Even though dietary oxalates may have a limited effect on kidney stone risk in most people, there are some predisposing factors that can put anyone at risk.
Oxalates in Spinach and Kidney Stones: Should We Be Concerned?
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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
Kidney stones affect as many as 1 in 10 people in their lifetime and can cause excruciating pain. Makes me cross my legs just thinking about them! Oxalate stones are the most common type, forming when the oxalate concentration in your urine gets so high it basically crystallizes out of solution, like rock candy. Some foods, like spinach, have lots of oxalates in them. Should we try to reduce our intake of oxalates to lower our risk? It turns out that people who do get stones don’t seem to eat any more oxalates on average than people who don’t get stones. It may be less what you eat, and more what you absorb. People who are predisposed to kidney stones just appear to be born with a higher intestinal oxalate absorption. Their guts just really suck it up: “so-called ‘super absorbers'” assimilate up to “50% more oxalate than non–stone formers.”
Overall, “the impact of [typical] dietary oxalate” on the amount of oxalates that end up in the urine “appears to be small.” “[E]ven a massive dose” of dietary oxalates typically only “results in a relatively mild increase” in the amount that makes it into your urine. A 25-fold increase in oxalate consumption doesn’t even double the concentration of oxalates flowing through your kidneys, so it’s really more determined by genetics than diet. But still, until you get your first stone, how do you know if you’re a super absorber or not? Is it safer to just generally avoid higher-oxalate fruits and veggies? People who eat more fruits and vegetables may actually tend to get fewer kidney stones. When researchers put it to the test and removed produce from people’s diets, their kidney stone risk indeed went up.
Removing fruits and veggies can make your dietary oxalate intake go down, but your body produces its own oxalate internally as a waste product, that you have a more difficult time getting rid of without the alkalizing effects of fruits and vegetables on our urine pH. This may help explain why those eating plant-based get fewer kidney stones (but it also may be due to their cutting animal protein intake, which can have an acid-forming effect in the kidneys). We’ve known this for 40 years. Just a single can of daily tuna fish can increase your risk of forming stones 250%. And even just cutting back on animal protein may help cut kidney stone risk in half.
Surely there’s some level of oxalate intake that could put people at risk regardless. There have been a few rare cases reported of people drinking green juices and smoothies getting oxalate kidney stones, though most had extenuating circumstances. This case describes a woman whose kidneys shut down after a 10-day juice cleanse, which included two cups of spinach a day.
Normally we might not expect a cup or two of spinach to cause such a violent reaction, but she had two aggravating factors—she had gastric bypass surgery (which can increase oxalate absorption) and a history of “prolonged” antibiotic use. There’s actually a friendly bacteria you want in your colon, called oxalobacter, that eats oxalate for breakfast, leaving even less for us to absorb, but it can get wiped out by long-term broad spectrum antibiotic use.
She still probably wouldn’t have run into a problem, though, if she would have used something other than spinach or beet greens or Swiss chard, the trifecta of high-oxalate greens. Kale has hundreds of times less oxalates than spinach. She would have had to have juiced in excess of 650 cups of kale a day to get a comparable dose, so over those ten days more than 6,000 cups of kale. But are the three high-oxalate greens only a problem for people with extenuating circumstances or who are otherwise at high risk? And what if you cook the greens? How much would be too much? I’ll answer all those questions, next.
Please consider volunteering to help out on the site.
- Curhan GC. Epidemiology of stone disease. Urol Clin North Am. 2007;34(3):287-93.
- Taylor EN, Curhan GC. Oxalate intake and the risk for nephrolithiasis. J Am Soc Nephrol. 2007;18(7):2198-204.
- Oxalate Content of Foods
- Voss S, Hesse A, Zimmermann DJ, Sauerbruch T, Von unruh GE. Intestinal oxalate absorption is higher in idiopathic calcium oxalate stone formers than in healthy controls: measurements with the [(13)C2]oxalate absorption test. J Urol. 2006;175(5):1711-5.
- Marcason W. Where can I find information on the oxalate content of foods?. J Am Diet Assoc. 2006;106(4):627-8.
- Taylor EN, Curhan GC. Determinants of 24-hour urinary oxalate excretion. Clin J Am Soc Nephrol. 2008;3(5):1453-60.
- Nouvenne A, Ticinesi A, Morelli I, Guida L, Borghi L, Meschi T. Fad diets and their effect on urinary stone formation. Transl Androl Urol. 2014;3(3):303-12.
- Holmes RP, Goodman HO, Assimos DG. Contribution of dietary oxalate to urinary oxalate excretion. Kidney Int. 2001;59(1):270-6.
- Sorensen MD, Hsi RS, Chi T, et al. Dietary intake of fiber, fruit and vegetables decreases the risk of incident kidney stones in women: a Women's Health Initiative report. J Urol. 2014;192(6):1694-9.
- Meschi T, Maggiore U, Fiaccadori E, et al. The effect of fruits and vegetables on urinary stone risk factors. Kidney Int. 2004;66(6):2402-10.
- Turney BW, Appleby PN, Reynard JM, Noble JG, Key TJ, Allen NE. Diet and risk of kidney stones in the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC). Eur J Epidemiol. 2014;29(5):363-9.
- Robertson WG, Peacock M, Heyburn PJ, et al. Should recurrent calcium oxalate stone formers become vegetarians?. Br J Urol. 1979;51(6):427-31.
- Robertson WG, Heyburn PJ, Peacock M, Hanes FA, Swaminathan R. The effect of high animal protein intake on the risk of calcium stone-formation in the urinary tract. Clin Sci. 1979;57(3):285-8.
- Borghi L, Schianchi T, Meschi T, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med. 2002;346(2):77-84.
- Makkapati S, D'agati VD, Balsam L. "Green Smoothie Cleanse" Causing Acute Oxalate Nephropathy. Am J Kidney Dis. 2018;71(2):281-286.
- Kelly JP, Curhan GC, Cave DR, Anderson TE, Kaufman DW. Factors related to colonization with Oxalobacter formigenes in U.S. adults. J Endourol. 2011;25(4):673-9.
- Chai W, Liebman M. Effect of different cooking methods on vegetable oxalate content. J Agric Food Chem. 2005;53(8):3027-30.
Image credits: ThiloBecker via pixabay and Jacek Proszyk via wikimedia. Images have been modified.
Motion graphics by Avocado Video
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
Kidney stones affect as many as 1 in 10 people in their lifetime and can cause excruciating pain. Makes me cross my legs just thinking about them! Oxalate stones are the most common type, forming when the oxalate concentration in your urine gets so high it basically crystallizes out of solution, like rock candy. Some foods, like spinach, have lots of oxalates in them. Should we try to reduce our intake of oxalates to lower our risk? It turns out that people who do get stones don’t seem to eat any more oxalates on average than people who don’t get stones. It may be less what you eat, and more what you absorb. People who are predisposed to kidney stones just appear to be born with a higher intestinal oxalate absorption. Their guts just really suck it up: “so-called ‘super absorbers'” assimilate up to “50% more oxalate than non–stone formers.”
Overall, “the impact of [typical] dietary oxalate” on the amount of oxalates that end up in the urine “appears to be small.” “[E]ven a massive dose” of dietary oxalates typically only “results in a relatively mild increase” in the amount that makes it into your urine. A 25-fold increase in oxalate consumption doesn’t even double the concentration of oxalates flowing through your kidneys, so it’s really more determined by genetics than diet. But still, until you get your first stone, how do you know if you’re a super absorber or not? Is it safer to just generally avoid higher-oxalate fruits and veggies? People who eat more fruits and vegetables may actually tend to get fewer kidney stones. When researchers put it to the test and removed produce from people’s diets, their kidney stone risk indeed went up.
Removing fruits and veggies can make your dietary oxalate intake go down, but your body produces its own oxalate internally as a waste product, that you have a more difficult time getting rid of without the alkalizing effects of fruits and vegetables on our urine pH. This may help explain why those eating plant-based get fewer kidney stones (but it also may be due to their cutting animal protein intake, which can have an acid-forming effect in the kidneys). We’ve known this for 40 years. Just a single can of daily tuna fish can increase your risk of forming stones 250%. And even just cutting back on animal protein may help cut kidney stone risk in half.
Surely there’s some level of oxalate intake that could put people at risk regardless. There have been a few rare cases reported of people drinking green juices and smoothies getting oxalate kidney stones, though most had extenuating circumstances. This case describes a woman whose kidneys shut down after a 10-day juice cleanse, which included two cups of spinach a day.
Normally we might not expect a cup or two of spinach to cause such a violent reaction, but she had two aggravating factors—she had gastric bypass surgery (which can increase oxalate absorption) and a history of “prolonged” antibiotic use. There’s actually a friendly bacteria you want in your colon, called oxalobacter, that eats oxalate for breakfast, leaving even less for us to absorb, but it can get wiped out by long-term broad spectrum antibiotic use.
She still probably wouldn’t have run into a problem, though, if she would have used something other than spinach or beet greens or Swiss chard, the trifecta of high-oxalate greens. Kale has hundreds of times less oxalates than spinach. She would have had to have juiced in excess of 650 cups of kale a day to get a comparable dose, so over those ten days more than 6,000 cups of kale. But are the three high-oxalate greens only a problem for people with extenuating circumstances or who are otherwise at high risk? And what if you cook the greens? How much would be too much? I’ll answer all those questions, next.
Please consider volunteering to help out on the site.
- Curhan GC. Epidemiology of stone disease. Urol Clin North Am. 2007;34(3):287-93.
- Taylor EN, Curhan GC. Oxalate intake and the risk for nephrolithiasis. J Am Soc Nephrol. 2007;18(7):2198-204.
- Oxalate Content of Foods
- Voss S, Hesse A, Zimmermann DJ, Sauerbruch T, Von unruh GE. Intestinal oxalate absorption is higher in idiopathic calcium oxalate stone formers than in healthy controls: measurements with the [(13)C2]oxalate absorption test. J Urol. 2006;175(5):1711-5.
- Marcason W. Where can I find information on the oxalate content of foods?. J Am Diet Assoc. 2006;106(4):627-8.
- Taylor EN, Curhan GC. Determinants of 24-hour urinary oxalate excretion. Clin J Am Soc Nephrol. 2008;3(5):1453-60.
- Nouvenne A, Ticinesi A, Morelli I, Guida L, Borghi L, Meschi T. Fad diets and their effect on urinary stone formation. Transl Androl Urol. 2014;3(3):303-12.
- Holmes RP, Goodman HO, Assimos DG. Contribution of dietary oxalate to urinary oxalate excretion. Kidney Int. 2001;59(1):270-6.
- Sorensen MD, Hsi RS, Chi T, et al. Dietary intake of fiber, fruit and vegetables decreases the risk of incident kidney stones in women: a Women's Health Initiative report. J Urol. 2014;192(6):1694-9.
- Meschi T, Maggiore U, Fiaccadori E, et al. The effect of fruits and vegetables on urinary stone risk factors. Kidney Int. 2004;66(6):2402-10.
- Turney BW, Appleby PN, Reynard JM, Noble JG, Key TJ, Allen NE. Diet and risk of kidney stones in the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC). Eur J Epidemiol. 2014;29(5):363-9.
- Robertson WG, Peacock M, Heyburn PJ, et al. Should recurrent calcium oxalate stone formers become vegetarians?. Br J Urol. 1979;51(6):427-31.
- Robertson WG, Heyburn PJ, Peacock M, Hanes FA, Swaminathan R. The effect of high animal protein intake on the risk of calcium stone-formation in the urinary tract. Clin Sci. 1979;57(3):285-8.
- Borghi L, Schianchi T, Meschi T, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med. 2002;346(2):77-84.
- Makkapati S, D'agati VD, Balsam L. "Green Smoothie Cleanse" Causing Acute Oxalate Nephropathy. Am J Kidney Dis. 2018;71(2):281-286.
- Kelly JP, Curhan GC, Cave DR, Anderson TE, Kaufman DW. Factors related to colonization with Oxalobacter formigenes in U.S. adults. J Endourol. 2011;25(4):673-9.
- Chai W, Liebman M. Effect of different cooking methods on vegetable oxalate content. J Agric Food Chem. 2005;53(8):3027-30.
Image credits: ThiloBecker via pixabay and Jacek Proszyk via wikimedia. Images have been modified.
Motion graphics by Avocado Video
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Title
Oxalates in Spinach and Kidney Stones: Should We Be Concerned?
LicenseCreative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)
Content URLDoctor's Note
Spoiler alert: As you’ll see in the next video, Kidney Stones and Spinach, Chard, & Beet Greens: Don’t Eat Too Much, anyone can overdo the three high-oxalate greens—spinach, beet greens, and Swiss chard. So, for anyone doing cups of greens a day (as you should!), better to choose any of the other greens, such as kale, collards, or arugula.
It takes a while for videos to be made, and so when I discover something like this in the research, I immediately go to our social media channels to alert people, as I did with this cautionary note on high-oxalate greens. To not miss critical “heads-up” info like this in the future follow us on Facebook, Instagram, or Twitter, and subscribe to our free monthly newsletter.
For some older videos I did on kidney stones, see How to Prevent Kidney Stones with Diet and How to Treat Kidney Stones with Diet. And a more recent video on an oxalate-rich food: Neurotoxicity Effects of Star Fruit.
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