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4
Water

SUMMARY

Water is the largest single constituent of the human body and is essential for cellular homeostasis and life. Total water intake includes drinking water, water in beverages, and water that is part of food. Although a low intake of total water has been associated with some chronic diseases, this evidence is insufficient to establish water intake recommendations as a means to reduce the risk of chronic diseases. Instead, an Adequate Intake (AI) for total water is set to prevent deleterious, primarily acute, effects of dehydration, which include metabolic and functional abnormalities.

The primary indicator of hydration status is plasma or serum osmolality. Because normal hydration can be maintained over a wide range of water intakes, the AI for total water (from a combination of drinking water, beverages, and food) is set based on the median total water intake from U.S. survey data. The AI for total water intake for young men and women (ages 19 to 30 years) is 3.7 L and 2.7 L per day, respectively.1 Fluids (drinking water and beverages) provided 3.0 L (101 fluid oz; ≈ 13 cups) and 2.2 L (74 fluid oz; ≈ 9 cups) per day for 19- to 30-year-old men and women, respectively, representing approximately 81 percent of total water intake in the U.S. survey. Water contained in food provided ap-

1  

Conversion factors: 1 L = 33.8 fluid oz; 1 L = 1.06 qt; 1 cup = 8 fluid oz.

 



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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate 4 Water SUMMARY Water is the largest single constituent of the human body and is essential for cellular homeostasis and life. Total water intake includes drinking water, water in beverages, and water that is part of food. Although a low intake of total water has been associated with some chronic diseases, this evidence is insufficient to establish water intake recommendations as a means to reduce the risk of chronic diseases. Instead, an Adequate Intake (AI) for total water is set to prevent deleterious, primarily acute, effects of dehydration, which include metabolic and functional abnormalities. The primary indicator of hydration status is plasma or serum osmolality. Because normal hydration can be maintained over a wide range of water intakes, the AI for total water (from a combination of drinking water, beverages, and food) is set based on the median total water intake from U.S. survey data. The AI for total water intake for young men and women (ages 19 to 30 years) is 3.7 L and 2.7 L per day, respectively.1 Fluids (drinking water and beverages) provided 3.0 L (101 fluid oz; ≈ 13 cups) and 2.2 L (74 fluid oz; ≈ 9 cups) per day for 19- to 30-year-old men and women, respectively, representing approximately 81 percent of total water intake in the U.S. survey. Water contained in food provided ap- 1   Conversion factors: 1 L = 33.8 fluid oz; 1 L = 1.06 qt; 1 cup = 8 fluid oz.  

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate proximately 19 percent of total water intake. Canadian survey data indicated somewhat lower levels of total water intake. As with AIs for other nutrients, for a healthy person, daily consumption below the AI may not confer additional risk because a wide range of intakes is compatible with normal hydration. In this setting, the AI should not be interpreted as a specific requirement. Higher intakes of total water will be required for those who are physically active or who are exposed to hot environments. Over the course of a few hours, body water deficits can occur due to reduced intake or increased water losses from physical activity and environmental (e.g., heat) exposure. However, on a day-to-day basis, fluid intake, driven by the combination of thirst and the consumption of beverages at meals, allows maintenance of hydration status and total body water at normal levels. Because healthy individuals have considerable ability to excrete excess water and thereby maintain water balance, a Tolerable Upper Intake Level (UL) was not set for water. However, acute water toxicity has been reported due to rapid consumption of large quantities of fluids that greatly exceeded the kidney’s maximal excretion rate of approximately 0.7 to 1.0 L/hour. BACKGROUND INFORMATION Water, which is the solvent for biochemical reactions, has unique physical properties (e.g., high specific heat) to absorb metabolic heat within the body. Water is also essential for maintaining vascular volume and serves as the medium for transport within the body by supplying nutrients and removing waste. In addition, cell hydration has been has been suggested to be an important signal to regulate cell metabolism and gene expression (Haussinger et al., 1994). Daily water intake must be balanced with losses in order to maintain total body water. Body water deficits challenge the ability to maintain homeostasis during perturbations (e.g., sickness, physical exercise, and environmental exposure) and can affect function and health. In very unusual circumstances, excess consumption of hypotonic fluids and low sodium intake may lead to excess body water, resulting in hyponatremia and cellular edema. Despite the importance of adequate water intake, there is confusion among the general public and health care providers on the amount of water that should be consumed (Valtin, 2002), in part because of misinterpretation of previous recommendations (NRC, 1989).

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate BODY WATER Fat-Free Mass Body water volume, as a percentage of fat-free mass, is highest in infants and declines in older children (Fomon, 1967; Van Loan and Boileau, 1996). High body water volume is particularly evident in newborns, whose body water content of fat-free mass may exceed 75 percent (Fomon, 1967). Infants also have a relatively higher water content in the extracellular compartment and a lower water content in the intracellular compartment compared with older children (Van Loan and Boileau, 1996). Figure 4-1 presents total body water as a percentage of fat-free mass and body mass in children through the teenage years. Total body water as percentage of fat-free mass decreases during childhood, albeit more slowly than in infancy. For adults, fat-free mass is approximately 70 to 75 percent water, and adipose tissue is approximately 10 to 40 percent water. With increasing fatness, the water fraction of adipose tissue decreases (Martin et al., 1994). Figures 4-2 and 4-3 provide the percentage of FIGURE 4-1 Total body water as a fraction of body mass (FW) and as a fraction of fat-free mass (FWFFM). Reprinted with permission, from Van Loan and Boileau (1996). Copyright 1996 by CRC Press.

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate FIGURE 4-2 Hydration of fat-free mass in relation to age for 95 African-American (closed circles) and 204 white (open circles) men. Reprinted with permission, from Visser and Gallagher (1998). Copyright 1998 by John Libbey Eurotext. FIGURE 4-3 Hydration of fat-free mass in relation to age for 99 African-American (closed circles) and 270 white (open circles) women. Reprinted with permission, from Visser and Gallagher (1998). Copyright 1998 by John Libbey Eurotext.

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate water (tritiated water) in fat-free mass measured by dual energy X-ray absorptiometry (DEXA) in relation to age for men and women, respectively (Visser and Gallagher, 1998; Visser et al., 1997). Note that individual variation exists for the hydration of fat-free tissue and values remain relatively stable with increasing age. Neither ethnicity nor gender altered the hydration of fat-free mass. Similar values were reported for whites (men = 74 percent, women = 74 percent) and African Americans (men = 75 percent, women = 75 percent). Other investigators have supported the observation that age and gender do not markedly alter the hydration of fat-free mass in adults (Baumgartner et al., 1995; Goran et al., 1994; Mazariegos et al., 1994). Total Body Water Total body water (TBW), comprising extracellular fluid (ECF) and intracellular fluid (ICF), averages approximately 60 percent of body weight, with a range from approximately 45 to 75 percent (Altman, 1961). Variability in TBW is primarily due to differences in body composition. TBW is usually measured by volume distribution of an appropriate indicator (e.g., antipyrine, deuterium oxide, tritium oxide). Table 4-1 provides TBW values for different age and gender groups based upon indicator dilution methods (Altman, 1961). Women and older persons have reduced TBW primarily because of having lower fat-free mass and increased body fat. Gender TABLE 4-1 Total Body Water (TBW) as a Percentage of Total Body Weight in Various Age and Gender Groups Lifestage TBW as a Percentage of Body Weight, Mean (range) 0–6 mo 74 (64–84) 6 mo–1 yr 60 (57–64) 1–12 yr 60 (49–75) Males, 12–18 yr 59 (52–66) Females, 12–18 yr 56 (49–63) Males, 19–50 yr 59 (43–73) Females, 19–50 yr 50 (41–60) Males, 51+ yr 56 (47–67) Females, 51+ yr 47 (39–57) SOURCE: Altman (1961).

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate differences in TBW are not observed until after approximately 12 years of age (Novak, 1989), when boys start increasing their fat-free mass at a rate faster than girls do. Athletes have relatively high TBW values by virtue of having a high fat-free mass, low body fat, and high skeletal muscle glycogen levels. High skeletal muscle glycogen levels increase the water content of fat-free tissue due to osmotic pressure exerted by glycogen granules within the muscle sarcoplasm (Neufer et al., 1991; Olsson and Saltin, 1970). Distribution Body water is distributed between the ICF and the ECF, which contain 65 and 35 percent of TBW, respectively. The ECF is further divided into the interstitial and plasma spaces. An average 70-kg man has approximately 42 L of total body water, 28 L of ICF, and 14 L of ECF, with the ECF comprising approximately 3 L of plasma and 11 L of interstitial fluid. These are not static volumes, but represent the net effects of dynamic fluid exchange with varying turnover rates between compartments (Guyton and Hall, 2000). Perturbations such as exercise, heat exposure, fever, diarrhea, trauma, and skin burns will greatly modify the net volumes and water turnover rates between these fluid compartments. Exchange Water exchange between the ICF and ECF depends on osmotic gradients. Water passes through membranes from regions of lower to higher solute concentration by osmosis, which attempts to equalize the concentration differences across the membrane. Cell membranes are freely permeable to water, but they are only selectively permeable to solutes. Water thus distributes across cell membranes to equalize the osmotic concentrations of extracellular and intracellular fluids. Although the two compartments contain different individual solute concentrations, the total equilibrium concentration of cations and anions is the same in each compartment as described by the Gibbs-Donnan equilibrium. In the ECF, the most abundant cation is sodium, while chloride and bicarbonate are the primary anions. These ions represent 90 to 95 percent of the osmotically active components of the ECF, and changes in their content alter the ECF volume. In the ICF, the most abundant cations are potassium and magnesium, while proteins are the primary anions. The marked differences in sodium and potassium concentrations be-

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate tween ICF and ECF are maintained by active transport-mediated ion pumps within cell membranes. Water exchange between the intravascular and interstitial spaces occurs in the capillaries. Capillaries of different tissues have varied anatomic structures and therefore different permeability to water and solutes. The transcapillary forces that determine if net filtration (i.e., water leaving the vascular space) or net absorption (i.e., water entering the vascular space) will occur are hydrostatic and oncotic pressures. Oncotic pressure is the osmotic pressure attributed to serum protein concentration (e.g., serum albumin levels) differences across the capillary membrane. Generally, filtration occurs at the arterial end of the capillary, while absorption occurs at the venous end. Incomplete fluid replacement resulting in decreased total body water affects each fluid space as a consequence of free fluid exchange (Costill and Fink, 1974; Durkot et al., 1986; Nose et al., 1983). The distribution of body water loss among the fluid spaces, as well as among different body organs during water deficit (dehydration or hypohydration), was determined in an animal model (Nose et al., 1983). The fluid deficit in rats thermally dehydrated by 10 percent of body weight was apportioned between the intracellular (41 percent) and extracellular (59 percent) spaces. Organ fluid loss was 40 percent coming from muscle, 30 percent from skin, 14 percent from viscera, and 14 percent from bone. Neither the brain nor liver lost significant water content. Various dehydration methods influence the partitioning of water loss from the fluid spaces (Mack and Nadel, 1996). Determinants of Body Water Balance Body water balance depends on the net difference between water gain and water loss. Water gain occurs from consumption (liquids and food) and production (metabolic water), while water losses occur from respiratory, skin, renal, and gastrointestinal tract losses. Water is normally consumed by mouth via liquid and food, and this mixture is digested and absorbed within the gastrointestinal tract. Therefore, water intake can be estimated from measured liquid volumes and tables of food composition. Water losses can be estimated from a variety of physiological and biophysical measurements and calculations (Adolph, 1933; Consolazio et al., 1963; Johnson, 1964). Depending upon a person’s age, health, diet, activity level, and environmental exposure, different physiological and biophysical methods can be used to quantify the water balance components. Table

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate TABLE 4-2 Estimation of Minimum Daily Water Losses and Productiona Reference Source Loss (mL/d) Production (mL/d) Hoyt and Honig, 1996 Respiratory loss −250 to −350   Adolph, 1947b Urinary loss −500 to −1,000 Newburgh et al., 1930 Fecal loss −100 to −200 Kuno, 1956 Insensible loss −450 to −1,900 Hoyt and Honig, 1996 Metabolic production   +250 to +350   Total −1,300 to −3,450 +250 to +350 Net loss −1,050 to −3,100   a Assuming conditions in which there is minimal water loss from sweating. 4-2 displays estimated minimum losses and production of water (mL/day) in healthy sedentary adults, assuming conditions in which there is minimal water loss from thermoregulatory sweating. The following sections describe each source of water loss or production listed in this table. Respiratory Water Loss The amount of respiratory water loss, via evaporation within the lungs, is dependent on both the ventilatory volume and water vapor pressure gradient (Mitchell et al., 1972). Ventilatory volume is increased by physical activity, hypoxia, and hypercapnia, whereas the water vapor pressure is modified by the ambient temperature, humidity, and barometric pressure. Physical activity generally has a greater effect on respiratory water loss than do environmental factors. Daily respiratory water loss averages about 250 to 350 mL/day for sedentary persons, but can increase to 500 to 600 mL/day for active persons living in temperate2 climates at sea level (Hoyt and Honig, 1996). For these conditions, respiratory water loss (y = mL/day) can be predicted from metabolic rate (x = kcal/day) by the equation y = 0.107x + 92.2 (Hoyt and Honig, 1996). High altitude exposure (greater than 4,300 m, 448 mm Hg) can further increase respiratory water losses by approximately 200 mL/day (Hoyt and Honig, 1996). 2   In general, dry bulb temperatures of approximately 70°F, 80°F, and 90°F are used for temperate, warm, and hot conditions, respectively, in this report.

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate Ambient air temperature and humidity modify respiratory water losses. Breathing hot, dry air during intense physical exercise can increase respiratory water losses by 120 to 300 mL/day (Mitchell et al., 1972). Breathing cold, dry air during rest and stressful physical exercise (Table 4-3) can increase respiratory water losses by approximately 5 mL/hour and approximately 15 to 45 mL/hour, respectively (Freund and Young, 1996). Freund and Young (1996) have calculated that for a 24-hour military scenario (8 hours of rest, 12 hours of moderate activity, and 4 hours of moderate-heavy activity), the respiratory water losses increase by approximately 340 mL/day when breathing −20°C versus +25°C air. Urinary and Gastrointestinal Water Loss The kidneys are responsible for regulating the volume and composition of the ECF via a series of intricate neuroendocrine pathways (Andreoli et al., 2000). Renal fluid output can vary depending upon the specific macronutrient, salt, and water load. However, for persons consuming an average North American diet, some of these effects may not be discernable (Luft et al., 1983). Since there is a limit to how much the kidneys can concentrate urine, the minimal amount of water needed is determined by the quantity of end products that need to be excreted (e.g., creatinine, urea). On typical Western diets, an average of 650 mOsmol of electrolytes and other TABLE 4-3 Influence of Breathing Cold Air and of Metabolic Rate on Respiratory Water Losses Temperature Relative Humidity (%) Water Vapor Pressure (mm Hg) Metabolic Rate (Watts) Respiratory Water Loss (mL/h) °F °C 77 25 65 15 Rest (100) ≈ 10 32 0 100 5 Rest (100) ≈ 13 −4 −20 100 1 Rest (100) ≈ 15 77 25 65 15 Light-moderate (300) ≈ 30 32 0 100 5 Light-moderate (300) ≈ 40 −4 −20 100 1 Light-moderate (300) ≈ 45 77 25 65 15 Moderate-heavy (600) ≈ 60 32 0 100 5 Moderate-heavy (600) ≈ 80 −4 −20 100 1 Moderate-heavy (600) ≈ 90 SOURCE: Reprinted with permission, from Freund and Young (1996). Copyright 1996 by CRC Press.

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate solutes must be excreted per day to maintain electrolyte balance; thus, if the urine is maximally concentrated (Uosm approximately 1,200 mOsmol/kg water), the minimum urine output is approximately 500 mL/day. For dehydrated subjects living in hot weather, minimum daily urine outputs can be less than 500 mL/day (Adolph, 1947b). Urine output generally averages 1 to 2 L/day but can reach 20 L/day in those consuming large quantities of fluid (West, 1990). Healthy older individuals, however, cannot concentrate urine as well as young individuals and thus have a higher minimum urine output. For example, older men and women (mean age 79 years) had lower maximal urine osmolalities of 808 and 843 mOsm/kg, respectively, compared with 1,089 mOsm/kg for young men (mean age 24 years). This corresponds to higher minimum urine outputs of 700 and 1,086 mL/day for the older men and women compared with 392 mL/day for the young men (Dontas et al., 1972). Urine output varies inversely with body hydration status. Figure 4-4 depicts the hyperbolic relationship between urine output and FIGURE 4-4 Relation of urine output to body hydration status. Reprinted with permission, from Lee (1964). Copyright 1964 Handbook of Physiology, Section 4, American Physiological Society.

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate body hydration status: one asymptote ascends steeply with hyperhydration, while the other descends gradually with dehydration (Lee, 1964). The apex of this hyperbolic relationship approximates a urine output of approximately 50 mL/hour. The extremes depicted in Figure 4-4 can be exceeded. For example, investigators have reported that urine output can transiently increase to approximately 600 to 1,000 mL/hour with water loading (Freund et al., 1995; Noakes et al., 2001; Speedy et al., 2001) and decrease to approximately 15 mL/hour with dehydration (Adolph, 1947b). Urine output can vary widely to maintain total body water; however, there are clearly limits to the amount of conservation and excretion. Physical activity and climate also affect urine output. Exercise and heat strain will reduce urine output by 20 to 60 percent (Convertino, 1991; Mittleman, 1996; Zambraski, 1996), while cold and hypoxia will increase urine output (Freund and Young, 1996; Hoyt and Honig, 1996). Gastrointestinal and thus fecal water loss in healthy adults is approximately 100 to 200 mL/day (Newburgh et al., 1930). Insensible and Sweat Losses Water loss through the skin occurs via insensible diffusion and secreted sweat. For the average adult, loss of water by insensible diffusion is approximately 450 mL/day (Kuno, 1956). During heat stress, eccrine sweat glands secrete sweat onto the skin surface, which cools the body when water evaporates from the sweat. In hot weather, sweat evaporation provides the primary avenue of heat loss to defend the body’s core temperature. When a gram of sweat water is vaporized at 30°C, 2.43 kJ (0.58 kcal) of heat becomes kinetic energy (latent heat of evaporation) (Wenger, 1972). For a given hot weather condition, the required sweating rate for evaporative cooling is dependent upon the physical activity level (metabolic rate). The following calculations provide the minimal sweat produced by persons performing moderately heavy (metabolic rate ≈ 600 W) exercise in the heat (Sawka et al., 1996a). If the activity is 20 percent efficient, the remaining 80 percent of metabolic energy produced is converted to heat in the body so that 480 W (0.48 kJ/second, or 28.8 kJ/minute or 6.88 kcal/minute) need to be dissipated to avoid heat storage. The specific heat of body tissue (amount of energy required for 1 kg of tissue to increase temperature by 1°C) approximates 3.5 kJ (0.84 kcal)/kg/°C. For example, a 70-kg man has a heat capacity of 245 kJ (59 kcal)/°C, and a 50-kg woman has a heat capacity of 173

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate Kenney WL, Tankersley CG, Newswanger DL, Hyde DE, Puhl SM, Turner NL. 1990. Age and hypohydration independently influence the peripheral vascular response to heat stress. J Appl Physiol 68:1902–1908. Kim AH, Keltz MD, Arici A, Rosenberg M, Olive DL. 1995. Dilutional hyponatremia during hysteroscopic myomectomy with sorbitol-mannitol distention medium. J Am Assoc Gynecol Laparosc 2:237–242. Kimura T, Minai K, Matsui K, Mouri T, Sato T, Yoshinaga K, Hoshi T. 1976. Effect of various states of hydration on plasma ADH and renin in man. J Clin Endocrinol Metab 42:79–87. Knepper MA, Valtin H, Sands JM. 2000. Renal actions of vasopressin. In: Fray JCS, Goodman HM, eds. Handbook of Physiology, Section 7, Volume III: Endocrine Regulation of Water and Electrolyte Balance. New York: Oxford University Press. Pp. 496–529. Koczapski AB, Millson RC. 1989. Individual differences in serum sodium levels in schizophrenic men with self-induced water intoxication. Am J Psychiatry 146: 1614–1615. Korzets A, Ori Y, Floro S, Ish-Tov E, Chagnac A, Weinstein T, Zevin D, Gruzman C. 1996. Case report: Severe hyponatremia after water intoxication: A potential cause of rhabdomyolsis. Am J Med Sci 312:92–94. Kriemler S, Wilk B, Schurer W, Wilson WM, Bar-Or O. 1999. Preventing dehydration in children with cystic fibrosis who exercise in the heat. Med Sci Sports Exerc 31:774–779. Kristal-Boneh E, Glusman JG, Chaemovitz C, Cassuto Y. 1988. Improved thermoregulation caused by forced water intake in human desert dwellers. Eur J Appl Physiol 57:220–224. Kuno Y. 1956. Human Perspiration. Springfield, IL: Charles C. Thomas Publisher. Kushner RF, Schoeller DA. 1986. Estimation of total body water by bioelectrical impedance analysis. Am J Clin Nutr 44:417–424. Kushner RF, Schoeller DA, Fjeld CR, Danford L. 1992. Is the impedance index (ht2/R) significant in predicting total body water? Am J Clin Nutr 56:835–839. Ladell WSS. 1955. The effects of water and salt intake upon the performance of men working in hot and humid environments. J Physiol 127:11–46. Lane HW, Gretebeck RJ, Schoeller DA, Davis-Street J, Socki RA, Gibson EK. 1997. Comparison of ground-based and space flight energy expenditure and water turnover in middle-aged healthy male US astronauts. Am J Clin Nutr 65:4–12. Latzka WA, Sawka MN, Montain SJ, Skrinar GS, Fielding RA, Matott RP, Pandolf KB. 1997. Hyperhydration: Thermoregulatory effects during compensable exercise-heat stress. J Appl Physiol 83:860–866. Latzka WA, Sawka MN, Montain SJ, Skrinar GA, Fielding RA, Matott RP, Pandolf KB. 1998. Hyperhydration: Tolerance and cardiovascular effects during uncompensable exercise-heat stress. J Appl Physiol 84:1858–1864. Lax D, Eicher M, Goldberg SJ. 1992. Mild dehydration induces echocardiographic signs of mitral valve prolapse in healthy females with prior normal cardiac findings. Am Heart J 124:1533–1540. Ledochowski M, Kahler M, Dienstl F, Fleischhacker W, Barnes C. 1986. Water intoxication in the course of an acute schizophrenic episode. Intensive Care Med 12:47–48. Lee DHK. 1964. Terrestrial animals in dry heat: Man in the desert. In: Dill DB, Adolph EF, Wilber CG, eds. Handbook of Physiology, Section 4: Adaptation to the Environment. Washington, DC: American Physiological Society. Pp. 551–582.

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