Dietary advice for stone formers urology leaflet

Drinking enough fluid is the most important way of preventing stone formation and reduces your risk of stone formation by almost one third (30-40%). Not drinking enough fluid causes your urine to become concentrated and makes stones more likely to form.

Try to drink two to three litres (four to six pints) of fluid each day (water, squash, or fizzy drinks). You should aim to keep your urine colourless throughout the day. This equates to a urine output of at least two litres (four pints) per day. In patients with cystine stones, however, an output of 3.5 litres per day is required.

Tea, coffee & alcohol can be consumed in moderation but the majority of your fluid intake should be as above. In addition, it is helpful to try and drink one or two glasses of water before going to bed and on rising in the morning.

Tips to help you increase your fluid intake:

• Drink a large glass of water at specific times each day (e.g. when you get up, when you arrive at work, after using the toilet etc)
• Drink a glass of fruit juice with your breakfast
• Keep a bottle or jug of water at your side all day; you can flavour the water with squash
• Drinking through a straw may help you drink more
• Try to drink one glass of water every hour
• Add slices of lemon, lime or orange to cool water, to give it a pleasant flavour and to help alkalinise your urine
• Eat more fruit and vegetables because they contain a lot of water
• Include moist/liquid foods in your diet (e.g. soup, stew and jelly).

We may sometimes ask you to test the acidity of your urine at particular times of day and we also measure it in your 24-hour urine collection specimens. The acidity of urine normally varies throughout the day, depending on your diet. Acidity/alkalinity is expressed as pH (pH 7 or less is acidic; pH greater than 7 is alkaline).

The acid-educing effect of water with a high bicarbonate content is useful for patients who form uric acid stones. Mineral water with a high bicarbonate content (e.g. Vichy, Badoit, Vittel, Buxton) also increases citrate levels in the urine; citrate is a known inhibitor of stone formation.

If you have pure calcium phosphate stones, you should avoid alkalinising urine and should drink tap water rather than mineral water. You should also avoid mineral waters with a high sodium content (e.g. Vichy, Vichy Catalan).

Fizzy drinks such as Diet Coke, Coke Zero & Diet Pepsi are relatively poor at alkalinising your urine. There is some evidence that Diet 7-Up, Diet Sunkist and Diet Sprite may be better, and is worth considering if you have uric acid stones or calcium oxalate stones.

Yes. A high intake of animal protein appears to increase the risk of stone formation. Avoid large portions of meat, fish, eggs, cheese and milk. Aim for four of the following exchanges each day:

• 50-75g red meat, fish or chicken
• two eggs l ½ pint of milk
• 50g cheese
• 120g yogurt (one small pot)

Two of the four exchanges should be milk, cheese or yogurt to ensure an adequate intake of calcium. You can replace protein with starchy foods (bread, potatoes, pasta, fruit and vegetables) to fill you up. Reducing your protein intake also increases the amount of citrate you excrete in your urine; citrate is a known inhibitor of stone formation. You should not consume protein build-up drinks.

An example for a daily meal plan would be:

Breakfast: Two eggs (scrambled) on toast.

Lunch: Sandwich with 50g cheddar cheese and salad, one apple.

Dinner: One small chicken breast (approx 75g) New potatoes, Vegetables, Fruit salad.

It is something to consider, and it will benefit you in other ways (by reducing your risk of Type 2 diabetes, high blood pressure and raised cholesterol). Being overweight has been linked to high uric acid levels and overweight people tend to have acidic urine; acidic urine can increase the risk of most types of stone.

Yes. A high salt intake can contribute to calcium stone formation as well as reducing urine citrate levels. Do not add salt to your food at the table. Use pepper, herbs, spices or vinegar as alternative flavourings. You can, however, add a small amount of salt during cooking.

Foods that contain less than 0.4g (40mg) of sodium per serving are low-salt choices and you should aim to keep your salt intake down to these levels. Avoid tinned, packet and processed foods (soups, salted crisps, nuts, tinned meats, meat paste, smoked fish and fish paste).

No. Severe calcium restriction can actually increase the risk of stone formation because it will result in high levels of oxalate in your urine. If you follow the recommendations above for milk, cheese and eggs, no further action is needed.

You should not take calcium supplements or ‘over-the-counter’ medicines for indigestion (which may contain a lot of calcium). If your GP has said that you must take calcium supplements, take them with food to reduce the risk of stone formation. Products containing calcium citrate are better at increasing citrate levels in your urine than those with calcium carbonate.

The calcium you drink in tap water cannot cause kidneys stones and there is no need to restrict your intake of tap water and no point in purchasing a water softener (which is not connected to your drinking water). Some people prefer the taste and smell of filtered water but there is no evidence that it reduces the risk of stone formation.

Fruit and vegetables have many beneficial effects and they also have an alkalinising effect on your urine. They contain a lot of fluid which helps with your daily fluid intake. Oxalate stone formers should, however, take care to avoid any oxalate-rich fruit and vegetables from the list above.

Drinking fruit juice does appear to reduce urine oxalate and increase citrate levels. Fruit juice should be consumed with caution because some contain a lot of sugar. The evidence for taking cranberry or grapefruit juice is uncertain and, as a general rule, increasing your intake of fruit juice is probably not beneficial. A single glass with your breakfast is, however, recommended (see page 1) but, if you have oxalate stones, fruit juices are probably best avoided.