The Alkaline Diet: Is There Evidence That an Alkaline pH Diet Benefits Health?

Abstract

This review looks at the role of an alkaline diet in health. Pubmed was searched looking for articles on pH, potential renal acid loads, bone health, muscle, growth hormone, back pain, vitamin D and chemotherapy. Many books written in the lay literature on the alkaline diet were also reviewed and evaluated in light of the published medical literature. There may be some value in considering an alkaline diet in reducing morbidity and mortality from chronic diseases and further studies are warranted in this area of medicine.

Full text

Hindawi Publishing Corporation
Journal of Environmental and Public Health
Volume 2012, Article ID 727630, 7pages
doi:10.1155/2012/727630
Review Article
The Alkaline Diet: Is There Evidence That an Alkaline pH Diet
Benefits Health?
Gerry K. Schwalfenberg
University of Alberta, Suite No. 301, 9509-156 Street, Edmonton, AB, Canada T5P 4J5
Correspondence should be addressed to Gerry K. Schwalfenberg, gschwalf@telus.net
Received 3 July 2011; Accepted 8 August 2011
Academic Editor: Janette Hope
Copyright © 2012 Gerry K. Schwalfenberg. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
This review looks at the role of an alkaline diet in health. Pubmed was searched looking for articles on pH, potential renal acid
loads, bone health, muscle, growth hormone, back pain, vitamin D and chemotherapy. Many books written in the lay literature
on the alkaline diet were also reviewed and evaluated in light of the published medical literature. There may be some value in
considering an alkaline diet in reducing morbidity and mortality from chronic diseases and further studies are warranted in this
area of medicine.
1. Background
Life on earth depends on appropriate pH levels in and
around living organisms and cells. Human life requires a
tightly controlled pH level in the serum of about 7.4 (a slight-
ly alkaline range of 7.35 to 7.45) to survive [1].
As a comparison, in the past 100 years with increasing
industrialization, the pH of the ocean has dropped from
8.2 to 8.1 because of increasing CO2deposition. This has a
negative impact on life in the ocean [1,2]andmayleadto
the collapse of the coral reefs [3]. Even the pH of the soil
in which plants are grown can have considerable influence
on the mineral content of the food we eat (as minerals are
used as buffers to maintain pH). The ideal pH of soil for
the best overall availability of essential nutrients is between 6
and 7. Acidic soils below pH of 6 may have reduced calcium
and magnesium, and soil above pH 7 may result in chemi-
cally unavailable iron, manganese, copper and zinc. Adding
dolomite and manure are ways of raising pH in an acid soil
environment when the pH is below 6 [4].
When it comes to the pH and net acid load in the
human diet, there has been considerable change from the
hunter gather civilization to the present [5]. With the agricul-
tural revolution (last 10,000 years) and even more recently
with industrialization (last 200 years), there has been an
decrease in potassium (K) compared to sodium (Na) and
an increase in chloride compared to bicarbonate found in
the diet [6]. The ratio of potassium to sodium has reversed,
K/Na pre-viously was 10 to 1 whereas the modern diet has
aratioof1to3[7]. It is generally accepted that agricul-
tural humans today have a diet poor in magnesium and
potassium as well as fiber and rich in saturated fat, simple
sugars, sodium, and chloride as compared to the pre-agri-
cultural period [6]. This results in a diet that may induce
metabolic acidosis which is mismatched to the genetically
determined nutritional requirements [8]. With aging, there
is a gradual loss of renal acid-base regulatory function
and a resultant increase in diet-induced metabolic acidosis
while on the modern diet [9]. A low-carbohydrate high-
pro-tein diet with its increased acid load results in very
little change in blood chemistry, and pH, but results in
many changes in urinary chemistry. Urinary magnesium
levels, urinary citrate and pH are decreased, urinary calcium,
undissociated uric acid, and phosphate are in-creased. All
of these result in an increased risk for kidney stones
[10].
Much has been written in the lay literature as well as
many online sites expounding on the benefits of the alkaline
diet. This paper is an attempt to balance the evidence that is
found in the scientific literature.

2 Journal of Environmental and Public Health
Tab le 1: Ph of selected fluids, organs, and membranes.
Organ, fluid or membrane pH Function of pH
(1) Skin Natural pH is between 4 and 6.5 [17] Barrier protection from microbes
(2) Urine 4.6 to 8.0 [18] Limit overgrowth of microbes
(3) Gastric 1.35 to 3.5 Break down protein
(4) Bile 7.6 to 8.8 Neutralize stomach acid, aid in digestion
(5) Pancreatic fluid 8.8 Neutralize stomach acid, aid in digestion
(6) Vaginal fluid <4.7 [13] Limit overgrowth of opportunistic microbes
(7) Cerebrospinal fluid 7.3 Bathes the exterior of the brain
(8) Intracellular fluid 6.0–7.2 [19] Due to acid production in cells
(9) Serum venous 7.35 Tightly regulated
(10) Serum arterial 7.4 Tightly regulated
2. The Role of pH in Various Cells, Organs,
and Membranes
ThepHinourbodymayvaryconsiderablyfromoneareato
another with the highest acidity in the stomach (pH of 1.35
to 3.5) to aid in digestion and protect against opportunistic
microbial organisms. But even in the stomach, the layer just
outside the epithelium is quite basic to prevent mucosal
injury. It has been suggested that decreased gastric lining
secretion of bicarbonates and a decrease in the alkaline/acid
secretion in duodenal ulcer patients may play a significant
role in duodenal ulcers [11]. The skin is quite acidic (pH
4–6.5) to provide an acid mantle as a protective barrier to
the environment against microbial overgrowth. There is a
gradient from the outer horny layer (pH 4) to the basal layer
(pH 6.9) [12]. This is also seen in the vagina where a pH of
less than 4.7 protects against microbial overgrowth [13].
The urine may have a variable pH from acid to alkaline
depending on the need for balancing the internal environ-
ment. Acid excretion in the urine can be estimated by a
formula described by Remer (sulfate + chloride + 1.8x
phosphate + organic acids) minus (sodium + potassium +
2x calcium + 2x magnesium) mEq [14]. Foods can be cate-
gorized by the potential renal acid loads (PRALs) see Table 2.
Fruits, vegetables, fruit juices, potatoes, and alkali-rich and
low phosphorus beverages (red and white wine, mineral soda
waters) having a negative acid load. Whereas, grain products,
meats, dairy products, fish, and alkali poor and low phos-
phorus beverages (e.g., pale beers, cocoa) have relatively high
acid loads [15]. Measurement of pH of the urine (reviewed
in a recent study with two morning specimens done over a
five-year span) did not predict bone fractures or loss of bone
mineral density [16]. However, this may not be reflective of
being on an alkaline or acid diet throughout this time. For
more details, see Table 1.
3. Chronic Acidosis and Bone Disease
Calcium in the form of phosphates and carbonates represents
a large reservoir of base in our body. In response to an acid
load such as the modern diet these salts are released into
the systemic circulation to bring about pH homeostasis [7].
It has been estimated that the quantity of calcium lost in
the urine with the modern diet over time could be as high
as almost 480 gm over 20 years or almost half the skeletal
mass of calcium [21]. However, urinary losses of cal-cium
are not a direct measure of osteoporosis. There are many
regulatory factors that may compensate for the urinary calci-
um loss. When the arterial pH is in the normal range, a
mild reduction of plasma bicarbonate results in a negative
calcium balance which could benefit from supplementing
bicarbonate in the form of potassium bicarbonate [22]. It
has been found that bicarbonate, which increases the alkali
content of a diet, but not potassium may attenuate bone
loss in healthy older adults [23]. The bone minerals that are
wasted in the urine may not have complete compensation
through intestinal absorption, which is thought to result in
osteoporosis. However, adequate vitamin D with a 25(OH)D
level of >80 nmol/L may allow for appropriate intestinal
absorption of calcium and magnesium and phosphate when
needed [24]. Sadly, most populations are generally deficient
in vitamin D especially in northern climates [25]. In
chronic renal failure, correction of metabolic acidosis with
bicarbonate significantly improves parathyroid levels and
levels of the active form of vitamin D 1,25(OH)2D3[26].
Recently, a study has shown the importance of phosphate
in Remer’s PRAL formula. According to the formula it
would be expected that an increase in phosphate should
result in an increase in urinary calcium loss and a negative
calcium balance in bone [27]. It should be noted that
supplementation with phosphate in patients with bed rest
reduced urinary calcium excretion but did not prevent bone
loss [28]. The most recent systematic review and meta-
analysis has shown that calcium balance is maintained and
improved with phosphate which is quite contrary to the
acid-ash hypothesis [29]. As well a recent study looking at
soda intake (which has a significant amount of phosphate)
and osteoporosis in postmenopausal American first nations
women did not find a correlation [30]. It is quite possible
that the high acid content according to Remer’s classification
needs to be looked at again in light of compensatory phos-
phate intake. There is online information promoting an alka-
line diet for bone health as well as a number of books. How-
ever, a recent systematic review of the literature looking for
evidence supporting the alkaline diet for bone health found
no protective role of dietary acid load in osteoporosis [31].

Journal of Environmental and Public Health 3
Tab le 2: Potential renal acid loads (PRALs) of selected foods [20].
Food or food group PRAL mEq of: Cl + P04+SO
4−Na −K−Ca −Mg
Dairy
Parmesan cheese 34.2
Processed cheese plain 28.7
Cheddar reduced fat 26.4
Hard cheese (average) 19.2
Fresh cheese (quark) 11.3
Cottage cheese plain 8.7
Yogurt whole milk 1.5
Ice Cream 0.8
Whole milk 0.7
Buttermilk 0.5
Eggs
Eggs yolk 23.4
Eggs white 1.1
Eggs chicken whole 8.2
Meats
Corned beef 13.2
Luncheon meat canned 10.2
Turkey 9.9
Veal 9.0
Lean beef 7.8
Frankfurters 6.7
Sugars
Sugar white −0.1
Honey −0.3
Vege t ab l es
Cucumber −0.8
Broccoli −1.2
Toma t o −3.1
Eggplant −3.4
Celery −5.2
Spinach −14.0
Fats and Oils
Butter 0.6
Margarine −0.5
Olive oil 0.0
Fruits and nuts and fruit juices
Peanuts 8.3
Walnut s 6.8
Grape juice unsweetened −1.0
Orange juice unsweetened −2.9
Apples or apple juice unsweetened −2.2
Apricots −4.8
Banana −5.5
Black currents −6.5
Raisins −21.0
Grains and grain products
Brown Rice 12.5
Rolled Oats 10.7
Spaghetti whole meal 7.3
Spaghetti white 6.5

4 Journal of Environmental and Public Health
Tab le 2: Continued.
Food or food group PRAL mEq of: Cl + P04+SO
4−Na −K−Ca −Mg
Cornflakes 6.0
Rice white 4.6
Bread rye flower 4.1
Bread whole wheat 1.8
Legumes
Lentils green and brown 3.5
Green beans −3.1
Fish
Trou t br ow n 10.8
Cod fillets 7.1
Beverages
Beer pale 0.9
Coca-Cola 0.4
Beer draft −0.2
Wine white −1.2
Coffee infusion −1.4
Wine red −2.4
Another element of the modern diet is the excess of sodi-
um in the diet. There is evidence that in healthy humans the
increased sodium in the diet can predict the degree of hyper-
chloremic metabolic acidosis when consuming a net acid
producing diet [32]. As well, there is evidence that there are
adverse effects of sodium chloride in the aging population.
A high sodium diet will exacerbate disuse-induced bone
and muscle loss during immobilization by increasing bone
resorption and protein wasting [33]. Excess dietary sodium
has been shown to result in hypertension and osteoporosis in
women [34,35]. As well, dietary potassium which is lacking
in the modern diet would modulate pressor and hyper-
calciuric effects of excess of sodium chloride [36].
Excess dietary protein with high acid renal load may
decrease bone density if not buffered by ingestion of supple-
ments or foods that are alkali rich [37]. However, adequate
protein is necessary for prevention of osteoporosis and
sarcopenia; therefore, increasing the amount of fruit and veg-
etables may be necessary rather than reducing protein [38].
4. Alkaline Diets and Muscle
As we age, there is a loss of muscle mass, which may predis-
pose to falls and fractures. A three-year study looking at a
diet rich in potassium, such as fruits and vegetables, as well
as a reduced acid load, resulted in preservation of muscle
mass in older men and women [39]. Conditions such as
chronic renal failure that result in chronic metabolic acidosis
result in accelerated breakdown in skeletal muscle [40].
Correction of acidosis may preserve muscle mass in condi-
tions where muscle wasting is common such as diabetic
ketosis, trauma, sepsis, chronic obstructive lung disease, and
renal failure [41]. In situations that result in acute acidosis,
supplementing younger patients with sodium bicarbonate
prior to exhaustive exercise resulted in significantly less
acidosis in the blood than those that were not supplemented
with sodium bicarbonate [42].
5. Alkaline Supplementation and
Growth Hormone
It has long been known that severe forms of metabolic
acidosis in children, such as renal tubular acidosis, are as-
sociated with low levels of growth hormone with resultant
short stature. Correction of the acidosis with bicarbonate
[7] or potassium citrate [43] increases growth hormone sig-
nificantly and improved growth. The use of enough pota-
ssium bicarbonate in the diet to neutralize the daily net
acid load in postmenopausal women resulted in a significant
increase in growth hormone and resultant osteocalcin [44].
Improvinggrowthhormonelevelsmayimprovequalityof
life, reduce cardiovascular risk factors, improve body com-
position, and even improve memory and cognition [45]. As
well this results in a reduction of urinary calcium loss equi-
valent to 5% of bone calcium content over a period of 3 years
[46].
6. Alkaline Diet and Back Pain
There is some evidence that chronic low back pain improves
with the supplementation of alkaline minerals [47]. With
supplementation there was a slight but significant increase in
blood pH and intracellular magnesium. Ensuring that there
is enough intracellular magnesium allows for the proper
function of enzyme systems and also allows for activation of
vitamin D [48]. This in turn has been shown to improve back
pain [49].

Journal of Environmental and Public Health 5
7. Alkalinity and Chemotherapy
The effectiveness of chemotherapeutic agents is markedly
influenced by pH. Numerous agents such as epirubicin and
adriamycin require an alkaline media to be more effective.
Others, such as cisplatin, mitomycin C, and thiotepa, are
more cytotoxic in an acid media [50]. Cell death correlates
with acidosis and intracellular pH shifts higher (more alka-
line) after chemotherapy may reflect response to chemother-
apy [51]. It has been suggested that inducing metabolic alka-
losis may be useful in enhancing some treatment regimes by
using sodium bicarbonate, carbicab, and furosemide [52].
Extracellular alkalinization by using bicarbonate may result
in improvements in therapeutic effectiveness [53]. There is
no scientific literature establishing the benefit of an alkaline
diet for the prevention of cancer at this time.
8. Discussion
The human body has an amazing ability to maintain a steady
pH in the blood with the main compensatory mechanisms
being renal and respiratory. Many of the membranes in our
body require an acid pH to protect us and to help us digest
food. It has been suggested that an alkaline diet may prevent
a number of diseases and result in significant health benefits.
Looking at the above discussion on bone health alone, certain
aspects have doubtful benefit. There does not seem to be
enough evidence that milk or cheese may be as detrimental as
Remer’s formula suggests since phosphate does benefit bone
health and result in a positive calcium balance. However,
another mechanism for the alkaline diet to benefit bone
health may be the increase in growth hormone and resultant
increase in osteocalcin. There is some evidence that the K/Na
ratio does matter and that the significant amount of salt in
our diet is detrimental. Even some governments are demand-
ing that the food industry reduce the salt load in our diet.
High-protein diets may also affect bone health but some pro-
tein is also needed for good bone health. Muscle wasting
however seems to be reduced with an alkaline diet and back
pain may benefit from this as well. An alkaline environment
may improve the efficacy of some chemotherapy agents but
not others.
9. Conclusion
Alkaline diets result in a more alkaline urine pH and may
result in reduced calcium in the urine, however, as seen
in some recent reports, this may not reflect total calcium
balance because of other buffers such as phosphate. There
is no substantial evidence that this improves bone health or
protects from osteoporosis. However, alkaline diets may re-
sult in a number of health benefits as outlined below
(1) Increased fruits and vegetables in an alkaline diet
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.
(2) The resultant increase in growth hormone with an
alkaline diet may improve many outcomes from car-
diovascular health to memory and cognition.
(3) An increase in intracellular magnesium, which is re-
quired for the function of many enzyme systems, is
another added benefit of the alkaline diet. Available
magnesium, which is required to activate vitamin
D, would result in numerous added benefits in the
vitamin D apocrine/exocrine systems.
(4) Alkalinity may result in added benefit for some
chemotherapeutic agents that require a higher pH.
From the evidence outlined above, it would be prudent to
consider an alkaline diet to reduce morbidity and mortality
of chronic disease that are plaguing our aging population.
One of the first considerations in an alkaline diet, which in-
cludes more fruits and vegetables, is to know what type of
soil they were grown in since this may significantly influence
the mineral content. At this time, there are limited scientific
studies in this area, and many more studies are indicated in
regards to muscle effects, growth hormone, and interaction
with vitamin D.
References
[1] A. Waugh and A. Grant, Anatomy and Physiology in Healthand
Illness, Churchill Livingstone Elsevier, Philadelphia, Pa, USA,
10th edition, 2007.
[2] University, Birmingham oAa, “Oceans reveal further impacts
of climate change,” ScienceDaily, 2010.
[3] O. Hoegh-Guldberg, P. J. Mumby, A. J. Hooten et al., “Coral
reefs under rapid climate change and ocean acidification,”
Science, vol. 318, no. 5857, pp. 1737–1742, 2007.
[4] J. Dam-ampai SO and C. Nilnond, “Effect of cattle manure
and dolomite on soil properties and plant growth in acid up-
land soils,” Songklanakarin Journal of Science and Technologh,
vol. 27, supplement 3, pp. 727–737, 2005.
[5] A. Str¨
ohle, A. Hahn, and A. Sebastian, “Estimation of the
diet-dependent net acid load in 229 worldwide historically
studied hunter-gatherer societies,” American Journal of Clinical
Nutrition, vol. 91, no. 2, pp. 406–412, 2010.
[6] A. Sebastian, L. A. Frassetto, D. E. Sellmeyer, R. L. Merriam,
and R. C. Morris Jr., “Estimation of the net acid load of the diet
of ancestral preagricultural Homo sapiens and their hominid
ancestors,” American Journal of Clinical Nutrition, vol. 76, no.
6, pp. 1308–1316, 2002.
[7] L. Frassetto, R. C. Morris, Jr. R.C. Jr., D. E. Sellmeyer, K.
Todd, and A. Sebastian, “Diet, evolution and aging—the
pathophysiologic effects of the post-agricultural inversion of
the potassium-to-sodium and base-to-chloride ratios in the
human diet,” European Journal of Nutrition,vol.40,no.5,pp.
200–213, 2001.
[8] M. Konner and S. Boyd Eaton, “Paleolithic nutrition: twenty-
five years later,” Nutrition in Clinical Practice, vol. 25, no. 6, pp.
594–602, 2010.
[9] R. D. Lindeman and R. Goldman, “Anatomic and physiologic
age changes in the kidney,” Experimental Gerontology, vol. 21,
no. 4-5, pp. 379–406, 1986.
[10] S. T. Reddy, C. Y. Wang, K. Sakhaee, L. Brinkley, and C. Y. Pak,
“Effect of low-carbohydrate high-protein diets on acid-base
balance, stone-forming propensity, and calcium metabolism,”

6 Journal of Environmental and Public Health
American Journal of Kidney Diseases, vol. 40, no. 2, pp. 265–
274, 2002.
[11] Y. S. Malov and A. N. Kulikov, “Bicarbonate deficiency and
duodenal ulcer,” Terapevticheskii Arkhiv, vol. 70, no. 2, pp. 28–
32, 1998.
[12] H. Ohman and A. Vahlquist, “In vivo studies concerning a pH
gradient in human stratum corneum and upper epidermis,”
Acta Dermato-Venereologica, vol. 74, no. 5, pp. 375–379, 1994.
[13] D. G. Ferris, S. L. Francis, E. D. Dickman, K. Miler-Miles, J. L.
Waller, and N. McClendon, “Variability of vaginal pH deter-
mination by patients and clinicians,” Journal of the American
Board of Family Medicine, vol. 19, no. 4, pp. 368–373, 2006.
[14] T. Remer and F. Manz, “Estimation of the renal net acid
excretion by adults consuming diets containing variable
amounts of protein,” American Journal of Clinical Nutrition,
vol. 59, no. 6, pp. 1356–1361, 1994.
[15] T. Remer, “Influence of diet on acid-base balance,” Seminars in
Dialysis, vol. 13, no. 4, pp. 221–226, 2000.
[16] T. R. Fenton, M. Eliasziw, S. C. Tough, A. W. Lyon, J. P. Brown,
and D. A. Hanley, “Low urine pH and acid excretion do not
predict bone fractures or the loss of bone mineral density: a
prospective cohort study,” BMC Musculoskeletal Disorders, vol.
11, article 88, 2010.
[17] E. Boelsma, L. P. L. van de Vijver, R. A. Goldbohm, I. A.
A. Kl¨
opping-Ketelaars, H. F. J. Hendriks, and L. Roza, “Hu-
man skin condition and its associations with nutrient concen-
trations in serum and diet,” American Journal of Clinical Nutri-
tion, vol. 77, no. 2, pp. 348–355, 2003.
[18] B. A. Ince, E. J. Anderson, and R. M. Neer, “Lowering dietary
protein to U.S. recommended dietary allowance levels reduces
urinary calcium excretion and bone resorption in young
women,” Journal of Clinical Endocrinology and Metabolism,
vol. 89, no. 8, pp. 3801–3807, 2004.
[19] W. F. Boron, “Regulation of intracellular pH,” Advances in
Physiology Education, vol. 28, pp. 160–179, 2004.
[20] T. Remer and F. Manz, “Potential renal acid load of foods and
its influence on urine pH,” Journal of the American Dietetic
Association, vol. 95, no. 7, pp. 791–797, 1995.
[21]T.R.Fenton,M.Eliasziw,A.W.Lyon,S.C.Tough,andD.
A. Hanley, “Meta-analysis of the quantity of calcium excretion
associated with the net acid excretion of the modern diet
under the acid-ash diet hypothesis,” American Journal of
Clinical Nutrition, vol. 88, no. 4, pp. 1159–1166, 2008.
[22] A. Sebastian and R. C. Morris Jr., “Improved mineral
balance and skeletal metabolism in postmenopausal women
treated with potassium bicarbonate,” New England Journal of
Medicine, vol. 331, no. 4, p. 279, 1994.
[23] B. Dawson-Hughes, S. S. Harris, N. J. Palermo, C. Castaneda-
Sceppa,H.M.Rasmussen,andG.E.Dallal,“Treatmentwith
potassium bicarbonate lowers calcium excretion and bone
resorption in older men and women,” Journal of Clinical
Endocrinology and Metabolism, vol. 94, no. 1, pp. 96–102, 2009.
[24] R. P. Heaney, M. S. Dowell, C. A. Hale, and A. Bendich,
“Calcium absorption varies within the reference range for
serum 25-hydroxyvitamin D,” Journal of the American College
of Nutrition, vol. 22, no. 2, pp. 142–146, 2003.
[25] G. K. Schwalfenberg, S. J. Genuis, and M. N. Hiltz, “Addressing
vitamin D deficiency in Canada: a public health innovation
whosetimehascome,”Public Health, vol. 124, no. 6, pp. 350–
359, 2010.
[26] K. C. Lu, S. H. Lin, F. C. Yu, S. H. Chyr, and S. D. Shieh, “Influ-
ence of metabolic acidosis on serum 1,25(OH)2D3 levels in
chronic renal failure,” Mineral and Electrolyte Metabolism, vol.
21, no. 6, pp. 398–402, 1995.
[27] T. R. Fenton, A. W. Lyon, M. Eliasziw, S. C. Tough, and D.
A. Hanley, “Phosphate decreases urine calcium and increases
calcium balance: a meta-analysis of the osteoporosis acid-ash
diet hypothesis,” Nutrition Journal, vol. 8, article 41, 2009.
[28] S.B.Hulley,J.M.Vogel,C.L.Donaldson,J.H.Bayers,R.J.
Friedman, and S. N. Rosen, “The effect of supplemental oral
phosphate on the bone mineral changes during prolonged bed
rest,” Journal of Clinical Investigation, vol. 50, no. 12, pp. 2506–
2518, 1971.
[29] T. R. Fenton, A. W. Lyon, M. Eliasziw, S. C. Tough, and D. A.
Hanley, “Meta-analysis of the effect of the acid-ash hypothesis
of osteoporosis on calcium balance,” Journal of Bone and
Mineral Research, vol. 24, no. 11, pp. 1835–1840, 2009.
[30] J. D. Supplee, G. E. Duncan, B. Bruemmer, J. Goldberg, Y.
Wen, and J. A. Henderson, “Soda intake and osteoporosis risk
in postmenopausal American-Indian women,” Public Health
Nutrition, pp. 1–7, 2011.
[31]T.R.Fenton,S.C.Tough,A.W.Lyon,M.Eliasziw,andD.
A. Hanley, “Causal assessment of dietary acid load and bone
disease: a systematic review & meta-analysis applying Hill’s
epidemiologic criteria for causality,” Nutrition Journal, vol. 10,
no. 1, article 41, 2011.
[32] L. A. Frassetto, R. C. Morris Jr., and A. Sebastian, “Dietary
sodium chloride intake independently predicts the degree of
hyperchloremic metabolic acidosis in healthy humans con-
suming a net acid-producing diet,” American Journal of Physi-
ology—Renal Physiology, vol. 293, no. 2, pp. F521–F525, 2007.
[33] P. Frings-Meuthen, J. Buehlmeier, N. Baecker et al., “High sod-
ium chloride intake exacerbates immobilization-induced bone
resorption and protein losses,” Journal of Applied Physiology,
vol. 111, no. 2, pp. 537–542, 2011.
[34] F. P. Cappuccio, E. Meilahn, J. M. Zmuda, and J. A. Cauley,
“High blood pressure and bone-mineral loss in elderly white
women: a prospective study,” Lancet, vol. 354, no. 9183, pp.
971–975, 1999.
[35] A. Devine, R. A. Criddle, I. M. Dick, D. A. Kerr, and R. L.
Prince, “A longitudinal study of the effect of sodium and cal-
cium intakes on regional bone density in postmenopausal
women,” American Journal of Clinical Nutrition, vol. 62, no.
4, pp. 740–745, 1995.
[36] R. C. Morris Jr., O. Schmidlin, L. A. Frassetto, and A. Seba-
stian, “Relationship and interaction between sodium and
potassium,” Journal of the American College of Nutrition, vol.
25, no. 3, pp. 262S–270S, 2006.
[37] U. S. Barzel and L. K. Massey, “Excess dietary protein may can
adversely affect bone,” Journal of Nutrition, vol. 128, no. 6, pp.
1051–1053, 1998.
[38] R. P. Heaney and D. K. Layman, “Amount and type of pro-tein
influences bone health,” American Journal of Clinical Nutri-
tion, vol. 87, no. 5, pp. 156S–157S, 2008.
[39] B. Dawson-Hughes, S. S. Harris, and L. Ceglia, “Alkaline diets
favor lean tissue mass in older adults,” American Journal of Cli-
nical Nutrition, vol. 87, no. 3, pp. 662–665, 2008.
[40] G. Garibotto, R. Russo, A. Sofia et al., “Muscle protein turn-
over in chronic renal failure patients with metabolic acidosis
or normal acid-base balance,” Mineral and Electrolyte Meta-
bolism, vol. 22, no. 1–3, pp. 58–61, 1996.
[41] G. Caso and P. J. Garlick, “Control of muscle protein kinetics
by acid-base balance,” Current Opinion in Clinical Nutrition
and Metabolic Care, vol. 8, no. 1, pp. 73–76, 2005.
[42] M. J. Webster, M. N. Webster, R. E. Crawford, and L. B. Glad-
den, “Effect of sodium bicarbonate ingestion on exhaustive re-
sistance exercise performance,” Medicine and Science in Sports
and Exercise, vol. 25, no. 8, pp. 960–965, 1993.

Journal of Environmental and Public Health 7
[43] E. McSherry and R. C. Morris Jr., “Attainment and mainte-
nance of normal stature with alkali therapy in infants and
children with classic renal tubular acidosis,” Journal of Clinical
Investigation, vol. 61, no. 2, pp. 509–527, 1978.
[44] L. Frassetto, R. C. Morris Jr., and A. Sebastian, “Potassium
bicarbonate reduces urinary nitrogen excretion in post-
menopausal women,” Journal of Clinical Endocrinology and
Metabolism, vol. 82, no. 1, pp. 254–259, 1997.
[45] J. A. H. Wass and R. Reddy, “Growth hormone and memory,”
Journal of Endocrinology, vol. 207, no. 2, pp. 125–126, 2010.
[46] L. Frassetto, R. C. Morris Jr., and A. Sebastian, “Long-term
persistence of the urine calcium-lowering effect of potassium
bicarbonate in postmenopausal women,” Journal of Clinical
Endocrinology and Metabolism, vol. 90, no. 2, pp. 831–834,
2005.
[47] J. Vormann, M. Worlitschek, T. Goedecke, and B. Silver, “Sup-
plementation with alkaline minerals reduces symptoms in
patients with chronic low back pain,” Journal of Trace Elements
in Medicine and Biology, vol. 15, no. 2-3, pp. 179–183, 2001.
[48] I. Zofkov´
a and R. L. Kancheva, “The relationship between
magnesium and calciotropic hormones,” Magnesium Research,
vol. 8, no. 1, pp. 77–84, 1995.
[49] G. Schwalfenberg, “Improvement of chronic back pain or
failed back surgery with vitamin D repletion: a case series,”
Journal of the American Board of Family Medicine, vol. 22, no.
1, pp. 69–74, 2009.
[50] E. Groos, L. Walker, and J. R. Masters, “Intravesical chemo-
therapy. Studies on the relationship between pH and cytotox-
icity,” Cancer, vol. 58, no. 6, pp. 1199–1203, 1986.
[51] S. R. Smith, P. A. Martin, and R. H. T. Edwards, “Tumour pH
and response to chemotherapy: an in vivo 31P magnetic reson-
ance spectroscopy study in non-Hodgkin’s lymphoma,” British
Journal of Radiology, vol. 64, no. 766, pp. 923–928, 1991.
[52] N. Raghunand and R. J. Gillies, “pH and chemotherapy,”
Novartis Foundation Symposium, vol. 240, pp. 199–211, 2001.
[53] N. Raghunand, X. He, R. Van Sluis et al., “Enhancement of
chemotherapy by manipulation of tumour pH,” British Jour-
nal of Cancer, vol. 80, no. 7, pp. 1005–1011, 1999.