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  • You’re Probably Drinking Enough Water

    You’re Probably Drinking Enough Water

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    As recently as the 1990s, Jodi Stookey, a nutrition consultant based in California, remembers hydration research being a very lonely field. The health chatter was all about fat and carbs; children routinely subsisted on a single pouch of Capri Sun a day. Even athletes were discouraged from sipping on fields and race tracks, lest the excess liquid slow them down. “I can’t tell you how many people told me I was stupid,” Stookey told me, for being one of water’s few advocates.

    But around the turn of the millennium, hydration became an American fixation. Celebrities touted water’s benefits in magazines; branded bottles overran supermarket shelves. Academic research on hydration underwent a mini-boom. After ages of being persistently parched, we were suddenly all drinking, drinking, drinking, because we felt like we should. It was an aquatic about-face—and it didn’t make total scientific sense.

    The importance of hydration, in the abstract, is indisputable. Water keeps our organs chugging and our muscles agile; it helps distribute nutrients through the body and maintains our inner thermostat. Take it away, and cells inevitably die. But the concrete specifics of adequate water intake are still, in large part, a mess. For hydration, “there are no clear numbers, or a threshold you have to maintain,” says Yasuki Sekiguchi, a sports-performance scientist at Texas Tech University. Experts don’t agree on how much water people need, or the best ways to tell when someone should drink; they differ on how to measure hydration, which beverages are adequately hydrating, and how much importance to attribute to thirst. They have yet to reach quorum on what hydration—a process that’s sustained life since its primordial inception—fundamentally is. The murkiness has left the field of hydration research, still relatively young and relatively small, rife with “vicious camps against each other,” says Tamara Hew-Butler, an exercise physiologist at Wayne State University.

    Forget, for instance, one of water’s most persistent myths: the oft-repeated advice to down eight 8-ounce glasses of water each day. No one can say for certain, but one theory is that the idea  sprouted from a misinterpretation of a nutrition document from the 1940s, which stated that 2.5 liters of water a day (that is, approximately 10 8-ounce glasses) was “a suitable allowance for adults” in “most instances.” The guidance also noted, in the very same paragraph, “Most of this quantity is contained in prepared foods.” But the bigger issue is this: Probably no single number for water intake will ever suffice—not for a population of people with varying weights, genetics, diets, and activity levels, living in varying climates. Even within an individual, what’s best will change through a lifetime. The answer to How much water should I be drinking? is invariably Uh, it really depends.


    Today’s hydration zeitgeist seems to hold that no amount of water is too much. The market teems with intake-tracking smartphone apps and time-stamped bottles that cheer drinkers toward hydration goals as high as a gallon a day—a quota astronomical enough to be stressful, even dangerous, should people flood their bodies all at once. But America’s hydration hype machine “has established a narrative that we are all walking around dehydrated, and need to drink more,” Hew-Butler told me. It’s no wonder that some people have reported legitimate anxiety over falling short on water intake.

    No single source sold America on water. But a 2021 episode of the podcast Decoder Ring points to Gatorade as one of the first companies to pitch dehydration as a health problem—while simultaneously offering a cure. The company’s sports drinks were originally billed as thirst-quenchers, designed to stave off performance dips. But by the 1980s, Decoder Ring reported, the Gatorade Sports Science Institute was churning out data that supported the benefits of drinking before the mouth got parched. A decade later, the American College of Sports Medicine was recommending that athletes consume “the maximal amount” of water they could stand to keep down.

    Around the same time, during the fitness craze of the ’70s and ’80s, water was acquiring another identity: the enlightened socialite’s clean drink of choice. When European companies such as Perrier and Evian brought their bottled water to North America, they found a market among those wanting a high-end, calorie- and sweetener-free alternative to sodas, alcohol, and juice. Water “had this healthy, good-for-you halo,” says Michael Bellas, the chair and CEO of the Beverage Marketing Corporation. “There were no negatives.” In 2016, water became the U.S.’s leading bottled beverage, a title it has maintained since.

    As water’s market share grew, so did its mythos. Companies hocked the illusion that their products could make people not just healthier but “sexier and more popular,” Peter Gleick, the author of The Three Ages of Water, told me. Hydration was so clearly vital to life that truth-adjacent ideas about its benefits, many of them pushed by prominent people, were easy to buy. Even concerns over single-use plastic bottles could not slow water’s roll: In response, the world cooked up eco-friendly Yetis, HydroFlasks, and Nalgenes, and made those trendy, too.


    It’s not that water isn’t healthy. There’s just no evidence to show that guzzling tons of water can fix all our ailments. For people prone to kidney stones and UTIs, drinking more has been shown to cut down on risks; as a swap for sugary beverages, it can also help with weight loss. But for a variety of other issues—such as heart disease, metabolic issues, and cancer—the data is often “really mixed,” Hew-Butler told me. Although researchers have sometimes found evidence that dehydration may raise certain conditions’ risks, that doesn’t automatically imply the inverse—that extra water intake then lowers risk from a typical baseline. At very rare extremes, overdoing it on water can kill us, too.

    The connections between hydration and health are shaky enough that health authorities have been reluctant to push a strict recommended daily allowance, like the ones that exist for various vitamins. Instead, the National Academy of Medicine proposes a tentative “adequate intake”: 3.7 liters of total water intake for men, and 2.7 for women (both including hydration from food). Recently, Abigail Colburn, a physiology researcher at Yale, and her colleagues ran an analysis that concluded those figures were sound. Still, the numbers came from population surveys, published in the early aughts, of the amounts that Americans were already drinking—a reflection of how things were, but not necessarily how they should be. And they represent medians within a huge range. Over the years, multiple studies have documented people living, by all appearances healthfully, on daily water budgets that span less than a liter to four, five, or six—sometimes more.

    If researchers don’t agree on how much water is good, they also differ on how little water is bad: the point at which dehydration starts to become a problem—or how long people can linger at that threshold without raising long-term health risks.

    A bit of water loss should be completely fine. Fluid status is, by design, “a constantly changing state,” Colburn told me. When the body doesn’t take in enough water to recoup the liquid it’s lost—as it naturally does throughout the day, via sweat, urine, and breath—the brain releases a hormone called vasopressin that prompts the kidneys to hold onto fluid. The urine gets darker and less voluminous; eventually, blood-salt levels rise, and the mouth and throat ache with thirst. The goal is to get the body to excrete less water out and take more in so we don’t wring our vital tissues dry. Life forms have evolved to tread carefully down this cascade of steps, and the flexibility is built in—much like a rubber band that snaps back after being stretched and released.

    But some researchers have started to worry about repeatedly asking the body to compensate for less than optimal hydration—stretching the band over and over again. The issue isn’t chronic dehydration, Colburn told me, but a subtler precursor state called underhydration, which occurs after a lack of water intake has prompted the body to conserve but before the appearance of signals such as thirst. It’s not clear how worrying teetering on that precipice is. In the same way a rubber band is “designed to stretch,” our fluid balance is built to bounce back, says Evan Johnson, a hydration expert at the University of Wyoming. Over time, though, wear and tear could add up, and resilience could drop.

    Tracking those outcomes gets even more complicated when researchers try to quantify how dehydrated individual people are—another thing that experts can’t agree on. “We really don’t have a gold standard for measuring the all-encompassing term of hydration,” Johnson told me, especially one that’s both simple and cheap, and can account for body water’s constant flux. Which leaves scientists with imperfect proxies. Broadly speaking, there’s a urine camp and a blood camp, Stookey told me. Those in the pee camp tend to be hydration conservatives. A change in urine color or volume, they argue, is an early sign—well in advance of thirst—of impending dehydration. The blood-camp crew is more laissez-faire. Diet, medications, and supplements can all alter the shade of urine, making it a fickle clue; Hew-Butler for instance, defines true dehydration as what happens when the plasma’s gotten saltier than usual, to the point where cells have started to shrink—a sign that retaining water is no longer sufficient, and that the body needs to drink.


    Which camp researchers fall into influences how bad they think America’s hydration problem is. “When you draw blood, most people are within a normal range if they’re not thirsty,” Hew-Butler told me. But Stookey, who’s firmly in the pee camp, contends that a majority of Americans are “walking around dehydrated” and should be drinking far more. Colburn, too, would rather err on the side of heeding urine’s warning signs. By the time thirst kicks in, “you’re already in a dangerous zone,” she told me.

    There can be a middle ground. Sekiguchi, of Texas Tech, told me that for most young, healthy people who are spending plenty of time in the air-conditioned indoors—as so many Americans do—it’s probably fine to just drink when thirsty. (That advice works less well for older people, because the sensation of thirst tends to dull with age.) When specific circumstances shift—a stint of heavy exercise, a week of toasty days—people can take notice, and adjust accordingly.

    But guidelines for typical water intake, under typical conditions, are quickly going out the window as heat waves get more frequent and intense. When temperatures skyrocket and humidity makes otherwise-cooling sweat stick stubbornly on skin, our bodies need more water to keep cool and functional, beyond what thirst alone might dictate. Part of the problem is that thirst vanishes more quickly than the body rehydrates, Sekiguchi told me, which means that people who drink until they think they’re sated tend to replace only a fraction of the fluids that they’ve lost.

    “We’re never going to be able to tell people an exact number,” Colburn told me, for how much to drink. But in reality, many of the healthy people most worried about fine-tuning their hydration to a perfect level are probably among those that least need to fret. The dangers of water tend to happen not in those middle grounds, but at its extremes—especially when failing infrastructure hampers access to water, or contamination makes it undrinkable. Many of the populations that are most vulnerable to dehydration’s effects also happen to be the same groups that probably aren’t getting enough to drink, Johnson told me. While bottled-water markets boom, plenty of pockets of the U.S. still lack consistent access to safe, reliable water from the tap. And the situation is even worse in many places abroad. Perhaps nothing reminds us of water’s power like dramatic deficit: Water, simply, is what keeps us alive.


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    Katherine J. Wu

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  • Think Twice Before Testing Your Hormones at Home

    Think Twice Before Testing Your Hormones at Home

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    Across the internet, a biological scapegoat has emerged for almost any mysterious medical symptom affecting women. Struggling with chronic fatigue, hair loss, brain fog, or dwindling sex drive? When no obvious explanation is at hand, an out-of-whack endocrine system must be to blame. Women have too much cortisol, vloggers and influencers say; or not enough thyroxine, or the wrong ratio of progesterone to estradiol. Social media is brimming with advice from self-proclaimed hormone “gurus” and health coaches; the tag #hormoneimbalance has racked up a staggering 950 million views on TikTok alone.

    Now dozens of start-ups promise to diagnose these imbalances from the comfort of your home. All it takes is the prick of a finger, a urine sample, or a vial of spit. You mail your sample out to a lab or run the test right in your kitchen, no co-pay or doctor visit required. A few days later, you receive a slick lab report and in some cases, a customized treatment plan to alleviate the depression, the insomnia, the feeling of just being off.

    Hormone imbalances can indeed contribute to an array of mental and physical symptoms, and hormone testing overseen by providers is a routine practice in medicine. Doing so remotely could theoretically improve women’s health and access to care. But despite their growing popularity and Amazon-like convenience, at-home hormone tests might cause more problems than they solve. Several women’s-health and hormone specialists told me that remote testing has long been useful for detecting pregnancy and tracking ovulation, but that few, if any, products now for sale have been consistently and rigorously proven to work for broader, newly advertised purposes. Testing kits are marketed as a way of helping women decipher puzzling symptoms or assess their fertility. But experts said that the technology—at least as it stands right now—is unreliable and could have the opposite effect, causing anxiety and confusion instead.

    Mindy Christianson, an ob-gyn and the medical director of the Johns Hopkins Fertility Center, told me that in the best-case scenario, an accurate home hormone test would lead its users to seek out necessary medical care for real medical problems. That’s what happened to Chrissy Rice, a 38-year-old in Georgia. From 2018 to 2022, Rice experienced a racing heart, panic attacks, skin rashes, fatigue, and stomach pain—but her blood work and cardiac tests kept coming back normal. Her doctor chalked her symptoms up to anxiety and prescribed an anxiolytic medication. Rice wasn’t satisfied, so she skipped the meds and ordered a $249 women’s-health-testing kit from a company called Everlywell. The kit, which uses saliva and finger-prick sampling, claims to check for abnormal hormone levels that may be keeping women from “feeling their best.” When Rice’s results lit up with four abnormal readings, she was “honestly relieved,” she told me: It gave her confidence that her symptoms hadn’t all been in her head. When she brought the results to another provider, he ordered more tests and eventually diagnosed her with an autoimmune condition called Hashimoto’s, for which she’s since been treated.

    Rice’s success story relied on a lot of things going right: The test correctly flagged that something about Rice’s body chemistry had gone awry. (In this case, #hormoneimbalance really did apply.) In response, Rice used her results to advocate for appropriate care from a trusted health provider. But not everyone is so lucky.

    Tests like the one Rice took rely on processes that have not yet been rigorously validated in clinical trials. Where traditional hormone testing involves in-person blood draws followed by a highly sensitive and specific process called liquid chromatography–tandem mass spectrometry, home tests typically use dried urine, dried blood, or saliva sampling and a variety of techniques for measuring what’s in those samples. Women have, of course, been peeing on pregnancy-testing sticks since the 1980s. But these tests work well because the target hormone is present at relatively high levels, and should be found only during pregnancy. By contrast, hormones such as estradiol, testosterone, and progesterone—which are commonly targeted by this new wave of start-ups’ tests—regularly circulate throughout the body during various stages of a woman’s life, and are far trickier to measure using the low-volume samples involved in dried urine, dried blood, and saliva tests.

    A handful of small studies from the past three decades (many of which are funded by direct-to-consumer testing companies or conducted by their employees) suggest that these methods may be accurate. Jennifer Conti, an ob-gyn physician and professor at the Stanford University School of Medicine who advises the home-hormone-testing start-up Modern Fertility, told me that the company’s internal data, especially a study published in the peer-reviewed journal Obstetrics & Gynecology in 2019, convinced her that its technology was useful for consumers who want to make more informed family-planning decisions. “But this idea that at-home testing is a godsend is not true,” Conti said. “It’s something that can be very helpful right now for a certain population of people to open the door and start a conversation.”

    Other experts still aren’t confident that the tests are worthwhile. I asked Andrea Dunaif, a professor and specialist in endocrinology and women’s health at Mount Sinai, and Hershel Raff, an endocrinology and molecular-medicine expert at the Medical College of Wisconsin, to review the 2019 study. According to the study’s authors, their findings suggest that Modern Fertility’s finger-stick testing methods can be used interchangeably with traditional blood draws to measure fertility-related hormones. But Dunaif and Raff pointed out a laundry list of methodological issues that they argue limit the power of the findings: The type of assay used isn’t accurate for determining testosterone or estradiol levels in women. Researchers didn’t use appropriate hormone-level ranges to test accuracy. Samples were analyzed within 48 hours—a timeline that doesn’t match up with real-world shipping. (Current leadership and members of Modern Fertility’s clinical-research team declined multiple requests for comment. But Erin Burke, a clinical researcher who co-authored the study and is no longer working for Modern Fertility, said she stands by the data. She told me that the team’s work shows that these testing methods are accurate and precise.)

    Although many experts see minimal data to support their use, at-home tests can still be sold on account of a regulatory loophole: The FDA does not typically review what it calls “low risk general wellness” products before they hit the market. Some endocrinologists advise looking for home hormone tests with a certification from the Clinical Laboratory Improvement Amendments program (which is legally required for every direct-to-consumer testing company) or the College of American Pathologists, both of which ensure that a company’s labs maintain certain quality standards and undergo regular inspections. But Dunaif told me the certifications don’t guarantee precise results. She would never recommend that consumers use a currently available product for testing women’s sex steroid hormones remotely, she said, arguing that people will waste money and likely get information that is either “falsely reassuring or falsely distressing.” (Dunaif recently consulted for Quest Diagnostics, a large clinical-lab chain that doesn’t offer home hormone tests.)

    Charlotte, a New Jersey woman in her mid-30s, experienced the muddle of uncertain results firsthand. (I’m identifying her by only her first name to protect her medical privacy.) In 2021, Charlotte ordered a hormone panel from Modern Fertility after she began experiencing irregular periods. Her results showed an abnormally high level of prolactin, a hormone involved in ovulation and lactation, which made her think she might be infertile. Charlotte spent days scouring the internet for information while she waited to discuss the results with her doctor. When she finally showed her ob-gyn the Modern Fertility report, the doctor was incredulous. She basically dismissed the at-home results out of hand, and instead put Charlotte on progesterone. A few months later, Charlotte got pregnant.

    Like Rice’s home test, Charlotte’s helped her start a conversation with a trusted health-care provider and develop a plan. But Charlotte told me that the process wasn’t worth the panic-filled waiting game and desperate Googling. She wishes she’d skipped the home test and consulted her doctor first.

    Even when home hormone tests are accurate, their results are not diagnostic on their own. Drawing a straight line from hormone levels to a diagnosis is impossible without a medical history or physical exam; a user can’t predict her chances of pregnancy, for example, solely based on measurements of her fertility-related hormones. Nor would low levels of, say, estradiol or progesterone be enough to indicate endometriosis. Most people’s symptoms aren’t tied directly to a hormone imbalance, says Stephanie Faubion, the director of the Mayo Clinic Center for Women’s Health and the medical director of the North American Menopause Society. The more than 50 chemical messengers that coordinate all kinds of processes, including metabolism, reproduction, and mood, are constantly fluctuating and difficult to measure with a quick-hit hormone test, Faubion told me; people’s symptoms may be attributable to multiple interrelated factors. “Just checking a hormone level and saying Here’s your problem doesn’t serve women well,” she said. “It’s oversimplifying an issue.”

    Some companies offer physician-reviewed reports, chat services, or phone calls with health providers to clarify any confusion. But Mary Jane Minkin, a gynecologist, menopause expert, and clinical professor at Yale School of Medicine, told me that those services might not be enough to curb misinterpretation, especially if test results aren’t reliable. Minkin worried that users may make drastic lifestyle changes or take off-the-shelf supplements. Christianson, of the Johns Hopkins Fertility Center, said that a growing number of her patients visit her clinic believing they are infertile or in premature menopause based on abnormal readings, when it’s not true. Others are rushing to freeze their eggs unnecessarily. And Faubion worries that providers, too, might use tests that aren’t evidence-based to make decisions about hormone therapy for patients. Some testing start-ups already offer personalized treatment plans and bioidentical hormone-replacement therapy via telehealth based on a user’s results.

    Other experts had the opposite concern: that women whose home-test results appear normal would miss out on crucial interventions. Christianson told me that she’s seen men skip out on necessary infertility evaluations based on at-home semen tests. Women could end up making similar mistakes. And Dunaif said that women experiencing chronically irregular periods might be falsely reassured by a home hormone test and delay needed treatment for endocrine disorders or polycystic ovarian syndrome (PCOS).

    At-home-hormone-testing companies aim to solve a pressing demand for clarity and control as women address their medical needs. If women have been tempted to blame their hormones for anything that’s wrong, that’s at least partly because they aren’t receiving sufficient guidance from doctors. For decades, female patients have been dismissed, misdiagnosed, and mistreated by their health providers more than male patients have. Far less clinical research has been conducted on women than men, which can make health care a guessing game. A diagnosis for a hormone disorder such as PCOS or endometriosis typically takes consultations with several doctors across two to 10 years. Plus, traditional hormone testing can be expensive, and specialists are difficult to find. Only 1,700 reproductive endocrinologists and 2,000 menopause specialists practice in the United States; fertility clinics are rare outside cities.

    In an ideal world, women wouldn’t feel the need to circumvent their doctors to test their hormones at home. But as it stands, many are desperate for answers, and direct-to-consumer testing companies are responding to their frustrations. Someday, the tests might help point users to the appropriate specialist, provide useful information for women in medical deserts, or enable people to better monitor chronic conditions for which the relevant hormones are simple to measure. But until they are rigorously evaluated, women are left with imperfect choices.

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    Ali Pattillo

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