Between a kidney stone and a hard place

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PeterM
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Between a kidney stone and a hard place

Postby PeterM » Fri Apr 09, 2021 8:05 am

As many of you already know one of the first and apparently foremost steps to reducing risk of kidney stone formation is dietary sodium reduction, preferably to under 2000 mg a day. For those of us who are committed long-term to the ketones-for-brain-health protocol this presents a real problem. Many, including Peter Attia, recommend anyone on a ketogenic diet maintain a minimum of 3500-4000mg of sodium intake daily if they wish to avoid a risk in cortisol rise, or invite increased insulin resistance. That 4 gm figure is about what I have historically consumed, and in Feb and March of this year I had back-to-back kidney stones. The deeper I read on the topic the more concerned I became about the consequences of repeated stone formation.

I did have a calcium oxalate stone three years ago, for the first time at age 69, but suspecting it was simply a case of under-hydration I increased my fluid intake, cut back on oxalates, and basically forgot about it. Surprisingly, to me at least, average age of first kidney stone for stone formers is 35-40. This from Dr Frederic Coe, clinician and researcher at the University of Chicago. His site covers a great deal of ground.

My question now is, assuming one is getting adequate dietary calcium (1000+ mg daily), is hydrating to at least 2.5 liters of liquid, keeping dietary oxalate below 100 mg a day, AND taking 2 gm each of potassium and magnesium citrates daily, what is the minimum daily amount of sodium one might consume daily on a keto diet without risking cortisol rise or increased insulin resistance? Having moderate chronic fatigue syndrome I unfortunately can’t introduce an exercise component into the equation to up carbs. As is I’m eating 3 gm of sodium a day, optimizing everything else and just waiting to see what happens. Advice anyone? Many thanks as always.

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SusanJ
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Re: Between a kidney stone and a hard place

Postby SusanJ » Fri Apr 09, 2021 8:53 am

What type of urine analysis have you had done? Do you know if you have hypercalciuria or hypocitraturia? How is your oxalic acid output now?

Sodium seems to be very important to reduce, and especially if you have hypercalciuria. AUA recommends no more than 2300 mg/day so you're well over their recommendation. But there are other issues, too. This article has a lot of good information on stone prevention.

A high dietary sodium intake is associated with increased risk of nephrolithiasis likely by causing increased urinary calcium and decreased urinary citrate (28, 66, 73, 74). For every 100 mmol/day increase in dietary sodium intake, urinary calcium increases by an average of 40 mg/day in non-stone forming adults and by up to 80 mg/day in hypercalciuric stone formers (66, 74-76). A low sodium diet reduced urinary calcium and recurrent stones in hypercalciuric stone formers (76, 77). Stone formers are therefore recommended to limit their dietary sodium intake to less than 2300 mg/day (or 100 mmol/day) which is equivalent to 5.9 grams of salt (sodium chloride) (27-29).

See also Table 8 in this article for issues related to labs, and also Table 10, for other ideas that might be causing problems in the Medical Management section.

It's tricky. I've never had stones, but 3 of 4 of my brothers have. When I found I had an oxalate problem, I started taking 150 mg of calcium citrate per meal, because dairy and I don't get along. Calcium citrate, along with stopping Vitamin C supplementation and a low-medium oxalate diet, has helped me tremendously. I also take 300mg of magnesium citrate per day (have for years). And a tiny bit of potassium citrate (99 mg/day). I salt my food, but not much, and don't shoot for any specific number. (All the minerals I take are from Pure Encapsulations.)

But one of my brothers was told to eliminate calcium completely, hasn't changed his diet (other than avoiding milk) and has avoided additional stones. :? Needless to say we're all quite different!

I've also been reading that shifting eating to earlier in the day can have a positive effect on cortisol. I hope to do a post in the near future on a few of the articles I found. If you do IF as part of your keto strategy, you might try reducing your sodium plus moving your eating window to earlier in the day to see what effect it has on cortisol.

Good luck!

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Re: Between a kidney stone and a hard place

Postby PeterM » Fri Apr 09, 2021 2:27 pm

SusanJ wrote:What type of urine analysis have you had done? Do you know if you have hypercalciuria or hypocitraturia? How is your oxalic acid output now?


Hi Susan. I’m waiting on a urology consult at end of April so all of those metrics are yet to be determined but I’m aware of all the targets to shoot for for each. Also I hope to get imaging—CT scan or ultrasound—for a baseline.

Good tip on moving eating window forward for cortisol purposes. Have not seen that before. And yes I also have dropped Vit C from my daily. And like for you, dairy is no friend to me and so I’m trying to better strategize the dietary calcium piece of things. Tough to get to 1200 mg. Sardines and canned salmon Can really help, but (sigh) the micro plastic issue with them.

Thanks for shedding some extra light my way. Your oxalate Wiki entry is awesome btw. Lastly, if you have an opinion, or would hazard one, do you think continuing a ketogenic diet at 2000 mg of sodium is unwise? I can’t imagine going back to being pre-diabetic, but I can’t imagine being a stone former either. A conundrum.

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SusanJ
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Re: Between a kidney stone and a hard place

Postby SusanJ » Fri Apr 09, 2021 8:39 pm

PeterM wrote:Lastly, if you have an opinion, or would hazard one, do you think continuing a ketogenic diet at 2000 mg of sodium is unwise? I can’t imagine going back to being pre-diabetic, but I can’t imagine being a stone former either. A conundrum.

It is a conundrum. I'm still sorting out the keto thing, which I find to be tough when eliminating nuts. I just can't seem to get enough fats or maintain weight without them (short of doing shots of EVOO). I avoid coconut as much as possible because it whacks my lipids pretty severely. I'm in the same boat as you, and too many carbs send my numbers towards pre-diabetic. I hear your pain.

That said, I'd give 2000mg and keto a whirl, and just be very attentive to oxalate load. I highly recommend the spreadsheet in the Facebook "Trying Low Oxalates" group. It does help to see the amounts per serving so that you're not inadvertently overdoing the daily intake. Fortunately (or maybe unfortunately), I know when I've overdone oxalates because I get symptoms within a few hours, including joint pain.

Sarah Ballantyne sent this out in her weekly email blast. This is what got me started thinking about eating earlier in the day, because like many, I was waiting for my first meal until late morning or later.

BREAKFAST VS. INTERMITTENT FASTING
First, there's a fairly large body of scientific research showing that breakfast skipping is associated with increased risk of obesity, hypertension, insulin resistance, diabetes, and cardiovascular disease. Meta-analyses have shown the magnitude of effect is huge, too. Regularly skipping breakfast increases risk of type 2 diabetes by 55%, increases risk of cardiovascular disease by 21%, and increases all-cause mortality by 32%.

I reviewed the science on breakfast benefits here: https://www.thepaleomom.com/breakfast-i ... e-answers/

Or, if you'd prefer to listen: https://www.thepaleomom.com/podcast-bre ... tant-meal/

Eating breakfast is strongly associated with healthier eating over all, but additional research points to a bigger reason for breakfast benefits. Studies have shown that breakfast skippers display a disrupted cortisol rhythm, with a prolonged morning spike of cortisol, high cortisol levels later in the day, and exaggerated cortisol release in response to stress. Conversely, regular consumption of breakfast is associated with lower stress levels, better regulated cortisol, and better physical and mental health, including reduced depressive symptoms.

And, studies of intermittent fasting show that, even though skipping breakfast does increase energy expenditure slightly for the day (by about 90 calories, the equivalent of walking for 14 minutes), it comes at the expense of higher inflammatory responses and a whopping a 54% increase in a measure insulin resistance (postprandial HOMA index) after lunch. Furthermore, while some studies have shown that an early time-restricted feeding window (where we skip dinner instead of breakfast) has modest cardiometabolic benefits (a small improvement to insulin sensitivity, blood pressure, and oxidative stress), it also comes at the expense of elevated morning cortisol and a potential interference with or shift in circadian rhythm.

I reviewed the science on intermittent fasting here: https://www.thepaleomom.com/intermittent-fasting/

Or, if you'd prefer to listen: https://www.thepaleomom.com/podcast-int ... t-fasting/

NEW SCIENCE ON EARLY BREAKFASTS
The new study presented last week was designed to further our understanding of the impact of breakfast versus time-restricted feeding on glucose tolerance and insulin sensitivity. And while we're still waiting for the peer-reviewed published paper on this study to be available, the data released so far is fascinating!

The researchers analyzed data from the National Health and Nutrition Examination Survey, which included 10,575 adults. They divided participants into three groups depending on the duration of their feeding window: <10 hours, 10-13 hours, and >13 hours per day. Then, the researchers created six subgroups based on feeding window start time. What they discovered is that the duration of feeding window did not matter. Instead, regardless of feeding window length, eating breakfast before 8:30am reduced insulin resistance and improved fasting blood glucose levels.

I think this makes a whole lot of sense when we think about the impact of breakfast on cortisol and the relationship between cortisol and insulin. What this data implies is that having breakfast within that first hour (or maybe two) after waking blunts morning cortisol and improves cortisol regulation throughout the day. But, if we delay breakfast past the natural morning cortisol spike, the harm to cortisol regulation throughout the day is already done.

It's another study showing that breakfast is super beneficial, and it adds to our understanding of timing: an early breakfast is best!

Looking forward to reading that paper when it comes out.

And here's one of the papers that underscores that eating earlier could help with cortisol regulation. It's in women, and I haven't read the full paper yet,

Compared to the breakfast eaters and on the control task visit only, breakfast skippers had higher circulating cortisol from arrival to midafternoon (p<0.01) and during the snack buffet (p<0.05). Furthermore, the lunch-induced cortisol reaction was larger in the 'skippers' (p=0.03). On both stress and control visit days, the diurnal cortisol amplitude was significantly (p=0.02) blunted in breakfast skippers. Self-reports of chronic stress did not differ between the groups. These data indicate that habitually skipping breakfast is associated with stress-independent over-activity in the HPA axis which, if prolonged, may increase risk (e.g., hypertension) for cardiometabolic disease in some people.

https://pubmed.ncbi.nlm.nih.gov/25545767/

And this one showed an increased risk of T2D in men in breakfast skippers, which persisted after stratification by BMI or diet quality. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325839/

I know they are both about "breakfast skippers", but I think the important thread is timing of eating to normal cortisol/circadian rhythms.

And I'm about to dive into a few papers on eating behavior and circadian rhythm of our microbiome.

Let me know how your labs turn out and let's keep kicking around ideas here.

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Re: Between a kidney stone and a hard place

Postby PeterM » Sun Apr 11, 2021 10:19 am

SusanJ wrote:
PeterM wrote:Lastly, if you have an opinion, or would hazard one, do you think continuing a ketogenic diet at 2000 mg of sodium is unwise? I can’t imagine going back to being pre-diabetic, but I can’t imagine being a stone former either. A conundrum.

It is a conundrum. I'm still sorting out the keto thing, which I find to be tough when eliminating nuts. I just can't seem to get enough fats or maintain weight without them (short of doing shots of EVOO). I avoid coconut as much as possible because it whacks my lipids pretty severely. I'm in the same boat as you, and too many carbs send my numbers towards pre-diabetic. I hear your pain.

That said, I'd give 2000mg and keto a whirl, and just be very attentive to oxalate load. I highly recommend the spreadsheet in the Facebook "Trying Low Oxalates" group. It does help to see the amounts per serving so that you're not inadvertently overdoing the daily intake. Fortunately (or maybe unfortunately), I know when I've overdone oxalates because I get symptoms within a few hours, including joint pain.


Susan, thanks so much for all this. I have always imagined there was an unhealthy user bias going on among breakfast skippers and their poorer metabolic outcomes. So I will read deeper and adjust accordingly. As an aside, I am stunned by how much extra sodium I have been consuming despite an almost exclusively whole food diet. Mustard alone was adding 500 mg daily. Sheesh. Again, appreciate your thinking. It’s really helped.

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SusanJ
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Re: Between a kidney stone and a hard place

Postby SusanJ » Sun Apr 11, 2021 3:28 pm

PeterM wrote:I have always imagined there was an unhealthy user bias going on among breakfast skippers and their poorer metabolic outcomes. So I will read deeper and adjust accordingly. As an aside, I am stunned by how much extra sodium I have been consuming despite an almost exclusively whole food diet. Mustard alone was adding 500 mg daily. Sheesh. Again, appreciate your thinking. It’s really helped.


Same here, I always bought into the old line that people who didn't eat breakfast would eat junk food or too much food the rest of the day, and so I assumed that I just needed to make sure I was eating healthy. Now, I'm looking more carefully at the timing issue. I definitely want to understand the cortisol/insulin business a bit more.

Interesting about the mustard. One of my brothers was fighting high blood pressure (my family shares another wonderful gene for salt-sensitive high blood pressure). He and his wife eat pretty well, but I suggested he give Cronometer a go, and he found a lot of sneaky places where salt was hiding. He's managed to bring his BP down on diet alone. So, keep trying!


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