Case study: old man can’t walk

Some time ago, a childhood friend of mine sent me this message:

I want to help this man. He has a problem with his tendons in both legs. In the morning, he can’ t stand up. Can you recommend some minerals and vitamins? Maybe some exercises that can help? Your advice is important.

oldMan

The old man that can’t walk from the pain in his legs.

That’s all he wrote. So, I replied:

How can I give any advice? I don’t know anything about him. I help/treat people with a complete eating and drinking programme. Vitamins and mineral supplements are only used as adjuncts to correct deficiencies. So, before saying anything, I need to know some basic things:

How old is he? What work does he do or did? How long has this problem been developing for? Does he drink water and how much? What does he drink? What does he eat every day? Does he have other complaints? How is his digestion? How is his skin (any rashes or dry skin or eczema)? What kind of other problems has he had in his life? And anything else about this health that could be useful?

Here’s what I got back:

  • How old is he? What work does he do or did?  He’s 81. He was a manager.
  • How long has this problem been developing for?  The problem started when he was around 65. It has gotten much worse in the past 2 years.
  • Does he drink water and how much?  He drinks little water, 0.5 litres a day.
  • What does he eat every day?  He eats meat, potatoes, tomatoes, some cheese, and a lot of bread.
  • Does he have other complaints?  Heart, kidneys.
  • How is his digestion?  He has problems going to the bathroom every day. He goes once every three days.
  • How is his skin (any rashes or dry skin or eczema)? His skin is fine.
His doctor told him to exercise, but he can’t even stand up or move properly.

With this info, I was able to get a better idea, and I replied:

Here is my diagnosis:
This man has been chronically dehydrated for most of his life. Being chronically dehydrated is one of the most health-damaging situation we can be in, but because it is not acute, the consequences are manifested over long periods of time. 
The lack of water first leads to a deterioration of the digestive system and digestive function: of the stomach (poor digestion and ulcers), and of the intestines (damaging of the lining, ulcers, and leaky gut), constipation and from it toxins and pathogenic bacteria going back from the colon into the bloodstream. 
Second, it leads to deterioration of the kidneys and the nephrons (little filters in the kidneys), because the only way to get the acids out of the blood is to dilute them in water, but if there is a lack of water, then the kidneys do everything they can to keep this water, because water is more important to keep than to get rid of acid. Therefore, not only do the kidneys get destroyed little by little, but the body accumulates the uric acid everywhere in the soft tissues, starting in the joints, and then in the tendons, ligaments and muscles. This leads to incredible stiffness, pain, and eventually to not being able to move.
Third, because our diet is usually rich in calcium but very poor in magnesium, everyone tends to be over-calcified and to accumulate calcium everywhere in the blood vessels, soft tissues of the joints, and in the muscles. This is made much worse by over-acidification and chronic dehydration. Calcification also leads to stiffness, pain, and eventually, to not being able to move properly.
Therefore, the most important things to do in order or priority are the following:
  1. Drink a lot more water (at least 3 litres per day), on an empty stomach (at least 20 minutes before eating), and making sure it is alkaline water (high pH 9-10).
  2. Take baths with 2 cups (500 g) of sodium bicarbonate and 1 cup of magnesium chloride (or magnesium sulphate). The bicarbonate and magnesium will be absorbed into the body through the skin, and will dissolve uric acid and calcium deposits throughout the body. 
  3. Drink juice of green vegetables to remove acid buildup in the body, and clean out the intestines.
  4. Take supplements of magnesium (the best form is L-Threonate, because it is bound to fat and is 100% absorbed) in order to help remove build-up of calcium.
  5. Take supplements of vitamins A-D-K2 (I recommend DaVinci’s combo supplement because of the high concentration of K2), as these are the most important fat-soluble vitamins, and K2 is the only nutrient that can effectively de-calcify blood vessels and soft tissues.
  6. Take supplements of vitamin C and collagen to help rebuild the cartilage and heal the damaged soft tissues, especially the blood vessels and the joints. It is essential to take whole-food vitamin C, and high quality collagen.
  7. Stop eating sugar, bread, cheese, yogurt, and eat basically very big salads and fatty meats like lamb, veal and porc (only outdoor-living animals).
Good luck, and make sure to let me know how things evolve. If you don’t understand something, just ask.

 

Three weeks later, I got his note from him:

Today I called the old man’s wife. She told to me that since yesterday he has no pain, and can move his arms and legs a lot better.  He drinks more than 2 litres of water per day, eats and takes the supplements as you prescribed. His grandson translated your message for him. I am very impressed. Thank you so much for you help. Your method works.

It’s a nice feel-good story, isn’t it? Here’s the thing, though. How many millions of people do you think are in the same situation as the one in which this man was? Suffering like he did, for decades growing older, stiffer, less mobile, and in more pain, until the end, which by that point comes as a relief from this difficult and painful life. And from what? Dehydration. Simple dehydration. Long-standing, chronic dehydration.

How much water do you drink each day? What’s the pH of the water you drink? How much salt do you eat each day? How much bread and potatoes do you eat? How is your digestion? How often do you go to the bathroom, and how is the wipe? Such simple things, so crucial to health.
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Such a simple and yet powerful natural anti-inflammatory

He knocks at the door, walks in to my office, and, barely capable of holding back his excitement and enthusiasm, says: “It’s amazing! The pain is completely gone! It’s just been six days since I started, and the pain is gone! I can’t believe it! It’s like a miracle!” I was very happy for him. “I’m glad to hear that”, I said, “and although it may seem like a miracle to you, it makes perfect sense to me. In fact, I would have been surprised if it hadn’t worked.”

About a month before that, we crossed paths in the bathroom. He was wearing a plastic and neoprene brace on one of his wrists. I had never seen him wearing it, and so I asked what had happened. He told me that about three years ago, he had injured his wrist and that it had never healed properly. Sometimes it hurt more, sometime less, but that it had been particularly uncomfortable for about a week, especially typing at the computer most of the day. He said physicians had prescribed anti-inflammatories of various kinds, and at different times, but none had helped in allowing the wrist to heal or making the uncomfortable pain and stiffness go away.

We hadn’t really talked much before that, him and I, and he said, rather jokingly: “Do you know what to do to help it heal?” To his surprise, I think, I said: “Of course I do!”, and then laughed, partly because it was a little funny to say that, but also to break the ice between us. This is what I then went on to say:

“Chronic pain like that, especially in or near a joint, is usually caused by the an excess of uric acid stored in the tissues. Uric acid is the primary metabolic waste excreted in the urine by the kidneys. Since most of us are deeply and chronically dehydrated, the blood becomes saturated with acid that cannot be eliminated in the urine because of the lack of water (and/or salt). But since blood pH cannot be allowed to drop, the acid is pulled out of the blood and stored in the tissues. Over time, all the tissues of the body become acidic. This makes us more susceptible to ailments and injuries of all kinds, and when something happens to cause damage to a soft tissue, like a sprain, for example, the injury does not heal, or takes an excessively long time to do so.”

“What do I need to do?”, he asked. “Do you drink water?”, “Very little: I have a small glass once in a while, with lunch, for example, but I hardly ever drink water, really.” “Well, you have a big part of your answer right here. You absolutely need to drink water. Otherwise, the kidneys cannot eliminate metabolic acids.”, I said.

“From now on, this is what you will do, every day: When you get up in the morning, drink half a litre of plain water. Thirty minutes before lunch, drink half a litre; and thirty minutes before supper, drink half a litre. That makes a total of one and a half litres of water, always on an empty stomach to ensure maximum hydration, and always about thirty minutes before meals to ensure good digestion.”

“Now, in addition to that, which is really the strict minimum amount of water anyone should drink, you will have to, and this is very important, drink one liter of water with the juice of two lemons, a teaspoon of unrefined sea salt, and a little bit of stevia to sweeten. You will do this either late morning, at least an hour before lunch, or late afternoon, at least one hour before supper. It is very important that you drink this lemon water on a completely empty stomach and wait about an hour before eating anything.”

“Doing this will hydrate the digestive system, the blood and the tissues; the lemon water with salt on an empty stomach will, in addition, alkalise the blood, and thus allow the tissues to release the stored acid back into the bloodstream; and these together will allow the kidneys to eliminate this accumulation of metabolic acid each time you pee. In a relatively short amount of time, your wrist will feel better, but everything else in the body will function a lot better as well. Inflammation is not localised; it is systemic. And to get rid of it, we need to get rid of it everywhere.”

“OK. I’ll do it.”, he said, “This is more water than I have ever drank in my life, and I don’t know if I’ll be able to actually drink that much, but I’ll try, and I’ll let you know.” One month later, exactly one week after he did start to drink more water and the lemon water with salt, the chronic pain he had in the wrist, the chronic pain he had had for about three years after the initial injury, the chronic pain for which he had been prescribed and taken a variety of different anti-inflammatory medications, and none of which had worked to help heal the injury, the chronic and long-standing pain was gone. It was completely gone, and it felt like a miracle to him; we can understand why.

I start every day with half a litre of plain water, at least. I usually drink a total of about one litre over the course of about 2 hours. About 1.5 hours later, around 10:00, I make myself a lemonade with one lemon, half a teaspoon of salt and a little stevia in a little more than half a litre (about 650 ml) of water. I drink it relatively quickly and then always rinse the mouth well with plain water in order to avoid any issue relating to the mild citric acid damaging the enamel of the teeth.

Then, I slowly drink my daily green juice over the course of about one hour. Around 12:00 I have another half litre of water, plain or with chlorella or evaporated green juice powder, salt and stevia. I eat around 14:00. For lunch I usually have my coconut milk pudding, but sometimes have a big green salad with some grilled fish at the canteen (once or twice a week).

After lunch, I wait at least two and usually three hours before drinking again, depending on what I ate, (high protein or not). I will usually have a good three quarters of a litre of plain water around 17:00. Then, around 18:00-18:30, I will prepare myself another lemonade with the juice of one lemon, half a teaspoon of unrefined salt and some stevia in a little over half a litre of water. I rinse the mouth with plain water, and usually leave work to ride back home on the bike. When I get there, I drink half a litre of plain water. We have supper about 30-45 minutes later. I usually don’t drink anything more after supper, except for a small glass before bed sometimes.

That’s it: lots of water, lots of salt, lots of lemon water, lots of green juices. A wonderfully simple, effective and powerful natural anti-inflammatory combination for you, your parents, your children, and everyone everywhere. I’ll be happy to hear from you if you want to share a personal story or experience that relates to this.

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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.

glass-of-water

Pure alkaline 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, magnesium deficiency, and calcification.

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.

Sel-gris_prod

Unrefined sea salt from the Atlantic coast – Sel de Guerande.

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.

Water, ageing and disease

Thinning skin, drying hair, wrinkles, brown spots here and there, patches of discolouration. Sagging eye lids, sagging cheeks, sagging skin all over the body. Loss of bone mass, loss of muscle mass. Stiffening joints, stiffening muscles, stiffening tendons and ligaments, stiffening veins and arteries. Weakness, tiredness, aching. Loss of memory, loss of concentration, loss of intellectual capacity, dullness. Metabolic syndrome, diabetes, senility, dementia, Alzheimer’s, arthritis, elevated cholesterol, atherosclerosis, stroke, kidney failure, liver failure, heart failure, cancer.

Are all these symptoms, these conditions, independent from one another? Are they different? Do they arise spontaneously and develop on their own? Do they just fall upon us unpredictably as rain does? Or are they consequences of more basic factors that elude most of us.

If we could ask the late Dr. Batmanghelidj (1931-2004), M.D., about ageing and disease, he would surely say that its primary cause is the cumulative effects of chronic dehydration on the body, and the plethora of consequences that this brings about. This chronic dehydration that only increases in severity with time, gives rise to so many problems.

But independently of anyone’s opinion, it is an observational fact is that when we are born, the body is 90% water, but when we die, it is only 50% water. Doesn’t this tell us something? Doesn’t this tell us that ageing and dying could be considered as a process of gradual dehydration?

The main way in which we provide water to the body is by drinking. And all of the nutrients required to sustain the body come from the foods we eat. Therefore, the digestive system is truly at the root of it all. As I explained in this previous post on the important of water in the digestive system, the direct consequences of not drinking adequately on an empty stomach long enough before eating, are the poor digestion of food, and the damage caused to the lining of the stomach and intestines that eventually lead to ulcers and leaky gut syndrome.

But poor digestion of food means improper break down of protein into amino acids, and the deficiency in the full range of these essential compounds necessary for so many functions in the brain and in every cell of the body. Poor digestion of food means improper break down of fats into their constituent fatty acids that provide not only the primary source of energy, but also the very building blocks of the membrane of every single cell in the body. Poor digestion of food means improper absorption of minerals and the complex molecules we call vitamins, that together with the proteins and fats are used not only in building all the tissues in the body, but also in every single chemical reaction, transport and communication between cells and tissues. Over time, poor digestion and damage to the digestive organs leads to the permanent loss of the ability to absorb certain minerals and vitamins. There is no doubt that this leads to complications that will manifest in various complex ways.

The lack of water in the digestive system leads to a lack of water in the bloodstream. The blood gradually thickens, its volume decreases, and its viscosity increases. This increases the friction between the blood and the walls of the blood vessels, and therefore the resistance in the flow. The heart is now under severe stress as it attempts to pump this thick, viscous, sticky blood to all parts of the body, and through all the vessels from the largest arteries to the narrowest almost microscopic veins. But this intense efforts by the heart also stressed the vessels themselves. Stress on the vessels leads to lesions. Lesions lead to plaques whose purpose is to patch up and heal the damaged tissues. The accumulation of such plaques, whose spontaneous bursting causes strokes, leads to atherosclerosis that eventually leads to heart failure. Pretty grim picture, isn’t it? But far from being complete yet.

The lack of sufficient amounts of water in the bloodstream obviously means that every organ and every cell of the body gradually becomes more and more dehydrated over time. For the cell, water is by far the most important substance, it is the context in which absolutely everything takes place, and on which everything depends. In order to maintain as much of this precious water as is possible, every single cell starts to produce more cholesterol to seal its membrane a well as possible and keep and protect its water. This is why dehydration leads to the appearance of excessive amounts of cholesterol, which in this case is the cell’s essential water preservation mechanism.

The lack of sufficient amounts of water in the bloodstream is particularly detrimental to the articulations. The joints of the body, all those areas where out limbs bend, are a complex assemblage of tissues whose primary component is cartilage. Cartilage is a kind of a simple matrix that holds water. It is the water content of the cartilage that gives it its suppleness and flexibility, allowing it to protect the bones from rubbing against each other in the joints when we move. It is well known that as we age, all of our joints and cartilage dries out, and we develop what we call arthritis. But is this because we are getting older, or is it because we are getting more and more dehydrated with every passing day? Is arthritis a disease of ageing or is it a consequence of chronic dehydration?

The amazing thing is that the only way to bring water to the cartilage in the joints to maintain their flexibility and prevent their degradation is through the porous ends of the bones to which the cartilage is attached. And the only way to bring water to the end of the bone is through its marrow. And the only way to bring water to the marrow is by way of the blood. Therefore, to prevent the gradual dehydration and subsequent breaking down of the cartilage in the joints, the blood must be well hydrated: thin, easy flowing and full of water.

And what does all this mean for the rest of the body? By weight, the muscles are 75% water; the blood is 82% water; the lungs are 90% water; the brain, the primary element of the central nervous system, is 78% water; even the bones are 25% water. So, it’s pretty simple: as dehydration increases over time, all organs, all tissues and all cells suffer, shrink, weaken, and succumb ever more easily to disease, whatever form it may take.

Dr. Batmanghelidj presents a convincing line of arguments linking breathing and lung disorders like asthma and allergies to chronic dehydration, and also believes that the dehydration of brain and nerve cells whose composition is also mostly water, leads to disorders of the central nervous system such as Alzheimer’s disease.

And the skin? Think about any fruit or vegetable that you place on a shelf in the fridge, like an apple, a carrot or a radish, and leave there for a long time. It will gradually soften, then start to wrinkle, and with time continue to soften and wrinkle more and more until it is nothing but a tiny little dry out thing. Moreover, you may also have noticed that if you take a partially dehydrated carrot or radish, for example, cut them and place them in water for a while, they will re-hydrate by refilling all the cells with water, and in so doing become hard and crunchy once again. However, if you wait too long, then no matter how much time you leave them in water, the cells will not re-hydrate. Logically, since our water content is similar to a fruit or vegetable, what happens to the body is probably very similar, and hence gradual the softening, wrinkling, weakening, and overall degradation of the bodymind at the days and years go by.

Obviously, this does not mean that by drinking enough pure water—no other liquids can be substituted for water—to ensure that the bodymind is well hydrated we will not age. Of course not. But at least, we will ensure that ageing and all the consequences associated with ageing are not accelerated by dehydration. The last thing we want is to accelerate our rate of ageing and our susceptibility to disease.

The truth is that for most living beings on Earth, water is life. There is no question about this. We and most terrestrial animals are constituted of about 60-70% water and 30-40% minerals—by mass. But in fact, in terms of the number of molecules in our bodies, we are 99% water! Can we grasp the significance of this? Can we now realise what dire consequences the slightest dehydration can cause to every cell, every tissue, every organ, and every system of the body? It is hard to quantify, but it is huge. And coming back to our initial question: are ageing and disease different? Are they related? What do you think?

Although chronic dehydration is so common that it is generalised, avoiding dehydration is very simple: drink water and unsweetened herbal teas or light green tea. Don’t drink coffee, black tea or alcohol-containing beverages because caffein and alcohol promote the excretion of free water, and therefore cause dehydration. Don’t drink sweet drinks, juices or sodas; these are full of sugar, including large amounts of fructose, that totally disrupt both the hormonal system and the metabolism, promoting hormonal imbalances and insulin resistance. Don’t drink milk; this is a food containing fats, proteins and carbohydrates that trigger all the required digestive processes that further exacerbate the problems associates with chronic dehydration. Just drink pure, clean, filtered water.

At the very least, drink half a litre when you get up in the morning (7:00), half a litre mid-morning (10:30), half a litre 30 minutes before lunch (12:30), half a litre in the late afternoon (16:30), and half a litre 30 minutes before dinner (18:30). Take a pinch of unrefined sea salt on at least some of the occasions when you drink to reach total of about 2 teaspoons over the course of the day, including the salt taken with the meals.

Why we should drink water before meals

We all need to drink at least about two litres of water every day. Not juice, not sodas, not coffee, not tea: plain water. None of these other liquids have the properties of water, nor do they have the desirable effects of water on the body. Most of us don’t however, and so we are chronically dehydrated. Whether it is 75% or as high as 90%, it is evident that a very large portion of the population is chronically dehydrated.

The digestive system can be viewed as the most fundamental because everything used to sustain life in the body goes through it. In a very real sense, we are a digestive system, supplemented by a central nervous system and refined sense organs to allow us to devise ways to get food (and avoid being eaten), coupled to a refined locomotor system to allow us to gather the food (and run away when it is needed). Since every component of every cell in the body is made from the nutrients in our food, it is obvious that everything in the body depends on the digestive system. And for the digestive system, the single-most important element is the presence of ample amounts of water.

As soon as we even think about eating, the digestive system starts to get ready. The pancreas secretes a little jolt of insulin just in case carbohydrates come in, and the stomach starts to produce the highly acidic digestive gastric juice (pH of 1-2). This gastric juice is composed of only a little bit (0.5%) of hydrochloric acid (HCl) and a lot of salt, both sodium chloride (NaCl) and potassium chloride (KCl). The stomach has sensor cells to know exactly how much protein, fat and carbohydrates are present at any given time, and thus can adjust the production and composition of the gastric juice.

Although present in very small amounts, the hydrochloric acid is the essential compound for activating the enzymes responsible for breaking down protein, which is its main purpose because both fats and carbohydrates are mostly broken down in the intestine. But to make it to the stomach without causing any damage along the way, the two constituents of this highly corrosive acid, the hydrogen (H) and the chlorine ions (Cl), are produced separately and transported to the inside of the stomach where they combine to form the acid.

The delicate lining of the stomach with all its different kinds of highly specialised cells, is protected from the acidic gastric juice by an alkaline layer of mucus. This mucus is between 90 and 98% water, with some binding molecules and a few other components. It can be regarded as a blanket of water whose primary role in the stomach is to protect its lining from the gastric acid. The very thin mucosa that produces and maintains the mucus layer, also secretes sodium bicarbonate that sits in it, and neutralises the acid upon contact when it penetrates the layer, leaving only sodium chloride (salt), water and carbon dioxide. The neutralisation reaction is simple: HCl + NaHCO3 -> NaCl + H2O + CO2.

As we get progressively more dehydrated, not only are the stomach cells incapable of releasing adequate amounts of water into the stomach in order to allow for the proper mixing of the food and acid into chyme with the optimal consistency, but the thickness of the protective mucus layer decreases, thus allowing the acidic contents to damage the fragile lining. This is what eventually leads to stomach ulcers, according to a well known specialist in the matter, Dr Batmanghelidj, author of Your Body’s Many Cries for Water.

The contents of the stomach are churned and blended between one and three hours depending on the amount and composition, until the chyme is liquified and smooth, at which point it is poured into the duodenum, the first part of the small intestine. It is in the small intestine that the real work of the break down and absorption of nutrients into the bloodstream takes place over a period of about 24 hours. The sensor cells in the duodenum will immediately determine the pH and composition of the chyme in order to send the messenger hormones to the pancreas to secrete the right amount of the alkaline, watery sodium bicarbonate solution necessary to neutralize the acid, and to the liver to secrete the right amount of bile needed for the breakdown of fats.

And even though the pancreas is known primarily for its role in producing and secreting insulin needed to clear the bloodstream of sugar, it is arguably its role in secreting this alkaline solution that is the most important. Indeed, as the duodenum does not have a protective layer of mucus as the stomach, it is this sodium bicarbonate solution that protects it and the rest of the small intestine from the devastating effects that the highly acidic chyme can have on it.

However, just as even partial dehydration causes the protective mucus layer in the stomach to dry out and shrink, making it permeable to the gastric acid that eats away at the delicate soft tissues, dehydration also causes the pancreas to be unable to secrete as much of the watery sodium bicarbonate solution as is required to fully neutralise the acidic chyme that, therefore, also damages the intestine. In fact, that there are several times more cases of duodenal as there are stomach ulcers attests to the reality that the lining of the intestine is all that much more fragile as it is unprotected and thus directly exposed to the excessively acidic chyme.

Therefore, water is of the utmost importance in protecting the lining of the stomach and intestine from the acid required for the break down of proteins into amino acids. Water is of the utmost importance for proper digestion and absorption of the nutrients in the food. And hence, water is of the utmost importance in maintaining a healthy digestive system meal after meal, day after day, and year after year throughout our life.

We must make sure that the body and digestive system are properly hydrated before eating. And for this, all we need to do is drink half a litre of plain water 30 minutes before meals, and not drink during nor after the meal for two to four hours.

Drinking during or soon after a meal will only dilute the chyme, making it excessively watery. This will not lower the pH, because water does not neutralise acid. It is best to ensure proper hydration prior to the start of the digestive process, providing the water necessary for the mucosa and pancreas to function optimally, and allow the stomach to adjust the water content of the chyme on its own. I personally usually wait two hours after a snack or small meal, and at least three to four hours after a large meal.

The time needed for the chyme to leave the stomach through the pyloric sphincter and enter the duodenum depends on its amount and composition. For example, fruit or any other food consisting mostly of simple sugars eaten on an empty stomach will make it into the intestine, and the sugar into the blood, in a matter of minutes: Since there is no protein, no acid is required for its breakdown in the stomach; and since there is no fat, no bile is required to break it down in the intestine.

Naturally, the time needed for the stomach to process a small meal will be less than that needed to process a large meal of more or less equal composition. In fact, given that our stomach is a very small pouch with an empty volume of about 50 ml, and a full volume of about 1 litre (up to a max of 2-3 litres when it is really extended),  the time needed for large meals increases substantially and disproportionately compared to smaller meals.