In my 13 years of working with stone formers, as a nurse in residence at Litholink Corporation and in my own practice, the number one question has always been: ‘How much water do I really need to drink?’ Maybe as important is: ‘How Do I Do It?’
Many patients leave their doctor’s office with the vague instruction to increase their water input. How much are you supposed to drink to reduce your stone risk?
Even more, patients are told to go home and start drinking a gallon of water a day. If you don’t drink more than a couple of glasses per day now, how are you supposed to drink a gallon tomorrow?
Drinking more water is a simple way to reduce your stone risk, but simple does not mean easy. Most of you find this task extremely hard. I tell everyone to start out slowly. If you drink one glass per day now, then drink two tomorrow. Set new goals to increase your water consumption each week. I have seen people go from 1 glass per day to 10 glasses per day within a month.
Spend Time to Avoid Pain
I can hear you saying now; “I don’t have enough time in the day to spend it in the washroom”.
This is a legitimate response and one I have heard many times throughout my career. I will not lie. You will spend more time in the bathroom, but you will get accustomed to your more frequent bathroom visits. The bigger picture is the one to focus on. Better hydration means you will be less likely to form more stones; this means that water can reduce ER and doctor visits, and lost time away from work. What is going to the bathroom a few more times a day compared to all of the pain, suffering, and expense you will endure if you don’t drink more water?
I have seen my share of pilots, teachers, surgeons, nurses, and traveling salesman all increase water intake despite the time constraints of their occupations. The one thing they all do is make the time.
I have worked with surgeons and surgical nurses before and it is true that they cannot leave the OR to use the bathroom during an 8 hour open heart surgery. Intermittent dehydration can be a real problem in this case. My clients who work in the OR do their best to drink for the rest of the day to try and make up for the loss. Sometimes there is really no choice. Thankfully this is the exception, not the rule.
Once you make up your mind that you do not want to suffer with the severe consequences that kidney stones bring to your life, you will find a way to incorporate more water into your daily routine. It is your choice, your commitment to your health that creates a one day at a time habit of drinking more water.
Under the usual conditions of life, 3 – 4 liters of fluids a day will provide 2.5 to 3 liters of urine volume, and this is enough. The average healthy adult bladder holds about 1/2 liter, so this means 7 – 9 bathroom trips in 24 hours.
Input Doesn’t Always Equal Output
Four factors make the answer harder to come by: sodium intake, geographical location, occupation, and exercise.
High sodium intake can confuse people. It is does not by itself change how much you need to drink, but salt intake can shift the timing of water loss so you think you are not increasing your urine volume even though you are drinking. It does something more. It increases urine calcium losses, a matter we will come back to at a later time.
When you eat a meal that is high in salt, you can count on it decreasing your urine output. I have clients tell me that they drink “a ton” of water but they never have to use the bathroom. The reason is that water is retained with the excess sodium. High sodium meals will decrease urine output that day and even that night, thus causing bloating, worsened hypertension, and higher risk for stones because of higher urine calcium.
But a steady high sodium intake, not just the effects of one meal, will cause a steady water retention and stable weight gain so after a while the extra water you drink will appear in the urine. In fact, when people lower their salt intake they become less thirsty so they have to focus more on drinking or they will ‘forget’.
Even so, keeping your water intake high and lowering your sodium consumption is best. Stone formers who have no medical contraindications to lower salt diets should be aiming for about 1500 mg of sodium per day. People become accustomed to high water intake and low sodium intake, and can benefit not only from the stone prevention but often from a lower blood pressure. How you lower your sodium intake to this number will be discussed in a future post.
There are actually places on the map that we who deal with kidney stones call the “stone belt”. Basically these are the states that are consistently hot and humid or hot and dry. Why is where you live a problem? Simply put, you sweat more. If you sweat more, you run the risk of becoming dehydrated, and being dehydrated reduces your urine volume and makes you more prone to form a stone. If you live in a hot, humid or dry state, you need to drink more to compensate.
Are you working construction in the summer in Texas? Are you a camp counselor in Arizona? Do you wash windows for a living in Florida? Your occupation can be the increased risk factor for your stone disease. The reason is the same as above. You are sweating more and need to drink more than the office worker seated in the air conditioned office whose windows you are washing.
I am very proud of you that you are doing your daily exercise. We all know how important that is to maintain good health. Exercise plays an important part in stone prevention so make sure you do it. Just remember to hydrate before, during, and after to balance the water lost from sweating!
Here are few ways to make water drinking more enjoyable.
Stylish water bottle
Find a water bottle http://www.zazzle.com/fun+water+bottles that you really like carrying around. Seems like such a silly thing, but it really does help. I like big ones so I don’t have to keep getting up to fill it and it makes me very proud to see it empty. You may find smaller ones keep you inspired and you can easily go refill it as you make your bathroom pit stop. Here is an awesome water bottle I have found to help http://www.amazon.com/Basily-Infuser-Bottle-Around-Hydrated/dp/B00M1UOF3K/ref=dp_ob_title_sports
Add fruit to your water. Adding lemons to your water has the added benefit of increasing your citrate level which is a natural inhibitor of stones, but use fruit that makes you smile most.
Using the product Mio http://www.makeitmio.com/ has helped many patients who constantly tell me that water is BORING. My reply is always, “better boring water than excruciating stones”. It is at that point that they take another sip.
Water is the most benign way to increase fluid intake, but don’t forget to include other beverages in your daily intake: Green tea, lemonade (no sugar), flavored waters, even fruit like watermelon, grapes, etc. will be helpful.
Eat Your Water
Here is a list of foods that are made up of at least 90% water. Be careful. Some of them are high in oxalate and for those of you who need to limit your oxalate intake I have asterisked them: cucumbers, radishes, iceberg lettuce celery*, tomato*, green peppers, cauliflower, spinach*, starfruit, strawberries, broccoli, grapefruit, baby carrots*, and watermelon.
Channel Your Inner Child
I have straws on my counter top in a cute container. They add color, fun, and make drinking water a much more whimsical experience. They also makes the water go down a bit faster. I find myself downing a glass with ease when I have a straw. My son likes it too. No matter what your age or disposition, straws add fun to an otherwise boring activity.
If you are enjoying some grape or apple juice, dilute it with half water. You will cut down on your sugar and increase your water intake. This is a win-win.
A neat way to add color and zest to your water without added calories or artificial flavors: Freeze grapes, or lemon, lime, or orange peels, and add to your water instead of boring ‘ole ice cubes.
Make new habits
Every time you reach for a diet soda, replace it with water. Soon you will just reach for water and your old diet soda will be a long forgotten bad habit.
Upon waking, drink a glass or two of water with lemon. This helps keep your urine alkaline and gets you feeling ready for the day.
In winter, get some hot water, lemon and honey. It will warm you up on a cold day.
Green tea (yes, low in oxalate).
Le Croix. For those of you who are addicted to bubbles. Try this no calorie, carbonated water. It comes in many flavors and has been a staple in my house for the past year. There are generic versions of it for budget conscience stone formers.
Drink a glass of water before and after a meal. Drink water. Eat less. Yet another win, win. Who knew it would be this fun?
Be Patient and Persist
I want you to know that incorporating large amounts of water into your life takes a bit of time. New habits are built with commitment, patience, and an understanding that you are not perfect. You will have days that you cannot get in the amount of water that you would like to. It is ok. Your goal is to do your best on more days than not. And when you don’t, you can get back on track the next day.
Drinking more water is the number one thing you can do to help prevent further stone formation. It also has no bad side effects. So what do you say? Let’s raise a glass, a refreshing, ice cold glass of water. It might just save you from your next ER visit.
Water is always the first line of treatment for stones.The most important thing to do about supersaturation is lower it, and water will do just that. In relation to kidney stone prevention, more is better. In a perfectly healthy younger (below age 50) person taking no medications, up to 5 or even 6 liters a day is safe provided it is consumed over the whole day and never all at once. But if you have heart disease, kidney disease, or liver disease, or are elderly, great caution is important and the amount of water needs to be determined individually for you. When diuretic drugs are being used, to lower urine calcium excretion for stone prevention or for blood pressure control, water intake needs to be no more than 3-4 liters a day and testing is necessary at intervals to be sure blood sodium levels have not fallen. Many other medications interfere with water excretion; psychoactive drugs can do this, for example. All drugs in use must be reviewed with your physician before drinking large volumes of water, above 2.5 liters daily. It is true that most people can easily and safely drink the extra water needed for stone prevention, but the reservations are important, always.
I have recently put together a private FB page called THE Kidney Stone Diet. It is a group that helps educate you on your physician prescribed treatment plans. I moderate it to keep it clinically sound. Come on over and join the discussion!
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