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Acid-Base Balance
for your patients - naturally!
SCIENTIFIC INFORMATION
(English Translation)
Acid-Base-Balance
for your patients – naturally!
SCIENTIFIC INFORMATION
(English Translation)
2nd edition 2008
PASCOE VITAL GmbH
D-35383 Giessen
Tel. 0641/7960-0 · Fax 0641/7960-123
[email protected] · www.pascoe-vital.de
All rights, including copying, reproduction, photomechanical
reproduction and translation are reserved.
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CONTENTS
CONTENTS
LATENT HYPERACIDITY ............................................................................... 6
OSTEOPOROSIS AND NUTRITION ............................................................ 26
Insidious, unnoticed, with no clinical symptoms ........................................ 6
Osteoporosis is among the 10 most economically significant
widespread diseases .......................................................................... 26
PRINCIPLES OF THE ACID-BASE BALANCE ................................................... 7
Our skeleton – more than just our external frame.................................... 28
Buffer systems ensure that physiological pH-values are kept constant .......... 9
Bone fulfils an important function: it acts as a reservoir
for protons and bicarbonate dispensers ............................................... 29
How an acid particle is eliminated depends upon
whether it is a volatile or a fixed acid ................................................... 10
Carbon dioxide is a volatile acid and is
eliminated via the lung........................................................................ 13
Protons are fixed acids and are eliminated by the kidneys....................... 13
Bone fulfils its important function as a buffer at the
expense of its mineral density .............................................................. 30
Hyperacidity increases with age,
but acid elimination capacity declines ................................................. 32
The connective tissue functions as the transport
route between the cell and the blood .................................................... 14
When diet alone is no longer enough to protect the bones ...................... 35
The bicarbonate buffer is the most important extracellular buffer .............. 15
The excretory organs adapt their metabolism to the conditions................. 17
BASENTABS pH-balance PASCOE® –
natural bicarbonate for effective deacidification ..................................... 37
WHEN THE ACID-BASE BALANCE IS DISTURBED ........................................ 20
APPENDIX ............................................................................................... 42
The pH-value becomes derailed: acidosis and alkalosis .......................... 22
Frequently asked questions .................................................................. 42
A protein-rich diet lacking in fruit and vegetables can
cause latent hyperacidity..................................................................... 24
International specialist literature extract ................................................. 46
The acid burden caused by a food can be quantified: PRAL .................... 24
Glossary ........................................................................................... 56
Chronic latent acidosis causes brittle bones ........................................... 25
Literature ........................................................................................... 60
4
Bicarbonate: protective shield for the bones .......................................... 36
Food table......................................................................................... 54
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LATENT HYPERACIDITY
PRINCIPLES OF THE ACID-BASE BALANCE
LATENT HYPERACIDITY
PRINCIPLES OF THE ACID-BASE BALANCE
Insidious, unnoticed, with no clinical symptoms
The end products of metabolism in the form of hydrogen ions (protons, H+)
feature thus in the acid-base theory: the concentration of hydrogen ions
(protons, H+) is the measure for the pH-value.
Living is a metabolic process. Our whole body undergoes continuous renewal,
which can adapt dynamically to meet external demands. The energy and the
nutrients required for these renewal processes are obtained from nutrition. In
the course of this, depending on the metabolic status, various end products are
produced, some of which must be eliminated. Acids (acid valences, protons)
are one of these endproducts . Normally our body manages to dispose of
these acids, because it has a variety of mechanisms for maintaining the equilibrium of the acid-base balance. The acid particles migrate from the site of
their production– the cells – through the connective tissue into the blood and
from here are transported to the kidneys or the lung.
If excess acids are constantly being produced in our metabolism, more and
more acid particles crowd on to the motorway in our body, resulting in a traffic jam in the elimination process: the acids remain in the connective tissue and
overtax the body’s buffer systems. The consequences are insidious: there are
no clinical symptoms as yet. The pH-value of the blood is still in the physiological range and the buffering capacity in the blood is not yet decreased. However, this is only possible because bones and muscles step in as buffers, in
order to maintain the buffering capacity in the blood. This condition is known
as latent acidosis, tissue acidosis or hyperacidity. We are now right in the
middle of the acid-base balance of the body. Since it is regulated by a complex interaction, the main features of the process should be outlined here to
provide a refresher and improve understanding:
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pH=-log [H+]
H+
pH
1
3
5
7
acid
9
neutral
11
13
alkaline
Fig.1: The definition of the pH-value
The lower the pH-value, the higher the concentration of free H+ ions. The
pH-value scale comprises values from 0 to 14, where a pH-value of 7 is
classified as neutral. In pure water (at 25 °C), 10–7 mol/L hydrogen ions
are present, because water is present not only in the form of H2O, but also
always to a small extent in the dissociated form, i.e. as a proton (H+) and
a hydroxide ion ( OH- ).
H2O
H+ + OH–
The negative decadic logarithm of 10–7 is pH 7. Stronger acids release more
protons in solution, and strong acids release all protons; the pH-value is lowered, and the solution becomes acid. If the relative proportion of H+ ions
decreases, the pH-value rises, and the solution becomes alkaline.
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PRINCIPLES OF THE ACID-BASE BALANCE
PRINCIPLES OF THE ACID-BASE BALANCE
Constant pH-values in the blood, cells and the individual organs is essential,
since fluctuations in the pH-value affects many metabolic processes, such as
the structures of proteins and those of the connective tissue. The bioavailability
of oxygen, the permeability of the membranes and the distribution of electrolytes also change depending on the pH-value.
Saliva
pH 6,7 – 7,2
Intracellular
pH 6,9 (ca.)
Skin
pH 5,5
Blood plasma,
connective tissue fluid
pH 7,35–7,45
Milk
pH 6,6–
Gastric juice
pH 1,2–3
Sweat
pH 6,6–7,0
Pancreatic
secretion
pH 8,6
Urine
pH 6,9 (ca.)
Deviations from the physiological pH-values therefore result in serious malfunctions. In order to avoid this, the body has various regulation mechanisms:
Buffer systems ensure that physiological pH-values are
kept constant
The pH-value is regulated both by buffer substances and by physiological
processes, which include respiratory immediate control and slowly adapted
renal processes. The buffer systems are closely linked and are found on an
organic, intra- and extracellular level. Buffers are mixtures of weak acids and
their corresponding bases, which can release or absorb release protons. This
does not alter their concentration in the solution, so that the pH-value does not
change.
The buffer capacity is a measure of how many H+- or OH–- ions can be added
without changing the pH-value. The acid burden at first causes a reduction in
buffer capacity. Only when large quantities of acid are added the buffer
capacity is exhausted and the pH-value changes.
The buffer capacity is highest in the range around the pKS value (+/-1) of the
acid. This is the pH-value at which the acid and its corresponding base are
present in the same concentration. Thus it describes a state of equilibrium between acid and base. As soon as the ratio between the acid and its conjugated
base shifts, the buffer capacity falls.
Intestine
pH 4,8–8,2
Stool in healthy person
pH 5,5–6,5
Fig. 2: Physiological pH-values in our organism
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PRINCIPLES OF THE ACID-BASE BALANCE
PRINCIPLES OF THE ACID-BASE BALANCE
How an acid particle is eliminated depends upon whether it
is a volatile or a fixed acid
Acids are produced in the human organism in the energy metabolism or in the
renewal, degradation and construction reactions as end products.
Aerobic
Carbohydrates
Glucose
Fats
Fatty acids
Proteins
Amino acids
CO2 + H2O
anaerobic
Carbohydrates/Amino acids
Lactic acid
(lactate)
Glucose
deficiency
Fatty acids
Keto acids
Sulphur-containing amino acids
N groups of amino acids
Other
catabolic
processes
Purines
Nucleic
acid
Under aerobic conditions fats, proteins and carbohydrates are burned
to within the cell to CO2 und H2O for the purpose of obtaining energy. The
CO2 continues to be used to a minor extent in the metabolism for carboxylation reactions, but it is mainly released via the lung as a so-called volatile acid.
So-called fixed acids are also produced in cell metabolism by nitrogen, sulphur and phosphorous compounds. However, these fixed acids cannot be
eliminated by respiration via the lung and therefore have to be eliminated by
the kidneys.
Sulphuric acid
(H2SO4)
Ammonium ions
(NH4+)
Uric acid
Pyrimidines
Ammonium ions (NH4+)
Phosphate
Phosphoric acid (H3PO4)
Fig.3: Metabolic end products are often acids
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PRINCIPLES OF THE ACID-BASE BALANCE
PRINCIPLES OF THE ACID-BASE BALANCE
Carbon dioxide is a volatile acid and is eliminated via
the lung
Nutrition and metabolism
Cheese
H+
H+
H+
H+
H+
Meat/
sausage
Grainproducts
Milk/
yogurt
H+
H+
H+
H+
Fruit/
vegetables
H+
H+
H+
H+
H+
CO2
Blood pH-value
HCO3-
CO2 penetrates the cell membrane and after passing through the intercellular
substance migrates into the blood vessels. Now an important intracellular protein buffer comes into play here: haemoglobin.
CO2 diffuses from the blood into the erythrocytes and is immediately converted by carbonic anhydrase into bicarbonate and a proton. While the bicarbonate temporarily migrates into the blood plasma and can become active as a
buffer substance, the ferrous haemoglobin in the erythrocytes acts as a buffer
for the protons produced during their transport to the lungs. In the lungs bicarbonate again penetrates the red blood cells, where it is converted back into
CO2 in the reverse reaction by carbonic anhydrase and can be eliminated by
respiration as a gas. Under physiological conditions, the respiratory protons
pose no problem to the body, since the corresponding base is immediately
produced at the same time and is also available to the body as a buffer at the
time of transport.
Kidney
Lung
Bicarbonate buffer system
HCO3-
CO2
CO2
+
OH-
H+
H+
Protons are fixed acids and are eliminated by the kidneys
H+
Protons take the following pathway to elimination:
HCO3-
Metabolically active cell
Connective tissue
Blood
Connective tissue, bone and muscles
Excretory organ
(liver, kidney, intestine, lung, skin)
Fig. 4: Physiological regulation of the blood pH-value
Fig. 5: The route of protons to the kidney
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PRINCIPLES OF THE ACID-BASE BALANCE
PRINCIPLES OF THE ACID-BASE BALANCE
In the cell system
The most important intracellular buffer is the phosphate buffer; sources are for
example ATP, ADP and sugar phosphates.
H3PO4
H+ + H2PO4–
HPO42– + 2H+
PO43– + 3 H+
The connective tissue functions as the transport route between the cell and the blood
In the connective tissue
On the way between the cell and the blood, the protons pass through the
extracellular space (also known as: matrix, extracellular matrix, Pischinger’s
space, interstitial space). The proteoglycans and glycoproteins of this connective tissue with their many negatively charged groups act as ion exchangers
and stationary buffer substances. This means that protons can accumulate
on these connective tissue molecules. They can “park” here until the blood and
the elimination organs have enough free buffer capacity to transport the
protons away.
Structure of a
proteoglycan
H+
H+
H+
In the blood
The blood buffers help to transport the protons to the excretory organs and are
primarily responsible for keeping the blood pH-value constant. A high buffer
capacity in the blood ensures on the one hand the stability of the blood pH is
kept constant even under extreme burdens and on the other hand the removal
of the protons “parked” in the connective tissue. The blood has four buffer
systems altogether: the bicarbonate and phosphate buffer, the haemoglobin
and plasma proteins. Many proteins can absorb and release protons; in
particular the imidazole ring of the amino acid histidine. Plasma proteins are
extracellular buffer proteins.
The bicarbonate buffer is the most important extracellular
buffer
CO2 + H2O
H2CO3
HCO3– + H+
The pK-value of the bicarbonate buffer is 6.1, thus below the adjusted pHvalue of 7.4 in plasma. The highest buffer capacity would thus be expected at
a pH-value of 6.1. This applies to a closed system. However, the bicarbonate
buffer functions as an open system in conjunction with the lungs and the kidneys: on the one hand the bicarbonate concentration is regulated by the change in respiratory frequency. On the other hand, the kidneys are flexible in
adjusting their elimination rate for fixed acids.
H+
H+
H+
H+
H+
H+
Negatively charged glycoproteins
bind H+ in the connective tissue
Fig. 6: Proton binding in the connective tissue
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PRINCIPLES OF THE ACID-BASE BALANCE
Lung ventilation
PRINCIPLES OF THE ACID-BASE BALANCE
The degradation of weak organic acid anions, such as lactate and citrate,
occurs even when bicarbonates are produced, which can thus be made
available for the blood buffer.
Normal
CO2
CO2 + H2O
H2CO3
HCO3- + H+
Blood
CO2
Cell metabolism
Fig. 7: The bicarbonate buffer as an open system
The bicarbonate buffer is the most important blood buffer, thus it can be said
that the pH-value of the blood depends on the ratio HCO3– and pCO2:
pH-value ~ HCO3–/pCO2 (according to Henderson-Hasselbach equation)
The major importance of this buffer system lies in the fact that the two buffer
components can be regulated independently of each other and by different
organs:
The concentration of HCO3 by the kidneys and the liver and that of CO2
by the lungs.
In the liver
Metabolisation of organic acids takes place in the liver. This is directly linked
with nitrogen degradation. The conversion of nitrogen compounds is determined by the current pH-value: if sufficient buffer base, that is, bicarbonate is
present, 2 molecules of ammonia and 2 molecules of bicarbonate are bound
together into urea. However, if there is a bicarbonate deficiency, the ammonia
is bound to keto acids, producing glutamine, and the buffer base is thus conserved.
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The excretory organs adapt their metabolism to the
conditions
In the lung
The lung is responsible in conjunction with the erythrocytes for the elimination
by respiration of volatile acids in the form of CO2. The respiratory frequency
can be quickly adjusted (extreme case: Kussmaul breathing). However, since
one molecule of bicarbonate is used up with every proton eliminated by
respiration, the buffer capacity of the blood decreases in excessive CO2
respiratory elimination.
In the kidney
The kidneys help to eliminate fixed acids, namely inorganic acids such as
phosphoric and sulphuric acid, uric acid and ammonium ions. Only around
1 % of protons to be eliminated is eliminated in free form. The majority is regulated via the kidney buffer. The ammonia/ammonium buffer deals with
around 60 % of the acids which occur: this buffer is produced in the renal cells
themselves: via the enzymatic degradation of glutamine (s. Fig. 8).
The second buffer in the kidney is the phosphate buffer. Around 30 % of
protons are eliminated by this.
H+ + HPO42–
H2PO4–
Bicarbonate is absorbed at the same time as the H+ elimination.
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PRINCIPLES OF THE ACID-BASE BALANCE
PRINCIPLES OF THE ACID-BASE BALANCE
Ammonia/ammonium buffer
Na
NH3 + H+
NH4
H+
Phosphate buffer
Na2HPO4
H+
Glutamin
CO2 (5) H O
2
Renal cell
HCO3Cl –
Na+
-
HCO3
Exchanger
(4)
K+
(1)
K+
H2CO3
NH3
NH3
Stomach lumen
Mucosa
Blood
+
H+
(2)
K+
H+ Pump
H+
Cl –
H+
Cl –
NaH2PO4
(3)
Cl –
Parietal cell
Renal cell
Bicarbonate absorption
HCO3- + H+
H+
CA
H2O + CO2
Tubulus
Na+
H+ + HCO3-
Fig. 9: The alkaline flood
HCO3-
CA
H2O + CO2
Renal cell
CA -Carbonhydrase
Fig. 8: The elimination of protons in the renal cell
In the stomach
Parietal cells in the stomach are responsible for the production of stomach acid
(HCl). They are governed hormonally (e.g. gastrin, histamine) and vegetatively via the parasympathetic system (vagus nerve).
18
While hydrochloric acid is released into the stomach lumen, NaHCO3 arises
at the same time and in adequate quantities. As a result the intracellular pHvalue can be kept constant. The bicarbonate is released by the parietal cells
into the blood. At the same time together with mucin it forms the gastric mucosa, which can protect the cells from autodigestion. The phenomenon of the
release of bicarbonate into the blood has been demonstrated in numerous
studies and is described as the alkaline flood. The measurement of this alkaline flood can also be used to determine acid secretion.
In the intestine
After passage through the stomach, the acidic chyme is neutralised with help
from the bicarbonate of pancreatic secretions. If neutralisation is not sufficient,
the enzymes, which have their pH-optimum in the alkaline range at approx.
pH 7-8, will not function adequately.
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WHEN THE ACID-BASE BALANCE IS DISTURBED
WHEN THE ACID-BASE BALANCE IS DISTURBED
WHEN THE ACID-BASE BALANCE
IS DISTURBED
Lung ventilation
Respiratory acidosis
CO2
The physiological blood pH-value is about 7.4; the laboratory normal range
has been set at pH 7.36 to 7.44. However, if the pH-value in the blood falls
below 7.35, this is referred to as manifest acidosis; if the pH-value in the
blood rises above 7.45, this is called manifest alkalosis. The acute condition
of a disturbance in the acid-base balance can be diagnosed on the basis of its
clinical symptoms and the clearly measurable deviation from the blood normal
values. Manifest or clinical acidosis is life-threatening and must receive immediate intensive medical treatment.
Depending on the cause of the change in the pH-value, a distinction is made
between respiratory and metabolic acidosis or alkalosis.
Lung ventilation
CO2 + H2O
H2CO3
HCO3- + H+
Blood
CO2
Cell metabolism
Fig. 11: Schematic diagram of respiratory acidosis
Respiratory acidosis always occurs when the respiratory elimination of carbon
dioxide is disturbed. The CO2 partial pressure in the alveoli and in the (arterial) blood increases, the buffer equilibrium is shifted to the right and thus an
excess of H+ occurs.
Metabolic acidosis
CO2
CO2 + H2O
H2CO3
HCO3- + H+
Blood
CO2
Cell metabolism
Fig. 10: Schematic diagram of metabolic acidosis
If the renal elimination of H+ is less than the metabolic H+ occurrence, the lung
must increase its CO2 respiratory elimination. Metabolic acidosis is the name
given to metabolism-related hyperacidity. It develops as a result of an increase
in the number of protons occurring in the body’s metabolism or their reduced
elimination or a loss of bicarbonate.
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WHEN THE ACID-BASE BALANCE IS DISTURBED
WHEN THE ACID-BASE BALANCE IS DISTURBED
The pH-value becomes derailed: acidosis and alkalosis
ACIDOSIS
ALKALOSIS
The condition in which the buffering capacity of the blood is severely reduced,
but no clinical symptoms are yet present, is known as compensated clinical
acidosis: the acid excess is intercepted, but the body buffers fewer and fewer
acid particles. The tissue acidosis or hyperacidity, also referred to as latent
acidosis, characterises a situation in which the pH-value of the blood lies
within the physiological normal range and also the buffering capacity of the
blood is reduced only slightly or not at all as yet, but a chronic acid flood
demands a high quantity of bicarbonate for buffering. In the long term, the
body turns to other endogenous buffer reserves: bones and muscles.
BUFFER
Respiratory acidosis
• Bronchial asthma
• Pneumonia
Respiratory alkalosis
• Hyperventilation
• Pregnancy
Metabolic acidosis
• Diabetic ketoacidosis
• Anaerobic metabolism
• Stomach drainage
• Hepatic, pancreatic,
renal insufficiency (age)
• Sepsis / Inflammation
• Diarrhoea
• Hunger / Fasting
• Intoxication
Metabolic alkalosis
• Increased metabolism of
lactate, citrate
• Loss of acid as a result of
vomiting, fever
A variety of symptoms are associated with hyperacidity in natural and empirical medicine. These include muscle and joint pain, increased susceptibility to
allergies, inflammatory reaction or increased susceptibility to infections in the
area of the mucous membranes and caries. For much of these there is as yet
no scientific evidence of a causal connection. The importance of a well-regulated acid-base balance is increasingly recognised and is reflected in an everincreasing number of scientific publications in renowned scientific journals.
Here osteoporosis, osteoarthritis, diabetes, gout and kidney stones are to the
fore. Ongoing clinical studies continue to focus on the development of latent
acidosis under severe physical stress, such as for example high-performance
sports.
Fig. 12: Causes of acidosis and alkalosis
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WHEN THE ACID-BASE BALANCE IS DISTURBED
A protein-rich diet lacking in fruit and vegetables
can cause latent hyperacidity
On the other hand, there is ample evidence to show that the diet plays an
important role in the acid-base balance: a diet rich in meat and protein causes
a permanent acid burden. Fruit and vegetables – although not vegetable foodstuffs in general– contain alkaline minerals, which form bases and thus unburden the acid-base balance. Grain products, however, are among the acidifiers. How therefore can one make reliable statements about acid burden?
The acid burden caused by a food can be quantified: PRAL
The scientists Thomas Remer and Friedrich Manz developed a model which is
reasonably able to estimate the potential renal burden, i.e. the net acid elimination of the kidney, caused by food. From this the food source tables indicating PRAL-values (in mEq/100 g) were developed. Only the primary effects on
the acid-base balance are reflected. This means: only those effects are considered which the food has on our body as a result of its chemical composition
and its rate of absorption. Positive PRAL-values indicate that more acids arise
in the balance as a whole than are used in the organism. According to this,
cheese, meat and fish should be regarded as potent acidifiers; negative PRALvalues mean that the metabolism of these foods is base forming. Many types
of fruit and vegetables are included in this group. The complete table can be
consulted in the Appendix.
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WHEN THE ACID-BASE BALANCE IS DISTURBED
With the help of a similar calculation model, prehistoric diets were compared
to today’s diet and analysed. Interestingly, the past diet had a far greater meat
portion than today’s diet, and yet it resulted in alkaline nutrition. Our modern
diet, because of its high proportion of grain products, refined sugar and hydrogenated/saturated fats and the low consumption of fresh fruit and vegetables, is unable to counteract acidic meat and protein consumption. In comparison to prehistoric diets, today’s foodstuffs are rich in sodium chloride and low
in potassium and bicarbonate and their precursors.
Today‘s Western nutritional habits should be regarded very critically, because
they may have long-term negative effects on the health of our bones:
Chronic latent acidosis causes brittle bones
In 1994 Sebastian et al. reported in the renowned New England Journal of
Medicine that even in normal endogenous acid production, a chronic burden
exists for bone under Western nutritional patterns. This chronic burden increases the risk of osteoporosis through the loss of bone substance. Osteoporosis
is a skeletal disease which is characterised by inadequate bone strength. This
inadequate bone strength predisposes to an increased risk of fracture. If osteoporosis is present and one or more fractures have occurred as a consequence
of the osteoporosis, this is referred to as manifest osteoporosis.
25
OSTEOPOROSIS AND NUTRITION
OSTEOPOROSIS AND NUTRITION
Osteoporosis is among the 10 most economically significant
widespread diseases
But it is not only the economic consequences which make clear the importance
of the prevention of osteoporosis. In the first years, bone loss usually progresses
without symptoms. But then the personal life of suffering begins for the person
affected by osteoporosis; often with symptoms of the spinal column. Initially
sharp back pain caused by a vertebral fracture is often not associated with the
disease, because the vertebral fracture is not detected. If there are several fractures in the spinal column, the posture changes up to the extreme of hyperkyphosis (“dowager’s hump”). Respiration is restricted and gait steadiness is reduced,
because the field of vision is restricted. In addition, the risk of suffering a fracture
for example of the wrist increases, even in minor falls. In the worst case, the hip
is broken simply by stumbling over the edge of a rug. This means long periods
spent in hospital and even longer periods of recovery. One third of those affected die within the following year from the consequences of the fracture, and
a further third becomes disabled.
Osteoporosis is the crunch point of the Western way of life, so to speak. As well
as a diet rich in meat, sausage and processed food, many of the features of our
modern lifestyle are risk factors for the development of osteoporosis: smoking,
lack of exercise, alcohol consumption. If hip fractures have occurred within the
family, the risk for this disease also increases.
Compromising our bone health means significant damage to our quality of life.
An estimated 75 million people in Europe, the USA and Japan are affected by
osteoporosis. On average almost one woman in four over the age of 50 and
one man in eight over the age of 50 in the industrialised countries develops
osteoporosis.
UNO and WHO have classified it among the 10 most economically significant
widespread diseases of the 21st century.
The costs of osteoporosis for Germany were presented in 2006. According to
this, the costs of osteoporosis amount to 5.4 billion euros annually. They are thus
on a par with those caused by diabetes or ischemic heart disease. The largest
proportion of the costs at 56 % arises from the in-patient treatment of more than
300,000 fractures per year.
Our skeleton – more than just our external frame
For many of us, our skeleton is simply our external static frame. It enables us
to walk upright and, in conjunction with muscles and tendon, makes it possible
for us to move. It also provides protection from injury for important organs
such as the brain, the heart and the lungs. These functions are obvious, and
we always become aware of them when we feel a stiffness somewhere: frozen
shoulder, a strain in the back and pain in the foot for example after unaccustomed movement. In the worst case, the unexpected broken rib caused by violent sneezing, when the bone has already become brittle. But our bones fulfil
more than just the obvious functions: they are storage organs for minerals,
OSTEOPOROSIS AND NUTRITION
There are a number of more recent studies which show the relationship between an unbalanced diet and osteoporosis:
• Diet-induced subclinical acidosis is now recognised as a significant,
pathophysiological factor in the development of osteoporosis (Tucker
2003).
• Heaney documents how the type and quantity of protein consumed affects
bone health (Heaney et al. 2007).
• Thorpe et al. (2008) relate protein consumption to bone density and found
that high protein consumption correlates positively, but high protein-sulphur
consumption results in lower bone density. This study also highlights the
fact that the type of protein is important for bone density.
• There is a linear relationship between calcium elimination and net acid
elimination (Fenton et al. 2008). Increasing acid elimination means higher
calcium loss.
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27
OSTEOPOROSIS AND NUTRITION
which are accessed as required: almost the entire store of calcium (98 %) and
around three quarters of the body’s phosphate is found in our over 200 bones.
The complete stock of bones is remodelled during the entire course of life. Up
until puberty, bone formation predominates, whereas in adulthood there is an
equilibrium between formation and degradation, and essentially the existing
bone is remodelled. Up to 20 % of bone is replaced annually. Three different
cell types are involved in this bone remodelling: bone-forming osteoblasts,
bone-degrading osteoclasts and osteocytes, which are responsible for the
transport of nutrients. In the healthy body the activities of the osteoblasts and
osteoclasts are in balance. The osteoblasts build the organic basic structure
from collagen fibres and amorphous intracellular substance. The inorganic
components are then stored in this organic frame: fluorapatite, carbon apatite,
calcium carbonate and magnesium carbonate. The inorganic main component is hydroxylapatite Ca10(PO4) (OH) , which is essentially composed of
6
2
calcium and phosphate and forms a store for them. In total, around 65% of a
bone is composed of inorganic components, 25 % of organic components and
10 % water.
The regulation of bone metabolism is subject to various influences. Thus tensile
and pressure loads e.g. through sport cause bone to thicken in the direction of
the load and to strengthen for future stresses. The sex hormones oestrogen and
testosterone also play an important role, as well as parathormone and calcitonin. The latter have an important function in ensuring a constant Ca2+ level in
the blood and regulate as antagonists either the storage or the mobilisation of
calcium ions in or from the bone.
28
OSTEOPOROSIS AND NUTRITION
Bone fulfils an important function: it acts as a reservoir for
protons and bicarbonate dispensers
One aspect which has hardly featured in the standard literature to date is the
important function of bone as a reservoir for protons and bicarbonate dispensers; it thus supports the acid-base balance of our organism as a buffer.
Bone acts as a local buffer by collecting excess protons. In this context it is
important to bear in mind that the physiological blood pH-value of arterial blood
is 7.40 and that of venous blood is pH 7.36. However, the pH-value of the
extracellular fluid around the bone cells is assumed to be below 7.36 and runs
as a gradient depending on the metabolic activity of the cells and their distance
from the next capillary.
How and where does bone collect protons?
There are negative charges on the surface of the bone, to which Na+, K+, und
H+ ions are flexibly bound. If the pH-value falls to below 7.4 – which means of
course that the absolute quantity of free H+ increases – the Na+ and K+ ions are
exchanged for the free protons. The blood or the immediate extracellular fluid
is relieved of the acid. However the bone loses sodium and potassium ions. At
the same time calcium and carbonate is released from the bone. Around two
thirds of the calcium present in the bone are firmly bound. However, one third
can be released at any time into the systemic circulation. Calcium carbonate
is dissolved out of this store. The carbonate ions can now buffer further protons
in the blood; increased levels of calcium are eliminated renally.
29
OSTEOPOROSIS AND NUTRITION
OSTEOPOROSIS AND NUTRITION
Bone fulfils its important function as a buffer at the expense
of its mineral density
This is first of all a purely physicochemical reaction without the involvement of
the bone cells. The illustration (13) shows schematically the exchange mechanism cation against proton on the surface of the bone:
Ca
2+
Na+
CO32-
K+
On the one hand the inhibition of bone-forming cells results in a decrease in
collagen synthesis. At the same time the calcium influx is reduced, which is
important for apatite formation. On the other hand acid stimulates bone-degrading osteoclasts, which are also activated by an increased release of parathormone. To sum up, this means a shift of bone remodelling processes towards bone loss; there is a loss of bone substance, which is associated with
increased calcium elimination and is reflected in reduced bone density.
HPO3H+
H+
H+
H+
acidosis
H+
Bone
H+
H+
H+
PO43-
Alkaline salts
Buffer acidosis
30
Ca2+
-
HCO3
Fig.13: The physicochemical response in the bone metabolism to metabolic
acidosis: (Krieger et al. 433)
In the event of longer-term hyperacidity, cell-mediated calcium release also
takes place: acid has a counter effect on the activity of the various bone cells:
the activity of the osteoblasts is inhibited and that of the osteoclasts is increased. At a physiological pH-value of 7.4 the osteoclasts are practically inactive.
If the pH-value falls to 7.1, their activity increases rapidly and remains at
around the same level as pH-values fall. Even at a pH-value of 6.3, at which
the survival rate of the osteoclasts is reduced, effective loss of bone substance
takes place.
Mineral
Absorption
CO32-
Osteoporosis
-
H2PO4
Kidney
Calcium is eliminated
with the urine
Ca2+
Fig. 14: Effects of chronic latent acidosis on bone metabolism
31
OSTEOPOROSIS AND NUTRITION
OSTEOPOROSIS AND NUTRITION
A: Blood concentration H+
44
Blood [H+] (neq/L)
Hyperacidity increases with age, but acid elimination
capacity declines
Hyperacidity increases with age, but acid elimination capacity declines.
The problems of latent acidosis are exacerbated with increasing age. An adult
with a typical Western diet already has low-grade chronic metabolic acidosis.
The extent of this acidosis increases with age.
Renal function also declines with the process of aging. Thus on the one hand
the acid burden is increased, but on the other hand its elimination capacity
declines.
42
40
38
36
34
160
140
120
100
80
60
r= 0,38
p<0,001
B: Blood concentration HCO3Plasma [HCO3-] (neq/L)
GFR (ml/min/70 kg)
180
r=-0,69
p<0,001
28
26
24
22
20
20
40
60
80
Age (years)
Frassetto, Morris et al., Am J Physiol (1996) 271, F1114-1122
Fig. 15: Renal elimination capacity declines with increasing age
r= 0,47
p<0,001
80
100
120 140
GFR (ml/min/70 kg)
160
Frassetto, Morris et al., Am J Physiol (1996) 271, F1114-1122
Fig. 16 A+B: The effect of renal function on the concentration of H+ and HCO3-
32
33
OSTEOPOROSIS AND NUTRITION
OSTEOPOROSIS AND NUTRITION
When the kidney reduces the H+ elimination for a longer period, the lung can
delay, but not prevent, the occurrence of acidosis. In persistent acidosis there
is the threat of demineralisation of the bone. The effect of diet-related hyperacidity is thus even more pronounced on bone metabolism with increasing age
and contributes to the risk of osteoporosis.
This thesis is validated by the results of a worldwide survey (33 countries) on
the incidence of hip fractures in women over the age of 50 (Frassetto, Nash et
al. 2000). A highly significant positive correlation was shown between proportion of fruit and vegetable consumption and the occurrence of hip fractures
(varied greatly between e.g. 0.8 (Nigeria) and 200 (Germany) per 100,000
inhabitants/year).
A: Blood concentration H+
Blood [H+] (neq/L)
44
42
40
38
36
34
r= 0,40
p<0,002
26
In this context there is also discussion about the decrease in muscle mass as a
result of exhausted glutamine reserves in the kidney cells: in order to be able
to eliminate the increasing numbers of acids via the ammonia buffer, ammonia
has to be produced in the intracellular metabolism. Glutamine acts as a source. If its reserves are exhausted, it receives additional deliveries from the muscle tissue.
24
When diet alone is no longer enough to protect the bones
Plasma [HCO3-] (neq/L)
B: Blood concentration HCO328
22
20
r= 0,40
p<0,002
20
40
Age (years)
60
80
Even if the population has become more diet-conscious according to a nutritional report of 2004, and the requirement of the German Nutrition Society
(DGE) – five portions of fruit and vegetables a day – has in many cases sunk
in, the implementation stills leaves a lot to be desired, partly because today’s
lifestyle has booked a regular date with fast food meals. Mineral bicarbonate
can help to supplement our diet so that hyperacidity can be avoided or counteracted.
Fig. 17 A+B: The effect of renal function on the concentration of H+ and HCO3-
34
35
OSTEOPOROSIS AND NUTRITION
OSTEOPOROSIS AND NUTRITION
Bicarbonate is the body’s own natural, main buffer
substance
BASENTABS pH-balance PASCOE® – natural bicarbonate for
effective deacidification
Because: Bicarbonate is produced during the absorption of nutrients from the
parietal cells and is released in the duodenum to neutralise stomach juices. In
addition, bicarbonate is necessary as a buffering substance in the blood and
is constantly used here. As a result, carbon dioxide is produced, which is eliminated by respiration via the lungs. In order to keep the bicarbonate pool of
the organism at a constant level, it has to be continually replenished. Ideally
directly, in the form of bicarbonate.
BASENTABS pH-balance PASCOE® fulfil all the requirements for professional,
effective deacidification. They are a mineral dietary supplement and contain
a balanced alkaline mixture of bicarbonates and carbonates with the additional of alkaline magnesium. Calcium and magnesium are present in an ideal
ratio of 3:1. Thus in addition to the natural blood buffer bicarbonate they also
provide the important building block calcium to maintain bone health: BASENTABS pH-balance PASCOE® work exactly like the body’s own bicarbonate. The body’s own bicarbonate is the most important physiological buffer
substance and is thus ideal for naturally reducing the intracellular and extracellular acid burden. Bicarbonate does not have to be metabolised first in order to be effective.
Bicarbonate: protective shield for the bones
The positive effect of bicarbonate on bone health has been proved by numerous scientific studies:
• An improvement in the bone density of postmenopausal women was
demonstrated after supplementation of bicarbonate (Sebastian, Harris et al.
1994). After 18 days of supplementation of oral sodium bicarbonate the
clearly negative balance for calcium and phosphorus was reduced.
A decline in bone loss and an increase in bone formation were measured
with the aid of metabolic markers of bone metabolism.
BASENTABS pH-balance PASCOE® have a very high acid-binding capacity
(16.12/g) particularly in comparison with “lifestyle preparations” such as Basica hot and cold powder (3.45/g), Basica vital (0.82/g), Basica instant
(0.75/g) and Basica compact tablets (10.82/g) (measurement of PASCOE
September 2008).
• In a 3-year study the same group showed that this effect lasted for a long
period of time (Frassetto, Morris et al. 2005).
• An intervention study with high and low protein consumption also showed
that administration of sodium carbonate at a level of 5.85 g per day halts
calcium loss.
• Bicarbonate clearly reduced calcium elimination and bone loss in men and
women over the age of 50 years.
Bicarbonate can thus protect against latent acidosis and reverse a negative
balance in calcium elimination. In this way bicarbonate can prevent loss of
bone substance.
36
37
OSTEOPOROSIS AND NUTRITION
OSTEOPOROSIS AND NUTRITION
Productt/Manufactur
Acid-binding capacity (SBK)
United States Pharmacopeia XXX, Method 301
(as at: September 2008)
PASCOE
VITAL
PASCOE
VITAL
Delta
pronatura
M.C.M.
Klosterfrau
Frisenius
Medical Care
Delta
pronatura
Protina
Pharm.
Nestmann
Pharma
Nestmann
Pharma
Protina
Pharm.
Protina
Pharm.
Protina
Pharm.
Protina
Pharm.
16,55
16,14
13,95
12,52
4,75
3,45
BASENTABS PASCOE
BULLRICHs VITAL (powder)
TAXOFIT Basis plus (tablets)
11,82
BICANORM (tablets)
11,73
BULLRICHs VITAL (tablets)
10,82
9,20
BASENPULVER PASCOE
BASICA Compact (tablets)
NEMABAS (tablets)
• Bicarbonates support the natural alkaline flood, which occurs in the blood
physiologically after meals. Citrates are removed from the blood
circulation very quickly after being taken.
• Bicarbonates remove acids which have accumulated in the connective
tissue. Citrates are not suitable for reducing this acid burden.
• Citrates have to be metabolised; they are as it were a preliminary stage of
bicarbonate and also have a calorie burden.
• Bicarbonates therefore act more quickly than citrates.
• Bicarbonates are safe: the body has a high capacity to regulate
bicarbonate floods.
NEMABAS (citrate powder)
BASICA hot + cold (powder)
BASENTABS pH-balance PASCOE® are
0,82 BASICA VITAL
• small tablets and therefore easy to swallow
0,75 BASICA (instant)
• free from flavourings, colourants and preservatives,
0,44 BASICA (Sport)
0
There are also products on the market for nutritional supplements which are
composed on the basis of alkaline citrates. Bicarbonates have many advantages in comparison with these:
2
4
6
• sugar, lactose, and gluten free
8
10
12
14
16
18
Acid-binding capacity (milli equivalente / g)
Fig. 18: The acid-binding capacity of BASENTABS pH-balance PASCOE®
• suitable for children older than 4 years
• permitted for use in pregnant and lactating women
• low-calorie (less than 1 kcal per daily dose)
Each pack of BASENTABS pH-balance PASCOE® also contains
21 pH-teststrips to determine the pH-value of the urine. These are used to
• very quickly and simply establish whether an acid-base imbalance is
present and
• directly check success after taking BASENTABS pH-balance PASCOE®.
38
39
OSTEOPOROSIS AND NUTRITION
OSTEOPOROSIS AND NUTRITION
This is how to produce the daily profile of the urine pH-values:
Between three and five urine pH-measurements should be taken spread over
the course of the day: Ideally the values lie within the white curve. Before
breakfast and in the evening the values are in the acid range. This is normal.
During the day however they should be in the alkaline range, i.e. higher than
the pH-value of 7. The pH-values fluctuate in the course of the day. If the pHvalues are in the acid range during the day as well, this is a clear indication
that the patient is hyperacidic or the kidneys can eliminate only insufficient
acid.
pH 5.6 – 6.8 = acid
pH 7.0
= neutral
pH 7.2 – 8.0 = alkaline
pH values
BASENTABS pH-balance PASCOE® and BASENPULVER pH-balance PASCOE®
supply important minerals such as calcium, magnesium, sodium and potassium, for cell function, the muscles and to strengthen the bones. One daily dose
(6 tablets) supplies almost half the daily calcium requirement and more than
half the daily magnesium requirement.
For optimum efficacy 2-3 BASENTABS pH-balance PASCOE® are taken 3
times daily after meals with plenty of fluid. BASENPULVER pH-balance
PASCOE® is stirred into water and drunk once daily.
Time of day
Fig 19: Daily profile of urine pH-value
40
41
APPENDIX I
Frequently asked questions
When should alkaline agents be taken?
Whether alkaline supplements should be taken with food or strictly outwith
mealtimes is a subject which is variously propagated and discussed. Taking
them with meals does cause partial neutralisation of the necessary stomach
acid and an increased development of carbon monoxide in the stomach,
which can manifest as eructation. But it has the advantage of the bicarbonate
and the minerals being mixed with the food, so that physiological conditions
prevail for the absorption of nutritional components. Practitioners have observed that adding alkaline agents to food is well tolerated by most people– something like a rebound effect is assumed, that is, stimulated gastric juice production after neutralisation. Nevertheless it is generally recommended that
they are taken after meals so that – especially in subacid patients – there is no
danger of neutralisation of stomach acid.
How can I detect if my patient is hyperacidic?
There are various possibilities for detecting hyperacidity. However, there is
unfortunately no direct diagnosis of the acid burden of the connective tissue.
Acid-base titration according to Sander
5 urine samples are taken at defined times and sent in a shipping tube with a
stabilising agent to a laboratory, which carries out the acid-base titration according to Sander. Here the buffering capacity of the urine is measured, which allows conclusions to be drawn about the buffer reserves of the whole organism.
A diurnal curve is produced from the measured values (rhythmic change of the
acid-base flood) and the average acidity quotient (indication of the degree of
acid burden) is calculated.
42
APPENDIX I
Blood gas analysis according to ASTRUP
This method allows very precise conclusions to be drawn about the acid-base
balance, but it has the disadvantage that he parameters to be examined are
very unstable and therefore the sample must be examined at once.
Anion gap in serum (also in 24 h urine)
Sodium and potassium ions make up 95 % of serum cations. Chloride and
bicarbonate ions represent 85 % of serum anions. The difference between
measurable cations and anions is referred to as the anion gap, which corresponds mainly to organic and inorganic acids, phosphate and anionic proteins. Acidosis results in an enlargement of the anion gap, and alkalosis in a
reduction.
Provocation test
This test was described at the beginning of the last century by van Slyke: One
tablespoon of bicarbonate, taken in the morning, must cause clear alkalisation
of the urine in the course of the following hours. If the urine pH-value does not
change, hyperacidity is assumed, because this is a sign that the body urgently
needs the buffer base and is therefore retaining it.
Daily profile of the urine pH-values
Measuring the urine pH-value is a practicable and low-cost option, if only of
limited validity. One-off measurements of pH-value have no validity. A daily
profile should be produced with at least 5 urine pH-measurements: upon rising, 2–3 hours after main meals, before lunch and in the evening. The measured pH-values should fluctuate clearly, that is, be subject to a Circadian
rhythm (around pH7); if the pH-value is permanently below 7, or is rigidity
detected (the pH does not fluctuate at all in the course of the day), then this is
a clear sign that the patient is hyperacidic or the kidneys can eliminate only
insufficient acid.
43
APPENDIX I
The daily profile should be produced over several days, and in addition the
time and type of meals should be documented.
Why do some alkaline powders not taste good?
Alkaline mineral salts naturally taste somewhat soapy. Of course it is possible
to add substances to the agents which change the taste. However, this restricts
the alkaline effect to some extent, and the risk of intolerance is increased. If the
user has a strong aversion to the taste, taking the agents with fruit juice or similar is a good alternative.
Does everything which tastes sour also have an acidifying
effect on the organism?
APPENDIX I
Sugar and coffee: acid- or alkali-forming?
Sugar is shown in the food table as a neutral food. However, in public discussion sugar is often denounced as an acid-forming food. So what is the truth?
In the food table according to Remer and Manz, the so-called PRAL-values are
listed. They indicate the estimated potential renal acid load (PRAL in mEq/100
g). Only the primary effects on the acid-base balance are reflected. This means
that only those effects are considered which the food has on our body as a result
of its chemical composition and its rate of absorption.
Secondary effects of the food such as the effect of sugar on the intestinal
flora cannot be taken into account here. The effects of coffee on the vegetative
nervous system and the consequences for the metabolism are also not
considered here.
A foodstuff is acid-forming when more acid than alkaline compounds are formed during its metabolism. This taste is not decisive here. Thus both lemons
and pickled cabbage are alkali-forming, whereas sugar, cereals, eggs, meat
and cheese, which do not taste sour, are acid-forming. The liver produces bicarbonate from weak organic acids – but only under aerobic conditions. They
therefore have an alkali-forming, and not an acidifying, action.
Can one overdose on alkaline agents and thus become
alkaline?
Clinically manifest cases of alkalosis have only been described as metabolic or
respiratory alkalosis. There are no indications that these states can be achieved
by alimentary administration. The body has many mechanisms for eliminating
surplus of alimentary alkalis. In particular the kidneys have a high capacity to
eliminate excess bicarbonate. The lungs and the liver also affect the concentration of bicarbonate.
44
45
APPENDIX II
APPENDIX II
Origins and evolution of the Western diet: health implications
for the 21st century
Origins and evolution of the Western diet: health implications for
the 21st century. Cordain et al., Am J Clin Nutr 81:341-354 (2005)
There is growing awareness that the profound changes in the environment
(e.g., in diet and other lifestyle conditions) that began with the introduction of
agriculture and animal husbandry 10,000 years ago occurred too recently on
an evolutionary time scale for the human body to adjust.
Many of the so-called diseases of civilization have emerged in conjunction
with this discordance between our ancient, genetically determined biology
and the nutritional, cultural, and activity patterns of contemporary Western
populations. In particular, food staples and food-processing procedures introduced during the Neolithic and Industrial Periods have fundamentally altered
7 crucial nutritional characteristics of ancestral human diets:
1. glycaemic load
5. acid-base balance
2. fatty acid composition
6. sodium-potassium ratio
3. macronutrient composition
7. fibre content
4. micronutrient density
The evolutionary collision of our ancient genome with the nutritional qualities
of recently introduced foods may underlie many of the chronic diseases of
Western civilization.
46
The effects of acid on bone
The effects of acid on bone. Bushinsky, D. A. and K. K. Frick (2000).
Curr Opin Nephrol Hypertens 9(4): 369-79.
A constant systemic pH-value is necessary to maintain stable physiological
conditions. However, in a number of diseases (such as chronic diarrhoea, renal insufficiency etc.) the acid levels increase or the alkaline level is reduced,
resulting in metabolic acidosis, which can only be corrected by the elimination
of acid.
The bone makes a substantial contribution to the maintenance of stable pH
conditions by releasing alkaline minerals, but the long-term cost is the mineral
content and the stability of the bone. In an acute metabolic acidosis the buffer
function of bone can be confirmed in vivo by the release of sodium,
potassium, calcium and carbonation from the bone and by the increase in the
serum calcium concentration. Because 98% of the total calcium content is in
bone and, for example, in the case of renal insufficiency intestinal calcium
reabsorption is not increased, an increase in the serum calcium concentration
in metabolic acidosis is primarily the result of release of calcium from bone.
This paper describes the measurement of the effects of acid on bone with the
assistance of an in vitro test model. In conjunction with the postulated buffer
function of the bone, metabolic acidosis changes the composition of minerals
in the bone. The decrease of sodium, potassium, carbonate and phosphate
results in buffering of acid and therefore an increase in the systemic pH-value
in physiological conditions. The altered bone mineral composition is primarily
caused by physical-chemical solution processes, and where the effects of acid
are prolonged also by changes in the function of bone cells. The bone exercises its buffer function at the cost of its store of minerals.
47
APPENDIX II
Effect of age on blood acid-base composition in adult humans:
role of age-related renal functional decline
Effect of age on blood acid-base composition in adult humans: role of agerelated renal functional decline. Frassetto, L. A., R. C. Morris, Jr., et al. (1996).
Am J Physiol 271(6 Pt 2): F1114-22.
The acid-base balance is primarily regulated by acid excretion from the kidneys, which are able to adapt to the endogenous net acid load resulting from
nutrition. Because renal function is significantly reduced with increasing age,
age-related metabolic acidosis can be expected, which over the long term,
can result in serious diseases such as osteoporosis.
This study was conducted to establish a relationship with age, based on evaluation of acid-base parameters of the blood and to investigate the effects on
regulation of the acid-base balance.
Method: 64 patients (39 men, 25 women) aged between 17 and 74 years
received one of nine diets with different endogenous acid production (approx.
25-150 mEq/day). After a preliminary phase of an average of 11 days,
blood samples were taken in the steady-state phase and the following parameters were tested: pH, carbon dioxide partial pressure (pCO2), carbon dioxide
(CO2), sodium, potassium, chloride and creatinine. The urine samples taken at
the same time were tested for the following: pH, carbon dioxide (CO2), ammonium ions (NH4+), titratable acids, sodium, potassium, chloride, inorganic
phosphate and creatinine.
The bicarbonate concentration in the two sample types was calculated from
the total carbon dioxide content and the pH with the Henderson-Hasselbach
equation. The renal net acid excretion (NAE) was measured from the total of
titratable acids and ammonium ions less the bicarbonate concentration in the
urine. The glomerular filtration rate (GFR) of the kidneys, based on a 70 kg
person, was determined from the 24 h creatinine clearance.
48
APPENDIX II
Results: There is a significant correlation between the age and the acid-base
balance of the blood in adults. With increasing age less acid is eliminated
renally and less bicarbonate is reabsorbed from the primary urine.
The pH of the blood increases easily within the normal range and the bicarbonate concentration in the blood decreases. A metabolic acidosis develops
slowly with increasing age and the chronic acid overload of the organism increases with it.
The age-related change in the acid-base composition of the blood is independent of the diet-related acid load and has a significant correlation with glomerular filtration rate as a marker of kidney function. A slight metabolic acidosis
can develop with a normal diet as a result of a slight decrease in the glomerular filtration rate. An initially diet-related metabolic acidosis can become more
serious with increasing age and accelerate physiological changes such as
bone and muscular metabolism and renal function. Older people in particular
must therefore be aware of a correct acid-base balance and sufficient intake
of alkaline nutrition.
49
APPENDIX II
Dietary intake and bone status with aging
Dietary intake and bone status with aging
Tucker, K. L. (2003). Curr Pharm Des 9(32): 2687-704.
Osteoporosis and related fractures represent major public health problems
that are expected to increase dramatically in importance as the population
ages.
Dietary risk factors are particularly important, as they are modifiable. However, most of the attention to dietary risk factors for osteoporosis has focused
almost exclusively on calcium and vitamin D. Recently, there has been considerable interest in the effects of a variety of other nutrients on bone status.
These include minerals (magnesium, potassium, copper, zinc, silicon, sodium),
vitamins (C, K, B12, A) and macronutrients (protein, fatty acids, sugars). In
addition, foods and food components, including milk, fruit and vegetables,
soy products, carbonated beverages, mineral water, dietary fibre, alcohol
and caffeine have recently been examined.
Prevention of osteoporosis by nutrition is a very complex topic. Previous results
have in some cases been contradictory. There is a great need to understand
the interactions of these factors within diets and on bone metabolism. Genetic
factors, which result in different reactions in different individuals, increase the
complexity of these effects.
Intensive research will perhaps make a more realistic contribution in future to
making effective recommendations for nutrition and prevention of bone loss
and osteoporosis in the aging population.
Intake of fruits and vegetables: implications for bone health
Intake of fruits and vegetables: implications for bone health.
Proc Nutr Soc 62:889-899 (2003) New SA,
Proc Nutr Soc 62:889-899 (2003) 1. Reviewed by IPEV© www.ipev.de
APPENDIX II
focus of increasing attention in literature in recent years. The role of bone in
the acid-base balance is of great interest in the area of osteoporosis. Natural
(e.g. starvation), pathological (diabetic acidosis) and experimental (intake of
ammonium chloride) states of acid load and hyperacidity are accompanied
by hypercalciuria and a negative calcium balance. The detrimental effect of
acid from the diet on bone minerals has only recently been demonstrated.
The most important findings: The net acid production depends on nutrition and
there is a quantitative relationship between the volume of acid produced
(indicated in the urine) and the volume of acid-forming substances in the diet.
The exact mechanisms of the destructive effects that acid has on the bone are
well-known. It has been demonstrated that a metabolic acidosis promotes
bone reabsorption by activation of mature osteoklasts and inhibits the growth
of new bone by osteoblasts. It has also been confirmed that excess acid
directly induces physical-chemical release of calcium from the bone.
It is surprising that for more than 30 years bone has been known to be the
source of buffer substances that are involved in maintaining the pH environment in the organism and also in defending the system against malfunctions in
the acid-base balance. However, only recently has the possibility of a positive
relationship between high intake of fruit and vegetables and the indices for
healthy bone been investigated.
The potential damaging influence of special nutrition has been investigated
based on the potential acid loading on the kidneys, which is particularly high
with many grains, some types of cheese and animal products. Some studies
conducted in the population published over the past ten years have demonstrated
that consumption of fruit and vegetables and intake of potassium has a
beneficial effect on the axial and peripheral bone mass and bone metabolism
in older men and in women before and after menopause. A detailed analysis
of those types of fruit and vegetables that have the greatest direct influence on
bone would appear necessary.
Background: The health benefits of high fruit and vegetable consumption and
the influence of this nutrition group on a variety of diseases have been the
50
51
APPENDIX II
The results of the DASH (Dietary Approaches to Stopping Hypertension) and
DASH potassium intervention studies provide additional reinforcement of the
positive relationship between fruit and vegetable consumption and bone
health. The DASH studies show that nutrition rich in fruit and vegetables with
low-fat dairy products and low consumption of red meat was associated with
a significant decrease in blood pressure compared to control groups, and that
the renal calcium excretion was reduced as a result of reduction of the acid
loading by increased consumption of fruit and vegetables.
The DASH sodium intervention study investigated three volumes of sodium
consumption (50, 100 and 150 nmol/l). It demonstrated that the DASH diet
reduced bone growth by 8-10% and bone reabsorption by 16-18% and sodium does not significantly influence the markers for bone metabolism.
The effects of a normal endogenous acid production on the bone were
investigated at the in vivo or cellular level in observations of clinical applications.
It was demonstrated that renal calcium and phosphate excretion decreased
and the calcium balance was overall less negative when alkaline potassium
carbonate was administered.
APPENDIX II
The data does not support the assumption that nutrition protein damages the
bone, because even women in the quartile with the lowest protein intake consumed protein volumes significantly above the average daily requirement
(82.5 g/day). The data demonstrate that the nutritional potassium is the deciding component. For example, nutrition types that have a lower acid loading
are associated with better indices for healthy bone.
Further studies: calcium plays a critical role in connection with the balance of
the beneficial and damaging effects of protein on the bone. Calcium supplements may be beneficial for bone not only because of the additional supply of
minerals but also because of the consumption of additional alkaline salts. Therefore, there is an urgent need to consider fruit and vegetable consumption
and the change of alkaline supplements in intervention studies on bone health
that evaluate the risk of fracture as the end point. Study of the existing data on
nutrition, bone mass and bone metabolism appears to be required to investigate the specific influence of the acid content of nutrition on bone.
Evidence: Determination of the acid-base balance of the consumed nutrition is
a useful method of making a quantitative determination of the relationship
between the acid-base balance and bone health.
Consumption of a normal Western diet results in a minor metabolic acidosis,
which is recorded by the endogenous net acid production (NEAP), which is
not the result of carbonic acid, and varies depending on nutrition. Frassetto et
al., Am J Clin Nutr 68:576-583 (1998) postulated a simplified model for
testing the net acid content of the nutrition by the ratio of acid-forming protein
(from sulphate excretion) and the alkalising effect of potassium (from the
supply of salts of weak organic acids such as citrate). If this theory is applied
to the baseline and longitudinally derived data sets of the Aberdeen Prospective Screening Study, it demonstrates that women with the lowest endogenous
net acid production have a higher bone density in the lumbar vertebrae and
hip bones and the renal excretion of the bone markers pyridinoline and
desoxypyridinoline is lower.
52
53
APPENDIX III
APPENDIX III
Food Table – PRAL-Values
Estimated acidic stress* of 114 frequently consumed foods and beverages (per
100 g).Modified from Remer and Manz. Journal of the American Dietetic Association 1995; 95: 791-797. *PRAL = Potential Renal Acid Load per 100 g of the
food, expressed in mEq = physico-chemical material unit.
Grain products
rye mixed-grain
bread
4,0
rye bread
4,1
wheat mixed-grain
bread
3,8
wheat bread
1,8
white bread
3,7
Cornflakes
6,0
rye crisp bread
3,3
egg noodles
6,4
oat flakes
10,7
rice, unhusked
12,5
rice, husked
4,6
parboiled rice
1,7
rye wholemeal
flour
5,9
PRAL-values reflect the level of acid-load:
distinctive negativ value = highly alkaline
distinctive positiv value = highly acidic
Blue
= alkali-forming foods
Orange = acid-forming foods
walnuts
6,8
herring
7,0
watermelons
-1,9
trout, roasted,
steamed
10,8
broccoli
-1,2
peas
spring carrots
-4,9
Fruits nuts and fruit juices
cauliflower
-4,0
-2,2
celery
-5,2
apple juice,
unsweetened
normal-strength
beer
apples, 15 sorts,
with skin, average
-2,2
Coca-Cola
apricots
-4,8
bananas
-5,5
chicory
-2,0
cucumbers
-0,8
aubergine
-3,4
leek
-1,8
ettuce, average of
4 sorts
-2,5
iceberg lettuce
-1,6
mushrooms
-1,4
onions
-1,5
peppers
-1,4
potatoes
-4,0
blackcurrants
1,2
-6,5
Beverages
-0,2
1,1
egg yolk
23,4
0,4
curd cheese
11,1
cacao, made of
skimmed milk
(3.5%)
-0,4
corned beef,
tinned
13,2
full fat soft cheese
4,3
19,2
frankfurter
6,7
hard cheese,
average of 4 sorts
coffee, infusion,
5 min.
-1,4
liver sausage
10,6
vanilla ice-cream
0,6
-1,8
luncheon meat,
tinned
10,2
pasteurised and
sterilised
1,1
lean pork
7,9
whole milk
0,7
rump steak, lean
and fat
8,8
Parmesan cheese
34,2
11,6
natural cheese
spread
28,7
salami
turkey
9,9
9,0
whole milk fruit
yoghurt
1,2
veal
natural whole milk
yoghurt
1,5
cherries
-3,6
grapefruit juice,
unsweetened
-1,0
mineral water
(Apollinaris)
hazelnuts
-2,8
mineral water
(Volvic)
-0,1
kiwi
-4,1
red wine
-2,4
lemon juice
-2,5
-0,3
-2,9
Indian tea,
infusion
radish
-3,7
spinach
-14,0
oranges
-2,7
Fats and oils
tomato juice
-2,8
peaches
-2,4
butter
0,6
tomatoes
-3,1
peanuts, untreated
8,3
margarine
-0,5
-4,6
-2,9
olive oil,
sunflower oil
0,0
dry white wine
-1,2
7,3
wheat flour
6,9
courgette
wholemeal wheat
flour
8,2
Pulses
pears, 3 sorts,
with skin, average
green beans
-3,1
pineapple
-2,7
Fish
3,5
raisins
-21,0
cod fillet
7,1
strawberries
-2,2
haddock
6,8
54
egg white
8,7
orange juice,
unsweetened
lentils, green and
brown, dried
8,2
7,8
wholemeal
spaghetti
-0,4
chicken egg
chicken
6,5
asparagus
1,2
lean beef
spaghetti
Vegetables
Meat and sausages
fresh and sour
cream
Milk, milk products and
eggs
buttermilk
0,5
camembert
14,6
Cheddar, reduced
fat content
26,4
Gouda cheese
18,6
full fat cottage
cheese
8,7
Sugar, preserves and
sweets
milk chocolate
2,4
honey
-0,3
Madeira cake
3,7
jam
-1,5
white sugar
-0,1
55
APPENDIX IV
APPENDIX IV
Glossar
Acids
Bases
According to Brönstedt, acids are proton donors. This means they release
hydrogen ions (H+) in solutions.
According to Brönstedt, bases are proton acceptors. This means they gain
hydrogen ions in solutions.
Acid-base balance
Buffer
This describes the regulation of protons and blood buffer which is so critical
for the functioning of the organism. It is a physiological term which takes into
account both absolute quantities of acids and bases and their reserves as
well as buffer capacity and/or acid-binding capacity.
Buffers are mixtures of weak acids and their corresponding bases, which can
release or gain protons without any change in their concentration in the solution, i.e. without their pH-value changing. Buffer capacity is at its highest in
the region around pK (+/-1) of the acid, i.e. when acid and base are at almost the same concentration.
Acid-base equilibrium
This is a purely physicochemical term indicating the relative ratio of H+ and
OH- without taking the absolute quantities of the ions into account. For
example, blood pH is maintained in equilibrium at pH 7.35-7.45. Outside
this range, acid-base equilibrium of the blood is disturbed.
Acidosis and alkalosis
Buffer capacity
Buffer capacity is a measure of how many H+ or OH- ions can be added
without changing the pH-value. Because of acid stress, initially buffer capacity is merely reduced. Only when large quantities of acid are added buffer
capacity is exhausted and changes in pH occur.
Acidosis and alkalosis should be considered as emergencies in intensive
medicine. A distinction is made between different forms of acidosis and
alkalosis.
Compensated acidosis/alkalosis
Respiratory acidosis
Metabolic acidosis
Occurs, when CO2 elimination is
decreased (pulmonary function
disorders, medicines such as
opioids, benzodiazepines)
Caused by severe renal, intestinal or
metabolic disorders
For example: diabetic ketoacidosis
opioids, benzodiazepines
This is the ion remaining after a disassociated acid has released its proton
(H2CO3
H+ + HCO3-).
Respiratory alkalosis
Metabolic alkalosis
Develops as a result of hyperventilation i.e. too high CO2 elimination,
which is often psychogenic but may
also result from various underlying
diseases
Is caused by hyperventilation and
loss of protons among other factors,
as a result of vomiting or gastric
drainage
56
Exhaustion of the buffer capacity in the blood.
Conjugate base
57
APPENDIX IV
APPENDIX IV
Glossar
Henderson-Hasselbach equation
pH
The Henderson-Hasselbach equation is also known as the buffer equation
and describes the acid-base balance of a partly dissociated, therefore weak,
acid or base in aqueous solution. Using this equation, the pH-value of the
bicarbonate buffer can be calculated as follows: pH=pKA + log (concentration HCO3-/concentration CO2).The pKA-value of the bicarbonate buffer is
6.1. A pH-value of 7.4 is achieved when bicarbonate concentration is 20
times higher than that of CO2. For log 20 = 1.3, which used in the equation
yields pH = 6.1 + 1.3 = 7.4.
The physiological concentration of bicarbonate is approx. 24 mmol/l and
that of CO2 in the blood 1.2 mmol/l.
The definition of pH is the negative base 10 logarithm of the hydrogen ions
in a solution. The lower the pH-value, the higher the concentration of free H+
ions. A pH-value of 7 is considered to be neutral. In pure water (at 25o C),
10-7 mol/l hydrogen ions are present, because water does not exist only in
the form of H2O, but is always present to a minor degree in its disassociated
form, i.e. as proton (H+) and hydroxide ion (OH-).
H2O
H+ + OHThe negative base 10 logarithm of 10-7 is pH 7. If the relative proportion of
H+ ions decreases, pH-value increases and the solution becomes alkaline.
Intracellular acidosis
Protons cannot be transported into the extracellular space as cell metabolism
is insufficient. However, this is difficult to detect.
Latent acidosis, acid stress
This does not refer to clinically manifest acidosis but to acid stress in tissues
and cells and/or incipient exhaustion of the buffer reserves. To differentiate
between this and pathological acidosis, it is more convenient to talk in terms
of acid stress or hyperacidity of the organism. Chronic acid stress can have
various consequences for health.
pCO2 value
The abbreviation pCO2 value stands for the partial pressure of carbon dioxide and indicates how much carbohydrate is dissolved in the blood.
58
pKa
This is the pH-value at which the acid and its conjugate base are present at
the same concentration. It describes a state of equilibrium between acid and
base. In the case of pure water, pH-value is also equivalent to pK-value. The
pK-value is always a specific constant for the corresponding acid-base pair.
When an acid releases more than one H+ ion, there are multiple pK-values.
Standard bicarbonate
To determine standard bicarbonate, a blood sample must be examined at
37oC, 100% acid saturation and a partial CO2 pressure of 40 mm Hg.
Reference values: 24 mmol/l.
Standard bicarbonate is unchanged in respiratory disorders. It deviates
when a non-respiratory disorder is present.
59
APPENDIX V
APPENDIX V
Literature
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APPENDIX V
NOTES
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• van Limburg Stirum, J. (2008): Moderne Säuren-Basen-Medizin, Hippokrates Verlag
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