Like yesterday's post, this will be a post that references our favorite dubious cancer doctor Stanislaw Burzynski but is not primarily about him. However, given the nature of the subject matter, it is impossible not to think of Burzynski, as comparisons are inevitable. Whereas yesterday all we were dealing with was a rather amusing "award" that Stanislaw Burzynski was awarded by a quack who had somehow conned a prominent Cardinal to give the Church's imprimatur on a Catholic medical order he wanted to resurrect to get other quacks to join, this week we're dealing with a serious subject: Cancer cure testimonials. This particular cancer cure testimonial brings Burzynski to mind for the simple reason that it is virtually identical to a typical Burzynski cancer cure testimonial for a brain cancer patient except that the therapy used was not antineoplastons. It has all the same elements: a child with a brain cancer who underwent conventional therapy with surgery, radiation, and chemotherapy but recurred; parents deciding to choose an "alternative therapy"; and finally a seemingly miraculous "cure." Regular readers of this blog who have seen my posts on Stanislaw Burzynski should be well familiar with the general outlines of such testimonials, but this one is not from a Burzynski patient.
I learned about this young patient from a quack about whom I've written several times over the years. I'm referring, of course, to Robert O. Young, for which every disease (excuse me, "dis-ease") is due to too much acid and the cure is "alkalinization," which is accomplished, or so Young claims, through an "alkaline" diet and lifestyle. Young is a remarkable variety of quack in that to him cancer isn't the problem; to him it's nothing more than a "poisonous acidic liquid" in which normal cells "spoiled by acid," and the tumor is the body's protective reaction to these cells. He also believes that bacteria don't cause sepsis (acid does), that viruses are in reality "molecular acids," and that there is no such thing as good bacteria. (Yes, basically at heart Robert O. Young is a germ theory denialist.) The amusing thing, not to mention evidence of Young's utter lack of understanding of basic human physiology, is that many of the foods Young recommends to "alkalinize" the body are, in fact fairly acidic, particularly citrus fruits. Young, as you might recall, is the quack responsible for treating Kim Tinkham, the woman with breast cancer who appeared on The Oprah Winfrey Show several years ago and announced that she would not use conventional therapy to treat her cancer but would instead rely on The Secret and Robert O. Young. The result was that she died of her disease two and a half years ago.
This time around, the quack is not Robert O. Young, but rather a naturopath named Bernardo Majalca who treated Josie using the same sort of brain dead ideas about human physiology that Young believes, which is probably why Young trumpets her story so proudly:
After having surgery, chemotherapy and radiation, eight year old Josie Nunez’s brain tumor reappeared for a second time and doctors gave her only weeks to live. Her parents searched the internet for anything that could help their daughter and found Dr Bernardo Majalca, a naturopath, who offered them hope as well as a natural cure for Josie.Dr Majalca said that Josie wasn’t dying of cancer but was dying from acidosis, and that only by addressing this issue would her body finally be able to heal. He prescribed an alkalizing diet which included drinking 4 freshly made juices per day, as well as various herbs to help detoxify and rebuild her immune system. He describes more about his treatment plans in the video links below.
The story, word for word, can also be found here and on the family's website. There is also a video describing her story included with both links. I'll embed it here:
Substitute the word "antineoplastons" for "alkaline diet" and the name Bernardo Majalca for Stanislaw Burzynski, and the above testimonial would be indistinguishable from many other Burzynski testimonials. This lets me bring up a point. Majalca's and Young's "alkalinization" are far more obviously quackery than Burzynski's antineoplastons. As I've already conceded many times, it is (or at least was) possible that antineoplastons had significant antitumor activity. I say "was" possible because I think that the evidence over the last several years has pretty conclusively shown that, if antineoplastons do have any anticancer activity at all (which is doubtful), it's minimal. Certainly it's not the magnitude of anticancer activity that would lead Burzynski's treatments to be so incredibly better than conventional treatments for inoperable brain tumors, for example. As far as all the available evidence appears to indicate, they are not. However, regardless of what Burzynski did with antineoplastons, they are chemotherapy. Compared to the utter nonsense and twisting of our understanding of physiology at the heart of the "alkaline lifestyle" as a cure for cancer. If you don't believe that it's utter nonsense, just try watching these two videos by Bernardo Majalca:
Yes, he is telling patients that cancer is "no big deal" and that they're "not going to die from it." He even says that most women get breast cancer because they're angry at men. I kid you not. In fact, he even claims it's the job of cancer to fertilize the egg and create the embryo. Again, I kid you not. As is so frequently the case among quacks, he copiously abuses poor Otto Warburg and says that it's not the cancer that kills patients but the treatments. To "Dr. Bernardo," angry, strong emotions cause acidosis, which causes cancer. My favorite quack claim is that when the body pH is 4.5 you die. Here's a hint for Dr. Bernardo. If your body pH (as in your plasma pH) is less than around 7.0, you're almost certainly dead. I don't recall seeing a patient with a pH below 7.0 who ultimately survived. In fact, as I described in great detail before, the body maintains its pH within a very tight range, usually between 7.35 and 7.45.
Of course, what Dr. Bernardo is referring to is not really the pH within the body. Like most acid-base quacks, Robert O. Young included, all he's referring to is pH of saliva or urine, which is how these quacks measure pH, thinking that these pH measurements are actually reflective of the acid-base status of the body.
If you're not convinced yet about Dr. Bernardo, more quackery follows:
So the claim is that Josie's two remaining tumors in her brain shrank so small that it took 3 MRI sessions at different positions to detect them and that not long after that they were undetectable.
In other words, comparing the results of this particular testimonial with the results of Burzynski's testimonials should tell you something, and that something is very instructive. Basically, the story of Josie Nunez tells us that it is quite possible for a useless therapy to appear effective from time to time even in a very bad brain tumor. Like many of Burzynski's patients, Josie had the full Monty, everything conventional therapy could throw at her tumor: surgical resection, radiation therapy, and chemotherapy. One thing we don't know is what kind of tumor she had. Nowhere have I been able to find a description of her tumor histology. Was it a glioblastoma (the most common childhood brain tumor)? Who knows? Be that as it may, compared to antineoplastons, the "alkaline lifestyle" used to treat Josie was almost certainly much, much less likely to have an effect on the brain tumor being treated. That Josie apparently did well while undergoing an ineffective treatment has implications for analyzing Burzynski's testimonials. Meanwhile, her parents held fundraisers, much like Burzynski patients do, and raised $130,000, $50,000 of which came from her school and $80,000 from a polo tournament fundraiser in which which Tommy Lee Jones and John Walsh played.
So what did happen? Note the description of events. Josie underwent surgery, followed by chemotherapy and radiation, after which the tumor appeared to be gone, Then an abnormality, apparently in the tumor bed, showed up on followup MRI, leading the doctors to think that Josie's tumor had recurred. There is, however, a phenomenon known as pseudoprogression that can confound treatment decisions regarding second line therapy after an apparent tumor recurrence. Pseudoprogression is a phenomenon in which late effects of radiation therapy can produce enhancing lesions that look all the world on MRI like tumor recurrence. There was a nice review of this topic a few years ago that describes the phenomenon thusly:
Now that concurrent TMZ and radiotherapy are used as standard therapy, the postradiotherapy radiological assessment is made earlier than before, when radiotherapy was given alone. However, it can be difficult to interpret the radiological image obtained, as any changes observed may be due to treatment-related pseudoprogression rather than true disease progression. In their recent study of 51 patients treated with radiotherapy and concomitant TMZ, Chamberlain et al.20 reported seven (14%) cases of early necrosis without signs of tumor recurrence; 26 patients had a radiological diagnosis of early disease progression and, of these, 15 underwent re-resection, with 7 (47%) of the 15 having a surgical diagnosis of radionecrosis. These data open a dual scenario: the possibility of a higher incidence of early radionecrosis and the risk of mistaking the latter for disease progression. In a series of 32 glioma patients, de Wit et al.21 observed that the first postradiotherapy MRI showed progressive enhancement in nine cases; in three of these nine cases, MR images showed improvement or stabilization for 6 months without additional treatment being given.
And:
In patients under treatment for brain tumors, worsening of the preexisting neurological focal deficits, suggesting tumor progression or recurrence, can be accompanied by a neuroradiological image of edema and contrast-enhancing lesion within the tumor bed. However, this radiological pattern is not necessarily associated with any clinical deterioration. These alterations, described in 1979 by Hoffman et al.3 in a group of patients treated with radiotherapy and carmustine (BCNU) at an interval of 8 weeks, were investigated with serial CT or MRI scans. Within 18 weeks following radiotherapy, 49% of patients had a deterioration that strongly suggested tumor progression. In 28% of the cases, however, spontaneous improvement occurred without a change in therapy. Following this pattern, which is indistinguishable from that of tumor recurrence, improvement usually occurs within a few weeks or months, with a thorough neuroradiological follow-up showing that these signs regress within 4–8 weeks. The timing of these clinical features, known as “early delayed reactions” following radiotherapy,4 seems to correspond to the turnover time of myelin.
In other words, in a small but not inconsequential number of cases (perhaps as much as 28%), apparent tumor progression really isn't. It's pseudoprogression, delayed but still early effects of radiation therapy mimicking tumor recurrence. The same phenomenon is very likely true for many Burzynski patients who are presented as "success stories." After all, if we can see cases like Josie from such obvious quackery as the "alkaline life style," there's no reason that the same sort of phenomenon couldn't be the primary cause of some of Burzynski's apparently amazing results. That's why in Burzynski's case clinical trials are absolutely essential. If there's a real antitumor effect from antineoplastons on brain tumors like glioblastoma above and beyond confounders like pseudoprogression, Of course, the number of patients exhibiting pseudoprogression who don't ultimately develop a real recurrence that kills them is much, much smaller, but not so small that it can't explain many of Burzynski's testimonials. Moreover, it's important to remember that dead patients don't give testimonials; so patients of Burzynski's who don't do well won't be around to support The Burzynski Patient Group.
Finally, as is the case with so many testimonials, there's something fishy here. If you go to the Nunez family website, you'll see that it hasn't been updated since 2009, and I have a hard time finding any reference to her after 2009; for instance, this story about her going back to her school after treatment, although there is an episode of a television show called The Incurables in which her episode apparently aired almost a year and a half ago. Either way, it's not entirely clear how Josie is doing now, which is another typical finding with these testimonials.
In the end, though, whenever Burzynski promoters claim that it's "impossible" that it couldn't be the antineoplastons that are responsible for how well certain Burzynski patients with brain cancer are doing. I'd use Josie Nunez as a counterpoint to suggest that it's quite possible that antineoplastons had nothing to do with their survival, just as it's almost certain that the "alkaline lifestyle" had nothing to do with Josie Nunez's good fortune. As is the case with Burzynski patients, it was almost certainly the conventional treatment, not the antineoplastons, that resulted remission. Sometimes, when Burzynski does his incompetent "personalized gene-targeted cancer therapy" for dummies, he might stumble on an effective combination by accident in an individual patient the way the proverbial blind squirrel occasionally finds the nut, but, either way, it's not Burzynski's "genius" that's responsible for such successes, any more than it's Dr. Bernardo's genius that was responsible for Josie's survival. I'm very happy that Josie survived and hope she's still alive and doing well, but her story is not in any way strong evidence that the "alkaline lifestyle" quackery so beloved of Robert O. Young and practiced by Dr. Bernardo saved her life.
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After watching these videos of Dr. Bernado, if his theory that anger causes cancer were correct my body would now be riddled with it. Just despicable.
I was happy to find that this disgusting quack is no longer among the living. Hmm, I wonder if the prostate cancer finally got him?
http://obits.dignitymemorial.com/dignity-memorial/obituary.aspx?n=Berna…
What a bastard, proudly describing how he berates women for denying that their husbands gave them cancer. His own self-portrayal is like the caricature of real doctors we always hear about from the SCAMsters.
You guys sound crazy, judgemental and closed minded. This blog should be taken down because you aim to discredit alternatives that do indeed help people. The world needs hope and people like Dr. Young that go outside of the paradigm even if it isn't the full picture or cure for every person. Healing takes many forms and surgery, radiation and chemotherapy do kill and make the body worse, no doubt. The lifestyle prescribed to alkalize the girls body would technically kill cancer, do some research,
It sounds like Dr. Bernado is also a promotor of German New Medicine.
How about ponying up some of that "research" for alkalizing the body to cure cancer, "young living"?
young living: "This blog should be taken down because you aim to discredit alternatives that do indeed help people."
Citation needed. That also might include the proof that lemons are alkaline. Just some clue you know some chemistry.
Also, if you look up that child there is nothing more recent than 2009. There is even an untouched Myspace account, and some old news reports this one, which is dated 2009 and says she is nine years old. She should be thirteen this year, but it seems than she has dropped off the face of this earth.
What is really horrible are the folks who are publishing videos and testimonies that she was cured, but with nothing that has happened in the past five years. That includes Bernardo dying three years ago.
I hope this child is still alive and cancer-free.
It's worth noting that quacks can be less than scrupulous about pushing testimonials for cancer cures that are not based on up-to-date information.
Take for instance Leo Spears, a chiropractor who ran a well-known "chiropractic hospital" which claimed to successfully treat cancer and many chronic ailments.
"In 1951 he was cited in an article called "Cancer Quacks" in Collier's magazine. He sued Collier's for $24 million. During the trial he admitted that five out of six persons giving testimonials in a Spears cancer pamphlet were actually dead."
He lost the case.
http://www.chirobase.org/05RB/AYOR/07.html
Oh, Young Living,
Is your name a paean to Robert O. Young or the Young Living essential oils pyramid scheme? In my years in Wooville, I was very into essential oils and was a Young Living distributor. I still like the way some of them smell. Our relationship to our sense of smell is fascinating, and many of the oils are very effective as antiseptics, being full of terpenes and other volatiles. That said, most of what aromatherapists say turned out to be total bullshit. I still love me some spearmint in my bathwater though.
So, let me give you a little advice if you're not going to be a drive-by commenter (which you most likely are), just get all of the logical fallacies out of the way in one conflagration. I'd go with pharma shills first and throw in a few arguments from authority and correlation/causation fallacies just to be sure. When you're shot down in flames, you can always come back, ad hom all over hell's half acre and then, clutching your pearls in righteous indignation, stick the flounce.
I'll make the popcorn.
#3 *We* sound crazy? Dude, we're not the ones trying to claim that lemons are alkaline.
Have you ever even *eaten* a lemon?
To Khani and Orac.
If you're going to mock the quackery, get your science right.
For the record I am in no way supporting alkalinisation therapy or any of its fruitcake claims. Anyone who thinks eating alkalinising foods will cure cancer or any other illness is a crank.
BUT eating citrus foods like lemons, oranges and limes DOES have an alkalinising effect on the body (one that is corrected immediately by increasing urinary bicarbonate excretion, maintaining your pH around 7.4) No dietary modification can change your homeostatic pH set point.
A brief explanation:
In its simplest form a lemon contains citric acid which exists in equilibrium with citrate and hydrogen ions.The metabolic consequence of digesting citric acid is acid\base NEUTRAL. But in a lemon some of the hydrogen ions are replaced by other cations like sodium and potassium, a lemon is actually a complex buffered system. Thus when you eat a lemon you are actually eating more of the citrate ion than hydrogen ion leading to a net alkalinising effect. The fact that a lemon's pH may be <7 and it tastes acidic is completely irrelevant when you consider the acid base consequences of the digestion of the lemon.
In truth any meal you eat is accompanied by a brief blood alkalinising effect as your gut ramps up acid production. Look up "alkaline tide".
Some foods particularly proteins and sulfur rich foods are metabolised in such a way as to acidify the body - again this acid base disturbance is very rapidly and effectively countered by decreasing renal excretion of bicarbonate. In extreme circumstances your kidneys will generate extra excretable acid. Your blood pH ain't changing.
My point is that if you're going to take someone down on the basis of their shoddy science, make sure you check you're clear on your own.
Marssan:
Citation needed. From the actual medical literature, not just your say so.
Indeed. When I read "angry, strong emotions cause acidosis, which causes cancer," a Hamer–Young hybrid was the first thing that came to mind.
It's been asked and answered here before.
Chris
None of what i'm saying is controversial.
Firstly lemon juice is a buffer system containing citric acid, citrate and salts.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC437303/?page=1
Look in the references for more detail but the first 2 paragraphs are sufficient background.
Ingestion of pure citric acid results in consumption of bicarbonate in the duodenum as highly alkaline pancreatic juice buffers it. The resulting citrate is absorbed in the gut and complete metabolism of citrate generates bicarbonate which has an alkalinising effect on the blood, however, to get this bicarbonate we consumed bicarbonate thus there is no net pH change in the body.
However, as the previous link demonstrates, lemon juice contains citrate as well as citric acid. Thus the metabolism of lemon juice generates more bicarbonate than it consumes.
Before you start harping about citations that citrate is metabolised to bicarbonate, remember none of what i'm saying is controversial, read your biochemistry textbook, or if you're too lazy, here is an excellent tutorial (pitched to anaesthesiologists) on acid base physiology.
http://www.anaesthesiamcq.com/AcidBaseBook/ab2_3.php
I have linked to the most relevant part.
Sadly the link posted by Narad is to a post by Krebiozen who gets it spectacularly wrong.
Chris
If you're still not convinced read some of the literature on estimating the acid base effects of food which has come out of the renal failure\dialysis population. Again not particularly new or controversial.
@Marssan - what is your point, exactly? You state that eating acidic foods will "temporarily" increase the acidity of the body, but any increase is immediately corrected for by the body.....again, what is the point?
This is a very popular belief among my woo-friends -- applied not just to cancer, but to health problems in general. They specifically link it to their metaphysical assumptions regarding what they call "nondualism."
In their view, the physical world is an illusion/an aberration originating and sustained by negative, non-spiritual attitudes: the only thing that really exists is "Love." The remedy for all sickness therefore involves letting go of resentment, attachment, judgement, and anger so that we revert to our original, true, holistic, loving form.
Uh huh. I sense you all being judgmental.
Amidst all the sloppy, wishful thinking here I'm particularly struck by the magical links between thoughts, words and reality as they slide around metaphors and take them literally. People with an acidic, sharp personal nature cause acidosis. That's just intuitive, isn't it? A child could figure it out.
Marrson,
Thanks for the science lesson but when you ingest a weak acid (buffered or no) the excess protons go *somewhere*. It is irrelevant whether your stomach produces acid (hence creating a brief mild buffered blood alkalinization from whence the protons pumped into the stomach came) or that the pancreas excretes a base (reversing the same). If it is your contention that excess protons remain in the gut and are not absorbed then fine. If it is your contention that after ingesting acid, excess protons are exhaled by mild hyperventilation to temporarily maintain pH 7.4 until renal excretion of the excess acid to return pCO2 to 40mmHg, then fine (somehow your textbook link goes to respiratory acid-base balance--I'm not sure why you believe this is relevant). If your contention that lemons do not have excess protons (buffering is irrelevant) then citation is needed.
In any case all of this is pedantry. It's quackery to suggest alkaline foods cure cancer and it's just plain dumb to suggest you could alkalinize your system by ingesting acidic foods. Why do you bother?
It is rather amazing how Marrson ignores the law of conservation of mass (OK, mass/energy, for you Einstein fans out there), isn't it. As you say, if you add an acid to the system, the protons have to go somewhere. That the body can buffer it is irrelevant. That citrate can be converted to bicarbonate at best means it's neutral.
Lawrence
No I make no such claim. Read my two posts again. I am saying that eating lemons temporarily DECREASES the acidity of the body, that indeed (as the woomeisters claim) citrus fruits do have an alkalinising effect on the body. Albeit a transient one that carries with it no significant long or short term health effects except slightly more alkaline urine.
The reason I posted this is that both Orac and Khani mocked the quackery by pointing out how ridiculous the claim that eating citrus fruit alkalinises the body. They are both wrong. My point being that if you're going to mock do so from a solid scientific background or you risk losing credibility.
Orac
Missing the point.
Eating a lemon you are adding more base to the system than acid.
Define "body." What, specifically, is being alkalinized? "Alkalinizing the body" is a meaningless statement. What specific compartment is being alkalinized? Blood? Extracellular fluid? Or just the urine? Be specific and show your work.
Except that you are not, by your own admission. If you're adding acidic fluid (pH < 7, which the pH of a lemon is, as you yourself admitted), you are adding acid. Period.
The blood compartment is briefly being alkalinised.
[quote]Except that you are not, by your own admission. If you’re adding acidic fluid (pH < 7, which the pH of a lemon is, as you yourself admitted), you are adding acid. Period.[/quote]
No, no, a thousand times no.
An acid fluid has a pH < 7 - yes absolutely. But a buffer solution of an acid like citric acid contains more base than acid.
To elaborate
Think back to high school chemistry when you first made a buffer solution. Say it was a citric acid one.
You take a quantity of pure powdered citric acid and dissolve it. The pH goes to say 4. Then you get some sodium citrate and add it to the solution. The pH goes up to say 5 and it's still an acidic solution BUT there is more base (in the form of citrate) than acid (hydrogen ions) in the system.
Agreed, good.
Um, Marssan. Lets not get confused by following the anion. Sodium citrate is a base, whereas citric acid is an acid, by virtue of having protons that are donated to water. The pKa of citrate protons are 3.1 and 4.8. In chemistry terms this means that these are the pH values at which exactly half the molecules of citrate will be protonated. Your statement that "A buffer solution of an acid contains more base (citrate) than acid" is only true for citrate at acidic pH values between 4.8 and 7 because there will be more non-protonated than protonated citrates at these pH values (limiting our discussion to the second proton). However, when you add this acidic solution a human which exists at a higher pH, the effect you will get is donating protons. After all the potential to donate protons to water is what pH measures. In short, you can make a citrate solution with any pH, but the pH of the solution made defines its potential to donate protons.
I feel like I am a chem 101 TA again....
BTW, my memory of high school chemistry is a bit fuzzy, but fortunately, I only had to go back to graduate training in pchem.
Yeah, it's amazing how someone can get such a simple concept so wrong. If you're adding a fluid with a lower pH to one with a higher pH, you're donating protons (acid) to the fluid with higher pH. It really is as simple as that. Alkalinizing the urine is not the same thing as alkalinizing the body.
MadisonMD you need to take Chem101 again. The pKa of the acid is irrelevant in this context all it does it define a pH range you can expect your buffer solution to have depending on the proportion of acid and conjugate base that you mix.
Yes citric acid is multi-protic, but lets not confuse the scenario unnecessarily.
At equilibrium, a buffer solution of an acid (as described above) will ALWAYS contain more base than acid at ANY pH that you can achieve mixing only citric acid and sodium citrate. It is unavoidable, because that's how the solution is made. We take a dissolved acid solution (which has 1:1 acid:base) and we ADD BASE to it. How can we not have more base than acid in it?
No Orac it's not as simple as that when there are acid-base consequences of the digestion and metabolism of the substances. You are taking an incorrectly simplistic view of the scenario.
It's true when eating a lemon you are donating (acid) protons to the body but you are also donating a LARGER quantity of (base) proton acceptors to the body.
Next
What happens if you drink a citric acid solution, not a buffer, just some pure citric acid dissolved in water.
In the stomach (pH 1 - 2) the hydrogen ion concentration is hundreds to thousands of times greater than in the container of citric acid solution. Any dissociated citrate gets its hydrogen ion handed straight back to it and you're left with almost totally un-dissociated citric acid.
Next the un-dissociated citric acid moves to the duodenum where essentially the opposite occurs. Pancreatic juices, bicarbonate rich, pH > 8, strongly alkaline, strip the hydrogen ion off the citric acid leaving citrate and making water and CO2 (you burp or fart).
This process has consumed a bunch of bicarbonate.
However, once absorbed by the gut, the citrate goes to the liver where it is metabolised to bicarbonate, repaying the consumption of bicarbonate that occurred earlier, leaving your body acid-base balance unchanged.
Now I leave it up to you to continue the thought experiment.
What is the acid-base consequence of drinking a citric acid buffer solution (i.e a lemon)?
I'm not sure I'm understanding your terminology. How is a dissolved acid solution considered to be a 1:1 mixture of acid and base?
Marssan:
That the liver resolves in the end? Because it is not a lab experiment like the 1946 paper, and most people are not hooked up to respirators when they are walking around like when an anesthesiologist would be around.
Somehow I think you forgot a few steps between gut and bladder. They are not directly connected, as you first implied... and the liver is very complicated. Thanks for finally mentioning it. It seems to be the big part of making sure there is balance in the whole system.
And the lemon juice is still acidic, but it is not even anything but additional molecules once it goes down your throat.
But it does point out that anyone who thinks eating certain foods will cure cancer is foolish, and those who claim acidic foods are alkaline are uneducated.
Marson,
In my laboratory is a bottle of 1M hydrochloric acid. It is chock full of choride base--in fact the bottle had 2.4x10^27 of these little chloride base anions before we started using it. Yet, when we add it to any other solution the pH actually decreases-- are you really surprised? But don't take the word of a PhD chemist. What I am saying is: GO SQUEEZE A LEMON. into a glass of water and then find out whether the pH goes up or down.
"The pKa of the acid is irrelevant in this context all it does it define a pH range you can expect your buffer solution to have depending on the proportion of acid and conjugate base that you mix."
The pKa is a single number which defines the strength of a particular proton donor and can scarcely be described as a "range."
At equilibrium, a buffer solution of an acid (as described above) will ALWAYS contain more base than acid at ANY pH that you can achieve mixing only citric acid and sodium citrate
As I said, 1M hydrochloric acid contains more chloride base than protonated acid (this is, in fact, what makes HCl a strong acid). Then you invoke gastric acid and respiratory physiology. You, my friend, are trying to obfuscate. What is your purpose... to show that the quacks are right and Orac is wrong? I do not have more time to waste on a troll.
Actually, it is irrelevant whether lemons are buffered acid solutions or not. The real question when discussion Young and his ilk are:
- do foods significantly affect blood pH?
- if so, does it matter?
I wish I had the science to jump into this melee, but alas my years in the liberal arts (those that left me so susceptible to woo) rendered me ill-equipped to help. This is how this non-scientist is following the fracas . . .
Marssan: You are obviously in the minority here, argument wise. I get that you're not advocating for the Alka-Quacks. If I follow correctly, it sounds like you're focusing on a minimal alkalizing that occurs when citrus is introduced to the human digestive tract, which is quickly resolved later by the pancreas and later by the liver, leaving the whole body's pH balance intact in the end.
Everyone else: Is there a raised urine pH when we consume citrus fruits?
High school chemistry was thirty years ago for me. I loved the labs, but the math crashed my brain big time. Dammit Jim, I'm an artist not a mathematician!
Didn't Orac get his undergraduate degree in chemistry? I think he much more than I do, and obviously Young and friends.
Yes, I got my undergraduate degree in chemistry with honors. Also, acid-base physiology is a very important component in surgery. It gets pounded into your head in medical school and then over and over and over again during residency, particularly during the critical care rotations. That's how I know Marssan is so wrong he's not even wrong. In fact, for yucks, I think will forward a link to this thread to a chemist friend of mine. I'm sure he will be quite amused.
Marssan,
No it doesn't.
Irrelevant to your point. As I have pointed out here before, the citric acid in lemons is neutralized by bicarbonate in the body, producing carbon dioxide (acidic) that is excreted by the lungs (if lemon juice really makes you "burp or fart" I suggest you see a doctor) and citrate (slightly alkaline) which is excreted in the urine.
The overall effect on the body before compensation is acidifying; just because it makes your urine alkaline doesn't mean it is alkalizing, and your explanation about citrate buffers is mere bafflegab; ingesting pure citric acid has the exact same effect.
In what way do I have it spectacularly wrong? I'm not the one claiming that a buffer solution with a very low pH is alkaline, and I'm not the one ignoring the carbon dioxide generated when citric acid is neutralized by bicarbonate.
And you accuse me of being spectacularly wrong? The bicarbonate secreted in the duodenum is normally neutralized by the stomach hydrochloric acid, but if there is citric acid in the stomach as well, the duodenal contents will be less alkaline, requiring more bicarbonate secretion, which in turn results in a net acidification of the body, compensated through blowing off more carbon dioxide.
Marssan,
Let's look at this a little differently. The pH of lemon juice is around 2.0, and I assume its osmolality is similar to human around physiological osmolality i.e. around 300 mOsm/kg. We can calculate the proportions of citric acid to citrate that will achieve this here. I figure that we would require around 62 g/L citric acid and 2 g/L sodium citrate to make a citrate buffer similar to lemon juice.
I think that knocks your argument on the head, but do please explain if I have it "spectacularly wrong" again [snorts indignantly and smooths ruffled feathers].
That should read "similar to human physiological osmolality". Lemon juice may be different, but citric acid concentration will still exceed citrate concentration by a factor of over 30.
Yep, It was often confusing to the chem 101 students that acid solutions harbor anions that are called weak bases. Raising your pH by drinking acid is just a dumb idea. Perhaps trying to change your pH even is a dumb idea. But then, as they say, there is one born a minute. Too bad some of them end up dying of cancer. Thanks, Orac, for continuing to pillory the sick people who dupe them.
OK
To Chris again. Who doesn't seem to add anything to the conversation but doubt. This link explains clearly the role of the liver.
http://www.anaesthesiamcq.com/AcidBaseBook/ab2_5.php
Krebiozen
An oral load of citrate is not excreted in the urine. It is a small easily absorbed molecule a readily taken up and metabolised by the liver to bicarbonate as described above. You ignore the "repayment" of the bicarbonate debt via the metabolism of citrate ion. You should read the above link also.
Mephistopheles O'Brien
Has the only valid point here. My terminology is a bit inconsistent.
A pure acid solution contains 1:1 acid:base ff you consider all the conjugate base a "base" and all the dissociated hydrogen ion the "acid". Which is how i conceptualise it. This can be confusing to others as the un-dissociated citric acid pool is also the "acid".
Orac.
I also have an honours degree in chemistry. I taught freshman chemistry for 2 years. I'm also a medical doctor, almost finished training as an anaesthesiologist. My basic science exams are only 2 years behind me, compared to say a decade for yourself. I guarantee you my knowledge of this material is more current and I use it in my day to day practice more than you.
In fact you should ask your most friendly anaesthesiologist what the acid base consequences of drinking a buffered citric acid solution are because we get pregnant women about to have a C section to drink them every day.
Although surgeons don't lke to admit it, we are the smartest guys in the hospital.
The fundamental mistake you all seem to be making is treating the body as a passive receptacle for the solution. Of course if you add an acidic buffer solution to a 20 gallon container of water you will decrease its pH. But the body ain't that and the consequences of adding the buffer solution the human body are counter-intuitive.
All of you should take this problem to someone you acknowledge to be smarter than yourself in the field of chemistry and get them to work you through it.
So by your thesis, would ingesting dilute hydrochloric acid also raise pH? Conversely, in your experience, does bicarb lower pH? You keep following the anion-- follow the proton, dude. So you are the smartest guys on the hospital. Good to know, but this stuff could be on anesthesia boards.
OK Marsson-- citrate is metabolized to bicarbonate in liver... pKa of bicarb is higher than of citrate. Maybe tenable that this would soak up a few protons, but then why all the confusing babble about citrate base, alkaline tide and the reference to respiratory physiology in all your posts today?
Marssan,
Of course it's metabolized in the liver, in the citric acid cycle, but citrate is also excreted in the urine as well - I have measured it myself. Low urinary citrate is associated with renal calculi formation, for example here. Whether urine pH is raised by citrate or bicarbonate makes no difference to my argument.
More to the point, lemon juice contains vastly more citric acid than citrate which renders your entire argument moot.
The metabolism of citrate produces acidic carbon dioxide, not bicarbonate directly, so it is not pH neutral as you imply and no "debt" is repaid.
I read it. It talks of endogenously produced acids being neutralized by the liver. We are discussing acids being introduced to the body from outside. Citrate alone introduced from outside will cause net alkalization because it is a weak base, but lemon juice contains around an order of magnitude more citric acid than citrate.
The consequences are alkalization of the urine as citrate and bicarbonate are excreted, which says nothing about the net effect of the acid-base of the body system as a whole.
You seem to be making the opposite error. The body cannot turn hydrogen ions into anything else when they are ingested or injected, it doesn't matter what buffers or enzymes are involved. If a patient was to ingest a glass of lemon juice and we observed what happened, we would see that the excess acid ingested was excreted in the form of carbon dioxide. Trying to claim this means it doesn't increase body acidity is like claiming that a compensated metabolic acidosis isn't really an acidosis because of respiratory compensation. It's nonsense!
I've spent the best part of quarter of a century working with this stuff in clinical biochemistry, and I have lectured medical students and biomedical scientists on the subject. I think I have a pretty good grasp of the subject, thanks.
I put this badly:
What I mean is that if you ingest something like lemon juice with a pH of around 2.0, the net effect is that you increase the number of hydrogen ions in the body, and the body cannot magically neutralize them without using up bicarbonate or excreting acids. The fact that homeostatic mechanisms take care of this very quickly doesn't mean that citric acid cannot cause acidosis. It most certainly can. Was that patient's metabolic acidosis "really" alkalosis?
Also perhaps worth noting - the patient who overdosed on citric acid in my last link has a greatly reduced ionized calcium because citrate binds ionized calcium, which can lead to hypocalcemia when large amounts of citrated blood are transfused, which is masked if you only measure total calcium, as you will also measure bio-inactive calcium citrate.
We often saw this in the early days of liver transplantation, and consequently had to get hold of an ionized calcium analyzer.
#39 I don't even know, man. I don't even know.
What's with the quacks' insistence that the body is somehow homogenous in its pH, anyway? My chemistry teacher taught us that blood was slightly basic, but I'm pretty sure the contents of my stomach aren't, judging by the nasty heartburn I get from time to time, in particular *right after unwisely drinking citrus juice on an empty stomach.*
And who cares what pH your pee is anyway, it's a waste product. It's going to get tossed whether it's acidic or alkaline or made of rainbows and faerie dust.
Major thanks to Orac, MadisonMD et al for going over things I forgot the instant I completed my biochem final exam in med school, so now I have ammo for the next time a woo-ster declares that citrus fruits alkalinize the body.
I'm just afraid that the stress of trying to understand once again what pKa and buffers are all about has acidified my system, and I'll need to inject a bunch of bicarb in order to straighten out my bodily pH before disaster strikes. :(
MadisonMD
Exogenous administration of hydrochloric acid generates a metabolic acidosis because the conjugate base (chloride ion) is not metabolised to bicarbonate like citrate is.
Krebiozen and others have said, rightly, that exogenous administration of citrate, say as oral sodium citrate or citrate in a blood product, generates a metabolic alkalosis. For each citrate ion metabolised in the liver a bicarbonate is produced, that is the mechanism i was taught.
So if metabolised citrate generates alkalosis, why is metabolised citrate + a proton (i.e. metabolised citric acid) not acid base neutral, which is my thesis?
There is no excess of protons in a citric acid solution, there are only as many dissociable protons as there are citrate ions.
Hence, drinking a buffered citrate/citric acid solution generates an alkalosis because every hydrogen ion ingested is matched by a bicarbonate produced from the metabolism of citrate. In the buffer solution there is an excess of citrate by definition, thus a brief, modest alkalosis occurs which is compensated for by increased urinary bicarbonate excretion.
If in the case of overdose, the hepatic metabolism of citrate to bicarbonate is overwhelmed you end up getting the acid load but not the bicarbonate generation, the acidosis is understandable in this context.
Talk of ionised calcium is irrelevant to this discussion
Should have done this before.
But here is a beautiful simple paper demonstrating my point.
http://www.ncbi.nlm.nih.gov/pubmed/1552616
They gave a bunch of volunteers a citric acid load orally.
The most relevant quote from the abstract is,
"Urinary pH, carbon dioxide pressure, bicarbonate, total carbon dioxide and ammonium did not change at any time after citric acid load..."
My thesis exactly
Actually, your initial thesis was that citric acid is alkalinizing, not neutral, although you do seem to flip back and forth on that in a way that makes it unclear to me which it is exactly that you are saying in any given comment.
How many net dissociable protons there are per citrate depends upon the pH of the citrate solution. Citric acid has three dissociable protons, with a pKa of the protons being 3.15, 4.77, and 5.19. Lemon, for example, has a pH of a little above 2 (around 2.3, actually); orange, of around 3. At a pH of 2-3, there would be roughly three dissociable protons per molecule of citrate. That's an excess of two. It's actually also part of the reason why citrate is such a useful buffer.
Uh, wouldn't the net effect of matching every hydrogen ion ingested with a bicarbonate ion be neutral, not alkalinizing? One H+ per one bicarbonate equals neutralization, does it not? Of course, one can't help but point out here that citrus juices are not actually particularly well buffered. That's why their pH tends to be so low.
Here's where I am puzzled. I might have made some mistakes in the comments, but in the actual post, all I started out with was a brief phrase in a 2,200 word post, a bit of snark directed at the "alkalinizing diet." Yet for some reason you felt the need to get on a high horse and hijack the thread with a rather long comment based just on an off-hand remark in the post, ignoring (yes, ignoring) the main point of the post. All I said was that the foods in the "alkalinizing diet" were rather acid and that it was silly to refer to them as "alkalinizing." That's it. Moreover, based on the pH of lemon and orange (for example) and the various pKa values for the dissociation of the three protons of citric acid, I'm actually not entirely wrong. Three protons neutralize three bicarbonates from a molecule of citric acid at pH 2-3. It's not alkalinizing. It's neutral. And the solution is acid.
In any case, you've made your point. Over and over again. Ad nauseam with hundreds of words. At the expense of distracting from the main message of the post, which is that alkalinizing diets are quackery. All over an offhand remark that made up less than 1% of the post and wasn't even anywhere near central to the main point of my post. We get it, already. I foresee your comments showing up as "evidence" that there is a controversy over Robert O. Young's quackery. This sort of thing has happened before.
JBC is fantastic-- has all the old archives to answer these questions.
When ingested 1.5-2.5% of citric acid escapes oxidation and is excreted
citation
Giving bicarbonate or citrate to dogs raises urine pH, but citric acid has no effect.
citation
How does this work? Well, metabolism of citrate in effect consumes the acidic protons into H2O, which of course has pKa of 7.
C6 H8 O7 + 4.5 O2 --> 6 CO2 + 4 H2O
No loss i.e. if the CO2 is exhaled, voila, we are left with pure water.
So there is plenty of mea culpa to go around myself included. Marssan, thank you for teaching me how urocit works (the acid is there apparently to make it palatable and more water soluble).
citric acid/citrate salt
No hard feelings about saying I need to do chem 101 and all...and now you have a chance at being board certified into the mystic rite of anesthesiology--the smartest doctors in the hospital (yeah right).
The pedantry was fun, but still--Orac was right-- these dudes are quacks. And I'm still not convinced a lemon has enough citrate to alkalinize. Aren't there other acids--what was Linus Pauling about-- ascorbic acid? Is that metabolized in a way that consumes protons as well?
BTW, in the second JBC citation, you need to scroll all the way down to Table IX to see the result I cite.
Orac
My position has consistently been that citric acid is neutral but a lemon which is a buffered citric acid/citrate solution is alkalinising. I havent flipped or flopped. Please don't attribute to me things i didn't say in a mealy mouthed attempt to discredit me.
Take the last of your selected quotes from me, if only you'd selected the next sentence from my post as well there would have been no ambiguity as to what i was trying to say. Yet you didnt.
"In any case, you’ve made your point. Over and over again."
Yes but to what reception? A patronising "It is rather amazing how Marrson ignores the law of conservation of mass" and "That’s how I know Marssan is so wrong he’s not even wrong. In fact, for yucks, I think will forward a link to this thread to a chemist friend of mine. I’m sure he will be quite amused. " Really?
In a blog that is supposed to be all about intellectual rigour, I read something patently false (i.e. the notion that eating citrus food cannot possbily have an alkalinising effect) being used as something to mock the quacks with.
Don't you see that this situation reduces your credibility?
I think chemistry is awesome and have a strongt urge (perhaps misplaced on the internet) to correct misconceptions. There is no "high horse" when it comes to scientific fact, just like no statement of fact can be insolent.
It would be a shame if this thread came up as evidence that there is controversy in the field. But that's not reason to avoid getting the facts straight.
Marssan,
I see your point, but what you say is true only if you ignore the considerable amounts of carbonic acid produced, simply because it can be easily excreted (assuming normal lung function). I have also learned something, since I didn't know just how much ingested citrate is converted to bicarbonate, so thanks for that.
I know, that why I put it in a separate comment, it was an aside, apologies if that was unclear.
Let's look at some actual numbers:
Lemon juice pH = 2.40 osmolality = 555 mOsm/kg (so my estimate of 300 above wasn't too far off)
Citation.
Assume for simplicity that sodium is the only cation present, that our unfortunate guinea pig drinks 1 liter of lemon juice, and that all citric acid and citrate ingested is absorbed and metabolized without overwhelming any metabolic mechanisms.
One liter of lemon juice contains approximately 111 g or 0.47 moles of citric acid and 8.3 g or 0.028 moles of sodium citrate (see citrate buffer calculator cited above).
That amount of citric acid will require 1.41 moles of sodium bicarbonate to neutralize it*, producing 1.41 moles each of carbon dioxide and water and 0.47 moles of citrate.
If all that citrate (0.028 + 0.47 = 0.50 moles) is then metabolized to sodium bicarbonate and water*** another 1.5 moles of CO2 would be produced along with 0.50 moles of water and 1.50 moles of bicarbonate.
Assuming no errors in my calculations, the net gain in bicarbonate is 0.09 moles, that's 7.6 grams, which isn't very much (less than a teaspoonful of sodium bicarbonate), especially if you consider that people are likely to consume very much less lemon juice than this. This ignores the 2.9 moles (128 grams), of CO2 produced, which in terms of acidity exceeds the amount of bicarbonate produced by a factor of about 30***.
It also ignores the fact that about 5% of ingested citrate is excreted unmetabolized in the urine; if we take this into account the gain in bicarbonate is 0.015 moles or 1.2 grams of sodium bicarbonate per liter of lemon juice, which is really negligible, even ignoring CO2, which we shouldn't.
I think it is accurate to state that ingesting lemon juice produces excessive acid that the body has to compensate for by exhaling excess carbon dioxide, as I stated in the comment you described as "spectacularly inaccurate".
* H3C6H5O7 + 3 NaHCO3 → 3 CO2 + 3 H2O + Na3C6H5O7
** Na3C6H5O7 + 4.5 O2 --> 3 CO2 + H2O + 3 NaHCO3
*** H2CO3 HCO3 + H+
Dammit that should read:
** Na3C6H5O7 + 9 O2 –> 3 CO2 + H2O + 3 NaHCO3
Also, what was supposed to be an equilibrium sign in H2CO3 <:==>-HCO3 + H+ got eaten. Sigh.
Last try:
H2CO3 <==>-HCO3 + H+
Marssan,
A hypothetical question, and then I'll drop this. A patient with emphysema has developed a severe respiratory acidosis. Would giving her a liter of lemon juice to drink:
a) Improve her acidosis because of the bicarbonate her liver makes out of the citrate in the lemon juice?
Or,
b) Make her acidosis worse because lemon juice is acidic and her mechanisms for excreting excess acidity are impaired?
Look, we all have that; otherwise we wouldn't be arguing on the Interne.. However, there comes a point where it becomes overbearing and a thread hijack that pulls the discussion off on a tangent. Sometimes such tangents can be interesting, but there comes a point when they take over. I've learned that lesson many times the hard way myself and still have to struggle with the tendency not to let anything slide that's "wrong on the Internet." So I get it. But I also get how annoying such behavior can be to others. You, apparently, do not. At least not yet.
Also, regular readers here also know that I get really irritated when someone hijacks the thread over a few words in a long post, which is exactly what you did over three words. If I were to remove those three words, you would have absolutely nothing to object to, and even with those three words in there, quite frankly, there isn't anything that is technically wrong. But that didn't stop you from going off on a tear and hijacking the thread. It was just damned rude. So if some of my words were a bit...intemperate...it's probably on that particular pet peeve. I'm sorry about that.
Also, looking at Krebiozen's calculations, I think he does indeed have a point.
Krebiozen That is awesome! Super useful stuff, now when someone says eating citrus fruit "alkalinises the body" I can say, sure it does but, a) the effect is tiny b) the effect is transient and c) it stresses your mechanisms for excreting CO2 and d) it certainly won't cure any specific malady.
Your hypothetical question is really hard.
I'm going to approach it from first principles. Emphysema is a disease of impaired CO2 excretion. Increased CO2 build up creates an acidosis which is compensated for by decreased renal bicarbonate excretion. A typical blood gas will have pCO2 of 60 pH slightly acidotic or low end of normal and a bicarb of say 28. (Boston "4 for 10" rule).
I've given this a lot of thought, and i'm still not sure but i think giving the lemon juice will make her acidosis worse. As discussed there is both a CO2 and a bicarbonate load associated with ingesting lemon juice, the bicarb increase would increase the pH (resolve the acidosis), but the CO2 cannot be easily excreted so it would accumulate, which worsens the acidosis. There is much more CO2 produced so the impaired CO2 excretion would dominate, worsening the acidosis? Difficult question.
Interestingly a treatment for severe chronic CO2 retention in people with COPD in intensive care is an infusion of dilute hydrochloric acid via a central line. The idea being you neutralise the accumulated bicarbonate, the CO2 goes up, pH goes down and suddenly their desire to breath returns! I've never seen it though, just read about it.
Orac your grievance is valid and I apologise for the thread hijack, it was poor behaviour on my behalf. It was absolutely a " wrong on the internet" moment.
For the record I'm a big fan of this blog I've been reading it for years, perhaps in future my contribution will be more on topic.
On a different tangent, one question that often comes to mind reading your pieces, don't you get depressed discovering and rediscovering the mind numbing woo out there? The anti-vax, the chiroquacks, the homeopaths etc . Reading about them here gives me a strong sense of despair about the direction society is taking.
Karssan,
I find it interesting that clinicians tend to ignore volatile acids since, assuming their patient is breathing, they are simply exhaled. Non-volatile acids and excess alkali can be almost as easily excreted by the kidneys, but of course renal impairment is common and this can't be taken for granted.
As a biochemist, I am more interested in my equations balancing, so the volatile acids are just as important as the non-volatile. I think this is where our differences arise.
I agree with you about the lemon juice making our hypothetical emphysemic patient's acidosis worse. I'm sure you see my point, so I won't labor it..
That's almost the definition of a heroic measure!
@Marssan:
Clearly I overreacted. However, after eight and a half years of this, it happens sometimes.
Thank you all. I actually learned something and I may have actually understood what you were saying. Let's see if I did. So in the end I gathered that: CItrus has a transient, vanishiingly tiny alkalizing effect on the urine, but not on our body's systems as a whole.
By the way, that interchange is what makes our side real and awesome, and their side total and utter bullsh•t.
Yes, I also lots. It seems that healthy people do not have to worry, and that the problems with acid, etc mostly occur with surgery and severe illnesses.
I already knew surgery was scary, since my son had open heart surgery over a year ago.
A bit sleep deprived: "Yes, I also learned lots."
I need more coffee.
I too thoroughly enjoyed the scientific exchange in this thread. It reminds me of the mass spec/NMR back and forth over on SBM a few months ago when the woo-peddling Tracy tried to win everyone over on the miracle that is, apparently, ASEA. I should also point out that she hasn't returned with her earth shattering evidence of its efficacy that was meant to be published in April. Someone should email her or something...
link for the interested:
http://www.sciencebasedmedicine.org/fan-mail-from-an-asea-supporter/
Marssan, I really hope you continue to comment here, just wanted to echo others as far as how much I enjoyed this exchange. People outside of academia tend not to realize that these sort of exchanges happen all the time in science...to me, the key to being a good scientist is learning how to be wrong.
There seems to be some interest, and the following is on topic, so...
Having waded through a lot of the literature some years ago, I know that there are some relatively mainstream researchers who believe that the increased acid load from our diets leads to chronic disease. They usually look at potential renal acid load, and their work is often published in nutrition journals, for example this paper (PDF) which states that:
I don't think this is true. Their evidence (followed by my criticism of it) mostly consists of:
a) Correlations between protein intake and hip fracture and urinary calcium excretion, which are claimed to be because of the acidifying effects of high protein diets which lead to leaching of calcium from bones.
The evidence I have seen suggests that these effects are actually due to high animal protein diets being low in calcium, magnesium and potassium (all important for bone health), and also because high protein diets increase dietary calcium absorption and this is why urinary calcium excretion is increased e.g. this study.
In a case control study that controlled for calcium intake, animal protein appeared to protect against osteoporotic fracture
b) Ingestion of potassium bicarbonate improves calcium balance, reduces bone resorption, and increases the rate of bone formation in postmenopausal women. However, sodium bicarbonate does not have the same effect, which strongly suggests the potassium, not the bicarbonate, is responsible.
c) Elderly people do tends to become mildly acidotic, which I have seen cited as evidence that we slowly accumulate dietary acids which lead to chronic illness. However, serum bicarbonate correlates with serum BUN (I can't find a reference at present), which strongly suggests it is mild renal impairment that is responsible for this acidosis, not accumulation of acids from the diet.
Also, I note that vigorous exercise produces a lot of volatile and non-volatile acids, which our bodies manage to excrete with little problems. I have done metabolic profiles on marathon runners after a race, and they all had impressive metabolic acidoses which resolved within the space of several hours.
I don't understand why some people believe we can excrete the acids from exercise, but accumulate acids from meat and cheese.
The following is from some notes I made a few years ago, and I don't have the references for the figures quoted, but I believe them to be accurate, and I think it is a good refutation of the claims of Young and his ilk.
A normal person produces about 1 kilogram (15,000 mEq) of carbon dioxide, which is exhaled and 40-80 mEq of organic acids from anaerobic metabolism every day. If we exercise vigorously we will produce considerably more than this (exercise can produce as much as 40 mEq of acids every minute), but luckily our lungs have a huge ability to exhale carbon dioxide (obviously we hyperventilate when we exercise), and our kidneys are capable of excreting 700 mEq of acids every day (by using some clever jiggery pokery).
Let's compare this to the amount of acidity generated by a very acid-forming foods, like cheese. A hard cheese will generate about 20 mEq of acids for every 100 grams (about 4 ounces) ingested. Soda drinks like colas contain about 2.5 mEq of acids in each liter. The organic acids generated by exercise are functionally identical to those generated by the consumption of acid-producing foods.
So, to overwhelm your body's capacity to excrete acids, you would have to drink hundreds of liters of cola every day, or eat several pounds of cheese or meat every day. I don't believe this happens, and I don't believe that chronic diseases are due to the large amounts of acid-producing foods in modern (unhealthy) diets.
Krebiozen et al:
Some years back, I admitted patient with severe acute respiratory acidosis due to COPD. I thought it was a good idea to give an amp of bicarb to hasten the compensatory metabolic alkalosis. However pulm/crit care attending said this was a dumb idea because he couldn't exhale the CO2. I haven't been able to straighten this out in my mind to figure out who was right. Ideas?
MadisonMD,
Thankfully I never had to make such decisions but, based on my training and experience, because respiratory acidosis doesn't cause the severe electrolyte disturbances that you see in metabolic acidosis, and because, as I understand it, these deranged electrolytes are the immediate life-threatening problem, I would guess that bicarbonate isn't indicated in respiratory acidosis.
That said, I don't think it would do any harm either since, as you say, increasing bicarbonate one way or another is how the body will compensate anyway. Please don't base any patient management on this!
Alright. I'll stop being so sensitive. Until the next time I'm sensitive, that is...
MadisonMD,
The question of bicarbonate in respiratory acidosis keeps surfacing in my brain, and a couple of other ideas have emerged.
Looking at your patient as a bicarbonate buffering system (I know it's really more complicated than that):
CO2 + H2O <==> H2CO3 <==> HCO3- + H+
In respiratory acidosis there is excessive CO2 which pushes the equilibrium to the right, reducing pH. By adding sodium bicarbonate to this system you will push the equilibrium to the left, reducing the H+ concentration i.e. increasing pH, but also increasing the pCO2 which, as your colleague pointed out, your patient is unable to exhale effectively. I'm not sure what effects an increased pCO2 has, other than lowering pH.
The other thing that occurred to me is that alkalosis is much more dangerous than acidosis in hypoxia, because oxygen binds more tightly to hemoglobin at higher pH, so giving bicarbonate to a hypoxic patient may make things worse.
WTF is #78 !?
Krebiozen you nailed it in #79. I'll try to fill in the clinical bit.
Higher than normal CO2 and elevated hydrogen ion concentration are extremely potent stimuli for ventilation.
To demonstrate , take a large bottle of coke that is about 3\4 empty, shake it up to get the CO2 to bubble out, and take a big deep breath of the gas and hold it. You will almost immediately feel a powerful and unpleasant sensation of needing to breath. You've just delivered a hit of CO2 to the brain and the chemoreceptors in the medulla that trigger ventilation go nuts.
In the emphysematous patient with an acute exacerbation of their disease, they are unable to breath out the CO2 due to mechanical changes in their lungs. They still feel the sensation of needing to breath though.
As Krebiozen says, giving the bicarb solution you do 2 things, decrease the acidosis and increase the CO2. As pCO2 rises beyond a certain level (about 80 mmHg) it stops being a ventilatory stimulant and becomes a central nervous system depressant. Look up CO2 narcosis for more detail.
So MadisonMD, by giving the bicarb solution you could easily have worsened the patient's condition by increasing their CO2 and potentially taken away some drive to breath. The combination of the two could have lead to a decompensation of the respiratory failure leading to worsened hypoxia leading to an intubated bed in the ICU...
Off topic still i know but MadisonMD asked the question and we couldn't just leave him hanging...
@ Marssan:
#78 is the efflux of someone who isn't exactly thrilled with our esteemed and gracious host ( or us): being tossed to the four winds after perseverating upon his *idees fixees* @ RI, he set up his own blog to continue upon this avocation wherein he dissects and dismembers logic and reason on a near-daily schedule.
Krebiozen and Marssan: thanks for your analysis. The patient in my memory had acute hypercarbic respiratory failure with normal oxygen (not uncommon with COPD flare). ABG showed low pH, high CO2, normal or minimally elevated bicarb, normal O2. Tachypnic, unable to lower CO2. Over time, I would expect renal compensation to raise HCO3 allowing pH to normalize despite hypercarbia.
I see both your points about making pCO2 go up in this patient (which yes if high enough causes CO2 narcosis--no need to look it up, I've seen it). I guess whether it is good or bad depends on whether raising pH is worth it given cost of raising pCO2. I accept that higher CO2 could be worse.
Fortunately, I was admitting to stepdown unit, I don't think a vent was needed if I remember right. I think my one ampule had a minimal effect.
I don't remember coming across CO2 narcosis before, and I found it interesting, but I'm a bit puzzled. Doesn't elevated CO2 (as opposed to low O2) stimulate respiration? How does giving oxygen suppress this? Is the respiratory center also affected by high O2 levels?
I agree that one ampule would have have had a vanishingly small effect.
People with acute exacerbations of obstructive airways disease don't die from the acidosis. They die from hypoxia.
The danger of the elevated CO2 is that you need higher and higher supplemental oxygen concentration to maintain adequate pO2 in the blood. Eventually CO2 narcosis sets in and once it does, without rapid treatment they are minutes to hours away from dying.
Krebiozen - yes elevated CO2 stimulates ventilation but only to a point, once the CO2 rises enough, CO2 narcosis leads to decreased level of consciousness and hypoventilation.
Giving oxygen doesn't suppress ventilation in a normal person but in someone who is chronically hypercapnic their sensitivity to high CO2 is reduced, thus they become dependent on hypoxia as a driver of ventilation. Thus giving these people oxygen (eliminating their hypoxia) is thought to decrease their drive to breath and worsen their condition. The idea in this last paragraph is contentious and there is some controversy as to whether what i've written is actually true however it is the current "textbook" teaching regarding control of ventilation.
The third paragraph is unclear, it should read:
The danger of the elevated CO2 is that you need higher and higher supplemental oxygen concentration to maintain adequate pO2 in the blood (which may or may not be realised by the treating team). Without treatment of the cause of elevated CO2, the patient inevitably tires and a deadly spiral of climbing CO2 sets in, until eventually CO2 narcosis sets in, they become stuporous and without rapid treatment they are minutes to hours away from dying.
Marssan,
Thanks for that explanation. If I understand you correctly, as pCO2 increases at first it stimulates respiration, but at higher partial pressures it is a general CNS depressant and thus depresses respiration.
I think I'm right in saying that partial pressures of gases 'compete', in that they can only add up to atmospheric pressure, so if pCO2 goes up, pO2 goes down and vice versa - if the blood has a high pCO2, less pO2 can dissolve in the lungs.
I wonder if CO2 narcosis is related to the nitrogen narcosis you see in divers who surface too quickly - there is no longer enough pressure to keep the nitrogen that dissolved in their blood at depth dissolved, so it forms bubbles in the blood, with devastating results. Could increasing CO2 in the blood come out of solution as bubbles?
I also wonder about CO2 binding to hemoglobin at higher partial pressures to form carbaminohemoglobin. Presumably a patient could be hypoxic with a normal pO2 because of elevated CO2 and carbaminohemoglobin in place of oxyhemoglobin.
I found an old paper that states that it is rapidly rising pCO2 that causes narcosis. If it rises slowly the body adapts. I have seen similar things in renal failure patients with ludicrously high potassium levels, when they have crept up slowly.
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Marssan, thank you very much for being objective and unbiased.
As a holistic nurse, I am treating a patient sent home to die with inoperable brain cancer. What would you need to prove that the treatment I am using is truly working? We are only 4 months into the 6 he was given to live. He is continuing to get better day by day.
Mr. Steele, that is a nice story. Please post the case report when you write up your cure next year. Thank you.
Mr. Steele,
Would the treatment you're using be the peanut butter, blackstrap molasses or chewing gum? (Eyes roll...)
http://www.selfgrowth.com/experts/jonathan-steele-rn
...Or maybe it's just plain ol' water?
https://twitter.com/UlteriorHealth
Protip: you should learn the difference between complimentary and complementary if you're going to peddle "alternative"or "holistic" therapies.
Water and breathing, Mr Steele, who would have thought those were good for you?
My apologies for my tone Mr Steele. You may indeed make a difference in your patient's life and that is a good thing, but cancer is a tricky beast. One remission does not an effective treatment make. I do wish you and the man you are helping all the best
A well designed appropriately controlled clinical study, with a large number of patients enrolled, which actually demonstrates the treatment you're using is working.
In other words, the same evidence that demonstrates aspirin is effective, or Claritan is effective, or Zithromycin is effective, or...
Well, I'm sure you get the picture.
Jonathan Steele,
Did your patient have a biopsy and/or radiotherapy? If so it is quite possible that most or all of the tumor was removed or destroyed, and that any apparent improvements are due to post-op or post radiotherapy inflammation slowly resolving.
This small study, for example, found that:In 9 out of 32 patients, the first post-radiotherapy MRI showed progressive enhancement. In 3 of these 9 the MRI improved or stabilized for 6 months without additional treatment. So if you had treated these 3 patients, it would have looked as if your treatment was working, even on CT scans and MRIs. when in fact it was late effects of radiotherapy.
A single case can't prove anything, since the patient may be responding to previous conventional treatment, and even if not, spontaneous remission has occasionally been reported in brain cancer (PDF).
I'll continue this in another comment to avoid moderation.
contd.
You should be aware that estimates of survival are merely educated guesses, the median of a very wide range of possibilities. According to SEER the median survival for brain cancers is 12 months, but almost 20% survive 10 years.
The only way to determine if a treatment is truly increasing survival is to conduct a randomized clinical trial. To persuade NCCAM or OCCAM that a treatment is promising enough for a clinical trial to be carried out, you need to present a case series. OCCAM has clear Best Case Series Criteria that you can follow if you have a case series that shows unexpectedly good results.
If you don't have this, at the very least, on what basis are you treating patients, and how can you justify charging (I assume) them money for this treatment?
Relax! I got the prevention and cure of any diseases.
I am The Lord of the Cancers and Infections - Because I got The Personal Cancer Killer - a devastating weapon of unlimited power against any cancers and infectious diseases on Earth - the prevention and cure for kids and adults of any diseases - from the common cold to cancer - done for a minute a day for prevention and for 3 - 4 minutes a day for the cure.
The price of The Personal Cancer Killer for the whole world is 2,25 Trillion US Dollars, Euro, or BP, because it can erase any cancers and infectious diseases from the face of the Earth once and for all.
Further details are available upon request.
Cancerkiller,
You've posted the same idiotic message here on a couple of different threads using different usernames. Why are you spamming us and why are you using sockpuppets?
I found dentical spam messages from you using many different names on several other cancer message boards all over the internet. You are either a lunatic or a joker. Please eff off and stop posting your garbage here. We are not interested in your nonsense.
Look, W.F.,
You better hide somewhere and enjoy your disbelieves.
So what is your miracle cure/prevention? You say details available upon request; I'm sure I'm speaking on behalf of all RI readers in requesting those details.
So what is your miracle cancer cure/prevention?
You say that details are available upon request; I'm sure I speak on behalf of all RI readers in requesting those details.
So what is your miracle cancer cure/prevention?
You say that details are available upon request; I'm sure I speak on behalf of all RI readers in requesting those details.
So what is your miracle cancer cure/prevention?
You say that details are available upon request; I'm sure I speak on behalf of all RI readers in requesting those details.
So very sorry for the multiple posts. RI comments are very wonky tonight. My comments kept disappearing and the entire RI website itself kept going down. I had no idea my comments had actually been posted.
I think "Cancerkiller" is a Poe.
If so, he's a prolific Poe. He's posted similar comments on several other message boards.
Perhaps an obsessive compulsive Poe?
Actually I had no idea it had been posted elsewhere.
This is what you get if you Google "Personal Cancer Killer":
https://www.google.ca/#q=%22personal+cancer+killer%22
Here is another version of the message Cancerkiller posted on a breast cancer board where he asks for checks of 50 million to reveal his secret. On second thought, this has got to be a Poe or a sick joke:
Breast cancer is just as easily controllable as any other cancer…
Is there a cure for cancer? - That is the question - And the answer to cancer is - A BIG YES! - The End Of Cancer Has Come! - And much more than that - The End Of All Infectious Diseases - plagues like HIV/AIDS, Flues, Malaria, etc. (to name a few) - no epidemics and pandemics worldwide can be at all possible in the future. Travelling around the world, nobody will feel concerned of any indections, for such will not exist anywhere on Earth.
Diabetes also can be prevented or completely cured.
I am The Lord of the Cancers and Infections - Becaus I got the PCK - The Pesonal Cancer Killer - a devastating weapon of unlimited power against any cancers and infectious diseases on Earth - the prevention and cure for kids and adults of any diseases - from the common cold to cancer - just an exercise for a minute a day for prevention and for 3 - 4 minutes a day for the cure - no slicing, no poisoning, no burning will ever take place inside your body.
Doing the cancer killer for a minute a day, at winter air temperature of -15C (5F), I walk around town just in my summer shorts and T-shirt for many hours, without getting sick - I cannot catch cold, flu, HIV/AIDS, or cancer - my body is absolutely proof against such things.
The price of the Personal Cancer Killer for the whole world is 2,25 Trillion US Dollars, Euro, or BP (just 300 US Dollars for evrybody on Earth), because it can erase any cancers and infectious diseases from the face of the Earth once and for all.
I accept any checks of 50 or more Millions US Dollars, Euro, or BP to describe personally the Cancer Killer and how one can feel like a God/Goddess all the time, all his/her life - absolutely untouchable for any diseases - known or unknown on the planet.
Further details of the incredible Cancer Killer are available upon request.
The End Of All [...] Flues
Someone is not keen on ventilation.
Or serious mental illness. The signs aren't as pronounced as in some, but I wouldn't bet against the prospect that Cancerkiller actually believes his false claims.
Especially since there is no link or contact information to learn about his cancer killer special stuff. It is most likely some kind of delusional behavior.
The same stuff has appeared under the signature "Kevin Worldsavior." From its Facebook page:
The price was only $500 billion back in January.
Yep, that sounds like someone without even a tenuous relationship with reality.