Acid–Base Balance,
Health, and Diet
Sala Horowitz, Ph.D.
A number of scientists have theorized that a range of health
problems result from a discordance between the modern diet
and genetically determined chemical balances and nutritional
requirements that evolved over millennia,1 effects of the post-
agricultural inversion of the potassium-to-sodium and base-
to-chloride ratios in the human diet.1,2 This article reviews
the effects on health of the body’s acid-base balance, questions
about whether and how alkalinizing diets and alkalized water
are beneficial for maintaining or restoring such homeostasis,
and related clinical issues.
The Evolutionary Context
Until relatively recently on the evolutionary scale, hu-
mans subsisted primarily on uncultivated plant foods. The
modern diet has substituted sodium chloride (NaCl) in
copious amounts for naturally occurring potassium alkali
(K-base) salts, along with an increased consumption of meat,
processed grains, and refined sugar, with potentially del-
eterious effects on the body.2 Consequently, many other-
wise-healthy contemporary humans may be suffering from
chronic, diet-induced low-grade systemic metabolic acido-
sis and its pathophysiologic sequelae. From an evolution-
ary perspective, a low-grade metabolic alkalosis may be the
optimal acid–base state.1
According to Susan E. Brown, Ph.D., C.C.N. (a medical
anthropologist and New York State certified nutritionist,
practicing as a bone-health nutritionist in East Syracuse),
“[d]espite this understanding of the importance of pH in
the maintenance of life, until recently, the mainstream med-
ical establishment overlooked the existence of low-grade
pH imbalances.”3
292 DOI: 10.1089/act.2009.15606 • MARY ANN LIEBERT, INC. • VOL. 15 NO. 6
DECEMBER 2009
Regulation of pH
Literally meaning “potential for hydrogen,” pH was first de-
fined in 1909 as the concentration of hydrogen ions in a fluid,
expressed as moles per L. All acids give off hydrogen ions,
whereas bases accept hydrogen ions. Because the hydrogen ion
is highly unstable, acids and bases react with each other; the
bicarbonate ion is the major base that neutralizes acids. For
proper bodily functioning, a slightly alkaline arterial blood pH
of 7.365–7.450 is considered normal (on a scale of 0–strongly
acidic to 14–strongly base, with a pH of 7 being neutral). Even
a slight deviation from the normal pH range can affect many
bodily functions and organs adversely. The body uses multiple
mechanisms, including the lungs, kidneys, and such buffer sys-
tems as the sweat glands, to control the essential blood acid–
base balance.3
Causes of Disturbed Acid–Base Homeostasis
Metabolic acidosis is defined as a disturbance in the
body’s acid–base balance that results in excessive acidity
of the blood. In the majority of mild chronic cases, overly
acidic pH levels are diet-induced. Severe acute acidosis can
result from various conditions. These conditions include
diabetic ketoacidosis, renal failure, ingestion of excessive
amounts of aspirin or certain toxic substances (e.g., anti-
freeze), and shock. Diagnostic indicators of acidosis vary
by condition.4 Acidosis can also result from disruption of
normal gut function caused by gastrointestinal (GI) infec-
tion, disease, or surgical complications.5
Clinically significant, subacute metabolic alkalosis (an ex-
cessively base pH), which is less common and rarely related
ALTERNATIVE AND COMPLEMENTARY THERAPIES

to diet, can be caused by excessive use of antacids or diuret-
ics, chronic vomiting or diarrhea, overactivity of the adrenal
glands, and living at high altitudes.3
Consequences of Disturbed Acid–Base
Homeostasis
Acidosis and alkalosis are not diseases in themselves, but
rather are imbalances indicative of underlying conditions. A
typical acidogenic Western diet low in K-base–rich plant foods
and high in acid-forming nutrients from animal protein in-
creases the body’s net systematic acid load and may result in
chronic, low-grade acidosis. Superphysiologic acid loads can
result in kidney-stone formation, decreased muscle and boss
mass in adults, and mental retardation in children. Death can
even result in severe cases.1
Christopher Vasey, N.D., a naturopathic doctor, based near
Montreux, Switzerland, has stated that chronic imbalance
results in health problems, including fatigue, slowed down
endocrine functioning (except in the thyroid), and suscep-
tibility to respiratory and urinary-tract infection (UTI), by
causing enzyme disturbances, aggressive activity by acids,
and demineralization of bones.6 Chronic demineralization
of bones can lead to osteoporosis, osteoarthritis (OA), and
other bone-related conditions, which have been associated
with animal protein–dominant, acid–base unbalanced diets,
and lifestyles not conducive to bone health.3
Chronic low-grade acidosis can also contribute to prema-
ture aging by impairing cellular-repair processes, accelerating
muscle loss (by breaking down cells to derive the amino acid
glutamine used in the manufacture of the base ammonia for
deacidification), and cognitive decline.3
Methods of Food pH Analysis
Estimates of acid–base food impact were originally based on
the concept of acid and alkaline ash. Foods were considered
acidic if, when burned, their remaining ashes contained such
acid-forming minerals as phosphorus, sulfur, and iodine. Foods
were deemed alkaline if their ashes contained such minerals
as calcium, magnesium, and potassium. A newer approach
examines foods’ metabolic effects (i.e., the types of minerals,
amino acids, and other compounds that the food contributed
to the body after being metabolized). Formulas were created in
*The Stewart model is based on the same principles as more-traditional
treatments of acid–base balance, but this mathematical approach treats
pH in terms of independent and dependent variables. Bicarbonate and
hydrogen ions are the dependent variables. They represent the effects
rather than the cause of acid–base imbalances and are regulated by the
independent variables in blood plasma of the partial pressure of CO2
(PCO2, the amount of CO2 gas dissolved in the blood), weak acids,
and the strong ion difference. As PCO2 levels rise, blood pH levels
decrease, making it more acidic; as PCO2 decreases, blood pH levels
will rise, making it more alkaline.
ALTERNATIVE AND COMPLEMENTARY THERAPIES • DECEMBER 2009
attempts to calculate the impact of the whole food—a daunting
task given the complexity of metabolism.3
A further step in the evolution of quantifying foods’ impact
on pH involved estimating the potential kidney-acid load of
foods (i.e., the extent to which foods affect urine pH and
urine acid excretion). This model enabled the development of
food tables showing estimates of the acid- or alkaline-form-
ing potential of many common foods. A simplified related
strategy analyzed a food’s ratio of protein (the major dietary
acidifying force) to potassium (the major dietary alkalizing
force) to predict the amount of acid excreted by the kidneys
Acidosis and alkalosis are not
diseases in themselves, but rather
are imbalances indicative of
underlying conditions.
and thus, the amount of acid created by the metabolized food.
Other formulas exist for quantifying the impact of foods on
acid excretion.3
A Model of Acid–Base Chemistry
A quantitative model was developed by Canadian physi-
ologist Peter A. Stewart, Ph.D. (1921–1993), to provide in-
sights into the complex chemistry of acid–base equilibrium,7
which is beyond the scope of this paper.* The Stewart model
has been influential in the understanding of the mechanisms
of this metabolic balance and its imbalances,8 and in main-
stream clinical practice,9 particularly in critical-care set-
tings.10 Even practitioners who only perform surgery under
local anesthesia need to be familiar with principles of the
acid–base balance.11
Assessing pH Level
Measuring a patient’s pH level as an index of acid–base bal-
ance can be conducted through blood, urine, and saliva tests.
Each bodily fluid has a slightly different pH level; arterial
blood has an average pH of 7.41, whereas urine pH can vary
from 5 to 8 over the course of a day, depending on the nu-
trients consumed.3 In critical care, metabolic acidosis can be
diagnosed through one of several blood tests: an arterial blood
test to assess severity; a complete blood count (CBC) to assess
possible cause(s); and a metabolic panel to reveal the severity
and cause of the condition.4
For assessing chronic low-grade metabolic acidosis in her
patients, Dr. Brown utilizes a time-specific urine sample (i.e.,
a test that uses pH litmus paper with a first-in-the-morning
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 ALTERNATIVE AND COMPLEMENTARY THERAPIES • DECEMBER 2009
urine sample provided by patients at home) for initial assess-
ment and subsequent monitoring. Dr. Brown suggests using
test paper that measures pH with sufficiently small gradi-
ents to detect the 6.5–7.5 pH range. For patients who can-
not sleep for more than 6 hours without waking to urinate, a
saliva test is an acceptable alternative. The normal range for a
saliva sample taken the first thing in the morning, which may
be higher than urine pH, is 6.5–7.5.3
Certain drugs can interfere with the accuracy of pH read-
ings. For example, ammonium chloride, which is found in
some cold and cough medications, may produce high acidic
urine. Acetazolamide, which is used for treating glaucoma
and other conditions, may produce a falsely high alkaline
reading because this chemical forces the kidneys to excrete
bicarbonate, which results in a lower blood pH. Conversely,
imbalanced acid–alkaline levels can interfere with the effec-
tiveness of some medications.3
Clinical Approaches to Achieving Acid–Base
Balance
To achieve a consistently acidic pH level, Dr. Brown ad-
vises her patients to make dietary modifications aimed at al-
kalizing their diet. She recommends that 80% of each meal
consist of alkalizing foods. When a patient’s pH level reaches
the healthful range, a 60% alkaline to 40% acid ratio food
diet is then recommended.3 Adjustment of tissue alkalinity
through an alkalizing food-rich diet and appropriate supple-
mentation can result in more-efficient metabolic detoxifica-
tion and chronic-disease prevention.12
Robert O. Young, Ph.D., a microbiologist and nutritionist
in Valley Center, California, applies principles of acid–base
pH balance to treating types 1 and 2 diabetes. Chi C. Mao,
M.D., Ph.D. (chief medical officer, Select Specialty Hospi-
tals, Houston, Texas, at the time of publication), has likened
this balance to the Traditional Chinese Medicine (TCM)
concept of the balance of opposite life forces necessary
for health.13
Herman Aihara (who died in 1998), a noted advocate for
the macrobiotic diet, explicitly linked acid–base balance with
the concepts of yin and yang and imbalances in both to health
problems, including cancer.14 TCM recommends a diet rich
in fresh vegetables and fruits, which are rich in bicarbonate
precursors, to promote health and longevity.15
In two controlled studies (combined N = 30) conducted in
2002–2003, Dr. Young found that 20 patients (ages 10–61)
who remained in either of the studies were able to control
their diabetes through a strict alkaline diet, nutritional sup-
plements, and aerobic exercise in 12 weeks following an ini-
tial 1-week liquid fast. The regimen also resulted in weight
loss, maintenance of normal blood sugar, lower blood pres-
sure (BP), reduced total cholesterol, and significant reduc-
tion in need for insulin or other diabetic medication (an 81%
reduction for type 1 diabetes and 96% reduction for type
2 diabetes).13
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Nutritional Therapy
Foods
Ideally, every meal should contain a balance of alkalizing
and acidifying nutrients. However, it is not always appar-
ent which foods are acidifying or alkalizing. For example,
although citrus fruits are chemically acidic, they have an
alkalizing effect once they are metabolized, because a sig-
nificant percentage of the citric and malic acids in these
foods is converted into bicarbonate in the liver. However,
It is not always apparent which
foods are acidifying or alkalizing.
because orange juice also contains high amounts of alka-
linizing potassium, this juice’s effect on raising urinary pH
is much greater than that of lemonade, which is low in po-
tassium.16 To complicate matters further, different forms of
the same food can be categorized differently. For example,
while miso (soybean paste) is highly alkaline-forming, other
soy products, including soybeans and tofu (soybean curd),
are considered highly acid-forming.3
It is important to note that different practitioners may classify
foods somewhat differently in terms of their degree of acidity or
alkalinity. Dr. Vasey has noted that the ripeness and processing
of foods affect their acid and alkaline levels. For instance, unripe
fruit is more acidic than ripe fruit. Although dairy products are
generally classified as acidifying, raw whole milk, fresh unheated
butter, and fresh soft unripened cheeses, such as well-drained
cottage cheese, are considered alkalizing.6
Dr. Vasey has added a third category of foods to the al-
kalizing and acidifying groups usually considered useful for
maintaining a proper acid–alkaline balance: weak-acid foods,
(i.e., foods that can increase the alkalinity of the blood by
the abovementioned mechanism). Strong or stable acids, in
contrast, come primarily from animal proteins and must be
eliminated by the kidneys. Weak acids, also called volatile ac-
ids, come primarily from plant foods containing unacetylated
salicylic, citric, oxalic, or pyruvic acid. However, yogurt and
whey are protein-based sources of weak acids. Plant-based
sources listed by Dr. Vasey include unripe fruits, acid fruits
(e.g., berries, citrus fruit), fruit juices, acidic vegetables (e.g.,
tomatoes, rhubarb, watercress), sauerkraut, lactofermented
vegetables, lemon juice, vinegar, and honey.
Dr. Vasey considers weak acid foods particularly important for
treating patients who, because of metabolic problems, cannot elim-
inate weak acids through the usual route of respiration. Because
“[t]he same food can have an entirely different effect depending
on the body of the person who ingests it,” according to Dr. Vasey,
diets for promoting a pH balance must be individualized.6
Russell M. Jaffe, M.D., Ph.D., C.C.N., of ELISA/ACT
Biotechnologies LLC, in Sterling, Virginia, lists antibiotics as
highly acidic.17 Other drugs that may have an acidifying effect

on the body include antihistamines, antiseptics, and nonsteroi-
dal anti-inflammatory drugs (NSAIDS).3
Dr. Brown advises against eliminating all acidifying foods
from the diet, because the body requires moderate amounts
of protein in order to build and repair tissues, and even to
establish and maintain reserves of alkaline minerals. Most
fast foods, however, should be avoided because they are
highly acidifying: They contain unhealthy fats, oils, and ad-
ditives; are highly processed; and, consequently, are low in
alkalizing minerals.3
Supplements
In conjunction with a diet of fruits, vegetables, and
whole grains, alkalizing mineral and other supplements in
the form of capsules, drops, or drinks can assist the body’s
shift from hyperacidity to a healthier acid–alkaline balance.
Dr. Brown recommends alkalizing supplements when diet
alone does not achieve a balance and in cases when ex-
tradietary factors such as stress lead to excessive depletion
of minerals. She prescribes various supplements, including
a mix of the alkalizing magnesium salts magnesium glyci-
nate, magnesium ascorbate, and magnesium citrate. Alkal-
izing green-vegetable juices, such as wheatgrass and barley,
may also be beneficial.3
Dr. Vasey has likewise noted that dietary adjustments may
be insufficient to eliminate accumulated acids, and, therefore,
he recommends alkaline supplements to support and acceler-
ate the body’s process of deacidification. The products he rec-
ommends are typically a blend of five base minerals—calcium,
potassium, magnesium, iron, and manganese—formulated to
restore the body’s acid–base balance and other minerals and
weak acids in an easily metabolizable form. Products that
contain sodium are contraindicated for patients with hyper-
tension. Dosage is individually tailored to each patient to re-
store pH to a normal level.6
Other supplements that Dr. Vasey recommends for de-
acidification include “green” foods (e.g., juices from chloro-
phyll-rich green vegetables, cereal-grain sprouts, and com-
mercially available green-food products), enzyme supple-
ments, prebiotic and probiotic complexes, and antioxidant
complexes. Patients whose diets lack in raw vegetables and
are high in refined foods are likely to also be deficient in the
enzymes needed to maintain a healthy acid–alkaline bal-
ance. Examples of enzymes featured in commercial prod-
ucts that Dr. Vesey considers useful for oxidizing acids in
the body include bromelain, papain, trypsin, lipase, amylase,
cellulase, and serrazimes.
In addition, preparations from medicinal plants that act as
diuretics (e.g., teas from black current, cranberry juice), and
methods of promoting elimination of acids through the skin
(such as hydrothermal baths), may be beneficial. Dr. Vasey does
not generally recommend fasting as an effective deacidification
method. A detoxifying diet based on green foods and alkal-
izing water is considered safe except for patients who cannot
metabolize weak acids properly; other mono diets (those based
on a single food) are not recommended.6
ALTERNATIVE AND COMPLEMENTARY THERAPIES • DECEMBER 2009
Table 1. Average Potential Renal Acid Loads
(PRAL) of Selected Foods
Food PRAL (mEQ)*
Fruits, fruit juices –3.1
Vegetables –2.8
Fats, oils 0
Grain products 3.5–7.0
Fish 7.9
Meat, meat products 9.5
Milk, dairy products 1.0–23.6
Adapted from Ref. 12.
*mEQ, milliequivalent per liter.
Exercise and Natural Therapies as Alkaline Boosters
Michelle Schoffro Cook, D.N.M., D.Ac., C.N.C., a doctor
of natural medicine and acupuncture and holistic nutritionist
in Ottawa, Canada, recommends exercise in conjunction with
diet to act synergistically to reduce acid and increase alkaline
to achieve a healthy pH balance. Dr. Cook has noted that
exercise—in addition to its other well-known benefits—helps
counter acidity in the body by accelerating elimination of ac-
ids through sweat. Natural therapies, including deep breath-
ing, meditation, massage, acupuncture, and saunas, “can shift
the balance between the ‘tending and befriending’ hormone
oxytocin and the ‘stressed out’ acidifying hormone cortisol.”18
In addition, slow, deep breathing depletes the body of carbon
dioxide (CO2), which raises the body’s pH.
Research on Acid–Base Chemistry
Two recent randomized studies exemplify the complexity
of acid–base chemistry in relation to diet. One, which was a
placebo-controlled, double-blinded study, examined the ef-
fect of an alkaline salt, potassium bicarbonate (KHCO3), on
countering the negative impact of acidic byproducts of protein
metabolism on the musculoskeletal system. Nineteen healthy
older adults (ages 54–82) were given up to 90 mmol per L per
day of KHCO3 or placebo for 41 days. The KHCO3 reduced
the rise in 24-hour urinary nitrogen excretion that accompa-
nied an increase in protein intake. The researchers concluded
that KHCO3 may promote calcium absorption independent of
dietary protein content, which has implications for older adults
with declining renal function.19
The other randomized study examined calcium excretion
and bone resorption in 171 healthy men and women, ages
50 and older. All subjects were given 600 mg of calcium (as
triphosphate) and 525 international units (IU) of vitamin
D3 daily. In this study, sodium bicarbonate, but not potas-
sium supplementation (in the form of 67.5 mmol per day of
potassium bicarbonate or potassium chloride), had positive
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 ALTERNATIVE AND COMPLEMENTARY THERAPIES • DECEMBER 2009
Recommended Reading
For practitioners
Stewart’s Textbook of Acid–Base, 2nd ed.
Edited by John A. Kellum, M.D.
and Paul W.G. Elbers, M.D.
Raleigh, NC: Lulu.com, 2009
For practitioners and patients
The Acid Alkaline Food Guide:
A Quick Reference to Foods & Their Effect on pH Levels
By Susan E. Brown, Ph.D., and Larry Trivieri, Jr.
Garden City Park, NY.: Square One Publishers, 2006
effects on calcium excretion and bone resorption after 3
months. The researchers suggested that increasing the al-
kali content of the diet may attenuate bone loss in healthy
older adults.20
Water Alkalizers
According to Dr. Brown, drinking water is not generally a
significant contributor to acidosis. In fact, mineral water high
in dissolved bicarbonates and low in chloride is an effective
means of countering chronic low-grade acidosis. She noted
that one might need to contact the manufacturer of a product
to find out that brand’s exact contents.3
Dr. Vasey’s recommendation is drinking alkaline spring wa-
ter, alkalized tapwater, or distilled water treated to increase its
alkalinity with commercially available alkaline preparations
only until the individual’s acid–alkaline balance is restored, up
to a maximum of 1 or 2 years.6
Advertisements have claims that water alkalizers (or wa-
ter ionizers) promote immunity against disease, as well as
assisting weight-loss, absorption of vitamins and minerals,
and antiaging by transforming acidic or neutral tapwa-
ter into alkaline water. Such products are said to work by
producing high levels of negative hydroxyl ions. Patients
should be advised to check with their clinicians before us-
ing such products.
Relevant research supports the positive biologic effects of
alkaline mineral water on bone metabolism. In a study of 30
females (average age 26.3) randomized to drink 1.5 L per
day of either alkaline-rich water or water rich in calcium
only, the subjects’ changes in blood and urine electrolytes,
C-telepeptides (CTX), urinary pH and bicarbonate, and
serum parathyroid hormone (PTH), were measured after
2 and 4 weeks. The subjects’ adhered to an identical bal-
anced diet. The calcium-rich acidic water had no effect on
bone resorption, while the bicarbonate-rich alkaline water
resulted in a significant decrease of serum-CTX (S-CTX)
and PTH.21
Another randomized study examined the effects of two
drinking waters with similar calcium (Ca) concentration, to
determine the role of ions other than Ca on bone metabolism
296 MARY ANN LIEBERT, INC. • VOL. 15 NO. 6
in 49 patients who remained in the study. These drinking
waters differed in mineral composition with respect to con-
centrations of bicarbonate (HCO3–) and sulfate. After the
subjects drank 1 L per day, for 28 days, of one type of water,
and a crossover to the alternate type of water for a further 28
The health costs of the contemporary,
highly acidifying standard
Western diet are clear.
days, changes in Ca metabolism and positive action on bone
metabolism were significant in the high-base group com-
pared with baseline.22
Water that has been alkalized during ionization has been
shown to produce active hydrogen to counter the active oxygen
or free radicals that cause oxidative damage to DNA.23
Conclusion
Given that acid–base balance is so essential to optimal
health, foods and supplements that promote this equilibrium
should be a high priority in health care and in consumers’ di-
ets. The health costs of the contemporary, highly acidifying
standard Western diet are clear. Studies on claims regarding
products for alkalizing water are warranted in light of research
that suggests the positive effects of alkaline drinking water on
bone metabolism. Patients should always check with a health
practitioner before going on any diet intended to affect acid–
base balance. n
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