“The acid-ash hypothesis posits that protein and grain foods, with a low potassium intake, produce a diet acid load, net acid excretion, increased urine calcium, and release of calcium from the skeleton, leading to osteoporosis.” (Fenton et al., 2009, see References).
Is it true?
Calcium, present in bones in form of carbonates and phosphates, represents a large reservoir of base in the body. In response to an acid load such as the high protein diets these salts are released into the circulation to bring about pH homeostasis. This calcium is lost in the urine and it has been estimated that the quantity lost with the such diet over time could be as high as almost 480 g over 20 years or almost half the skeletal mass of calcium!
Even these losses of calcium may be buffered by ingestion of foods that are alkali rich as fruit and vegetables, and on-line information promotes an alkaline diet for bone health as well as a number of books, a recent meta-analysis has shown that the causal association between osteoporotic bone disease and dietary acid load is not supported by evidence and there is no evidence that the alkaline diet is protective of bone health (but it is protective against the risk for kidney stones).
Note: it is possible that fruit and vegetables are beneficial to bone health through mechanisms other than via the acid-ash hypothesis.
Excess dietary protein with high acid renal load may decrease bone density, if not buffered by ingestion of foods that are alkali rich, that is fruit and vegetables. However, an adequate protein intake is needed for the maintenance of bone integrity. Therefore, increasing the amount of fruit and vegetables may be necessary rather than reducing protein too much.
Therefore it is advisable to consume a normo-proteic diet rich in fruits and vegetables and poor in sodium, that is, a Mediterranean Diet-like eating patterns, eating foods with a negative acid load together with foods with a positive acid load. Example: pasta plus vegetables or meats plus vegetables and fruits (see figure below).
Alkaline diet and muscle mass
As we age, there is a loss of muscle mass, which predispose to falls and fractures. A diet rich in potassium, obtained from fruits and vegetables, as well as a reduced acid load, results in preservation of muscle mass in older men and women.
Alkaline diet and growth hormone
In children, severe forms of metabolic acidosis are associated with low levels of growth hormone with resultant short stature; its correction with potassium or bicarbonate citrate increases growth hormone significantly and improves growth. In postmenopausal women, the use of enough potassium bicarbonate in the diet to neutralize the daily net acid load resulted in a significant increase in growth hormone and resultant osteocalcin.
Improving growth hormone levels may reduce cardiovascular risk factors, improve quality of life, body composition, and even memory and cognition.
Alkaline diet may result in a number of health benefits.
- Increased fruits and vegetables would improve the K/Na ratio and may benefit bone health, reduce muscle wasting, as well as mitigate other chronic diseases such as hypertension and strokes.
- The increase in growth hormone may improve many outcomes from cardiovascular health to memory and cognition.
- The increase in intracellular magnesium is another added benefit of the alkaline diet (e.g. magnesium, required to activate vitamin D, would result in numerous added benefits in the vitamin D systems).
It should be noted that one of the first considerations in an alkaline diet, which includes more fruits and vegetables, is to know what type of soil they were grown in since this may significantly influence the mineral content and therefore their buffering capacity.
- Fenton T.R., Lyon A.W., Eliasziw M., Tough S.C., Hanley D.A. Meta-analysis of the effect of the acid-ash hypothesis of osteoporosis on calcium balance. J Bone Miner Res 2009;24(11):1835-1840. doi:10.1359/jbmr.090515
- Fenton T.R., Lyon A.W., Eliasziw M., Tough S.C., Hanley D.A. Phosphate decreases urine calcium and increases calcium balance: a meta-analysis of the osteoporosis acid-ash diet hypothesis. Nutr J 2009;8:41. doi:10.1186/1475-2891-8-41
- Fenton T.R., Tough S.C., Lyon A.W., Eliasziw M., Hanley D.A. “Causal assessment of dietary acid load and bone disease: a systematic review and meta-analysis applying Hill’s epidemiologic criteria for causality.” Nutr J 2011;10:41. doi:10.1186/1475-2891-10-41
- Schwalfenberg G.K. The alkaline diet: is there evidence that an alkaline pH diet benefits health? J Environ Public Health 2012; Article ID 727630. doi:10.1155/2012/727630