Our bodies are always in a battle with too much ACID. I discussed this briefly before and am revisiting this topic again because of the metabolic impact metabolic acidosis (MA) has on our bodies (that is, too much acid)
In the process of digesting meats and animal proteins, our body produces acids as well as internal processes that contribute to high acid levels. Our body uses bicarbonate and other mechanisms to neutralize the excess acid.
Metabolic acidosis (MA) affects every system in our body. MA at a chronic level activates bone resorption and can increase the rick of osteoporosis. Treatment of MA can decrease this risk when it is present. Skeletal strength is impaired by MA because the body cannibalizes it’s own muscle to help neutralize the extra acid. Likewise, MA will impair insulin release and insulin receptor functioning. This results in glucose intolerance and diabetes. MA will also cause the progression of kidney failure and impair the functioning of thyroid hormones and it’s receptors.
We see metabolic acidosis in 1 out of 30 patients with normal kidney function. the number affected increases as kidney function declines.
BMC Nephrol, 2013 Jan 9;14:4 : Use of bicarbonate to normalize MA can prevent progression of chronic kidney disease. How much bicarbonate and what type of bicarbonate is used? Sodium bicarbonate, in amounts starting at 1300 mg twice a day to get the serum bicarbonate levels to 24 mg/dl. Baking soda has 850 mg of sodium bicarbonate in a teaspoon.
Sodium bicarbonate intake does not worsen high blood pressure because the sodium load resulting from the sodium bicarbonate cannot be reabsorbed in the kidney through the usual NACL cotransporter.
The body normally excretes extra acid loads produced in the body in the form of ammonia, which is produced from glutamine (an amino acid) When metabolic acidosis is present, the body quickly runs out of glutamine from its usual sources and gets extra glutamine from muscle breakdown. The glutamine then goes to the kidney to be broken into ammonia which absorbs the extra acid. So metabolic acidosis leads to increased muscle breakdown and weakness.
Diet affects the production of acid, especially with the consumption of animal proteins, which results in a lot of acid production in the body. This speeds UP the loss of kidney function in predisposed individuals. It has been shown that fruits and vegetables create little acid production in the body and a vegan diet as such decreases the rate of kidney function decline in patients with kidney failure.
Here is the summary:
Treatment of metabolic acidosis, when the serum bicarbonate level is below 20 mmol/L, using sodium bicarbonate at doses of 1300 mg twice a day to increase serum bicarbonate to 24 mmol/L has positive impacts in multiple fronts as below.
Increased bone density results from treatment of MA, thus decreased fractures and falling.
There is better glucose control by treating MA due to better insulin sensitivity and insulin receptor responsiveness.
Treatment of metabolic acidosis decreases the progression towards kidney failure in susceptible individuals with chronic kidney disease.
Treatment of MA results in better muscle strength and muscle mass.
Eat more fruits and vegetables to decrease your intake of acids.
Have your doctor asses your blood for low bicarbonate (Less than 20 mmol/L)
Consult your doctor prior to initiating any medical regimen as discussed.
Gluten is a substance present in rye, wheat, and barley. In some individuals, the body gets sensitized to this substance in the form of an autoimmune disease that results in damage of the gastrointestinal tract lining.
First we will discuss basic information about cereal grains and grasses. The cereal grains form part of the Gramineae (Poaceae) family and have four subfamilies.
Pooideae – which is subdivided into the Triticeae/Hordeae family (wheat, barley, rye) and Aveneae family (oats)
Ehrhartoideae (rice) subfamily
Chloridoideae (ragi and teff)
Panicoideae: which includes millets, corn, and sorghum
Non-cereal grains are grains from families other than the Gramineae family:
Amaranth from the Amaranthaceae family
Quinoa from the Chenopodiaceae family
Buckwheat from the Polygonaceae family
A grain is an individual fruit that contains a single seed in which the fruit wall and seed coat are fused and cannot be separated. Wheat, rye, barley, oats, rice, and corn are grains.
Seeds can have their coat separated from the fruit
Corn originated from the Americas and is the major world grain produces, while wheat originated from the Near East/Ethiopea and is consumed in pasta, wheat noodles, breads, bulgur, and couscous as examples. It is the second most produced grain. Rice originated from China and can be ground into flour and made into rice milk among other uses. Millet is the 6th most produced grain in the world and is grown in the African/Indian subcontinent for bird and cattle feed primarily. Amaranth is consumed in India as a cereal and also is ground into flour or popped into popcorn. Buckwheat (is not related to wheat) is used to make a dark flour in Asiatic and European dishes in the form of crepes, pancakes, bread, and bagels. Quinoa has it’s origin from the Andean regions of Bolivia and Peru.
Allergy to wheat is fairly common and is IgE mediated (common from of allergy pathway) to different components in the wheat. In childres, a reaction to the omega-5-gliadin component is the most common cause of allery. In Baker’s asthma, its the alpha-amylase inhibitor that is the wheat component causing the reaction. However, the most common allergen in wheat is the Lipid transfer protein (LTP). Allergies caused by these generaly are in the form of rashes, hives, respiratory reactions such as wheezing, abdominal pain., nausea, vomiting, and anaphylaxis symptoms. These are more common in childres. It is possible to have reactions to cooking vapors as the grain proteins are volatalized into the atmosphere. Hives can result from toucing certain grain proteins in susceptible individuals.
IgE-type reactions have been found to occur in all cereal grains except for sorghum. Wheat is the most common IgE mediated allergen causing food-dependent exercise -induced anaphylaxis at its extreme (where a person gets anaphylaxis upon execising after exposure to wheat) and also Baker’s asthma, in which wheezing occurs during the baking of wheat-containgin items.
Rice can also caause IgE mediated reactions in some individuals, especially on exposure to rice dust or from boiling rice.
Eczema can result from or be worsened by food alleries. Eggs and milk are the most common culprits, but wheat is the third most common cause of worsening eczema and atopic dermatitis in children.
Milk products and wheat products can cause an allergic eosinophilic esophagitis allergic phenomena that causes chronic reflux symptoms (GERD), vomiting, abdominal pain, weight loss, and food impactions.
Grains (oats and rice), wheat, and barley can cause a Food Protein Induced Enterocolitis (FPIES) that results in nausea, vomiting, and diarrhea two to four hours after eating products with these grains in them. it can result in dehydration and shock in some. Chronically, a perason can get chronic nausea, vomiting, and diarrhea, with low blood albumin levels.
Celiac disease is the most famous process that results form wheat exposure and is the focus of this segment. It is an immune mediated small intestine inflammatory process caused by dietary gluten. The sources of gluten are:
Triticale ( a newer source of gluten used in breads, pasta, and cereals)
In summary : Gluten sources include: wheat (durum, emmer, spelt, farina, farro, KAMUT® khorasan wheat and einkorn), rye, barley and triticale.
A wide variety of foods and food products may have gluten mixed in the product. Croutons and flour-cereal and brown rice syrup are gluten sources. Imitation seafood, bacon, pasta, and processed lunch meat have gluten, as does self-basting poultry, soupd, stuffing, salad dressing, and communion wafers. Also, play-dough and crayons may have glutenin them as well.
Celiac disease results from an autoimmue reaction to the Gluten component of wheat and results in many manifestations:
Anemia, dental enamel defects, osteoporosis, arthritis, and elevated liver function tests (transaminasemia) are vague manifestations. SOme people develop neuroapthy in the form of tingling in theri hands and feet. Abdominal pains, nausea, and bulky stools may be present. Growth failure, weight loss, and vitamin D deficiency can occur. there has been an association of migraine headaches, depression, and eppilepsy with celiac disease. Vitamin deficiendies found in celiac disease include Vitamin B1 (thiamine), Vitamin B2 ( riboflavin), Vitamin B3 (niacin), Vitamin B6 (pyridoxine), Vitamin B12, as well as Vitamins A, D, and E. Also copper, zinc, carotene, folate, ferritin, and iron levels may be low. This is due to malabsorption in the gut from the chronic inflammation.
With celiac disease, there is mucosal inflammation throughout the small bowel, leading to vllous atrophy (the absorption of the gut is through the villi) and crypt hyperplasis inthe small bowel. This leads to recurrent diarrhea, malabsorption, weight loss, bloating, and lactose intolerance.
There is an association of celiac disease with recurrent miscarriages.
Other asscoiated conditions include aphthous stomatitis (canker sores), cerebellar ataxia (incoordination), dental enamel loss, osteoporosis and bone mineral density decrement, atrophic glossitis (burning tongue), pancreatitis, myocarditis, menstrual irregularities, and growth delay problems.
There is an increase risk of type 1 Diabetes as well.
The incidence of celiac disease is 1:100 – 1:250 in whites of European ancestry. It is rare in those of Chinese, Japanese, and sub-saharan African descent.
Testing can be performed by serum testing for IgA/G antitissue transglutaminase antibodies, which are elevated in the disease primarily. There are other serological test as well. If there is high suspicion of the disease, an endoscopy to look at the small intestine, with a biopsy, would be indicated. One should be checked for vitamin deficiencies in Vitamins A, D, E, and B vitamins, as well as copper, zinc, carotene, folate, ferritin, and iron levels.
A Dual energy Xray Absorptiometry scan (DEXA) scan can be considered in the right populations to check for low bone mineral density and osteoporosis
Be certain that your pneumococcal vaccination has been made up to date, because patients with celiac disease may have hyposplenism ( which has an immune function).
Gluten-free diets have become more common lately, especially as gluten has been attributed to causing memory loss, arthritis, and weight gain. People who have followed the diet claim to have better digestion, more weight loss, better immune systems, and lower cholesterol..
Gluten-free foods do not necessarily have more nutritional value than regular foods, in fact, many gluten-free foods are not enriched or fortified with nutrients such as folate, iron, and other agents. The gluten that is removed in the gluten-free foods removes certain desirable flavors that are then replaced by extra fat, sugar, and sodium. This may mean that some gluten-free foods may be worse with respect to their nutritional content than regular foods.
Gluten not only adds flavor to foods, it may also have beneficial effects on triglycerides and blood pressure. There are fructan starches in wheat that support healthy bacteria in the gut, so less gluten in the diet can result in an altered gut bacteria biome.
Another issue with gluten-free foods is that many of the products have rice flour or another form of rice in them. The problem with this is the arsenic content that this adds. Arsenic is carcinogenic. 17 % of the average person’s arsenic load comes from rice products, but this percentage increases in people who follow a gluten-free diet. It is possible that a person on this diet may be consuming 10 times the normal amount of Arsenic.
A gluten-free diet is not a weight loss strategy as most gluten-free foods have more calories, sugars, and fat. The best way to lose weight on this diet is to replace items with foods that have more fiber. For example, eating an apple instead of a sugary dessert.
Be certain you still include grains in you gluten-free diet, so you can replace wheat with amaranth, corn, quinoa, millet, teff, and rice. Also, fruit, vegetables, fish, meat and poultry have no gluten content, so include these in your diet, Be certain to watch out for the fat, sugar and sodium content in your gluten-free food.
Be careful that gluten isn’t sneakily present in your ‘gluten-free’ foods. For example, some gluten-free chips and energy bars have malt or malt extract or malt syrup, which are made from barley.
Per the FDA, gluten-free foods cannot contain an ingredient from a gluten grain unless it was processed to remove the gluten, and not just a measurement of less than 20 ppm gluten in the ingredient.
The foods that we eat produce acid in the body that can lead to increased bone breakdown and increase the risk of kidney stones as well. Certain food, such as cereal grains and proteins are associated increased with overall acid production. Fruits and vegetables produce a net alkaline environment in the body. This has a positive effect on bone health and muscle strength.
Too much acid intake from acid producing foods has negative effects in our bodies such as increased bone breakdown and osteoporosis and also muscle loss. In addition, certain types of kidney stones have increased formation when the diet is too high in acidifying food sources.
Of interest is that muscle strength can be improved by having a more alkaline diet. In an acidic environment, the body wastes muscle to get rid of the acid. The muscle releases amino acids which neutralizes the acidic hydrogen ions. Hence the muscular system acts like a acid-base status regulator.
Bones store calcium and this tends to get leached out in acidic environments. Bone is an alkaline reservoir that breaks down to neutralize body acid. Studies have shown that potassium citrate, when taken orally, breaks down in to an alkali which protects bone from breaking down, thus decreasing fracture risk. Potassium bicarbonate may also do the same.
Fruits and vegetables generally break down into alkali. Orange juice (which is acidic in the mouth), gets broken down into alkali in the body. So it is the metabolism of the fruits and vegetables in the body that makes them acidic or alkaline, not the way that they taste.
It has been found that diet intake can acidify or alkalinize the urine. This is beneficial in kidney stones, in which infective stones such as struvite and calcium phosphate stones can be reduced by acidifying the urine with a more acid diet. Likewise, cystine and uric acid stones can have the urine alkalinized to reduce the presence of these kidney stones.
The potential renal acid load of foods are listed below as PRAL. Negative PRAL foods (fruits and vegetable) metabolize to alkali in the body, whereas positive PRAL foods (cereal grains, protein) break down into acids in the body.
Nutrienta content (10) and estimated potential renal acid load (PRAL)b of 114 frequently consumed foods and beverages (related to 100-g edible portion
Key: Na = sodium; K = potassium; Ca = calcium; Mg = magnesium; P = phosphorus; Cl = chloride.
The characteristic postabsorption determinants of PRAL are also presented; these are the primarily protein-dependent urinary sulfate excretion: SO4; the phosphate excess: PEX (PEX [mEq] = PO – Ca – Mg); and the alkali excess: ALEX (ALEX [mEq] = Na + K – Cl). Each is estimated from the corresponding nutrient data by the conversion factors described in Table 1; PRAL (mEq of Cl + P04 + S04 – Na – K – Ca – Mg) also corresonds to SO4 + PEX – ALEX.
Data were derived from the manufacturer’s literature (Apollinaris, Bad Neuenahr-Ahrweiler, Germany; Volvic, Puy-de-Dome, France).
For those processed (ie, salted) foods for which the tabulated Cl contents deviated by more than ± 10% from the values determined under the assumption of an equimolar Na and Cl content, Cl was calculated from the listed Na data on an equimolar basis, ie, Cl (mg) = Na (mg) × 1.54.
For egg white protein, known to have a particularly high methionine and cysteine content, a 1.5-fold higher conversion factor (ie, 0.7332×10−3) was used to estimate renal sulfate excretion. Methionine and cysteine content related to 100 g protein is approximately 1.5-fold higher for egg white than, eg, for beef (32).
Average potential renal acid loads (PRAL)a of certain food groups and combined foods (related to 100-g edible portion
Data represent the arithmetic mean of the PRAL values of the respective foods listed in Table 2.
Beverages (phosphorus <30 mg/100 g) with several times higher sodium + potassium content compared to chloride, for example, red wine, white wine, certain mineral (soda) waters, and coffee.
Beverages (phosphorus <30mg/100 g) with similar sodium + potassium vs chloride content. Cocoa (alkali- and phosphorus-rich) also falls in this PRAL category. Because of a medium phosphorus content (eg, 28mg/100 g) some European pale beers have a relatively high PRAL value (about 1mEq/100 g).
Without dried fruits.
Irrespective of the type of flour (whole meal or white, plain).
Primarily whey based.
Less than 15g protein per 100g.
More than 15g protein per 100g.
Without asparagus (very low alkali excess) and spinach (very high alkali excess).
Bones need more than just calcium. They need Magnesium, Vitamin C, Vitamin D, and Vitamin K. There are medical factors as well that come into play with respect to bone health. For example, there are medications that can wash out your bones, such as prednisone, and diseases, such as parathyroid disorders, that can result in early osteoporosis. Get checked for these types of issues. From the nutrition point of view, there are measures you can take to help prevent osteoporosis.
Calcium: You need 1000-1200 mg a day. This is the backbone of your bones, literally!
Magnesium: The RDA is 310-420 mcg (micrograms) a day. Magnesium is tied in with bone health, in that a lower magnesium intake is associated with lower bone mineral density. Supplementation to near the RDA suppresses bone loss in postmenopausal women. Around half of your magnesium stores are in the bones. Food sources high in magnesium include: Almonds, spinach, black beans, kidney beans, avocado, peanut butter, edamame, and whole-wheat bread.
Vitamin C: This is important for the immune system and also linked to less bone loss. the RDA is 75-90 mg a day. Good sources include: oranges, strawberries, red and green bell peppers, kiwi, mango, and others.
Vitamin B12: The RDA is 2.4 mcg a day. Low B12 levels affect the nervous system as well as bone mineral density and osteoporosis. Sources include clams, salmon, haddock, canned tuna, milk, yogurt, egg, cottage cheese, breakfast cereals that are fortified.
Vitamin D: The RDA is 600-800 IU a day. It is essential to Calcium absorption in the gut. Supplementing at 800 IU a day decreases the risks of hip and non-vertebral fractures. Sources include: Cod liver oil, swordfish, canned tuna, fortified orange juice, eggs, and sockeye salmon.
Vitamin K: The RDA is 90-120 mcg a day. There appears to be a link between vitamin K intake and decreased risk of fractures. Sources of Vitamin K include: spinach, brocolli, green leaf lettuce,kale, swiss chard, collard greens, and brussel sprouts. If you take blood thinners, be careful of interactions with vitamin K. Ask your doctor.
Osteoporosis is diagnosed by bone density tests or fragility fractures. Bone densitometry is reported in the form of a T-score. A normal value is a value that is within a standard deviation (S.D) of a young adult mean bone density value. Anything that is 2.5 S.D. or more below the mean is osteoporosis.
Target serum 25-OH-D (25-hydroxy-vitamin D) level is 30-60 ng/ml. This is a measurement of how much vitamin D is in your system.
We obtain vitamin D from food sources (see link above) such as salmon, tuna, milk, and many other sources. Calcium is obtained in milk products and vegetables. See the link above for sources.
Calcium supplementation: There is no evidence that calcium supplements increase your heart attack risk up to 1000 mg a day when taken with 400IU of vitamin D, based on the women’s health initiative. The choice of calcium supplement would include Calcium citrate if you take anti-acid medications such as proton pump inhibitors or proton pump inhibitors. If your take calcium carbonate, it should be taken with food to increase absorption.
treat osteoporosis if you (1) get a hip or spine fractue (2) you have a T score of less than -2.5 at the spine, femoral neck, or total hip area, or (3) if your FRAX risk is > or = 3% for hip fracture and your T score is between -1.0 and -2.5.
Options for treatment include Biphosphonates, which are non-hormonal agents that inhibit osteoclasts, which break down bone. Examples are Alendronate (Fosomax), Risendronate, Ibandronate (Boniva), and Zoledronic acid (Reclast). each has various routes of administartion and frequency of administration. You have a choice of once a day, weekly, monthly, or even annual intake of some medications.
Side effects that are common with bisphosphonates include heartburn and esophagitis if you don’t drink enough water and stay upright for 30 minutes after taking the pill. Osteonecrosis of the jaw is rare, but more common in immunocompromised patients. If use occurs for longer than 5 years, there is an increased risk of atypical hip fractures.
Duration of treatment is not clear, but continuing bisphosphonates beyond 5 years does decrease the number of vertebral fractures, but not non vertebral fractures. Some doctors recommend stopping treatment for a while after 5 years of medication with Bisphosphonates.
Denosumab (Prolia) is a monoclonal antibody that inhibits osteoclasts and decreases bone breakdown. It is injected every 6 months and decreases vertebral, hip, and nonvertebral fractures as well as increasing bone density.
Estrogen antagonists such as Raloxifine is useful to prevent and treat postmenopausal osteoporosis. It reduces only vertebral fracture incidence, not non vertebral fracture rate. It can reduce the risk of invasive breast cancer.
Duavee, a combination of estrogen and Bazedoxifene ( a selective estrogen receptor modulator like Raloxifene), is useful in postmenopausal women with an intact uterus. It increased bone density. There was no increase in endometrial, ovarian, or breast cancer.
Contact your doctor to discuss the options right for you.
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