I’m a pretty simple cook, but sometimes the simple things in life are the best. You don’t have to achieve great feats of molecular gastronomy to get a hearty nutrient dense start to the day.
This recipe is a simply egg and spinach fried up with some dill, some cream with the egg and coconut oil with the spinach for cooking.
The ‘secret’ here is to go heavy on the spinach. Spinach always gives an amazing nutritional profile.
Even with four eggs and 300g of spinach the end result is still very much ketogenic as well as being nutrient dense!
For some extra taste and you could throw in some mozzarella with the egg.
Whether you think eating alkaline foods is useful or woo woo junk it appears that metabolic acidosis is a thing.
Metabolic acidosis seems to be interrelated with insulin resistance, Type 2 Diabetes and retention of muscle mass.
To prevent metabolic acidosis it appears prudent to ensure that your body has adequate minerals to enable your kidneys to balance pH over the long term. This can be achieved by eating plenty of veggies and / or supplementing with alkaline minerals (e.g. magnesium, sodium, potassium, zinc etc).
If you eat plenty of veggies you’re probably getting enough alkalising minerals, however you can easily test your urine to see if your dietary acid load is high.
If you are targeting a high fat therapeutic ketogenic diet, following a zero-carb dietary approach and / or taking exogenous ketones it seems then it may be even more important to be mindful of your acid load and consider mineral supplementation.
some unique ketone and blood glucose results
Recently I had a very interesting, surprising and exciting experience during a fast. The chart below shows my ketones, glucose and ‘total energy’ (i.e. glucose plus ketones) over the seven days.
My ketones increased to above 8.0 mmol/L. They even couldn’t be read on my ketone metre!
I really did feel sky high on ketones!
It was the full keto brochure experience. It was like my body fat was effortlessly feeding my brain with delicious, succulent ketones! I felt great.
This chart shows my glucose : ketone index (GKI) dropping to below 0.5 after a few days.
The orange dots in this chart shows the relationship between glucose and ketones about 18 months ago when I first started trying this keto thing (after I read ‘Jimmy’s Moore’s Keto Clarity’). The blue dots show the relationship between my glucose and ketones during the recent fast. As you can see from the much flatter line, my blood glucose levels were lower and I could more easily access my body fat for fuel to manage my appetite.
The frustrating thing is that, thinking I was now a bonafide keto super hero, I’ve tried to repeat this feat of super ketones and perfect blood glucose levels without any luck! My ketones just didn’t go as high again!
So, what’s the go? What changed? What gives? What was it that let me trip with the magic ketone fairies in Keto Land for such a short period!
are ketones acidit?
So let’s rewind the story a little and give some context…
In July 2016, I got some blood tests. I’d been good with my diet, eating nutrient dense foods, with some fasting and intense exercise.
My HbA1c was great at 4.9% and the cholesterol markers were all good.
I went to see Elizma Lambert (pictured below), my family doctor / naturopath / friend / mentor / hero, with the simple request that I wanted to feel superhuman. I felt like I had been doing all the right things (e.g. good food, exercise etc) but not quite getting results that I was after (e.g. weight loss, energy levels, higher ketone levels).
Elizma said everything looked good but my blood tests indicated that I was acidic. But what does this mean?
You can see in the test results shown below that my uric acid levels are at the top of the normal range. High uric acid levels can be affected by fasting and exercise (i.e. lactic acid)[1] which may have influenced my test results.
My “other anions” test was at the top of the normal range.
I had also been using exogenous ketones occasionally around workouts leading up to these tests. I wondered whether they might contribute to the acidity.
My bicarbonate levels were on the low end which I’ve now learned suggests that I was running low on alkalising minerals (i.e. magnesium, calcium and potassium) for my kidneys to balance the acid load I was serving up with my exercise, diet and fasting.
My calcium and potassium were also on the lower end of the normal range.
So Elizma sent me away with a mineral mix of magnesium, potassium, N-acetyl Cysteine and Calcium-D-Glucarate to help with the acidity issue that she had observed in my tests and to help improve my fat metabolism.
I wasn’t sure what to expect, if anything. But after a couple of weeks of taking this stuff my brain felt really clear and sharp and I felt full of energy. I actually felt the superhuman energy and crispness that I’d been hoping for!
My blood glucose and ketone levels were spot on. And my hunger seemed to be massively reduced.
So, just for interest, I decided to see how long I could go without eating.
Seven days later I had some spectacular ketone readings.
As well as the alkalizing mineral mix, I was also taking some Celtic sea salt, Carnitine, Creatine and some alkalising green powder to keep my micronutrients up during the seven days. I was aware of keto experts like Steve Phinney advocating adequate electrolytes during keto or fasting and I wanted to give myself the best chance of surviving and keeping up with my day job as well as riding to work. I also started taking Nicotinamide Riboside which arrived on day four of the fast.
So unfortunately, it wasn’t a really well controlled experiment to understand which supplement during my ‘fasting’ had the biggest effect.
Towards the end, I ran out of the alkalising mineral mix and I spent the day in the sun at a birthday party with my daughter (pictured below on the last day… she knows how to pose for better for photos than me).
I started to feel a bit shabby, so I decided to eat.
I figured seven days was a good ‘achievement’.
Since then I’ve tried a number of four-day fasts with various supplements (i.e. the alkalising minerals, Nicotinamide Riboside, exogenous ketones, a ‘fat fast’ and Robert Miller’s MitoFuel) to understand what the magic ingredient was, but I haven’t been able to repeat the phenomenal ketone excursions.
I quizzed Elizma about what she thought might have happened. Could it simply be the alkalising mineral mix that causes the magic ketone fairies to visit me? She said:
Whether you call it resistance or stuck, the alkalizing minerals can open up a lot of enzyme pathways that work at more neutral pH levels, which means it’s like opening the door with a massive crowd outside.
Once the door is open everyone just rushes through (giving you those big readings), but the crowd eventually thins out and becomes a regular stream of customers walking through the door again.
Very interesting though. Every single person on ketogenic diet that I have tested have high acidity levels, which is natural considering that ketones are highly acidic, but it does mean it’s something to really look out for when ketogenic.
Hmmm… intriguing.
Then I came across a Ben Greenfield podcast with Yuri Elkaim where he talked about alkaline diets. It got interesting when Yuri started talking about the Potential Renal Acid Load which is based around the balance between the foods that leave an acidic residue (i.e. sulphur from protein and phosphorus) versus the foods that leave an alkaline residue once metabolised (i.e. magnesium, calcium and potassium).
Previously when I’d heard talk of alkaline foods I’d written it off as woo woo. But maybe this might explain the symptoms what I’d experienced (e.g. loss of appetite, high ketones, perfect blood glucose etc)? Given the fact that taking the magnesium, potassium and calcium supplements had worked wonders for me I was interested and thought I’d dig into the topic a little further.
Here’s a video from Yuri on the pros of the alkaline dietary approach. I’m not saying I’m advocating 100% of this, but it’ll give you an overview of some of the theory on alkaline diets from one of the less fringe advocates of the concept of alkalising.
let’s start with the basics
As I am prone to do, I went down a bit of a ‘rabbit hole’ looking at the research on this topic looking for answers trying to understand and explain my experience. In this article I have tried to explain my journey and learnings along the way.
So let’s start with the less controversial stuff. Basic biochem.
pH (or “potential hydrogen”) is a measure of the number of negatively charged hydrogen ions (H+).[2]
More formally, “pH is the negative of the logarithm to base 10 of the molar concentration, measured in units of moles per liter, of hydrogen ions.”
But why should we care about pH?
Well, when it comes down to it, your entire metabolism exists to pass around hydrogen ions.
You call it energy. It’s important.
maintaining pH homeostasis
The body goes to great lengths via a range of different systems to keep different parts of your body at a specific pH to enable the chemical reactions that fuel metabolism to continue function.
A pH of 7.0 is “neutral”, however the blood is slightly alkaline at somewhere between a pH of 7.35 and 7.45. It’s virtually impossible to change the pH of your blood outside this range.
If your pH drops to 6.9, you’re in a coma. At 6.8 you’re dead.[3]
At this point many people simply say “see, we can’t change the pH of our blood so worrying about alkalinity is bogus garbage” (or something to that effect) and walk away. Conversation over.
However, I think it’s interesting to think about how the body actually maintains this tight homeostasis and whether a pH of 7.35 is different (more acidic) to a pH of 7.45 (more alkaline).
The body has so many different buffers and so many different systems and ways of mitigating pH. Intracellularly, it has phosphate; extracellularly, hydrogen types of proteins. The lungs get involved, the kidneys get involved. Which just tells you is the more processes or mechanisms in the body, or systems, devoted to a certain subject or topic of process, the more important that process is.
Part of the body’s pH balance involves our kidneys which use the various minerals that it obtains from our food to keep a tight rein on the acid / base balance of our blood.
The minerals that can donate acid forming negative charge are:
Bromine (Br-)
Chlorine (Cl-)
Copper (Cu-)
Fluorine (Fl-)
Iodine (I-)
Phosphorus (P-)
Silicon (Si-)
Sulphur (Su-)
The minerals that can donate alkaline positive charge are:
Boron (B+)
Calcium (Ca+)
Iron (Fe+)
Magnesium (Mg+)
Manganese (Mn+)
Nickel (Ni+)
Potassium (P+)
Sodium (Na+)
Zinc (Zn+)
alkalinity, carbon dioxide and oxygen
In Australia, one of our premier tourist attractions, Great Barrier Reef, is dying as the ocean absorbs CO2 from the atmosphere and becomes more acidic.[5] It’s not hard to see how an increasing environmental acid load could similarly be affecting our internal microbiome.[6]
Every farmer knows the importance of getting the pH of the soil right before planting a crop. A higher pH is achieved by adding extra potassium and lime which is taken up by the plant. The pH of the soil in which plants are grown can have considerable influence on the mineral content of the food we eat.
When it comes to the pH and net acid load in the human diet, there has been considerable change from the hunter gather civilization to the present.[7]
As we continue to grow mono crops in the same field year after year with farmers relying on chemical fertiliser to provide nutrients for the plant, it’s understandable that our veggies are also decreasing in nutrient content, particularly the alkalising minerals.
With the agricultural revolution (last 10,000 years) and even more recently with industrialization (last 200 years), there has been a decrease in potassium (K) compared to sodium (Na) and an increase in chloride compared to bicarbonate found in the diet.
It is generally accepted that agricultural humans today have a diet poor in magnesium and potassium as well as fibre and rich in saturated fat, simple sugars, sodium, and chloride as compared to the pre-agricultural period. [8]
This results in a diet that may induce metabolic acidosis which is mismatched to the genetically determined nutritional requirements. With aging, there is a gradual loss of renal acid-base regulatory function and a resultant increase in diet-induced metabolic acidosis while on the modern diet.[9]
Even if you don’t like veggies, it’s not hard to see how the meat from animals fed with grains (which contain less alkalising minerals than grass) grown with chemical fertilisers could be leading to a higher acid load compared to animals that are able to eat grass and other natural stuff.
When the pH of something is higher (more alkaline) it can hold more dissolved oxygen. If it is more acidic (lower pH) it can hold less oxygen. Blood with a pH of 7.3 (more acidic) and can carry 65% less oxygen than blood at a pH of 7.45 (more alkaline).[10]
Good things happen when there is more oxygen available. For example, when there is more oxygen the body is able to utilise the fat burning Krebs Cycle based / aerobic metabolism (with oxygen) and less on the sugar based Cori cycle / anaerobic metabolism (without oxygen).
While still controversial, in the 1930s Otto Warburg (pictured below, with poodle) suggested that “cancer cells live in hypoxic, very low oxygen, and acidic conditions and derive energy from sugars by fermenting them the way yeast does.” [13] From this, he theorized that these low-oxygen and more acidic conditions caused cancer.
So low oxygen = bad. Lots of oxygen = good.
Wim Hof, Iceman Extraordinaire, achieves superhuman feats essentially by hyperventilating to increase the oxygen in his blood.
the effect of food and alkalinity
There is some indication that this ability to absorb more oxygen is also affected by the food we eat.
The chart below shows how athletes on a lower acid load dietary approach appear to be burning more fat (as indicated by a lower respiratory exchange ratio or RER[14]) and have a longer lead time to exhaustion.[15]
The study Effects of Dietary Acid Load on Exercise Metabolism and Anaerobic Exercise Performance (Caciano et al, 2015) noted that:
An alkaline promoting (low-PRAL) diet increases anaerobic exercise performance, as evidenced by greater time-to-exhaustion during high-intensity treadmill running.
Preliminary evidence suggests that an alkaline promoting (low-PRAL) diet increases lipid oxidation and may have a carbohydrate-sparing effect during submaximal endurance exercise, although further studies are needed.[16]
More fat burning = winning!
This aligns with my personal experience. During a good workout it feels like my cells can “breath better”. My stamina and performance in my cycling or kettlebell workouts is not so much limited by my strength but more by my ability to recover my breath quickly. When everything is working just right I seem to be able to maintain a high heart rate easily for a longer time without running out of breath.
The chart below shows my heart rate during a good kettlebell session.
It seems that a lower insulin load (i.e. low carb / ketogenic) diet with lower levels of insulin enables us to tap into our fat stores more easily. However, in addition, it seems that a more alkaline pH also helps us burn more fat by enabling us to access more oxygen as well.
potential renal acid load
So how does all this this relate to nutrition and optimising our food choices?
Well, back in the late 1870s a scientist named Marcellin Berthelot used the Bomb Calorimeter to study the amount of heat produced or absorbed during chemical reactions.[17] This machine consisted of a cylinder-shaped chamber, pressurized oxygen, and a small amount of water.
Berthelot would take various food substances and incinerate them within this device which turned the item into an ash-type substance. When this ash was mixed with water, Berthelot could check the pH of each item to determine whether a food was acidic or alkaline after it had been burned.
The Potential Renal Acid Load (PRAL) revolves around the idea that there is a residual ash remaining after a food is metabolised in our body that is either acidic or basic. This residual ash, which has a net acidic or alkaline property, then needs to be cleared from the body to maintain optimal pH.[18][19][20]
A simplified PRAL value can be calculated based on the most dominant nutrients affecting pH. That is, protein (which forms sulphur) and phosphorus (acidic) minus the magnesium, calcium and potassium (alkaline).
Potential renal acid load (PRAL) = [0.49 x grams of protein + 0.037 x mg of phosphorus] – [0.026 x mg magnesium + 0.013 x mg calcium + 0.021 x mg potassium]
If the PRAL value is negative, then you are left with an alkaline residue.
If the PRAL number is positive, then you are left with a net acidic residue that needs to be cleared by the kidneys.
urine ph
While significantly changing the pH of the blood is controversial, the food we eat does seem to have an impact on the pH of our urine as the kidneys clear the excess acid load that is not used up in balancing our pH.[21][22] The theory is that pH of our urine changes based on whether the residual ash from our food after it is metabolised is either acidic or alkaline.
The chart below shows the urine pH of the test subjects in the Effects of Dietary Acid Load on Exercise Metabolism and Anaerobic Exercise Performance study mentioned above. In the cross over trial participants performed the best when they had a more alkaline urine pH greater than 7.0 (alkaline) in comparison to when they had a pH less than 6.0 (acidic).
balancing electrolytes
If you’re a die hard low carber / ketonian congratulations in getting this far into the article before switching off and writing me off as a vegan tree hugging hippie.
You’ll also likely be aware that in The Art and Science of Low Carbohydrate Performance Volek and Phinney talk a lot about how important it is to manage minerals and electrolytes when following a low carb / ketogenic dietary approach. Chapter 9 of The Art and Science of Low Carbohydrate Performance is all about how important it is to make sure you keep up your electrolytes in the form of sodium, potassium, magnesium and zinc.
[Steve was recently in Brisbane and we had the privilege of having him stay at our place. Not only did he make us his famous blue cheese dressing (see action shot below) I also got to pick his brains for a day!]
You get bonus points if you realised that these critical electrolytes that Volek and Phinney talk about are the same as the alkalising minerals in the PRAL formula (i.e. magnesium, calcium and potassium)! Maybe erring on the side of being alkaline and ensuring good mineral / electrolyte management in a keto diet are two sides of the same coin?
We can get this critical electrolytes from supplements or more ideally from real food.
As you dig further you quickly find that the discussions around PRAL can go sideways really quickly and turn into a keto / carnivore vs vegan / plant based argument.
I have tried to wade through the science versus woo woo, which I’ll try to summarise later in this article. But for now let’s jump into what the analysis of PRAL could mean for our choices around what we should eat.
the most alkaline foods
The table below shows the most alkaline foods with their nutrient density (ND), and PRAL value per 100g and PRAL / 2000 calories.[23]
Most lists I’ve seen use PRAL per 100 calories. However, I think it’s more useful to think of it in terms of the amount as a proportion of your daily energy intake (i.e. per 2000 calories).
To make the lists more concise I’ve filtered for the most nutrient dense foods for each category.
vegetables and spices
The PRAL values of the most nutrient dense vegetables are listed below. Overall vegetables are quite alkaline (i.e. negative PRAL values). Only alfalfa has a positive PRAL value due to high levels of phosphorus.
The other observation here is that nutrient density and alkalinity don’t necessarily go hand in hand. It’s not as simple as saying ‘eat your veggies’ because there is a wide range of nutrient density and PRAL values within the vegetables.
If you are striving for optimal in terms of ND and PRAL then some veggies are better than others.
food
ND
PRAL / 2000 cal
PRAL / 100g
beet greens
19
-1,523
-17
Chinese cabbage
20
-1,241
-7
watercress
24
-1,034
-6
spinach
25
-895
-10
chard
19
-857
-8
coriander
23
-841
-10
chicory greens
18
-724
-8
dill
16
-721
-15
endive
19
-707
-6
arugula
16
-629
-8
parsley
19
-618
-11
celery
12
-610
-5
basil
22
-569
-7
mustard greens
16
-507
-7
escarole
15
-495
-5
zucchini
20
-489
-4
pickles
11
-424
-3
lettuce
19
-419
-3
summer squash
13
-397
-4
brown mushrooms
16
-383
-4
yeast extract spread
12
-369
-34
dandelion greens
16
-353
-8
cauliflower
15
-351
-4
sauerkraut
11
-328
-3
chives
16
-317
-5
turnip greens
13
-307
-4
banana pepper
10
-296
-4
sage
13
-295
-46
cabbage
10
-286
-3
paprika
11
-262
-37
okra
15
-243
-3
seaweed (kelp)
12
-224
-5
cloves
13
-216
-30
snap beans
11
-215
-2
white mushroom
13
-205
-2
portabella mushrooms
13
-204
-3
asparagus
20
-199
-2
broccoli
27
-167
-2
collards
11
-141
-2
shiitake mushroom
11
-80
-2
mung beans
13
-64
-1
seaweed (wakame)
17
-59
-1
spirulina
11
-1
-0
alfalfa
12
154
2
dairy
Dairy is widely regarded to be some of the most acidic of foods. As you can see below there are a wide range of PRAL values, from slightly alkaline high fat cream and butter to the low fat cheeses which are quite acidic.
Even though dairy can be nutrient dense, many people seem to do better with their weight or allergies when they limit dairy.
Personally, I know I lost some weight when I reduced dairy for a period. I thought it might be related to the energy density. Maybe the minerals and pH balance plays a role too and living on a low carb diet primarily comprised of cheese could be a problem for some people in the long term.
Baked products, cereals and grains, in addition to generally having quite poor nutrient density values are also typically highly insulinogenic.
Baking soda or bicarbonate is a powerful alkaline supplement that can be used to aggressively shift pH.
Other than wheat bran and baker’s yeast (think vegemite, marmite or brewer’s yeast), processed grains have a poor nutritional value while also being quite alkaline AND insulinogenic.
According to Bill Davis the phytates in grains also make it harder to absorb alkalising minerals.[24]
No wonder processed grains are problematic for so many people.
Animal products have a high PRAL values due to their protein content. Grain fed animals are likely to be even worse than animals able to eat their natural diet.
food
ND
PRAL/2000 cal
PRAL/100g
chicken liver pate
7
105
11
rib eye steak
5
130
14
lamb chop
5
139
16
bison
5
166
14
beef brains
8
166
13
ground pork
6
168
16
ground beef
6
171
12
leg ham
6
175
14
pork shoulder
6
178
14
turkey heart
8
182
16
turkey meat
6
188
15
turkey drumstick
6
188
15
chicken
7
189
14
pork chop
6
195
17
beef tripe
6
208
11
lamb heart
8
212
17
lean beef
9
216
16
turkey liver
14
218
21
pork liver
10
218
18
beef heart
5
220
18
beef heart
8
229
21
turkey
6
230
16
chicken liver
15
233
14
ham
11
239
13
veal
8
239
18
veal liver
16
244
23
chicken liver
14
250
22
beef liver
16
262
23
lamb kidney
19
267
15
lamb liver
18
274
23
beef kidney
13
283
22
fruits
Fruits are typically quite alkaline, however the nutrient density value is typically less than ideal. Fruits are also typically quite insulinogenic. So I don’t think it’s a matter of simply saying that we should eat a ton of “fruits and vegetables” if nutrient density or insulin load are also an issue. https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js
food
ND
PRAL/2000 cal
PRAL/100g
rhubarb
3
-621
-7
cantaloupe
-2
-298
-5
honeydew melon
-4
-247
-4
jackfruit
-3
-186
-9
kiwifruit
-2
-184
-6
apricots
-4
-180
-4
grapefruit
-4
-174
-3
peaches
-4
-160
-3
strawberries
-1
-159
-3
oranges
-4
-156
-4
carambola
-2
-138
-2
blueberries
-0
-137
-3
blackberries
-1
-130
-3
limes
-3
-115
-2
avocado
-1
-102
-8
raspberries
-2
-93
-2
boysenberries
-2
-86
-2
blackberries
-4
-69
-2
legumes
Legumes have a range of PRAL values, though again the nutrient density values are not that great compared to the veggies, seafood or animal products.
food
ND
PRAL/2000 cal
PRAL/100g
navy beans
0
-32
-5
soybeans
2
-21
-5
cowpeas
1
-14
-2
peanut butter
2
-5
-1
broad beans
-1
-2
-0
lentils
0
37
2
tofu
4
41
2
soy protein isolate
0
400
67
nuts and seeds
There are a range of PRAL values when it comes to nuts and seeds depending on the mineral content.
Anything based on coconut seems to do well in terms of nutrient density and alkalinity. There’s nothing quite like fresh coconut water. The photo below shows how we finished our recent holiday in Fiji!
So my big takeaway from the analysis above is that alkalinity and nutrient density are not necessarily related. You can’t just say ‘eat your fruits and vegetables and avoid protein’ to manage your alkalinity and maximise nutrients at the same time. Particularly given that protein is the one macronutrient that seems to be correlated with nutrient density.
Recent clinical studies and a meta-analysis have indicated either no effect or a modest benefit associated with higher protein intakes. These contradictory considerations may be explained by the existence of a two-faced relationship between protein and bone, with simultaneous positive and negative pathways. In opposition to the negative effects of dietary acid load, protein may exert positive effects related to improving calcium absorption, increasing insulin-like growth factor 1, or improving lean body mass, which, in turn, improves bone strength.[26]
The chart below shows a comparison of the nutrient density of the top 10% of the USDA food database for a range of dietary approaches. If we prioritise our food choices based on low PRAL values alone we end up with a lower nutrient density.
Most things in nutrition are not binary. We can’t just take one parameter and use it to guide ALL our decisions about nutrition. That includes protein, carbs, fat, energy density, nutrient density or alkalinity.
Where it gets gets is when we mix and match a number of factors to prioritise our food choices to suit our goals.
Nutrient dense low alkaline foods typically have quite a low energy density so we don’t have to worry too much about that. To develop the list of more alkaline nutrient dense in the following section I have factored in:
nutrient density,
PRAL, and
insulin load.
The chart below shows a comparison of the nutrients provided by the top 10% of foods for the following approaches:
low PRAL,
nutrient dense alkaline, and
nutrient dense maintenance.
If we just prioritise low PRAL (grey bars) then the amino acids drop. However, if we prioritise low PRAL and nutrient density we get a better balance of alkalinity and nutrient density across the board.
The chart below shows a comparison of macronutrients.
The nutrient dense approach is quite high in protein while the more alkaline approach has less protein and more carbs from more veggies.
If we only look at minimising PRAL we get a lot of fibre and less protein.
The nutrient dense alkaline approach provides a reasonable balance in terms of macronutrients.
From an insulin load perspective, the low PRAL approach is relatively insulinogenic. Considering insulin load in the multi criteria analysis gives us a little bit of additional dietary fat which is useful for blood glucose regulation or satiety, particularly if we’re not trying to lose weight. Moderate amounts of dietary fat help with the absorption of the fat-soluble vitamins A, D, E and K).
The chart below shows a comparison of some of the key minerals provided by a number of dietary approaches (note: phosphorus is acidic while the magnesium, calcium, potassium and sodium are alkaline).
The therapeutic ketosis and the average of all foods do not have a lot of alkalising magnesium, calcium, potassium and sodium to balance the acid forming phosphorus.
By comparison, the nutrient dense alkaline and low PRAL foods have a lot more alkalising minerals to balance the acidic phosphorus.
Rather than worrying about actively balancing our pH I think we focus on maximising nutrient density our body will have what it needs to do what is necessary to balance pH. Maximising nutrient density will also minimise nutrient hunger so our bodies will be satisfied with less and our kidneys won’t have to process as much.
The chart below shows that after Vitamin D and Vitamin E, many people are getting less than the recommended intake of magnesium, calcium and zinc (i.e. alkalising minerals).
PRAL value of different nutritional approaches
The chart shows the PRAL value for thirteen different nutritional approaches outlined on this blog.
The nutrient dense vegan approach the is the most alkaline while the zero-carb approach is the most acidic.
The nutrient dense alkaline foods (listed below) end up being nearly as alkaline as the vegan.
On average, the 8000 foods in the USDA database have a net acid load.
The zero carb, high insulin load and therapeutic ketogenic approaches have net acid load.
Most of the other approaches that focus on nutrient density have adequate vegetables to ensure that they are alkaline overall.
If the alkalinity of our diet does actually have a bearing on insulin resistance, oxygen availability / hypoxia, insulin sensitivity I wonder if people pursuing a therapeutic ketogenic approach should actually be considering prioritising their veggies and / or or mineral supplements that will balance their alkalinity to balance out their diet.
Results of recent observational studies confirm an association between insulin resistance and metabolic acidosis markers, including low serum bicarbonate, high serum anion gap, hypocitraturia, and low urine pH.[27]
nutrient dense alkaline foods
The list of foods is prioritised for nutrient density, alkalinity and a lower insulin load.
vegetables, spices and fruit
The list of vegetables and fruit below are both nutrient dense and highly alkaline. Whether you buy into this alkaline food theory it will be hard to go wrong if you eat more of these foods which are nutrient dense and have a low insulin load.
If you are concerned that your body is lacking alkalising minerals, focusing on the green leafies at the top of this list will be a good first step. Real food is always going to be a better option than supplements.
food
ND
insulin load (g/100g)
PRAL/2000cal
MCA
watercress
13
2
-1,034
2.8
spinach
11
4
-895
2.7
endive
9
1
-707
2.7
chicory greens
8
2
-724
2.5
basil
9
3
-569
2.3
coriander
7
2
-841
2.3
chard
9
3
-857
2.3
beet greens
7
2
-1,523
2.2
escarole
6
1
-495
2.2
zucchini
7
2
-489
2.2
Chinese cabbage
8
2
-1,241
2.1
lettuce
8
2
-419
2.0
mustard greens
6
3
-507
2.0
parsley
7
5
-618
2.0
arugula
7
3
-629
2.0
dandelion greens
8
7
-353
1.9
sage
6
26
-295
1.9
asparagus
9
3
-199
1.9
turnip greens
7
4
-307
1.8
summer squash
6
2
-397
1.8
okra
7
3
-243
1.7
alfalfa
8
1
154
1.6
thyme
5
31
-257
1.6
cloves
6
35
-216
1.6
curry powder
5
14
-107
1.6
collards
6
4
-141
1.6
paprika
4
26
-262
1.6
cucumber
4
1
-424
1.5
pickles
4
1
-424
1.5
celery
4
3
-610
1.5
chives
5
4
-317
1.5
brown mushrooms
7
5
-383
1.5
broccoli
6
5
-204
1.4
marjoram
3
27
-364
1.4
cauliflower
4
4
-351
1.4
bamboo shoots
4
5
-591
1.3
banana pepper
3
3
-296
1.2
celery flakes
3
42
-530
1.2
sauerkraut
3
2
-328
1.2
seaweed (wakame)
8
11
-59
1.2
cabbage
4
4
-286
1.2
dill
3
8
-721
1.2
radicchio
4
4
-413
1.2
radishes
2
2
-551
1.2
rhubarb
3
3
-621
1.2
seaweed (kelp)
6
10
-224
1.2
portabella mushrooms
5
5
-204
1.2
edamame
5
13
7
1.1
artichokes
4
7
-211
1.1
kale
4
5
-302
1.1
poppy seeds
3
23
-7
1.1
white mushroom
5
5
-205
1.1
snap beans
4
3
-215
1.0
eggplant
1
3
-314
1.0
caraway seed
3
28
-80
1.0
yeast extract spread
3
27
-369
1.0
dill seed
2
43
-218
0.9
cumin
2
44
-171
0.9
turnips
2
3
-275
0.9
shiitake mushroom
5
7
-80
0.9
onions
3
6
-312
0.9
jalapeno peppers
1
3
-269
0.9
soybeans (sprouted)
4
12
-16
0.9
tarragon
2
56
-437
0.9
pumpkin
3
4
-380
0.9
spirulina
6
6
-1
0.9
red peppers
2
3
-219
0.8
chayote
1
3
-228
0.8
nuts and seeds
Coconuts do pretty well. Some of the other nuts are not so nutrient dense or alkaline, so this list isn’t too long. Keep in mind that drinking a lot of coconut water might not be ideal for someone with diabetes due to the carbohydrate content.
food
ND
insulin load (g/100g)
PRAL/2000cal
MCA
coconut water
2
3
-539
1.0
coconut milk
1
5
-16
0.9
flax seed
1
16
8
0.9
coconut meat
1
9
-15
0.9
coconut cream
1
7
-9
0.8
almond butter
1
26
5
0.8
pumpkin seeds
2
29
98
0.8
almonds
1
25
7
0.8
sunflower seeds
1
22
110
0.7
seafood
If you are eating plenty of veggies I think you can so afford to also eat plenty of nutrient dense seafood as the acid / alkaline will balance each other out in the long run. While there have been some concerns that a high protein diet will cause acidity that will, in turn, cause osteoporosis due to calcium being used to buffer the acid, more recent research indicates that protein has a net positive effect on bone health.[28][29]
food
ND
insulin load (g/100g)
PRAL/2000cal
MCA
fish roe
11
18
285
1.6
caviar
7
23
76
1.5
trout
8
18
131
1.3
salmon
8
20
180
1.3
sturgeon
8
16
165
1.2
sardine
6
19
153
1.2
oyster
8
14
146
1.1
halibut
9
17
175
1.1
mackerel
3
10
34
1.1
anchovy
6
22
69
1.1
cisco
5
13
75
1.1
cod
9
48
205
1.1
flounder
9
12
322
1.1
crab
9
14
238
1.1
crayfish
9
13
253
1.1
pollock
8
18
168
1.1
rockfish
8
17
168
1.0
lobster
8
15
201
1.0
perch
8
14
297
0.9
herring
4
19
114
0.9
white fish
7
18
123
0.9
whiting
7
18
197
0.9
shrimp
8
19
282
0.9
haddock
7
19
188
0.8
clam
7
25
128
0.8
dairy and egg
A number of cheeses make it onto the list due to their nutrient density along with egg, butter and cream. Cheese are typically acidic however, in moderation, they can potentially form part of a well-rounded diet.
The problem, I think, is a that a lot of people looking for a low carb / keto dietary approach (me included) end up eating large quantities of dairy (e.g. cream, cheese and butter) and end up struggling to keep the weight off or find that they are “allergic to dairy”. Perhaps excess acid load without adequate minerals to balance it from green leafy veggies may be playing a role here?
food
ND
insulin load (g/100g)
PRAL/2000cal
MCA
egg yolk
4
12
133
1.1
feta cheese
4
15
85
1.1
whole egg
5
10
133
1.0
milk
5
7
5
1.0
Swiss cheese
4
22
104
1.0
cheddar cheese
3
20
85
1.0
gruyere cheese
3
23
103
1.0
gouda cheese
4
21
113
0.9
Eggnog
5
11
14
0.9
kefir
6
7
14
0.9
edam cheese
3
21
100
0.9
mozzarella
4
26
123
0.9
cream
1
5
3
0.9
Monterey cheese
3
19
88
0.8
limburger cheese
2
15
90
0.8
butter
0
3
-0
0.8
muenster cheese
3
19
87
0.8
goat cheese
3
14
119
0.8
sour cream
1
6
-2
0.8
cream cheese
1
10
15
0.8
Colby
2
20
83
0.8
camembert
2
16
87
0.8
low fat milk
5
8
-1
0.8
blue cheese
2
19
68
0.8
cream cheese (low fat)
8
19
306
0.7
parmesan cheese
3
35
102
0.7
ricotta
2
12
71
0.7
animal products
Several animal products make the list even though they carry an acid load. I don’t think “animal protein” is really a concern if you are also eating your alkalising veggies. Seafood and animal products are also nutrient dense and have beneficial properties, including lean body mass[30] and bone health. If you can, it’s going to be ideal to consume seafood and animals that aren’t fed more acidic grains.
food
ND
insulin load (g/100g)
PRAL/2000cal
MCA
lamb liver
7
20
274
0.9
beef brains
3
8
166
0.9
ham (lean only)
7
17
239
0.8
lamb kidney
6
15
267
0.8
turkey liver
5
21
218
0.7
ground turkey
3
19
115
0.7
turkey heart
4
20
182
0.6
pork
3
22
128
0.6
roast ham
3
18
137
0.6
lamb brains
2
10
197
0.6
beef kidney
5
20
283
0.6
roast pork
3
20
130
0.6
chicken liver
5
20
250
0.6
lamb sweetbread
4
15
313
0.5
turkey drumstick
4
21
188
0.5
turkey meat
4
21
188
0.5
pork chop
5
23
195
0.5
leg ham
4
22
175
0.5
other dietary approaches
I’ve added this list to the various dietary in the table below. If you’re already getting plenty of veggies then acidity probably won’t be a problem with your acid balance. But if you already have metabolic acidosis, gout or kidney concerns they you may want to focus on getting more of the alkaline foods.
If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help you identify your optimal dietary approach.
am I getting enough veggies?
If you have blood tests handy you can see if they show any of the following signs that may suggest that your diet is more acidic and / or you are struggling to balance your acid load:
These values will give you an indication whether your kidneys are keeping up and you might need to review your diet.
If you don’t have the blood tests available, you can test your urine pH which gives you an indication of how much acid versus alkaline ash your kidneys are clearing after digestion. This will not necessarily tell you how alkaline your blood is, but rather whether your body is having to excrete alkaline or acidic waste products after digestion which appears to still be a relevant guide.
The chart below shows the urine pH of people in the Caciano et al study noted above when they changed their diet to a low PRAL (alkaline) or high PRAL (acidic) dietary approach. Most participants could achieve the high PRAL acidic target of greater than a pH of 6.0 within four days. However, it took some participants up to nine days of changing their diet to achieve an alkaline pH of greater than 7.0.
If you’re interested, you can grab some pH test tape and see where you are currently at. If you find your urine is more acidic (i.e. pH lower than 6.0) you could consider manipulating your diet and / or use mineral supplements until you are achieving a pH of greater than 6.8 or so.
supplementation
Obviously eating real food such as the ones listed above is preferable. However, if simply adding more non-starchy veggies listed above doesn’t work for you there are a number of other more aggressive options that you can turn to.
One popular approach is to use a greens powder. On the positive side, a few spoonful’s of this will quickly give you lots of micronutrients and alkalising minerals. However, real veggies are always going to be better and it will give you about one gram of carbohydrates per serving.
Another option is to use baking soda which is highly alkaline and has been shown to improve athletic performance in a range of studies (check out the plethora of study reviews on Adel’s SuppVersity site if you are interested in seeing how the alkalinity provided by Bicarbonate can affect exercise performance).[32][33][34]
In situations that result in acute acidosis, supplementing younger patients with sodium bicarbonate prior to exhaustive exercise resulted in significantly less acidosis in the blood than those that were not supplemented with sodium bicarbonate.[35]
The pros of baking soda is that it is cheap and effective and will turn your urine pee sticks blue very quickly (see picture below). It may also cause gut distress if you have a sensitive gut (as many people with diabetes do). And you’ll also be missing out on all the other benefits of eating whole veggies.
I prefer citrate minerals since taking bicarb soda can dilute stomach acid when taken with meals whereas citrate minerals can be taken at any time. Using citrate minerals has a ‘bicarbonate sparing’ effect without necessarily taking bicarbonate.
By reducing the workload on the pancreas more ATP is available to produce insulin. The lungs can only deal with volatile acids that can be excreted via CO2, but the kidneys have to do the rest via ammonia.
I think people try and simplify it for themselves by talking about acid / alkaline diets when it’s more to do with minerals imbalances and other factors that shift metabolic acid production.
But does it really matter what we call it if people eat better?
In our house what we’re trying to do is maximise the green leafy veggies, not overdo the dairy, perhaps increase the coconut intake as well as taking the a little and then take the potassium, calcium and magnesium citrate mineral supplement mix until the urine pH consistently is above 6.8.
are ketones acidic ketones?
If you are taking exogenous ketone supplements, then making sure you get your green leafies or taking a mineral supplement may be even more important.
Your body will likely secrete some insulin to bring down the total energy in your bloodstream if you have really high ketones, particularly in a fed state. A recent study indicated that the pancreas does not secrete insulin in response to ketones alone, but rather when glucose is greater than 5.0 mmol/L or 90 mg/dL and you add in additional ketones.
So, I wondered if adding exogenous ketones to a diet that is not already ketogenic (i.e. high blood glucose levels) is a recipe for accelerated hyperinsulinemia and acidity?
I had some exogenous ketones lying around the house so I thought it would be interesting to test at what point they become acidic.
Seems the answer is yes for the ketone salts…
… and so is the ketone ester.
So maybe some of the acidity that I saw on my blood tests could also have been contributed to by me dabbling with exogenous ketones?
So are exogenous ketones also acidic inside the body? In the name of science I downed two packets of Keto//OS. My ketone value went from 0.6 to 0.8mmol/L and the increased insulin released to clear the exogenous ketones also brought the blood glucose levels down over a period of about five hours.
But the pH of my urine also went from alkaline to acidic as my kidneys worked to clear the acid load from the exogenous ketones. I sure hope all those people with the recurring order of Keto//OS are also taking mineral supplements and ideally eating lots of green leafy veggies.
I also wonder what the long term effects of high levels of exogenous ketones will be on people who are taking them for cancer and other conditions which appear to be exacerbated by insulin and acidity. I suppose time will tell.
Interestingly there are some people who feel that increased ketones are more a downstream symptom of increased NAD+. It’s actually the increased NAD+ that occurs in fasting and carb restriction and the upregulated Sitruins that is causing the positive outcomes and not actually the ketones themselves.
endogenous ketones
Endogenous ketones are acidic too,[37][38] though this is not really a problem in someone who has a functioning pancreas and is producing adequate insulin to keep ketone levels under control. When the pancreas fails to produce adequate insulin in (i.e. Type 1 Diabetes) it is called ketoacidosis and it can be very dangerous.
In a metabolically healthy person, alkalising minerals play a role in balancing out the acid load of the ketones and actually neutralising them. Perhaps this is part of the reason that many metabolically fit athletes do not tend to see really high blood ketones even if they have been following a ketogenic diet for a long time? If their kidneys and pancreas are functioning well they have adequate minerals to balance their acidity they will be able to happily operate most of the time with very low glucose and ketone values (i.e. low total energy).
Perhaps the reverse could be an interesting “hack” if you really wanted to achieve higher blood ketone values without fasting?
In his Keto Summit interview Bryan Walsh (pictured below) raised some interesting questions about pH balance on a long term ketogenic diet.
Can we deplete our buffering capacity by being in this chronically acidic state all the time, a self-induced acidic state, meaning a ketogenic diet? Long term can we deplete our body’s ability to mitigate this pH shift?
The body will still maintain an incredibly tight pH. But at what expense? What are we using up that we may have used for something else to try to maintain this golden egg of pH in the body?
I don’t think over time you’d see somebody’s pH shift. But what I do think is that other things would suffer as a consequence.
metabolic acidosis and insulin resistance
When you dig into the literature there seem to be a lot of parallels between Type 2 Diabetes and metabolic acidosis.[39][40][41] Type 2 Diabetes and kidney disease often occur together.
“[The] dietary acid load is directly associated with an increased risk of type 2 diabetes. From a public health perspective, dietary recommendations should not only incriminate specific food groups but also include recommendations on the overall quality of the diet, notably the need to maintain an adequate acid/base balance.”[42]
The pancreas’ job is to maintain normal blood glucose levels within a tight range. The adipose tissue continues to store the excess energy from processed carbs through de novo lipogenesis until it can’t take anymore and we become insulin resistant in order to slow the storage of fat in the adipose tissue. Then, in the long run the pancreas burns out and we require exogenous insulin.
Similar to the pancreas’ role with glucose, it seems the kidneys maintain our pH within a tight range. But then over time if it is subjected to excessive acid load, just like excessive glucose in our pancreas, our tight grip on pH may slip, even a little. Then the kidneys start to burn out. They no longer maintain optimal acid levels, but rather slightly more acidic levels and then lose their grip on optimal oxygenation of the blood which leads to a plethora of metabolic issues.
Similar to maintaining tight blood glucose control, part of the solution to slow the decline in our kidney function may be to eat some more leafy greens while minimizing the acidic load from nutrient poor foods such as sugar and processed grains.
muscle loss
Another parallel between Type 2 Diabetes and metabolic acidosis is muscle loss. Our ability to optimise lean muscle mass is critical to maintaining good glucose disposal and insulin sensitivity.
Recent insights indicate that several consequences of metabolic acidosis including the development of insulin resistance can stimulate muscle protein degradation.[43]
So if we don’t eat our veggies maybe we risk losing our gainz?!?!?
In Type 2 Diabetes we often see excess gluconeogenesis when the body can’t burn fat due to high insulin / insulin resistance and instead to protein in our diet and body for energy.
Evidence increasingly suggests that acidosis promotes muscle protein wasting by both increasing protein degradation and inhibiting protein synthesis.
Correction of acidosis may therefore help to preserve muscle mass and improve the health of patients with pathological conditions associated with acidosis.[44]
The chart below shows that people with the highest amount of potassium excretion in the urine (i.e. most alkaline) had a greater percentage of lean body mass. Perhaps the quickest way to get buff is to get adequate protein AND eat your veggies to enhance fat burning and reduce your reliance on glucose and protein for energy.
It has been demonstrated that even the slightest degree of metabolic acidosis produces insulin resistance in healthy humans. Many recent epidemiological studies link metabolic acidosis indicators with insulin resistance and systemic hypertension.
The strongly acidogenic diet consumed in developed countries produces a lifetime acidotic state, exacerbated by excess body weight and aging, which may result in insulin resistance, metabolic syndrome, and Type 2 diabetes, contributing to cardiovascular risk, along with genetic causes, lack of physical exercise, and other factors…
Even very slight levels of chronic kidney insufficiency are associated with increased cardiovascular risk, which may be explained at least in part by deficient acid excretory capacity of the kidney and consequent metabolic acidosis-induced insulin resistance.[45]
As we age, there is a loss of muscle mass, which may predispose us to falls and fractures. A three-year study looking at a diet rich in potassium, such as fruits and vegetables, as well
as a reduced acid load, resulted in preservation of muscle mass in older men and women. Conditions such as chronic renal failure that result in chronic metabolic acidosis result in accelerated breakdown in skeletal muscle.
Correction of acidosis may preserve muscle mass in conditions where muscle wasting is common such as diabetic ketosis, trauma, sepsis, chronic obstructive lung disease, and renal failure.[47]
summary
Whether you think eating alkaline foods is useful or woo woo junk it appears that metabolic acidosis is a thing.
Metabolic acidosis seems to be interrelated with insulin resistance, Type 2 Diabetes and retention of muscle mass.
To prevent metabolic acidosis it appears prudent to ensure that your body has adequate minerals to enable your kidneys to balance pH over the long term. This can be achieved by eating plenty of veggies and / or supplementing with alkaline minerals (e.g. magnesium, sodium, potassium, zinc etc).
If you eat plenty of veggies you’re probably getting enough alkalising minerals, however you can easily test your urine to see if your dietary acid load is high.
If you are targeting a high fat therapeutic ketogenic diet, following a zero carb dietary approach and / or taking exogenous ketones it seems then it may be even more important to be mindful of your acid load and consider mineral supplementation.
epilogue
So, you may be wondering how my ketones are going these days with the alkalising minerals on board. They seem to be a little lower now with the mineral supplementation. When I fast for a few days they kick in and might get to around 2.0mmol/L and hunger is not a big deal. I think the ketones are doing what they’re meant to do.
I’m still not exactly sure why my ketone spiked off the chart that brief period. I think Elizma’s explanation makes sense. That is, my insulin sensitivity improved and the flood gate of free fatty acids was released for a time and then settled down. In time though I think the alkalising minerals balance out the ketones and keep them from getting too high.
I have also been taking the Niacel on an ongoing basis to increase NAD+ which in appears to increase the breath acetone (fat burning) and decreases the ketones in the blood (BHB). But more on that in future posts. This one is already too long.
The ratio of β-OHB to AcAc depends on the NADH/NAD+ ratio inside mitochondria; if NADH concentration is high, the liver releases a higher proportion of β-OHB.[48]
I think being able to run with a lower total energy (i.e. glucose plus ketones) in the blood most of the time might be a good thing. When high levels of glucose or ketone are required (e.g. fasting or explosive exercise) they can be easily accessed if we have good insulin sensitivity.
Considering how very nutrient dense offal is, it’s been surprisingly hard to find organ meat recipes that do really well in the nutrition ranking because so many of the recipes are ‘diluted’ with lots of sweet stuff to mask the taste.
Tristan and Jessica Haggard from Primal Edge Health moved from California to Ecuador to seek a healthier place to live and raise their family.
Clean water. More sunshine. Closer to the equator.
These guys are the real deal.
The recipes in their new cookbook document’s how Jessica lovingly makes sure they ensure they ensure they thrive with their food. It’s not all offal, but it’s clean, nutrient dense and simple, even when it comes to the deserts.
This recipe for curried eggs with cows brains does spectacularly well with the vitamins and minerals as well as the amino acids while still being 68% fat.
The table below shows the nutritional data per 500 calorie serving.
Combining the brains with the egg, spinach and avocado makes for a pretty unbeatable combination when it comes to nutrient density. In fact it ranks at:
For most people, the optimal dietary approach seems to include a balance of plant and animal based foods. Some people prefer more (or all) plants due to ethical or religious reasons, while others prefer to avoid vegetables and grains.
Some people just don’t like veggies, while others struggle to digest plant fibres and find relief from debilitating digestive, mental health[1] or other symptoms when they avoid plant based foods and even dairy.[2][3][4]
Others feel that the nutrients in plant based foods are less bioavailable and that the nutrients in animal based foods will be more easily absorbed.[5]
The chart below shows a comparison of the nutrients provided by:
the most nutrient dense zero carb foods,
the most nutrient dense plant based foods, and
the most nutrient dense foods available.
As you might expect, the zero carb foods (red bars) do well in the proteins and fatty acids while the plant based foods (blue bars) generally contain more vitamins and minerals.
Going zero carb will reduce the insulin load compared to most dietary approaches, although the higher levels of protein may mean that you won’t necessarily be ‘ketogenic’ or showing high levels of blood ketones.
While the recommended daily intake values for various nutrients is debatable, it appears that it is more difficult to obtain the recommended quantity of calcium, magnesium, potassium, vitamin E and vitamin C on a zero carb approach compared to others that contain plant based foods and hence it may be useful to supplement these nutrients.
You’ll notice the most nutrient dense zero carb foods listed below contain a solid amount of organ meats which are very nutrient dense. The chart below shows the nutrient density of the highest ranking zero carb foods with and without organ meats (cutting out all carbohydrate containing foods narrows the list of available foods from 8000 to 2887 and removing offal narrows the list to 2784 available foods). Organ meats makes a significant difference to the levels of copper, manganese, selenium, vitamin A and vitamin B-12. So if you are going to go with a zero carb approach it makes sense to maximise your organ meats.
The table below contains links to separate blog posts and printable .pdfs for a range of dietary approaches (sorted from most to least nutrient dense) that may be of interest depending on your situation and goals. You can print them out to stick to your fridge or take on your next shopping expedition for some inspiration.
If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help identify the optimal dietary approach for you.
[6] However, keep in mind that this analysis is based on the USDA database that includes all the nutrients in the food rather than what will be absorbed. Species specific nutrient bioavailability is still an emerging area. While we can measure the nutrient in a food, it is hard to quantify how much of those nutrients are digested and absorbed into the body.
