Above-normal water intake may be harmful for your bladder…and the planet

Rainfall on the bus window en route from Manila to Baguio City, Philippines. In the background — roadside debris, open field and trees, and part of a small market

By Aldene Zeno, MD

I am amazed how American culture is inundated with messaging to hydrate. It seems that the marketing I grew up with around drinking milk has evolved to push water. Water comes in so many forms now — alkaline water, flavored water, water with probiotics, caffeinated water, carbonated or mineral water, and in many cases, some combination of all the above.

Despite all of the water options, Americans are not any healthier for it. In fact, more people live with obesity now than ever in the past two decades, according to the CDC, despite our increasing water consumption and messaging that water is so healthy that it may make you lose weight. And yet, many of my patients swear that their doctor has encouraged them to drink so many ounces of water per day, or if it’s not their doctor, then their nutritionist or health coach. There are a few diseases where overly-hydrating is important. For the most part, a healthy body will tell you when to drink — it’s called thirst.

Water intake directly links to bladder health

I care about proper hydration because many of my patients suffer from a condition called overactive bladder (OAB). OAB is characterized by frequent urination and the urgent need to urinate which cannot be suppressed and sometimes causes leaking. Some people also have these issues at night time, to the point that they cannot sleep. It tends to be more common in younger women, particularly during pregnancy and peri-menopause. However, as we age it has a similar prevalence among older men and women. There are many causes, including hormonal issues, pelvic floor muscle problems, and bladder nerve miscommunications. However, over-hydration is a common culprit.

Over the years I’ve heard many versions of absurd fluid intake. I had one patient drinking 10 beers a day. Many of my patients on high liquid diets drink their weight in ounces, or half their weight in ounces, in addition to other soups, shakes or smoothies. I also remember a patient who drank 2 liters of soda daily, and it was typically caffeinated. A common American misconception is the need to drink eight, 8 oz glasses of water daily. If one chooses to drink large volumes of fluid daily and doesn’t have bladder bother, then it’s not a problem. But once you make it into my office, I cannot, in good faith, condone high fluid intake while also trying to treat your bladder leaks.

Where does the notion of high fluid intake come from?

This review article underscores how no scientific evidence to date supports fluid intake based on a given volume. When patients ask me, “How much water should I drink every day,” here’s my typical response: 1) Drink when thirsty. 2) A typical adult drinks about 3–4 bottles of water per day (about 48–64oz or 1.5–2L daily). Typical adults are fairly sedentary (at least in the U.S.), so that fluid intake may vary based on your climate and activity level.

“Water requirement equations should be used as a guide only while employing additional means (such as monitoring short-term weight changes, physical or biochemical parameters and urine output volumes) to ensure the adequacy of water provision in clinical or health-care settings.” — European Journal of Clinical Nutrition, 2012

Origins for water-drinking equations are hard to find. Many of my friends in fitness advocate drinking a gallon of water per day or your body weight in water daily. The source for these recommendations and evidence behind them are limited according to the review article cited above.

Messaging behind water is confusing, though, because many doctors and other experts give advice about it without much evidence to back it up. In this article from Johns Hopkins, a physician describes several benefits from water. However, if the reader just stops at the title, “Yes, Drinking More Water May Help You Lose Weight,” one would conclude that more water is good. The details are much more nuanced. When reading further, the article is full of great, evidence-based recommendations including the following:

“The majority of healthy people adequately meet their daily hydration needs by letting thirst be their guide…”

How may your high volume, bottled water intake harm the planet?

I’m currently in the Philippines visiting family, and despite water being everywhere, it is a precious, limited resource. The Philippines is made of several islands — most people here are surrounded by water. Where I am near Baguio City it is rainy season, and a deluge begins around midday everyday. I hear a swollen river down the hill. Lush greenery speaks to the abundant rainfall in this area. And yet, getting clean, drinkable water is becoming increasingly difficult as overcrowding, poor waste management, and industrialization increase.

My first time here I was 12 or 13 years old. My family here at the time captured rain water and developed a complex system to use it for bathing, washing dishes, and laundry. As more family members became educated and employed, they eventually moved to housing with running water pumped from wells. As I come every 3–5 years, I see more houses built in the area, more retail, and more people. I also smell more pollution from the autos mostly reliant on diesel fuel. More trash litter the streams. More urban sprawl up in the mountains and more urban environmental issues, too.

Plastic water bottle waste is a well-documented crisis, and most of it ends up in landfills or our oceans. My first exposure to the magnitude of this issue was as a child, seeing people living in giant trash heaps in the Philippines. Tens of thousands of Filipinos derive their livelihoods from and even live in mountains of trash near the capital, as detailed here. Sadly, most bottles get trashed because only a fraction of water bottles get placed in recycling. Less than half of recylcing is actually recycled, according to National Geographic. Additionally, plastic bottles and jars represent 75% of all plastic waste in the U.S.

“We’ve become a society that seems to think if we don’t have water at hand, terrible things will happen. It’s kind of silly. It’s not as though anybody died from thirst in the old days”…(Peter Gleick, co-founder and president emeritus of the Pacific Institute in Oakland, California)

But what if I don’t want/can’t drink tap water?

Access to safe drinking water is a major issue in third-world countries. For people in this situation, bottled water is the only safe water. Here, in the Philippines, many people burn their own trash in rural areas if they’re responsible. Otherwise the trash flows into the streams and surrounding areas. Human waste is still disposed into septic tanks, or sometimes, into surrounding areas, with little oversight from local governments. All of this waste ends up in the ground water. The ability to pipe water over land is a challenge facing many countries.

These same issues are starting to hit parts of the U.S. Nearly one million Californians have unsafe drinking water, according to a recent audit. The Flint water crisis highlighted how unsafe drinking water tends to hit communities of color and other disadvantaged areas. Without drastic changes, we may see these issues become more commonplace.

For those that absolutely do not have access to safe drinking water, options may be to treat the water at home. So far I’ve seen here in the Philippines water filters, UV light treatment devices, and I’ve also encountered iodine tablets and good old boiling the water. However, on the go, bottled water may be the only solution. It is up to our international will, as well as governments at all levels, to continue to work toward safe drinking options for their citizens.

For the majority of people in the U.S., bottled drinking water is simply convenience or a taste preference. I’m no saint when it comes to being responsible with my plastic use, though I try my best. Even writing this article is a good reminder to me to carry my reusable water bottle with me and drink responsibly. I also do my best to recycle — again, not perfect with this. Despite knowing a lot of plastic bottles end up in landfills, I try my best with the info I have to get the bottle recycled and reused.

You may not need as much water as you think, and that may be good for the planet

I hope everyone can broaden their understanding when it comes to personal water consumption and bladder health. The retailed water industry has become the number one bottled beverage worldwide. There is a concerted effort to market water without evidence that we need to hydrate beyond just satisfying our thirst. That messaging has unfortunately infiltrated well-meaning professionals in healthcare, fitness, and nutrition. Hydration is key, no doubt, but not at the expense of frequent urination, uncontrolled bladder urges, or other overactive bladder symptoms. Our daily water needs come from other sources such as fruits/vegetables, soups, and other beverages. Sadly, as water intake increases among our growing world population, so has our bottled water usage.

For those of us with access to safe tap water, we have a responsibility to minimize our plastic use. Bottled beverages are the primary plastic waste culprit. Worldwide and even in parts of the U.S., some legitimately have no sanitary drinking water aside from water in single-use plastics. I hope there’s the will for us as a society to change that. We all have a role in advocating for safe water access, more effective recycling, and policies that support those endeavors.