A dietician's prescription for kidney stones, what do you think?

This is a case study, still not solved completely yet, a person on my life, not a client.

The case in hand, a 54 year old male. A fairly healthy person, on no medications, to date no abnormal blood tests (except slightly high LDL and total cholesterol), fit, eating a close to a paleo diet, low gluten rather than no gluten, i.e maybe a small serve of bread every couple of days. Eats some dairy – cheese and milk.  Drinks about 300 mls wine a day. Earlier this year cut down on carbs to lose a little weight, about 10 lbs. Eats approx 1.8 g per kg protein per day and about 50 grams carbs. He also drinks a lot of sparkling water, 2 -3 espresso shots a day and several cups of tea. Takes a multivite, that includes anti-oxidants, a good quality omega 3 about 1000mg day, and sometimes takes vit C (Ester C and bioflavanoids). Prior to May 2010 he took about 2000iu per day vitamin D per day, In May 2010 his blood test showed Vit D (25 Hydroxy) was 95nmol/L (38ng/l if you are in the USA). He increased vit D to about 4 – 5Kiu per day after that.

In April, May this year, complains of feeling tired, constipated, headaches. Not quite feeling his best. Doctor recommends lactulose for constipation. I wonder if he is eating too few carbs. (See Paul Jaminet’s series on problems with low carb diets, this post on constipation). I suggested he increase starchy carbs – root veggies. About a month later he got pain in his kidney area and rusty colour in urine a day later. I suggest he gets checked for kidney stones, stop the vitamin D, and get his vit D and calcium levels measured.

I was concerned that he may be absorbing too much calcium, as a result of too high a vitamin D level. Other bloggers have posted about this for example Jenny on Diabetes Update in this post “Too much calcium and vitamin D => Trouble” She writes about a condition called “Milk Alkali Syndrome” and her experience with it after increasing her vitamin D… ‘caused by the combination of high calcium and high Vitamin D and that the recent spike in cases has been caused by the recent fad of people supplementing with high levels of Vitamin D.’  (‘Calcium supplements can increase risk of kidney failure‘)

And from Dr William Davis: “Here’s a curious observation I’ve now witnessed a number of times: Some people who supplement this (1200mg day) dose of calcium while also supplementing vitamin D sufficient to increase 25-hydroxy vitamin D blood levels to 60-70 ng/ml develop abnormally high levels of blood calcium, hypercalcemia.” (‘Increased Blood Calcium and vitamin D’)

Paul Jaminet also writes in this post “Some people over-do vitamin D supplementation and/or calcium supplementation. Elevated blood calcium levels, which can be brought about by too much vitamin D, will cause constipation. If you supplement either vitamin D or calcium and have constipation, ask your doctor to check serum 25OHD, 1,25D, and calcium levels.”

I also wondered if the kidney stone was a result of his low carb diet Dangers of Zero carb diets: Kidney Stones (although at 50 – 80 g per day – his is not a Zero carb diet)

Then perhaps it is a genetic issue, as his father also once had a kidney stone. (Perhaps exacerbated by the increased vitamin D?)

Test results: D3 test 126nmol/L (50ng/L if you live in the USA). Urine test shows high calcium – 12.9mmol/collection (2.5 – 7.5) and a high volume (4 litres)

Sent to endocrinologist, who does further tests, for hyperparathyroidism (negative) wonders about diabetes insipidus, (negative). Measures serum calcium and phosphate (normal) Urinary osmolality, urea, oxalate and citrate (normal). Blood pressure 110/70. Ultrasound showed no kidney stones.

His verdict: long term vitamin D supplementation leading to hypercalciuria, and sends him to a dietician for advice on eating to reduce the risk of kidney stones.

Here’s the dietician’s advice:

Continue with high fluid intake, to keep urine dilute. (Drinks suggested: water, low sugar drinks e.g. diet cordial and soft drinks, milk – to achieve adequate calcium, tea, coffee, dilute fruit juice, moderate beer and win, BUT don’t drink sugary drinks)

Reduce sodium intake: “Getting sodium intake low enough can reduce the amount of calcium in your urine”. She noted he usually eats out at lunch, and suggested low sodium food choices, avoid added salt, sauces, and processed foods.

Ensure RDI of calcium – calcium bonds with oxalate from food and keeps it entering the blood, then urinary tract. Include dairy in diet rather than a supplement.

Moderate animal protein – too much animal protein increases calcium and lowers citrate in urine. Smaller portions 120g or less, eat less meat, eat legumes instead.

Eat high fibre foods as they contain phytate which binds with calcium and oxalate so you absorb less, which reduces stone formation. Choose wholegrain bread, pasta and cereal products, use wholemeal flour in baking.

Don’t take vit C or D as they may increase stone formation. Vitamin C is ascorbic acid and can be turned into oxalate by the body.

I asked the dietician a few questions:

If phytate binds to calcium, won’t it also bind to other minerals like zinc and cause deficiences? Her answer “He should be getting plenty of minerals from dietary sources”

Can you give me some evidence that vitamin C increases the risk of kidney stones? “Sure I’ll email you that” Consequently emailed various studies showing vit C increased kidney stone risk.

What about Vitamin K2, would it be useful to take? “I don’t know, I’ll ask the senior dietician, I haven’t heard anything about it” She later emailed that she knew of no benefit in taking K2

The Dietician’s sample meal plan and fluid guide:

Glass of water
Breakfast
High fibre cereal with milk or yoghurt, 1 cup
wholegrain toast and margarine
tea with milk
Morning snack
Bran muffin and coffee
Lunch
2 eggs / 120 grams chicken or meat with salad in a sandwich or roll (wholemeal)
Fresh fruit and yoghurt
glass of milk or pottle yoghurt
Afternoon snack
Fruit with glass of water
Dinner
Pre-dinner drink – diet lemonade
120 grams meat / fish / chicken – palm size serve
large serve vegetables
Lite tinned fruit and scoop icecream
glass of diluted fruit juice
Supper snack
Bran biscuit
glass of milk
Overnight
glass of water

MEAL plan provides: 11 cups fluid, lower sodium foods, 4 serves high calcium foods, 2 serves meat, and high fibre foods.

What do you think? What would you do if this were you?
(In a few days – I’ll post what he is doing, after advice from alternative paleo friendly sources.)

Here is an interesting post to read in the meantime:

Tufts University Confirms That Vitamin A Protects Against Vitamin D Toxicity by Curbing Excess Production of Vitamin K-Dependent Proteins

Is Vitamin D Safe? Still Depends on Vitamins A and K! Testimonials and a Human Study

Are Some People Pushing Their Vitamin D Levels Too High?