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

Understanding what you can and can’t drink for stone prevention can be exhausting. 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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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.

Need more support getting in fluids or changing your diet?

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!

Return to Walking Tour about Supersaturation

Understanding what you can and can’t drink for stone prevention can be exhausting. 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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88 Responses to “A THIRST FOR VARIETY”

  1. Neal Fusner

    A friend of mine has suggested I may want to try a green tea that has come on strongly in the USA. It is called Yerba Mate. It is made from the leaves of a South American holly plant (llex paraguariensis). The product being suggested is pure leaf, air dried, never smoked, never aged. As a prolific stone former of over 30 years, I don’t take dietary changes lightly, seeking knowledge before taking action. I was a former Calcium Oxalate stone former that morphed into a brushite former about two years ago. I remain on a reduced calcium, low oxalate diet at the urging of my urologist who has consulted with Dr. Coe regarding my case several times. Is anything currently understood about the oxalate levels of Yerba Mate. Please advise.

    Thank You,
    Neal

    Reply
  2. Margaret Kesinger

    Can I drink herbal teas with honey while passing a kidney y?

    Reply
    • jharris

      Hi Margaret,

      You can, but water is best. Have a true cup or two, but mostly water.

      Warmly,
      Jill

      Reply
  3. Bill

    I use Xylitol to sweeten my Espresso instead of sugar. Is Xylitol high in Oxalate? Or should I switch to sugar?
    I like to drink about 3 Espresso’s a day, along with plenty of water. I am in the process of trying to figure out why I keep creating kidney stones. I just received results back showing Calcium Oxalate stones from one that I caught, and 48 Urine Analysis showing low urine pH at 5.215 with Urine Calcium at 218 and total Urine Volume was 2.84. I am also a Type 1 Diabetic. I go back to my Urologist on Monday to discuss the results from all tests that Dr. Coe recommended on this website. Thank you for all of the information on this site.

    Reply
    • jharris

      Hi Bill,

      The sweetener is fine. How is your sodium (Na) on your test? And your citrate levels? Your urine is pretty acidic which does not bode well for a stone former. I wonder since you are a diabetic if you are eating too much protein in order to avoid carbs that will lead to higher blood sugar levels? If so, this could be a problem for your stone condition as well. Would need more info. There are different reasons why and you may want a nutritional consult to help you deal with both problems. You can reach out to me at jillharriscoaching.com to get some help if you like-
      Hope this addressed your concerns for now-
      Jill

      Reply
    • Fredric Coe, MD

      Hi Bill, YOu might bring up the low urine pH. Although your stones are calcium oxalate you have a high uric acid stone risk and might want to raise that pH. Diabetes itself lowers urine pH and as Jill mentioned a diet protein intake will do the same. Regards, Fred Coe

      Reply
      • Bill

        Thank you both for you prompt replies. I did the 48 hr urine test as you suggested on your site. The first day these were the levels Vol – 2.84. SS CaOx – 4.53, Ca – 156, Ox – 37, Cit – 527, SS CaP – 0.09, pH – 5.215, SS UA – 0.84, UA – 0.362, Na – 59, K – 54, Mg – 96, P – 0.785, Nh4 – 45, CI – 57, Sul – 19, UUN – 11.56, PCR – 1.0 . The second day these were the levels Vol – 3.09. SS CaOx – 3.69, Ca – 218, Ox – 33, Cit – 763, SS CaP – 0.24, pH – 5.493, SS UA – 0.86, UA – 0.563, Na – 136, K – 74, Mg – 139, P – 1.142, Nh4 – 42, CI – 150, Sul – 12, UUN – 10.79, PCR – 0.9 . I have been taking 300mg of Allopurinol since 2009. At that time I had very low pH and had what my urologist called gout of the kidneys. It always felt like I was peeing glass. After being on the Allopurinol for a couple of months, the pain went away. In 2011 I caught a 6mm stone that was a Calcium Oxalate / Uric Acid stone. I had been doing pretty well until last December, when this new series of kidney stones have started. It has been a very painful year. My Urologist has pointed it back to last June when I started a new low carb, high protein diet, and started working out at the gym and lost about 25 pounds. I realized in January that I had added a lot of nuts back into my diet, forgetting that with my history I shouldn’t be eating them. In the last couple of months I found your website, and have made changes to my diet, but just 2 days ago was back at the ER with more pain, and they saw more stones in my kidneys. I just did these urine tests on August 1 & 2, and my blood test last Friday, so now going back to the Urologist on Monday to discuss the results. Any suggestions either of you may have would be greatly appreciated as well.

        Reply
        • Fredric Coe, MD

          Hi Bill, you have formed uric acid stones and have a low urine pH – common in diabetes. I would discuss with your physician raising pH with potassium citrate. Allopurinol is without value against uric acid stones as opposed to raising pH. Also mention to your physician that your urine ammonia is a lot higher than your urine sulfate; is this because of potassium delpetion, or are the numbers copied wrong? It was this way in both urine samples. Apart from low pH you have no specific stone risk. Be sure and analyze the new stones – they may contain uric acid. Regards, Fred Coe

          Reply
          • Bill

            Thank you for your reply. My urologist prescribed Potassium Citrate 10mEQ twice a day after meals. The Litholink 24 urine report suggests a recheck after 6 wks, which he also setup for me. I still have pain in my right kidney, and an ultrasound from ER 1 1/2 wks ago noted there are still stones in my kidneys. The most recent stone caught in July (small fragments) was Calcium Oxalate. I showed the urologist your comment about the urine ammonia higher than the urine sulfate, and he was not aware of why this would be. Those numbers are correct as written in the previous comment above. Do I need to eat more foods with potassium as well or make other diet changes? Will the Potassium Citrate dissolve or break up my current stones in my kidneys? If so, how long does that normally take? I am hoping this will get me out of this long episode of pain in my life.

            Reply
            • Fredric Coe, MD

              Hi Bill, The stone analysis of calcium oxalate helps. Given the high ammonia I would suspect potassium depletion as a possibility or colonization with a urea splitting organism. K citrate cannot affect CaOx stones but can prevent more. I would use it along with the whole kidney stone diet. I see no reason to omit the diet as it is correct one for all US citizens. Regards, Fred Coe

              Reply
  4. Lynn

    I’ve been using pure erythritol as a substitute sweetner in my green tea and in my oatmeal. I can’t find any information on the web about it’s oxalate content or it’s effect on forming kidney stones. I see that there are blends of stevia and erythritol which I don’t use, as stevia is high in oxalates. I have a 5mm x 3mm stone in one kidney found by a sonogram. I used to drink 5 or 6 cups of instant coffee everyday which I don’t do anymore.
    How good (or bad) is erythritol?

    Reply
    • Fredric Coe, MD

      Hi Lynn, erythritol is a polyol sweetener that has no oxalate nor converts to oxalate that I know of. It is an approved sugar substitute. Chemical stevia has no oxalate, only the plant extract has that. The erythritol has no relationship to stones and is preferable to sugar that can raise urine calcium and could indeed be a stone risk. To prevent your stones follow a plan – here is a good one. Do not rush to this or that possible cause or treatment – never works. Regards, Fred Coe

      Reply
      • Lynn

        Thank you so much for this information, I have found your site on kidney stones to be the best on the web.

        Reply
        • jharris

          Dear Lynn,

          It makes us very happy to know that it is useful to you. Thanks for taking the time to let us know-

          Dr. Coe and Jill

          Reply
  5. Mark McCall

    I enjoyed the article and I appreciated the information provided. I had a 7 mm stone a year ago and I have a 6 mm stone now with 2-3 smaller stones in my kidneys so it is time to get serious. My urologist mentioned diet last year but did not provide any guidelines or recommended diets, so I basically forgot about it. The article, while discussing beer and wine, did not mention any spirits. Is that because there is no data, or is there another reason? Do spirits in moderation increase, reduce, or have no effect on stone formation?

    Reply
  6. Sherri

    I just thought I had researched this topic and don’t know how I missed all of your valuable research. I have the common calcium oxalate stones( 2x in 4 years), and this last time my dr started allopurinol and gave me a list of low oxalate to high oxalate foods. There is so much contradictory information on the web ( reputable sources too) in regards to what is low and what is high in oxalates. UAMS to webmd makes it hard to know which is true. Thank you fo so much clear information and references to your publications!

    Reply
  7. Nancy

    I’m new to kidney stones (no family history), having just had surgery to remove a 6 mm principally calcium stone. The minute I heard it was calcium based, I stopped eating foods rich in calcium, and now have calcium levels at or slightly (.2 – .4) above 10. If I’m tracking you correctly (and this seems somewhat counterintuitive to me), it sounds like I should increase my calcium intake to reduce my blood and urine calcium levels. Is this correct?

    Reply

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