A healthy patient of mine called me last week to discuss the “alkaline” diet. I was quite enthusiastic to help him because patient empowerment is extremely important to me. I love the fact that he was doing his own research to try make himself better. What we loosely call “biohacking”. His goal: make himself healthier than healthy, and resilient to disease and aging. He heard that if he consumed baking soda (an alkaline), it could lower the acidity in his body. This could help digestion, buffer the lactic acid from exercise, prevent cancer, etc. Surprisingly, he didn’t really want to ask me if it worked. I think he was already convinced of that. He really just wanted my help choosing an appropriate dosage.
Biohacking - a DIY approach to health with the goal of making yourself healthier than healthy, and resilient to disease and aging
I found it strange that he seemed so confident about these claims. I don’t even feel comfortable messing around with the pH of my pool, let alone my body. Actually, he is not alone. The alkaline diet is quite commonly mentioned in social media. Many products, such as alkaline water and special water filters, are sold under its premises. A plethora of biohackers, integrative medicine doctors, chiropractors, massage therapists, yoga instructors, Tony Robbins, personal trainers, and other YouTube health influencers recommend it. They all seem to feel comfortable messing around with the acid/base balance of the body. Yet, Internal Medicine doctors like myself and experts in physiology are not. How can this be?
The answer: science-based doctors understand that the human body is a complex system and approach the human body with holistic thinking. Yes, holistic thinking. Surprised at that answer? Isn’t science accused of “reductionist” thinking? Let me explain what a system is, the difference between holism and reductionism, and then apply this to acid/base diets. (You will find learning about systems theory relevant regardless of what field you are interested in. It crosses over into many different disciplines including economics, ecosystems, engineering, city planning, climate science, the internet, and social networks.)
What is a system?
A system is a group of individual parts interconnected to make up a whole. The parts complement each other, work together, and create something greater than their sum. In other words, the whole is greater than the sum of its parts. The whole has properties the parts do not have. These properties are called emergent properties.
A system is a group of individual parts that work together to create something greater than themselves
A car is a system, and it has emergent properties. It has many parts, but none of the parts themselves can provide transportation. Only when the parts are put together can they provide transportation. Thus, transportation is an emergent property of a car. The brain is also a system with emergent properties. A neuron can’t think on its own. Only when it is in a network of billions of neurons in a brain can thought happen. Thus, thought is an emergent property of the brain.
Trying to understand a system and it’s emergent properties by looking at its parts is called reductionist thinking. Trying to understand a system and it’s emergent properties by looking at the whole, is called holistic thinking. (“holistic” should actually be spelled "wholistic", but for unknown reasons is not).
What is a complex system?
A complex system is a system, but it has multiple levels of organization. It has subsystems, and those subsystems have subsystems, etc. The economy, for example, is a complex system with multiple levels of organization. It has subsystems. The world economy is made up of national economies, which are made up of local markets, which are made up of local businesses.
In addition, a complex system is not “designed” like a car is “designed”. Instead, a complex system evolves over time, adapting to changes and stresses in its environment. The economy, for example, was not designed by an individual, but evolved over time. (Notwithstanding any conspiracy theories).
Lastly, a complex system has no central controller; instead, the individual parts respond autonomously to local conditions with a set of simple rules. The economy has no central controller; instead, the individual parts act autonomously and follow supply/demand laws. (Once again, notwithstanding any conspiracy theories). In a termite colony, none of the individual termites have a “master plan”. They each are following a very simple set of rules; yet, the whole colony can build incredible structures.
A complex system has subsystems, evolves over time, and has no central controller
Other examples of complex systems include: ecosystems, cities, the climate, the internet, and social networks.
The human body is a complex system
The human body is another example of a complex system. Probably the best example. It has multiple levels of organization and subsystems. It is made up of organs, and organs are made of different tissue types, and different tissue types are made up of cells, and cells are made up of organelles, and organelles are made up of molecules. There are so many subsystems that we continue to discover new ones every day; such as: the human genome, the epigenome, the microbiome, the brain connectome, and the glymphatic system. We have only just recently begun to explore these new subsystems. How they work, and how they communicate with other subsystems is a great mystery at this point. They add millions of unknown variables to this already complex system. They are currently physiology’s black box.
New subsystems add millions of unknown variables to this already complex system
Like other complex systems, the human body was not designed. It evolved over time adapting to changes and stresses in its environment. It has no “master organ” (men excluded). Instead, it’s individual parts respond autonomously to changes and stresses in the environment. The goal is to keep the system stable - in physiology we call this homeostasis.
Homeostasis works through feedback loops, similar to the thermostat in your house. For example, your body temperature is set at around 98.6 F. If you are put in a hot environment your body will sense this, and try to maintain 98.6 F. It can implement this through one or more of its cooling strategies, including: redirecting the circulation of blood flow to other organs, slowing metabolism, sweating, and even behavior modification (resting). Once the external heat is removed, the cooling strategies are shut down.
Complex systems are inherently unpredictable
On its own, an isolated component of a system is predictable. We say it is “linear”. For example, if we heat up a piece of dead meat - like a steak - the more heat applied, the greater the rise in temperature of the steak. There is a one to one relationship. If we were to plot this relationship on a graph, it would make a straight diagonal line. Hence the term "linear". Linear relationships are predictable, or what is also know as “deterministic” - if we know the present state of the component, we can extrapolate past states and future states.
Complex systems, on the other hand, are interconnected, adaptable, and have many layers of redundancy. Their response is non-linear. If we heat up a human, for example, the body temperature, at first, will not change. Instead, the body will compensate through homeostasis, as mentioned above. However, at some point the system will break down. Given enough heat and time, the body temperature will rise - and the body will go into heat shock.
Complex systems are interconnected, adaptable, and have many layers of redundancy. Their response is non-linear.
When will a complex system break down? This is dependent on the state of thousands or even millions of variables. The ambient humidity, the altitude, how acclimatized you are, how good your kidneys work, how good your heart pumps, how hydrated you are, medications you are on, psychological states, etc. It is unique to the situation and to the individual.
If this wasn't unpredictable enough, system theory makes things even more unpredictable with its corollaries. Chaos theory, and the butterfly effect. These ideas establish that very small changes to the initial state of a system can lead to immensely varied downstream outcomes (chaos theory), and large downstream outcomes (the butterfly effect). This makes complex systems prone to chain reactions and runaway events, such as: market crashes, global warming, or “cytokine storm”. Cytokine storm is a phenomenon of the immune system where it produces too much of a response because it gets stuck in a feedback loop. This is the proposed mechanism for death in COVID - you are ironically killed by your own immune system.
Complex systems are prone to chain reactions and runaway events
The core message is: complex systems are unpredictable, and human physiology has many black boxes. Because of this, it is a mistake to expect an accurate prediction of a complex system, like the human body, by reducing it to only a few of its linear predictable parts. In other words, reductionist thinking often leads to the wrong conclusions in medicine.
(If you are interested in learning more about complex systems and systems theory, this is the first of an excellent and easy-to-understand animated course.)
Applying complex systems theory to acid/base diets
Now that we have a grasp of complex systems theory and holistic thinking, let’s apply it to acid-base diets… What are the effects of adjusting the pH of our food?
The acid/base balance in our body is part of a complex system. The body keeps it under very very tight control. This is because pH balance is fundamental to organic chemistry - the chemistry of living things. All organic molecules are made from carbon and hydrogen. Therefore, somewhere along the path of every reaction in your body there is a transfer of hydrogen atoms. This is where pH comes in; pH is simply a measure of the free hydrogen atoms. Thus, changing the pH can affect literally thousands of chemical reactions in your body. It can speed up or slow down these reactions, and can alter the flux of other essential elements like sodium, potassium, and calcium in and out of the cell. Each of these reactions can consequently affect a cascade of other reactions. And so on and so on.
The body, and all of its reactions, evolved with a pH of 7.4. It desperately tries to maintain the pH at exactly 7.4. There are several built-in autonomous feedback loops to keep the pH in this state of homeostasis. These can be found in the kidneys and lungs. Suppose you ingested a lot of acid, your body could buffer it simply by breathing it out from the lungs. This is because CO2 is a byproduct of carbonic acid. In a matter of minutes, by slightly and imperceptibly increasing your respiratory rate, the pH is kept at 7.4. This system is so robust that the only time we measure a pH in the blood that is not exactly 7.4, is when a patient's organs are failing. Therefore, our first conclusion from systems or holistic thinking is that we cannot adjust the pH of blood with food, even if we tried.
We cannot adjust the pH of blood with food, even if we tried
Suppose for a moment, by some miracle that flies in the face of human physiology, that we WERE able to change blood pH with food. What would be the consequences of changing the blood pH to the rest of the complex system? As mentioned above, changing the pH would potentially affect thousands of chemical pathways and activate thousands of feedback loops. All of which would interact with one another. The net results would be impossible to predict. Therefore, our second conclusion from holistic thinking is that changing the pH of the blood would lead to a cascade of events, impossible to predict.
Changing the pH of the blood would lead to a cascade of events, impossible to predict
How then can we find out the effects of an acid/base diet on a complex system? The answer is actually quite simple. Instead of trying to predict the effects using a couple of isolated pathways in a test tube, or on a chalkboard, we test it out on the whole system. In other words, a clinical trial. In a clinical trial of an acid/base diet, we would give an acid/base diet to the whole system (an entire human), and measure the response of the whole system. Clinical trials are holistic tests of complex systems. Unfortunately, there are no large clinical trials testing acid/base diets. Hence, it would be considered “reductionism” at this point to conclude that any acid/base diet is safe and/or effective.
Clinical trials are holistic tests of complex systems
Applying reductionist thinking to acid/base diets
Reductionist thinking tries to simplify the human body into a single, or a few, simple pathways. It ignores the fact that these pathways are tightly regulated and bathed in thousands of other pathways and feedback loops. This leads to two false conclusions as it pertains to acid/base diets: that blood pH can be changed by changing food pH, and if the blood pH could be changed, the consequences are predictable.
However, it gets much worse. The real problem with reductionist thinking is that there are so many pathways to choose from, and they are so interconnected, that one can derive any conclusion they wish. With just a little bit of creativity, one can explain any disease or justify any treatment using their favorite physiologic pathway.
The real problem with reductionist thinking is that there are so many pathways to choose from, and they are so interconnected, that one can derive any conclusions they wish.
To provide a poignant example of this to my patient, I introduced him to a video by Eric Berg DC, a chiropractor with over 10M subscribers on youtube. He too, uses reductionist thinking with respect to acid/base balance. However, instead of concluding that an alkaline diet is good for you, he derives the exact opposite conclusion. A diet high in acid (from apple cider vinegar) is good for you. (You will notice in the video that he uses only isolated pathways to justify his conclusion. At no point does he mention evidence from a clinical trial.) This demonstrates that reductionist thinking can lead to mutually exclusive conclusions. “An alkaline diet is good for you” - Tony Robbins, and “an acid diet is good for you” - Eric Berg. Obviously, they both can’t be right.
Reductionist thinking can lead to mutually exclusive conclusions
Reductionist thinking has its place
Let me clarify that I am not dismissing reductionist thinking in medicine. In fact, it is one of the most crucial and productive techniques of the scientific method. It has generated the ideas that led to thousands of lifesaving discoveries. We isolate a single variable, investigate it, and it turns out to be THE cause, or THE treatment, for a disease. For instance, Borrelia burgdorferi causes Lyme disease, or vitamin C treats scurvy.
However, we need to bear in mind that most reductionist thinking leads to the wrong conclusions. The success rate of reductionist thinking is dismally low. We know this because most ideas generated by reductionist thinking fail when tested in holistic (clinical) trials. In fact, even in the best of circumstances, only one out of every hundred reductionist ideas are confirmed (I have covered this in prior emails). In other words, the few successes we are familiar with lay on a mountain of failures long forgotten.
The few successes we are familiar with lay on a mountain of failures long forgotten
Therefore, reductionism is a good place to start in medicine. It is a method to generate ideas. Unfortunately, it generates too many ideas. Perhaps, millions of ideas. Most of which are wrong. We must confirm these ideas with clinical trials. In the days before clinical trials reductionism is all we had. But now there are hundreds and thousands of clinical trials. With few exceptions, untested reductionist ideas should be considered antiquated. They should be for “experimental” use only, and reserved for the very ill or dying. You deserve much better. Demand at least a clinical trial from those trying to sell you their ideas, products, or services.
(It is important to note that clinical trials are far from perfect, and vary greatly in quality like anything else. For instance, an anecdote is a clinical trial - a clinical trial of a single person. However, it is a highly unreliable form of evibe. A topic perhaps for another email.)
Summary of acid/base diets
Science-based Internists like myself do not have any headline-worthy statements to make about acid/base diets because:
Acid/base balance is under very tight control in the body and next to impossible to change with diet.
If it could be changed, it would lead to a cascade of thousands of events and feedback loops making prediction of an outcome close to impossible.
Any attempt to predict the effects by isolating a single pathway would likely lead to incorrect conclusions.
The only way to know the response of the whole system would be to study the whole system - perform a clinical trial.
No large trials have been performed testing acid/base diets.
Advice for biohackers
Empowering patients to take health into their own hands is a primary goal of my practice. However, being empowered as a patient also entails knowing your limitations, and learning how to tell information from misinformation. The above exploration into acid/base diets was to demonstrate that we are surrounded by reductionism in medicine. Seeing the human body reduced to its simple parts makes a complex system appear simple. It lulls us into a false sense of confidence, and generates the wrong conclusions (misinformation). It is therefore essential to understand the human body from a holistic perspective. The body is a complex system; and from this, the following basic advice for biohackers can be derived:
Be humble. Don’t mess with the human body unless you really know what you are doing.
Complex systems are extremely difficult to predict.
Do not be enticed by physiologic explanations. They look at a single component in a complex system while ignoring the rest of the system.
At a minimum ask for clinical trials as evidence. Clinical trials are holistic tests of complex systems.
Don’t mess with healthy people - they have the most to lose and the least to gain from experimentation.
If you must mess with the human body, find an expert in that particular field. For example, if you seek information about acid/base physiology, ask someone that has at least formal training in biochemistry and physiology. (Hint - Chiropractors and personal trainers do not have training in acid/base physiology.)
After you have consulted an expert in the field, get a second opinion from an expert in complex systems biology. A doctor that does not look at one organ or one pathway. A doctor that views the body as a complex system and demands holistic trials of complex systems. A holistic doctor, like… your Internist.
Seeing the human body reduced to its simple parts makes a complex system appear simple. It lulls us into a false sense of confidence.
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