This week, Jill answers a listener question about lemon juice and preventing kidney stones.
Jeff Sarris: Welcome back to the Kidney Stone Diet podcast, the show about reducing your kidney stone risk and living your best life. I’m your host and fellow student, Jeff Sarris.
Jill Harris: I’m Jill Harris, your kidney stone prevention nurse.
Jeff Sarris: We’ve got a hoodie today! I don’t mean to comment on all the merch every time, but I just love it.
Jill Harris: Well, where else am I gonna wear it? I mean, obviously, I wear it out, too, but I’m like, “This is the perfect place to wear it!” Because I’m living my best life!
Jeff Sarris: Uh huh. Yeah, love the typography.
Jill Harris: With my kidney stone–see it?–in the back!
Jeff Sarris: Yeah, definitely.
Jill Harris: And they’re cozy and warm.
Jeff Sarris: Yeah, that looks really soft. I know a lot of times it can be hit or miss with hoodies.
Jill Harris: I’m very happy with the quality and I, you know, I’m the queen of hoodies. So I’m for quality and the quality is good. This is why they’re not cheap, people. I don’t care if I say that. They’re not. They’re not cheap. And, you know, we don’t make a lot of money off these. We put these–we get a couple nickels. It’s not a lot. So when I buy these, I’m buying these, too, just like you, so I know they’re not cheap. But we’re not going to put out things that are cheap and not quality. That’s not–go look at our website! You’ll find we like to put a lot of effort into what we’re putting out here. And we made these things because people kept asking us for them. So in our spare time, these were whipped up.
Yeah, and there’ll be more! Always changing it up when there’s an opportunity. But yeah, what do you say we dive into this week’s question?
Yes, sir.
Jeff Sarris: It’s Adam from Texas.
Jill Harris: Adam, from Texas!
Beware vague instructions from your doctor!
Listener Voicemail: Hey, this is Adam from Texas! I had a kidney stone last November. Did the urinary collection 24 hour and I was told to drink more water and start drinking lemon juice, which I’ve been doing religiously up to the point where I think it’s doing my teeth some harm. Feeling some pain and everything. Gotta call to my dentist about that, but my question is, what’s a good ratio and how much lemon juice per water that you need to drink when you’re drinking lemon juice? Again, I do not want that pain again. So I’m not dropping–not scaling back on the lemon juice, but I want to make sure I’m taking it in the right dose. Should I be using a straw versus just putting it in the water and drinking it? So, any advice you have on that would be greatly appreciated for the future of my teeth. Thank you!
Jill Harris: Oh, yeah, this is a question I get all the time! But, Adam, I have a lot of questions for you. So, we as healthcare providers–doctors, nurses, everybody–when we’re asking a patient to do something, we should really explain it well. “Go drink lemon juice!” You go home and you’re like, “Oh shit, how much though? How much though?” I mean, you know, or “Lower your salt.” Okay, but what does that really mean? I mean, what does that mean?! So the Kidney Stone Diet–I’ve worked with thousands and thousands of people. In almost a quarter century, I’ve talked to a lot of people and I know they don’t know what that means, “lower salt.”
Well, if you’re eating a buttload of salt, like 10,000 milligrams a day–”Who would do that, Jill?” You’d be surprised, people. You’re gonna think lowering it to 8,000 a day is, “God! Wow, could I go any lower? I couldn’t possibly!” And the goal of the Kidney Stone Diet and the American Heart Association and all the big groups in medicine is 1500. Fifteen-hundred milligrams of sodium day. “Jill, why are you talking about sodium when he’s talking about lemons?” Hold on! The point is this: we just give this general blanket “lower salt, lower sugar, drink lemon juice.” What does that mean?
When I left my oncology appointments, “Do this, do that,” but how? How much? Your level is high? “How high? Where do you want me to be? Who cares? What does that mean if it’s high/low?” This is why the urine analysis consult is amazing because I help you form all the questions you’re going to ask the doctor so they’re not left behind. So, Adam from Texas, I have questions for you. You said your dear doctor did a 24 hour urine collection and from that collection, the doctor wanted you to do lemon juice. How much, I don’t know. You know why? Because I don’t know how low your citrate is. Typically, they start you on lemon juice because your citrate is low. But, B-U-T, a lot of people–doctors–will just generically say “Drink lemon juice.”
You need to know: is your urine alkaline or acidic?
I’m going to assume this doctor didn’t. I’m going to assume that doctor based that order on your citrate level and/or your pH level on your urine collection. I don’t know. I don’t have your urine collection. So, if I’m your doctor and I was looking at your urine collection, I would say, “This is your citrate level. It is low.” We care about that in stone disease because it’s great to have a urine that’s more alkaline than it is acid. Also, it will help lower urine calcium a bit. It also will raise your pH. Again, we want a more alkaline urine as opposed to an acidic urine. It’s complicated, guys. I make this seem like, “Oh, she’s just a girl talking about stuff.” But this is complicated, so there’s many different factors to look in here.
So, I would need to see the urine collection. I don’t know how much you should be drinking. Not enough, though. If you’re drinking so much it’s bothering your teeth. That’s not good for your teeth, obviously. So, if you are going to continue drinking lemon juice, you most definitely need to drink it out of a straw, but the bigger question is this, Adam: is your citrate really low because there ain’t enough lemon juice in the world that’s going to bring it up? Is it just a little low? For a guy, it should be over 450–the citrate–and every reference range will be a little different. But research shows we really do want it over 450 for a guy, 550 for a woman. And so, if you’re citrate is a bip low, yeah, suck on a lemon. Put like, you know, four ounces of lemon juice in a gallon of water. Do your best to drink as much as you can have that, okay?
But, if it’s really low, you need to be started on the supplements, which would be potassium citrate. Otherwise, you’re sucking on those lemons and you ain’t hitting your numbers. The other thing I’m going to ask is: make sure you do a follow-up urine collection to see if sucking on all this lemon juice is having the desired effect. The desired effect being your citrate’s now raised, your urine calcium is a little lower, your pH is a little higher–if that needed to be raised–and your stone risk is lower. I can’t tell you how many people–their doctor starts them on a treatment plan, based upon a urine collection, and nobody ever followed up with them! So you don’t know if what you asked the patient to do is working because it may not be working and more tweaks need to be placed, put in place!
And then you do another follow-up to see if it’s working then. “Working” means looking at the lab results and saying, “You’ve lowered your stone risk. That equals working.” So, I don’t know how much you should be drinking. And, of course, you don’t know how much you should be drinking because you were just generically told to drink more lemon juice. If your citrate is very low, lemon juice is not going to hit that. You may need a supplement, but you also need a urine collection to let you know. I cannot tell you–first of all, I love the question. It’s one I get all the time. But I’m just saying it’s very important that we explain to the very best of all our abilities as healthcare people why we’re asking patients to do it because when they understand the “why” they’re more apt to do it.
When they’re not being told why, it’s just some arbitrary stupid thing we’re throwing, yet again, at a patient. When I talk to patients on the phone, I’m telling them what it’s doing to their body, so they are like, “Oh, holy bragioli! I don’t want that to happen to my kidneys.” And not to scare them, but to let them know! If we were walking around without all this covering on our organs and we saw what we were really doing to them every day, we’d be a lot more passionate about how we treated our bodies and what we fed it. But when we don’t understand what a treatment plan is doing, it’s really easy to let it go down the wayside. This way we’re like, “Oh my God! I know that if I don’t have enough citrate, I’m drinking the lemons. I didn’t have any lemon juice today. My citrate could be lower, which means my calcium can be higher and blah blah blah blah blah.”
It’s complicated, guys. But there’s a reason you’re being asked to do that. I worry about your teeth. Sounds like you’re drinking a little bit too much. So you have homework. Ask your Doctor–first of all, if you’ve done a urine collection, make sure that you know how low your citrate is. If it’s really low, then that’s where you start. Is it too low that you shouldn’t even be drinking lemon juice? You should have potassium citrate or is your citrate not even low it and it was just a generic catch-all order? There’s lots of things to ask, okay? So, lemon juice can help patients alkalinize their urine. That means making their urine more alkaline, so crystals don’t grow in it.
When you have an acidic urine crystals like that environment, they like to grow in that environment. But also calcium phosphate stones love an alkaline urine and so, sometimes, people’s urine pH is way too high, making it even more alkaline and then they can grow a calcium phosphate stone. So we’ve got to be careful. There’s a lot of things, a lot of components, if you do one thing here, it doesn’t mean you don’t do all the other things, or you did one thing here, now it affects this. There’s a flowchart here and it’s very specific. And so you want to make sure you’re doing everything you can. It sounds like you’re really trying to do everything you can.
Lemon juice will NOT fix everything!
Kidney stone disease is going to be a lot more than just lemon juice. It’s going to be the whole Kidney Stone Diet: sugar–let’s just say this, folks. I’ve never seen a patient just minimize their risk of kidney stones by sucking on a lemon. There’s usually other things going on. I really want to make sure you understand that. The Kidney Stone Diet is just a healthy diet. We’re asking people to get fluids, get enough calcium for your bones, and to lower oxalate because that’s how we get rid of oxalate in the body, and to lower their added sugar. We eat way too much of it. Lower all that salt we’re eating and eat normal amounts of meat protein. It’s a healthy diet. Watching all of those things, paying attention to all the goals of it. If you don’t know the goals of the Kidney Stone Diet, go to kidneystonediet.com. They’re all over my website.
So, I can’t answer your question, because I don’t know how low your citrate is, but you should ask your doctor that based upon your urine collection results. So that’s really important. Makes sense, Jeff? It’s a lot of words I put in there, but sometimes a simple question like he’s asking, “How much?” I don’t know because there’s more information needed. It should never just be a generic order because we, patients, will do whatever we want or think about that. I’ve had patients drink, you know, 64 ounces of pure lemon juice until they eroded their esophagus. So, people interpret what we say in a whole bunch of different ways. That’s why I’m very careful of what I just put on the internet.
You have to be careful because people just–it’s not anything they’re doing wrong. It’s just how they heard it and what they think. Typically, human nature is “More is better,” right? So, if the doctor told me to drink lemon juice, by golly, I’m drinking it, right? Because they never want to go through that kidney stone and it makes perfect sense. So, it’s a little bit more complicated than knowing exactly how much. Dr. Coe, my mentor, his name is Fred Coe, C-O-E. Not coal, it’s Coe, C-O-E. So, if you Google “Fred Coe and the price of potassium citrate,” you will get some studies that they did on lemon juice in that article. That’s website at kidneystone.uchicago.edu. But if you just Google “Fred Coe and the price of potassium citrate,” you’ll see him talking about lemon juice there, too, so you can get some more information.
Make sure you get a follow-up
Jeff Sarris: Yeah, I was just pulling that up right now. Just pulled it up on the screen. But yeah, so you’ll see this, right on the screen and, yeah, “the price of potassium citrate” is the title that you’re looking for. I think the one other thing, like you mentioned, the follow-up, the follow-up test to see if there’s a change. That’s something that I think it’s very easy to overlook aand not even consider, just because it’s like “I’ve been tested now this,” but if we’re doing some sort of change that we want to have an influence, an impact on some levels, we need to know where those levels are after the change as well.
Jill Harris: It’s so important and this is what happens. The follow-up gets dropped so often, so often. The doctor never orders it, so the patient doesn’t know it’s supposed to be ordered. Or the doctor orders it and the patient doesn’t do it. Let me tell you, folks, I can’t tell you how many patients, they’ll call me “Jill, I got a stone. I’m gonna do the 24 hour. I’m gonna send it to you. We’ll have a consult about it.” Good. Greg calls me gets his we go over his urine collection. I say “Talk to this, this, this to the doctor and, Greg, make sure you get a follow-up!” “I know, Jill, I know.” So, three years go by, I get a phone call. “Oh, shoot! Greg is on my roster today. I hope it’s good news.”
Greg calls me–”Jill”– right from his tone I’m like “uh oh.” “I got another stone.” “All right, let’s see what’s going on. Let me see that follow-up.” “Well, Jill, I never did the follow-up.” Here’s what happens, people. If you don’t do the follow-up, you don’t know if what you’re doing is lowering your stone risk. So you get on your initial plan–there’s a couple things. Over time, people forget about that pain. Over time, salt starts coming back in, sugar. “Oh, I haven’t had a stone in two years. I’m good. I’m good!” Bad habits come back into play: new stone. Or you did your first 24 hour urine collection. The doctor told you to follow the Kidney Stone Diet. Okay, you go back home. You practice the Kidney Stone Diet. You lower salt, you lower sugar to what you think is a low sugar-low salt diet.
“Hey, I was eating 10,000 milligrams of sodium. I got it down to eight. It’s a low salt diet to me!” You never do the follow-up. You get a new stone. The follow-up that’s the gold standard. You do a 24 hour urine collection, you get your first kidney stone. Many doctors say, “Wait till the second stone.” Why would you wait for a second stone?! That would be like a doctor saying to me, “You got one tumor, Jill. Let’s start chemo after the second tumor.” That would never happen! So, why are we doing that in the stone world. You have a kidney stone, let’s find out! We’re going to do a urine collection because that’s going to tell us why you’re forming stones. Then, based upon that urine collection, you’re going to get on a treatment plan.
You’re going to do the treatment plan for a couple months and then you’re going to do a follow-up. And the follow-up is going to tell you, “Hey, he’s doing the Kidney Stone Diet, but we still have things out of whack.” Now we’ve got to bring a medication into play because a lot of kidney stone patients have to go on a medication along with the Kidney Stone Diet. Two more months go by, then you do a follow-up to make sure the medication is having a desired effect. If it does, boom, great. You’re done until the next year. You do an annual, obviously, every year and your doctor is not going to send you a little note like the dentist’s “Time for the annual.” That’s not going to happen. Be your own advocate.
“Dear doctor, I’m ready for my annual. Please order my test.” Because then you can see, maybe you got another medical condition. Maybe now you have diabetes. You forget about the almonds and spinach and the nutritionist for your diabetes says “Almonds are your best friend.” You start re-eating almonds again because now your priority is diabetes. When we’re juggling a lot of medical conditions, it’s very difficult. And our latest medical condition becomes our largest priority. So, again, old foods creep back. Maybe we stopped eating calcium, but we brought nuts back, almonds, specifically. Boom, new kidney stone! But not if you do your annual urine collection and you say “Holy bragioli! I’ve got some high oxalate again. Gotta get back to work.” And then you juggle both.
I have many patients juggle diabetes and kidney stones because that’s a very common twofer. So, again, I don’t even know who I’m talking to anymore. Adam with the lemons? Is that where we were? So, it’s important, though, to do all of this stuff. I know people will say, “Oh, here she goes about urine collections, but, again, we’ve got to monitor these things. The number one thing to do to prevent kidney stones is figure out why you’re making them. How to do that? Get a urine collection. If a doctor says you don’t need it, push back. It’s your body. You don’t want another kidney stone get your testing done, people. Get your testing done. The end.
Jeff Sarris: That’s the perfect message to end on. It’s just so important. The testing is everything because you can throw a bunch of things at the wall and see what sticks, but what’s it sticking to, even? What is the effect it’s having? You don’t know what you’re trying to do, but, anyway, with that, if you want to dive in deeper, head over to kidneystonediet.com. There you’ll find the urinalysis where you can send your urine analysis to Jill and have a discussion over what has happened, and what she sees, and how you can have that better doctor’s visit or you can download the free doctor visit resources and all the myriad free resources we have on the site, including the oxalate list and everything. Right there, you can find the Prevention Course, the weekly newsletter where Jill’s in your inbox every Saturday with a little dose of inspiration that sort of keeps you on track and on your journey, but all of that can be found at kidneystonediet.com.
Jill Harris: Yeah, and the course is on sale right now! We’re taping this at the end of October, so by the time you by the time you see this, it could be off, but go to kidneystonediet.com. We’re offering a once in a lifetime $40 discount because of the recession. It’s the lowest it’s ever been, so take advantage of it if it’s available for you when you’re watching.
Jeff Sarris: Yeah. So with that, I think we’ll wrap. Oh, if you have a question, the number again is 773-789-8763. And we’ll feature you next time. But with that, we will see you next week.
Jill Harris: Thank you, Adam.
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