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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150 Responses to “A THIRST FOR VARIETY”

  1. Christine

    I have had Lupus all my life, kidney function has always been something my doctor and I have monitored – every 6 months. while oxalates in the urine are mentioned here, I am interested in creatine levels in the urine and what less oxalates will do for creatine levels. The “leaking” of protein from my kidneys is also an issue. foods high in phosphate, high in potassium, and diet high in animal protein are thought to make the kidneys work harder..your thoughts??

    Reply
    • Fredric L Coe

      Hi Christine, This is not a kidney stone issue but one of kidney disease from an immune disease. Urine creatinine arises from muscle metabolism and can be raised by large intakes of muscle – meat – but proof is lacking that meat damages kidneys except perhaps with large extremes. Phosphate and potassium are issues when kidney function falls, and urine protein losses are a very important gauge of kidney disease, but these are matters for your nephrologist and outside the range of this site. As for oxalate, our group has offered evidence that it might affect kidney disease, but in cases when its losses in urine are far above normal. Right now I am not able to say that reduced diet oxalate is advisable in kidney disease patients whose urine oxalate is unremarkable. But one recent article does implicate oxalate in progression of kidney disease, so the matter is unsettled. Regards, Fred Coe

      Reply
  2. Gerald Arcuri

    With all due respect, the recommended liquid intake volumes shown in the examples are utterly unrealistic for most people. Would they produce well-diluted urine? Sure. But trying to gulp down that much fluid in one day would amount to becoming obsessive about it. Which, I suppose may be ideal for preventing stones, but is, if I may be so bold, unnatural. Something doesn’t add up here. Why would nature not instill in us the desire to consume three liters of fluid a day, if that was what the body required to achieve a kidney and urine solute homeostasis? I have no natural desire to consume more than a liter of fluids in one day, sometimes much less. And I am an active person. I am a stone-former, and I have modified my diet to increase dietary calcium intake and lower oxalate intake. I have recently and successfully eliminated added sugar from my diet. But I simply cannot conceive of drinking anywhere near the amount of fluids recommended here. I have tried, and it feels as if I am becoming a fluidaholic. Everything revolves around trying to flood my body with fluids. Seriously? It’s just not natural.

    Reply
    • Fredric L Coe

      Hi Gerald, Here is the problem. Evolution fitted us for water conservation under conditions of very low diet sodium availability. With really low diet sodium stone risk is not present as calcium losses become very tiny. The entire thirst/vasopressin axis is very complex and aimed, as I said, at water conservation under conditions of variable and often slight water availability. So you are right. We are fighting against a disease due entirely to our modern ‘dietscape’ – If I may use such a neologism. We cannot go back to where we started, and stone prevention tries to accommodate. Reduced diet sodium, high diet calcium reduced diet sugar – there never was abundant sugar until about 400 years ago – will take you long way. If you are one of the many people who cannot stand high fluid intake, and the diet does not lower stone risk enough, meds are a reasonable answer. Lots of us like water, for example I do, but that is certainly not a rule. Regards, Fred Coe

      Reply
  3. Rhys James

    Thanks for writing the article. As noted Tea is high in oxalate, would that negate the benefits say in Green Tea?

    Reply
    • Fredric L Coe

      Hi Rhys, Green tea is not so high in oxalate, but do make it a treat not your main beverage. Regards, Fred Coe

      Reply
  4. Brok

    I am in the process of trying to make alterations to my diet, and recently realized that I pay for insurance to include access to a nutritionist, so I should work with them to make changes to my diet. That said, I had been attempting to make such changes myself. One thing I read about was that ascorbic acid (vitamin C) breaks down into oxalic acid in the body, but citrate helps the body prevent the formation of stones. So I thought about it and began to add lime juice to my water. Limes are relatively low in ascorbic acid compared to other citrus fruits, but high in citric acid; classically this is why, although they were good enough in the navy to prevent scurvy, they would have been far more effective had lemons been used instead.

    I would value your thoughts on using lime juice in lieu of lemon to the water. I am not looking for “natural” “holistic” blah blah blah, I am trying to work with what is scientifically justified, but there is a terrifying amount of misinformation and contradictory information out there. I found a urology center who recommend eating spinach to prevent formation of stones because of the high magnesium content. Some places report some fruits and veggies are containing insignificant quantities of oxalate while others contain high amounts; I even found a paper which decided to search google to determine oxalate concentrations and found the reported concentrations varied wildly. For me, this is a huge step, trying to bring my health under greater control. It is upsetting, frustrating, scary, and difficult to navigate.

    Reply
    • Fredric L Coe

      Hi Brok, The web is variable thence I wrote this site to as high a scientific rigor as possible. But I am not clear about your goals. Do you know your stone type? Have you had 24 hour urine studies? Do they point to a need for altered diet oxalate. Juices can provide citrate, but have limitations; is your urine citrate low? I would hope you have been or will be fully evaluated with serum and 24 hour urine studies to define the cause of your stones, and also find out what crystals comprise the stones. Regards, Fred Coe

      Reply
      • Brok

        I appreciate all the work and advice on these pages. I have not had a urine study done, but my most recent stone was analyzed (after ten years of stones and my arguing with doctors that I wanted them tested rather than them just assuming without even looking at the stones what caused them). It was Calcium Oxalate Dihydrate (Weddellite) 20%, Calcium Oxalate Monohydrate (Whewellite) 80%. So, okay, dietary changes are a must. I am trying to do that and to put together a careful dietary plan which takes all the info I have read into account so that I can go over it with my nutritionist and get her approval.

        The biggest thing I have been tripping over has been the 1984 data from USDA, which keeps being 10-1,000x higher than studies before and since. There is no explanation for this anywhere that I have found. Dr. Duke’s info seems good but for 19 items has “oxalate” as a separate category than “oxalic acid” where the numbers are astronomically higher. I am trying to do my best here, but I do not have the background to evaluate truth from nonsense. Do you have an explanation for the USDA and Duke numbers?

        Reply
        • Fredric L Coe

          Hi Brok, That the stone was calcium oxalate means nothing about urine oxalate or a need to alter it. High urine calcium, low urine citrate can cause the same stone with urine oxalate being normal. So you really are not best advised to begin diet change without urine study. I like at least 2 24 hour samples one at work one on weekends. If urine oxalate is indeed high the main thing is to increase diet calcium, as that will lower oxalate. If urine calcium rises from that calcium intake, the next step is to lower diet sodium to reduce the calcium. Here is a good article on what the kidney stone diet looks like – it is the science version, but it links to the more general one. As for lists and lists, we used the one compiled from Harvard, and asked an established authority on food oxalate, Dr Ross Holmes, to curate it for us. Our lists are probably as good as we presently can get. Older data sets used methods of questionable accuracy. I know nothing about the USDA data set as the Harvard group did all the original sifting of prior data to create their list. In point of fact, very few foods create the greatest fraction of risk, and they are highlighted on the graph in this article. Regards, Fred Coe

          Reply
  5. Phil

    I’m totally confused. Reputable internet sites don’t seem to agree on what is or isn’t good for stones. My urologist listed coffee as a top 3 to cut out but this article says coffee is fine. Urologist also listed lemons to go with but here it seems maybe/maybe not.
    Oy

    Reply
    • Fredric L Coe

      Hi Phil, Well, here is a reputable site and I have found lots of confusion – among patients and others. The problem is the question. How do you determine a mode of prevention sans knowledge of cause? Most medical process goes from diagnosis, so you might be happier getting a full evaluation for cause via 24 hour urine and serum testing so you can aim your prevention efforts. As for coffee, the main evidence is from the work of Dr Gary Curhan at Harvard. It is that work leads us to exonerate coffee as noted in the article. As for lemons, that remedy was put into public view by my friend Dr Marshall Stoller at UCSF, and I am not enthusiastic about it because there are so many alternatives in the event that potassium alkali – what lemons offer – is the right thing for you. So, I would find out the problem and treat it. Regards, Fred Coe

      Reply
  6. Mark Smith

    I wonder if the authors have considered that whether coffee is good or not for kidney stones depends on the elimination rate. Dr Greger of nutrition facts has gathered the research for fast eliminator of caffeine coffee is good for them which has good cancer effects and for slow eliminators coffee is bad for them increasing their cancer and other ill effects.

    Reply
    • Fredric L Coe

      Hi Mark, the only reliable science we have is the epidemiology Gary Curhan did linking coffee drinking to a reduced risk of stones – quoted in the article. I do not know anything about Dr Greger’s work, but know of no scientific data that caffeine will have no obvious effects to cause or prevent stones. Regards, Fred Coe

      Reply
  7. Lindsay

    I’m confused on this, don’t lemons go in the body as being acidic and later turn alkaline? I was under the impression too to add lemons to your water to help raise your urine PH? So all my lemon water drinking has been done in vain…

    Only crystal lite will do?

    Reply
    • jharris

      Hi Lindsey,
      It can raise it a bit, but upping your fruits and veggies, in general, will def raise it and that is what I would advise you to do. Try that instead. Also, have you done a urine collection to find out if you need to raise your pH?
      Best, Jill

      Reply
  8. Jamie Harris

    So many people use lemon for stone prevention it could help protect their teeth. Lemon is actually not an ideal way to get potassium and citrate; -Fredric Coe MD.

    I find this odd since the acid would help break down the oxalate. I’ve been told by several Urologists and nurses to drink water with lemon. So I find it hard to believe ONE doctor that I don’t personally know.

    Plus, since having to drink so much water it’s more convenient to add lemon to the water. Just makes sense to me.

    Best regards,
    Jamie

    Reply
    • Frederic L Coe

      Hi Jamie, I am not sure which article you are quoting, but I cannot find the comment in the one you have posted on. I believe the ‘it’ concerned using a straw to drink lemon juice which can damage tooth enamel if used chronically. The citric acid in lemon has no effect on oxalic acid whatever. It is that if the lemons are not too acid, the citrate species in the fruit will include a predominance of citrate vs. citric acid, the latter will do nothing for stone prevention. The former is metabolized as citric acid and thereby creates alkali for the body that will in turn raise urine pH and urine citrate. But lemons are variable, and not very reliable as a source of citrate compared to medication or even some commercial beverages. Adding lemons to water is a nice taste treat, and why not, but no evidence at all for efficacy in stone prevention. Urologists and their nurses are perhaps encouraging one to drink more by adding a piquant flavor, and no harm in that, but it is not a stone prevention treatment. I am sorry to be the one outlier, but professors are apt to be that way because we are paid to study things. Warm regards, Fred Coe

      Reply
  9. Tanialee

    Why not mix orange juice with Chrystle Light lemonade to get any / all effects in one drink?

    Reply
    • Frederic L Coe

      Hi Tanialee, You can. I am sorry I missed this question and am so late!! Best, Fred

      Reply
  10. John Asaro

    Dr. Coe, I was recently prescribed potassium citrate to prevent recurrence of kidney stones. But, as you indicate, the drug is relatively expensive so I began searching for a natural option. I read your article regarding Crystal Light lemonade and started drinking it. However, I recently read the following article which claims “that orange juice provides an alkali load, promotes hypercitraturia, and reduces the propensity for crystallization of calcium oxalate and uric acid, whereas lemonade does not.” Here is a link to the article: https://cjasn.asnjournals.org/content/1/6/1269. So, now I’m confused…which is correct? Thanks.

    Reply
    • Frederic L Coe

      Hi John, thanks so much for the link. The paper is a wonderful example of good technique applied to a very flawed hypothesis. Crystal light was chosen because at the time we made measurements it contained the highest amounts of citrate. Lemonade concentrate contains citrate but I suspect mainly as citric acid because it is more acidic than orange juice or Crystal light. That may be why the analysis of the concentrate revealed little potassium to go with the measured ‘citrate’. Citrate assays measure citric acid whether protonated or not, and if protonated by an acid juice the resulting molecule will not raise urine citrate or pH – as happened here. I never have recommended lemons or their juice for this reason, and the work hold no surprise, novelty, or even vague interest for me. Orange juice provides sugar we do not need, and I avoid it, too. So, that is what confused you and you had every reason to be confused. But not now. Thanks again! Fred

      Reply
      • Whitney

        This is very confusing. If Jill Harris wrote the article, why is Fred Coe responding to comments, and more importantly–why are you providing contradictory advice? Fred, you state here that you have never recommended lemons or their juice, and in a later comment say it’s because you believe that lemon juice has no efficacy for stone prevention. Yet Jill’s article above has an entire section recommending lemonade from a variety of sources, including fresh squeezed and concentrates.

        This is contradictory and does not serve your patients. Please agree on a consistent message and revise for clarity. Thank you.

        Reply

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