High Protein Diet and Metabolic Acidosis: Health Risks Correlations

Protein, Optimal Diet, Paleo Diet

Low levels of metabolic acidosis is a common occurrence in the standard American diet. Most people are in a state of chronic acidosis and are not aware of it.
Milos Pokimica

Written By: Milos Pokimica

Medically Reviewed by: Dr. Xiùying Wáng, M.D.

Updated June 10, 2023

Key Takeaways:

– Western-style diet dominated by animal products promotes the accumulation of non-metabolizable anions.
– Even extremely mild levels of metabolic acidosis prompt serious health diseases like skeletal muscle insulin resistance and kidney failure.
– The acid burden might be a significant variable in the cardiovascular disease risk for the entire population on top of the risk of obesity.
– Calcium loss as a consequence of a high-quality animal protein-rich diet is a scientific consensus.
– Muscle wasting appears to be an adaptive response, to acidosis in calcium deficiency.
– Metabolic acidosis by itself is correlated to type 2 diabetes, hypertension, osteoporosis, connective tissue loss, fibromyalgia, hyperuricemia and gout, kidney function damage, and decline, kidney stones, dehydration, decreased exercise performance…
– Balance your DAL with fruits and vegetables if you don’t want to change your diet. Add nutrient-dense, mineral-rich, antioxidant-rich fruits and vegetables on the top of your SAD diet as a first step.

Standard American Diet.

The standard Western-type diet is a processed food-dominated diet with high levels of animal product consumption. This type of diet is severely lacking in not just green leafy vegetables but also in all types of nutrient-dense and antioxidant-rich whole food sources and contains extreme amounts of high-quality animal protein.

One of the results of this type of diet is the promotion and accumulation of non-metabolizable anions and a condition that significantly worsens in aging because of the physiological decrease in kidney function.

In response to this type of diet-induced metabolic acidosis, the kidneys will implement different metabolic pathways that aim at reestablishing the acid-base equilibrium.

This will have a negative health correlation in the long run.

Metabolic processes.

Some metabolic processes in diet-induced acidity (metabolic acidosis) include the extraction of the non-metabolizable anions, the preservation of citrate, and the increase in kidney ammoniagenesis and urinary excretion of ammonium particles.

These metabolic processes will bring down the urinary pH but will also promote a broad change in urinary synthesis, including hypercalciuria, hypocitraturia, and nitrogen and phosphate removal.

The negative side effect of this is the promotion of calcium stone development.

What is even worse than stones is the fact that even extremely mild levels of metabolic acidosis prompt serious health diseases like skeletal muscle insulin resistance and kidney failure.

Results of observational studies had proven the health risk correlation in insulin resistance and diabetes with all metabolic acidosis markers, including low serum bicarbonate, high serum anion gap, hypocitraturia, and low urine pH. Also, the acid burden might be a significant variable in the cardiovascular disease risk for the entire population on top of the risk of obesity (Adeva and Souto, 2011).

Most people when they hear “acid-forming food” just think about calcium loss not realizing the scope of the problem.

Calcium loss.

Calcium loss as a consequence of a high-quality animal protein-rich diet is a scientific consensus (Thorpe and Evans, 2011). And it is a reasonable hypothesis that by eating acid-forming food (like meat), our body will use calcium to buffer it and as a result, we were, fundamentally, in danger of urinating our bones out. This hypothesis was backed by the fact that when we do eat high protein diet we get an increase in urinary calcium concentrations.

Calcium testing showed in all situations that when we add high protein sources like meat or eggs or dairy the rise in calcium will correspond to the amount of protein added. The hypothesis due to the testing was introduced, and this was at beginning of the 20th century, that animal products, not just meat are acid-forming food. Later testing showed that plant-based whole foods are both acid forming and alkaline but mostly alkaline.

In acid reflux, people will use calcium pills to try to buffer the stomach acid so this is nothing new. Calcium carbonate (chalk) treats heartburn and upset stomach, or other conditions caused by too much stomach acid.

But what about the rest of the body in a standard American animal products-dominated diet?

Sulfur-containing amino acids.

Meat and eggs have a great deal of sulfur-containing amino acids. Amino acids are building blocks of protein and not all of them are made equal. Meat has two to in some cases four times more sulfur-containing amino acids than beans or grains for example and much more than in common vegetables.

That sulfur creates sulfuric acid by oxidation of protein, which needs to be neutralized by the kidneys (Brosnan & Brosnan, 2006).

There was even a debate about dairy for a long time because of this. Milk was considered to be a good source of calcium but also a source of protein that needs to be buffered by calcium. In the end, dairy might not be a good source of calcium when we calculate calcium loss due to metabolic acidosis.

One step further will be a question of how much calcium we need to consume on a standard protein-dominated Western diet if we have to calculate calcium loss.

If we don’t take enough calcium and calcium deficiency is a common deficiency then where will our body pull the calcium from? The logical answer will be from the bones.

This is especially problematic for people with already-developed osteoporosis. For every 40 grams of protein we add to our diet, and in the SAD (standard American diet) average is 90 grams a day, the loss of calcium in our urine will be around 50mg. If you are already calcium deficient or in a risk group for osteoporosis, this would translate into a two percent loss in a year. We just have around two pounds of calcium in total stored whiting our body including bones. Our bodies need 30 grams of protein at max rest of the protein goes for gluconeogenesis, around 60 grams in SAD. At average. That is 75mg a day of calcium loss multiplied by 365 is 27375mg of calcium loss. This is 27 grams and we have a total of around 2000 grams for about 1,5 to 2 percent of total loss annually.

If you are calcium deficient and on a high protein diet especially a high-quality protein diet this can be one of the problems. If you are not calcium deficient then the body will just pull more of the calcium from the diet as a defense mechanism (Calvez et al., 2011).

There was a study that proved that if there is calcium in the food our body will pull additional amounts to buffer the acids. They gave subjects radioactive calcium and also increased protein in their diet (Cao et al., 2011). Then scientists measure an increase in urinary calcium loss with a special emphasis on radioactivity.

The calcium loss did increase but all of the urinary calcium or most of it around 90 percent was radioactive.

An increase in dietary protein created an increase in calcium retention from 20% to 26%. There is still no consensus among scientists on how dietary protein helps calcium assimilation but if there is calcium in the meal it will be more bioavailable due to protein.

Calcium deficiency.

The problem arises in situations with already preexisting calcium deficiency.

One other problem is aging.

If there is already preexisting calcium deficiency where will our body pull additional calcium to buffer the acids and also what happens in aging? As we age our blood gets more acidic due to renal decline (Frassetto et al., 1996). The worst scenario is in patients with renal disease. They have strictly regulated protein intake monitored by certified dietitians.

In these situations, excess acids will be buffered from calcium that has to be pulled from our body, and the first on the line is not bone calcium.

It is pulled from the muscles.

Catabolism of the muscle tissue.

Catabolism of the muscle tissue will be a primary source for acid neutralization. Muscle wasting appears to be an adaptive response, to acidosis (Mann et al., 2021). When our body catabolizes muscle protein it would have a source of the amino acid l-glutamine that will come out of a catabolized protein (Gurina, 2022). Then it will use glutamine to neutralize acids.

Glutamine is a common anti-catabolic muscle-building supplement that bodybuilders like to use.

glutamine supplement — Glutamine supplement.

It might be a good idea if you don’t have an adequate intake of calcium to at least add glutamine as a supplement if for any reason you don’t want to decrease protein consumption. Also, glutamine is predominantly a renal gluconeogenic substrate, whereas alanine gluconeogenesis is essentially confined to the liver (Stumvoll et al., 1999). And no you cannot eat calcium carbonate chalk or any other mineral as a supplement. Minerals are only able to be fully bioavailable for biochemical processes if they are small enough in physical size or if they are in the monoatomic form that plants create.

glutamine kidney — Renal gluconeogenesis contributes 20 to 25% to whole-body glucose production Adapted from (Stumvoll et al., 1999).

In sarcopenia due to protein wasting in aging the common practice is to increase protein requirements for the elderly and also to add a calcium supplement. This is done because calcium is needed to buffer the metabolic acidosis that will be a consequence of an increase in dietary protein. If not corrected this low level of chronic metabolic acidosis will contribute to both osteoporosis and muscle wasting in old age.

For people eating SAD the amount of calcium needed to buffer acidity is a minimum of 800mg a day.

In correlation, African women in rural parts of the continent don’t get osteoporosis on average of 300mg of calcium a day. In aging, you don’t have to drink milk to get calcium or eat meat to get protein. Beans for example have as much protein as meat but are not acid-forming. Poppy seeds have 1,4 times more calcium in 100 grams than 1 liter of milk and sesame seeds have the same amount of calcium in 100 grams as 1 liter of milk. Grains and some seeds like sunflower seeds are mildly acidic, not at the same level as meat but also sunflower seeds are one of the rarely available sources of vitamin E and it is a must in most diet plans.

The one solution will be to stop eating a high-quality protein diet because there are other health risk factors correlated with it than just metabolic acidosis that can be easily corrected if it exists in the first place.

Dietary acid load (DAL).

In evolutionary terms, all hominin diets were plant-based. This means that our body unlike the bodies of carnivores species had not evolved to cope well with a chronic acid-forming diet. Hominin diets based on whole food plant-based sources were more base than acid-forming.

There are two categories basically.

Animal protein-rich foods that promote acid formation and metabolic acidosis and fruits and vegetables are base-inducing foods.

More about alkaline diets will be discussed in correlated articles. Dietary acid load (DAL) is calculated as the sum of all of the food we have eaten during the day. DAL is calculated based on the intake of acid-forming and base-forming foods, such as animal proteins and fruits and vegetables, respectively. Two common methods for estimating DAL are potential renal acid load (PRAL) and net endogenous acid production (NEAP). PRAL is based on the intake of protein, phosphorus, potassium, magnesium, and calcium, while NEAP is based on the intake of protein and potassium. DAL needs to be in normal ranges because it is correlated to more serious diseases like kidney damage, (Osuna-Padilla et al., 2019).

“Diets high in PRAL induce a low-grade metabolic acidosis state, which is associated with the development of metabolic alterations such as insulin resistance, diabetes, hypertension, chronic kidney disease, bone disorders, low muscle mass and other complications.“
(Osuna-Padilla et al., 2019)

Other correlations include independently of any other factor of insulin resistance and cardiovascular disease (Krupp et al., 2018),

“Diets rich in fruits and vegetables, like the Dietary Approaches to Stop Hypertension (DASH)-diet, are usually characterized by high potassium intake and reduced dietary acid load, and have been shown to reduce blood pressure (BP).”
“PRAL was significantly associated with higher systolic BP (p = 0.0002) and higher hypertension prevalence (Odds ratio [OR] high vs. low PRAL = 1.45, p = 0.0004) in models adjusted for age, sex, body mass index (BMI), estimated sodium intake, kidney function, relevant medication, and further important covariates. “
“Our results show, for the first time in a comparative analysis of a large representative population sample, significant relationships of BP and hypertension prevalence with questionnaire- and biomarker-based estimates of potassium intake and with an estimate of dietary acid load.“
(Krupp et al., 2018)

It is not just a question of calcium loss. You can read more about health risk correlations with a high protein diet in a correlated article about this (High protein diet- Health risk correlations).

Food source	PRAL value
Meat	9.5
Cheese	26.8
Eggs	8.2
Fruits	-3.1
Vegetables	-2.8

A positive PRAL value means that the food is acid-forming, while a negative PRAL value means that the food is base-forming. A lower PRAL value indicates a lower dietary acid load.

Metabolic acidosis health risk correlations:

When we consider just chronic low-level acidity caused by a Western-type diet without any other correlation, just metabolic acidosis by itself is correlated to (DiNicolantonio and O’Keefe, 2021):

Insulin resistance and type 2 diabetes.
Increased gluconeogenesis (conversion of amino acids to glucose).
Hypertension.
Bone loss in calcium deficient individuals.
Osteoporosis/osteopenia/sarcopenia in calcium deficient individuals.
Muscle loss and reduced muscle strength in calcium deficient individuals.
Connective tissue loss in calcium deficient individuals.
Fibromyalgia.
Hyperuricemia (too much uric acid in your blood) and gout.
Kidney function damage and decline.
Kidney stones independent from renal decline.
- Less citrate to bind to calcium and more calcium to oxalic acid increasing calcium oxalate stone formation.
- Reduced urine pH increasing uric acid stone formation.
- Negative sodium and chloride balance.
Salt loss and mineral deficiencies.
- Increased loss of sodium, chloride, potassium, calcium, magnesium, sulfate, and phosphate out of the urine.
- The sodium and potassium loss are due to a decrease in the reabsorption of these minerals by the kidneys, which likely reduces the reabsorption of taurine
- The loss of calcium, magnesium, and phosphate is from bone losses
Taurine loss
Increased water loss out of the urine.
- Dehydration.
Decreased exercise performance.

Low-grade acidosis.

Why low-grade acidosis is so common in the standard American diet:

The average diet in the Western world leads to a net acid excretion of 50–100 mEq/day.
The kidneys must be relied on to prevent low-grade acidosis as the lungs cannot affect acid-base status over the long run.
The kidneys of a healthy person can only excrete 40–70 mEq of acid per day before the acid is retained in the body.
Animal-based, keto, or carnivore-type diets typically provide 150–250 mEq of acid per day.
Once the kidneys reach their threshold approximately 1 mEq of acid is retained per 2.5 mEq of acid above the threshold.
If the diet does not contain enough bicarbonate (bicarbonate-forming substances or citrate) and minerals (sodium, potassium, magnesium, and calcium) to neutralize the excess acid then negative consequences to numerous bodily systems take place.

Solution:

The solution for this is simple as it can be. Balance your DAL with fruits and vegetables if you don’t want to change your diet. Add nutrient-dense, mineral-rich, antioxidant-rich fruits and vegetables on the top of your SAD diet as a first step. Add sesame seeds to your muesli and eat kale in salads and it would help your body to neutralize some of the metabolic acidosis. This will be a step to prevent acidity from the diet and nothing else. Add glutamine supplement.

Food	Calcium per serving
Poppy seeds (30g)	432 mg
Sesame seeds (30g)	201 mg
Chia seeds (30g)	189 mg
Calcium-fortified soy milk (200ml)	240 mg
Calcium-fortified oat milk (200ml)	240 mg
Calcium-fortified almond milk (200ml)	240 mg
Calcium-fortified coconut milk (200ml)	240 mg
Calcium-set tofu (100g)	350 mg
Kale (80g cooked)	185 mg
Figs (30g dried)	75 mg
Almonds (30g whole kernels)	81 mg

However, other health consequences of high-quality protein-dominated diets cannot be so easily avoided.

Conclusion:

A Western-style diet dominated by animal products promotes the accumulation of non-metabolizable anions.
This accumulation significantly worsens in aging because of the physiological decrease in kidney function.
In response to this type of diet-induced metabolic acidosis, the kidneys will implement different metabolic pathways that aim at reestablishing the acid-base equilibrium.
Metabolic processes in diet-induced acidity (metabolic acidosis) include the extraction of the non-metabolizable anions, the preservation of citrate, and the increase in kidney ammoniagenesis and urinary excretion of ammonium particles.
These metabolic processes will bring down the urinary pH but will also promote a broad change in urinary synthesis, including hypercalciuria, hypocitraturia, and nitrogen and phosphate removal.
The negative side effect of this is the promotion of calcium stone development.
Even extremely mild levels of metabolic acidosis prompt serious health diseases like skeletal muscle insulin resistance and kidney failure.
The acid burden might be a significant variable in the cardiovascular disease risk for the entire population on top of the risk of obesity .
Calcium loss as a consequence of a high-quality animal protein-rich diet is a scientific consensus.
Meat and eggs have a great deal of sulfur-containing amino acids.
That sulfur creates sulfuric acid by oxidation of protein, which needs to be neutralized by the kidneys.
If you consume a calcium-deficient diet and a high protein diet especially a high-quality protein diet additional calcium will be lost.
As we age our blood gets more acidic due to renal decline.
The worst scenario is in patients with renal disease.
Muscle wasting appears to be an adaptive response, to acidosis in calcium deficiency.
In sarcopenia due to protein wasting in aging the common practice is to increase protein requirements for the elderly and also to add a calcium supplement.
For people eating SAD the amount of calcium needed to buffer acidity is a minimum of 800mg a day.
Hominin diets based on whole food plant-based sources were more base than acid-forming.
Dietary acid load (DAL) is calculated as the sum of all of the food we have eaten during the day.
DAL needs to be in normal ranges because it is correlated to more serious diseases like kidney damage.
Animal protein-rich foods that promote acid formation and metabolic acidosis and fruits and vegetables are base-inducing foods.
Balance your DAL with fruits and vegetables if you don’t want to change your diet.

FAQ

A: Mild levels of metabolic acidosis can prompt serious health diseases like skeletal muscle insulin resistance and kidney failure. The acid burden might also be a significant variable in the cardiovascular disease risk for the entire population on top of the risk of obesity.

A: Some metabolic processes in diet-induced acidity (metabolic acidosis) include the extraction of the non-metabolizable anions, the preservation of citrate, and the increase in kidney ammoniagenesis and urinary excretion of ammonium particles.

A: Calcium loss is a consequence of a high-quality animal protein-rich diet. By eating acid-forming food (like meat), our body will use calcium to buffer it and as a result, we were, fundamentally, in danger of urinating our bones out. This hypothesis was backed by the fact that when we do eat high protein diet we get an increase in urinary calcium concentrations.

A: In response to this type of diet-induced metabolic acidosis, the kidneys will implement different metabolic pathways that aim at reestablishing the acid-base equilibrium. This will bring down the urinary pH but will also promote a broad change in urinary synthesis, including hypercalciuria, hypocitraturia, and nitrogen and phosphate removal.

A: Calcium testing showed that when we add high protein sources like meat or eggs or dairy the rise in calcium will correspond to the amount of protein added. In other words, an increase in urinary calcium concentrations is observed with a high-protein diet.

A: The scientific consensus is that calcium loss is a consequence of a high-quality animal protein-rich diet (Thorpe and Evans, 2011).

A: Sulfur-containing amino acids are building blocks of protein found mostly in foods such as meat and eggs.

A: Sulfur oxidizes protein and creates sulfuric acid.

A: Our kidneys need to neutralize sulfuric acid to maintain proper pH balance in our body.

A: Dairy was considered a source of calcium, but also a source of protein that needs to be buffered by calcium. This created a debate about whether dairy is a good source of calcium overall.

A: A high protein diet can cause calcium loss in urine, which can be detrimental for people who are already calcium deficient or at risk for osteoporosis or sarcopenia.

A: As we age, our blood becomes more acidic due to renal decline, which can further deplete our calcium levels.

A: Muscle wasting is the catabolism of muscle tissue as an adaptive response to metabolic acidosis.

A: Glutamine supplements may help neutralize acids produced through metabolic acidosis and prevent muscle catabolism.

A: The minimum amount of daily calcium needed to buffer acidity in people eating SAD is 800mg.

A: Yes, beans, grains, and seeds can provide protein without being acid-forming, and seeds like poppy and sesame can provide more calcium than milk.

A: Yes, chronic metabolic acidosis can contribute to both osteoporosis and muscle wasting in old age.

A: On average, African women in rural parts of the continent don’t get osteoporosis despite consuming an average of 300mg of calcium a day.

A: Correction of low levels of chronic metabolic acidosis is important in aging because it can contribute to not only osteoporosis but also muscle wasting.

A: There is still no consensus among scientists on how dietary protein affects calcium assimilation.

A: Dietary acid load (DAL) is the sum of all the acid-forming and base-forming foods consumed during the day, which are calculated using methods such as potential renal acid load (PRAL) and net endogenous acid production (NEAP).

A: Animal protein-rich foods promote acid formation, while fruits and vegetables are base-inducing foods.

A: Meat, cheese, and eggs have a positive PRAL value that indicates their acid-forming nature.

A: The solution is simple – add more fruits and vegetables to the diet to neutralize the excess acidity. Additionally, one can consume nutrient-dense, mineral-rich, antioxidant-rich foods such as sesame seeds and kale to avoid metabolic acidosis.

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About the Author

Milos Pokimica

Milos Pokimica is a doctor of natural medicine, clinical nutritionist, medical health and nutrition writer, and nutritional science advisor. Author of the book series Go Vegan? Review of Science, he also operates the natural health website GoVeganWay.com

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