Modern Western diets, in general, and ketogenic diets, in particular,  are thought to produce a chronic low-grade metabolic acidosis. Buffering capability may be supported in the following ways:

Avoid, when approved by the treating neurologist, anti-convulsant drugs that may interfere with acid/base (pH) homeostasis: valproate (Depakote; Depakene; Epilim; Epival and other brand names);  carbonic anhydrase inhibitors: topiramate (Topamax), zonisamide (Zonagran), acetazolamide (Diamox); and felbamate (Felbatol), which may inhibit beta-oxidation.

Monitor urinary pH. Urine may have a pH as low as 4.5 or as high as 8.0 depending upon the nature of the wastes to be excreted. Consistently low urinary pH may serve as an indicator that increased buffering of acids is needed.

Avoid processed foods. For example, vinegar (acetic acid), a common additive in commercially prepared mayonnaise, should be avoided. Excessive sodium chloride is another characteristic of processed foods. Chloride  is an acid mineral.

Avoid acidic beverages (colas and sodas, coffee, tea).

Learn how to manage stress. Strong emotional states increase muscle tension while, at the same time, reducing blood flow that oxygenates (alkalinizes) tissues.

Acids in medications and supplements are best avoided if possible. For example, ascorbic acid (vitamin C) can be replaced by Ester C, a patented alkaline form. Salicylic acid (aspirin) is best avoided. Restricting OTC medications as much as possible, and consulting a pharmacist as required, are good practices.

Awareness of KD dieters’ heightened susceptibility to respiratory acidosis and metabolic acidosis is important. Pneumonia and respiratory infections require prompt treatment. Chronic disorders, burns, severe diarrhea, and surgery causing accumulation of waste products are particularly threatening to those in ketosis. Metabolic acidosis can occur with diarrhea when alkaline minerals are lost through the digestive tract. Emergency treatment is required: intravenous (IV) electrolytes must be promptly restored. Dehydration must be avoided. Young children in ketosis who become dehydrated may lapse into coma. Compromised liver function may be a problem in KD patients with prior drug-induced liver impairment.