on the Skin

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It has been established in recent years that the skin is a direct target of psychological stress via a cascade of hormones, neuropeptides, and neurogenic signals (causing nerve hypersensitivity and inflammation). The skin has been shown to be capable of launching its own local response to stress as well by producing many of the same substances that the brain produces, further enhancing the local effect at the skin level when someone is under acute or prolonged stress. It is no surprise that the skin can perceive and respond to stress similar to the brain and nervous system, since the two systems have evolved from the same germ layer during embryonic development.

The main skin cells (keratinocytes), mast cells (involved in allergy type reactions and inflammation), immune cells, and peripheral nerve endings all will have an effect on various cell behaviour and processes within the skin under stress that can lead to skin disruption, premature ageing and disease development.

The skin is rich in nerve endings, so when an individual is stressed the peripheral nerve endings secrete numerous substances such as Substance P and Nerve growth factor that contribute to hypersensitivity, inflammation, and allergic reactions.

Due to the impact of stress related hormones and peptides, and growth factors on the skin, stress can play a role in the development and exacerbation of skin disorders such as Eczema, Acne, Psoriasis, and Rosacea.

Psychological stress activates the autonomic nervous system to trigger release of catecholamines [e.g. epinephrine and norepinephrine] from the adrenal glands, and in situations of chronic stress corticotrophin releasing hormone [CRH] and ACTH (adrenocorticotropic hormone), mediate a release of glucocorticoids (Cortisol) from the adrenal cortex.

Here is a brief outline of some key stress mediators and the effect that they have on the skin:

Glucocorticoids:

Excess levels can cause atrophy and impaired wound healing by interfering with keratinocyte and fibroblast function. Keratinocytes are the primary skin cells that form the epidermis of the skin, and fibroblasts are responsible for collagen and elastin formation.

This manifests as atrophy and thinning of the skin, increased trans-epidermal water loss related to disruption to the skin permeability barrier, and easy bruising with impaired wound healing.

The skin barrier is also negatively impacted by excess cortisol as this effects the lamellar bodies in the skin cells which are responsible for lipid synthesis; the lack of essential lipids weakens the barrier resulting in dry skin, allergies and sensitivity, delayed healing and infections.

Insulin:

Excess glucocorticoids stimulate Insulin production and lead to insulin excess and Insulin resistance. Elevated Insulin stimulates IGF2 (Insulin growth factor) which increases growth of keratinocytes, and stimulates abnormal keratinocyte growth, (exacerbates Psoriasis and Acne) and increases androgens and testosterone release.

Substance P:

This is neuropeptide released in times of stress. Substance P stimulates sebaceous germinative cells and proliferation of sebaceous glands which results in excess oil production and blockage of the oil ducts and the development of acne. Substance P also activates mast cells, increasing histamine release and itch sensation. Substance P induces vascular permeability and inflammation, which aggravates conditions like Eczema and Rosacea.

Corticotropin Releasing Hormone (CRH):

CRH stimulates release of MSH (melanocyte stimulating hormone) causing hyperpigmentation and blotchy skin.

Catecholamines (Adrenaline, Noradrenaline)

Decrease blood perfusion to skin reducing availability of oxygen and nutrients resulting in poor texture and sallow / pallor. Catecholamines have also been shown to cause immune suppression, interfere with DNA repair and contribute to ageing.

Managing stress

While the effects of stress on the skin are only briefly outlined above, it illustrates the significant impact this can have on individuals predisposed to skin conditions. It is therefore imperative to minimise stress where possible in order to avoid any exacerbation of skin disorders.

There are some straight forward tips to reduce stress such as getting a good night’s sleep, exercising and following some simple dietary guidelines (listed below).

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Reduce salt intake

Avoid alcohol

Avoid caffeine

Avoid skipping meals

Avoid refined, processed foods.

Avoid high fat foods

Do eat high fibre, low glycaemic index diet

In the following blogs we will present some relaxation techniques that are easy to implement and will have a direct effect in reducing the side effects of stress.

 

References

  1. Dunn, Jeffrey HKoo, John; Psychological Stress and skin aging: A review of possible mechanisms and potential therapies; Dermatology Online Journal 19 (6): 1 University of Colorado, School of
  2. Medicine, 2 University of California, San Francisco, Department of Dermatology 2013 Permalink: http://escholarship.org/uc/item/3j0766hs
  3. Jessica M. F. Hall, desAnges Cruser, Alan Podawiltz, Diana I. Mummert, Harlan Jones, Mark E. Mummert; Psychological Stress and the Cutaneous Immune Response: Roles of the HPA Axis and the Sympathetic Nervous System in Atopic Dermatitis and Psoriasis; Dermatology Research and Practice Volume 2012, Article ID 403908, doi:10.1155/2012/403908
  4. Ying Chen, John Lyga; Brain – Skin Connection: Stress, Inflammation and Skin Aging; Inflammation & Allergy – Drug Targets, 2014, 13, 177-190
  5. Theoharis C. Theoharides, Jill M. Donelan, Nikoletta Papadopoulou, Jing Cao, Duraisamy Kempuraj, Pio Conti; Mast cells as targets of corticotropin releasing factor and related peptides; TRENDS in Pharmacological Sciences Vol.25 No.11 November 2004

The Importance of Adequate Hydration

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“Water is defined as an essential nutrient because it is required in amounts that exceed the body’s ability to produce it. All biochemical reactions occur in water. It fills the spaces in and between cells and helps form structures of large molecules such as protein and glycogen. Water is also required for digestion, absorption, transportation, dissolving nutrients, elimination of waste products and thermoregulation” (regulation of body temperature) (Kleiner, 1999).Hydration fact sheet- facebook (1)

cucumber-salad-food-healthy-37528mineral-water-lime-ice-mint-158821Key Facts 

Up to 2 litres of Water is lost daily due to bodily functions, such as perspiration, respiration, urination and defecation.

Diuretic substances in your diet such as caffeinated beverages, alcohol, high sugar and salty foods will increase water loss from the body.

Water requirements range from 8-10 glasses per day depending on diet and physical activity levels. As we age, we have a diminished sense of thirst and tend to drink less fluid, although water is still required. It is therefore important to ensure we drink an adequate amount of water, even in the absence of thirst.

Water can be consumed from drinking pure water as well as from eating certain foods. Depending on diet, up to 50% of your daily water intake can be derived from foods provided they are high in water content such as fruit, salad, soup and vegetables (i.e. iceberg lettuce and cucumber).

How dehydration impacts your skin condition

Key signs of mild to moderate dehydration include increased sensation of pexels-photo-136871pain, thirst, stiffness, headaches, lack of concentration, fatigue and skin problems.

The skin contains approximately 30% water. “Water intake, particularly in individuals with low initial water intake, can improve skin thickness and density and offsets transepidermal water loss (water lost through the skin surface)” (Popkin, Rosenberg & D’Anci, 2010). Hydration improves skin resiliency, elasticity and texture.

The water content in the skin contributes to important functions of the skin such as the development of a healthy skin barrier. The skin barrier guards the skin from microbial infections and infiltration of foreign substances which can cause skin flare ups.

Water deficiency can also lead to impaired skin processes, which can then worsen skin disorders such as dermatitis, psoriasis, acne and rosacea (Rodrigues, Palma, Tavares Marques & Bujan Varela, 2015).

Key tips to keeping hydrated

Create a routine: If you aren’t used to drinking water on a regular basis, start with four glasses of water a day. One glass on rising, one mid-morning, one mid-afternoon and one on retiring. This eliminates 4 out 8 glasses per day. Once you establish this routine, start adding additional glasses of water throughout the day, for example before meals

Convenience: Keep water with you at all times. Keep a refillable water bottle with you at work, in your car, and to take with you when you go on walks etc. Get used to sipping on water as part of your daily routine. Convenience is key, otherwise if it’s out of sight, it’s often out of mind!

Flavour: If you don’t like the taste of water, there are several ways to make it more enticing. Add some fresh herbs like mint, or fresh fruit, or a very small amount of juice (just enough to add a hint of flavour).

Variety: Mix up your water variety and add in some natural sparkling mineral water.

Eat foods high in water content: Eat plenty of fresh fruit and vegetables, in doing so will assist in keeping your body hydrated (this information should not replace any dietary information given by your psoriasis eczema clinic practitioner).

Be aware of cravings: if you are craving salty foods as this can be a signal from the body that you are dehydrated. Try drinking a glass of water before reaching for salty foods.

For more information on the health benefits of water and charts for daily consumption visit: https://www.nrv.gov.au/nutrients/water

Reference:

  1. Popkin, B., Rosenberg, I., & D’Anci, K. (2010). Water, Hydration and Health. National Institute of Health68(8), 439–458. http://dx.doi.org/doi:10.1111/j.1753-4887.2010.00304.x
  2. Kleiner, S. (1999). Water. Journal Of The American Dietetic Association99(2), 200-206. http://dx.doi.org/10.1016/s0002-8223(99)00048-6
  3. Rodrigues, L., Palma, L., Tavares Marques, L., & Bujan Varela, J. (2015). Dietary water affects human skin hydration and biomechanics. Clinical, Cosmetic and Investigational Dermatology4(411), 413. http://dx.doi.org/10.2147/ccid.s86822

HEALTHY SKIN and WATER INTAKE- PART 2

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There are a number of challenges in trying to link chronic dehydration and fluid consumption to various diseases and health outcomes:-

Only a limited number of good studies have been  conducted to date. More long-term studies are needed.  Larger patient numbers need to be included in future studies. 

There are difficulties in assessing patient daily fluid  intake and compliance is difficult to monitor. Hydration status constantly changes and hydration can be difficult to measure in some patients especially when daily fluid requirements vary widely from patient to patient.

The diseases that can be complicated or worsened by dehydration are multi-factorial and there are many differences among these diseases. 1

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There is, however, increasing evidence that even mild dehydration can play a role in the development of various morbidities (diseases) or conditions. The medical evidence for good hydration shows that it can assist in preventing or treating ailments such as:

  • Pressure ulcers   – Dehydration is a known risk factor for PU development because of its effect on blood volume and circulation and skin turgor and has been shown to be associated with an increased risk of developing pressure ulcers in 42% of residents in long-term care facilities, home care patients, and elderly patients.2                           
  • Wound healing – Fluid intake to correct impaired hydration, increases levels of  tissue oxygen and enhances ulcer healing.3
  •  Constipation – Studies have confirmed the recommendation to simply increase intake of fluids such as water to prevent constipation.4
  • Urinary infections – Urinary tract infections result from a bacterial contamination of      the genitourinary tract [35]. They are highly prevalent in both men and women of all age groups, but their frequency is about 50 times higher in adult women. More than half (50–60%)  present with at least one UTI at some stage during their lives. Increasing fluid intake and thereby increasing diuresis (the production of urine) has a diluting effect on contaminating bacteria and virulence factors. Secondly, consecutive to increased diuresis, is the flushing effect that occurs with each void, washing out contaminants and cleaning the epithelia. Also, increasing the frequency of voiding has a shrinking effect on the bladder, effectively reducing the available surface area on which bacteria can thrive.5
  • Chronic kidney disease – CKD is an inevitably progressive, serious condition     associated with impaired quality of life and early mortality, and its prevalence is increasing constantly. CKD is more common among women, men with CKD are 50% more likely than women to progress to end-stage renal disease (ESRD), defined as kidney failure requiring dialysis or transplantation. 44% of people with ESRD have a primary diagnosis of diabetes and 28% of hypertension. Some studies have suggested that increased fluid intake/urine output is associated with a delay in the onset or progression of CKD.6
  • Kidney stones – It is predicted that, based on the effects of global warming, the percentage of people living in areas designated as high risk for kidney stone formation would increase from 40% in 2000 to 56% by 2050, and up to 70% by 2095. This would result in a significant “climate-related” increase in kidney stone events.14  Drinking sufficient levels of fluid on a daily basis is an important part of kidney health. Dehydration, especially chronic dehydration, results in the production of urine which has a higher concentration of minerals and waste products. This can lead to the formation of crystals which can affect kidney function and contribute to certain kidney diseases, such as kidney stones. By moderately increasing water intake, to around two litres per day, you may reduce the risk of decline in kidney function 7
  • Stokes – Stroke conditions worsened or stayed the same in 42 percent of dehydrated patients, compared to only 17 percent of hydrated patients. Dehydrated stroke patients also had about a four times higher risk of their conditions worsening than hydrated patients.8
  • Low blood pressure – Even mild cases of dehydration can cause low blood pressure. Patients with mild dehydration may experience only thirst and dry mouth. Moderate dehydration may cause orthostatic hypotension –  a form of low blood pressure in which a person’s blood pressure falls when suddenly standing up or stretching, and severe dehydration                                             (hypovolemia) can lead to shock, kidney failure, confusion, acidosis, coma, and even death.
  • Diabetes – Hypernatremia dehydration is the most devastating type of dehydration because it can result in severe neurological damage from haemorrhage. Normally, an increased osmolality results in water conservation. This does not occur in central Diabetes Insipidus due to a malfunctioning hypothalamus. In hypernatremic dehydration, extracellular osmolality increases and water moves ou of the brain cells. This movement of water causes brain cells to shrink and the blood vessels tear as the brain is pulled away from the skull and the meninges. The tearing of blood vessels results in haemorrhaging and potential for thrombus formation.10
  • Cognitive impairment – Delirium is a common manifestation of dehydration that  clearly reflects the global impact of dehydration on cerebral function. However, the three areas of the brain most vulnerable to the effects of dehydration are the reticular activating system, which subserves attention and wakefulness; the autonomic structures that regulate psychomotor and regulatory functions; and the cortical and mid-brain structures that are responsible for thought, memory and erception.11
  • Dizziness – Dizziness, vertigo or light headedness can occur simply by changing positions, or moving your head or it can occur at the time of or during strenuous exercise.
  • Xerostomia –  also known as “dry mouth,” is a common but frequently overlooked condition that is typically associated with salivary gland hypofunction. It is estimated that 12-47% of the elderly and 10-19.3% of people in their early 30’s have been suffering from dry  mouth. Whilst dehydration may not be the single cause of this condition it can certainly aggravate or worsen the condition.12
  • Skin conditions – once the body becomes dehydrated and the skin dries out there is   a dysfunction in the skin barrier with an increase in water loss from the body and, subsequently, increased penetration of harmful substances from the environment. This causes the development of sensitization and initiates immune responses resulting in the inflammation of the skin. Skin barrier function depends on several factors including the level of hydration, cellular properties of corneocytes (skin cells), association of these cells in the stratum corneum and speed of changes (turnover) of these cells, amount and composition of intercellular lipids (oils), and skin surface pH (6-20). Water content of the stratum corneum and surface lipids form a balance, which is very important for the function and appearance of the skin, any disturbance of this balance leads to clinical manifestations in the form of dryness and pruritus (itch).13

Recommended daily fluid intake

Approximate adequate daily intakes of fluids (including plain water, milk and other drinks) in litres per day include:

  • infants 0–6 months – 0.7 (from breastmilk or formula)
  • infants 7–12 months – 0.9 (from breastmilk, formula and other foods and drinks)
  • children 1–3 years – 1.0 (about 4 cups)
  • children 4–8 years – 1.2 (about 5 cups)
  • girls 9–13 years – 1.4 (about 5-6 cups)
  • boys 9–13 years          – 1.6 (about 6 cups)
  • girls 14–18 years – 1.6 (about 6 cups)
  • boys 14–18 years – 1.9 (about 7-8 cups)
  • Adult women – 2.1 (about 8 cups)
  • Adult men – 2.6 (about 10 cups).

These adequate intakes include all fluids, but it is preferable that the majority of intake is from plain water (except for infants where fluid intake is met by breastmilk or infant formula).

Sedentary people, people in cold environments, or people who eat a lot of high-water content foods (such as fruits and vegetables) may need less water. 14

Those working in heated environments or who do heavy work and sports players may also need to increase their water intake.

Care should be taken not to overhydrate.

Also read our blog “HEALTHY SKIN and WATER INTAKE – PART 1”

 

REFERENCES

  • Armstrong LE. Challenges of linking chronic dehydration and fluid consumption to health outcomes. J Amer Coll Nutr 70(11): S121-S127, 2012.
  • Horn Sd. Et al.; The National Pressure Ulcer Long-Term Care Study: Pressure Ulcer Development in Long-Term Care Residents; Journal of the American Geriatrics Society
  • Stotts NA, Hopf HW. The link between tissue oxygen and hydration in nursing home residents with pressure ulcers: preliminary data. Journal of Wound, Ostomy & Continence Nursing 2003;30:184-90
  • Arnaud MJ.; Mild dehydration: a risk factor of constipation?; European Journal of Clinical Nutrition (2003) 57, Suppl 2, S88–S95
  • Lotan Y. et al.; Impact of fluid intake in the prevention of urinary system diseases: a brief review; Curr Opin Nephrol Hypertens 2013, 22 (Suppl 1):S1–S10
  • Romero V. et al.; Kidney Stones: A Global Picture of Prevalence, Incidence, and Associated Risk Factors; Rev Urol. 2010 Spring-Summer; 12(2-3): e86–e96.
  • HYDRATION AND KIDNEY HEALTH; Natural Hydration Council UK:http://www.naturalhydrationcouncil.org.uk/wp-content/uploads/2015/03/NHC_hydration_and_kidney_health_FINAL.pdf
  • Bahouth MN. et al.; A Prospective Study of the Effect of Dehydration on Stroke Severity and Short Term Outcome; Abstract T MP86:2015; International Stroke Conference Moderated Poster Abstracts – Session Title: In-hospital Treatment Moderated Poster Tour:
  • Manouchehr Saljoughian; Hypotension: A Clinical Care Review; US Pharm. 2014;39(2):2-4
  • https://www.uspharmacist.com/article/hypotension-a-clinical-care-review#sthash.1Ku9Afv2.dpuf
  • Hospital Hydration Best Practice Toolkit The health and economic benefits of providing water; https://www2.rcn.org.uk/__data/assets/pdf_file/0003/70374/Hydration_Toolkit_-_Entire_and_In_Order.pdf
  • Hudson MJ.; Complications of Diabetes Insipidus: The Significance of Headache; Pediatric Nursing
  • Wilson MG. and Morley JE.; Impaired cognitive function and mental performance in mild dehydration; European Journal of Clinical Nutrition (2003) 57, Suppl 2, S24–S29
  • Mortazavi, H et al. “Xerostomia Due to Systemic Disease: A Review of 20 Conditions and Mechanisms.”Annals of Medical and Health Sciences Research 4 (2014): 503–510. PMC. Web. 4 Aug. 2016.
  • Knor T. et al.; Stratum Corneum Hydration and Skin Surface pH in Patients with Atopic Dermatitis; Acta Dermatovenerol Croat 2011;19(4):242-247
  • https://www.betterhealth.vic.gov.au/health/healthyliving/water-a-vital-nutrient

HEALTHY SKIN and WATER INTAKE – PART 1

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Water is an essential element for our existence as it performs a number of vital functions in the body.  It is a key component of the fluid that forms the basis of saliva that helps us to swallow, of synovial fluids that cushion the joints and of the fluids that fill our eyeballs and lubricates our eyes. It provides the medium for by which most of the chemical reactions in the body occurs, it acts as a cushion for the nervous system (cerebrospinal fluid), allows us to get rid of waste products principally via the kidneys and urine production, and helps to regulate body temperature by the process of sweating. 1,2,3

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The body tightly controls its water volume and, under normal conditions, the volume fluctuates by less than 1% per day. Dehydration can be defined as a 1% or greater loss of body mass due to fluid loss e.g. urine, eye lubrication, sweating, breathing etc. 1,2,3

Research experiments using fluid restriction to induce dehydration, has shown that loss of body mass of about 1% can be seen after 13 hours, about 2% after 24 hours and nearly 3% after 37 hours when no fluids and only relatively dry foods are consumed. It was noted, however, that the subjects undergoing fluid restriction had a strong desire to drink and would have been unlikely to become dehydrated to such an extent accidentally. These experiments do show how quickly body fluid loss can occur and the importance of continued rehydration by the consumption of water. 1,2,3

 If water losses are not sufficiently replaced, dehydration will occur and extreme dehydration is very serious and can be fatal. More mild dehydration (about 2% loss of body weight) has been shown to result in headaches, fatigue, increased stress/anxiety, reduced physical performance and cognitive function. Some studies have refined the level of dehydration, where detectable symptoms and changes occurred, to the following: in males, dehydration of 1·59 % body weight loss and in females   1·39 % body weight loss. Such modest loss in body weight can occur in everyday activities, demonstrating the importance of maintaining optimal hydration. Taking into consideration various changes attributable to factors such as ambient temperature, physical activity, state of health, the European Food Safety Authority has recommended that the appropriate water intake should be approximately 2 litres per day for women and 3 litres per day for men. Higher water intake requirements will, of course, be higher for athletes and those that are physically active in hotter climates.4,5,6  

The Stratum Corneum (SC) of the skin consists of the essential barrier between the internal and external environment. Although most of the skin is between 2-3mm (0.10 inch)  thick, the SC plays a vital role in forming a protective barrier and helps to prevent percutaneous entry of harmful pathogens (e.g. germs) into the body. In addition to serving as a physical barrier, the SC has other important functions, including the regulation of body heat (thermoregulation), respiration and maintenance of the body’s water content – transepidermal water loss (TEWL)   Stratum Corneum properties and its protective function can be modified by various internal and external/environmental factors.7

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So what happens to human skin when the body becomes dehydrated?

Any change in the structure of the stratum corneum (SC) is potentially associated with alterations of both its barrier function and water holding capacity. Decreased hydration with reduced elasticity of the stratum corneum is responsible for cracks and fissures in the skin. The rate of TEWL is higher in dry skin than in normal skin where the integrity of the barrier function is not disturbed. The impaired barrier in skin conditions such as psoriasis and atopic eczema makes the SC less efficient in excluding substances that come in contact with the surface and patients with skin conditions e.g. atopic dermatitis are believed to be more prone to contact dermatitis than a normal population and those with psoriasis more susceptible to flare ups after exposure to chemicals.8 

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How can you tell if you are dehydrated?

One simple test is to gently pinch the skin on your hand …. hold for a few seconds and then release the skin. If the skin springs back you are not dehydrated, if the skin remains tented (turgor) then it is a sure sign that you are dehydrated and need to drink at least two glasses of water immediately. Another way of checking is the simple observation of the colour of your urine when you go to the toilet. Some charts have numerous colour options but the simple chart that the NSW Government Health Department has on their website “Beat the Heat” is probably the best and easiest to use:-

REMEMBER IF YOUR URINE IS DARKER THAN THAT INDICATED THEN YOU ARE SERIOUSLY DEHYDRATED AND SHOULD ATTEND YOUR NEAREST HOPSITAL EMERGENCY DEPARTMENT

URINE COLOUR CHART

This urine colour chart will give you an idea of whether you are drinking enough water or you are dehydrated (lost too much water from the body)

 Very Dehydrated ……. DRINK 1 litre of water 
 Dehydrated …….. DRINK 2 -3 glasses of water 
 Somewhat Dehydrated ……. Drink 1 glass of water 
 Hydrated, You are drinking enough, continue drinking as normal

http://www.health.nsw.gov.au/environment/beattheheat/Pages/urine-colour-chart.aspx

 

Also read our blog “HEALTHY SKIN and WATER INTAKE – PART 2

 

REFERENCES

  • Popkin B. M. et al.; Water, Hydration and Health; Nutr Rev. 2010 August ; 68(8): 439–458. doi:10.1111/j.1753-4887.2010.00304.x.
  • Benelam B. and Wyness L.; Hydration and health: a review; Journal compilation © 2010 British Nutrition Foundation Nutrition Bulletin, 35, 3–25
  • Je´quier E. and Constant ; Water as an essential nutrient: the physiological basis of hydration; European Journal of Clinical Nutrition (2010) 64, 115–123
  • Ganio M. S. et al.; Mild dehydration impairs cognitive performance and mood of men; British Journal of Nutrition (2011), 106, 1535–1543 doi:10.1017/S0007114511002005
  • Armstrong L. E. et al.; Mild Dehydration Affects Mood in Healthy Young Women; The Journal of Nutrition Ingestive Behavior and Neurosciences; First published online December 21, 2011; doi:10.3945/jn.111.142000
  • EFSA (2008). Draft dietary reference values for water. Scientific Opinion of the Panel on Dietetic Products, Nutrition and Allergies, (agreed on 11 April 2008 for release for public consultation). (http://www.efsa. europa.eu/it/scdocs/doc/1459.pdf