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What is Tea and Toast Hyponatremia? 

“In tea and toast it all comes down to too much tea and not enough [avocado] toast.”

While there are many etiologies for why folks become Hyponatremic, few are more fascinating than the infamous tea and toast. 

This condition has also been dubbed non-beer drinkers potomania. The word Potomania derives from Latin Poto meaning ‘To Drink’ and Mania ‘too much’.  This phenomenon has to do with relative excess water intake with relative low solute intake. In tea and toast it all comes down to too much tea and not enough [avocado] toast. 

The way I explain this to the medical students is the kidneys require a certain amount of stuff to get rid of water. The average American may consume ~800 milliosmoles (mOsm) of stuff. Stuff in this case is mostly consistent of salt, potassium, and protein. In health your kidneys can dilute your urine all the way down to about 50 milliosmoles per Liter of water (mOsm/L). What this means is if you eat 800 mOsm than 50/800 is 16 liters. In theory you could drink 16 liters of water and your kidneys can excrete it all. Most people even if they tried hard couldn’t drink that much liquid. On the other hand if your older and perhaps your kidneys have slowed down you may not be able to dilute the urine quite as well and perhaps can only dilute to 100 mOsm/L.  100/800 is still equal to 8 liters of water before you would begin to have Hyponatremia, which is still over 2 gallons a day.  The issue comes into play when the amount one eats starts to drop off.  For example if you are only eating 300 mOsm of stuff a day and can only dilute to 100 mOsm/L of urine than you can see if someone were to drink 4 liters of liquids than the dilution would start to take hold, and the serum sodium would drop.  

In the referenced article below Thaler et al describe a patient who presented with significant Hyponatremia with symptoms of dizziness and fatigue.  The sodium was consistently in the 120’s.  She was young and healthy running 30-40 miles a week.  On detailed questioning and urine analysis they noted her intake of sodium potassium and protein were all very low and her liquid consumption exceeded 5 liters a day.  In short her Hyponatremia was actually reversed by simply increasing her protein intake to a a more potent 80  grams a day.  They also noted when the patient was left to her own dietary indiscretions she reverted back to a low protein diet and the sodium level subsequently dropped.  

One can see from the chart pilfered from the AJKD article referenced below, that at a maximum dilution (50 mOsm) and a solute intake of 900 mOsm the water excretion comes in at nearly 20 liters.  One can also see if only consuming 300 mOsm and dilution to 100 mOsm/L of urine the water excretion is now back under 4 liters.  

In summary it is imperative in Hyponaremia to not only decrease ones fluid intake but also increase ones solute intake.  Solute is Salt, Potassium, and protein.  By doing this we can aid the kidney in excretion of of the daily water load. UreaAide is an additional way to add solute to ones regimen.  One scoop of our Unflavored Urea is equal to 250 mOsm of solute.  One can see on the chart, that increasing the solute consumption in this manner can nearly double your water excretion and diminish the dilution effect.   

References:

  1. Beer Potomonia in Non beer drinkers:  Effect of low dietary solute intake.  SM Thaler, Teitelbaum, Berl.  AJKD VOLUME 31, ISSUE 6, P1028-1031, JUNE 01, 1998

DOI:  https://doi.org/10.1053/ajkd.1998.v31.pm9631849

2.  Impact of Solute excretion intake on urine flow and water excretion 

JASN June 2008, 19 (6) 1076-1078; DOI: https://doi.org/10.1681/ASN.2007091042