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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.

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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 slightly 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 CO2 deposition. This has a negative impact on life in the ocean [1, 2] and may lead to 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 chemically 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 agricultural 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 previously was 10 to 1 whereas the modern diet has a ratio of 1 to 3 [7]. It is generally accepted that agricultural 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 preagricultural 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-protein 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 increased. 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.

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2. The Role of pH in Various Cells, Organs, and Membranes
The pH in our body may vary considerably from one area to 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 environment. 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 categorized 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 phosphorus 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.



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