Image via @statsguyuk

Image via @statsguyuk

A recent case report in BMJ Case Reports tells the story of a 47 year old healthy woman who decided to do a New Year’s detox and wound up in intensive care:

A 47-year-old woman presented with seizures secondary to euvolaemic hyponatraemia. A collateral history revealed recent increased oral fluid intake and increased use of herbal remedies including valerian root over the New Year period. There was no history of psychiatric disease to support psychogenic polydipsia. She responded to careful sodium replacement in the intensive care unit and was discharged with no neurological sequelae.

It seems about once a year we remind our readers that detox is a scam. The basic idea is that modern life results in the accumulation of “toxins” in your body, and every now and then you should have a tune up by flushing those toxins out. The specific toxins are never mentioned. There is also no basic science reason or clinical evidence to support the notion that the methods recommended actually remove any specific toxins from the body.

Of course we are assaulted by toxins on a daily basis. Everything is potentially a toxin – as the saying goes, the dose makes the poison. Some things are toxic at tiny doses while others would require a significant dose to cause problems. Even water is toxic at high enough dose (usually around 10 liters or more per day).

The natural world basically wants to kill us. Plants evolved toxins to protect themselves from being eaten, for example. That is why animals evolved mechanisms to process and remove toxins that get into their system. One primary function of our livers, which are giant chemical factories, is to filter anything potentially toxic from the blood, metabolize it, and excrete it. Toxins are also filtered from the blood by the kidneys, and excreted in the urine. A healthy liver and pair of kidneys are all most of us need to sufficiently “detox.”

Problems arise when the liver or kidneys are not healthy enough to do their job, or if you ingest a poison in a sufficient dose to overwhelm these organs.

Sometimes people deliberately expose themselves to harmful levels of a drug (alcohol, for example), and may need to be legitimately “detoxed” from that drug.

The detox scam

The term “detox,” however, has been hijacked for clever marketing of worthless products and treatments. Like much of what happens under the umbrella of so-called alternative medicine, a successful marketing slogan is more important than science or evidence. “Detox” is now frequently attached to many dubious treatments as a handwaving explanation for how they allegedly work. This is often the case, where a new idea is retrofitted onto an old treatment. In fact the treatments rarely change, but the justification for them evolves to optimize marketing.

Some detox treatments include coffee enemas, with the idea that many toxins get clogged up in the colon. Other “colon cleanse” products are meant to be consumed orally. This is as unnecessary as “detox.” The colon removes waste on its own – that’s what it does.

You can also detox (by which I mean waste your time and money accomplishing nothing) by soaking your feet in a bath. They may use some kind of salt or even gentle electric current to draw out the toxins. Offered as evidence that the foot baths are working, the water will become dark over time. This is simply a result of corrosion of the electrodes in the salt solution. Detox foot pads are similar, and also offer discoloration of the pads as evidence they are working. The color change there is likely due to chemicals contained in the pads which simply oxidize.

The changing color is a simple parlor trick meant to deceive the unwary, and in both cases the water or pad will change color even if they never go near your feet. You can’t really remove significant toxins through the skin, and most of the chemicals you would want to remove are colorless.

One popular component of detox regimens, as with the case reported here, is drinking lots of water, as much as 60 liters. This is far more than is safe, and is more than enough to cause hyponatremia, which is a dangerously low sodium level in the blood. Animals evolved elaborate mechanisms to maintain electrolytes, water, and other substances in the blood and body in proper amounts. We drink when our bodies need more water, and our kidneys can concentrate the urine over a wide range to keep electrolytes like sodium within an optimal range. It takes effort to overwhelm this system in a healthy individual.

As an aside, the notion that we can do better than evolution in managing our fluid and electrolyte status is naïve. For most people in most situations, you should drink when you are thirsty. Your body knows how much fluid it needs. If you are going to be in an extreme situation (heat, dry environment, high altitude, athletic performance) then you could benefit from staying ahead of your fluid and electrolyte needs because dehydration can happen quickly. Otherwise, just listen to your thirst.

If you try to override your thirst by forcing fluid intake, your body can adjust (you will just pee out the excess) – but these mechanisms have limits. There is a minimum amount of electrolytes that pass through the urine. So if you drink too much water, you can overwhelm your kidneys’ ability to maintain a sufficient concentration of electrolytes like sodium. What you will be flushing out of your body is mainly salt. The result will be hyponatremia.

I have treated several cases of self-induced hyponatremia over the years, mostly due to primary polydipsia (drinking too much water). In one case a patient increased their water intake and was also taking a supplement called tri salts, which contains magnesium, calcium, and potassium. The kidneys had to get rid of the unnecessary and excess salts, and in doing so they also eliminated sodium. The result was hyponatremia.

Hyponatremia is extremely dangerous. It can cause delirium, and even seizures. There is also a risk of correcting the low sodium too quickly, which can cause brain damage.

Sometimes detox regimens include herbal remedies. As we have discussed many times before, herbs are drugs. They typically contain many potential active ingredients in variable doses, making their effects difficult to predict. The herbal industry is also poorly regulated, leading to a high risk of substitution, contamination, and adulteration.

Even when the bottle contains what is on the label, we generally have a dearth of information about all the risks and effects of the poorly-regulated drugs.

This brings us back to the current case report. The patient did increase their fluid intake, but according to the case report, not enough by itself to explain the hyponatremia. The authors can only speculate about what other factors were at work, and their attention turned to the many herbal supplements she included in her regimen. It is possible that one or more of the herbal drugs are diuretics, which themselves can contribute to hyponatremia.

The authors found another case report of a man who suffered hyponatremia after taking herbal drugs. The one herbal product that the two cases have in common is valerian root. Valerian root is known to be a diuretic, so this is a possible mechanism.

The lesson

There are several lessons we can take from this case and others like it. The big one, in my opinion, is the realization that there are two worlds out there. There is the medical world which is based on science and evidence, and strives for a coherent understanding of health, disease, and medication interventions. This exists alongside an “alternative” world which is not built upon logic and evidence, but upon marketing of appealing and simplistic narratives.

The notion of a “detox” treatment is one such narrative. It is not based on our understanding of biology or medicine, and in fact runs contrary to it. Detox treatments are entirely unnecessary, and should not be assumed to be benign.

Another lesson is that we cannot simplistically hack our health and think that we can do better than the elaborate feedback systems that evolved to maintain optimal physiology. This applies to many claims within so-called alternative medicine – taking megadoses of vitamins, shifting the balance of oxidative compounds, or drinking more than our bodies seem to want.

Finally, we should not assume that any intervention “can’t hurt.” As a matter of principle, if something can help, then it can also hurt. No intervention is entirely benign. That is part of the CAM narrative, however, that treatments which are “natural” are magically risk free. This and other cases prove otherwise.

All interventions should be considered in the context of risk vs benefit, with the best evidence available being the guide.

Detox treatments have no benefit, and as this case illustrates they also have risk. Stay away.



Posted by Steven Novella