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A THIRST FOR VARIETY

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I have heard this one million times from patients in my practice. Make stones? Drink water. Water, water, and more water. Drink it all day long, all night long. Just drink water.

What about other fluids? Are they safe? Are they high in oxalate? Will they count toward your daily intake? Is caffeine a problem?

Your Physician Prescribes How Much

I will be offering as much variety as I can, and encouraging you to drink, but the volume you need comes from your physician. This applies especially to my two day long examples. I made them to provide very large amounts of fluids for those who need them. If your physician prescribes less, just scale my recommendations back. Under no circumstances should you follow a fluid prescription in this post unless it fits with your physician’s specific recommendations for you.

Some Beverages Raise Stone Risk

What Did People Who Developed Stones Drink?

Perhaps the most useful study of this matter is by Ferraro and colleagues. Two large groups of nurses and one group of physicians have been followed for many years to ascertain habits and diets that appear healthy or unhealthy.

Some of the people in each group developed kidney stones. Most, as expected, did not. Because diet habits were closely monitored by well established questionnaires over the years, the scientists could determine which beverages, my particular concern here, were associated with a higher or lower risk of becoming a stone former.

The amounts are important to keep in mind. For coffee and tea it was 8 ounce servings. For juices, a small glass. For carbonated drinks and beer a glass, bottle or can. For wine a 5 ounce glass. Servings were graded from less than 1 weekly, over the range of 1, 2-4, 5-6 weekly, and more than 1 serving a day. A significant effect meant that as the amounts increased, the risk of new stones increased or decreased in rough proportion – there was a ‘dose’ effect.

Winners and losers

Sugar sweetened colas and non-cola drinks were associated with development of kidney stones. Punch was also associated with more stones. But drinks with sugar in them were not all bad. Apple juice, grapefruit juice, and tomato juice did not raise or lower risk of stones.

Coffee, decaffeinated coffee, tea, red wine, white wine, orange juice, and beer were the winners. People who used more had a lower risk of new stones.

No Special Effect on Stones

We already mentioned apple, grapefruit and tomato juices. Add to them liquor, artificially sweetened sodas – cola and non-cola (clear sodas), whole and skim milk, and water itself.

Water Is Not Your Only Option

Nothing is totally off limits when it comes to increasing fluids. The main point is that you do, indeed, increase them. If having a soda here and there helps you maintain your ultimate daily fluid goal, then by all means, treat yourself once in a while.

I am certainly not advising you to have as many Coke’s as you would like, nor am I advocating that you drink very large amounts of coffee all day long, even if coffee drinking lowers risk of stones. What I am saying is that all fluids count and water is NOT your only option. Other beverages help provide variety but my principle is to use them in moderation.

This post will help you decide which other beverages you might incorporate into your diet to help raise your total daily fluid intake. Keep in mind that you need to take into consideration other medical conditions you may have that will contraindicate some of these choices. Review your version of my plan with your physician to be sure.

Pucker Up!

Lemonade is an excellent way  to increase your total daily fluid intake and raise your urine citrate level. Citrate is a molecule that binds to calcium so that calcium does not have the chance to bind with phosphate or oxalate. It also slows the formation of stone crystals. Both actions decrease your risk of forming new kidney stones. Lemonade use was not part of the large beverage study I have already quoted, but is thought to be beneficial for stone prevention, or at least not a specific risk like sugared drinks.

The Best Tasting Ones

The Huffington Post polled people on the best store bought lemonades. The winner was Whole Foods brand 365 Pasteurized Lemonade. The next two best were Simply Lemonade and another Whole Foods product, brand 365 Organic Lemonade. Read the whole article and let us know which ones you like.

Unfortunately, all three winners have extra sugar added to them. Simply Lemonade seems free of extra sugar, but comments to a review of the product document added cane and beet sugars.

Sugar in any form can raise kidney stone riskand sugared drinks raise risk of stones – as I have already pointed out. Of course sugared drinks promote weight gain, and raise blood glucose and insulin. But if you follow my moderation principle some of these tasty treats are fine. ‘Some’ means some.

My Favorite for You

I recommend Crystal Lite™ lemonade for my patients, as it is a no calorie alternative. The other reason I love this for you is its convenience. Here is a link for on the go” packets. Another recent post on this site points out that those who need potassium citrate treatment can use this beverage in place of some of their pills.

Make Your Own

You can also just squeeze some fresh lemons to add to your water. If you don’t have time to always buy, cut up, and squeeze fresh lemons, here is an excellent, convenient, alternative: Pre-made concentrate. I get it at Whole Foods, but you can find it at Walmart and Amazon as well. In order to increase your citrate level with a recipe that has been tested in a research experiment, you need to add one half cup of RealLemon© to 7 1/2 cups of water. The Whole Foods concentrate may work as well, but has not been tested.

Got Milk?

Adding low fat, skim or 2% milk is a great way to increase your daily fluid intake and also help you to increase your diet calcium intake. For those of us who are lactose intolerant, here are lactose free alternatives.

Lots of Calcium and Protein

Getting normal amounts of calcium into your diet (about 1000 mg/day) is necessary for your bone health. An 8 ounce glass of milk contains about 305 mg of calcium. Two percent contains 295 mg. You can check the amounts for all milks at the site. There is a lot of protein (8 grams) and other nutrients, too. The protein content is the same whether for fat free or whole milk.

Not So Many Calories As You Might Think

Milk is a calorie bargain. An 8 ounce glass of 2% has only 120 calories, and 1% 105 calories.

Soda Pop

The Skinny on Diet Sodas

Having a diet soda a few times a week will add to your overall fluid intake and, as I have already pointed out, does not increase risk of forming kidney stones to a significant extent. But, unlike milk and lemonade, most sodas offer you no health benefits.

There May be Real Risks

There may indeed be drawbacks. For example, in one study, risk of hip fracture seemed related to diet soda intake in women.

There is Risk By Association

Among diabetic young men, use of diet, but not sugared, sodas was associated with higher average blood glucose. This was ascribed not so much to the beverages as to the generally unhealthy life style of those who consumed larger amounts of such beverages. Likewise, in another study, diet sodas were associated with new onset of type 2 diabetes in men. But with full adjustment for other factors that might predispose to diabetes, the effect of diet soda disappeared. It seems as if men who were trying to lose weight, or compensate for high diabetic risk, preferentially used diet sodas.

Cola vs Uncola

Given that there are drawbacks to sugared sodas and no benefits to diet sodas, what about the clear sodas – the non-cola drinks, as a special case?

The clear sodas have citric acid instead of phosphoric acid. We have already presented the chart of citrate levels in clear soda and you can read it over yourself: Higher is better. Likewise, in the same post, this site has presented the case for the use of beverages as a source of citrate in place of expensive potassium citrate pills.

 7UP and Sprite have no caffeine which may be an advantage for some people.

The Final Verdict

Think of diet sodas as a treat, probably not a good protection against stones. The higher urine volume is offset by what else is in the soda. It is not something to have all the time. Diet soda may increase hip fracture risk in older women. Sugared sodas raise risk of stones, so just avoid them except for a special treat once in a while.

Given the high price of potassium citrate pills, many patients may need to use high citrate beverages, which are clear sodas, as a supplement. For those who do not need supplemental citrate, and there are very many stone formers in this category, the clear sodas serve no special purpose except for variety and taste.

Unless you are using high citrate beverages to replace potassium citrate pills, limit how many times a week you are choosing soda as an alternative to water. I would recommend no more than 3 cans a week. If you’re somebody who drinks it every day, start weaning yourself off of it.

Try substituting a LaCroix for each can of soda. It is carbonated and flavored, but without the calories, sugar, and yucky stuff that soda has in it.

Wake Up and Sip The Coffee

I drink one cup of coffee every morning. Not the 72 ounce cup you can get at Dunkin’ Doughnuts, just one true cup. I need it, I love it, and I will not do without it. There is no doubt that coffee can contain considerable oxalate. Instant coffee has even more oxalate per gram than the regular coffees. The question is whether drinking coffee increases urine oxalate, which has not been determined. 

I suspect it does not because coffee drinkers have a lower, not a higher kidney stone risk. In the same prospective study I quoted  for sodas, caffeinated coffee drinkers had a 26% statistical reduction in new stone onset compared to people who did not drink coffee and there was a graded reduction in risk as the amount increased from none, through 1 cup per week, up to 1 cup or more every day. The decaf drinkers had a 16% reduction.

These coffee drinkers were not using coffee as a form of stone prevention. I presume they used it as a pleasurable beverage. So there is something about coffee drinking that offered a protection.

The issue is therefore not about kidney stone risk but about how much coffee people should drink every day. That is something you need to discuss with your physician. But, I cannot imagine anyone will use coffee, even iced coffee, as more than a small fraction of the many liters of fluid needed daily for stone prevention.

Terrible Teas?

Every patient I have worked with (thousands at this point) has told me that they have been told NEVER, EVER, to drink tea. Tea is known to be high in oxalate. It is true that tea is a higher oxalate beverage, but if you drink it in moderation, a cup here and there will not increase your risk of forming new stones and does add to your total daily fluid intake. In support of what I just said, in the same study I have already quoted in the prior paragraph, tea drinkers had an 11% reduction in stones.

Even though a cup or more of tea every day appears to decrease stone risk, tea, and iced tea, are not a reasonable source for the majority of the large quantities of fluid used in stone prevention. Tea is like coffee: A source of some fluids and variety.

Lovely Libations

The very important epidemiological study on beverages which I have been quoting offers perhaps a little surprise: Wine drinkers (5 ounce glass between 1 per week and 1 or more a day) had a progressive reduction in stones of 31% to 33%. Beer drinkers (1 can between 1/week and 1 or more daily) had an even higher reduction of 41%.

None of these quantities are like the scale of water drinking, or even milk drinking. These are like coffee and tea: Pleasure drinks.

Overall, your alcohol intake is between you and your physician; drinking in excess is never advisable. One glass of wine, or one can of beer a day may confer real benefits for stone reduction.

In between rounds, remember to raise a glass to your old friend water. Your body will thank you the next day.

Sport Drinks

I have not encountered very many patients who use sport drinks in important quantities. Maybe I travel in the wrong circles. Sweetened sport drinks all have the obvious disadvantages of their sugar in relation to stones, and, of course, for weight control. None were remarkable sources for citrate. They are like the sodas: Occasional treats to break up monotony.

Juicy News

If you want risk reduction specific to a juice, orange juice, 1 or more small glasses a day, was effective (12% reduction). Apple, grapefruit, and tomato juices had no effect.

But the lack of an effect is not critical here. The study refers to a small glass daily and did not test larger volumes for urine dilution. Given that none of the juices increased risk, I see no reason larger volumes cannot be used as part of the day’s fluids, apart from the problem of calories – from sugar.

Although cranberry juice may help in protecting you from recurrent UTI’s, no studies have shown it reduces kidney stone risk.

A Day In The Life

 How do these suggestions play out in normal day life?  Let’s take a look at an example weekday and weekend day. For those of you who are trying to increase urine citrate, we have a whole post to help you.

These are Examples; Your Physician Sets The Amounts

I have already said this and say it again. These examples are for very large volumes of fluid. They show you how you can achieve such large volumes with variety. Your physician will tell you how much to drink. Scale back these examples to match what you are told.

Perfection Is Not a Realistic Goal

You may notice that depending on your day you may drink less than your goal. You may not reach your intended goal every day. It is OK. You are not going to be perfect every single day. Try your best on most days, and if you have a really bad one, just make up for it on the following day.

Monday – A Weekday Fluid Plan That Provides 120 ounces (~1 gallon)

Here is a weekday example for your sunny, early riser with a job and a lot to do. The plan provides 120 ounces – one gallon – of fluids a day and aims for modest front loading so you do not have to get up at night. It includes a treat – diet coke – which could be any diet drink. It does not favor milk because many people do not like it or cannot tolerate it. If you can, milk can substitute for water whenever you wish.

Wake Up – 6 am

1 cup of coffee or tea (5 ounces).

5 ounces of milk with cereal

One 8 oz glass of water with lemon

Mid-morning

Three 8 oz glasses of water

Lunch

One 8 ounce glass of fresh lemonade or diet lemonade beverage

One 8 ounce glass of water

Mid Afternoon

Two 8 ounce glasses of water

One (5 ounce) cup of tea

Dinner

One 8 ounce glass of water before dinner

One 8 ounce glass of water during dinner

One can of diet soda — 12 ounces toward the end

After dinner / before bed

One 8 ounce glass of water

One cup (5 ounces) of herbal mint tea

Saturday – A weekend plan that provides 148 ounces

No work for most of us but a lot of chores. Weekends may be a time to up the ante and go over a gallon. Even if you fall short on the weekdays a bit, and likewise on the weekends, these plans are large enough to give you some margin. But it would be ideal to stay on the high side more days than not. You are buying insurance by the day, after all.

Wake Up – 8 am

1 cup of coffee or tea (5 ounces)

One 8 oz glass of water with lemon

5 ounces of orange juice

Mid-morning

Three 8 ounce glasses of water

Lunch

12 ounces of iced tea

8 ounces of water

Mid Afternoon

One liter of water with workout at gym (about 34 ounces)

5 ounces of green tea

Two 8 ounce glasses of water

Dinner

Two 8 ounce glasses of water

Two 5 ounce glasses of red wine

One 5 ounce decaf

The Wrap Up

My intention was to convey that water does not have to be the only thing you choose when calculating your daily fluid intake. All fluids DO count toward the total.

I think this is important to note, as many patients tell me they hate drinking so much water everyday and then wind up not drinking at all. You can safely add items like diet soda, fruit juices, tea, and alcohol if you do it sparingly throughout the week along with your best friend: water.

Personally, I choose water most of the time. It is free, without any calories, supposedly good for my skin, and does a great job of quenching my thirst during the day and after exercise. As a middle-aged woman, it checks all my boxes.

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37 Responses to “A THIRST FOR VARIETY”

  1. Jeanne O'Brien

    How do I measure oxalate in my urine? My urologist has never
    mentioned this. He just gives a list of foods to avoid. Thank you.

    JO

    Reply
  2. syam

    is red wine good for kidney stone ?

    Reply
    • Fredric Coe, MD

      Hi Syam, As far as I know it is not a risk nor a special benefit. Regards, Fred Coe

      Reply
    • Diane Stephenson

      I had a heart attack on 3-12-16 on the way to the E.R. passing a 9.5 mm stone……….Then I had to have a heart cath; I was advised that the heart enzymes became elevated due to the intense pain of passing that stone. I had no blockages. I never want another kidney stone………….all prevention methods would be appreciated. Thank you.

      8-5-16

      Reply
      • Fredric Coe, MD

        Hi Diane, I am not sure if that was a heart attack or just massive cardiac overload from hormones released because of all that pain; I Hope your heart recovers perfectly. As for prevention, the best way is to follow an organized approach. Here is one I wrote and like. Let me know. Regards, Fred Coe

        Reply
  3. คลิปโป

    You ought to take part in a contest for one of the mօst useful blogs on thе web.
    I will recommend this website!

    Reply
  4. Dana

    Crystal Light “Pure” is now available in their “on the go” packets. Apparently it contains no preservatives or artificial flavors. It does contain 3 grams or sugar and Stevia, a natural sweetener from the stevia leaf. Do you see this product in the same positive light that you see the artificially sweetened Crystal Light? Thanx!

    Reply
    • Fredric Coe, MD

      Hi Dana, My colleague Dr John Asplin measured citrate in the product I mentioned, and we published what we measured. I cannot know if the pure product is the same. But, you could tell. If you are using it in place of potassium citrate, see if your urine pH remains as high with the new product as with the old one. Get a 24 hour urine on the old one, and then the new, of course, so you can do this. Also notice the urine ammonium ion; it should be low using the old one and if it stays low then the new one is fine. Old and new are in relation to urine sulfate. Here is a link to how to read this on your lab reports. The uric acid link says a lot about ammonia, the calcium one less so. Regards, Fred Coe

      Reply
  5. Nilesh Pandey

    I have had a surgery of kidney stone in 2012 and have developed again.I have 2cm stone in my right kidney and 1cm in my left kidney.I dont want to go for surgery again.Please help if you have any ideas.

    Reply
  6. Colin

    I have had a ct scan which confirms I have 2-3 stones per kidney which are 3-5mm in size. My doctor has told me not to drink tea and has offered little less advice. What do you think?

    Reply
  7. MegRN

    I’ve gone back to coffee after my last kidney stone, and although I love coffee, my stomach does not! Someone recommended Teeccino. I tried it (with milk of course!) and it’s good; but I am concerned about the oxalate levels. I could not find any resources about the oxalate levels in Teeccino, but the ingredients include almonds, figs, and dates; those ingredients are high. Thoughts?
    Thank you.

    Reply
    • Fredric Coe, MD

      Hi Meg, The constituents are high, so I guess the product has a lot of oxalate. One possibility is to use the product and recheck a 24 hour urine to see if oxalate has risen. Regards, Fred Coe

      Reply
  8. M Mohammed

    This study shows that grape fruit increased the risk of kidney stone formation: http://aje.oxfordjournals.org/content/143/3/240, unlike some other studies sited here.

    Reply
    • Fredric Coe, MD

      Hi M, It is true that this article makes that comment. But in a much larger and much more recent article the same lead author – Curhan – found no effects of grapefruit juice. It was that more recent article Jill referenced. It is not all about recency, it is that in the later article the group had better access to more data. The values for grapefruit juice were RR values of 1.06, 1.01, 0.99, and 1.10 for 1 week, 2 -4 weeks, 5-6 weeks and >1/day usages; the 95% CI for all five values passes through 0 meaning lack of deviation from 1, and the p value for a trend with time was 0.26 age adjusted and 0.22 fully adjusted. So grapefruit juice poses no detectable risk of stones. Thanks for your careful reading. Regards, Fred Coe

      Reply
  9. m Smith

    Is it okay to use Mio water enhancers when you have a body that’s makes kidney stones?

    Reply
    • Fredric Coe, MD

      Scientifically there is no data at all, so I am just guessing. It seems harmless although loaded with chemicals. The amounts of the additives is small, and if the flavoring does it for you it is a fair trade off. Regards, Fred Coe

      Reply

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