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Optimal fluid intake in daily diet: Avicenna’s view

Article  in  Journal of Integrative Medicine · July 2016

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● Global Views
Optimal fluid intake in daily diet: Avicenna’s view
Majid Nimrouzi1,2,3, Vahid Tafazoli1,2,3, Babak Daneshfard1,2,3, Manijhe Zare3
1. Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical
Sciences, Shiraz, Iran
2. Department of Traditional Persian Medicine, School of Medicine, Shiraz University of Medical Sciences,
Shiraz, Iran
3. Essence of Parsiyan Wisdom Institute, Phytopharmaceutical Technology and Traditional Medicine
Incubator, Shiraz University of Medical Sciences, Shiraz, Iran

ABSTRACT
Adequate daily water consumption is an important factor of keeping regular homeostasis. However, the
best quantity of daily water consumption for a healthy individual is not virtually stated in the literature.
Despite the dearth of evidence-based recommendations, it is commonly thought that ingesting eight
glasses of water a day is good for a healthy person. Avicenna had a unique viewpoint. He believed that
daily water intake depended on numerous elements together with age, intercourse, body temperament,
season, occupation and various internal and external elements. He also cited a few essential and useful
measures regarding proper water consumption, which have additionally been emphasized in Islamic
hadiths.
Keywords: Avicenna; traditional Persian medicine; daily water intake; optimal fluid intake; balance, water;
drinking
Citation: Nimrouzi M, Tafazoli V, Daneshfard B, Zare M. Optimal fluid intake in daily diet: Avicenna’s view.
J Integr Med. 2016; 14(4): 241–244.

1 Introduction daily water need that is truly estimated by urine output

As it comprises the primary part of our body, we want
water to preserve ourselves healthy. Human beings need
this vital fluid to maintain adequate tissue perfusion,
which is required to deliver fuel to the end-organs[1]. We
respond to fluid deficits through the sense of thirst, which
stimulates consumption of water or other fluids[2].
Many people believe that water is superb for their
health, but how much water should we drink to keep
ourselves healthy without bringing on health problems?
It is commonly thought that we have to drink eight
glasses of water every day; however, such inspiration for
healthy individuals is poorly supported by evidence-based
research. It should be tailored individually regarding
volume[3,4].
The literature mostly addresses to the complications
of drinking too much water. But how much is too much?
Hyponatremia, water intoxication and insomnia are
some of the complications of excessive water drinking[3].
Moreover, patients with renal failure or congestive heart
failure have further physiological limits on healthy levels
of water consumption. However, there is no special
consideration for the risks of excessive water consumption
in normal healthy individuals.
On the other hand, recurrent dehydration followed
by intermittent water drinking increases the risk of
kidney disease and exasperates hypertension[5]. For this
reason, a balanced daily water intake is crucial for health

http://dx.doi.org/10.1016/S2095-4964(16)60262-5
Received January 20, 2016; accepted May 15, 2016.
Correspondence: Babak Daneshfard, MD, PhD; E-mail: babakdaneshfard@gmail.com

Journal of Integrative Medicine 241 July 2016, Vol 14, No.4

 www.jcimjournal.com/jim
maintenance.
A study in the United States on children under
10 years of age showed no association between water
intake and ambient temperature[6]. In addition, Perrier et
al[7] found that urine color was correlated with daily water
intake and urine specific gravity; lower water intake was
accompanied by more colorful urine and increased urine
specific gravity[7]. However, in hot weather, daily water
needs rise due to the increase in rate of water loss through
sweat. Other factors such as age, gender and employment
may contribute to water balance beyond seasonality[8,9].
Moreover, daily water intake may affect people’s mood.
A recent study in women showed a relationship between
total daily water intake and negative/positive mood.
Lower water intake was correlated with a more negative
mood[10].
In this study we reviewed the most important traditional
Persian medical encyclopedia, Al-Qanun Fil-Tibb (The
Canon of Medicine). Additionally, MEDLINE, Embase,
Scopus, Iranmedex and Science Iranian Database were
searched, focusing on the keywords of “traditional
medicine”, “water intake”, “fluid” and “complementary
and alternative medicine”, in order to identify relevant
literature.
2 Avicenna’s opinion about water drinking
Avicenna (980–1037 CE), the great Persian scholar of the
Islamic Golden Age (the 9th–12th century CE)[11], believed
that daily water demand is not the same in different
individuals[12]. The determinant variables mentioned in
his book, “The Canon of Medicine”, comprise mezaj
(temperament), health status, age, gender, season, place,
habits, occupation and others. As a Muslim physician,
most of his medical views were in accordance with the
Islamic hadiths quoted from the Muslim prophet (PBUH).
Avicenna believes that drinking water with or just after
meals causes a delay in gastric function and disturbs
digestion. In addition, he prohibits drinking two (or more)
different types of water together (e.g., drinking water with
a piece of ice in it) and recommends that drinking should
be in the form of “sipping”[13].
It is recommended in hadith quoted from the Muslim
prophet (PBUH) that the water should not be drunk in one
breath and anyone who is concerned about his/her health
should sip water slowly at least in three breaths. Drinking
water in one breath causes liver disease in the long term[14].
According to Islamic hadiths, it is also banned to drink in
a standing position. Moreover, using water that has been
warmed with sunshine (especially in a cupric container)
has been proposed as one of the causes of vitiligo[14].
It should be kept in mind that the volume of water
consumed should be adjusted with the body’s need and
July 2016, Vol 14, No.4 242
fluid loss. Drinking water more than the body demand
causes frailty and weakness. Avicenna emphasizes the
avoidance of excessive water intake. He believes that too
much water would quench the innate heat (hararat-e-
gharizi). This is the basal internal heat needed to convey
normal homeostasis and metabolism in the body[13].
Drinking water should be fresh, soft and should not
cause a feeling of heaviness. Soft fresh water enhances
the appetite and helps the digestion without causing
flatulence. This kind of water warms and cools faster than
hard water[13].
According to Avicenna’s belief, water is considered to
be the mobadregh (escort) of the foods, which enhances
the penetration of nutrition into the organs. Digestion
of food is impossible without water; however, excess
water disturbs the digestion. Water alleviates the heat of
the stomach and liver, relieving thirst. It is necessary for
excretion of the wastes and makes the skin smooth and
soft. On the other hand, indulgence in drinking water
causes darkening of the skin. Sleepiness, aggravation of
joint disease, sue-al-qoniah (fatty liver) and edema are the
other complications of excessive water intake[13].
3 Proper time for water drinking
The best time for drinking water is when a person is
really thirsty. Water should be cold enough to relieve
thirst. Drinking too much lukewarm water not only
does not relieve the thirst, but also causes an increase
of wetness in the body, and makes it susceptible to
gastrointestinal disturbances and other diseases [15] .
According to Avicenna and the Islamic sages, drinking
water, especially cold water after physical activity, sauna,
long bath or intercourse, is harmful for the body, because
it will quench the innate heat. Avicenna believes that the
innate heat or the internal heat is derived from essential
wetness (rotoobat-e-gharizi) or essence of life and since
it is not a renewable resource, its end is the end of one’s
life [15]. In addition, drinking cold water on an empty
stomach, after a long night of sleep, or in the time of rage
or fright, is harmful to the body[15].
4 Special considerations
Children and young adults need more water because
they generally have a warm temperament[16,17]. Conversely,
the elderly need less water, and drinking too much water
exacerbates their problems, especially gastrointestinal
disorders and osteoarthritis[18].
The existence of morbid matters and phlegm in the
stomach causes the sensation of thirst, in response to
which the person is driven to drink water without relief.
These people usually state that drinking hot water or other
Journal of Integrative Medicine

fluids relieves their thirst. Drinking water aggravates their
problem and they should be treated with medicines that
eliminate the phlegm from their stomach, like ginger,
fennel or cinnamon. It is better that these patients do not
drink water, but drink syrup of honey in warm water to
relieve the thirst. In cases where the thirst is intolerable,
patients should drink water with a straw or sip just a little
cold water[19].
Other incorrect drinking habits include: drinking water
with fruits, which is very harmful to health due to the
accumulation of excessive moisture in gastrointestinal
tract; drinking water with ice, which is totally banned in
traditional Persian medicine; and drinking lukewarm and
warm water, which is a harmful habit and could lead to
gastrointestinal and respiratory disorders[14].
5 Discussion
There are some clinical notions, attributed to past
evidence, that maintaining water intake to achieve
a diuresis of above 2 L/d may prevent renal stone
formation, and prevent reintegration of renal stone
in susceptible people. Actually, an enhanced water
consumption is regarded as a medical strategy to maintain
a normal adequate urine output and decrease the chance
of nephrolithiasis recurrence[20–22]. A recent randomized
clinical trial showed a beneficial effect of a 1.3-liter extra
water intake in decreasing urinary stone formation in
healthy individuals, as the subjects decreased other usual
sources of fluid intake[23]. Nevertheless, evidence that
states preventive effect of increasing daily water intake
in recurrence of urinary stones in susceptible individuals
is inconclusive. According to a recent systematic review,
there was no existing evidence that indicated the benefit of
increasing water consumption for the primary prevention
of urinary stones[24].
About 60% of our body weight is water and we need
about 1.5-liter water intake daily to preserve homeostasis.
Besides, we may also get water from the other sources
such as food and beverages. Thence, it is difficult to
establish a general rule to estimate the net amount of
water intake needed to maintain normal homeostasis,
and it should be determined individually based on their
activities and diets[25].
Fluid replacement with increasing water intake in
patients suffering from acute respiratory infection was
thought to be beneficial due to the compensation of
dehydration and mucus viscosity decrease[26]. However,
some theoretical reasons are also alluded to noxious
effect of increased fluid intake in aforementioned patients
such as increase of anti-diuretic hormone secretion[26].
Accordingly, there is no precise evidence in favor or
against the recommendation of increasing fluids in acute
Journal of Integrative Medicine 243
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respiratory infections[26]. Kelm et al[27] showed similar
findings regarding harmful effect of fluid overload
on septic shock patients treated with aggressive fluid
resuscitation.
Another Cochrane review regarding proper water intake
in premature infants revealed that the most cautious
prescription for them in order to decrease their mortality
and morbidity would be water intake restriction in a
careful manner, either supply their physiological needs
or prevent harmful dehydration[28]. These findings affirm
Avicenna’s viewpoint about the amount of water intake.
Dehydration is defined as “loss or removal of fluid”
from the body when fluid intake fails to fully replace fluid
loss in the body[29]. Water-loss dehydration is a common
cause of mortality and morbidity in seniors but, helpful
laboratory tests and clinical signs and/or symptoms to
detect their dehydration in initial phase have not yet been
clearly determined. Within a systematic review Hooper et
al[30] assessed 67 different tests, however, none of them was
consistently beneficial in identifying whether the elderly
drink enough, or are dehydrated. Some tests did appear
useful in some studies; nonetheless, these propitious tests
should be re-checked to see whether they are also useful
in specific older population or not. There is adequate
evidence suggesting that some tests should not be used for
evaluation of dehydration, including feeling thirsty, dry
mouth, heart rate, urine color, as well as urine volume[30].
6 Conclusion
The traditional Persian medicine approach to diagnosis
and treatment opens a new window for researchers
interested in the field of complementary and alternative
medicine. It provides an opportunity to think more deeply
about the effect of the quadruple qualities (i.e, hotness,
coldness, wetness and dryness) on our health in the
context of modern clinical research. In the case of daily
water intake, as discussed above, it is not acceptable
to prescribe a fixed amount for all people. Different
influential factors such as age, sex, temperament,
occupation and season should be regarded in conjunction
with an individual’s special needs to estimate his/her
recommended daily fluid intake. Moreover, the manner
of water drinking as mentioned in this paper should be
observed to avoid undesirable complications.
7 Conflict of interests
The authors have no conflict of interests.
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