Sally K. Norton

Vitality Coach, Speaker & Health Consultant

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Painful Gout, Joint Pain, and Oxalates

Do you have painful gout, arthritis, bursitis, or stiff and swollen joints?

Hands and feet showing gout inflammation

Pain is too Popular

Together, painful arthritis, gout, lupus, or fibromyalgia afflict over 53 million adults in the United States. As of 2014, twenty-seven percent of U.S. adults have chronic joint symptoms.[1] An earlier 2006 study revealed that even young people—over 8% of patients under the age of 20—complain of pain, typically in the feet, knees, or back.[2] Joint pain—arthritis and rheumatism—is the most common cause of disability in the U.S., affecting 9.1 million adults in 2010[3].

Chronic pain of one kind or another has become an expensive public health problem in the U.S., costing $635 billion in medical treatments and lost productivity in 2011 alone.[4]  In 2016, Americans spent over $4 billion on pain-killing drugs that did nothing to address the cause of the pain[5]. And monetary cost estimates alone cannot begin to capture the losses associated with pain.

What if we could cheaply get out of pain? What if gout, arthritis, rheumatism, and back pain are a product of our diets—something very much under our individual control. Let’s take a closer look at gout.

What is Gout?

Gout is a form of inflammatory arthritis that can affect anyone. Sufferers experience sudden, severe attacks of pain, swelling, redness, and extreme tenderness in one or more joints, often the big toe, ankle, or fingers. The pain can have a burning quality as if the joints are on fire. Even after the acute gout pain subsides, joint discomfort may linger for days or weeks. With time, repeated attacks tend to last longer and affect more joints.

Gout and Diet

If you have gout, your doctor may be blaming your diet, and in particular the protein and salt you eat. The advice you’re likely to get? “Eat less meat and more low-fat vegetables.” Chances are such advice is tragically wrong.

Oxalate gout, a crystal-induced arthritis, as well as bursitis and tendinitis, can be caused by an oxalate-overloaded diet. Meats, fats, and salt don’t have oxalate, but dark chocolate, spinach, chard, almonds, buckwheat, peanuts, potatoes, and sweet potatoes do. Routine use of high oxalate foods can be the culprit in gout. When I had gout in college, I was a low-salt vegetarian. Thirty-some years later, I discovered that my gout was oxalate gout, caused by my vegetable-heavy diet, overloaded with oxalate.

Oxalate gout can appear, as it did for me, as a symptom of oxalate overload from my high-oxalate diet. But gout episodes can also occur during oxalate clearing as a transient symptom against the backdrop of improved health overall.

Crystals, Inflammation and Gout

Oxalate crystals forming and collecting in joints are known to trigger gouty inflammation and pain. The inflammation can be destructive to joint tissues. The accumulation of calcium crystals in cartilage (a.k.a. “calcification”) affects the elastic qualities of joints as well as their strength and stability. A lack of joint stability can cause pain. When I cut back on oxalate foods at age 49, my arthritis and long-standing foot problems (arising from weak connective tissues) finally disappeared.

Showing the opening paragraph of Dr. Simpkin's 1988 editorial about naming schemes for the sub-types of gout. Here he states that an article written by Rosenthal et. al. uses nine different terms to indicate oxalate gout.
Opening paragraph from Peter Simpkin’s 1988 Editorial from JAMA about types of gout.

Being a toxic irritant, crystals within joints lead to acute or chronic inflammation including gouty arthritis. Oxalate is one of several crystal types associated with arthritis. In 1988, Rheumatologist and editor of the Journal of the American Medical Association (JAMA) Dr. Peter Simkin, pointed out that the medical field uses too many difficult terms including “articular oxalosis” and “calcium oxalate micro-crystalline-associated arthritis” when referring to oxalate gout. The lack of simple, clear, and consistent terms for the various types of gout, especially oxalate gout, interferes with the clinical recognition of oxalate gout.

Oxalate is Hard to See

Diagnosis distinguishing one type of gout from another is problematic and depends on elusive analysis of joint fluid. Several authors, including rheumatologist and medical textbook author Antonio Reginato, call out the difficulty of identifying calcium oxalate crystals in synovial fluid of joints because they can easily be confused with other crystals.[6] Reginato’s work helped to establish the connection between crystals in joint spaces and arthritis and other bone and joint symptoms.

Invisible oxalate nanocrystals and oxalate ions are reactive and mobile, and thus are more toxic than the “prominent” crystals that are typically discovered by pathologists.[7] Slow to notice even the visible crystals, researchers, doctors, and pathologists are even slower to imagine the possibility of toxic trace deposits of nanocrystals and other chemical forms of oxalate in tissues. Although we can’t see them, nanocrystals do the most damage because of their ability to enter cells. And collectively, they have a larger surface area that interacts with living tissues.[8] Consequently, they are simultaneously stealthy, undetectable, and harmful.

Oxalates can also collect in tissues in other difficult to detect forms. In 1967, researchers Zarembski & Hodgkinson noted the presence of a non-crystalline complex of calcium and lipid in the liver and intestine: the oxalate lipids. [9] Similarly Reginato reported findings of lipid crystals and inflammation in joint fluids from patients with gout, rheumatoid arthritis, and traumatic bursitis.[10] He explains that analysis of joint fluids is rarely performed in cases of oxalosis, although joint pain is a known problem for these patients.

Another experiment led by a Belgian hematologist exposed human serum and dishes of living human cells that line blood and lymphatic vessels to oxalate crystals. They confirmed that oxalate crystals collect in blood vessel walls and trigger the immune cell reactions associated with the pain of gout and vasculitis[11].

Accepted clinical standards seem to miss the connection between oxalate and joint pain. Gout is strongly associated with kidney stones and chronic kidney disease. Despite this association, gout patients are typically excluded from studies on oxalate kidney stones. That is unfortunate given that high levels of oxalate (promoting stones anywhere in the body) seem to encourage uric acid gout and oxalate gout.

the formation and accumulation of crystals in tissues is a hallmark of many metabolic and inflammatory conditions, not just kidney and bladder problems.

Other Reasons High Oxalates Create Pain

Based on existing science, let me explain why minimizing oxalate exposure can get at the root cause of inflammatory problems and solve chronic pain problems. Science now recognizes that crystals forming in tissues are part of the development of gout and atherosclerosis[12]. Many studies have demonstrated that calcium oxalate crystals cause renal inflammation and damage renal immune cells[13]. In fact, the formation and accumulation of crystals in tissues is a hallmark of many metabolic and inflammatory conditions, not just kidney and bladder problems.

In addition to oxalate collecting in joint spaces, tendons, cartilage, and bones, oxalate causes nerve damage that creates pain, and increases uric acid, which is also associated with joint pain and gout. Most doctors blame uric acid for gout symptoms, which is elevated in people with oxalate kidney stones.

Inflammation

When oxalic acid grabs calcium and changes into crystals, calcium oxalate nanoparticles activate human monocyte cells and enhance local tissue inflammation[14]. That process and the related cell damage stirs up defensive innate immune system actions. These actions include “foreign body” alerts and “inflammasome” reactions, which call in platelets, causing tissue damage and promoting the development of auto-immune symptoms and fibrosis.

The immune engagement caused by exposure to high levels of either oxalate ions or oxalate crystals can lead to inflammatory conditions such as intermittent and chronic pain[15]. Oxalic acid ions and crystals create free radicals in cells that stimulate immune cells to secrete an immune signaling protein called MCP-1 (Monocyte chemoattractant protein-1). MCP-1 is implicated in the development of many diseases, including cancers, neuroinflammatory diseases, rheumatoid arthritis, and cardiovascular disease.

Aside from mechanical damage to the tissues, oxalate can also have a dramatic effect on cell physiology, including inhibiting the immune response to infection and shifting immune system toward uncontrolled inflammation.

Long before oxalates become crystals in tissues, oxalic acid damages immune cells (macrophages) and puts them in a pro-inflammatory state (with reduced cellular energy, increased oxidative stress, and damaged mitochondria)[16]. Dr. T. Mitchell’s team at the University of Alabama found damage to circulating immune cells in their human volunteers just 40 minutes after giving them a spinach smoothie with 720mg of oxalate[17].

Famous Gout Sufferers

Queen Anne (b. 1665, d. 1714)

Image of Queen Anne from Wikimedia Commons.
Queen Anne from the Workshop of John Closterman, Public domain, via Wikimedia Commons.

The famously gouty monarch of Great Britain and Ireland, Queen Anne, experienced bouts of pain in her limbs, stomach, and head. Today’s doctors may have said she had systemic lupus and pelvic inflammatory disease.

Anne Stuart suffered from other illnesses too—diseases associated with modern foods like tea, chocolate, and way too much refined carbohydrate: diabetes, nutrient deficiency, and probably oxalate overload.

Not only was she morbidly obese and diabetic at age 30, but pain also tormented her. By age 33, Queen Anne’s gout was a migratory arthritis affecting many of her joints, especially her feet, knees, and hands. The debilitating joint pain prevented walking: in 1702 she was carried to her coronation in a sedan chair. She was 35. She also had other forms of chronic inflammation: headaches, stomach pain, skin problems (red and spotted face eruptions that coincided with her bouts of joint pain).

Her issues suggest that her high oxalate diet was likely a factor behind her suffering.

In childhood, sickly Anne was sent to France for treatment of a serious eye condition with excessive discharge known as “defluxion.”[18] (Some of my clients report copious fluid draining from their eyes with fine grit in it.) While she lived with her French relations as a child, she was introduced to using chocolate, sweets, and tea to help her cope. Anne loved all things sweet.

She adopted a habit of a nightly cup of sweetened hot chocolate. Anne also enjoyed tea every day. Even more so than chocolate, tea was a great exotic novelty of her age, initially popular with the Dutch and French (she had Dutch family and married a Dutchman).

Irish Anglian cleric and author of Gulliver’s Travels, Jonathan Swift (1667 – 1745) was a contemporary of Queen Anne. Swift, who frequented taverns serving hot chocolate, or “chocolate houses,” wisely blamed gout on the over-consumption of chocolate. (According to Wikipedia, Swift hoped for a church appointment in England, but the Queen disliked Swift, finding his first book, A Tale of a Tub (1704), blasphemous.)

The severity of Queen Anne’s symptoms was both cyclical and progressively worsening until her death in 1714 at age 49. Some scholars speculate that the ultimate cause of death was kidney failure.

Ben Franklin

Quotes about Ben Franklin's gout from Walter Isaacson's biography of Franklin.
Ben Franklin and Gout, photos from: A Benjamin Franklin Reader, Edited by Walter Isaacson. Simon & Schuster, 2003.

Decades later, in 1780, American founding father Ben Franklin was bedridden with gout. Pen in hand, he asked, “What have I done merit to these cruel sufferings?” ‘Madam Gout’ had an answer. She told him his gout was due, in addition to his sedentary amusements, to his “inordinate breakfast, four dishes of tea with cream, and one or two buttered toasts . . .” People had been drinking tea from china bowls (without handles) since Queen Anne’s day. When she ruled England, tea had been around for just a few decades; by Franklin’s time, tea was standard daily fare in Great Britain and its territories.

Science Explains the Connection Between Tea, Chocolate and Pain

In the early 1940’s, researchers produced dramatically stunted growth in rats by adding 16% cocoa to their normal diet. They concluded that “indiscriminate and excessive use of chocolate flavored foods, especially in a diet already low in calcium, is not to be recommended”[19]. Today it’s easy to consume a diet consisting of 16% high oxalate foods like chocolate (and lots of sugar too). Yet, chocolate is now heralded as a health food. Previous generations knew better: two of our long-favored stimulants, chocolate and tea were not to be trusted.

Healing story of Joint Pain Relief with Diet

I have heard and have witnessed many remarkable cases of relief from joint pain after the removal of high oxalate foods from our diets.

My husband who developed debilitating carpal tune syndrome in the wake of the high-oxalate diet he adopted after we met reversed it with a low-oxalate diet.

My friend Ron mentioned in Chapter 13 of Toxic Superfoods also reversed pain in his thumb joints.

Many others have shared their stories online or written me directly, as did this woman from Australia. She is over-joyed to have relief from 8-years of gout. Here is her story:

Dear Sally,

I came across your work through Dr. Bill Schindler who was being interviewed on Episode 108 of the WildFed Podcast. My ears perked up as he was describing his health issues with gout and he explained how he had discovered your work with oxalates. My eyes widened and jaw dropped! I have been suffering from gout for the last 8 years. My mind was completely blown! I felt like a 1000-piece puzzle just fell completely into place at once.

Chard (silverbeet greens), tahini, dark chocolate, almonds, and sweet potatoes were all a part of my “healthy” diet. I expected they would get my gout pain to subside.

I have now been on a low-oxalate diet for three months and my gout has entirely disappeared. My receding, brittle fingernails are looking the best that they ever have and the eczema around my mouth (which I have always had and thought was a dairy related issue) is completely gone.

Since hearing that interview, I have immersed myself in your work. I’ve read and listened to everything that I can find!

From the bottom of my heart, thank you so much for the work that you are doing. The gratitude that I feel is beyond words. Thank you for your passion, your love, your genuine care for people, and your integrity. You are changing lives!

Reversing Oxalate Crystal Deposits in Joints: It’s not over until it’s over

Though low-oxalate eating can lead to remarkable improvement from gout and other joint and connective tissue conditions, gout can also be a symptom of oxalate clearing. When recovering from oxalate overload and enjoying overall improvements in health, the immune system’s efforts to remove oxalate from joint tissues can provoke occasional gout attacks in some people as they recover. The process can take years, but these painful episodes become less frequent and eventually end, seemingly for good.

Footnotes

[1] CDC, “Age-Adjusted Percentages of Selected Diseases and Conditions Among Adults Ages 18 and over, by Selected Characteristics: United States, 2014 Summary Health Statistics: National Health Survey, 2014 Table A-4a” (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2014), http://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2014_SHS_Table_A-4.pdf.

[2] Albert Tan et al., “Epidemiology of Pediatric Presentations with Musculoskeletal Problems in Primary Care,” BMC Musculoskeletal Disorders 19, no. 1 (06 2018): 40, https://doi.org/10.1186/s12891-018-1952-7.

[3] Theis, K. A., Steinweg, A., Helmick, C. G., Courtney-Long, E., Bolen, J. A., & Lee, R. (2019). Which one? What kind? How many? Types, causes, and prevalence of disability among U.S. adults. Disability and Health Journal, 12(3), 411–421. https://doi.org/10.1016/j.dhjo.2019.03.001

[4] Institute of Medicine (US) Committee on Advancing Pain Research.

[5] “OTC Sales by Category,” accessed December 12, 2017, https://www.chpa.org/OTCsCategory.aspx.

[6] A. J. Reginato and B. Kurnik, “Calcium Oxalate and Other Crystals Associated with Kidney Diseases and Arthritis,” Seminars in Arthritis and Rheumatism 18, no. 3 (February 1989): 198–224.

[7] Xin-Yuan Sun et al., “Mechanism of Cytotoxicity of Micron/Nano Calcium Oxalate Monohydrate and Dihydrate Crystals on Renal Epithelial Cells,” RSC Advances 5, no. 56 (May 18, 2015): 45393–406, https://doi.org/10.1039/C5RA02313K.

[8] Xin-Yuan Sun et al., “Size-Dependent Toxicity and Interactions of Calcium Oxalate Dihydrate Crystals on Vero Renal Epithelial Cells,” Journal of Materials Chemistry B 3, no. 9 (February 18, 2015): 1864–78, https://doi.org/10.1039/C4TB01626B.

[9] P. M. Zarembski and A. Hodgkinson, “Plasma Oxalic Acid and Calcium Levels in Oxalate Poisoning,” Journal of Clinical Pathology 20, no. 3 (May 1967): 283–85.

[10] Reginato, A.J., and Kurnik, B. (1989). Calcium oxalate and other crystals associated with kidney diseases and arthritis. Semin. Arthritis Rheum. 18, 198–224.

[11] M. A. Boogaerts et al., “Mechanisms of Vascular Damage in Gout and Oxalosis: Crystal Induced, Granulocyte Mediated, Endothelial Injury,” Thrombosis and Haemostasis 50, no. 2 (August 30, 1983): 576–80.

[12] Franklin, B.S., Mangan, M.S., and Latz, E. (2016). Crystal Formation in Inflammation. Annual Review of Immunology 34, 173–202. 10.1146/annurev-immunol-041015-055539.

[13] Mulay, S.R., Kulkarni, O.P., Rupanagudi, K.V., Migliorini, A., Darisipudi, M.N., Vilaysane, A., Muruve, D., Shi, Y., Munro, F., Liapis, H., et al. (2013). Calcium oxalate crystals induce renal inflammation by NLRP3-mediated IL-1β secretion. J Clin Invest 123, 236–246. 10.1172/JCI63679.

[14] Mulay, S.R., Herrmann, M., Bilyy, R., Gabibov, A., and Anders, H.-J. (2019). Editorial: Nano- and Microparticle-Induced Cell Death, Inflammation and Immune Responses. Front Immunol 10, 844. 10.3389/fimmu.2019.00844

[15] Umekawa, T., Chegini, N., and Khan, S.R. (2002). Oxalate ions and calcium oxalate crystals stimulate MCP-1 expression by renal epithelial cells. Kidney Int 61, 105–112. 10.1046/j.1523-1755.2002.00106.x.

[16] Kumar, et al 2021 Oxalate Alters Cellular Bioenergetics, Redox Homeostasis, Antibacterial Response, and Immune Response in Macrophages.

[17] Kumar, et al 2021. Dietary Oxalate Loading Impacts Monocyte Metabolism and Inflammatory Signaling in Humans.

[18] https://www.willowandthatch.com/history-queen-anne-britain-favourite/; https://www.historyofroyalwomen.com/anne-queen-of-great-britain/queen-anne-an-unhealthy-life-part-three/

[19] W. S. Mueller and M. R. Cooney, “The Effect of Cocoa upon the Utilization of the Calcium and Phosphorus of Milk.,” Journal of Dairy Science 26 (1943): 951–58, https://doi.org/0.3168/jds.S0022-0302(43)92791-2.

See Also:

Hoffman, G.S., Schumacher, H.R., Paul, H., Cherian, V., Reed, R., Ramsay, A.G., and Franck, W.A. (1982). Calcium oxalate microcrystalline-associated arthritis in end-stage renal disease. Ann. Intern. Med. 97, 36–42.

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A Chronic Illness: What Recovery Looks Like

Five+ Years of Low Oxalate — Reflections, Lessons, & Progress.

Back in November of 2018, I had a big anniversary: Five years since my (re)beginning and consistently sticking with the low oxalate diet (LOD)! Those of you who are considering or starting on this path of self-care might like some sort of note from your possible future. What will things be like after years of staying the course? I hope my experience will help to encourage you when things aren’t going as well as you are wanting. First let me offer some context.

A Quick Flash Back

I was in Graduate School at the University of North Carolina (UNC-CH), a patient at the medical clinic for student health. I dared to confess (to the grey-haired doctor) not only my weird symptoms but my observation that my symptoms would follow eating a variety of foods. I knew I was risking his skepticism or criticism, but I really needed help.

After eating whole wheat bread, I would feel both mentally and physically exhausted; soy seemed to cause my face to break out; and some days I would wake up with puffy eyes and a lot of fine wrinkles on my face, other days, not. He ran no tests, asked few questions, and quickly told me that my symptoms were all imaginary. He said, “you need psych-services”—three times. Belittled and soundly dismissed and by “my” doctor, I did sort of feel like I could use a shoulder to cry on. But there was no time for that with a statistics final exam the very next day!

In the meantime, my gynecologist at the UNC student clinic was taking repeat biopsies of my cervix because the tissues there looked so very cancerous. Fortunately, the results kept coming back as “chronic inflammation”. Neither of my doctors could imagine that my body was reacting to toxins, or that my immune system was in hyperdrive, agitated by irritants.

Medical “Care”

Medical practitioners (and other “experts”) have a long history of dismissing problems they don’t understand by accusing the victims of being hysterical or mental cases who need counseling. If you don’t fit their preexisting menu of “legitimate” problems, if you have too many complaints or otherwise feel sort of crummy a lot of the time, then the general attitude is: Well, you can’t be suffering from an organic illness with real causes.

They, the experts, don’t approve of conditions that don’t fit their lists or don’t conform to their assumptions or respond to symptom-hiding remedies. Their inability to help makes us malingerers, cry-babies, or one of the “worried well” (a new blanket term replacing previous labels like “female hysteria”). Likewise, family and friends can also be dismissive, or at best, at a loss as to how to be supportive of us when we struggle with a chronic mystery illness. And, few are tolerant of the idea that dietary changes might have merit.

Sharing to Teach

Given this cultural context, it must be either an act of bravery or recklessness to share publicly the depth and breadth of a multi-focal and wholly ignored illness like dietary oxalosis (oxalate toxicity). Am I foolish, brave, or reckless to admit that I had a lot of stuff bothering me that nobody could figure out? Yes, Yes, Yes. Accuse me of all three. I’m willing to stick my neck out in sharing my story for those who also suffer from a bunch of nasty problems hamstringing their lives.

How Weird is This?

Invariably, the characterization used in the medical literature for this oxalosis problem is “heterogeneous.” The symptoms of excess oxalate in the human body are indeed variable: different for the same individual at different times and different from person to person. Medical writers also use the term “asymptomatic” a lot—but that is yet another issue. The silent start of this disease might mean that things appear normal and healthy until symptoms show up later in the more problematic stages.

The bottom line, confusing as it can be, is this: The same disease looks very different in different people (and is often “silent” in the early stages). All the systems and all the tissues of the body can be affected by oxalate. All of them, every last one. On the other hand, in some people only a few body parts protest. There are no rules of toxic biology that comply with medical expectations or the handbook of medical diagnosis.

A Look at Oxalate Illness

The visible signs that oxalates are interfering with the maintenance and smooth running of our bodies don’t present specific universal patterns unique to this disease. In general, we can divide the likely factors behind this into two general categories. For one, the differing effects and severity in each person most likely reflect a person’s unique history of exposure. Here are some examples of what I mean:

  • timing of intake of high oxalate foods with age and related developmental stages,
  • states of wellness or infection at the time (or pseudo-infections that comes with vaccination),
  • a status of injury or overuse in some area(s) of the body,
  • personal nutritional and sleep habits,
  • levels of physical or emotional stress,
  • microbiome status, gut health,
  • kidney function.

Another source of the varied individual expressions of this disease are each person’s unique vulnerabilities that come from constitutional or metabolic tendencies and factors influencing genetic expression.

Remember too that the various body parts entangled with oxalate are unlikely to hold meetings to decide who among them can be harmed by oxalate, who may be spared (or appear to be spared for now), and who can cope with their level of oxalate exposure without subpar performance.

Reflections After 5 Years on the Low Oxalate Diet

Trite as it sounds, this diet has brought me back to life. Now, life-long health mysteries are not so mysterious. After years of suffering with pain, fatigue, sinus problems and bad feet, there was the possibility of a cure—discovering the cause, putting an end to it, and reversing my chronic symptoms.

It’s Not Just My Joints that Are Happier

The crazy-long list of my health problems (involving sleep, joints, feet, chemical sensitivity, skin, etc.) has shrunk considerably! The payoff from this diet is many-fold. It has allowed me to work and live a full life again, where once that was far from the case. I feel like I’ve grown 30 years younger. My spine moves, my brain works, I can sleep, run, and play in ways that were not possible five years ago. Back then, I was debilitated—too tired to work, to think, to read, and unable to tolerate exercise without extreme fatigue for days after.

I had an explanation and I had undeniable results. But the explanation, which initially seemed more than perplexing to me, also felt like an outrageous double cross. “Healthy” foods can make you very sick?  Oh yes they can!

About the Cause

The toxicity caused by too much oxalate in my diet was the result of eating real, whole foods. It was the result of abiding by the best health advice I knew: “Eat vegetables, emphasize leafy greens, eat beans in place of meat, eat walnuts for omega-3 fats and low-carb snacking”, I did all these things for years. I was very fond of vegetables even as a little kid. I loved real food, and still do.

Discovery, Frustration, and So Much to Learn

When I started oxalate-aware eating, I knew nothing about the chemistry or biology of oxalate and oxalic acid or its tendency to leave deposits in the body that needed to come out. (Neither do most doctors and nutritionists.) Knowing so little, I was shocked by all the benefits and funny reactions I was getting. I did not fully understand why this dietary change improves both new and old health problems, yet triggers rashes, eye sties, cold sores, peeling skin, or a variety of other oddities.

My scientific understanding needed a big boost, so I headed to the medical library. Information on chronic oxalate illness wasn’t simple to dig up there, either. After a lot of effort and time, I learned that oxalate is a known toxin with wide-ranging effects on the body. It has a long history of causing illness and the low oxalate diet is known to reverse illness.

Oxalate is known to collect in tissues. This phenomenon lacked much explanation except in cases when the disease is the genetic form, or the oxalate poisoning is acute. The chronic effects of either acute or chronic exposure on the body are still not well understood. Sadly, even the possibility of long-term effects is ignored by the establishment. In its entirety, the science is still waiting to be valued, explored, and understood.

Tragically, the many fascinating scientific findings about oxalate over the last 200 years are not adequately followed-up (if they are not soon forgotten) and the repeated warnings about the risks of routinely eating high oxalate foods are ignored. Of all the many problems with our understanding and recognition of oxalate-related diseases the most frustrating problem is this: Even receptive scientists or clinical workers do not demand accurate information about oxalate in foods. Without this, we cannot implement or study the effects of oxalate-aware eating. Thus, the diet cannot really be successful as a clinical tool. (Not that doctors are receptive to using an elimination diet, as they don’t wish to practice nutrition.)

A Quick Recap of Science Lessons Learned: A List

Here is a short list of some of the science about oxalate’s effects in our bodies. For more about this, please check back with my science page.

Oxalate:

  • creates crystals anywhere in the body, including in the arteries, joints, bones, and thyroid gland.
  • gets stuck in our tissues in idiosyncratic ways (different in each individual).
  • disturbs digestive health and the function of other organs, connective tissues, and cells.
  • causes muscles to lose potassium (and creates other electrolyte imbalances too), which can cause muscle knots, weakness, and heart palpitations.
  • triggers immune reactions that promote inflammation, pain, and autoimmune disease.
  • are toxic to nerves and the brain.
  • can destroy your sleep. (This is a repeated and widespread finding from real people, I have not seen mention of oxalate specifically in the sleep literature.)

The Beginning is Just the Beginning

As is true with most illness, the condition of oxalate toxicity does not immediately end when the diet begins. Internal residues of oxalate persist. The gradual process of dismantling them can generate difficult symptoms. These symptoms are often inflammatory and typically have some consequences for the nervous system, affecting mood, attention, sleep, physical coordination. This is true for me even after five years of faithful conformity to the diet. The diet allows the healing process to continue in its own mysterious ways.

Still Not on Easy Street

But the five years of recovery have been challenging. There’s much more to it than just “eating less and getting better”, even though that’s a great place for almost anyone to start.

The healing process can be brutal in the first few years. For me, there have been days, way too many days, where the pain and despair caused me to question the extent of the benefits of avoiding oxalate. My own doubt, skepticism, or uncertainty would, at times, compound the miserable physical and mental symptoms. Despite near perfect execution of the diet, pain and ill feelings would reappear in an on-again, off-again fashion. Sometimes they rise up in the middle of a really good week and abruptly stop me in my tracks. Sometimes symptoms would linger. Those days the abyss was wide: The gulf between the struggle I was living and my hope of fully restored health framed a dismally disappointing picture. And yet, it was also fascinating, because it is undeniable that I was continuing to get better. Something powerful is going on here.

Ongoing Recovery Means Still Improving and this Means Some Suffering

The often unpleasant, recovery process is far from over. My body is still blasting away at the oxalate within. Thick, cloudy, crystal-loaded urine both coincide with and follow days of back pain, fatigue, and mental fog. Then, finally a really great day appears: mental clarity and strong supple body enjoying abundant sustained energy. Then a day of symptoms again. So it goes, up and down. The down days get more bearable and the good days more common. Still healing.

So many melodramatic symptoms! They are likely a sign of a strong vital force whipping up a storm intended to blow up and move the mess—out! After one episode passes, the healing force moves on to another junk pile to blow away. And so the process continues on and on. Up and down. Up and down. One good day is followed by 5 hard days. One good week is followed by six hard days. The trend is upward, but the line is jagged!

Is this continuing drama because of some other metabolic problem? Or is this just oxalate deposit removal work? A number of things make it hard to recognize that oxalate is the key to so much suffering. The variable symptom patterns are one factor. The lack of recognition of the implications of persistent high oxalate levels inside the body (due to the sequestering self-defense strategy used when intake is high) is another. Until we have intensive clinical research, the only good way to test this is to eat this way and learn from personal experience. You might be surprised by the benefits that will win you over.

As the body works hard undoing the mess, let’s work with the ways and rhythms of biology. Make your lifestyle supportive. Think: yoga, meditation, rest, limiting sugar and over all carbs, avoiding toxins and junk food. Other modalities (targeted supplements and sauna, for example) can round out a path to vibrant health. All of these self-care practices require constancy to yield the results that unfold gradually over time. Remember that the tortoise won the race. (Rabbits, on the other hand, push too hard, jump around, and either get lost, distracted or burnt out.)

Turn Off the Healing?

How do you moderate or turn-off the body’s impulse to clean out the mess? (We want to do this because it can be brutal.) Hopes of having some say in this requires us to understand the triggers of the clearance process. Down here in the trenches, we can only guess. The triggers seem to be low oxalate intake and being well nourished (with minerals, energy and protein). Does this mean we have to add back some oxalate in the diet? Or fast, or stop taking minerals? Perhaps a diet of 40 mg of oxalate in every meal would hold back the healing reactions? The answers may not be simple, but it would be nice if someone could study this formally. No one individual can do this and prove it a better approach. Careful testing and monitoring of many people over several years would be needed. (I have not done a statistical power calculation.) Such research would take resources and expertise that is out of reach, for now.

Challenge Testing

Some of us don’t notice the benefits or for other reasons. They are more likely to drift off the diet – especially in the early years. This drifting tends to create unintended, private (n=1) “oxalate challenge tests”. This can wake up an oxalate sufferer to the reality of it and pulls them back on course. Just a bowl of freshly picked figs, a baked potato, or a few nut bars and, wow, significant feedback from their body usually pops up—an agitated, sleepless night; too many trips to the bathroom; fatigue; achy wrists; something. It’s as if one’s previous apparent tolerance has been unmasked by the period of avoiding oxalate.

Still, by going back to shunning high oxalate foods and making smart selections among the many other food options, one can relax back into a healing path.

Where I am Today

Now, I am living a full life doing more than most people manage to do. So far, the low oxalate diet has given me a lot. See this table for a before and after comparison:

NowBefore Low Oxalate Diet
Sleep is restorative (after about 10 days on the diet I started waking up feeling good). Restless legs: 95% gone and milder when it does happen. Brain waking up 29 times every hour. Extreme fatigue, even during mornings. Restless legs (Diagnosis based on sleep lab was “Periodic limb movement disorder” and involved arm movements too).
I can read and think and write.Had lost my reading comprehension and mental energy (likely due to sleep problem).
Fully functional feet (not seen in 30 years!), My feet did not tolerate jumping, darting side to side, the wearing of heels, or going barefoot without aching.
More flexible and strong joints with very little pain. Stiffness of joints and connective tissues; occasional random swelling and weakness of fingers, wrists, knees.
Quick recovery from exercise Post exercise fatigue would last 3 -4 days
A seemingly better vascular system and improved lung capacity. No more hiccups. Cold hands and feet. Mildly restricted ability to breathe deeply. Hiccups at night (often severe and painful).
Immune system is calmer with less inflammation overall.   Several “autoimmune” problems like indigestion, IBS, rheumatoid arthritis; “fibro” symptoms, many allergies, and allergic fatigue, puffy eye bags.
Bloating and belching is rare. Unstoppable belching fits at bedtime.
A more youthful and regenerating body (I’m reclaiming my physical abilities.) Felt worn out, aged, physical vitality slipping away.
Skin is stronger and less wrinkled.
Few to no hangnails. Much tougher skin on the bottoms of my feet. 		Bagging neck skin and eye area wrinkle. Frail skin especially noticeable around my nails where hangnails were constant. Tender skin on feet.
Less tartar; no more cavities; less tooth sensitivity (despite some significant flare-ups in the first 2 years on the diet). Constant tartar and frequent cavities in rear molars, sensitive to sweet and cold. Chewing could be uncomfortable.
Few muscle knots. (Potassium supplements were required to achieve this.) Abundant painful muscle knots in shoulders and back.
Increased bone density (increase of 4% at hip; 10% in back, according to DEXA scans) (Potassium may be helping with this too.) Osteopenia.
Improved tolerance to chemicals and fragrances. (No long tail of fatique.) Headaches and persistent fatigue easily triggered by breathing chemicals and exhaust.
Thyroid lumps and enlargement are gone. Reduced thyroid medication by half. Lumpy thyroid and below normal thyroid levels.

Changing Perspective

At the five-year point, I can see how far I have come. Yes, I want even more days of awesome. But being alive in this very honest way is good. After all, it is the amazing progress that emboldens me to dare hope for more. New possibilities expand across my horizons, even if some days those possibilities seem teasingly out of reach!

From this high peak of five years of recovery I can enjoy the view. I remember how far I have come. I can do so much more than before. I see so much progress. Part of “getting there” is a matter of remembering just how good you have it now. Not fighting this moment is part of making our next moments better.

Letting the process be what it is (vs demanding different results)

For those of us who are especially loaded with oxalate, the recovery process is a hard endurance challenge. The body needs to and wants to clean out and recover from decades of excessive oxalate consumption. As the body works to heal, it necessarily uses some rough techniques for blasting out oxalate calcifications. It unearths, attacks, dismantles, disintegrates, disperses and expels toxic crystals from cells and tissues. This work involves disruption of the status quo with inflammation and destruction. This can be painful, nerves don’t like it, muscles don’t like it, kidneys don’t like it. Your brain, your mood, your whole self, they all take a hit. It can be truly awful. (This is one major reason why both researchers and individuals overlook the benefits of the diet — the amount of oxalate in the blood and urine doesn’t necessarily drop consistently and the related symptoms persist.)

Don’t fight the waves, let the tide carry you forward.

Well, the bumpy healing process is what it needs to be. I may want joy, bliss, energy, and strength all the time; after all, I’ve been so good! What I get instead is occasional, unpredictable pain, wavering hope, and feelings of defeat. When these conditions prevail, it is our own expectations and impatience that erodes our confidence and threatens our resolve. Don’t give in to the downward pull of the bleak moments. Just know that it is temporary and will pass. Be willing to wait.

In the not-too-distant future, you’ll be feeling better and taking advantage of that. The bigger issue will be the tendency to take the better health for granted while neglecting the memories of just how bad things once were. Even when getting better, it is possible to focus too much on what is still not better. That is a sure path to misery.

Being Complete vs Not

Without acknowledging successful progress, the striving and wishing for physical perfection can generate a kind of illness of its own. It is an illness of discontent, defeat, and feeling incomplete. Instead, I resolve to be complete inside this day. As a personal hero of mine, Geneen Roth (a prolific author and guide for people struggling with food addiction and body image)[i], likes to teach: “ I am enough”. Likewise, this experience of today can be enough. I don’t need all that I desire to make it a good day. I need only my willingness to persist in a spirit of gratitude.

Today and tomorrow I am sticking with this. Joyfully I celebrate the miracles of being alive in an amazing body able to heal itself. I invite you to stick with it too. Look for and enjoy the miracle of healing.

Some Take-Aways:

  1. You are not crazy. You don’t need a doctor to validate you.
  2. It is not always obvious at the beginning that you are benefiting.
  3. The healing process for some of us carries on for years and years.
  4. There will be times when symptoms are in play making the benefits seem subtle, meager, or inadequate. These are not times to give up, but to resolve to stay the course.
  5. Not everyone has dramatic problems or healing symptoms. Still, it is common to overlook the connection between the oxalate clean-out your body is undertaking and the pain, skin issues, headaches, clumsy days, and tired days that arise in the process (even years after you started the diet).
  6. The pain of healing is part of the process. Six months of tooth pain, three weeks of sinus pain, periodic joint pain, a month of emotional fatigue—each will resolve on its own. You don’t need to intervene medically when your body is already taking care of you. 
  7. Stick with it despite it all; and find ways to enjoy the ride.
  8. Recovery is real. This diet is a gift that has saved me and many others from a downward spiral that was undoing our lives and our sense of who we are.

My future is about living life fully in ways that were for so long compromised by pain and fatigue. Today, my bad days are so much better than my good days were before taking the oxalate out of my diet. I am convinced that my body will perform best with as little oxalate on board as it can manage.

A Brief Note of Gratitude and Thanks

This is a good time to take stock and express gratitude to everyone who made this possible. Thank you, Susan Owens[ii] and your devoted moderators, list mates, and loyal followers for sharing your stories of oxalate mobilization (“dumping”) reactions. Your recognition of this process is not only a brilliant insight, it has helped thousands.

Our current recognition of the connection between food oxalate and pain starts with Joanne Yount, founder and director the VP Foundation[iii]. For over 25 years, she has bravely, fiercely, and loyally attended her mission to test foods for their oxalate content on behalf of people with chronic unexplained pelvic and genital pain.

Let me start and end each day with a grateful heart.

Footnotes

[i] Geneen Roth https://geneenroth.com/books/

[ii] Autism Oxalate Project / Trying Low Oxalate Group: http://lowoxalate.info/

[iii] The VP Foundation: http://www.thevpfoundation.org/


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We’re on a Leading Edge

Oxalate Awareness is missing from the menu of options for healthy living. That is because other people have decided what matters and what doesn’t. What if they based their decisions on wrong and very incomplete information? Can you find peace and confidence despite the experts’ ignorance?

Painful Searching for Missing Answers

My clients and followers care about their health. They’ve read, they’ve done research, they’ve made admirable efforts to do the right thing when it comes to their food, their fitness, and so on. Despite all this intention, attention, willingness and effort, they still don’t feel good. Something is bothering their organs and cells. In one form or another, irritating problems don’t seem to get better no matter what they do. Worse still is that the continuing slide in their well-being can be downright scary or demoralizing.

Increasing desperation keeps them hunting for options and answers. They suffer, they try, they seek, they apply the given remedies, they still suffer. They seek, they try—again and again. People around them question their sanity. Friends start to wonder if these people are malingering, or fanatical, or just plain weak in the face of normal aches, pains, and fatigue. Some loved ones watch them suffer in utter helplessness and confusion.

But like me, my tenacious seekers know they are not meant to suffer so. This conviction keeps them searching for real relief, for that obscured path to a more livable existence. By grace, thousands of us have found the oh-so-elusive solution. We’ve learned how to avoid oxalate. We have started down the long path of supporting our bodies’ efforts to lower our oxalate burden and rebuild our health.

In the wake of some simple diet changes, miracles commence. We’re dumbfounded. So many of the foods we now know to avoid are still being heralded as good for you, and not acknowledged as what we know them to be: the source of pain, bad sleep, bad skin, fatigue, digestive problems, and urinary tract and kidney problems.

Missing Option

Why was this healthy eating option missing for us despite all our reading and research? Why is oxalate awareness absent from the marketplace of ideas and from the curiosity of researchers? Why are doctors, nutritionists, and health coaches ignoring this very real problem? “Why” may be a futile question to attempt to answer. There are many forces that keep the oxalate problem hidden. Exploring them all could fill a book (and might someday).

The fact is that these “experts” (for example: text book authors, university professors, and clinicians) are comfortable with their own ignorance of the science on this subject and happy to discount the experience of those who suffer from very real (and serious) oxalate-induced health problems. They are sure of themselves based on their own social position and cultural forces that valorize their attitudes. Their opinions glitter with a disingenuous veneer of rationality. Shrouded by social prestige, their dismissals of real-world observations and lived experience hold sway. They expect us all to agree with what they believe, because, well, they are the experts. Too often we cooperate.

They are willing to “think” for us and decree what is possible without checking their facts, and with a tenacious resistance to considering phenomena that suggest that some of what they think they know might be wrong. Experts who know nothing about oxalate (and its effects on the body) are the norm, not the exception. That means we’re on our own.

On a Leading Edge

We oxalate sufferers have to become leaders in our own healing journey. Out here on the oxalate-aware path we’re on a new frontier. We are pioneers, willing or not. That is disturbing for many of us because it is a life and death matter. We expect to get some validation or some form of help and understanding from health professionals. All that is in short supply. And that is the reason I became an oxalate researcher and educator.

What we have discovered out here on the frontier is that a toxic substance, when consumed on a regular basis, has toxic effects on the body. Insidious, long-lasting toxic effects. Accumulation of the toxin and the resulting cumulative damage causes a huge variety of real and debilitating problems. Why would anyone deny this reality? Why do experts show no interest in the thousands of people who have benefited by lowering their oxalate intake?

Alas, the experts in white coats, the authors, the sellers of nutbars and smoothies, and the plant-based diet demagogues don’t care if you are right. They will deny your reality, despite its logic and simplicity (and scientific backing), because they have concluded that what you are experiencing simply can’t be true.

An Inconvenient Truth

Oxalate (the toxin) is made by plants and occurs in familiar, profitable, and tasty foods. These “advantages” are enough to cancel simple logic and close down the discussion, end exploration, and stifle understanding. The implications (for our diets and our culture) are too painful to face.

Another issue is that oxalate is tricky to study. Although pathologists have repeatedly called out oxalate as trouble, it manages to evade condemnation by researchers and academics. The science is incomplete; our understanding of biology is extremely limited. Current science still tends to treat the biological systems that manage whole-body health too much like a simple machine, rather than a complex actor making use of many interacting systems to maintain its well-being. Our simplistic thinking has made it convenient to dismiss concerns about oxalate before we ever developed the tools to identify its subtle and sneaky effects so we can catch it in the act of ruining our health.

Know What you Know

If you are benefiting from avoiding oxalate, let what is true be true. Celebrate that! Your ultimate success depends on you staying the course. Be glad that you found the missing answer and that your path to health is finally clear.

Please know in your heart that what you have discovered about oxalates’ effects on your health is real and really serious. The most precious thing you can possess is your health and a peaceful heart. You can have both, even in a world that does not yet “get it” when it comes to oxalate.

Remember

You deserve to be informed, even when your doctor is not. Although it has its appeal, you don’t need your doctor to think for you or to validate your experience.

May you move forward in 2019 with hope and transformative healing. May you share the good news with others! May you ring in the New Year with confidence and a peace-filled heart!

Happy New Year!

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Keto Getaway: Eat Less Plants and Feel Better!

In January I spoke at a wonderful nutrition and health conference, the Keto Getaway Conference, in West Palm Beach held by LowCarbUSA. Even though I was sick and the weather in Florida was cold, I had a wonderful time. Way to go Pam and Doug Reynolds, the founders and organizers who pulled together a wonderful program and a terrific line-up of speakers for the 2018 Keto Getaway!

Including a presentation on dietary oxalate in a low-carb nutrition event… this was a first! I am so grateful to have had the opportunity to introduce oxalates to some of the leaders in the keto nutrition movement. The credit goes to Carole Freeman (a.k.a. Keto Carole) who recommended me to Doug Reynolds. Thanks to her I shared and gained a number of important insights about the relationship between low-oxalate eating and a keto diet, some of which I have summarized below.

For those of you who are new to ketogenic diets, the first part of this post explores the whats, whys, and hows of “ketogenic” eating.  If you’re already familiar with keto, you might want skip ahead to My Insights from Hanging in the Keto World.

What is Keto?

Keto is the popular term for eating a diet that is nearly free of carbohydrates, creating a fat-burning body “economy”. The term “keto” comes from the molecules (referred to “ketone bodies”) that your body generates when it burns fat instead of glucose to fuel activity and metabolic functions. Even the brain can switch to burning ketones when carbs are cut from the diet, which is a good thing.  Doctors will sometimes worry about the body creating ketones, because they don’t understand the difference between nutritional ketosis (a normal healthy process that occurs when your body burns fat) and ketoacidosis (which also creates ketones, but which occurs when your metabolism is not working due to diabetes or other metabolic disorders).

Long having held the ecological niche of game hunters, human beings have been eating low-carb for many tens of thousands of years. Today’s carb-centric diet is a recent invention; the idea that processed carbs (eaten in abundance) are safe just came into being about 40 years ago. This is about the same time the 24-hour grocery store was invented. Not long after that, cup holders in our cars became standard equipment by the 1980s as well. By then we were hooked on sugar-on-the-go.

Why Keto?

A low-to-no carb diet is not new but is being explored anew by people seeking to:

  1. cure obesity,
  2. reverse diabetes,
  3. treat brain and neurological disorders (Epilepsy, Parkinson’s, Alzheimer’s Disease, brain injury, mood problems and more),
  4. manage endocrine disorders (Polycystic Ovary Syndrome),
  5. support cancer treatment; and to
  6. improve general health, well-being, and longevity.

Also, fasting has become a big buzz of late. Training your body to be good at burning fat and ketones is the best preparation for fasting. For my own health, I have been a carb-restricting eater for at least eight years, with the last year going lower and lower and relying on my fat-burning capacity more consistently over the last 6 months so I can experiment with fasting (and still stay energetic and fully-functioning).

How Keto?

To “go keto,” people remove sugars and starchy foods from the diet: grains, fruits, potatoes, junk foods, juice, sweet drinks, etc. The only effective way to lower carb intake is to eat something else, specifically fats (not excessive protein). Basically, if you want to burn fat for fuel, you need to eat fat. Simple logic, right?

The best example of this type of diet is The Atkins induction diet. Typically, a low-carb, high-fat (LCHF) diet involves a reduction in the amount of plant foods (no grains, beans, or potatoes), more animal foods (eggs, meats, fish) and many more fat calories from both animal (full-fat meats, bacon, chicken skin, bone marrow, lard, tallow, butter, heavy cream, cheese) and vegetable sources (coconut, avocados, nuts).

Bone Marrow

Shrimp Salad

Is it Safe?

A ketogenic diet means eating more butter, olive oil, heavy cream, coconut, avocados, and fatty meats. This is a shock to most people because we have been wrongly told over-and-over again for four decades that eating fat is bad for our health. It turns out that the only real problems with fats come from:

  1. trans-fats (hydrogenated vegetable oils),
  2. processed vegetable oils (e.g. canola, soy, corn),
  3. poor-quality fats in the context of a sugary, high carb diet, and
  4. the contamination of fats with environmental chemicals and, perhaps, with certain naturally-occurring plant sterols (as in soy oil).

Clean animal fats like lard, egg yolks, beef tallow, cream, and butter are beneficial to health because they contain needed nutrients, help the body assimilate nutrients, help act as a solvent, moisturizer, and clean-burning energy source in the body. Coconut oil, and fats from avocado are also safe and beneficial in the context of a low-junk, low-sugar diet. Despite the many unknowns still surrounding very low-carb, high fat diets (see the next section), lowering carbohydrate intake is safe for most people because a healthy body has no intrinsic need for them. (Some conditions, including heart failure, kidney stones, and gout may need special attention from a keto-aware medical professional who can monitor liver, kidney, and heart function to ensure safety.)

The State of the Art of Ketogenic Living

The science and even the definition of ketosis is still emerging. That is, although there are many scientific papers on the subject, many basic questions are just starting to be explored. For example: what is the most accurate way to measure ketone bodies so that we can monitor the state of ketosis? (Is it by the breath, urine, or blood?) How does a fat-burning metabolism affect our need for micro-nutrients? How do we correctly interpret diagnostic testing that has been standardized based on the modern grain-based, high-carbohydrate diet, when these tests are performed during prolonged ketosis? We may need more salt and electrolytes on a keto diet, but how much and when?

I have my own question too: Is the reduction of plant foods (such as wheat, beans, and potatoes) part of the reason that people on a keto diet feel better and love this way of eating? The keto diet is dramatically different from the standard diet, and there are many moving parts that are very much unaccounted for! (Especially the effects of reducing our intake of plant toxins.)

Does a Keto Diet Work?

Yes—if you do it right and give it enough time! That is, to feel your best while burning fat, your cells need to change the equipment they use for energy production. That takes time. There is a transition period of several months or a year, or even longer for some people. This transition can be a bit of an ordeal or it can be straight-forward: everyone is different.

There are several factors that can make the transition period challenging or even unpleasant. For example, you have to face the addictive nature of carbohydrates–they stimulate insulin and brain chemicals that make us crave sugar, bread, pasta, pizza, fries, chips, potatoes, donuts, desserts, chocolate, etc. Carb withdrawal is ugly. The addictive pull of carbs sets us up to abandon our body’s keto-metabolism training due to “cheats”. When we cheat and eat carbs, the progression to keto is up and down—prolonged and delayed by the internal food fight, personal habits, and the cultural challenges that are waiting around every corner in a carb-centric world. Patience, persistence, and starting again and again eventually pay off for some, but many people give up and prematurely declare themselves “not-a-fit” for this approach.

Key Tips on the Keto Journey

From my experience in being strict about carbs, there a few critically important keys to success:

  1. Eat more salt, a lot more, because your kidneys will “waste” salt and potassium when you switch to low carb. If you keep switching on and off ketosis (like I did for years), you may end up depleted of salt and potassium and electrolytes generally. This can mean dry connective tissues and induce muscle aches and knots.
  2. Get enough food: “strict low-carb” is not “low-calorie”.
  3. Embrace fats: eat much, much more ghee, butter, and other animal fats than you think you should.
  4. Let it take the time it takes (measure in months, not days). You will be reworking daily habits, holidays, ways to celebrate, etc. This involves the psychologly, sociology, and the physiology of eating!
  5. While slowly progressing toward maintaining a consistent keto lifestyle, live and love your life as it is without fretting about the “depth” of your ketosis.

My Insights from Hanging in the Keto World

High-carb foods come from plants, and many (namely: grains, potatoes, beans) are high oxalate.  Switching to ketogenic eating means cutting out grains, potatoes, and beans—completely! Unless you are frequently eating spinach, swiss chard, mixed salad greens, nuts, and chocolate, you will often be eating less oxalate on a keto diet. Some keto dieters even move to an all-meat, or mostly animal foods diet. This is exemplified by Amber O’Hearn (find her here and here) and many other 100% carnivorous eaters (think of this as the “feline diet”). What keto dieters may not realize is that this all-animal diet is also one way to do a zero oxalate diet.

One of the medical leaders in the field of therapeutic ketogenic diets is Dr. Eric Westman of Durham NC. He and other keto-promoters like to mention (okay: brag) that not only can they correct (cure) diabetes and obesity with diet, but that their patients also report less pain and digestive problems. He says that 80% of his patients with reflux get relief on the keto diet. He’s crediting ketosis for these bonus outcomes, without considering the effect of reducing plant toxins. However, pain and digestive problems regularly clear up on a low oxalate diet—even without ketosis.

Could it be that cutting out wheat, potatoes, and beans while eating more meat is a path to a moderate oxalate diet? Surely, reducing or removing oxalates and other plant toxins from the diet adds to the benefits of the low-carb, high-fat, ketogenic diet. Still, the keto world is mostly invested in the idea that ketones in the body are the principal source of the “keto magic”. Ketones are only one of the many reasons that people feel better on a keto diet. (Subtracting plant toxins feel good!)

Eat Less Plants

Who is looking at the changes in exposure to plant toxins? Sadly, not many researchers are exploring this angle in nutrition. But some keto proponents do suggest that a “low plant, high animal food diet” results in better health than a keto diet that includes more plants. Psychiatrist Georgia Ede does a great job explaining this seemingly radical idea.

Here is quote from Dr. Ede:

“There’s no evidence that I could find proving that plant foods are good for us. You see many, many studies showing that plant extracts can be used as medication when someone has a disease, are using [a subset of] their naturally toxic properties to your advantage. But if you are a healthy person, do you need to eat plants? As far as I can tell, you don’t…. When it comes to anti-nutrients, these natural chemicals within plants not only can irritate our systems, but they can interfere with our ability to digest and absorb nutrients, key nutrients …. The part of the plant which is most risky for us… is the seed. Because that’s the most heavily protected, that’s the future of the plant. …grains, beans, nuts and seeds are all seeds and they are very heavily protected. And I think that that is why… many people feel better on that [keto] diet, because they’ve removed legumes, they’ve removed grains… They have [often] not removed nuts and seeds, although I think some people who don’t feel better enough on a [low-carb] diet might want to consider that .”

Other Hints that Keto Sometimes Works Like a Low-Oxalate Diet

Example of the Low Oxalate Diet Rash

  • The “keto rash” sounds just the low-oxalate rash (see the picture nearby)!
  • Reports of “keto gout” sound a lot like oxalate flooding (dumping) reactions that may happen on the first year or two of a low-oxalate diet.

Why Oxalate Awareness is Needed in the Keto World

Oxalate is one more factor that makes ketogenic eating a good idea, SOMETIMES. There are at least 2 ways oxalate could be a problem in a keto diet:

1. Too Much Oxalate.

Some keto dieters may overdo oxalate by making these mistakes:

  • relying too heavily on nuts;
  • routinely eating some of the classic super-high-oxalate greens (spinach, swiss chard, beet greens, micro green salad mixes);
  • spicing up their foods with high oxalate spices like cinnamon, cumin, turmeric, etc.; or
  • treating themselves to keto “fat bombs” and hot drinks made with coco and dark chocolate.

Any combination of these low-carb/high-oxalate ingredients can quickly add up to a dangerously high oxalate diet.

2. Too Few Oxalates, Too Fast.

Another Low Oxalate Skin reaction – on a foot

The mostly-animal food version of keto may mean abruptly (and unawarely) switching to a much lower (near zero) oxalate intake. In some people with a history of eating high oxalate foods: Oops!  They may experience an abrupt outbreak of a whole new set of problems. Why? Because this switch is likely to destabilize oxalate deposits in the body and trigger oxalate flooding / dumping. Boy can that be unpleasant! Flooding your tissues with ionic or nano-oxalate is hard on your body. The deleterious consequence of the body’s desire to be rid of oxalate can be softened with certain supplements and other strategies that are just beginning to be explored (and that need to be figured out for each individual).

Lets Get Together

In my own experience, Low-Oxalate and Low-Carb are a wonderful combination for enhancing mood and energy, and for managing pain. Both are important for optimal brain development and function, limiting the effects of brain aging, and for preventing and perhaps treating dementia. There is a potentially powerful symmetry in the union of know-how in the previously unconnected worlds of low-carb and low-oxalate. Lets keep thinking together about what we need to learn and teach to bring the greatest possible benefits to human health.

 

To view videos of 2018 Geto GetAway speakers go here. (https://www.lowcarbusa.org/videos/video-members-area/2018-wpb-premium-videos/)

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Sloppiness of Standard Practices in Science

The public is unaware of many problems in how science is conducted and the ramifications for patient health.

For example, poor handling and significant time lapse before pathologists see the fragile and perishable tissues they examine can yield unreliable, meaningless data. Richard Harris discusses such problems in modern biomedical science in a new book, Rigor Mortis: How Sloppy Science Creates Worthless Cures, Crushes Hope, and Wastes Billions. The book is long overdue! It is certainly an important topic in need of some light, and I’m looking forward to reading it. Thanks to Richard Harris for tackling this massive problem!

In a book excerpt on the NPR site, Harris describes how researchers finally revealed one of the hidden problems in pathology.  While evaluating a breast cancer test, researchers in a lab at the University of Rochester let breast tissue biopsy samples sit out for an hour or two before testing them. They didn’t realize that at room temperature, the sample decays! Folks: dead tissues decay, and decay changes what a pathologist can detect.  Harris writes:Rigor Mortis Book Cover

“And that was enough to degrade the sample and turn a positive result into a negative one. The molecule detected by the HER2 test breaks down at room temperature. “You can have the best test in the world and still get the wrong answer if you bugger up what you are testing,” Compton said.”

Oxalate Detection is a Problem for These Same Reasons Too

This problem of tissue degeneration is certainly true for oxalate crystals. These crystals are known to disappear from tissue samples within 2 hours of death, especially from the thyroid gland. Surgeons and their assistants lack training in the best methods for preserving biopsy samples and do not prioritize a speedy passage to the microscope. These processes are not priorities for biomedical institutions. Science and the public both suffer as a result.

I will write more soon about problems in tissue sampling and examination, focusing on overlooked oxalate deposits.  Unseen due to normal but faulty biomedical procedures, oxalate deposits in human tissues are more common than believed by researchers.

Link to NPR book excerpt:

http://www.npr.org/books/titles/522223284/rigor-mortis-how-sloppy-science-creates-worthless-cures-crushes-hope-and-wastes#excerpt

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Radio Program: Gut Health, Inflammation, and Oxalate in Foods

Check this out. I was recently interviewed about Oxalates and Health by Sunny Gardener on Lightly On The Ground Radio on 97.3 WRIR, in Richmond VA. This show aired on Aug. 12, 2015.

Sunny and I discussed the back bone of all disease: inflammation.  We cover the connection between changes in the bacteria in our colons and increased susceptibility to inflammation.  We touched on oxalates in foods as a possible contributor to gut health deterioration and inflammatory illnesses.

 

Thank you to WRIR’s Lightly On The Ground, produced in Richmond VA.

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Letting Patients Down

No one goes through medical training so they can disappoint people with lousy outcomes and grievous errors in performing dangerous procedures. Yet, this is happening as a regular course of business in American Medicine. In my post, The Cost of Too Much Spinach, we have a case in point.  A young woman suffers from a painful aliment, kidney stones. When she turned to medicine for relief, she was granted a series of tests and surgery that were likely injurious. None of these procedures offered any benefit, not even an accurate diagnosis. Patients like tests, as they believe that a test offers them a definite understanding of their condition. This case shows that tests don’t always perform up to our expectations. Our reliance on technology and invasive procedures illustrate some serious failures in how American medicine is practiced.

In hindsight, we know that this young woman’s problem was kidney and urethral stones. She had terrible pain in her rib cage on both sides of her body. The local university medical clinic found a 110-degree fever and kidney infection. They performed many tests and also removed her healthy appendix. As Scott Miners wrote in the article I discussed in my previous blog post, the young woman “was very frustrated and still in pain when the clinic staff released her.”

Still in pain, she traveled across the border to Mexico where a naturopathic doctor performed an ultrasound test that found two kidney stones working their way out of her urinary tract. The naturopath’s herbal treatment may have assisted the stones passing and provided relief for the patient.

Many questions are raised by this case: Why did the doctors do so many expensive tests and surgery, yet not find the real problem? Are doctors unaware of kidney stones? Do they assume that only old men get kidney stones? Are they aware that kidney stones are becoming increasingly common in females and in children? Are they aware that extreme diets with very high oxalate foods can trigger kidney stones (not to mention other health conditions)? Will they ever consider a person’s diet when they’re trying to determine what’s wrong with their patient?

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Catastrophic Complication of Weight-Loss Surgery: Kidney Failure

Figure 1 Nagaraju (2013). Large intraluminal translucent crystals of calcium oxalate, tubular epithelial degeneration (foamy cytoplasm, pyknosis, karyorrhexis, indistinct cell borders, dilated lumina), lymphocytic infiltration in the interstitium (H and E, ×400)

Figure 1 Nagaraju (2013). Large intraluminal translucent crystals of calcium oxalate, tubular epithelial degeneration (foamy cytoplasm, pyknosis, karyorrhexis, indistinct cell borders, dilated lumina), lymphocytic infiltration in the interstitium (H and E, ×400)

A case of kidney failure after bariatric surgery is stopped with low-oxalate diet.

Canadian nephrologists reported a case of life-threatening kidney damage caused by kidney deposits of oxalate crystals.1 The doctors performed a kidney biopsy on their patient, a 54-year old man, 20 months after duodenal switch weight-loss surgery. His blood creatinine levels had tripled over the previous nine months. The biopsy found oxalate crystals causing tubular damage and atrophy, fibrosis, and inflammation. They also noted hardening of the blood-filtering glomerular capillaries.

The patient was treated with a low-oxalate diet, calcium citrate (1,000 mg 3 times a day with meals), high water consumption, and the drug cholestyramine to help reduce oxalate absorption. This stabilized his blood creatinine levels and his urine oxalate dropped by a third from 99 to 63mg per day. Normal urine oxalate is under 40-45 mg/day. The authors’ want practicing clinicians to be aware of the increased risk of excessive absorption of oxalates from food following weight-loss surgery (“secondary enteric hyperoxaluria”) which can lead to kidney stones and life-threatening renal failure due to oxalate-induced kidney damage.

This case illustrates: 1) changes to gut function can alter oxalate absorption; 2) oxalates in foods can cause tissue damage; and 3) this process may be arrested by limiting oxalate absorption with a low-oxalate diet and supportive therapies.

Interestingly, this patient’s urine oxalate levels, although lower, remained elevated (63mg/day) despite effective diet therapy. Consistent with reports from cases of genetic oxalosis, this may indicate that the patient’s tissues are shedding existing oxalate deposits in the kidney and elsewhere in the body. The clearing of oxalate deposits may contribute to urinary oxalate, perhaps for years. It is likely that shrinking tissue oxalate deposits leave in their wake persistent renal scarring and tissue damage elsewhere.

Oxalate deposits can develop over time after either Roux-en-Y gastric bypass surgery (RYGB) or duodenal switch surgery. These surgeries can trigger an increase in the absorption of dietary oxalates (perhaps due to bile salts in the colon and fat malabsorption in the small intestine). This potential complication -the possibility of increased oxalate absorption leading to high urine oxalates and, eventually, kidney failure – is not typically discussed at the time of consent to surgery.2 Nor are these patients typically told that they can minimize the risk by modifying their diet to avoid oxalates in foods. Discharge and follow-up counseling and education should include instructions for the low-oxalate diet. The gastric banding procedure is not likely to cause this problem.2

Oxalate deposits in the body develop gradually and often without symptoms.3 Although rarely prescribed by clinicians, a low oxalate diet can help avert the risk of too much oxalate and may be especially important for people with intestinal and digestive problems, including, but not limited to weight-loss surgery.4 Other surgical procedures (intestinal resection, ileostomy, bladder diversion surgery) and GI conditions such as irritable bowel syndrome (IBS), celiac disease, Crohn’s disease, small intestinal bacterial overgrowth (SIBO), pancreatic insufficiency, or poor fat digestion (steatorrhea) can also contribute to excessive absorption of oxalates in the digestive tract.

The renal damage caused by oxalates may not be reversible so it is important to start the low oxalate diet as early as possible. Anyone who is increasing their water intake or taking calcium citrate to reduce absorption of oxalates needs to be aware that timing is important. Water with meals can increase oxalate absorption, so drink fluids between meals. Also, calcium citrate tablets need time to dissolve, so take them about 20 minutes before meals to maximize the oxalate sequestration effects.

Key Point: Dietary oxalates can cause kidney failure after bariatric surgery. The progression of the disease can be halted by the low-oxalate diet, if implemented correctly and early enough.

For my low-oxalate grocery shopping list click here.

References

  1. Nagaraju SP, Gupta A, McCormick B. Oxalate nephropathy: An important cause of renal failure after bariatric surgery. Indian J Nephrol. 2013;23(4):316-318. doi:10.4103/0971-4065.114493.
  2. SenthilKumaran S, David SS, Menezes RG, Thirumalaikolundusubramanian P. Concern, counseling and consent for bariatric surgery. Indian J Nephrol. 2014;24(4):263-264. doi:10.4103/0971-4065.133045.
  3. Marengo S, Zeise B, Wilson C, MacLennan G, Romani AP. The trigger-maintenance model of persistent mild to moderate hyperoxaluria induces oxalate accumulation in non-renal tissues. Urolithiasis. 2013;41(6):455-466. doi:10.1007/s00240-013-0584-5.
  4. Lieske JC, Tremaine WJ, De Simone C, et al. Diet, but not oral probiotics, effectively reduces urinary oxalate excretion and calcium-oxalate supersaturation. Kidney Int. 2010;78(11):1178-1185. doi:10.1038/ki.2010.310.

Further Reading about Bariatric Surgery and Oxalates

  1. Agrawal V, Liu XJ, Campfield T, Romanelli J, Enrique Silva J, Braden GL. Calcium oxalate supersaturation increases early after Roux-en-Y gastric bypass. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2014;10(1):88-94. doi:10.1016/j.soard.2013.03.014.
  2. Ahmed MH, Byrne CD. Bariatric surgery and renal function: a precarious balance between benefit and harm. Nephrol Dial Transplant. 2010;25(10):3142-3147. doi:10.1093/ndt/gfq347.
  3. Asplin JR. Hyperoxaluria and Bariatric Surgery. In: AIP Conference Proceedings. Vol 900. AIP Publishing; 2007:82-87. doi:10.1063/1.2723563.
  4. Froeder L, Arasaki CH, Malheiros CA, Baxmann AC, Heilberg IP. Response to Dietary Oxalate after Bariatric Surgery. Clin J Am Soc Nephrol CJASN. 2012;7(12):2033-2040. doi:10.2215/CJN.02560312.
  5. Kumar R, Lieske JC, Collazo-Clavell ML, et al. Fat Malabsorption and Increased Intestinal Oxalate Absorption are Common after Rouxen-Y Gastric Bypass Surgery. Surgery. 2011;149(5):654-661. doi:10.1016/j.surg.2010.11.015.
  6. Lieske JC, Mehta RA, Milliner DS, Rule AD, Bergstralh EJ, Sarr MG. Kidney stones are common after bariatric surgery. Kidney Int. October 2014. doi:10.1038/ki.2014.352.
  7. Nasr SH, D’Agati VD, Said SM, et al. Oxalate Nephropathy Complicating Roux-en-Y Gastric Bypass: An Underrecognized Cause of Irreversible Renal Failure. Clin J Am Soc Nephrol CJASN. 2008;3(6):1676-1683. doi:10.2215/CJN.02940608.
  8. Patel BN, Passman CM, Fernandez A, et al. Prevalence of Hyperoxaluria After Bariatric Surgery. J Urol. 2009;181(1):161-166. doi:10.1016/j.juro.2008.09.028.
  9. Ritz E. Bariatric surgery and the kidney – Much benefit, but also potential harm. Clin Kidney J Clin Kidney J. 2013;6(4):368-372.
  10. Whitson JM, Stackhouse GB, Stoller ML. Hyperoxaluria after modern bariatric surgery: case series and literature review. Int Urol Nephrol. 2010;42(2):369-374. doi:10.1007/s11255-009-9602-5.

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