What We Drink
“Salud,” “L’Chaim,” “Sláinte.” In countries around the world, when you drink, you often toast to your health and the health of your friends. What you drink is as important as what you eat, and it can have a large impact on your overall health. We have more beverage options now than we ever have before in human history. This clinical tool reviews some of the research on the different things we drink and offers suggestions on how we can drink for optimal Whole Health.
Around 21% of our daily caloric intake comes in the form of beverages. This is about 500 calories a day for a moderately active male in the United States. If you are looking for a single piece of advice to give patients who want to lose weight, this is a low-hanging fruit: changing what you drink has a powerful effect on weight loss.
By cutting out or minimizing the amount of soda, sweetened tea or coffee, juice, alcohol, energy drinks, milk (yes, milk), or smoothies you drink in a day, people cannot only improve their health, but they can also decrease their total caloric intake. More nutritious options include water, of course, but also unsweetened teas (e.g., herbal, green, or black), coffee, and wine or beer (in moderation). The ideal amount of liquid to drink in a day varies from person to person. The standard recommendation is 64 ounces of water (or eight 8-ounce cups daily), but this has not yet been confirmed by research findings.
People may require more or less if they are very active; live in a hot, dry climate; or have a medical condition that causes them to retain fluid. If someone is thirsty, he or she is already showing signs of early dehydration. Another good guide to assess for hydration is if one is passing colorless or clear urine every 2-3 hours. If your urine is too yellow, drink more!
More on Specific Beverages
Pure water is the world’s first and foremost medicine. —Slovakian proverb
Water is the second most popular beverage in the United States (second to soda but ahead of beer). Water is the perfect drink because it has no calories and no additives, and, when enjoyed from the tap, it costs very, very little (fractions of a penny per cup). There is no regulation on bottled water. Although a bottle of water has a picture of water bubbling down a mountain stream, it does not mean that water came from a mountain stream. It may have actually come from the tap, as 25% of bottled water does. Any water source that flows naturally to the earth’s surface may be called spring water regardless of location.
Unless their home water is somehow unsafe, it might be wisest for people to do the environment and their checkbooks a favor and not buy bottled water. Tap water is actually much more closely monitored for safety than bottled water. In general, there is no evidence that using bottled or filtered water prevents disease in immunocompetent people. The Environmental Working Group website is a wonderful resource for information about water safety, water in your area, different water filters, and bottled water grades.
By now, most people are aware of the cardiovascular benefits of drinking red wine, which came to light largely in the 1990s after 60 Minutes did a health report on “The French Paradox.” This research has been reproduced in many different populations with the same results; it is thought that resveratrol, a phenol found in the skin of grapes, plays an important role in wine’s health benefits. More surprising is that further studies have shown that beer also has health benefits. While there is not a huge body of evidence, some early studies indicate it is cardioprotective and that it also has more B vitamins and protein than wine, as well as a different flavonoid profile.
One important detail that came from studies on the benefit of red wine consumption is the presence of a J- or U-shaped curve that indicates a health benefit from alcoholic beverages only for those who drink modestly—1 drink daily for women and 2 drinks daily for men. Those who abstained from alcohol and those who drank in excess of those quantities had poorer health outcomes. If your patients drink alcohol, encourage them to drink in moderation and carefully monitor them for signs of misuse or overconsumption. It is generally not recommended that clinicians encourage a patient to begin drinking for health benefits if they do not drink in the first place.
Tea is a delightful way to begin or end the day. Herbal teas are flavorful, and many of them offer health benefits. Green tea seems to be helpful for preventing multiple cancers and all-cause mortality. Extracts have even been found helpful for treating genital warts.9 It is thought that the health benefits of green tea come from the polyphenols and catechins found in the tea leaves.
Examples of herbal teas that are generally recognized as safe and their potential uses are listed in the section below.
Herbal Teas and Their Medicinal Uses[10,11]
- Chamomile (can be enjoyed with lemon balm or valerian, which also have sedative properties)
- Cassia cinnamon
- Stinging nettle
- Sedative, anxiolytic; used to treat diarrhea and colic in infants
- Treats flatulence, lowers blood glucose and lipids, is an appetite stimulant
- Postoperative nausea and vomiting, arthritis, migraine
- Benign prostatic hypertrophy, diuretic effects
- Digestive aid, irritable bowel syndrome (when enterically coated), tension headache
Coffee may confer some health benefits, particularly for the prevention of type 2 diabetes, Parkinson’s disease, colorectal cancer, and hepatocellular cancer. Previous studies linking coffee to cancer had methodological flaws and did not account for the fact that many of those studied who drank coffee were also smokers. A recent meta-analysis showed an inverse relationship between coffee consumption and prostate cancer, as well as no evidence of increased risk of renal or bladder cancers.
When taken in excess (5-10 cups/day), coffee (and caffeine) can cause insomnia and anxiety, and it can increase risk for coronary heart disease (CHD) and myocardial infarction (MI), though the most recent meta-analysis for the data on coffee and CHD/MI is over 20 years old. Data has not shown that drinking a moderate amount of coffee puts one at increased risk of arrhythmia or sudden death. The relationship between caffeine and osteoporosis is unclear at this time, as data has been conflicting. It appears that caffeine inhibits some calcium absorption. It has been recommended that women limit coffee to 3 cups daily (or the equivalent of 300 mg of caffeine) and make certain they get adequate calcium and vitamin D from their diet. There has been considerable debate over drinking coffee or consuming caffeine during pregnancy and the risk of spontaneous abortion. Recent epidemiological reviews did not demonstrate a causal relationship between coffee and spontaneous abortion. The American Board of Obstetrics and Gynecology states that consuming 2 cups or less of coffee per day is safe during pregnancy.
Milk is one way to get calcium, but carries with it a lot of extra calories and saturated fat. Also, 50 million adults in the United States cannot digest milk due to lactose intolerance. It is possible to get plenty of calcium from foods other than milk, such as fortified cereals, greens, tofu, sweet potatoes, or garbanzo beans.
Over the years, cows have been bred for increased milk production, and they are now routinely milked far into pregnancy. This means that there are more hormones (e.g., estrogen, progesterone, androgens, and insulin-like growth factors) in the milk we drink now, as well as more antibiotics. Organic milk will not necessarily have lower hormone levels, but there may be differences based on the diet of the cows. There are also hormone-free milk options that are available. Some sources of them use recombinant bovine somatotropin, held to be a safe way of augmenting milk production. It is perhaps best to consider milk and dairy as an optional part of the diet, depending on the availability of alternate calcium sources.
When taken in moderation, juice offers a way to quench thirst with the added benefit of vitamins and minerals and a small amount of fiber. When buying prepared juices, a person should look at the label to be sure there are not any added sweeteners. Research has shown that people still eat the same amount of calories as food, regardless of the amount of beverage calories they drink. This means that if juice or other high-calorie drinks are enjoyed regularly, it can lead to weight gain over time.
Home juicing has become increasingly popular and is a convenient way to obtain the benefits of fruits and vegetables and their nutrients in beverage form. Typically, juicing removes most of the pulp/fiber from the beverage, while making smoothies allows the pulp to be kept in the drink. Juicing vegetables and fruits oneself (with a blender or more robust juicer) allows a person to derive greater nutritional benefit than would be gained from buying a similar product from the store. Part of the reason for this is that homemade juice is not pasteurized. If homemade juices are prepared in a clean environment, they should be safe for consumption the same day. Juicing can destroy some of the polyphenols (chemicals with antioxidant properties) in fruits and vegetables, so drinking juice may not be as healthy as eating whole fruits and vegetables, but it is much better than no fruit at all.
Soda and energy drinks
According to the Beverage Marketing Corporation, Americans, on average, drink around 44.7 gallons of carbonated soft drinks annually. That equates to 40 (12-can) cases per year and almost a gallon of soda per person per week. Multiple studies have shown a relationship between sugar-sweetened beverages and metabolic syndrome, caries, osteoporosis, gout, and insulin resistance.[22,23] There is no health benefit from drinking these beverages. Encourage your patients to avoid them altogether. Even diet sodas are not recommended as an alternative.
Since their introduction to the market in 1997, energy drinks have become increasingly popular with young adults, and those in the military consume more energy drinks than the civilian population. In contrast to soda and coffee, which contain approximately 35 mg of caffeine per can and 150 mg caffeine per cup, energy drinks may contain levels of 500 mg of caffeine or more, as well as sweeteners and other herbal supplements. Supplements frequently added to these beverages include bitter orange, guarine, ephedra, yohimbine, taurine, and 5-hydroxytryptophan, which can interact with medications and have other side effects.
Excessive amounts of caffeine can lead to long-term health effects and adverse reactions such as anxiety, insomnia, tachycardia, caffeine intoxication syndrome, and caffeine withdrawal. An Australian study found an association between energy drink consumption and increased anxiety in males, but not depression or stress. Data on whether energy drinks improve reaction time, promote weight loss, or boost performance, mood, and concentration are conflicting. Athletic performance improvements have been attributed to caffeine and glucose.[26,27]
- Nielsen SJ, Popkin BM. Changes in beverage intake between 1977 and 2001. Am J Prev Med. 2004;27(3):205-210.
- United States Department of Agriculture Economic Research Service. Food availability: spreadsheets. http://www.ers.usda.gov/Data/FoodConsumption/FoodAvailSpreadsheets.htm#beverage. Published 2008. Accessed April 28.
- Olson ED. Bottled water: pure drink or pure hype? http://www.nrdc.org/water/drinking/bw/bwinx.asp. Published 2014. Accessed June 2.
- Kopp P. Resveratrol, a phytoestrogen found in red wine. A possible explanation for the conundrum of the’French paradox’? European Journal of Endocrinology. 1998;138(6):619-620.
- United States Department of Agriculture. USDA nutrient database for standard reference, release 13. http://www.nal.usda.gov/fnic/foodcomp/Data/index.html.
- Madigan D, McMurrough I, Smyth MR. Determination of proanthocyanidins and catechins in beer and barley by high-performance liquid chromatography with dual-electrode electrochemical detection. Analyst. 1994;119(5):863-868.
- Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ. 2011;342.
- Kuriyama S, Shimazu T, Ohmori K, et al. Green tea consumption and mortality due to cardiovascular disease, cancer, and all causes in Japan: the Ohsaki study. JAMA. 2006;296(10):1255-1265.
- Tatti S, Swinehart JM, Thielert C, Tawfik H, Mescheder A, Beutner KR. Sinecatechins, a defined green tea extract, in the treatment of external anogenital warts: a randomized controlled trial. Obstetrics & Gynecology. 2008;111(6):1371-1379.
- Jellin JM, Gregory P. Pharmacist’s Letter, Prescriber’s Letter Natural Medicines Comprehensive Database. 9th ed. Stockton, CA: Therapeutic Research Faculty; 2007.
- Wagner S, Rakel D. Medicinal Uses for Herbal Teas: Evidence, Dosing, and Preparation Methods. 2007; University of Wisconsin Integrative Medicine Department of Family Medicine website. http://www.fammed.wisc.edu/sites/default/files//webfm-uploads/documents/outreach/im/ss_herbal_teas.pdf. Accessed September 11, 2014.
- Salazar-Martinez E, Willett WC, Ascherio A, et al. Coffee consumption and risk for type 2 diabetes mellitus. Ann Intern Med. 2004;140(1):1-8.
- Ascherio A, Weisskopf MG, O’Reilly EJ, et al. Coffee consumption, gender, and Parkinson’s disease mortality in the cancer prevention study II cohort: the modifying effects of estrogen. Am J Epidemiol. 2004;160(10):977-984.
- Tavani A, La Vecchia C. Coffee, decaffeinated coffee, tea and cancer of the colon and rectum: a review of epidemiological studies, 1990-2003. Cancer Causes Control. 2004;15(8):743-757.
- Gelatti U, Covolo L, Franceschini M, et al. Coffee consumption reduces the risk of hepatocellular carcinoma independently of its aetiology: a case-control study. Journal of hepatology. 2005;42(4):528-534.
- Huang T-b, Guo Z-f, Zhang X-l, et al. Coffee consumption and urologic cancer risk: a meta-analysis of cohort studies. International urology and nephrology. 2014:1-13.
- Myers MG. Caffeine and cardiac arrhythmias. Ann Intern Med. 1991;114(2):147-150.
- Frost L, Vestergaard P. Caffeine and risk of atrial fibrillation or flutter: the Danish Diet, Cancer, and Health Study. Am J Clin Nutr. 2005;81(3):578-582.
- Signorello LB, McLaughlin JK. Maternal caffeine consumption and spontaneous abortion: a review of the epidemiologic evidence. Epidemiology (Cambridge, Mass). 2004;15(2):229-239.
- American College of Obstetricians and Gynecologists (ACOG). Committee opinion #462: Moderate caffeine consumption during pregnancy. 2010; http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Moderate-Caffeine-Consumption-During-Pregnancy. Published 2014. Accessed August 13.
- Flood JE, Roe LS, Rolls BJ. The effect of increased beverage portion size on energy intake at a meal. J Am Diet Assoc. 2006;106(12):1984-1990.
- Malik VS, Popkin BM, Bray GA, Després J-P, Willett WC, Hu FB. Sugar-sweetened beverages and risk of etambolic syndrome and type 2 diabetes: maeta-analysis. Diabetes care. 2010;33(11):2477-2483.
- Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ. 2008;336(7639):309-312.
- Johnson LA, Foster D, McDowell JC. Energy drinks: review of performance benefits, health concerns, and use by military personnel. Mil Med. 2014;179(4):375-380.
- Trapp GS, Allen K, O’Sullivan TA, Robinson M, Jacoby P, Oddy WH. Energy drink consumption is associated with anxiety in Australian young adult males. Depress Anxiety. 2014;31(5):420-428.
- Wilhelm P, Van Diepen M, Nieuwenhuis L, Boulogne T. The effect of energy drinks on the cognitive performance of adolescents. Tijdschrift voor psychiatrie. 2012;55(1):57-62.
- Ballard SL, Wellborn-Kim JJ, Clauson KA. Effects of commercial energy drink consumption on athletic performance and body composition. Physician and sportsmedicine. 2010;38(1):107-117.