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  • Josh Rossi

You Might As Well Drink Bleach!

If this sounds crazy (God, I hope this sounds crazy – please don’t actually drink bleach!), I would invite you to consider the case of alkaline water. As someone who loves the idea of healing myself and bettering myself using novel approaches and solutions, I want to begin by saying that although the above example seems harsh, I use it as a brain exercise, not as an attempt to make anyone feel dumb for drinking alkaline water. Many people are fans of this substance and I’m very happy when something as innocuous as water makes people feel great. But I’m also a bit concerned about how easily all of us (including myself) get drawn into believing various things are healthier or better than others just because we’ve seen ads on Instagram about them or read articles citing studies that may not be the most scientifically robust.

So, this post is about diving in to look at the pros and cons of alkaline water and how it is perfectly safe, but may not be worth the extra money (except in a few rare circumstances). But first, a history lesson!

“Save the children of the world from their acidic lifestyles and diets and their acidic parents who are feeding them.” – Robert O Young

In 2002 an alternative medicine practitioner named Robert O Young came up with the acid-ash hypothesis of disease in his book “pH Miracle Living”. He noted that certain foods get metabolized into acid in the body (namely protein, beans, dairy, grains) and the breakdown of those foods leaves behind an “ash” (much like a fire burning leaves behind ash) that is also acidic. His contention was that this acid ash is the basis for all diseases. Foods such as fruits and vegetables, he said, leave an alkaline ash. He noted that “Alkalization is the cure – for everything”.

This book started what would become a two-decades-long (and counting) obsession with dietary acid intake. If you google “alkaline diet” now, you will find dozens of books, and thousands of articles (scientific and otherwise) on the topic.

By the way, Robert O Young also swore that he was able to turn red blood cells into bacteria by moving them to an acidic environment (which is a fun trick… but also impossible) and that septic shock is caused by “acidic lifestyle choices, including acidic food, drink, and drugs…”. Oh, and he was jailed in 2017 for practicing medicine without a license. But, somehow, his dietary advice is still thriving and bottled water companies around the world are making a killing on it.

Proponents of Alkaline Diets note that such diets can protect from cancer, decrease muscle wasting associated with age, and decrease the risk of osteoporosis. The short version of my review of the evidence is that there is no compelling evidence that an alkaline diet does any of these things. There are observational, animal and lab (petri dish) studies that provide some evidence that these diets may be beneficial for each of these problems, but there is a notable lack of any good consistent observational data and no randomized controlled trials that show benefit. For example, in a review article in 2016, Tanis Fenton noted that while there were 8278 citations involving alkaline diet/alkaline water and cancer, there were only 252 actual abstracts and only ONE study that met his strict inclusion criteria. He notes: “despite the promotion of the alkaline diet and alkaline water by the media and salespeople, there is almost no actual research to either support or dispute these ideas.”

There is some evidence that an alkaline diet (alkaline water paired with a 90% plant-based Mediterranean diet) may decrease complications from acid reflux (heartburn or esophageal ulcers). But, this was a small study and it’s possible that the change to a healthier diet was responsible for any benefits seen (vs changes in alkalinity being the cause). For the majority of people, the amount of acid or base in the diet seems to be less important than the food itself. Why is that? Simply put, changing the acidity of your food and drink does not significantly alter the pH of your body. Your urine can change its acidity, but your blood pH is extremely constant. If it wasn’t, we’d all be dead by now.

PH is a 1-14 logarithmic scale that rates solutions based on their ability to donate hydrogen ions. The strongest acids, such as the stomach’s hydrochloric acid (pH 1.5-3.5) have a large number of hydrogen ions that are readily available for donating. Weaker acids may still have hydrogen present but the tightness of the bonding with other substances can make those hydrogen ions less likely to be “donate-able”. Alkaline (or basic) solutions are high in hydroxide ions (OH-). The higher the pH, the more alkaline it is.

Water by itself has a pH of 7, but much of the water we are exposed to has a pH slightly higher or lower than 7 because of dissolved minerals, chemicals, and other ions. Tap water that is more acidic, such as that with a pH of 6.5, is not intrinsically bad for health, but it can cause corrosion of pipes so it may contain harmful metals such as copper, zinc, and cadmium. Tap water can also be alkaline (or basic) if it spent a long time near limestone or if it has a significant amount of calcium or magnesium. This more alkaline water is also often described as “hard water” and has a pH closer to 8.5. Again, the pH itself doesn’t affect health but the harder water can cause scale build-up in plumbing, making the ideal tap water range between 6.5 and 8.5.

But, if you don’t drink tap water perhaps the above argument is moot. Now that you’ve shelled out $2.50 for a bottle of “Alkaline Water” (because you heard about how good it is for you and you are nothing if not health-conscious), what’s next?

When you guzzle a bottle of alkaline water, which generally has a pH of 8-10, the water immediately goes into a stomach full of acid where the pH is 2-4. So, that fancy-pants water is no longer alkaline. Even if it somehow managed to jump past the acid-cauldron that is your stomach, maintaining its alkalinity, the water would generally become neutralized in the intestines where a variety of enzymes are released to counteract the stomach acid. If our magic alkaline water happened to circumvent the small intestines and get absorbed into the blood in its original alkaline form, bicarbonate (from the kidneys) would immediately buffer the acid, producing carbon dioxide. Carbon dioxide is then easily exhaled by your fully-functional lungs and any remaining salts are excreted by your kidneys, keeping your blood pH at 7.4.

This perfect balance between blood acid and base levels is maintained by your kidneys and lungs. If you have healthy kidneys and lungs, you will have a very hard time changing the acidity (or alkalinity) of your blood. Full stop.

If that’s the case, why are there a number of studies that point to alkaline water and food as being healthy? Let’s look at the most cited benefits of alkaline water.

There is one hypothesis that acidic diets result in muscle wasting and osteoporosis because either amino acids or calcium are being pulled out of the tissues to off-set the acid in the blood. Small studies have shown that giving postmenopausal women alkaline salts positively affects muscle mass. Another similarly small study indicated that increased potassium intake (a positively charged “alkaline” electrolyte) was associated with greater lean body mass in older men and women with chronic renal disease or obesity. But, these studies are small, not prospective, and didn’t have the participants eat alkaline-rich foods (rather, they used salt supplements to mimic an alkaline diet). Perhaps the salts were intrinsically helpful regardless of how they affected pH. So, it’s hard to make much of this “evidence”. As noted above, a review of the studies on alkaline diets for cancer is similarly (un)compelling.

Finally, there is the question of alkaline water for athletes. Since exercise creates a mild metabolic acidosis (blood becomes transiently more acidic), the idea is that if alkaline water was consumed instead of regular water, it might off-set the acidity of exercise, which could be enough to affect performance and recovery. Some small studies support this idea, although, in one of them, the participants had to drink 3+ L of alkaline water daily for 14 days just to increase post-exercise pH by 0.07. Whether this slight (and transient) increase in blood pH is clinically beneficial is unknown.

Most of the benefits attributed to alkaline water in relation to exercise are that it is “more hydrating”. This becomes confusing because most of the alkaline water tested in athletes is made alkaline by adding positively-charged electrolytes, such as potassium, magnesium or calcium. These electrolytes, we know, can be helpful and “hydrating” to athletes in their own right, regardless of whether they’re given in a fancy alkaline water bottle or as part of another electrolyte blend. Some athletes, who know exactly how their body best performs, will add sodium bicarbonate to their tap water to make it more alkaline. In these cases, when dealing with high-level athletes who may actually feel the difference between a blood pH of 7.4 and 7.45, maybe alkaline water makes sense. But, I still doubt it.

Let’s take an extreme example to illustrate my point. Imagine someone dove into your swimming pool and hit his head on the bottom, creating a large rapidly-bleeding laceration. The pool, previously clear and “neutral” in color, begins to become pink due to the bleeding. What do you do? Do you add more blue color and chemicals to the pool so you can’t see the bleeding? No, of course not. You stop the bleeding first then crank up the pool’s fantastic filtering system so it can begin to deal with the blood. Instead of trying to make the pool water look better, you work on fixing the problem that leads to the initial abnormality.

The same wisdom applies to using alkaline water to treat things like exercise-induced metabolic acidosis. A person may experience transient acidosis (which means the blood becomes acidic, something less than 7.35) with strenuous exercise because muscles eventually run out of oxygen and become reliant on non-mitochondrial sources for creation of ATP (energy). This anaerobic energy creation in the muscles release protons, creating an acidosis. (By the way, contrary to popular belief, the lactate generated during this same circumstance does not cause or contribute to the acidosis, it is actually created to retard acidosis by preventing pyruvate accumulation and to supply the NAD(+) needed for glycolysis). In most cases though, this acidosis is brief because the body knows how to handle it. The lungs increase the rate of respiration, thus blowing off carbonic acid (in the form of carbon dioxide). Your kidneys are also there, at the ready, to buffer the blood. So, if you have working lungs and normal kidneys, any brief drop in blood pH will be swiftly dealt with by your super-smart body without the need for the addition of supplemental alkaline water.

Interestingly, there are circumstances where the blood becomes dangerously acidic (exercise is rarely one of those circumstances). In those cases, it was once considered the standard of care to address the scary-low blood pH by adding a strong base to the blood intravenously. Type 1 diabetics can go into diabetic ketoacidosis (DKA) and the blood pH can fall below 7.0, which becomes extremely dangerous. No doctor likes getting a blood pH back and finding that it’s <7 because that person is SICK. Previously, we’d begin by trying to fix the optics – just like in our swimming pool example we would add a bunch of base (such as sodium bicarbonate) to the body via an IV so the pH of the blood looked better. But guess what, it didn’t affect the course of the illness! Until the CAUSE of the acidosis was addressed, the patient didn’t get better. In fact, in pediatric patients, giving bicarbonate during DKA is actually associated with brain swelling and prolonged hospitalization. If adding something basic to the system intravenously is not helpful in disease states where actual acidity of the blood is present, why do we think that giving it orally (where it most likely won’t even reach the blood in its original form) is going to be helpful in non-disease states where the blood was never really acidic, to begin with?

Finally, to hammer my point home, I’d like to point out that if alkaline substances are so darn healthy, why aren’t we adding bleach to our water bottles or salad dressings? Bleach has a pH of 13 so just a dash of it would undoubtedly give us a nice bolus of “alkalinity”. Heck, why not just be uber-healthy and throw down a few bottles of bleach? This sounds silly (please don’t drink bleach!) but the logic is similar to that of drinking alkaline water. If alkalinity in food and drinks makes them inherently healthy, bleach should be a superfood.

As I leave this long-winded rant I will say that although I don’t see much evidence to support an alkaline diet I do agree that many of the foods on such a diet are healthy. Vegetables and fruits are healthy. If checking your urine for acidity with pH paper makes you more likely to eat healthy foods, I’m all for it. If you prefer thinking about your broccoli as a big, fat hydrogen-binding-cancer-fighting-machine, great. If concerns about acidity make you less likely to eat sugar, super (although sugar is generally considered to have a neutral pH and is, by all accounts, much worse for you than acid-ash foods!). Finally, if drinking expensive bottles of alkaline water makes you more likely to drink water… well, I’d argue that maybe you should make your own “ionically charged water” in a reusable water bottle so you can continue to feel “healthy” but aren’t contributing to the 1.5 million tons of plastic water bottles discarded each year in the U.S. Just sayin'.

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