AMJ Vol 7 No 4 December 2020.indd
Althea Medical Journal. 2020;7(4)
194 AMJ December 2020
Urine Color Analysis of Hydration Status in Employees Working in
Bandung, Indonesia
Liza Karina Hauteas R. Sutono,1 Rudi Supriyadi,2 Yenni Zuhairini1
1Faculty of Medicine Universitas Padjadjaran, Indonesia, 2Department of Internal Medicine
Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung,
Indonesia, 3Department of Public Health Faculty of Medicine Universitas Padjadjaran, Indonesia
Correspondence: Liza Karina Hauteas R. Sutono, Faculty of Medicine Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km. 21,
Jatinangor, Sumedang, West Java- Indonesia, E-mail: lisakarinahauteas@gmail.com
Introduction
Well-hydrated or normohydration is a
condition where water intake and excretion
are in balance.1 When the fluid balance in the
body fails to be preserved, dehydration can
occur, which is the process of fluid loss in the
human body. One of the causes of dehydration
is excessive sweating with insufficient water
intake.1 Previous study conducted on workshop
workers demonstrates a strong connection
between fluid intake and hydration status.2 A
group respondents considered to be at risk
of dehydration is field workers because they
work in a hot working environment among
others under the sun exposure, and they
spend a lot of energy while doing their work.
Field workers also often do not pay attention
to the balance of water intake and excretion.
Loss of fluid, approximately 1% of body
weight, can usually be compensated within
24 hours by the body. It is characterized by
increased thirst and urine concentration. If
the process of fluid loss continues, the water
volume in the blood will decrease and overall
blood volume is decreased as well. As a result,
the heart will have difficulty maintaining
blood perfusion to other organs, leading to
impaired cardiovascular function, which can
be marked by a decrease in blood pressure
and an increase in heart rate. Dehydration that
occurs persistently can cause blood perfusion
to the skin, kidney, or brain to decrease.
Furthermore, it can cause disturbances
in concentration, headaches, fatigue,
reduced physical performance, impaired
thermoregulatory function, kidney damage,
and can be life-threatening.1,3
There are various ways to assess a
hydration status, one of which is to observe
the color of urine, which is simple, practical,
fast, and inexpensive. This assessment has
AMJ. 2020;7(4):194–9
Abstract
Background: Dehydration can be compensated for by the body. However, if it occurs persistently,
it can cause concentration problems, thermoregulation disorders, kidney damage, and other life-
threatening disorders such as cardiovascular disorders. Urine color is a simple indicator to assess a
person’s hydration status. The purpose of this study was to explore the hydration status of employees
working in Bandung, Indonesia.
Methods: This was a descriptive cross-sectional study conducted from March to November 2019. This
study was a part of another study exploring urine color levels. Urine was collected on Sunday morning
when the employees were free. Water intake and workload before urine examination were not taken
into account. Hydration status was divided into three categories: well-hydrated, mild/moderate
dehydration, and severe dehydration. A total sampling method was used to collect data.
Results: In total, 178 subjects who met the study criteria participated in the study. The majority of
respondents were 40-79 years old, male, did not have hypertension or diabetes, and active smokers.
Most respondents experienced severe dehydration (44.7%) although 58.1% had consumed ≥8 glasses
of water/day.
Conclusions: More than half employees have consumed adequate amount of water; however, the
majority are severely dehydrated when assessed based on their urine color. Further study on the
balance of water intake and excretion is needed to explore the phenomenon of dehydration in the
morning.
Keywords: Dehydration, hydration status, urine color
https://doi.org/10.15850/amj.v7n4.1916
Althea Medical Journal. 2020;7(4)
195
been validated, both in adults and children.4,5
One of the factors that can affect the urine
color density is the amount of water that
dissolves urine color compounds, which are
urochrome, uroerythrin, and urobilin. The
water amount in the urine in the dehydrated
individuals will be lower than the urine color
compounds, causing darker urine color.5,6 This
study aimed to determine the hydration status
variations by observing the color of urine
among field workers in Bandung, for early
detection of dehydration status, in order to
further exploring the preventive action.
Methods
This research was a descriptive, cross-
sectional study, conducted from March to
November 2019. The hydration status based
on urine color analysis was determined among
adult employees in Bandung. This study used
the secondary data from a previous study. In
brief, a questionnaire was distributed during
the World Kidney Day 2019 event, held by Dr.
Hasan Sadikin General Hospital in collaboration
with the Indonesian Nephrology Association
(Perhimpunan Nefrologi Indonesia, PERNEFRI).
Urine was taken on a Sunday morning when
the employees were free or not working. Their
water intake and workload before the urine
examination were not taken into account.
The exclusion criteria were incomplete data
on age, gender, amount of water intake per
day, smoking status, or comorbid disease
statuses such as hypertension and diabetes.
After consent, the respondents filled out a
questionnaire and collected their urine on a
transparent tube for free urine examination.
The result was consulted to the doctor present
at the event. The urine obtained was then
compared with the standard urine color chart,
released by the Ministry of Health Republic
of Indonesia (2018) by placing a white paper
behind the tube, and therefore the urine
color was more visible (Figure 1). There were
eight colors of urine that was designated
into level 1 to 8, indicating the palest urine
color to the darkest concentrated urine color,
respectively. This level of urine color was
pointing out to the hydration level that was
categorized into well-hydrated (level 1–3),
mild/moderate dehydration (level 4–5), and
severe dehydration (level 6–8).
All respondents were given information
about this study, and those who were willing
to take part in this study were asked to sign
an agreement form. This study had been
approved by the Research Ethics Committee
of Universitas Padjadjaran Bandung (No. 996/
UN6.KEP/EC/2019).
Results
In total, 178 data were obtained for this study,
however, 73 data were incomplete and thus
only 105 data were taken into further analysis.
The characteristics of the employees showed
that the majority was male (80.95%) and aged
Figure 1 Standard Urine Color Chart7
Liza Karina Hauteas R. Sutono et al.: Urine Color Analysis of Hydration Status in Employees Working in
Bandung, Indonesia
Althea Medical Journal. 2020;7(4)
196 AMJ December 2020
Table 2 Hydration Level and Water Intake among employees in Bandung
Frequency (n) Percentage (%)
Level of hydration
Well-hydrated 26 24.76
Mild/moderate dehydration 32 30.48
Severe dehydration 47 44.76
Water Intake (glass/day):
<8 44 41.90
≥8 61 58.10
Note: well-hydrated (level 1–3), mild/moderate dehydration (level 4–5) and severe dehydration (level 6–8).
>40 years old (52.38%). Hypertension was
detected in 10.48%, diabetes in 2.86% and
half of them were active smokers (50.4%), as
shown in Table 1.
The majority of employees were in severe
dehydration (44.76%), although the majority
of subjects had consumed ≥8 glasses of water
per day (58.10%) as shown in Table 2.
The hydration level based on water
intake per day was shown in Figure 2, which
illustrated the high number of respondents
who were in mild/moderate and severe
dehydration conditions despite consuming
water ≥8 cups per day (Figure 2). However, a
T-test performed to reveal the significance of
the relationship between hydration level with
consumed water had shown no significant
relationship between hydration level with the
consumed water (p=0.059, data not shown).
Discussions
The level of hydration has been divided into
three categories; well/good hydration, mild/
moderate dehydration, and severe dehydration.
The hydration has been based on age, gender,
or whether there is a comorbid disease such
as hypertension and diabetes, type of smokers,
and how much water per day is consumed. The
daily water intake is recommended as much as
8 cups or about 2–2.5 liters per day.1,8 However,
Table 1 Characteristics of Employees
Characteristic (n=105) Frequency(n) Percentage (%)
Age (year):
19–39 50 47.62%
>40 55 52.38%
Gender
Male 85 80.95%
Female 20 19.05%
Hypertension
Yes 11 10.48%
No 94 89.52%
Diabetes
Yes 3 2.86%
No 102 97.14%
Smokers
Active 53 50.48%
Passive/Non-Smoker 52 49.52%
Althea Medical Journal. 2020;7(4)
197
this study shows that there is no significant
relationship between daily consumed water
with hydration level (p=0.059), although
others reported a strong relationship.2 This
different result might be caused by the study
number. Further study is needed to explore
this relationship.
Interestingly, the condition of mild/
moderate or severe dehydration is still high
in individuals who have consumed 8 glasses
of water per day (Figure 2). Dehydration
usually occurs due to lack of water intake or
when water excretion exceeds water intake,
therefore, the urine will be concentrated and
produce a darker color.6,9 Morning urine may
have a darker color since there is a is lack of
water intake at the previous night. The lack
of water in the blood can reduce the blood
plasma rate towards the kidneys, it can reduce
the rate of renal filtration that will be detected
by the kidneys. The kidneys will increase
water reabsorption and only a small amount
of water is excreted through urine. The body
can detect the rise of water in the blood within
10 minutes after rehydration.9,10
Our study has shown that the highest
percentage of severe dehydration are those
among the aged range of 40–79, however,
the majority have consumed more than 8
cups of water per day, as recommended by
the Ministry of Health Republic of Indonesia.
Kidney function will decrease through aging,
and there will be changes in the structure and
function of the kidneys, leading to a reduced
number and size of the nephron. The change
begins at the age of 20 years, which occurs
progressively but slowly. The significant change
might be detected at the age of 50 years. This
study also reported that reduced renal ability
to concentrate urine comes along with aging
thus it can increase the risk of dehydration,
11 making this one of the factors that causes a
large number of concentrated urine findings in
the elderly individuals in the study.
The majority of our respondents were
male and the largest percentage of severely
dehydrated man has consumed more than 8
glasses of water per day. In opposite to this
study, other study showed that dehydration is
more common in women because women have
more fat proportion in the body, thus, the water
amount is lower.12 However, when associated
with kidney aging, males produce consistently
more concentrated urine than females.13 After
the age of 40 years, the glomerular filtration
rate (GFR) in males will decline by 1% per
year, while in women GFR will remain stable
until 50 years of age.14 This can be caused
by the estrogen hormone that may provide
a protective effect on the kidneys. Androgen
hormones instead may have a negative effect
on kidney aging. Estrogen can stimulate the
synthesis of nitrite oxide (NO) which has a
vasodilator effect on various blood vessels
including the renal arteries. The vasodilator
effect may improve the perfusion to kidney
cells and it maintains kidney cell survival.
Estrogen cans also the amount of angiotensin
II and angiotensin-converting enzyme (ACE)
and therefore reducing its activity, which is
Figure 2 Hydration Level based on Daily Water Intake
Liza Karina Hauteas R. Sutono et al.: Urine Color Analysis of Hydration Status in Employees Working in
Bandung, Indonesia
Althea Medical Journal. 2020;7(4)
198 AMJ December 2020
vasoconstrictors in blood vessels, including
blood vessels in the kidneys. Poor blood flow
may accelerate kidney damage as the age
progresses. Conversely, the androgen hormone
that presents in large amounts in males can
stimulate the renin-angiotensin system (RAS),
causing dehydration to occur easier in males
than in females.11, 13–15
Dehydration is one of the causes of
acute kidney dysfunction, which is usually
reversible and has no long-term effects on
the kidneys. However, when dehydration
occurs persistently, it can cause permanent
kidney damage. Kidney damage can lead to
the disruption of the overall kidney function,
including kidney function to concentrate
urine, which then can indirectly affect the
color of the urine.3 In addition to dehydration,
some conditions such as hypertension,
diabetes, and smoking status, can also affect
kidney health. According to the National
Institute of Diabetes and Digestive and Kidney
Disease, hypertension is the condition of
consistently rising or high blood pressure.16
Hypertension can thus damage blood vessels
in the kidneys. High blood pressure in the
blood vessels will cause the blood vessels to
constrict so that nutrients to the kidney will be
reduced and can cause kidney cells damaged
and disrupt kidney function.17 However, the
number of respondents with hypertension
status in our study is only about 10.5%. In
addition to hypertension, hyperglycemia
in uncontrolled diabetic patients can cause
glycosylation of the basement membrane
protein resulting in thickening of the
glomerular basement membrane. There is an
accumulation of glycoprotein-like substances
in the mesangial basement membrane that
may disrupt glomerular capillaries, and all
of that complex processes can cause kidney
damage.18,19 Kidney damage can also be caused
by the nephrotoxic effect of smoking whose
mechanism is not completely clear. However,
some hypotheses state that smoking can
cause endothelial cell dysfunction, produce
oxidative stress, proinflammation, leading to
glomerulosclerosis and atrophy of the kidney
tubule. The adverse effects of smoking can
affect the incidence of chronic renal failure
in adults.20 Dehydration can adversely affect
the health conditions in general, leading to
reduced concentration and work performance
and thus affecting the effectiveness and work
results. In addition to being detrimental at the
individual level, it can also have an impact at
the community level.
This study’s limitations are the data
obtained through questionnaires regarding
water intake per day, hypertension status,
smoking status, and diabetes status. Question
on data on water intake per day has used
glass/day as a unit, and there is no specific
volume on how many ml of glass referred to
the questionnaire. Hypertension and diabetes
status are also not accompanied by the length
of time they have the disease. Hypertension
or diabetes may exist without the individual
knows. Smoking status is not accompanied
by information on smoking intensity. The
category of passive smokers/non-smokers is
also not further detailed. The medication used
is not documented. The standard urine color
chart for reference has been taken from the
leaflet, making a speculative assessment due
to the color change over time. Future study is
needed to obtain more specific information in
the questionnaire. It is also recommended to
add some other variables that influence the
hydration level such as body weight, fat mass
in the body, physical activity performed by
each subject, kidney disease status, and others.
To conclude, the majority of male
respondents in our study are in severe
dehydration based on urine color taken in the
morning, although most of them have a habit
of consuming ≥8 glasses per day. They are
aged 40–79 years, do not have hypertension
or diabetes, and are active smokers. Therefore,
it is important to educate the male workers
on kidney health, the importance of adequate
water intake, and the impact of dehydration
on health. Moreover, forging a standard chart
of urine color in the bathroom can trigger the
employees to easily identify their hydration
status and drink more water in case of severe
dehydration.
Acknowledgment
We were grateful to the employees of PD
Kebersihan, Bandung, who participated in the
study.
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Liza Karina Hauteas R. Sutono et al.: Urine Color Analysis of Hydration Status in Employees Working in
Bandung, Indonesia