How to Eat a High Calcium Low Sodium Diet

Many patients assume that they are forming calcium stones and should therefore limit their calcium intake. That assumption could not be more wrong. Low calcium diet won’t stop your stones and may even increase your risk. Lets not forget that our bones are in desperate need of calcium to avoid osteopenia and osteoporosis.

But, many of the best foods for calcium are also high in sodium, and sodium raises urine calcium loss and stone risk.

Now what?

How Much Calcium do We Need?

The National Institutes of Health tells us age matters. Nineteen to fifty year old male or female need 1,000 mg of calcium a day. Fifty one to seventy year olds need 1,000 mg for males and 1,200 mg for females. Those above seventy one need 1,200 mg, both sexes.

We all know that much of our calcium comes from diary products. But did you know that dairy products are very high in sodium?

When we eat a high calcium food that is also high in sodium the sodium can undo the benefits of the calcium by raising urine calcium losses. This is especially true for stone formers with idiopathic hypercalciuria whose urine calcium is much more sensitive to sodium than in normal people.

So we need to search for dairy products that are lower in sodium than usual.

We also have to find what else there is because not everyone can tolerate dairy products. This means fruits and vegetables, and they may contain oxalate.

How to Read Food Labels for Calcium

All food labels are based on a 2000 calorie per day diet. Calcium is given to us in the form of a percentage.

How do we figure out how much we are getting per serving?

Take a look at the featured picture. It shows Friendship Dairy cottage cheese no salt added.

This is a great product for high calcium and low salt. On the label it tells us that per serving you will receive 10% of your daily value for calcium.

How do we convert this to milligrams?

Since we know that every food label is based upon a 2000 calorie per day diet, and gives the percent of the recommended 1,000 mg of calcium for that diet, we can just put a 0 at the end of the percent. So 10 percent is 100 mg of calcium. In this case a serving size is half of a cup. Eat more or less and the calcium from the product will vary.

Eating a low sodium, high calcium diet can be overwhelming and difficult to incorporate into your daily life. I just released a course called The Kidney Stone Prevention Course to help you understand how to implement your physician’s prescribed treatment plans.

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We are going to continue with the example of the cottage cheese

breakstone reduced sdium cottage cheese

The low salt version of Friendship Cottage Cheese has only 60 mg of sodium per serving. The regular Friendship cottage cheese contains 260 mg/serving. This is a great sodium savings in that the ideal intake of sodium is only 1,500 mg daily.

As a contrast take a look at this product.

The label, which does not show, says a serving contains 15% of daily requirement which is 150 mg of calcium. But the sodium in that serving is 290 mg!

The Trouble with Food Labels

These Friendship and Breakstone cottage cheese products are two excellent examples of how difficult it is to distinguish between really low sodium and rather high sodium products.

The 30% less sodium label is correct, but it is 30% less than a lot of sodium. The Friendship label tells you there is no salt added, which is also true.

But the actual sodium amounts are what you want to look at. They have to be accurate by law and they are.

You have to notice the small subtleties in all food labelling. It is definitely worth the time if you want to keep sodium low while getting adequate calcium.

How to Shop for Low Sodium Dairy Products

We have to become experts at reading food labels. Don’t pay mind to the front of the package. The nutrition label is the only thing you need to look at. You want the highest calcium for the lowest sodium, and the only way to get it is by looking at the label. Sometimes this may require you to look at several brands. You may have to stop using your favorite brand.

In the beginning of this process it may seem this is a daunting task.

But before long you will become quite efficient and even a food label expert.

No Food Label?

Many of  you will shop at the deli counter or prepared food section, or eat in a restaurant. You will just have to remember that certain dairy products have a lot of salt – like cheese – and find the low sodium alternatives. When you are asking the deli counter person to cut you some cheese or the waiter to bring you a fancy cheese plate you have to ask for the low sodium varieties if there are any.

What if You Can’t or Won’t Eat Dairy Products

If you won’t maybe you should take a look at our list and reconsider. The list is ordered by how much calcium is in a serving. Dairy products win by a big margin. So if you possibly can use them, use them.

The remaining options are fruits, vegetables, fish, and supplemented foods. We have consulted the usda data laboratory charts for calcium and sodium, and our own oxalate lists to give you what we can find with modest oxalate and a high calcium per sodium ratio. We have redacted from the immense usda lists our list of the best calcium to sodium bargains adjusting for oxalate from our oxalate lists.

The list is what we think will be most useful to you. Below we highlight a few foods in each category that we specially like.

Fruits and Juices

Fruits have very little sodium when raw and fresh, so it is all about their calcium content.

The most calcium in this category will be found in one cup of calcium fortified orange juice – 366 mg. Calcium supplemented grapefruit juice gives 350 mg of calcium in 8 ounces. The oxalate in grapefruit is modest and will fit into most diets. Apple juice fortified with calcium has little oxalate and is a good choice. We emphasize that these are calcium supplemented juices, otherwise they will not do.

Some useful foods have too little calcium to make our list but are good, Pineapple juice, 6 ounces gives 84 mg of calcium. Plums and apricots are very low in oxalate and a cup gives about 70 mg of calcium. Blueberries and pears are low in oxalate and give about 60 mg for a cup. Peaches give about 50 mg of calcium/cup.

Fish and Seafood

Sardines, no salt added, have about 150 mg of calcium and 50 mg of sodium in a serving. Three ounces of canned salmon provides 212 mg of calcium and 64 mg of sodium. Most other fish, even fresh, have about 80 mg of sodium for every 120 mg of calcium, which is not a great ratio. Crustacea have very high sodium levels even when fresh.

Vegetables

From the list, here are a few highlights.

Kale, frozen, boiled, and drained without salt has 179 mg of calcium, 20 mg of sodium and little oxalate – a great bargain. Mustard greens, frozen, are low in oxalate and have 152 mg of calcium with 38 mg of sodium. Chinese cabbage (bok choy) has 158 mg of calcium and 58 mg sodium in 1 cup, and very little oxalate.

Several foods are too low to make the list but are tasty and can be used. Winter squash gives 80 mg calcium and 8 mg sodium in one cup. Raw onions have little oxalate but 72 mg of calcium and 8 mg of sodium in a cup. Cowpeas, if you find them, also known as black eye peas,  have 184 mg of calcium, and 27 mg sodium in a cup.

So Now What?

You may not like what I am about to say but that’s not going to stop me from saying it. For people who choose to avoid dairy products by choice or because of lactose intolerance or food allergy, it is difficult to get enough calcium into the diet without an excess of sodium and in the case of fruits and vegetables too much oxalate. There is one usable alternative milk and yogurt product: coconut. Soy and almonds are too high in oxalate.

That leaves supplements. We have already mentioned calcium supplemented juices. Pill supplements can be used – check with your physicians – but only with substantial meals. Taken without food they can raise urine calcium a lot and it is not clear that bone cells will use the calcium. So used improperly supplements can increase stone risk. With meals, supplements can and do lower urine oxalate.

Eating a low sodium, high calcium diet can be overwhelming and difficult to incorporate into your daily life. I just released a course called The Kidney Stone Prevention Course to help you understand how to implement your physician’s prescribed treatment plans.

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45 Responses to “How to Eat a High Calcium Low Sodium Diet”

  1. Lois

    Hi Dr. Coe. I have idiopathic hypercalciuria and an asymptomatic 8 x 8 x 12 mm kidney stone. Blood serum Calcium 8.9. 24 hour Litholink urine collection results: volume 3.85, SS CaOx 2.03, Urine calcium 227, Urine Oxalate 21, Urine Citrate 945, SS CaP 0.31, 24 Hour Urine pH 5.911, SS Uric Acid 0.32, Urine Uric Acid 0.492. Today I also was diagnosed with osteopenia. My internist said I should take over the counter calcium pills 500 mg three times a day with a 2,000 unit Vitamin D3 pill. Am I correct that taking calcium supplements in pill form will increase stone risk, especially if you take it with Vitamin D? What do you do in this situation? Also, do the above results indicate that I have a calcium phosphate stone and therefore do not need to eat a low oxalate diet? Thank you so much for your help.

    Reply
    • Fredric Coe, MD

      Hi Lois, Your urine calcium is marginally high, blood oxalate low normal, and you have bone disease. I agree that diet calcium should be high but if diet sodium is not also lowered urine calcium will rise and bone disease may not benefit. Here is an overview of the proper diet. The article on high calcium low sodium diet conveys the key sodium information. Pill supplements will do only if taken exactly with the larger meals; otherwise urine calcium might rise too briskly. But what about foods with calcium in them? Regards, Fred Coe

      Reply
      • Lois

        Hi Dr. Coe. I will follow your advice– low sodium, no sugar, and lots of water. I don’t want to risk increasing urine calcium by taking calcium pills, so I have decided to make sure that I eat foods that will give me 1,500 mg of calcium every day instead of taking calcium pills. I also will take a 2,000 unit Vitamin D3 pill. Thank you for your invaluable help.

        Reply
        • jharris

          Hi Linda,

          Just want to make sure you are not too restrictive. It is advised that you eat less than 25 grams of ADDED sugar per day. Don’t try to do no sugar as when we deprive ourselves that much we inevitably “fall off the proverbial wagon”. You can tell if it is added to a product as you will see it in the ingredient list. So milk is fine even though it has sugar in it. It is naturally occurring, just like fruits. But if you are looking at a cereal label and it has high sugar, take a look at the ingredient list. You will undoubtably find sugar hidden a few times within it.

          Read the article on this website called: How to Wean Off Sugar- it will help a lot.

          Hope this helps-
          Jill

          Reply
  2. Hina

    Hi Dr Coe,

    I was diagnosed with a PUJ obstruction in my left kidney and was operated in 2007 by under going a pyloplasty. Now after 10 years I experienced a sudden unbearable pain that I had to be rushed to the emergency where they finally diagnosed that I have a cluster of Kidney stones in my left Kidney. I was then operated for Stone removal and then a procedure called endopylotomy was performed. After which 15 stones were removed and a stent was placed to be removed after 3-4 weeks. The stones were tested and were confirmed as Calcium Oxalate stones. The entire process was so painful the second time around that I cannot think of being operated ever again. The shape of my kidney is always swollen and thats why the stones found a place to rest in the base. The doctor mentioned I had an obstruction as well due to which urine was stagnant a lot of times in my Kidney. Quite honestly I use to not drink 2-3 liters of water too. Please help me understand how can I avoid stones in the future as 15 stones is way too much and I must be doing something wrong. Do you think we can also analyze the age of the stones? Is there a medicine that I can take to clear or flush my kidneys?

    Reply
  3. Shari

    I really appreciate all your information about low oxalate and a good level of calcium since I’m having trouble with too much oxalate. However, I noticed your spreadsheet showing best calcium to sodium foods has whole grain Total cereal mislabeled. The box says one serving (3/4 cup) provides 2% of the daily requirement for calcium, which would make that 20 mg. based on your formula, not 1.000! mg. Since I have high cholesterol despite a low dairy, low meat diet, I could really use better calcium sources that don’t also contain cholesterol. I am a small person so I’m looking for high calcium sources that don’t require me to eat more calories than my small frame needs. Any ideas?

    Reply
    • Fredric Coe, MD

      Hi Shari, Thanks, and we will fix it. Low calcium diet is not a good idea and without dairy products it is hard to get enough calcium. If you cannot use them, then calcium supplements are a difficult second: they must be taken with the main meals to avoid sudden calcium loss in the urine. But ‘too much oxalate’ may not be all that is wrong. Take a careful look at your own reports to be sure that is all. Jill and I exhausted ourselves finding the foods on the list, and do not know any more. Regards, Fred Coe

      Reply
  4. Kathy

    I have calcium oxalate stones and the consensus seems to be that calcium supplements are not good to take and may contribute to the formation of kidney stones. I took calcium supplements for many years until I had my first kidney stone a couple years ago. I’m now trying to increase dietary calcium in my ‘plant based’ diet, but am confused with why fortified foods like plant milks, orange juice, and cereals are considered good sources to get calcium when they are not truly natural food sources, such as kale, broccoli, cauliflower, dairy milk, etc. Isn’t the calcium carbonate added to fortified foods just as bad as in the supplemental form? I’ve read conflicting viewpoints on how well the body is able to utilize the calcium from fortified food sources, so this concerns me. And if calcium fortified foods are indeed a good way to obtain calcium, wouldn’t taking calcium supplements along with a meal serve the same purpose? My doctor has told me it’s ok to take calcium citrate, one capsule twice per day with meals (1 capsule is 160 mg). What is your take on this and what do you recommend, especially for those of us that would like to avoid dairy? The only way I see to get my recommended 1,200 mg calcium per day is to eat these fortified foods and/or get some of it met via the supplements.

    Reply
    • Fredric Coe, MD

      Hi Kathy, The big issue with diet calcium – supplements or foods is timing. If you eat high calcium foods they are foods and the calcium is absorbed more slowly. Most importantly, you want the calcium eaten where the oxalate is – with meals that have oxalate from plants. If you just take supplements away from meals the calcium goes into the urine and does not block oxalate which comes in with meals. If supplements are timed exactly with meals they will block oxalate absorption. We need a trial of this, so I am presently assuming based on research. Regards, Fred Coe

      Reply
  5. Kate

    I have just had surgery to remove a calcium oxalate stone. Hopefully my one and only. My doctor just told me to avoid cheese, yogurt, red meat eat less salt, more fresh fruits and vegetables and drink a ton of water. In reading all of your material (which is so helpful, by the way) I saw where it said to avoid Vitamin D? I also have Multiple Sclerosis and take 5000 mg of Vitamin D a day. It’s necessary for MS and I can’t stop taking it. Will it cause a problem?
    Also, I drink a glass of sweet tea almost every day. I’ve read tea is OK and I’ve read that it’s not. Which is right?
    Thank you so much for all your information, explanations and encouragement!

    Reply
  6. serypeta

    Hey there, Gidday from Australia.
    Have purchased your kidney stone program, but haven’t had a chance yet to look through it as so busy with work. In saying that I have been researching some thing which are important to me.

    I have had 3 kidney stone attacks, the last one being the last as far as I am concerned.

    Problem is I am following a ketosis diet right now to lose weight (9kg in 4 weeks so far) which means, high good fats, medium protein and 20gram carbs in one day.

    Due to the kidney stone I obviously have to be wary of HIGH Oxolate foods, as have felt the wrath off too much spinach before I realised it.
    All my studies have shown to have god calcium foods with the moderate or so oxolate foods, so am trying to get a good list of everything. High Calcium foods also can mean high oxolate and so on. making lists of everything.
    1. Do you have a list of High Calcium, Low Oxolates (I mostly eat fresh foods, not packet or canned except will try the sardines and tuna)

    2. If I have to eat moderate to high oxolate foods will these calcium foods stop stone formation (ie: lots of liquid and lemon water during the day to keep the urine flowing as well)?

    Obviously once I finish this ketosis diet which is the first thing in my life to help me lose weight finally, I can be a bit more picky with food rather than watching the carbs etc, and then I want to lessen the meat as not a big meat eater.

    3. Also I have been making protein bread, and products, is this as bad as meat for kidney stones or better.
    hope this all makes sense and you can answer me thanks
    serypeta

    Reply
  7. Sheila Nichols

    Dr Coe and Jill,
    The calcium list is incorrect, the Total Cereal only has 2 % calcium and not 100 % calcium as listed. This list can be misleading as I was fooled for a while thinking that Total Cereal was providing me with all the calcium I needed until I read their label on the box !

    Reply
  8. Linda Santomenna

    Dear Dr. Coe, Thank you for your wonderful resources! I was wondering if you have any thoughts concerning Vitamin D supplementation for IH patients? My vitamin D is quite low and I do now have osteoporosis. My nephrologist has given his blessing to 10,000 IU/day for 10 weeks followed by 2,000 IU/day thereafter as prescribed by my endocrinologist. The general recommendations from my Litholink report advise against Vitamin D supplementation excess, however no upper limit is given. Thank you.

    Reply
  9. Jason

    Why are calcium supplements frowned upon for people with calcium stones and yet dairy products and fruits/veggies that contain calcium are not? Are they absorbed differently?
    I’m really in a bind here because I have mixed calcium oxalate and phosphate stones and suffer from osteoporosis, so I need my calcium and have always had dairy in my diet, however, since finding out about the stones, my doctor and dietician wanted me to ramp up dietary calcium intake and I’m finding the increased amount is too much for me–it’s actually making my stomach turn. I also suffer from IBS and severe acid reflux, so excess dairy is causes symptoms and I cannot drink acidic orange juice (yes, I know…my whole body’s a mess). I’ve looked into lactose free milk, however, most people don’t realize that the potassium levels in it are astronomical (I’m not sure why), and, as we know, potassium is not great for the kidneys either. Is it ok just to take a calcium supplement and if so, what’s the best ratio?

    Reply
    • jharris

      Hi Jason,

      I am sorry to hear of your troubles. It is very hard to adhere to a treatment plan when that treatment plan stirs up trouble with other medical conditions. I would discuss with your doctor about switching over to supplements, but you can do this. It is true that the body does like its nutrients from food best, but sometimes that is not possible. Supplements should be taken with meals and split throughout the day.

      Thanks for writing-
      Jill

      Reply
    • Fredric Coe, MD

      Hi, Jason, I do not know of any reason to say that the potassium in lactose free milk poses any dangers to your kidneys. There is no evidence for your belief and you can indeed use the product. One glass of this produce contains 4120 mg of potassium, which is just over 10 mEq. A common dose of potassium citrate for stone prevention is 20 mEq twice daily. US diet recommendations for normal US citizens is 4,500 mg of potassium daily from fruits and veggies in addition to whatever is in other foods. Regards, Fred Coe

      Reply

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