Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
15 Dec

Do You Know How to Properly Hydrate?

Couple drink waterHydration. It seems like it should be so easy: drink some water, go about your day, the end. If only it was that simple. In fact, there are many (often contradictory) opinions out there about what we should be drinking, and how much, and when, especially for the athletes among us. I have written about hydration before, and kept up to date with breaking research in recent years. Now, as I am working on the completely revised, updated, and expanded edition of The Primal Blueprint (slated for release in December 2016), I’d like to share a more sophisticated and nuanced opinion on the subject. As you might recall, in the original Primal Blueprint I essentially said, “obey your thirst like Grok did” and left it at that. So let’s dig a little deeper, especially for those of us who are active and athletic.

Hydration is a critical component of optimal health. It is important for digestion, muscle contraction, circulation, thermoregulation, and neurologic functioning, among others. My seemingly flippant “obey your thirst” message actually has good scientific support. Your body has a built in, well-regulated thirst mechanism that will tell you if you need to drink additional fluids. If you’re low, besides initiating thirst to get you to drink more, your body is able to respond by releasing an anti-diuretic hormone called vasopressin, or AVP, to retain more fluid in your body. To hydrate optimally, you simply need to tune in to your body’s thirst sensations, tailor your fluid intake to your individual needs, and make appropriate adjustments for exogenous factors like climate (drink more if it’s hot) and exercise (replenish water lost through sweat). Obviously, these outside influences should be reflected in your thirst. There is no good evidence that we should all adhere to conventional wisdom’s old 8×8 rule: drink at least eight eight-ounce glasses of water every day without fail. Nor is there any benefit to drinking even greater quantities of water; in fact drinking too much can bring about the dangerous condition of hyponatremiawhere excess fluid compromises the all-important sodium balance in your blood. This situation can quickly become debilitating and even fatal. You may have heard the news stories in recent years of novice marathon runners losing consciousness, or radio station contestants drinking themselves into the ER or even to death.

Nothing I’ve seen in the past few years, since the last time I updated The Primal Blueprint, makes me inclined to change my advice for the average healthy person who isn’t engaged in heavy physical activity. Drinking to thirst is still the best bet. Remember, too, that we get up to 20% of our hydration needs met through food, especially watery fruits and veggies, which you should be eating plenty of if you are eating primally. If you are eating a healthy (Primal!) diet, drinking when you feel thirsty, and aren’t exhibiting signs of dehydration (headaches, dizziness, very dark urine, etc.), you should be fine.

And don’t forget about salt. Dietary sodium has been positioned in a negative light by conventional wisdom. I have argued that that is unfounded, and scientists are beginning to reconsider the anti-salt crusade as well. Sodium, which we get from salt (NaCl—high school chemistry anyone?), helps transport water through the walls of your small intestines, where 95% of fluid absorption takes place. You need salt, and we primal peeps are probably getting less of it compared to the rest of the population since a large proportion of most Americans’ dietary sodium comes from processed foods. In fact, when transitioning from a Standard American Dietary pattern to a primal/paleo style pattern, it’s possible to become deficient in sodium and develop a need to consume supplemental sodium to get rebalanced. In general, don’t be afraid to salt your food. If you are not eating while you drink, you can even add a pinch of salt to your water to boost absorption (keep reading for a further recommendation that will really blow your mind).

Advice for Fitness Enthusiasts (and Other High Energy, High Calorie Burners)

For athletic types—anyone who goes out and works up a serious sweat—the hydration issue is considerably more complicated, and my view on how they should hydrate has become more nuanced. For us folks, especially those of you engaged in endurance sports such as long distance running or triathlons, or back-to-back events such as CrossFit competitions featuring multiple physical efforts in the same day, or those doing physical labor in warm climates, you are putting your body under considerable physical and metabolic stress. (I won’t lecture you about chronic cardio here, but you know how I feel about it). You have greater-than-average hydration needs both because you are losing fluids through sweat and because you need to be properly hydrated in order to perform at a high level. Your body (your muscles, your digestive tract, your brain) is really counting on water, just when it is being depleted. While some amount of incidental dehydration is inevitable during intense exercise, being as well-hydrated as possible is important for performance, thermoregulation, and recovery, and it can be difficult to right the ship if your hydration starts being compromised.

So what is the responsible, hydration-conscious athlete to do? Here is where it gets tricky. Athletes need to consider a range of factors, including exercise duration and intensity, environment and temperature, training status, heat acclimatization, previous hydration level, diet, body mass, and so on. It is clear that there is no single best practice for all athletes. However, there are some guidelines that have been suggested by some of the leading researchers in hydration and athletic performance.

What to Drink

While plain water is ok, you are better off consuming a solution of water, salt, and glucose/sucrose. WAIT, STOP THE PRESSES! Did Mark Sisson really just recommend adding sugar to water?!? I did. Hear me out. For maximal water absorption, the body requires sodium and glucose/sucrose to facilitate the transport of water through channels in the small intestine. Please be clear, this sugar is not for fueling, and it’s not a lot. Your food/fuel is a totally different issue for a different post. What the experts are now talking about here is a solution of 16 oz of water, a pinch of salt, a teaspoon of maple syrup (because it has a good composition of sucrose and glucose).

I do not advise you to rely on engineered “sports nutrition” drinks in general. They are usually carbohydrate dense because they are designed to combine hydration with fueling. Many follow the long-standing advice to consume a solution of 7% glucose, although Dr. Stacy Sims (exercise physiologist, nutrition scientist, and co-founder of Osmo Nutrition) recommends a 2-4% osmolality solution for optimal hydration. It can be extremely difficult to know how concentrated your drink is, and you might purposefully be making it extra concentrated if you are using one of those powdered formulas you mix yourself. This is a problem because fluids that are too concentrated and too sugary, like many sports drinks on the market, can sit in your stomach (if you have experienced the dreaded sloshing belly during a marathon know about slow gastric emptying). Then, once the sugary fluid is in your digestive tract, your body actually draws stored water into the intestine to dilute them. This has a net dehydrating rather than a rehydrating effect. Ouch! Time to change the narrator’s text in the sports drink commercials, eh? Note that anything like a lemonade or fruit juice or even coconut water can also be problematic because they too have too much glucose to provide ideal hydration.

What’s more, engineered sports drinks like the ubiquitous Gatorade often have undesirable ingredients like dyes and chemical preservatives that I don’t want in my system. (Unless they sign me to a multi-year endorsement deal; how does “Gatorade presents MarksDailyApple.com” sound?) If you do decide to use one of these products, dilute it with water unless you know it is specifically engineered to have a lower osmolality.

When and How Much to Drink

There are many respected scientists, including the inimitable Dr. Timothy Noakes (author of Waterlogged, world-renowned expert on hyponatremia, long considered one of the leading endurance exercise physiologists in the world, and recent convert to primal-style eating!) and Drs. Marty Hoffman and Kerry Hoffman (Director of Medical Research and Medical Director of the Western States 100-mile endurance run, respectively) who recommend drinking to thirst even for extreme endurance athletes. This means no schedule, no “per hour” guidelines, all idiosyncratic and intuitive. However, there is also ample evidence that the thirst sensation can be suppressed even with systemic dehydration. Plus, in a high-stress situation like an Ironman, or during a high stress block of training or living (jet travel, etc.), there is a real concern that individuals might become too mentally and physically taxed to be attuned to their thirst. This could happen in the middle of an endurance event or ultra race, where so much focus is on pacing/competing instead of on biofeedback, or it could happen over time from the accumulation of ambitious workouts.

Brad Kearns, my Primal Endurance co-author and Primal Blueprint Publishing sidekick, sustained a serious medical setback this past summer (severe dehydration and emergency appendectomy—sordid details are in the book for your reflection and edification) despite his decades of experience as a seemingly optimally hydrated athlete. This happened in June during a week of 100-plus-degree heat and two high-intensity sprint/strength workouts over a four-day period. The lesson here is that as the athlete stacks up big workouts over time, it’s possible to bring a bit of dehydration to the table at successive workouts. You might not notice your condition working at your desk the day before you bang out sprints and max effort high jumps in 106 ºF heat, but entering a hard workout slightly underhydrated, then burning up more energy and generating more heat at the workout, might throw you into catch-up mode that could spiral downward over time. Yes, even if you faithfully down fluids right after the workout until your thirst is temporarily quenched.

Brad recalls, “Of course I drank like a fish after my high intensity session on Tuesday in the heat, rested carefully for a couple days, then hit it hard again Friday. I felt fine—recovered, hydrated, and explosive during the workout. But that pretty much always happens during a workout when the juices get flowing! After the Friday workout, I started to not feel so good (appendix acting up as I would learn later). As I convalesced in bed over the weekend, the health disturbance was enough to put my thirst mechanism out of order. By Sunday, I had burned up an organ and received nine IV bags in succession before and after the surgery, until I was finally declared rehydrated.”

If you are exercising primally, you are not putting sustained, intense stress on your body (by design!), so you can safely drink to thirst. Likewise if you’re only out there for an hour or two in temperate conditions. If you are exercising for more than a few hours, or in extreme conditions, I think it is wise to have a hydration plan. This does not mean a hard-and-fast rule to drink a certain amount per hour, despite what some experts recommend. This means reminding yourself to drink periodically and doing so if it feels comfortable. It also means going into races adequately trained, having tested and practiced hydration strategies, and being heat acclimatized if appropriate. But by all means, never force yourself to drink! This is a primary way people induce hyponatremia, which can be fatal.

Advice for Women

As Dr. Sims reminds us, “women are not small men.” Most of what researchers “know” about hydration comes from studies of men, whose hydration needs can be very different from women’s due to female hormone cycles. In particular, for women during the luteal phase (between ovulation and onset of period), when estrogen and progesterone are high, blood volume and total body sodium are low. At the same time, women’s homeostatic threshold for AVP release and thirst are lowered. The effect of these together is that women are physiologically closer to being hyponatremic and so have to be particularly careful not to overhydrate (this might be why women are at greater risk for exercise-associated hyponatremia). Dr. Sims also advises that women in the high hormone phase sodium preload before exercise and hydrate using a water-sodium-glucose/sucrose solution as described above (this advice applies to all women, but is it especially important for female athletes).

The Bottom Line

  • For the average person, people engaged in shorter-duration exercise, and endurance athletes not immediately preparing for or actively engaged in long workouts or races, drinking to thirst is still the best recommendation.
  • Drink throughout the day. Keep water handy so it is available if you want it, but don’t be a slave to it. Remember, we can only absorb so much water. Drinking more doesn’t necessarily make us more hydrated. If you are a Nalgene addict who is in the bathroom every 30 minutes, you are just cycling water in and water out with no actual physiological benefit.
  • Eat lots of high water-content fruits and vegetables.
  • Don’t be afraid of salt. Salt your food to taste. Add a pinch of salt (and a teaspoon of maple syrup) to your water. Athletes, especially women in the luteal phase of their menstrual cycles, should consider sodium preloads, particularly before hot workouts.
  • Athletes should consider hydration preloads before extreme events or training phases, particularly in hot weather.
  • Never force yourself to drink or drink past the point of comfort.
  • Most sports drinks are not your friend. Look for ones that use a combination of glucose and sucrose instead of fructose, maltodextrin, sucralose, or xylitol, and avoid ones with a lot of unnatural ingredients like dyes. In a race situation, if you are desperate you can drink whatever is available at the aid station, but dilute it with water.
  • Remember, hydration needs and optimal strategies are idiosyncratic. Just as I advise you to experiment with your diet to find what works best for you, do the same with hydration. Especially if you are an athlete, you must do the tinkering in training so you know what your body needs and how it responds.

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You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. Two questions:

    1. Does stevia count as “sugar” in the water? Carbs kill me no matter where they come from, or why I consume them.

    2. What about post-menopausal women–what should THEY do lacking a luteal phase?

    Wenchypoo wrote on December 15th, 2015
    • As a personal preference, I’ll pass on the sweetener. I don’t like sweetened drinks of any kind although I do love good-tasting water. In fact, it has long been my drink of choice, often with a slice of lemon or lime squeezed in, but plain works just fine for me. I sip it all day long, summer and winter.

      Shary wrote on December 15th, 2015
    • Stevia for post-menopausal women can be an issue. Dr. Sarah Ballantyne does not recommend it in The Paleo Approach. She states that it was used for birth control. Was using stevia in my tea and occasion paleo baking and had very little soy [only the soy lecithin in my chocolate.] So, after reading The Paleo Approach, I asked my doctor to test my hormones at my annual physical and estrogen was more than double what it should be for post-menopausal. My doctor was emphatic that I stop using stevia and any soy and scheduled a retest in 1 and 3 months.

      Susan wrote on December 15th, 2015
  2. I use an old field hand method of determining if I need to add salt. You touch the tip of your tongue with a finger that has been dipped in salt. If you taste salt instantly you are high in salt and should lay off, if there is the briefest delay you are about right. If there is about a second lag, you are low and should supplement. This only works once, and only if you have not eaten lately, i.e., no second opinion until much later.

    Steve Maxson wrote on December 15th, 2015
  3. Really appreciate this nuanced look at hydration, particularly how “extreme” exercise patterns can change the game.

    I practice yoga for 90 minutes each morning and 90 minutes each evening in 105+ degrees (at my current studio, it’s sometimes cranked well over that). Though (at least from a Chinese Medicine perspective), the extreme sweat loss this involves is not balanced or healthy, I’m hooked and have no plan to give it up in the near future.

    That being said, after particularly hot, strenuous practices, I sometimes find myself needing either a mineral-rich Gerolsteiner or a low-sugar kombucha to fully recover. By “recover,” I mean alleviate what, in Chinese Medicine, we call “dispersion thirst” (sort of like the diabetic thirst…one that seems impossible to quench). These are also practically the only times when I might crave a few bites of fruit (otherwise, I don’t have much interest).

    And yet, during one of those classes, the thought of drinking anything sugary (even coconut water) is a complete turn off. Not only does it not digest and make me feel awful, but it makes the class harder and definitely makes that “dispersion thirst” worse. Really cool to read some of the science behind this in todays post!

    Dr. Dana Leigh Lyons wrote on December 15th, 2015
    • I do hot yoga as well and have no intention of stopping anytime soon. I am absolutely in love with it. Do you drink anything else besides water to fully recover? Electrolytes supplements ?

      Dina wrote on December 15th, 2015
      • Gerolsteiner is particularly high in mineral content…and when that doesn’t do the trick I choose a low-sugar kombucha.

        Otherwise, I find eating well (primal, real, whole food) the rest of the time takes care of my needs.

        Dr. Dana Leigh Lyons wrote on December 15th, 2015
        • Thank You

          Dina wrote on December 15th, 2015
    • I practice Iyengar yoga alongside a more free-form style as well – I have to say yoga sessions in such heat as the hot yoga (Bikram) style, resulting in such thirst, aren’t in alignment with my understanding of yoga at all or my knowledge of Chinese medicine (including a basic understanding of qigong practice).

      I have an acquaintance who is also a hot yoga fan taking 7 classes a week for 90 minutes and she too appears ‘addicted’ and unwilling to consider other styles or fewer workouts. I wonder what might be going on physiologically that induces this, or perhaps it’s the nature of class that attracts a certain personality type … and I speak as a recovered IM triathlete who was slowly destroying herself with that addiction.

      When I stopped, and reflected I realised there was an awful lot of psychological stuff underpinning the ‘addiction’. Working on my inner self (which is where the heart of yoga actually lies – read about the 8 limbs …) has delivered me to a more balanced position with regard to movement (in all its forms).

      Kelda wrote on December 17th, 2015
  4. These are great. As someone who knows to drink water all day, I wish more people understand this more. Not only does it make you feel better, but most of the time if you are suffering from a headache it could just be from dehydration.

    Wod Crusher wrote on December 15th, 2015
  5. Will a teaspoon of honey do it?! I don’t have access to maple syrup.

    Can I make a 1,000 liter solution of 200ml of coconut water and 800ml of water? Is the sodium/sugar ratio of coconut water ok for this purpose, or is coconut water more sugary than salty?

    Frank wrote on December 15th, 2015
    • Frank I’ve seen coconut water in the health food store, looked interesting but had too much sugar. Not sure what the sugar content would be if you make it yourself. Probably OK a couple of times a week pre or post workout, but maybe not something you’d want to drink multiple times a day.

      HealthyGuy wrote on December 15th, 2015
      • Hello HealthyGuy!

        I don’t know about bottled coconut water. They probably add some sugar since the taste of fresh coconut water is not sugary, they don’t have that many sugars.

        100ml has about 4g of sugar, so if I add 200ml of coconut water to 800ml of water will come up with 8g of sugar for a litter, which is about the same as 1 tablespoon of maple syrup, I guess.

        I live in Brazil and I buy fresh coconut for about 50 cents. :)

        Frank wrote on December 16th, 2015
  6. I have found that I require 64 ounces of clear liquid (water or green tea) every day to feel well. Adding an extra cup of coffee or some other beverage doesn’t help. On workout days and/or in summer and/or after a high-carb meal, I need an extra 16-32 oz. I’m a small person- 5’3″ and 115lb- so this seems like a ton of fluid. I’m wondering now if this is a problem. Am I drinking too much? If I drink less, I feel sluggish and get sweets cravings.

    Kelly wrote on December 15th, 2015
  7. What about then, for a mild sweetening, blackstrap molasses? Lots of minerals, some carbs….

    jill wrote on December 15th, 2015
    • I am curious regarding molasses as well, it is something I have plenty of on hand. I also have honey. Have wanted to get maple syrup for “a while” but it gets pushed back on the shopping list in favor of other things.

      I have a pair of 3 liter bottles that I’ve been filling with water and adding 3/4ths tsp of sea salt to, so about 1/8th tsp per pint. If I get the maple syrup (and my math is correct) then about 2 tbsp of syrup per bottle?

      James wrote on December 16th, 2015
  8. One good thing to do is to drink a large glass of water upon rising IMHO. I put a few drops of some mineral concentrate (which has a fair amount of sodium) and some d-ribose in it. Once a day I will have a glass of water with a lemon squeezed into it, and once a day I will have a shaker full of water with a spoonful of greens.

    HealthyGuy wrote on December 15th, 2015
    • I wake up and have a large glass of water with magnesium. Great start to the day!

      Noconago wrote on December 15th, 2015
  9. I’m after some advice, it’s been a long time since I’ve ever really felt like I have consumed enough water. Years really. I obviously drink and get water from food but most days this is a single cup (200ml). I often have dry lips and other signs of dehydration. The problem of listening to my thirst is that I am never thirsty. Regardless of how dehydrated I am it’s like my body doesn’t recognise any signals for water. How do I fix this? I’ve been able to drink 600ml the last few days (living in Australia with 37* temps) and hope to increase consumption to where I don’t see and signs of dehydration. But it’s really difficult.

    Crystal wrote on December 16th, 2015
    • Also in Aus, hot central Qld. I have to work hard outdoors to experience definite thirst. Suspect consumption of 3-4 creamy coffees/ day interferes, that cutting dairy might change that. It’s my fast food, however, when I come in pooped.

      Urine colour and volume is what I use to remind myself to get stuck into the water.

      Rose wrote on December 18th, 2015
  10. How about milk?

    Troels Rasmussen wrote on December 17th, 2015
  11. I really appreciate the in depth article regarding HYDRATION, it’s definitely a subject needed for clarification and professional advice. As you mentioned in the article there are many opinions and suggestions but the logic or science behind them are not always solid or very reassuring. Thanks again.

    I would like to know if possible, your feel on carbonated water/ fizzy water ….
    cheers! – Vishal Kawatra

    vishal Kawatra wrote on December 18th, 2015
  12. Can you comment on the whole hydration and salt issue for people who have had kidney stones? Already on a low oxalate diet. Thanks.

    Dee wrote on December 18th, 2015
    • After my oxalate stone lithotrypsy, I asked my urologist how much water was enough to drink to prevent recurrence. He said that he was more concerned with output than input. So, I measured output, and found that, for me, two extra 16 oz. glasses of water with half an tablet of nuun in each, gave the 1200 – 1500 ml output per 24 hours I was after. Not scarfing kale salad (high in oxalates) was harder.

      Tony wrote on December 19th, 2015
      • Tony,

        Thanks, I hadn’t heard of nuun before. I’m already over 2000 ml, so I guess I don’t need to increase my water intake. :-)

        I’ve been lucky so far, that all of my stones passed on their own, even though they were kind of big. Did lithotripsy go ok for you?

        Tuscan (aka Dino) kale is lower oxalate, if you really miss it.

        Dee wrote on December 19th, 2015
  13. hmm, I’m a little confused on the glucose/sucrose ratio. You promote the benefits of a “good” ratio of glucose to sucrose. You don’t say what that ratio is, however. In the FAQ section for Osmo Nutrition they say their optimal glucose/sucrose ratio is “proprietary”, so that doesn’t help much. Then you recommend a teaspoon of maple syrup per 16 ounces water. But maple syrup is essentially all sucrose, with a sucrose:glucose ratio of 100:1 or higher, see http://www.uvm.edu/~pmrc/sugarprof.pdf for detail. Now, a teaspoon of maple syrup is about 5 grams of sugar, so not much sugar to begin with, so perhaps it doesn’t much matter, but it’s still confusing.

    T Nelson wrote on December 21st, 2015
  14. I used to agree with “just drink to thirst” but I think there’s some good evidence that we can lose our ability to discern how much water we need as we age. It seems ludicrous–why would nature do that? But other parts do wear out and in my experience, I feel a lot better when I drink a bit more water than I really want and monitor urine color as an indication of hydration. Never thought I’d hear myself say that!

    Dthalman wrote on December 30th, 2015

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