Reversing diabetes: understanding the process

The fundamental problem, the cause of all the complications associated with diabetes, is the chronically elevated glucose and insulin levels. Independently of the fact that each individual, each one of us, has a different tolerance to carbohydrates, a different metabolic response to the presence of glucose and insulin in the blood, there are basically only two ways that blood glucose can be elevated: the first is by the consumption of sugar or starch that finds its way into the bloodstream through the intestinal wall; the second is by the stimulation by stress hormones of liver glucose production whereby the glycogen reserves are broken down and the resulting glucose released into the blood. Therefore, in order to most effectively bring down chronically elevated blood sugar levels, it is essential to eliminate insulin-stimulating carbohydrates, but it is also essential to eliminate chronic stress.

The sugar

The vast majority of the millions of type II diabetics that constitute the body of what is now generally considered to be a diabetes epidemic in many western countries, have developed the condition primarily from the consumption of dietary insulin-stimulating carbohydrates, from eating high-sugar and high-starch diets over the course of decades. The process of growing insulin resistance due to chronic consumption of carbohydrates is described in several other posts (like, for example, We were never meant to eat simple or starchy carbohydrates, A diabetic’s meal on Air France, and Cure diabetes in a matter of weeks). It is for this reason that the same vast majority of type II diabetics responds extremely well to the elimination of these carbohydrates from their diet, whereupon glucose levels drops, insulin levels drop, the cells gradually regain insulin sensitivity, and the tissues and organs gradually recover from years or decades of the toxic environment created by continuously being exposed both to glucose and insulin. Naturally, the recovery process depends intimately on how long and how bad things were before implementing these dietary changes, but it happens in more or less the same way in every person.

The stress

The tendency, in many western societies and especially in North America, to create and generate in all sorts of ways, very high levels of stress in most spheres of our activities and our life, and, in fact, thrive on this stress throughout most days, often for years and even decades, in order to be highly “productive” and “successful”, or at least, make ourselves feel or believe that we are, is extremely bad. This, compounded with the fact that most of our standard western diets are very top-heavy in insulin-stimulating carbohydrates, makes one’s evolution towards of type II diabetes faster, more pronounced and much more harmful. As a consequence, there is without a doubt an non-negligible fraction of diabetics that suffer from both a high intake of sugary and starchy foods, as well as high stress levels.

In the extreme, however, it is definitely possible to develop diabetes uniquely or primarily due to chronically high levels of stress. The most important, and indeed, very important difference between elevating blood sugar through diet or as a consequence of stress hormones, is that the former is naturally corrected by the secretion of insulin, which helps put aways the sugar either as glycogen or as fat, whereas the latter, the presence of high levels of stress hormones, simultaneously induces insulin resistance in order to keep the glucose in circulation as long as possible. This makes perfect sense from an evolutionary standpoint because under stress, under a fight or flight situation, we need lots of glucose in the blood and we want it to stay there to allow us to respond physically to whatever needs to be done: to run, jump, climb, fight, survive. The problem is that our high levels of stress are not only chronic, but they are not associated with a situation in which we need to have access to high levels of sugar in the blood in order to respond to the stressor physically with our muscles. And so, glucose remains high and circulates, insulin remains high but is not effective, and from this, all our blood vessels, tissues and organs get damaged: glycated from the glucose, oxidised from the free radicals, and literally corroded by the insulin.

This clearly implies that chronically high levels of stress are far worse than a high carbohydrate diet, and explains in no uncertain terms why high-stress professionals—even low-carb eaters—can not only suffer from chronically elevated blood sugar levels and the full array of damaging consequences, but also develop diabetes, and almost inevitably, heart and artery disease, because they all come from the same place: high stress leads to high levels of cortisol and other stress hormones; high levels of stress hormones lead to high glucose and insulin resistance no matter what is eaten because it comes from the liver; high glucose levels and insulin resistance leads to artery disease which leads to heart disease, and it also leads to type II diabetes. This is why, for those high work volume and high stress high-strung high-achievers, it is essential to eliminate all insulin-stimulating carbohydrates, but it is crucial to significantly reduce, and ideally, eliminate chronic stress. (We have looked at many of the physiological effects of stress in The kidney: evolutionary marvel and in At the heart of heart disease.)

The physiological consequences

As every diabetic knows, or at least should know, the consequences or complications associated with the condition of diabetes are horrific. What is very unfortunate is that it appears as though many doctors do not understand the biochemical and physiological connections and chains of  reactions and responses that develop and grow more sever over time as a consequence of the underlying chronically elevated blood sugar and insulin levels (as you may remember from your reading of Why do diabetics have high blood pressure?). What happens in the body when levels of blood sugar and insulin resistance stay high? Let’s follow this through:

High blood pressure, atherosclerosis and heart disease

The most immediate consequences are the rise in blood pressure and increased damage to blood vessels from glycation: the elevated levels of glucose that the kidneys have evolved to keep in circulation causes a rise in osmolarity (blood concentration), which the kidneys try to counter by retaining water in order to keep the blood from getting too concentrated. Since blood pressure is mostly a function of the amount of water in the blood, this causes the pressure to rise. Because glucose is meant to remain in minimal circulating concentrations or otherwise be quickly cleared from the bloodstream by pancreatic insulin shuttling it into cells, long-lasting elevated sugar concentration leads to the glycation of tissues, which is the damage of protein or fatty structures of the cells due to the glucose molecules “sticking” in the wrong places and in the wrong way. This, in combination with the higher blood pressure, is the perfect recipe for much increased damage to the blood vessels, especially the large arteries in which the pressure is greatest, the increased production of cholesterol and lipoproteins for cholesterol transport and damage repair, and the consequent plaque buildup termed atherosclerosis, which eventually (sooner than later) leads to artery disease, heart disease, and heart attacks from the occlusion of vessels bringing blood to the heart muscle (the coronary arteries).

Kidney disease

Even though it is the kidney that regulates the blood pressure and retains water in order to keep the blood from getting too concentrated with the increasing concentration of glucose, the higher blood pressure puts great strain on all of its micro filtering units, the nephrons, whose function is to filter out acidic metabolic waste from the bloodstream and get rid of it through the urine. The nephron works optimally under optimal conditions, but optimal for it, which means ideal blood pressure: not too low, but especially, not too high. It’s a self-regulating system in that if we are relaxed and at rest, then breathing is slow, heart beat is slow, blood circulation is slow, blood pressure is low and the kidneys are under little strain. As we get moving, through exercise, for example, then breathing is faster, heart beat is faster, blood flow is faster, blood pressure is higher, and the kidneys filter a larger volume of blood per second in order to eliminate as much of the acid that is building up from the activity and that needs to be eliminated in order for the muscles to continue working in ideal conditions.

With chronically high blood pressure, the kidneys are continually under stress and the nephrons get damaged. However, because there are millions of nephrons in each of the two kidneys, and it has been estimated that we can live with only 1/3 of the nephrons in only one of the two kidneys, this problem of the gradual deterioration of kidney function is not really considered as a big issue until the kidneys fail (or little time before), at which point it is far too late, and the situation is irreversible.

In addition, insulin resistance—to any degree—promotes the break down of muscle tissue, because as soon as sugar levels drop after a few hours after a meal or snack, during the night is the most apt example, since the cells cannot use fats for energy, the muscle tissue is broken down and constituents of its proteins made into glucose. This leads to chronically high levels of circulating creatinine that, as a metabolic waste product, must also be filtered out and eliminated by the kidneys. This happens in everyone with insulin resistance, and the amount of muscle breakdown is a function of the degree of insulin resistance. In the case of extreme insulin resistance as is seen in type II diabetics, the process is far more pronounced. The excessive stress on the kidneys inevitably leads to deterioration, nephron dysfunction, and eventually to failure. (You can read more about kidney function in The kidney evolutionary marvel.)

What makes things even worse is that most diabetics/heart disease sufferers have elevated lipoprotein (and cholesterol) levels due to the excessive inflammation and speed at which tissue damage is taking place in the blood vessels and all over the body. This, as you all know, has been wrongly interpreted and widely promoted as a major risk factor for heart attacks. The “treatment” of choice for these patients are a lifelong prescription for statin drugs. Very unfortunately, not only do statin drugs not confer any health or longevity benefits, but they accelerate the speed at which muscle breaks down, causing even greater amounts of creatinine to make its way into the bloodstream, and thus creating a heavy additional load on the kidneys. Is it any wonder that the rise in kidney disease closely reflects the rise in diabetes but also in statin consumption? If you’ve been taking statins, don’t get overly worried: physiological degradation is a slow process, and it is rarely too late to make the intelligent choices and changes that will help stop and reverse the disease process, and in time allow the body to heal itself.

Systemic acidosis

The way in which the kidney regulates blood pressure upwards is by secreting different hormones that prevent water from being eliminated, that thicken the blood, and that contract the blood vessels. In most people, the majority of which is chronically dehydrated, there is already a shortage of water and therefore a dehydration response by the kidneys; the elevated sugar concentration makes this far worse, of course. And under dehydration conditions, the means by which the kidney can retain even more water, as much water as it can, is by increasing the concentration gradient in the interstitial medium through which the nephron passes in order to pull as much water out of the filtrate as possible.

Increasing the concentration gradient is done by keeping and concentrating sodium and uric acid. It is more important to retain water than to eliminate uric acid, because water is primordially important for all body functions. Consequently, urea and uric acid levels rise, gradually but consistently over time. Because acid cannot accumulate in the blood, whose pH must absolutely be kept pretty much exactly at 7.4 (7.35-7.45), but because, at the same time, it cannot be eliminated by the kidneys under the given circumstances, it is stored away in the tissues all over the body: joints, ligaments, tendons, muscles and organs. Chronically high levels of uric acid in the blood lead to the condition known as gout. The buildup of acid in the tissues leads to pain, inflammation, arthritis, cartilage breakdown, bone demineralisation and osteoporosis, and a slew of other undesirable consequences, including increased susceptibility to all forms of infections: yeast, viral and bacterial, and severely depressed immunity. (You can read more about acidosis and alkalisation in A green healing protocol, Detoxification, and Such a simple and yet powerful natural anti-inflammatory.)

Maybe the most critical point about acidosis in how it relates to diabetes is that the pancreas and its precious beta cells, those that produce the insulin, are extremely sensitive to pH, and simply cannot function when the blood and cellular environment is acidic. The cells simply stop functioning because of the overload of acid that is not excreted and not neutralised. This makes the pancreas more and more dysfunctional over time, and eventually leads to exhaustion and the complete inability to secrete insulin or do any of the other functions that it is intended to perform. Something very similar happens in the liver, and, in fact, everywhere else, when chronic acidosis defines the internal environment of the body.

Pancreatic exhaustion

The distinction between type I and type II diabetes is usually highlighted by calling the first insulin-dependent diabetes, and the second insulin-resistant diabetes. Type I diabetics are usually identified and diagnosed as children or young adults because their pancreas does not produce insulin, and are then “treated” by having to inject themselves insulin after they eat for the rest of their lives. Naturally, over time, from the continual and usually excessive exposure to insulin, their cells become insulin-resistant, and they subsequently develop all the same problems as type II diabetics, whose condition is, in a way, exactly the opposite, in the sense that they suffer from chronic hyper-insulinemia, because their pancreas that senses the elevated glucose concentration in circulation, produces more insulin in order to clear it out and store it away. The problem is that the cells are not sensitive to the presence of insulin, and therefore do not take in the sugar. The pancreas is then forced to produce and secrete more insulin, and on it goes. Amazingly, type II diabetics are also “treated” by insulin injections, which increase insulin levels even more, and increase insulin resistance even more, obviously making the situation far worse. Eventually, the pancreas of the type II diabetic gets completely exhausted, and loses the ability to manufacture and secrete insulin. At this point, the type II becomes a kind of type I. Interesting how this goes, isn’t it.

The pancreas’ main function is not to secrete insulin, even though in our diabetic-centric worldview it is certainly considered as such. This is one of its functions, but not the most important. By far the most essential is the production and secretion of enzymes, the specialised proteins that break down foods but also do everything else that needs to be done, especially tissue building and repair throughout the body. The third essential function of the pancreas is the concentration and secretion of sodium bicarbonate in the small intestine following the movement of the pre-digested chyme from the stomach into the small intestine. This is also extremely important because all absorption and digestion in the intestine must take place in an alkaline environment, compared to the acidic environment required in the stomach when protein is present. Pancreatic exhaustion from the over-production of insulin for years on end, therefore spells disaster on many more fronts than just insulin and glucose metabolism. It spells disaster for all digestion and absorption processes, and all enzyme regulated activities, which basically means everything, really. This is very serious.

Liver dysfunction

The liver does an amazing amount of vital work, most of it incredibly complex. This includes filtering the blood from all sorts of toxins, both biological and chemical in nature, and breaking those down for elimination; it includes the manufacture of cholesterol and lipoproteins, vital for survival, but the details of which are so intricate that they are still not completely understood after a century of study; it includes the transformation of excess glucose into glycogen and into fat for storage; and in includes the manufacture of glucose from liver-stored glycogen to continually adjust the levels of glucose in the circulation depending on the body’s needs, or more specifically, on the hormonal and biochemical environment. The distinction may appear subtle, but it is quite important in the sense that it is really the hormones and biochemistry of the blood that regulates the function of most tissues and organs, especially those of the vital glands like the liver, pancreas and adrenals, and there is hardly anything more disruptive and unbalancing to the hormonal and biochemical makeup than chronically elevated glucose, stress hormones and acid levels.

Under such conditions, the liver must manufacture an inordinate amount of glucose from the glycogen stores that it itself must also replenish, but also from the broken down muscle tissue. At the same time it converts as much as it can of the glucose into fat for storage, but unfortunately, insulin resistance makes it impossible for the triglycerides to be used, and they are therefore left in circulation for longer than they should before eventually being stored in our fat cells. To top up the list, the free-radical and glycation damage to the vessels and tissues require the liver to also manufacture an inordinate amount of cholesterol and lipoproteins in an attempt to repair these damaged cells, which is no small feat, (you can read more about cholesterol and lipoproteins in But what about cholesterol? and in Six eggs per day for six days: cholesterol?). All of these processes are perfectly natural. However, they are not meant to be running in overdrive for years on end. It is no surprise then that imposing upon the liver to cope with this, eventually leads to dysfunction, deterioration, exhaustion and failure.

Towards a working solution

This is definitely not the end of the list of the complications and physiological consequences that develop from chronically high circulating glucose and insulin levels, but they are some of the most important. Also, it is essential to understand the process by which these consequences first arise and then grow in severity and into the disease process over time. It is, however, infinitely more useful to know what to do in order to maintain a biochemical and hormonal environment in which none of these various dysfunctions and complications can arise if they haven’t yet, or how they can be stopped and reversed if they have.

It shouldn’t be surprising that these are the same, and that they are keys to any optimal health plan, simply because the cells, tissues and organs that make up the human body function, or rather, should function in the pretty much the same way in everyone, allowing for small differences in some of the details. For example, the fact that different people have different tolerances to carbohydrates does not change anything to the consequences of chronically elevated glucose levels on physiological function. It only changes the details relating to the thresholds and time scales involved in developing the same problems. The same goes for vitamin D: the fact that different people require different amounts of vitamin D in order to remain healthy does not in the least alter the basic fact that virtually all complex living creatures depend on it for life. So, yes, everyone is different, but, at the same time, everyone is the same.

No sugars, no starches, no dairy

The first step to take is to eliminate from the diet foods that cause glucose and insulin levels to rise. For this, we must

  1. Eliminate all simple sugars: that’s basically anything that tastes sweet, including sweet fruit, because all simple sugars will elevate blood glucose levels almost immediately after consumption;
  2. Eliminate all starchy carbohydrates: that’s all grains and grain products (at least 90% carb), beans (typically more than 70% carb), potatoes (virtually 100% carb), and other starchy veggies like sweet potatoes, yams, taro, etc, because the starches they contain are broken down to glucose by enzymes in the digestion process; but also sweet root vegetables like carrots and beets, which are just full of simple sugars (you’ll know this if you’ve ever had carrot or beet juice?)
  3. Eliminate dairy: that’s all milk products, which, even those low in sugars like hard cheeses, cause a rise in insulin levels. Besides, most people are allergic or intolerant to dairy products, whether they are aware of it or not.

And aside from just glucose and insulin levels, as we discussed in At the heart of heart disease, insulin-stimulating carbohydrates are highly inflammatory, triggering more than 300 inflammatory pathways. So, excluding them from our diet not only brings about plenty of positive metabolic and physiological changes, but it is, as far as I am concerned, a requirement to make those positive changes happen.

Drop the stress

For those people to whom we referred to earlier that suffer mostly from the chronically elevated stress hormone levels, it is crucial to eliminate the causes of stress, ensure long hours of high quality sleep, and incorporate exercise and activities that effectively reduce stress levels, as well as supplements that can help with that. Obviously, the most important sources of stress for most professionals are psychological ones. But what is also well established is that the level of stress that is experienced (i.e., the amount of stress hormones secreted and in circulation) depends entirely on each person’s outlook and attitude. Therefore, it is this—the attitude and outlook—that are the most influential factors in generating or relieving stress on a daily basis.

Having said this, it is also obvious that going to a remote holiday house on sandy beach without access to phone or internet communications, and making a point of simply relaxing, going for walks, swimming in the sea, reading good books, watching good films, taking naps, eating healthfully and sleeping long and soundly every night, is inherently far more conducive to eliminating stress than the usual school year and work day conditions. What we must find a way to do is to function well in all circumstances with minimal stress, and most importantly, without chronic stress. It is chronic stress that is the problem; not relatively short periods of high stress. And stress, it shouldn’t be surprising, is also happens to be extremely acidifying (haven’t you ever noticed the strong, acidic smell of underarm stress sweat?).

Very helpful in this is taking Tulsi in the morning and at lunchtime (only during the day), and valerian root before bed. But exercise, conscious relaxation, and modifying outlook and attitude towards a more open and relaxed position are definitely most important.

Lower blood pressure

Lowering glucose levels will automatically lower blood pressure. Lowering stress will also automatically lower blood pressure. Biochemically though, the most important muscle relaxant—and this most definitely applies to the smooth muscle cells that line the blood vessels—is magnesium. Therefore, magnesium baths, oil and oral supplementation is essential. On the other hand, calcium is contractile and unfortunately, much more present in the foods we eat. Therefore, most of us are magnesium deficient but also over-calcified. Hence, minimising calcium intake is also very important. (You can read more about these topics in Minerals and bones, calcium and heart attacks, and in Why you should start taking magnesium today.)

Proper mineral balance, especially sodium and chloride, are essential for blood pressure regulation. Eating plenty of unrefined sea salt with meals (and with drinks) is also crucial. Naturally, we seek balance, and salt intake has to be balanced with water intake, and this leads to optimal kidney function. (You can read more about water, salt and physiological function in How much salt, how much water and our amazing kidneys, Why we should drink water before meals, and in Water, ageing and disease)

Support the kidneys

The kidneys want to maintain optimal blood pressure; regulate water, sodium and mineral content of the blood; and clear out metabolic wastes, mostly uric acid. To have them do what they are trying to do as best they can, we must very simply provide plenty of water, plenty of unrefined salt rich in sodium and all the other essential minerals, plenty of alkalising sources in drink and food, minimise glucose levels and minimise creatinine levels. The importance of alkalising the body intensely at first and continuously thereafter cannot be overstated with regards to the proper function of all the vital organs discussed here, and everything else really: every cellular process and every enzymatic action; everything depends on this.

Rejuvenate the pancreas

The pancreas senses and responds to glucose in the blood by manufacturing and secreting insulin. It responds to the movement of food from the stomach to the intestines by manufacturing and secreting sodium bicarbonate and digestive enzymes. To rejuvenate the pancreas, we need to not only give it a break, but help it recover. For this, we need to minimise glucose levels in the blood, and thereby minimise the need for it to manufacture insulin; maximise intake of enzymes to minimise the need for it to produce them; and, especially in light of what we discussed under acidosis, we need to maximise alkalisation, including through oral and transdermal absorption of sodium bicarbonate and magnesium chloride, with a focus on chlorophyl and chlorophyl-rich foods and drinks.

Cleanse the liver

The liver’s most taxing function is the breakdown of toxins (all substances foreign and dangerous to the body). Another taxing function of the liver is the manufacture and recycling of cholesterol and lipoproteins that, as we said earlier, are in production overdrive because of the excessively fast free-radical and glycation damage to the lining of the blood vessels, as well as the damage these cause everywhere else in the tissues of the body, accompanied by the chronic systemic inflammation this leads to (you can read more about systemic inflammation in Treating Arthritis and At the heart of heart disease.)

To help the liver, we must therefore first stop ingesting chemically manufactured medications, and we must eliminate sources of toxins and chemicals from the things we eat and drink; from the air we breathe, especially from those toxic cleaning products we use; and from all the chemicals we absorb through the skin in soaps, shampoos, lotions and creams. Second, we eat and drink to minimise inflammation and internal tissue damage, therefore minimising the strain of excessive manufacture of cholesterol and lipoproteins. And third, we must take regular toxin cleansing and alkalising baths with sodium bicarbonate and magnesium chloride. This simple therapy is the most effective means of detoxifying the body from chemicals and toxins or all kinds, including the most notorious radioactive isotopes that can make their way into our bodies from nuclear weapons, spills and power plant accidents through the air, water and food. Here again, chlorophyl and chlorophyl-rich foods and drinks are essential.

In conclusion

The basic conclusion is the same as what we have come to whenever we discussed type II diabetes: while it is a devastatingly damaging condition that affects every metabolic and physiological function of the body, it is incredibly easy to prevent, and even after many years of deterioration for the diabetic sufferer, it is relatively easy to reverse the condition and cure the disease, including the beta cells of the pancreas, by understanding the disease process thoroughly, and by adopting an appropriate healing protocol. Here, we have detailed several of the key problems or complications that stem from chronically elevated glucose and insulin levels, with specific discussion of the ensuing dysfunction in some vital organs, and highlighting the crucial importance of considering the effect of stress in addition to the effects of dietary insulin-stimulating carbohydrates.

You might have noticed that a discussion revolving around overweight, obesity and fat metabolism is missing, maybe conspicuously so. This is not an oversight, but a conscious move towards a focus on the underlying causes of the metabolic, hormonal and physiological natures of the disorder instead of the superficial and rather inconsequential repercussions of it that take expression in the form of excess body fat. The only point I want to mention about this is that by correcting the causes of the disorder, excess body fat stores will melt away on their own. Some help from supplements and hormonal manipulation through diet and timing here and there will be useful. But, the point remains that if the body is in optimal biochemical balance, then physiological and metabolic functions will also be optimal, and no excess body fat will remain, no matter how young or old we are, and no matter what our genetic makeup happens to be.

The overview of the basic strategy for preventing and overcoming diabetes should make it clear that what it implies, although in some aspects quite specific and targeted, is very simple in that it relies mostly on drinking clean water, eating unrefined salt and clean foods, especially those that are chlorophyl-rich, eliminating damaging foods, chemicals and toxins, alkalising and detoxifying with sodium bicarbonate and magnesium chloride, and finally, using a number of important supplements to correct deficiencies and restore optimal biochemical balance. In a subsequent post we will formulate a detailed programme that incorporates all of the elements and strategies discussed here in general terms, together with some additional considerations about details like the timing and amount of food, drink, exercise and supplements.

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Why do diabetics have high blood pressure?

This is the question that someone in the audience asked at the end of a presentation on diabetes that I attended a few months ago. Remarkably, the speaker was unable to answer this question. Amazingly, neither could any one of the three medical doctors that were in attendance. I was, naturally, quite shocked by this obvious display of ignorance on all of their part. At the same time, I wasn’t really surprised, and, in fact, relieved to be vindicated in my belief that probably the majority of MDs don’t understand the most basic things about human physiology and metabolic function.

Now, you, on the other hand, you who has been following and reading this blog, might (or even should), I believe, be able to answer that question. But since you’re reading this, and therefore cannot be put on the spot, as was the speaker and those MDs at that presentation, you don’t have anything to worry about if you can’t. And yes, I am going to explain. On top of that, I’ll be as quick as I can about it.

As always, first things first: How is blood pressure regulated? What is it that does the regulating? And why is it important?

Blood pressure regulation is of the utmost importance for the proper functioning of every organ because every cell in the body depends on a properly functioning circulatory system to bring nutrients and carry away waste. Blood pressure is like the voltage that drives current through wires and electronic components: it is a driving force. And exactly like it is for electric and electronic devices, the driving force must be just right: it cannot be higher and it cannot be lower than what it needs to be in every moment depending on what the immediate circumstances and needs happen to be. Therefore, blood pressure regulation is essential for the moment to moment adaptation of every metabolic and physiological function, to the different activities we do, and circumstances we find ourselves in.

The main organ responsible for blood pressure regulation is the kidney. I use the singular because the two kidneys work in the same way. It’s just that their function is so vitally important that there are two of them, most logically for redundancy, as a fail-safe system. I have written at length about kidney function in two articles entitled The kidney: evolutionary marvel; and How much salt, how much water, and our amazing kidneys. By the way, this is what I meant earlier: if you’ve read those, understood and happen to remember a few essential bits, then you would be in a good position to answer the question as to the relationship between diabetes and blood pressure. Here it is in a few words; well, maybe a few paragraphs.

The kidney’s vital role is filtration of metabolic acids out of the blood, and elimination of these through the urine. To do this as best it can, because the first and most important part of the filtration process relies on the separation of the liquid from the solids in the blood, and because this is done through what is a mostly “mechanical” filtering through a membrane as it is in water filters, the kidney must maintain optimal pressure to ensure optimal function of the little filtering units, the nephrons. If pressure is too low, the membrane filtering does not work well. If pressure is too high, the membrane tears or pops, and the filtering units stop working altogether.

The good news is that damaged nephrons can sometimes recover when the conditions are made conducive to it, and that there are millions of them in each kidney. The real bad news is that when they die, they do not come back to life. Another bit of bad news, although some would surely take this as good news instead, is that this process of deterioration of kidney function and death of nephrons takes place gradually but silently over the years and decades of our life. When the consequences of poor kidney function become noticeable or even critical, and we finally go see our MD because we’re not feeling good, or worse, are brought directly to the emergency room, it is far too late, for most of the nephrons are already dead.

And to be perfectly clear on this, if the kidneys fail and we don’t get immediate attention and artificial filtering of the blood through dialysis, we die within hours. This is what is meant by the word vital when qualifying the kidney as such an organ.

As I often highlight, the cells, tissues and organs that constitute the entirety of the body that we erroneously call ours and mistakenly believe this to be the case, do not care about you in the least. They do not know anything about you and never will. They, as all living things, are only concerned with survival and self-preservation. It is for this reason that they continually adapt in all sorts of ways to the environment in which they find themselves: this is the internal environment of the body. And it is for this reason that the kidney regulates blood pressure so accurately and so well when allowed to function as it should.

How does it do this regulating? By very closely monitoring the concentration of the blood and secreting hormones to induce the necessary adjustments. The concentration of the blood is the balance between the amount water and the amount of solutes (things dissolved in the water). Most important is the amount of water, because it gives the blood its volume and thus pressure within the closed circulatory system of somewhat malleable veins and arteries. Of the solutes, the most important is sodium, because it holds and must be held in the highest concentration of all solutes, accounting for about half of the overall solute concentration (140/300 mOsmol/L). But the kidney works to keep the entire spectrum of natural solutes, especially the minerals, each in its optimal physiological range.

Two nutrients that the kidney works to keep in circulation are proteins and glucose for the obvious reason that they are essential to proper physiological function, and, evolutionarily speaking, rather rare to come by and thus precious. As they are also solutes circulating in the blood plasma, each contributes to the total concentration. And this is where we get to the point:

As glucose concentration rises, the total concentration of the blood rises accordingly. For insulin-resistant diabetics whose cells have lost their sensitivity to insulin, and with that their ability to take up glucose from the blood, there is no outlet for this excess glucose that just keeps on rising in concentration. But unlike what the kidney does in regulating the concentration of sodium and other minerals by excreting any excesses through the urine, glucose is kept in circulation, as much as possible.

After some time, whether because the concentration is through the roof, because the kidney cannot anymore function as it should to keep the glucose in the blood, or both, glucose spills into the urine. This is how, in fact, it was discovered that all of the symptoms that we described as the condition of diabetes are due to a dysfunctional metabolism of glucose: because the urine of diabetics was sweet smelling and sweet tasting. (What dedicated MDs we had 100 years ago! Do you think your MD would taste your piss today to make sure you’re not sick?).

In response to this, to maintain the concentration as close to 300 mOsmol/L as possible, the kidney retains water to dilute the blood from the excessive glucose. This makes the blood volume increase and therefore also the blood pressure. This is why diabetics have high blood pressure. This is also why diabetics have very high incidence of kidney disease. This is also why diabetics have water retention and circulatory problems.

But this is also why they suffer from a lot more strokes, heart attacks, Alzheimer’s, dementia, arthritis, why they have elevated cholesterol, why they age so much faster, and why they go blind.

Chronically elevated glucose leads to chronically elevated levels of glycation. Glycation damages cells and tissues everywhere in the body, but firstly in the veins and arteries, which are already significantly more susceptible to damage because of the chronically elevated blood pressure. This leads to more and faster plaque formation, as well as cholesterol production for damage control and repair. Elevated glucose levels and heightened glycation lead to a flood of free radicals and vastly increased systemic inflammation, which makes everything worse, much worse.

And all of these conditions, all stemming from insulin resistance and chronically elevated blood sugar, give rise to the multiplicity of the health problems just enumerated that are the main causes of death in the general population, but which are seen with an approximate three to four fold increase (that’s 300-400% more!) in incidence for a given age in the diabetic population.

What about non-diabetics? Do they need to be concerned about this? Does it mean that there is a direct relationship between blood sugar and blood pressure in all of us? Does it mean that all of us suffer from the whole lot of direct and indirect consequences of having high blood glucose concentrations in the same way as diabetics do, but in proportion to the concentration and the time it takes for it to drop depending on insulin sensitivity? What do you think?

Is any of this surprising? Not in the least: it makes perfect sense. Is it difficult to understand why it happens? Not really: when we understand some basic physiology and biochemistry, everything becomes relatively easy to grasp and explain. At least that’s what I hope I was able to show here, and at the very least, in regards to the question posed in the title that we set out to answer in the first place. You got it, right? And you’ll remember? And next time you see your MD, (if you have one, that is), ask them why diabetics have high blood pressure, and see what they say…

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Cure diabetes in a matter of weeks

Both the incidence and growth rate of insulin-resistant diabetes have reached epidemic proportions in many countries. It is most remarkable in the US with probably close to 30 million by now, and thus about 10% of the population (1, 2). Globally, the numbers are even more impressive: 370 million with diabetes predicted to grow to 550 by 2030 (3). This entails that as a disease, type-II diabetes (90% of diabetics) is one of the fastest growing causes of death, now in close competition with the well-established leaders, cardio-vascular disease and cancer, that each account for 25% of deaths in more or less all industrialised countries.

Insulin-resistant diabetes is very similar to both vascular disease (cardio and cerebro) and cancer, as well as intestinal, kidney, pancreatic and liver disease, arthritis, Parkinson’s and Alzheimer’s, in the sense that it is also a degenerative disease that develops over a lifetime, or at least over several decades. It is, however, quite different from all other chronic degenerative diseases because it is, in a way, the ultimate degenerative disease, in which the occurrence of all others increases markedly, and in some cases two to four times (4).  That’s not 10 or 15%, this is 200 to 400% more!

For this reason alone, it seems clear that all these degenerative conditions are intimitely related, and that furthermore, understanding insulin-resistant diabetes will most definitely give us keen insights into the genesis of degenerative diseases in general.

What boggles the mind is that, in a very real sense, we understand precisely and in exquisite detail how and why insulin-resitant diabetes develops, how and why it is related to all other degenerative diseases, and consequently, both how to prevent diabetes and all disease conditions for which it is a proxy, and why what is needed to achieve this actually works (5, 6).

In fact, type-II diabetes can be cured; not just controlled or managed, but cured; not just partially or temporarily, but completely and permanently. And this, in a matter of weeks.

This may seem simply impossible to the millions of suffering diabetics that live with their disease for years and more often decades, but it is the plain and simple truth, which has been demonstrated by more than one, but unfortunately rather few exceptional health care practitioners, already several decades ago by Robert Atkins (7), and more recently by Ron Rosedale and Joseph Mercola, for example (89), in a remarkably repeatable, predictable and immensely successful manner on most probably tens of thousands of people by now.

About insulin and glucose (or should it be glucose and insulin)

Insulin is a master hormone one of whose important roles is to regulate uptake of macronutrients (carbs, proteins and fats) by facilitating their crossing the cellular membrane through channels guarded by insulin receptors, from the bloodstream into the cell, either for usage or storage. It is for this role that insulin is mostly known.

However, arguably insulin’s most important and critical role is the regulation of cellular reproduction and lifespan, a role which is, as amazing as it may seem, common to all animals that have been studied from this perspective, from microscopic worms to the largest animals.

As such, insulin is a master and commander for regulating reproduction and growth in immature and therefore growing individuals, and regulating lifespan and ageing in mature and therefore full-grown adults (10).

Insulin is absolutely essential to life because in its absence cells can neither use glucose—a most basic cellular fuel, nor reproduce correctly—making growth impossible. It is, however, needed in only very small amounts. Why? Because insulin is very damaging to tissues and especially blood vessels, something that has been well known for a long time (look at this short review on the role of insulin in atherosclerosis from Nov 1981—that’s 32 years ago!, and you’ll see what I mean.)

Insulin is secreted by the beta cells of the pancreas in response to glucose concentration inside of these. As blood passes through the pancreas, these special cells that produce and store insulin, sense how much glucose there is by taking it in, and release insulin into circulation proportionally. This release is pulsed (while eating, for example) with a period of between 5 and 10 minutes, but only in response to blood sugar concentration, meaning that insulin is released only if blood sugar rises above the individual’s threshold, which depends on the metabolic and hormonal state of that individual.

However, it is important to note that pretty much no matter what the metabolic or hormonal states may be, eating fat and having fatty acids circulating in the bloodstream does not stimulate the release of insulin, while eating protein, in particular the animo acids arginine and leucine, does, albeit a lot less than glucose. This is because insulin is generally needed for cells to take in and use amino acids.

An insulin molecule that has delivered a nutrient to a cell can be degraded by the cell, or it can be released back into the bloodstream. A circulating insulin molecule will be cleared by either the liver or the kidneys within about one hour from the time of release by the pancreas.

Exposure to most substances, including lethal poisons such as arsenic and cyanide, naturally and systematically decreases sensitivity, or from the reverse perspective, increases resistance to it (as demonstrated by generations of Roman emperors and their relatives). This applies to cells, tissues and organs, and happens in the same way for biochemical molecule like messenger hormones, for the one that concerns us here, insulin. Thus, as cells are more  frequently and repeatedly exposed to insulin, they lose sensitivity and grow resistant to it.

Insulin primarily acts on muscle and liver cells where glucose is stored as glycogen, and on fat cells where both glucose and fats are stored as … fat, of course. Muscle cells grow resistant first, then liver cells and in the end, fat cells. Fortunately or unfortunately, endothelial cells (those that line the blood vessels), do not become resistant to insulin, and this is why they continue to store glucose as fat, suffer severely from glycation, and proliferate until the arteries are completely occluded and blocked by atherosclerotic plaques.

What happens when a large portion of the muscle and liver cells, and enough of the fat cells have become insulin-resistant? Glucose cannot be cleared from the bloodstream: it thus grows in concentration which then stays dangerously high. This is type-II, adult onset, or most appropriately called, insulin-resistant diabetes.

Unnaturally high glucose concentrations lead to, among other things, increased blood pressure, extremely high rates of glycation (typically permanent and fatal damage) of protein and fat molecules on cells throughout the body, heightened stimulation of hundreds of inflammatory pathways, and strongly exaggerated formation of highly damaging free radicals, which, all in all, is not so good. This is why insulin is secreted from the pancreas so quickly when glucose is high in the first place: to avoid all this damage and furiously accelerated ageing of all tissues throughout the body.

The five points to remember

  1. Insulin is a master hormone that regulates nutrient storage, as well as cellular reproduction, ageing and therefore lifespan.
  2. Insulin is vital to life, but in excess concentrations it is highly damaging to all tissues, especially blood vessels.
  3. If blood sugar is high, insulin is secreted to facilitate the uptake of the glucose into cells, but at the same time, because it is present, also promotes the storage of amino and fatty acids (protein and fat); if blood sugar is low, insulin is not secreted.
  4. Chronically high blood glucose is remarkably damaging to the organism through several mechanisms that are all strongly associated with degenerative disease conditions in general.
  5. Chronically high blood glucose concentration leads to chronically high insulin concentration; chronic exposure to insulin leads to desensitisation of muscle, liver and fat cells, and, in the end, to type-II or insulin-resistant diabetes.

And in this succinct summary, in these five points to remember, we have the keys to understanding not only how diabetes develops and manifests, to understand not only the relationship between diabetes and other degenerative diseases, but also to understand how to prevent and cure diabetes as well as degenerative conditions in general.

And I’m suppose to say …

But you already know what I’m going to say:

Because the basic, the underlying, the fundamental cause of insulin-resistant diabetes is chronic over-exposure to insulin, it means that to prevent—but also reverse and cure it—what we need is to not have chronic over-exposure to insulin. And this means to have the very least, the minimal exposure to insulin, at all times, day after day.

The good news, which is indeed very good news, is, on the one hand, that it is utterly simple to do and accomplish, and on the other, that almost independently of how prone we are to insulin resistance (genetically and/or hormonally) or how insulin-resistant we actually are right now, insulin sensitivity can be recovered quite quickly. And here, “quite quickly” means in a matter of days, which is truly remarkable in light of the fact that our state of insulin resistance grows over decades, day after day, and year after year. It is rather amazing, miraculous even, that the body can respond in this way so incredibly quickly.

Now, type-II diabetes is nothing other than extreme insulin-resistance. Naturally, the longer we are diabetic, the more insulin-resistant we become. But unbeknownst to most (almost all MDs the world over included), if your fasting blood glucose is higher than 75-80 mg/dl or your insulin higher than 5 (mU/L or microU/ml), then the muscle and liver cells are insulin resistant. And the higher the insulin, the more resistant they are. In fact, if you have any amount of excess body fat, your cells are insulin resistant. And the more body fat, especially abdominal but also everywhere else, the more insulin resistant they are.

Because insulin sensitivity is lost gradually over our lifetime through daily exposure, some consider that everyone is becoming diabetic more or less quickly, and that eventually, if we live long enough, we all become diabetic. But this is only true in a world where virtually everyone suffers from chronic over-exposure to glucose and insulin. It is not true in a world in which we eat and drink to promote optimal health.

In practice, because basically everyone is more or less (but more than less) insulin-resistant, concentrations around 10 mU/L are considered normal. But when I wrote earlier that insulin is vital but needed in very small amounts, I really meant very small amounts: like optimally between 1 and 3, and definitely less than 5 mU/L (or microU/mL; and the conversion from traditional to SI units is 1 mU/L = 7 pmol/L).

So how do we do it?

You already know what I’m going to say:

Because insulin is secreted in response and in proportion to glucose concentration, when it is low, insulin is not secreted. Therefore, insulin sensitivity is regained by completely eliminating insulin-stimulating carbohydrates. This means zero simple sugars without distinction between white sugar, honey or fruit; zero starchy carbs without distinction between refined or whole grains, wheat or rice, bread or pasta, potatoes or sweet potatoes; and zero dairy, which triggers insulin secretion even when sugar content is low. It also means minimal protein, just enough to cover the basic metabolic needs (0.5-0.75 g/kg of lean mass per day). Consequently, it means that almost all calories come from fat—coconut oil, coconut cream, animal fats from organic fish and meats, olive oil and avocados, as well as nuts and seeds—and that the bulk of what we eat in volume comes from fibrous and leafy vegetables.

And what happens? In 24 hours, blood glucose and insulin have dropped significantly, and the metabolism begins to shift from sugar-burning to fat-burning. In 48 hours, the shift has taken place, and the body begins to burn off body fat stores, while it starts the journey towards regaining insulin sensitivity. In a matter of days during the first couple of weeks, the body has released a couple to a few kilos of water and has burnt a couple to a few kilos of fat. We feel much lighter, much thinner, much more flexible and agile, and naturally, much better. In four weeks, blood sugar and insulin levels are now stable in the lower normal range. All of the consequences and side effects brought on by the condition of insulin-resisitant diabetes decrease in severity and amplitude with each passing day, and eventually disappear completely. In eight weeks, the metabolism has fully adapted to fat-burning as the primary source of energy, and we feel great. (See 11 for more technical details.)

The result is that within a matter of weeks, we are diabetic no longer: we have regained insulin sensitivity, and have thus cured our insulin-resistant diabetes. Over time, a few months or maybe a few years, feeling better with each passing day, there remain very few if any traces of our diabetes, and we live as if we never were diabetic. Amazing, isn’t it? So simple. So easy. So straight-forward. And yet, still so rare.

And what about the relationship between diabetes and heart disease, diabetes and stroke, diabetes and cancer, diabetes and Alzheimer’s? Why do diabetics suffer the various health problems that they do, like high blood pressure, water retention, blindness, kidney disease, and how do those come about? What of the lifespan-regulating functions of insulin, how does that work? All these interesting and important questions and issues will have to wait for another day. This article is already long enough.

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How much salt, how much water, and our amazing kidneys

Salt, the one we put on food, is composed almost exclusively of sodium chloride (NaCl) that very easily dissolves in water into positively charged sodium (Na+) and negatively charged chloride (Cl-) ions. And there is something very special and unique about these ions: in our blood, Na+ and Cl- are present in the highest concentrations and maintained in the narrowest of ranges. This is very revealing, and means, quite plainly, that sodium and chloride are the most important  extracellular electrolytes. This is a simple fact. Now, forget everything you’ve heard, been told, or read about salt being bad for you, and consider this:

Our blood is made of red blood cells (45%) and white blood cells and platelets (0.7%) floating in blood plasma (54.3%). Blood plasma shuttles nutrients to cells around the body and transports wastes out. It consists of 92% water, 8% specialised mostly transporter proteins, and trace amounts of solutes (things dissolved or floating in it). And although circulating in trace amounts, the solutes—especially sodium—are vital. The concentration of solutes in blood plasma is around 300 mmol/l (don’t worry about the units for now). In the highest concentration of all is sodium at 140 mmol/l. In the second highest concentration of all is chloride at 100 mmol/l. The sum of these is 240 mmol/l. So, from these numbers alone, we see that blood plasma is more or less just salty water.

Don’t you find this amazing? Don’t you find it amazing that nobody has ever told you this straight out in this way? And isn’t it amazing that we have been and continue to be told to avoid eating salt because it is bad for us: that it causes hypertension that predisposes us to heart disease? It really is completely amazing and ridiculous and also rather sad. But misunderstandings of this kind are unfortunately much more common than they should, as you may remember from What about cholesterol and Six eggs per day for six days: cholesterol?, but also from Minerals and bones, calcium and heart attacks and A diabetic’s meal on Air France. As you will understand for yourself in a few moments, the problem is not too much salt; the problem is not enough water:

Hypertension is not caused by excessive salt consumption. It is caused primarily by chronic dehydration and magnesium deficiency.

Taking a look at the other electrolytes, bicarbonate (HCO3-), the primary pH regulator, is the third most highly concentrated molecule in plasma at 20 mmol/l. Potassium (K+) is the fourth at 4-5 mmol/l, then calcium (Ca 2+) and magnesium (Mg 2+) both at about 1 mmol/l. Therefore, the concentration of sodium in the blood is 7 times higher than that of bicarbonate, 40 times higher than that of potassium, and about 140 times higher than that of calcium and magnesium. And as with everything else in our body’s exquisite physiology, there are very good reasons for this:

Every cell in every tissue and in every organ of our body relies on an electrical potential difference between the fluid inside the cell membrane and the fluid outside of it in order to function: produce energy and transport things in and out. This is particularly important in active “electrical” tissues such as muscles and nerves, including neurones, that simply cannot work—cannot contract and relax in the case of muscle fibres, and cannot fire off electrical pulses in the case of nerve fibres and neurones—without a well-maintained and stable potential across the cellular membrane.

This resting potential across the membrane results from the delicate balance of the equilibrium potential and relative permeability through the cellular membrane of the three most important ions: Na+, K+ and Cl-. The potential is maintained by the sodium-potassium pump: a specialised protein structure in the membrane that ensures the concentration of potassium (K+) stays low outside the cell and high inside the cell, and conversely, the concentration of sodium (Na+) stays high outside the cell and low inside. This is the main reason sodium is so important and why it is so carefully monitored and scrupulously reabsorbed by the kidneys, but there are plenty more.

Obviously, this is not an accident. Nothing about the way our body functions is an accident, and no matter how well a particular physiological function or mechanism is understood or not, we can be confident that it is as perfect and finely tuned as it can be because each and every bodily function is the result of adaptations and refinements over billions of years of evolution. This is not a typo: I really did mean to write billions of years. Because every single cell of which we are made has evolved from all of its predecessors as far back as the very first organic molecules that eventually organised in the very first cell: a group of more or less self-organising organelles that developed a symbiotic relationship with one another just because it benefitted them in some way, and found it safer to cluster together behind a fatty membrane through which they could interact with the outside on their own terms.

The aim of every single self-organising entity, from the simplest virus, bacterium or organelle like the mitochondria (our cellular energy-production furnaces), to highly specialised cells in the brain, in the liver or lining a part of the microscopic nephron tubule of one of the millions of these specialised filtering units in our kidneys, to largest groupings of cells in tissues, organs and systems of organs, has always been and always will be the same: survival. Therefore, to understand living systems objectively we have to understand them from the fundamental perspective of the cell itself, the tissue, the organ and the system of organs itself because every adaptation it undergoes is always aimed at improving its own odds of survival. It is very important to keep this in mind and know that everything that happens in a living system always does so in relation to something else and always for good reason, even when we don’t understand the reason, which in itself is also very important to remember.

I use this opportunity to whole-heartedly recommend Lewis Dartnell’s book Life in the universe. Almost every page for me was a delightful discovery of things I was unaware of and found the book truly illuminating.

Coming back to salt, even though we look mostly at sodium and chloride that are the principal constituents of any kind of salt we put on our food, I very strongly recommend always and exclusively using a real salt: any kind of unrefined sea salt (French, cold water, Atlantic salt is particularly clean and rich in trace minerals), Himalayan salt, Smart Salt or Real Salt (the last two are registered trade marks and very rich in trace minerals). On the contrary, I strongly discourage eating chemically manufactured table salt or even refined sea salt, which are not only stripped of trace minerals found in natural, unrefined salts, but contain varying amounts of chemical additives such as whitening agents, for instance.

Now, without regard for polemical disputes, pseudo-scientific discussions and debates, or otherwise unfounded views and opinions about salt, can we answer the simple question: how much salt should we generally eat? I believe we can, but although it may seem so, it is not that simple a question. So let’s first ask a simpler one:

How do we make a solution with the same concentration of sodium and chloride as our blood plasma?

To answer this our approach is simple: use the mean concentrations of sodium and chloride in the blood to calculate how much salt we need to match these such that drinking our salt water solution will neither increase nor decrease their concentration. It might seem a little technical at first, but bear with me, it is in fact quite simple.

This approach is rather well motivated physiologically because the kidneys’ primary function is to maintain blood pressure and concentration of electrolytes—sodium above all others, and each within its typically narrow range of optimal concentration—while excreting metabolic wastes. The kidneys do this by efficiently reabsorbing most of the water and electrolytes from the large volume of blood that goes through them continuously throughout the day and night, getting rid of as much as possible of the metabolic wastes, and carefully adjusting the elimination of ‘excessive’ amounts of water and electrolytes. (You will soon understand why I placed quotation marks around the word excessive.) Let’s start.

You already know that the mean concentration of sodium in the blood is 140 mmol/l. What we haven’t mentioned is that it must be maintained in the range between 135 to 145 mmol/l. You also know that the mean concentration of chloride is 100 mmol/l, and it must be maintained between 95 and 105 mmol/l. The atomic mass of Na is 23, hence one mole (abbreviated mol) is 23 g, and thus one millimole (abbreviated mmol) is 23 mg. The atomic mass of Cl is 35.5, hence one mole is 35.5 g, and therefore one millimole is 35.5 mg. The molecular mass of NaCl is the sum of the atomic masses of Na and Cl, which implies that one mole of NaCl is 58.5 g, and a millimole is 58.5 mg. (A mole is the amount of substance that contains 6×10^23, Avogadro’s number, elementary entities, in this case, atoms. The molar mass is the same as the atomic or molecular mass.)

Multiplying the concentrations in mmol/l by the molar mass in mg/mmol we get the concentration in mg/l. For Na this equals 140 x 23 = 3220 mg/l or 3.22 g/l, and for Cl it is 100 x 35.5 = 3550 mg/l or 3.55 g/l. This is the mean concentration of sodium and chloride there is in our blood. For a small person like me, weighing, say, 56 kg, there are 4 litres of blood that contain a total of 13 g of Na and 14 g of Cl. This is equivalent to about 2 tablespoons of salt.

It is important to note that this is truly quite a lot in comparison to other ions or molecules in our blood. Glucose, for example, which many—probably most people—mistakenly think as the ‘energy of life’, giving it such great importance, is ideally maintained around 80 mg/dl or 0.8 g/l. This is, therefore, also the amount we would need to add to our salt and water solution to make it have, in addition to that of the salt, the same concentration of glucose as that of our blood. And 0.8 g/l for 4 litres of blood makes a total of 3.2 g of glucose in that (my) entire blood supply. This is about 10 times less than the amount of salt!  What does this tell you about their relative importance in our system?

Now, given that Cl (35.5) is heavier than Na (23), NaCl will have a higher mass fraction of Cl: its mass will be 60% chloride (35.5/58.5) and 40% sodium (23/58.5). This just means that 10 g of NaCl or salt has 6 g of Cl and 4 g of Na. So to get 3.22 g of sodium, we need 8 g of sodium chloride, which provides 4.8 g of chloride.

The simple conclusion we draw from this calculation is that dissolving a somewhat heaping teaspoon of salt in one litre of water gives a solution that has the same concentration of sodium as that of our blood (with a little extra chloride).

Does this mean that we should generally drink such a salt and water solution? No, I don’t think so. Are there times when we should? Yes, I believe there are. But say we drink 4 litres per day, 8 g of salt per litre adds up to 32 g of salt just in the water we drink! If we add even half of this amount to our food, we are looking at about 50 g of salt per day! Isn’t this utterly excessive, especially since we are told by the medical authorities to avoid salt as much as possible, with some people today consuming nearly no salt at all? (This article here takes a sobering look at the evidence—actually, the lack thereof—of the claimed benefits of salt reduction.) And more questions arise: What happens when we eat less salt? What happens when we eat more? What happens when we drink less water? What happens when we drink more?

Eating more or less salt. Drinking more or less water.

Remember that the kidneys try very hard to maintain the concentration of solutes in blood plasma—to maintain plasma osmolarity. Also remember that sodium is by far the most important in regulating kidney function, and it is also in the highest concentration. It is nonetheless total osmolarity that the kidneys try to keep constant, and besides sodium, the other important molecule used to monitor and maintain osmolarity by the kidneys is ureathe primary metabolic waste they are trying to eliminate.

As an aside to put things in perspective about the importance of sodium, plasma osmolarity is typically estimated by medical professionals using the sum of twice the concentration of sodium with that of urea and glucose: calculated osmolarity = 2 Na + urea + glucose (all in mmol/l). Since sodium is typically around 140 mmol/l whereas glucose is less than 5 mmol/l and urea about 2.5 mmol/l, it’s obvious that we could just forget about the latter two whose contribution is less than 3% of the total, and look exclusively at sodium concentration (2 Na = 280; glucose + urea = 7.5, so their contribution is 7.5/(280+7.5) = 2.6%).

Eating anything at all, but especially salt or salty foods, raises plasma osmolarity. In response—to maintain constant osmolarity—the kidneys very efficiently reabsorb water and concentrate the urine. Drinking water dilutes the blood and therefore lowers its osmolarity. In response, the kidneys very scrupulously reabsorb solutes and eliminate water, hence diluting the urine.

If we eat nothing and just drink plain water, beyond the body’s minimum water needs, every glass will dilute the blood further and thus cause the kidneys to try to retain more of the sodium while eliminating more of the water. We are drinking quite a lot, but as the day progresses, we are growing more thirsty. We drink more but go to the bathroom more frequently, our urine grows more diluted, and by the end of the day we find ourselves visibly dehydrated, with chapped lips and dry skin. This seems paradoxical in that while drinking water, we are getting increasingly dehydrated. But it is not paradoxical. It is simply the consequence of the kidneys doing their work in trying to maintain constant blood plasma concentrations of sodium (and solutes). For those of you who have fasted on plain water for at least one day, you mostly likely know exactly what I’m talking about. For those who have not, you should try it and experience this first hand for yourselves. Avoiding dehydration in this case is simple: eat salt to match water intake.

If, on the other hand, we do not drink, then the blood gets more and more concentrated, the concentration of sodium and other ions, urea, and everything else for that matter, rises with time, and the kidneys keep trying, harder and harder with time, to maintain the osmolarity constant by retaining as much as they possibly can of the water that is present in the blood. You might think: why not just eliminate some of the solutes to lower their excessively high concentration? But eliminating solutes can only be done through the urine, which means getting rid of water that, in this state of increasing dehydration, is far too precious, and the kidneys therefore try to retain as much of it as possible, hence concentrating the urine as much and for as long as possible to make full use of the scarce amount of water that is available for performing their functions. But here is a crucial point to understand and remember:

In order to reabsorb water, the kidneys rely on a high concentration of solutes—hyperosmolarity—in the interstitial medium through which passes the tubule carrying the filtrate that will eventually be excreted as urine. This is how water can be reabsorbed from the filtrate: the higher the difference in concentration, the more efficient the reabsorption. If there is plenty of excess salt—sodium and chloride ions—then these solutes is what the kidneys prefers to use to drive up and maintain the hyperosmolarity of the interstitial medium, and urea can be excreted freely. If, however, there is a scarcity of sodium and chloride ions, then the kidneys will do everything to reabsorb as much of the precious ions that are in circulation to maintain adequate concentrations of these in the bloodstream, and at the slightest sign of water shortage and dehydration—to ensure the hyperosmolarity of the interstitial medium for maximum water reabsorption—the kidneys will begin to recycle urea, excreting progressively less of it as dehydration increases.

Most of you will have experienced a long day walking around, maybe while on a trip visiting a city, during which you did not drink for several hours. You might have also noticed that you probably didn’t go to the bathroom either, which you may have found unusual compared to the frequency with which you usually go pee when you’re at home or at work. You will have noticed that your mouth was drier and drier as the hours passed, but also that you felt more and more tired, heavy-footed and without energy.  Eventually it struck you just how thirsty you were, or you were finally able to find water to drink, and drank to your heart’s content. As you drank, you might have felt a surge of energy within as little as a minute or two or even immediately following the first few sips. Soon after, you finally did go to the bathroom, and noticed how incredibly dark and strong smelling your urine was. Now you understand what was happening in your kidneys, why you didn’t go pee for these long hours, why your urine was so dark and smelled so strong. However,  the reason why you felt your energy dwindle as the hours passed, and then return when you drank is still unclear.

Water in the blood regulates its volume. And volume in a closed system determines internal pressure. Our circulatory system is a closed system in the sense that there are no holes where blood either goes in or comes out. Yet at the same time it is not a closed system because water enters and leaves the system: it enters the bloodstream through the wall of the intestines, and leaves it through the kidneys and out into the urine. All physiological functions depend intimately on blood pressure: whether it is shooting up through the roof as we face a huge brown bear towering over us and growling at the top of its lungs, and priming us in this extremely stressful fight-or-flight situation for some kind of high-energy reaction in response, or whether it is as low as it can be during our most soothing and restful sleep deep into the night, when the body is repairing and rebuilding itself. And what is the primary regulator of blood pressure? The kidneys.

I will address the details of how the kidneys function and regulate pressure and osmolarity in another post. For now, what is relevant to understand why your energy faded as the hours passed or, more precisely, as the body got progressively more dehydrated, is straight forward:

As water content decreases, blood volume decreases. As the volume decreases, blood pressure drops. And as blood pressure drops, energy levels go down. It’s as simple as that.

It does not help that as soon as the kidneys detect dehydration and drop in pressure, they release hormones to provoke the contraction of the blood vessels in order to counter the pressure drop. This works to a great extent, but since the arteries and veins are constricted, blood flow throughout the body decreases, which in turn contributes significantly to our feeling increasingly heavy-footed and sleepy. With every passing minute, dehydration increases, pressure decreases, blood vessels contract more and our energy level drops further, to the point where we just want to sit down, or even better, lie down, right here on this park bench, and have a long nap.

Interesting, isn’t it? And here again there is nothing strange or paradoxical in this self-regulating mechanism that eventually puts us to sleep as we get increasingly dehydrated. It is simply the consequence of the kidneys doing their work in trying to maintain constant osmolarity and blood pressure. Avoiding dehydration in this case is even simpler: drink water.

If you’ve read this far, you know that both solutions to prevent dehydration are intimately linked: if we don’t drink enough water we get dehydrated, but if we drink too much water without eating salt we also get dehydrated. So let’s now ask another question:

Precisely how much water?

An adult human being needs on average a minimum of 3 litres of water per day to survive for more than a few days (Ref). This depends on climate and level of activity and a bunch of other factors, but in general the range is well established to be between 2 litres in cooler and 5 litres per day in the hottest climates. As suggested from our previous considerations, minimum water intake is also related to salt and food intake. And although this was obvious to me from my own experience of fasting rather regularly between 1 and 3 days at a time, I had not read about it. But as it turns out, the NRC and NAS both (independently) estimated minimum water intake as a function of food intake to be between 1 and 1.5 ml per calorie. For a diet of 2000 calories this would amount to between 2 and 3 litres. But this obviously does not mean that if we don’t eat anything, we don’t need any water! So, what is the very strict minimum amount of water the body needs before physiological functions break down? The short answer is 1.1 litres. For the slightly longer answer, here is a excerpt from page 45 of The Biology of Human Survival:

If obligatory losses are reduced to an absolute minimum and added up, the amounts are 600 milliliters of urine, 400 milliliters of insensible skin loss, and 200 milliliters of respiratory water loss, a total of 1.2 liters. Because maximum urine osmolarity is 1200 milliosmoles/liter, if diet is adjusted to provide the minimum solute excretion per day (about 600 mOsmol), minimum urine output may fall, in theory, to 500 milliliters per day and maitain solute balance. Hence, the absolute minimum water intake amounts to just more than 1 liter (1.1) per day.

(This is also taught in renal physiology lectures such as this one. If you are interested, you will learn a lot from this longer series of 13 segments on urine concentration and dilution here, as well as from this series of 7 segments on the renin-angiotension-aldosterone system here. I found all of them very instructive.)

Keep in mind that 1100 ml of water per day is the very bare minimum for survival, and that there are absolutely no other water losses: basically, you have to be lying, perfectly calm and unmoving at an ideal room temperature where you are neither hot nor cold, not even in the slightest. That’s not particularly realistic unless you’re in a coma. And to show just how extreme it is, let’s see how much of the water the kidneys need to reabsorb to make this happen:

For someone like me weighing 57 kg, the mass of blood is 57*7% = 4 kg. Since the density is almost equal to that of water, 4 kg corresponds to 4 litres. Of this, we know that plasma accounts for a little more than half (54.7%) by volume which makes 2.2 litres, and since plasma is 92% water, the volume of free water in the blood supply is almost exactly half: 2 litres. Blood flow through the kidneys is, on average, around 1.2 l/min. This amounts to more than 1700 litres per day, and means that for 4 litres of blood in the body, every drop of blood goes through the kidneys 425 times in 24 hours, each and every day.

In the kidneys the first step in filtration is the “mechanical”, particle-size-based separation of the blood’s solids from its liquid component. Water makes up half the blood volume, and therefore represents half the flow through the kidneys: 0.6 l or 600 ml/min (850 litres per day). But only 20% of the total flow goes through nephron filtration, which makes 120 ml/min. In the extreme case we are considering, urine output is taken to be 500 ml in 24 hours, equivalent to 20.83 ml/hour or 0.35 ml/min (500 ml/24 h/60 min). Therefore, to achieve this, the kidneys must reabsorb 119.65 ml of the 120 ml flowing through them every minute. This translates to an astounding 99.7% reabsorption efficiency! I’m very skeptical that your average person’s (generally compromised) kidneys could achieve this, but the point was to quantify how extreme this situation at the limit of human survival really is, and as you can see, it is indeed as extreme can be.

Also, keeping in mind that these minimum vital physiological water losses in these circumstances would occur at a more or less uniform rate throughout the day, it would probably be much better to drink a little at regular intervals during our walking hours than to drink everything at once and nothing else during the remaining 24 hours. But what would be the ideal rate at which we should replenish our water in these extreme circumstances?

Assuming the theoretically minimum combined water losses of 1100 ml are lost evenly over the course of the 24 hours, this corresponds to a water loss rate of 0.76 ml/min (1100 ml/24 h/60 min). This is therefore the ideal rate at which to replenishing it. In practice, we may not have an IV system to do this for us, and we will probably be sleeping long nights as our heart rate and blood pressure will have hit rock bottom. Drinking 1100 ml in 11 hours (to work with round numbers) could be done by taking 100 ml, (half a small glass), every hour. This would be the simplest and most reasonable way to maintain solute balance as best we can.

Naturally, with such a minimal water intake, the kidneys are struggling to maintain osmolarity by retaining as much water as possible. Any additional intake of salt (or food) would make things worse in the sense that it would raise the concentration of sodium (and solutes) in the blood whose balance the kidneys will not be able to maintain without additional water. But remember that eating a 200 g cucumber, for example, supplies nearly no calories as it contains virtually no sugar, fat or protein, while proving almost 200 g (ml) of water. And that, conversely, any drink containing caffeine or alcohol will actually dehydrate as those substances are diuretic and cause the excretion of free water.

A somewhat more realistic scenario is one in which we are not eating, but very moderately active at comfortable temperatures. In this case, most experts would agree that the minimum water requirements would be around 2 litres per day. Since we are fasting, these additional water needs are due to greater water losses through evaporation and physiological activity; not to offsetting increased water needs due to food consumption. Consequently, we should ideally drink about 10 glasses of 200 ml, one approximately every hour from 7h to 19h, and we should not eat any salt.

More realistic but still not so common, is that you are doing a 24 hour fast. The purpose of the fast is to give a break to the digestive system, rehydrate bodily tissues, stimulate more fat burning and flush toxins out of the system. Say we drink 4 litres instead of the minimum of 2. In this case we should, in fact, eat some salt in order to ensure good hydration of tissues by supplying plenty of water through a well hydrated bloodstream without diluting the sodium and thus causing the kidneys to excrete more water. And this brings us back to the basic question that set us on this rather long  investigation:

Precisely how much salt?

But you already know the answer to this question: 1 teaspoon per litre in 2 of the 4 litres. Because we don’t drink during the night for about 12 hours, the body inevitably gets dehydrated. Therefore, the best strategy is to start with plain water to rehydrate the concentrated blood and bodily tissues dehydrated from the night, and end with a litre of plain water in preparation for the dry night coming. You should take the equivalent of 1 generous teaspoon of salt with each of the additional litres of water during the day. This will ensure proper hydration of tissues by preventing excessive dilution of blood sodium levels, and maximum urea excretion. Excess sodium, chloride and any other electrolyte will be readily excreted in the urine.

Finally, the far more realistic scenario and, in fact, the one that for most of us is the everyday, is that we are normally active and eating around 2000 calories a day, typically over the course of about 12 hours. In this case we need the basic 2 litres to offset minimum evaporation and physiological losses, and between 2 and 3 litres to offset the 2000 calories. This makes between 4 and 5 litres, 2 of which must be plain water, and 2 or 3 of which must be matched by a good teaspoon of salt per litre that will most naturally, and maybe also preferably, be taken with the food.

Keep in mind that this is the total salt requirements and many prepared foods contain quite a lot already. The hotter or drier the climate, the more water we need. The more we exercise, the more water and the more salt we need. The more we sweat, the more water and the more salt we need. The more stress we experience, the more water and the more salt we need. And in all of these cases, we also need a lot more magnesium.

By the way, it is interesting but not surprising that this conclusion on the amount of salt per day: about 10-15 g, is also the recommendation of the late Dr Batmanghelidj, the “Water doctor”, as well as that of Drs Volek and Phinney, the “Low-Carb doctors” (see References  for details), although the former emphasises the importance of an abundant water intake, while the latter hardly mention it if at all.

So this is it. We know how much water we should generally drink, and we know how much salt we should generally eat:

We should always drink the bare minimum of 2 litres per day. Ideally we should drink 4-5 litres every day. If for some reason we drink 2 litres or less, we should not take any salt (or food for that matter!). If we drink more than 2 litres, we should match each additional litre of water with 1 teaspoon of salt, taking into account the salt contained in the food we eat. It is always better physiologically to drink more than to drink less. And remember that we hydrate most effectively on an empty stomach by drinking 30 minutes before meals.