Rethinking Alkaline Eating: What Really Drives Metabolic Health

Forget the hype about a food’s pH in your glass. What shapes your health is the acid produced after digestion—and how your kidneys manage it all day, every day. We unpack the science behind dietary acid load, explain the difference between DAL, PRAL, and NEAP, and show how a modern, grain-heavy pattern quietly raises acid burden while delivering minimal nutrients. The goal isn’t to fear protein; it’s to pair it with the right plants so bones, muscles, and metabolism get stronger together.

We walk through how the kidneys buffer acids using ammonium and titratable pathways, why blood pH won’t reflect diet, and how a simple first-morning urine pH can be a practical window into your load. Then we get tactical: spinach, tomatoes, avocados, Swiss chard, and sweet potatoes are heavy hitters for generating bicarbonate and neutralizing the acids that come from protein. We also dig into evidence linking higher PRAL with fatty liver in type 2 diabetes and explore mechanisms that tie low-grade acidosis to insulin resistance and muscle catabolism.

If you train hard, there’s a performance angle too. Some athletes use sodium bicarbonate to improve tolerance to lactic acid, and low-PRAL phases show promise for faster lactate clearance. For kidney stone formers, potassium citrate can meaningfully alkalinize urine and improve uric acid handling. The simple blueprint: keep protein adequate, cut refined grains and sugars, and choose alkalinizing plants that support your kidneys. Try a one-week experiment, track your morning pH, and notice how energy, recovery, and clarity respond.

If this resonated, follow the show, share with a friend who loves both science and good food, and leave a review to help others find us. Your feedback shapes future episodes.

For video, open-source references and powerpoint slide deck go to: www.thehealthedgepodcast.com

Transcript

Setting The Acid–Alkaline Stage

SPEAKER_00 0:00

Welcome to the Health Edge, translating the science of self-care. I am Mark Pettis, and I'm with my friend colleague John Bagnulo. John, good morning, my friend.

SPEAKER_01 0:10

Hey, good morning, Mark. Great to see you.

SPEAKER_00 0:12

Great to see you as always. We have been looking at some research on a topic that, again, I think is so fascinating, John, as it relates to the acid production of the foods that we eat, and the extent to which many observational studies suggest that the more acid from foods that we consume that we produce over the course of the day, the greater the likelihood of developing more chronic complex diseases from diabetes to obesity to cardiovascular disease. And there has long been an approach around alkalinizing foods and the alkaline diets through the years that have had a wide range of touted health benefits from reducing cancer risk, improving outcomes, general health across the board improvements. And so it seemed a really good time to look at that in more detail and with more granularity. And I think like many things that we emphasize, John, in our conversations, the acid production from a food that we consume is another example of a non-nutritive attribute. And some non-nutritive attributes, like getting polyphenols from plant-based foods. And in this example, the amount of acid one produces or not having a potential for wide-ranging health effects is really important because not everything comes down to how much uh particular nutrients that a food contains. And so it'll be interesting to look at this from that perspective.

What Acid Load Really Means

SPEAKER_01 2:36

Yeah, no, it's a it's it's an awesome topic, and I think for several reasons. Number one of which is, you know, it it touches every area of medicine, right? You can't, when you look at how far-reaching the effects of uh like a chronic kind of subacute metabolic acidosis is, right? It affects every area, right? Skeletal health, muscular health, obviously, you know, renal health, the health of our liver, cardiovascular. It's incredible. And if I can just back up for a minute, it's interesting because you know, you you said that for a long time there have been so many advocates or approaches that would recommend for patients that have one condition or another a more alkaline diet, right? And some of that would be cultural. Um, you know, like there's different, there are different cultures where this is much more appreciated. And then there are some approaches that might have developed here in the US, for instance, that use this as a big part of their of their like advocacy for a certain way of eating. And, you know, what's interesting is though those different approaches, as you and I can both appreciate, they have been received in a very, very diverse set of conditions. Like some people totally dismiss that. You know, a lot of like, you know, traditional Western medicine is like, you know, what there's nothing to this alkaline-loaded diet, which I find fascinating because, you know, I'm pretty sure, and I know with your with your area of expertise, you know, you know, as a nephrologist, you're gonna, this is gonna be ingrained, right, in in what you learn. And but I think most people that take a biochemistry course or have a at least a basic understanding of understanding of human physiology, you know, have to realize that, yeah, the body does need to maintain a blood pH of 7.39, right? Or very close to that. And it's got a few mechanisms by which it can do that. And when that doesn't happen, when you have like a just this chronic acid load being placed on the body, well, the compensation is going to take its, it's gonna take its toll in one system or another, right? Which we see. So I think it's an amazing topic for those reasons. Um, and I think a lot of the confusion, at least, you know, again, I just want to put this out there in case it helps our listeners. When you and I are talking about, you know, the the acidic contributions that a food makes, I just want to make sure everyone understands that it's post-digestion and absorption. It's not the pH of a food when it's in our glass or when we take a bite of that food, because a lot of those foods, you know, that I hear people say, well, coffee, you know, isn't coffee a that's an acidic food. It's only acidic when you drink it, but it it actually has a net like alkaline effect on the body because it doesn't really have any protein, doesn't have a phosphorus or a sulfur content. So it's, you know, it's a so just a modest amount of potassium at the end of the day. Um and so I just think that is also an area of confusion that immediately you lose certain people when you start talking about the pH of a food. We're talking about, and you just you did a great job of articulating that a moment ago. How does a food, how does that contribute, like acidogenic, right? How does it make that type of effect on the body? And it really comes down to protein, phosphorus, and sulfur. The more of those nutrients that a food contains, the more it's going to contribute to this metabolic acid load. The more potassium, calcium, and magnesium a particular food contains, and the and less of the phosphorus and sulfur and protein, the more of an alkaline contributing food. And so if we start there, I think it can, you know, it can can add a little clarity, whether that's for a person interested in improving their health or a clinician, because I, you know, I know you in the past as well. We I've I've talked to clinicians and I've said, you know, I just think this person has bone loss because they're there's just no potassium in their diet. There's no source of of helping the body neutralize all the acids in their diet. And you know, that's kind of just been like, you know, I get raised eyebrows with that. So at any event, I love the topic. Um, and I'll end here because it's also one that emphasizes balance, right? We're such a monolithic society. And I can be guilty of that as well. I can get, you know, we can look at a person's blood work, or I could think about a certain angle to take, and then that really becomes the dominant approach. But this really brings us back to the importance of balance, which look, ancestral medicine, that's the one thing it should teach us, right? Is that the body needs balance in every way, right? And this is a great example of that. If we're just really focused on eliminating carbohydrates and loading up on protein, you know, you can lose some really important components of that balance. And obviously, you know, that happens. We have people that are making all the wrong choices with carbohydrate dense foods. That's a big part of our, you know, society's problems as well. But it's really about balance and making sure that every meal has this kind of weighed approach, right? Where we're getting enough of those alkaline contributors, but we also need to make sure we get enough protein. And once that kind of mindset, I think, is developed, I think it helps everybody remarkably.

Protein, Grains, And The Balance Problem

SPEAKER_00 8:22

Yeah, that's that's just the perfect prologue for for what we're going to be diving into here, John. Uh and hopefully, just looking at some of this research, we can bring a little clarity, but it's it's just so important what you said about the big picture. Um uh, because we don't want uh people to come away thinking, ah, animal protein produces more acid, therefore it's horrible. Avoid it at all costs, right? Which which has been the clinical meme. Yeah, not so much because of the acid, uh, you know, because of the cholesterol. And right it's um, but it's really important that one not condemn a food uh based on that attribute alone. Um and and this is where the balance becomes so important. Well, well, let's I'm gonna share my screen back here, John, and we'll uh um and and you've already beautifully set the stage for this, but but I did think it would be helpful to refining uh terms here. And really, so the question we're trying to help reconcile, you know, does acid production from the foods that we eat uh drive metabolic disease? And um uh as you suggested, John, this is a much more nuanced story. Uh but but frequently when you look at the research that we will be looking at, the researchers will refer to DAL, the dietary acid load. And again, just quick definitions. This this is a very high-level term that looks at the net balance of acidifying versus alkalinizing foods in the diet. Um, so it's total dietary intake, and then there are formulas that one would use to calculate the acid contributing and the alkalinizing contributing, and one would just sort of look at the balance of that. Um what one tends to see uh more specifically in research studies is what's referred to as the PRAL or the potential renal acid load. And to your point, John, this is after the food is is digested, after uh that food is burned as a fuel. Um, so these are the metabolic byproducts of metabolism of these foods. Uh and so this is uh again, these are formulas that, again to the point that you raised, John, when you look at the sulfur and the phosphorus in a food, that that is really how the calculation of acid contribution is made. When one looks at uh the potassium, magnesium, calcium of those foods, that uh contributes to the alkalinizing contribution. And so it's a um it's a more commonly employed uh term and measure where a positive score uh would suggest net acid and a negative score net alkalinizing. And then this last term, this NEAP, this net endogenous acid production, is a measure of both the acid contribution from metabolizing the foods that we eat. We might call that exogenous. Uh, and then there's the internal acid production uh just from uh metabolic processes that we require day to day just to maintain our ability to function. And and so not all acid that is produced in the body comes from the food that we eat.

SPEAKER_01 12:14

Uh, and here you're looking at that would include like the uric acid we talked about, you know, a couple weeks ago.

SPEAKER_00 12:21

Exactly, John. It might uh maybe someone has lactic acid from uh uh uh ischemia, they're not getting enough circulation to their extremities, for example. Uh it might be uh uh uh someone who's got poorly controlled diabetes and has some keto acids. Uh and and so uh this is just a uh a more global measure, including food and non-food uh contributors. So just to kind of set the stage for these definitions, and again, you know, when you look at sort of the the published literature, the the average um uh acid you know production, that that that which the kidneys confront, uh, because as we'll emphasize, the kidneys are the primary way that we buffer or neutralize acid that is produced. So you know the average PRAL in the American diet will be anywhere from 50 to 80 uh milli equivalents of acid per day. When you look at mean values, and often you'll see mean values used, because when you're looking at averages, um people that have a really, really high PRAL might falsely raise the average uh in a way that when you look at mean values, which you a mean value is of the value where 50% fall below, 50% fall above, um, it's a little less skewed by what might be a smaller percentage of people with a really high PRAL. And so when you look at means, uh, you know, you you'll see this in the 24 approximately milli equivalent per day.

SPEAKER_01 14:11

And Mark, hey, the the one thing if I could add to this, these are some great talking points here. Um and I I don't want to overwhelm our listeners with bad news, but this one slide I think says a lot. First of all, we know that the average American adult probably doesn't consume enough protein, right? Especially older adults. So what's really startling about this is you look at this, you see the high PRAL value, and that is with a current set of conditions where we're not consuming enough protein. So, you know, right. So think about that. Like if we actually consumed as much protein as we need to support more lean body mass, well, the prowl's gonna go up unless we make the concomitant increase in alkaline contributing food. So like everything has to improve, right? We need more protein, and we also need more of an ability to buffer out the acid that's gonna that's gonna come from the result of that of that protein's metabolism. And I think that's what's really like crazy when you look at this is that here we've got a population in the U.S. that already has a very high prowl and they're not eating enough protein.

SPEAKER_00 15:25

Yeah. I mean, that is such a great point, John. And we'll we'll come back to this repeatedly because at the end of the day, you don't want to throw the baby out with the bathwater.

SPEAKER_01 15:34

Yeah.

SPEAKER_00 15:35

Most people need more protein and animal protein, as we talk about, um, has the most complete in terms of essential, non-essential amino acids, and and and the best bioavailability. So a much greater percentage of that protein is absorbed and utilized into muscle uh protein synthesis and lean body, all of these things that are important.

SPEAKER_01 15:59

So we don't want the crosshairs to be put, and too often I think the plant-based community does this, they put the crosshairs of this problem on the protein intake.

SPEAKER_00 16:08

Yes.

SPEAKER_01 16:08

And really, we have to make a huge shift in the perspective on this issue.

SPEAKER_00 16:14

And that's where this second bullet point of key drivers uh begins to bring us to what you were saying, John, that it while it's true that animal proteins will have a higher uh Prawl, it's the processed foods and and and the refined grains which are so problematic. Not only do they have a high prowl, but they have very little nutritional value. They're they're right low in protein, low in fiber, and they're very high glycemic. Um so uh if one looks at this and says, oh man, I need to cut back on my animal protein, um, that again, just to emphasize the point that you made, John, really one wants to make start by making sure you're getting good and adequate protein, which you know is is a minimum of a gram and a half of protein per kilogram of body weather per day. Minimum. And um whole sources of of pasteurized meats and whole fat dairy and eggs is not where you want to be uh cutting back. It's processed meats, certainly processed foods, refined grains, flour, um, they are that's really uh the the bullseye on the target.

SPEAKER_01 17:32

And much of the Yeah, and hey, to just to build on what you just said about the grains, I mean, first of all, the whole grains aren't gonna make too much of a difference. So, you know, while refined grains are the worst, right, the whole grains aren't gonna really help you very much with your net acid load either. And and back in the late 90s, um, I think it was like 1998, Tufts did a study on women over the age of 50 and bone loss, and they found that the it wasn't actually the animal protein uh that was associated with greater or accelerated bone loss at age 50. It was actually the more servings of grains and cereals that women ate. And and this was a and this is a large number of women that were in this study, and it got you know, it got headlines at the time. A lot of this has unfortunately been it's fallen on deaf ears or it's been lost, but it was the women that had the greatest volume of dietary cereal grains and foods made with those things, flowers, that had the most bone loss. And I just think that, you know, that really gives us a much better insight, right, than again, thinking that, you know, the eggs we're eating or the meat we're eating is somehow that's what's responsible for the average, you know, woman's bone loss. It's just not the case.

Defining DAL, PRAL, And NEAP

SPEAKER_00 18:44

Yeah, and to your point, John, we know that more animal uh uh protein consumption is associated with better bone and connective integrity. So this is where it's really important uh not to focus on one attribute uh without considering the holistic uh effect of all that comes with that that food source and how that food source is balanced with other foods. So that's such a great uh point of emphasis. Um so you know, and and again, we we talk about the fact that we don't get enough of these alkaline producing uh foods. So um uh, you know, eating a uh prime rib um without any vegetables, and you know, it it we're not here to talk about the carnivore diet, and there's certainly uh a lot of uh there's a lot of interest in this out there, a lot of testimonials. Uh there's no question um that uh when one switches to essentially a zero carb uh diet, that many metabolic things will get better.

SPEAKER_01 19:58

Absolutely. It's a step in the right direction. direction. Yeah.

SPEAKER_00 20:01

And I think it can be a remarkable reset for someone who's struggling. We just don't have good long-term data. And so here again, the emphasis on balancing protein, animal protein sources with good alkalinizing plant-based foods. I mean you you said something years ago, John, that has that was etched into my DNA, this simple concept of getting two cups of greens a day. And you know that's a great example of a beautiful alkalinizing balance to whatever acid producing food that that you might be getting.

SPEAKER_01 20:45

And and so this high at the minimum mark at the at the minimum, just quickly on that, I mean just so people understand, two depends on the greens, but you get some things that are off the charts in terms of what the how much acid they can neutralize. Like when you get into and there's they're more esoteric. These aren't things that people are going to eat regularly. I'm fully aware of that. But a cup of dandelion greens, a cup of Swiss chard, I mean, that has the ability to neutralize like an eight ounce steak or you know even more of a like a certain like fish. You could neutralize eight ounces of steak, four or five eggs, you know, 10 ounces or 12 ounces of salmon with that volume of greens. So it doesn't take a lot of certain greens but even like like romaine lettuce like you know a couple cups of chopped romaine lettuce can neutralize you know like a chicken breast or you know three or four eggs. And I think you know I think people lose sight of that. We're not talking about mountains and mountains of vegetables. And to add to what you say I look I think the carnivore diet for a lot of people is a huge step in the right direction. And I felt I feel the same way about like just the Atkins diet, which has got, you know, there's mountains of evidence that it can take someone from metabolic syndrome to a better place, right? I think what you and I always try to do is to try to help people find the next level or to see you know like maybe a better destination, a better point. And it's always important to to recognize that like these these approaches get people on the right path. But I don't know as though they're long term, this isn't what you want to be on indefinitely. You want to be able to weave in a more balanced approach. And it doesn't mean you bring back grains or cereals or you bring back you know refined carbs. No, we're not talking about that. We're just talking about bringing back some ancestral foods that human populations really subsisted on along with the meats and in the fish and everything else. So yeah it's um again we're just people get really locked into this like one approach or there's just one way. And it, you know, it it's a lot of times those one ways are really they're you're you're going in the right direction, but you probably don't want to stay locked into that much of a reductionistic uh way of eating.

SPEAKER_00 23:01

Absolutely this is just a uh schematic of of how the kid this is great to manage acid uh and again uh the kidneys do this 24-7 and so most of the acid that is produced both from foods we eat as well as endogenous uh metabolic effects you know the kidneys do a beautiful job of uh they will take that acid and uh most of it is excreted in the urine in the form of ammonium um uh the kidneys make ammonia uh which which is that odor that people might notice particularly in a more concentrated first morning urine uh and that ammonia will take a proton that acid uh to form ammonium and uh is excreted and um people with normal kidney function uh will do this superbly well um another part of that acid is is is excreted by what's called titratable acid and and this is uh often using phosphate as the kidney filters phosphate um that phosphate can take on the proton and the combination of that with ammonia production really for the overwhelming majority of people with normal kidney function will allow you to handle um what is you know your your mean or typical uh prol for the day uh the kidneys are also really good when they have to at uh reabsorbing holding on to things that the body might be in more in need of in this case bicarbonate which which is the uh the primary buffer um in our um in the extracellular fluid that fluid around that bathes our cells and so bicarbonate is the primary uh buffer and the kidneys do a pretty good job of that uh what's important is that uh people with a chronic acid load will often have a and most of the time will have a normal bicarbonate level in the blood uh because of their uh efficacy at maintaining that so you really this is that's a really important point Mark what you're saying here is is critical for our listeners because a lot of times you know there'll be pushback against this entire concept by and I've had people come up to me and say do you mean to tell me that if I test my patient's blood it's gonna be and the answer is absolutely not.

SPEAKER_01 25:41

And it's the same thing with if we want to test the bicarbonate ion that's like the last place and things are going to be really bad when you see that a shift in the pH of the blood or you see a significant loss of bicarbonate ion, right? I mean it's it's triage and that's what the body maintains until there's a complete breakdown elsewhere. So so anyways I I just find that important I love that you bring that up it's like those levels are going to look like and they're going to be physiologically acceptable until there's a complete crash right and at that point you're in full blown like acidosis and and we're that's not what we're talking about. We're not talking about you know like an acute keto acidosis. What we're talking about here is low grade metabolic acidosis where that measuring someone's bicarbonate it's not going to tell you anything.

The Kidney’s Role In Acid Handling

SPEAKER_00 26:32

Yeah exactly John great point uh nothing with respect to our diet from that from this perspective will be uh will show up in your blood pH or in your um serum bicarbonate um we where you will see an effect is in the urine pH the urine pH is a is a a bit of a surrogate for um acid load um and so that first morning urine pH um uh with uh what might be a higher pral intake you will see a maximally acidic urine generally that urine pH will be much less than six um so urine pH as it turns out is a is a a a better surrogate uh for um this balance of acidification and alkalinization um it's not used routinely unless you're a kidney stone former where um uh alkalinizing the urine becomes a very important strategy uh uh to uh mitigate uh stone propagation and new stone formation so a urine pH is a for for those who are interested uh is a is a better sort of surrogate for that uh you know if you look at again we we've touched on this these are just very general categories so you know the the more acid producing foods will tend to be animal protein sources this is a huge one as it's the mainstay of the standard American diet right grains and starches and and and then sugar processed foods so and interestingly yeah absolutely market interestingly uh when it comes to grains and starches rice has by far um the lowest acid load you know wheat has the worst yeah so some of that you know may or may not be relevant to our listeners but if you think about the number of cultures that rely predominantly on rice as opposed to wheat they tend to fare much better when you look at everything from all-cause mortality to any of these chronic diseases that are associated with with higher prol or acid-loaded diets I I find that interesting anyways but yeah yeah and and again you know alkalinizing foods are are certainly going to be you know root vegetables greens and some you know avocado some you know beans legumes things that that we've we've touched on are yeah and the real heavy hitters here for our listeners and it surprises people tomatoes are an incredible um they have an incredibly low negative prowl value so that tomatoes actually help us neutralize large amounts of acid and spinach is the most commonly consumed green leafy vegetable um with you know again incredible ability here to contribute to that whole potassium bicarbonate system um and avocados so those are three real you know valuable whereas a banana it's it's decent but it doesn't give you the same return on your sugar consumption your carbohydrate as the others so sweet potatoes spinach avocados tomatoes those are by by far the the four biggest players that if you can find a way to keep those in your diet on a regular basis you know you can see that with spinach and avocados and even tomatoes you can still be on a low carb diet and have a very very balanced approach.

Urine pH As A Practical Gauge

SPEAKER_01 30:02

I'm sorry about that I think excellent no I know John that's great and we talk a lot about ancestral approaches and and so much can be learned from um studying how the dwindling ancestral cultures today subside uh and you'll see prol values in my review of this John really over a very wide range uh um those closer to the equator equatorial uh you will have more access to alkalinizing um um produce and fruits vegetables and as you migrate more northward uh you know you'll you'll see greater consumption of uh animal protein and so there's the the point of this is that there's a wide range of prowls and ancestral cultures and um they will often vary during the year depending on the climate the the the growth season what what's available um but the what you see in all cultures is this uh tendency toward balance as as you point out yeah a couple a couple other papers that you know I know you're aware of Mark our listeners might find interesting one is by Lauren Cordain 1997 uh Origins and implications of the Western diet in light of you know our ancestral history uh and then Boyd Eaton had several papers and their prowl values you know to your point here would suggest that we were our our ancestors were very balanced this is Paleolithic era okay so we're going back you know going back at least 10,000 years. Root vegetables were huge um and then to the point you're making as human populations move further away from the equatorial regions that our ancestors had to take concerted efforts to prevent acidosis. You know everybody's heard stories about you know what happened to the pioneers that just ate rabbits and didn't eat right didn't eat higher fat foods they developed acidosis at a really extreme extreme level to the point where um you know they died. I mean it was toxic levels right um but you know cultures that might live farther north than you're gonna have access to any type of fruit or vegetable would do things like they'd crush crush oyster shells and consume that, which is again it's mostly calcium carbonate. So I mean they would do whatever they whatever they could even thousands of years ago to try to neutralize acid that they couldn't identify but they knew was having systemic effects on on early human populations. So it's really remarkable how our ancestors were aware of the importance of this without actually being able to put their finger on you know what the process was yeah that's that's great Sean and it um uh reminds me of the um uh the great Jared diamond the Pulitzer Prize author of uh Gunge Germs and Steels and the uh the the the world until yesterday yeah uh and uh the the the very famous quote that I I think was in Discover magazine 1999 where he talks about this transition from the Paleolithic to the Neolithic where the advent of agriculture might be looked upon as the single greatest uh and most devastating uh uh uh shift in in human evolution uh uh based on awesome books right the need the need right to to you have these more population dense areas migrating you you you know needed to develop agriculture and they were growing grains and right wheat and and there were some advantages there to store that food to have availability during harsh times but when you look at the archaeologic data uh you know within generations of shifting you see you see differences in skull uh uh dental jaw um anatomy bone anatomy humans become much shorter the fossil record does not lie the fossil record speaks to the downside of introducing right these wholesale monocommodity uh grains and um and the population mark the population that and I you know again Jared Diamond you gave me the world until yesterday that's one of my favorite all-time books um for our listeners that aren't familiar with Jared Diamond's work I mean he you know in the late 60s uh as an anthropologist at UCLA he would travel to Papua New Guinea and spend time with the New Guinea Highlanders and he did this for two decades and you know that they are in in lesser today than than 20 years ago but they have been considered one of the last living examples of a Paleolithic kind of hunter-gatherer society but more Neolithic um to your point because they did cultivate sweet potatoes and that was the one crop that they that they planted harvested and got a significant percentage of their calories now what's interesting about this population is that as a New Guinea Highlander gets older their blood pressure goes down as a New Guinea Highlander gets older right their bone density improves and researchers from all around the world not just because of Jared Diamond's work but because of some of the evidence that was coming forth about just the incredible paradox to what we were seeing elsewhere in the in the developed world they would travel there totally bewildered by the physiological changes that took place over the aging cycle that just people couldn't explain. But the the net acid load is a big part of the story, right? Because sweet potatoes are amazing. There's no grains in their diet um and it's just they're constantly in a low to zero prattle daily balance. And so their body is always mineralizing and their body is maintaining lean body mass at a much much easier uh it's a much easier process for the human body to maintain muscle mass and lean body mass overall when it's not constantly compensating robbing Peter to pay Paul so to speak with potassium. So I mean you look if if our listeners read Guns, Germs and Steel, you know, if they haven't I'm sure a lot of a lot of our listeners have I so much of the ancestral um picture just clicks in just the first few pages of that book it sure does.

SPEAKER_00 36:43

And the take home message there for me John is choose your plant carefully not all plants are created give me the sweet potato over the wheat any any day of the week. So you know we see and and I'll I'll put these these open source review articles up on our um website John thehealthedgepodcast.com but but you can see a fair amount of um epidemiologic observational data that that clearly shows that um people with a high prowl chronically that sort of overwhelms their kidneys' ability uh to neutralize uh and again these are frequently um standard American diets that have very little alkalinizing balance uh with with with the foods that that we've talked about uh there's no question that you see a much higher prevalence of chronic complex disease over time these are correlations and we're trying to offer some mechanistic perspective here uh just to to add a little bit of clarity uh and as we talked about this is a very busy slide but it's from it's from this this paper uh it uh it's really hard to measure through traditional ways any change in systemic or extracellular fluid pH the the the kidneys are just so damn good at balancing that you will not uh see those changes uh and day to day in the absence of some catastrophic event like uh ketoacidosis or um lactic acidosis that's overwhelming or acute kidney injury that that overwhelms the kidney's ability to handle an acid load otherwise these chronic low-level microenvironmental changes will not be picked up if you do look at urinary pH uh and I'm not recommending people do this unless they form kidney stones but that morning pH um and your pH throughout the day it's just a dip dipstick of a urine sample is really very very helpful uh and that's a nice way of looking at um whether your kidneys uh have the need to maximally acidify which they will only do if the acid load they're confronted with um requires that maximal acidification of the urine. So uh um I put this up here just for those who are saying help what can I measure?

SPEAKER_01 39:28

Yeah this is great. This is great Mark because I think like to your point not everyone has to do this but if you have like let's say you're someone that has a lot of bone loss or you know you've you feel like you lose lean body mass much more quickly than than you'd expect which we'll maybe explain in a moment when we look at potential mechanisms that that go on here. But I think you're measuring urinary pH, I you know look I think it has value for people, not forever, but just do it for a week. And look how your last meal of the day to your point affects That first, you know, that first um diuresis in the morning.

unknown 40:05

Yeah.

SPEAKER_01 40:05

First urine sample, yeah.

Plants That Power Alkalinity

SPEAKER_00 40:07

That's where you will see maximum acidification after that overnight fast. So it can also be a good way to see how concentrated your your urine isn't forming. Uh and you know, maybe you're not getting enough water. So yeah, it's uh obviously an easy and very inexpensive uh thing to do. Let's just look at a uh a few more studies here um that again are observational. This and I I brought these up, uh, some you have shared with me, John, which are just outstanding, but just to give people a sense of what's out there. Most this was uh published earlier um in uh 2025. This looked at the association between dietary acid load, risk of metabolic dysfunction, uh, with in particular fatty liver, and in people with type 2 diabetes. So these were people who already had metabolic uh disruption. Uh and what they do typically in these in these observational studies is they stratify um from lowest to highest, in this example, the Prawl, and in this example the the net acid production uh with respect to uh you know diabetes, and and what you find is that as you go from a low prahl to the highest uh uh Prawl in people with diabetes, that the risk of fatty liver goes up. These are hazard ratios. So in this example, uh the highest prawl uh tended to have about two to three times the risk of fatty liver compared to those with the lowest prawl. Uh if you looked at net acid production, which is a bit more of an accurate measure of what the kidneys are actually left with at the end of the day, taking into account both dietary and non-dietary, the hazard ratios in the lowest to the highest acid producers is you know four plus times. So these are pretty significant changes. Um relatively small numbers of people, but again, the point here is that fatty liver, as a very important inflammatory feature of metabolic syndrome, does tend to correlate more strongly with higher acid production. And uh again, this is similar, these are similar methodologies. Uh this in this example looking at cancer risk and prognosis. So this was Frontiers in Medicine from 2022. And again, uh this is um uh a forest plot looking at various studies. Uh and this is a null effect, no no difference one way or the other. This one value, anything to the right would suggest a correlation, uh, anything to the left would suggest a risk reduction. Uh, and and so this open diamond here is just sort of an average of what these several studies show, with a slight increase in the hazard ratio of uh cancer progression and worsening prognosis. Again, these aren't, when you look at these um uh uh hazard ratios, they're not off the chart big. Uh but if you uh have cancer and you're not getting a lot of right plant-based alkalinizing foods, uh, you're eating right too many refined grains and and and flour, uh wheat, um uh, you can appreciate how that would very much influence any clinical outcome uh where the acid production is really just a manifestation, uh, one attribute that correlates, um, but but these are people who probably aren't getting enough nutrient density in the foods that they're consuming, uh, and just aren't you know getting enough fiber, all of the things that we frequently talk about. But I but I think here you see this reflected in terms of the acid production. And uh again, these are all just variations on the on the theme here.

SPEAKER_01 44:51

This was a good one, though, Mark, and I really appreciate you sending this one to me because they did get into the mechanisms for each of the different chronic diseases as it relates to net acid load, potential renal acid load. And I, you know, I thought what was really fascinating to me that you know, under each chronic disease, uh, you know, the effect of extracellular changes in the pH on, for instance, insulin resistance. And what had been shown, at least in animal models, is that if you reduce the pH of the extracellular fluid, that you do drive insulin resistance and that there may be a protective mechanism there by which the body could more effectively break down protein, skeletal muscle, when that happens. So, much like we talked about with this uh evolutionary use of fructose, it was something similar here where, you know, if you had a very, very acidic condition setting in on the body, that there would be a survival mechanism to driving insulin resistance. You'd catabolize more skeletal muscle, you generate more of that ammonium to act as a base. So I thought that was really interesting. The other thing that I wanted to hear your thoughts on was it did reference an in an improvement in or a reduction in all-cause mortality. So with the use of sodium bicarbonate by dialysis patients. And I, you know, again, I and I'm sure you've met people that use baking soda. Uh, you know, it's like folk medicine, right? So immediately you lose a lot, you lose a lot of a lot of people. When you start, whether it's apple cider vinegar or it's baking soda, you know, people just kind of roll their eyes. But, you know, what was really clear from the section in that paper on renal disease was that patients that did eventually go on dialysis, they did fare much better and had a much lower all-cause mortality when they use baking soda as part of their approach. And I just what do you what do you what do you think about that? Because I, you know, again, I come across it from in working with athletes, sports medicine now. Um, there are a lot of athletes using baking soda to neutralize or be more effective at neutralizing lactic acid. What about for our listeners that you know know that this might be an issue for them? Is that something they would, you know, maybe consider just even if it's temporarily?

Ancestral Diets And Seasonal Balance

SPEAKER_00 47:11

Yeah, that that is a really good question, John. And I and I brought up uh one of the tables looking at um uh supplemental, if you will, strategies uh that can accompany dietary uh intake to lower uh acid production that uh certainly range from what we've been talking about, alkalinizing foods, eliminating, of course, those acid-producing, particularly uh grain and processed carbs, from alkalinizing agents like sodium citrate, sodium bicarbonate, uh potassium citrate. Um these are the most commonly uh, you know, there's alkalinized water, but for the most part, these are the supplements that have been most time tested in my experience in the renal world. And sodium bicarbonate was a standard um um addition to a renal diet for all people with end-stage renal disease, uh, and and the the acid production in somebody with end-stage renal disease on dialysis, in addition to being huge because the kidneys can no longer handle that acid load, you have to restrict potassium, high potassium, and high magnesium foods in people with end-stage renal disease because the kidney's ability to excrete potassium and magnesium is so compromised that you can quickly develop life-threatening elevations of potassium and magnesium. And and I've got some stories there that would would uh uh make your hair stand on end. Um I I've seen people's potassium go up um uh quickly enough for them to become paralyzed by hyperchalemic, hyperkalemic legs up and literally within within minutes away from cardiac arrest, short of getting them on dialysis. And so these are um so you can't eat the alkalinizing foods to the same extent that somebody without um so it is a huge issue. Um I think um, well, I'm not convinced that the sur the mortality benefits are great. Um, I I think the data there is is a bit mixed. Uh, not everyone can tolerate um sodium bicarbonate. Um in the doses required to neutralize uh daily acid load, um, a lot of people get gastrointestinal intolerance. Uh um, so so there there can be a dose limitation in terms of side effects, but there's no question it's an effective strategy. Um and there you will see it in the electrolytes when you measure that bicarbonate, only because it's a more severe acidemia. Uh the potassium citrate has a lot more supportive research in people who are kidney stone formers. And in my view, almost anyone who forms kidney stones should be taking potassium citrate a few times a day to alkalinize the urine. Uh, so many people with who who form kidney stones do so on the basis of high uric acid, which we've talked about recently. And and as you alkalinize the urine, the kidney's ability to excrete much larger amounts of uric acid uh is made possible. The dissociation of uric acid into urate goes up dramatically, so you can clear that uric acid in orders of magnitude greater when you alkalinize the urine, and potassium citrate is a really effective way of doing that.

SPEAKER_01 51:10

Umligrams, how many milligrams of potassium, just to help our listeners, this would be for someone with again healthy kidney function. How many milligrams of potassium are in that three grams of potassium citrate?

SPEAKER_00 51:25

You're probably getting um uh couple hundred, right? Yeah, at least. I would say several hundred grams of potassium. Yeah.

SPEAKER_01 51:36

Okay.

SPEAKER_00 51:37

Uh and so, you know, it I do think, uh, and I I've yet to see the research. You may be, I know you look at the research in terms of um uh intense activity and and performance in terms of mitigating lactic acid. I I'd love to just to hear your thoughts on that on another time and another topic, John. But I've yet to see good research looking at the addition of, say, potassium citrate on somebody on a carnivore diet, you know, or or somebody on a ketogenic diet, you know, something with higher protein and lower carb, and and how that might uh affect long-term outcomes. I don't believe that.

SPEAKER_01 52:18

That's not out there. No, that's that study's not out there. All all that we know right now are the sodium bicarbonate, you know, uh those trials, which are definitely favorable to your point that you have to be able to tolerate the sodium bicarbonate, and that has been circumnavigated as of late with the use of enterically coated capsules and these hydrogels that, you know, you don't get that reaction in the stomach, it gets into the small intestine. And those trials are showing significant benefits to um to athletic performances where lactic acid is the rate limiting factor, right? A 400-meter, 800-meter event. But, you know, even in the more recent past couple years, um, marathon runners who do have some of that lactic acid accumulation towards the end of a run when they really take up the intensity or pick up the pace, so to speak, in the last mile or two, they're also using um sodium bicarbonate effectively. So it's really changing, you know, for for many athletes, it's changing their ability to tolerate lactic acid. What's interesting though is that to your point, we have so many athletes that are using ketogenic diets as part of their training, you know, so they're better at any given intensity at burning fat, you know, whether that's a cyclist or whatever. And I there isn't any research right now on on um the use of potassium citrate in those athletes, larger doses of it. And it's it's interesting that there that there isn't. But I do know that there have been a few studies that have looked at a a low pral reducing the renal acid load for four or five days, and then looking at an athlete's ability to clear lactic acid, and those two have been very favorable. Um, you know, any athlete that goes on a low renal acid low diet for I think it's four days, they have shown at least a modest improvement in their ability to to clear lactic acid when they bring it to the ana anaerobic threshold or a very high intensity. So I think this, you know, again, I think we're covering a topic here today that it reaches into not only areas of medicine, but into sports performance. And I think it's uh we're at the front of the wave here with this. I think this will be implemented into more disciplines you know, as we go forward. I you know, something like cancer treatment, to your point, where the mechanism is less understood and there you don't see quite the risk reduction that you do with other chronic diseases, maybe that'll be the last to adopt this as part of a, you know, an oncologist's approach. I that would be my feeling. But I but I think when you get into skeletal changes, skeletal muscular health, you get into that area, I just think there's unequivocal evidence now that it's a game changer. And I think that will those will be the first areas of medicine to adopt this. I don't can't tell you how many years that'll be. Yeah.

Evidence Links To Fatty Liver And Cancer

SPEAKER_00 55:08

To see that evolve. Uh so as we bring this home, John, I mean, my my takeaways are that um when you look at the epidemiology of chronic complex disease, and when you look at changes in the um the diet of Americans over the last three generations, there's no question that the prol value of the standard American diet as compared to more ancestral approaches uh day-to-day tends to be higher. And and no one can deny the correlations between that attribute, that change, and the growing and ongoing growing prevalence of chronic complex disease. Uh the um the other takeaway for me is that while this this is real, the the opportunity largely in terms of reducing acid-producing foods, prawl foods, would be to focus more on the grains, refined grain, sugar, processed foods, uh with without immediately going to the animal protein, though I think good sources of that animal protein are important. The processed meat will not be the same as a nice pasteure finished piece of beef. Um, but that that assuring adequate protein, as you emphasized, and then reducing um uh processed foods and the grains, flour, uh would be one great opportunity on the reducing acid-promoting foods. And then, of course, you know, the corollary to that is getting more alkalinizing foods, whether that comes in the form of many of the foods that you emphasize, the plant-based foods, avocados, um, you know, swish chard and you know, um uh tomatoes. Uh and um really that is the uh uh you know one really nice way of creating better balance with respect to this acid alkaline uh connection. And then lastly, uh, you know, considering checking, monitoring pHs of one's urine, I think can be really helpful, just to give you a sense of of what your acid load might be. Your kidneys will reveal that to you, and and those patterns might be helpful as you play with foods that you're eating in relationship to that. So those are a few of my temples, John.

SPEAKER_01 57:48

Absolutely. I love that. Give yourself a litmus test, you know? I mean, and that's what those pH strips are basically going to do. Just do it for a week. And then you should really be able to dial in, you know, what your acid load is, at least for the night before, maybe even the whole day before. And then the other thing is, uh, you know, I'm a big fan of making shakes and smoothies. I do that and I try to make them really high protein. I, you know, I make most of my protein shakes are 50 or 60 grams of protein in a 24-ounce bottle, but I make sure that I I weave in like a couple really high potassium foods. And and avocados are easy to throw in the blender. Um, but you've got other really good choices too, whether it's a handful of spinach. I mean, you know, and what some people might benefit from, Mark, and I'll just leave our listeners with this, is there are so many different powders now that give you varying milligrams of potassium or potassium citrate. You know, I think LMNT is something that a lot of people use. I think it's a thousand milligrams of potassium in one of those little sachets. That's, you know, that's gonna have significant contributions in terms of neutralizing acid and in and helping reduce the prowl for that smoothie, that shake that you make, or whatever. So, you know, take some of those real heavy hitters and weave them into your shaker bottle or your blender. And like you said, you know, get a sense for where you're at, either by looking at the total day and what foods you had that might be high in potassium, or try to try to find the balance there. But I think those pH strips are great. And I, you know, I think that's really um, really a great tool for people to consider using for at least a again, a short period of time. Not like you got to do it for the next two years, just do it for a week. Great stuff, though, man. Great stuff.

SPEAKER_00 59:30

Great stuff. And and we hope this was of some value to um to our Health Edge listeners. Uh, all of uh the many papers that we reference that are open source, we will have available on our website, the health edgepodcast.com. Um, if um you want to uh check out the videos, our our YouTube channel, uh obviously you can see all the content there. Uh, we'll also have the slide deck on our website. And always a lot of fun, John, and always learning experience i absolutely i always absolutely i'm grateful for you i'm grateful for you buddy love you yeah yeah love you too john this is uh it feels really good to share and to and to uh connect and so thank you for that and uh we wish our uh health edge listeners well be well stay well and don't forget to love yourself and uh join we'll see you next week sounds great buddy