Acid–Base Homeostasis and Skeletal Health: Current Thinking and Future Perspectives

  • Helen Lambert
  • Claire Huggett
  • Richard Gannon
  • Susan A. Lanham-New


We urgently need public health strategies to help with the prevention of poor bone health across the age ranges. It is especially useful to focus attention on factors that are amenable to change, with nutrition and exercise having clear potential. The aim of this chapter is to review the current evidence for a role of acid–base homeostasis in bone. Analysis of existing literature enabled a combination of observational, clinical, and intervention studies to be assessed in relation to dietary alkalinity, dietary acidity and bone health. Mechanisms of action for a dietary alkalinity “component” effect were examined, and the role that fruit and vegetables can play in bone health was addressed. Natural, pathological, and experimental states of acid loading/acidosis have been associated with hypercalciuria, and negative calcium balance and, more recently, the detrimental effects of “acid” from the diet on bone mineral have been demonstrated. At the cellular level, a reduction in extracellular pH has been shown to enhance osteoclastic activity directly, resulting in increased resorption pit formation.

A number of observational, experimental, clinical, and intervention studies have suggested a positive link between fruit and vegetable consumption and the skeleton. Further research is required, particularly with respect to the influence of dietary manipulation using alkali-forming foods on fracture prevention. There remain no long-term Dietary Approaches to Stop Hypertension (DASH) on bone health in younger and older age cohorts, and this is urgently required. Should the findings of the DASH/fruit and vegetable studies prove conclusive, a “fruit and vegetable” approach to bone health maintenance may provide a very helpful strategy for bone health development and maintenance throughout the life cycle.


Acid–base balance Dietary acidity Fruit and vegetables Bone health Muscle function Vegetarianism Protein Calcium Bone metabolism Vegans 


  1. 1.
    Goulding A. Nutritional strategies for osteoporosis prevention. In: New SA, Bonjour JP, editors. Nutritional aspects of bone health. Cambridge: The Royal Society of Chemistry; 2003. p. 709–32.CrossRefGoogle Scholar
  2. 2.
    World Health Organization. Assessment of osteoporotic fracture risk and its role for screening for postmenopausal osteoporosis, WHO technical report series. Geneva: WHO; 1994.Google Scholar
  3. 3.
    Green J, Kleeman R. Role of bone in regulation of systematic acid–base balance (Editorial Review). Kidney Int. 1991;39:9–26.PubMedCrossRefGoogle Scholar
  4. 4.
    Frassetto LA, Morris Jr RC, Sebastian A. Effect of age on blood acid–base composition in adult humans: role of age-related renal functional decline. Am J Physiol. 1996;271:F1114–22 (Renal Fluid Electrolyte Physiol 40).PubMedGoogle Scholar
  5. 5.
    Frassetto LA, Sebastian A. Age and systemic acid–base equilibrium: analysis of published data. J Gerontol. 1996;51A:B91–9.CrossRefGoogle Scholar
  6. 6.
    Goto K. Mineral metabolism in experimental acidosis. J Biol Chem. 1918;36:355–76.Google Scholar
  7. 7.
    Lemann Jr J, Litzow JR, Lennon EJ. The effects of chronic acid load in normal man: further evidence for the participation of bone mineral in the defence against chronic metabolic acidosis. J Clin Invest. 1966;45:1608–14.PubMedCrossRefGoogle Scholar
  8. 8.
    Barzel US, Jowsey J. The effects of chronic acid and alkali administration on bone turnover in adult rats. Clin Sci. 1969;36:517–24.PubMedGoogle Scholar
  9. 9.
    Arnett TR, Dempster DW. Effect of pH on bone resorption by rat osteoclasts in vitro. Endocrinology. 1986;119:119–24.PubMedCrossRefGoogle Scholar
  10. 10.
    Kreiger NA, Sessler NE, Bushinsky DA. Acidosis inhibits osteoblastic and stimulates osteoclastic activity in vitro. Am J Physiol. 1992;262:F442–8.Google Scholar
  11. 11.
    Arnett TR, Spowage M. Modulation of the resorptive activity of rat osteoclasts by small changes in extracellular pH near the physiological range. Bone. 1996;18:277–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Bushinsky DA. Metabolic alkalosis decreases bone calcium efflux by suppressing osteoclasts and stimulating osteoblasts. Am J Physiol. 1996;271:F216–22 (Renal Fluid Electrolyte Physiol).PubMedGoogle Scholar
  13. 13.
    Meghji S, Morrison MS, Henderson B, Arnett TR. PH dependence of bone resorption: mouse calvarial osteoclasts are activated by acidosis. Am J Physiol Endocrinol Metab. 2001;280:E112–9.PubMedGoogle Scholar
  14. 14.
    Bushinsky DA, Sessler NE, Glena RE, Featherstone JDB. Proton induced physicochemical calcium release from ceramic apatite disks. J Bone Miner Res. 1994;9:213–20.PubMedCrossRefGoogle Scholar
  15. 15.
    Wachman A, Bernstein DS. Diet and osteoporosis. Lancet. 1968;1:958–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Barzel US, Massey LK. Excess dietary protein can adversely affect bone. J Nutr. 1998;128:1051–3.PubMedGoogle Scholar
  17. 17.
    Remer T, Manz F. Potential renal acid load of foods and its influence on urine pH. J Am Diet Assoc. 1995;95:791–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Fox D. Hard cheese. New Sci. 2001;2329:42–5.Google Scholar
  19. 19.
    New SA, Macdonald HM, Reid DM, Dixon ASJ. Hold the soda. New Sci. 2002;2330:54–5 [Letter].Google Scholar
  20. 20.
    Heaney RP. Excess dietary protein may not adversely affect bone. J Nutr. 1998;128:1054–7.PubMedGoogle Scholar
  21. 21.
    Meyer HE, Pedersen JI, Loken EB, Tverdal A. Dietary factors and the incidence of hip fracture in middle-aged Norwegians. Am J Epidemiol. 1997;145:117–23.PubMedCrossRefGoogle Scholar
  22. 22.
    Dawson-Hughes B, Harris SS. Calcium intake influences the association of protein intake with rates of bone loss in elderly men and women. Am J Clin Nutr. 2002;75:773–9.PubMedGoogle Scholar
  23. 23.
    Heaney RP. Protein and calcium: antagonists or synergists? Am J Clin Nutr. 2002;75:609–10.PubMedGoogle Scholar
  24. 24.
    New SA, Millward DJ. Calcium, protein and fruit & vegetables as dietary determinants of bone health. Am J Clin Nutr. 2003;77:1340–1 [Letter].PubMedGoogle Scholar
  25. 25.
    Dawson-Hughes B. Calcium, protein and bone health. Am J Clin Nutr. 2003;77:1341 [Letter].Google Scholar
  26. 26.
    Frassetto L, Todd K, Morris Jr RC, Sebastian A. Estimation of net endogenous noncarbonic acid production in humans from dietary protein and potassium contents. Am J Clin Nutr. 1998;68:576–83.PubMedGoogle Scholar
  27. 27.
    Lemann Jr J, Pleuss JA, Gray RW, Hoffmann RG. Potassium administration increases and potassium deprivation reduces urinary calcium excretion in healthy adults. Kidney Int. 1991;39:973–83.PubMedCrossRefGoogle Scholar
  28. 28.
    Bushinsky DA. Decreased potassium stimulates bone resorption. Am J Physiol. 1997;272:F774–80 (Renal Fluid Electrolyte Physiology).PubMedGoogle Scholar
  29. 29.
    Sebastian A, Harris ST, Ottaway JH, Todd KM, Morris Jr RC. Improved mineral balance and skeletal metabolism in postmenopausal women treated with potassium bicarbonate. N Engl J Med. 1994;330:1776–81.PubMedCrossRefGoogle Scholar
  30. 30.
    Wood RJ. Potassium bicarbonate supplementation and calcium-metabolism in postmenopausal women – are we barking up the wrong tree. Nutr Rev. 1994;52(8):278–89.PubMedGoogle Scholar
  31. 31.
    Morris R, Masud T. Measuring quality of life in osteoporosis. Age Ageing. 2001;30(5):371–3.PubMedCrossRefGoogle Scholar
  32. 32.
    Sebastian A, Hernandez RE, Portale AA, Colman J, Tatsuno J, Morris RC. Dietary potassium influences kidney maintenance of serum phosphorus concentration. Kidney Int. 1990;37(5):1341–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Kraut JA, Coburn JW. Bone, acid and osteoporosis. N Engl J Med. 1994;330(235):1821–2.PubMedCrossRefGoogle Scholar
  34. 34.
    Ceglia L, Harris SS, Abrams SA, Rasmussen HM, Dallal GE, Dawson-Hughes B. Potassium bicarbonate attenuates the urinary nitrogen excretion that accompanies an increase in dietary protein and may promote calcium absorption. J Clin Endocrinol Metab. 2009;94:645–53.PubMedCrossRefGoogle Scholar
  35. 35.
    He FJ, Marciniak M, Carney C, Markandu ND, Anand V, Fraser WD, Dalton RN, Kaski JC, MacGregor GA. Effects of potassium chloride and potassium bicarbonate on endothelial function, cardiovascular risk factors, and bone turnover in mild hypertensives. Hypertension. 2010;55:681–8.PubMedCrossRefGoogle Scholar
  36. 36.
    MacDonald HM, Black AJ, Aucott L, Duthie G, Duthie S, Sandison R, Hardcastle AC, Lanham-New SA, Fraser WD, Reid DM. Effect of potassium citrate supplementation or increased fruit and vegetable intake on bone metabolism in healthy postmenopausal women: a randomized controlled trial. Am J Clin Nutr. 2008;88:465–74.PubMedGoogle Scholar
  37. 37.
    Marangella M, Di Stefano M, Casalis S, Berutti S, D’Amelio P, Isaia GC. Effects of potassium citrate supplementation on bone metabolism. Calcif Tissue Int. 2004;74:330–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Sakhaee K, Maalouf NM, Abrams SA, Pak CYC. Effects of potassium alkali and calcium supplementation on bone turnover in postmenopausal women. J Clin Endocrinol Metab. 2005;90:3528–33.PubMedCrossRefGoogle Scholar
  39. 39.
    Sellmeyer DE, Schloetter M, Sebastian A. Potassium citrate prevents increased urine calcium excretion and bone resorption induced by a high sodium chloride diet. J Clin Endocrinol Metab. 2002;87:2008–12.PubMedCrossRefGoogle Scholar
  40. 40.
    Appel LJ, Moore TJ, Obarzanek E, Vallmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336:1117–24.PubMedCrossRefGoogle Scholar
  41. 41.
    Barzel US. Dietary patterns and blood pressure. N Engl J Med. 1997;337:637 [Letter].PubMedGoogle Scholar
  42. 42.
    Lin P, Ginty F, Appel L, Aickin M, Bohannon A, Garnero P, Barclay D, Svetky L. The DASH diet and sodium reduction improve markers of bone turnover and calcium metabolism in adults. J Nutr. 2003;133(10):3130–6.PubMedGoogle Scholar
  43. 43.
    New SA. The role of the skeleton in acid–base homeostasis. The 2001 Nutrition Society Medal Lecture. Proc Nutr Soc. 2002;61:151–64.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  • Helen Lambert
    • 1
  • Claire Huggett
    • 1
  • Richard Gannon
    • 2
  • Susan A. Lanham-New
    • 1
  1. 1.Department of Nutritional SciencesUniversity of SurreyGuildford, SurreyUK
  2. 2.Department of Health and NutritionCentre de Recherche NestléLausanneSwitzerland

Personalised recommendations