Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
23 Apr

Dear Mark: Risk of Gout?

goutEvery so often, a health malady arises that seems to clash with Primal living. And when a doctor brings it up, or a family member with intimate knowledge of the illness expresses concern, it can be intimidating and troubling. We’ve all heard how we’ll suffer heart attacks, diabetes, ketoacidosis, lowered marathon performance, kidney disease, and osteoporosis from “eating all that meat,” but that’s not what I’m covering today. No, today the subject is gout, which occurs when excess uric acid crystallizes and accumulates in the extremities. The jagged shards embed themselves in the joints, tendons, and other tissues, causing excruciating pain, inflammation, and swelling, particularly in the big toe. Suffice it to say, it is extremely unpleasant. Sounds great, right?

Let’s move on to the question that prompted today’s post:

Hi Mark,

What’s your take on gout? It apparently runs in my family, and while I haven’t gotten an attack yet, I’ve heard that a “rich diet” is the cause, which as I understand refers to meat and animal fat. Does this mean I shouldn’t eat Primal? What does the science actually say?

Thanks,

Will

In previous centuries, gout was described as a “rich man’s disease” or “the disease of kings.” Ambrose Bierce called it “A physician’s name for the rheumatism of a rich patient.” Basically, it primarily affected the upper class, the royalty, the aristocracy – those who could afford “rich” foods like meat, sugar, and port. In the mid-19th century, uric acid was identified as the causative agent in gout. Where does uric acid come from? Purines.

Purines are in pretty much every cell – plant and animal alike – because they provide some of the chemical structure of both DNA and RNA. When cells are broken down and recycled (like in digestion – yum, love those delicious cells!), their purines get metabolized right along with everything else. Uric acid is a major product of purine metabolism, and this is a good thing; uric acid acts as an antioxidant in our blood, protecting blood vessels from damage. But if for some reason an excessive amount of uric acid (hyperuricemia) is produced, enough to crystallize and lodge in joints and other tissues, you might get gout.

And so the standard tale goes like so:

Since we get uric acid from breaking down purines, the natural solution is to reduce one’s intake of purine-containing foods – right? That seems sensible. Reduce purines, which turn into uric acid, and you reduce hyperuricemia, which causes gout. Boom. Problem solved.

The problem for a Primal eater given this advice, however, is that the richest sources of purines also happen to be some of our most treasured foods: organ meats like sweetbreads, kidneys, liver, and brain; seafood like sardines, anchovies, herring, mackerel, scallops, and mussels; and wild game meat. Even beef and pork are moderate sources of purines. In short, everything we talk about eating on MDA is apparently contraindicated for gout prevention. How do we reconcile without destroying our brains with cognitive dissonance?

Easy. We look for the real problem. What’s more logical? That purines, which appear in all foods and particularly in some of the most nutrient-dense foods (like organs and seafood), are the problem? Or that hyperuricemia, an excess of uric acid, is the problem?

Let’s table the purine talk for awhile, given the importance of purine-rich foods in the ancestral human diet, to look at some other causes of high uric acid. What else causes uric acid to rise?

Dietary Fructose

When the liver is loaded with fructose, whether by excessive intake or a lack of liver-glycogen-burning activity, purine metabolism is disturbed and uric acid spikes. One study (PDF) found that 0.5 g/kg body weight was enough to increase uric acid levels by this mechanism.

Fructose also decreases urinary excretion of uric acid, so it’s a double whammy: fructose both increases uric acid and decreases its excretion.

Insulin Resistance and Metabolic Syndrome

Elevated insulin levels, especially the chronically-elevated levels (hyperinsulinemia) seen with insulin resistance, also reduce urinary excretion of uric acid. It’s no surprise that gout patients often display the classic trappings of metabolic syndrome, too, including diabetes, vascular disease, and poor glucose tolerance.

Back to purines. Does the advice to drastically reduce purine intake hold up?

Not really, according to this 2002 review paper (PDF). And the fructose/alcohol connection is looking stronger. Among their findings:

“A diet rich in purines will produce only a small and transient (read: impermanent) rise of serum urate by about 60–120 μmol/l (1–2 mg/dl).”

“Conversely, an isocaloric purine-free diet for 7–10 days will slightly lower serum urate by about 60–120 μmol/l (1–2 mg/dl).”

“A dietary study of 61 men with gout and 52 healthy men showed that although the average daily intake of most nutrients, including total purine nitrogen, was similar in both gout sufferers and control subjects, the group with gout drank significantly more alcohol than the controls.”

“Alcohol intake, whether alone or with a purine-rich meal, produces greater effects on serum urate levels than a high purine diet.”

“There is growing evidence that a low energy, calorie restricted, low carbohydrate (40% of energy), high protein (120 g/day, or 30% of energy) diet, with unsaturated fat (30% of energy) and high dietary fiber, is more beneficial in terms of lowering serum urate, insulin, LDL-C, and triglyceride levels, and hence reducing CAD risk, than the conventional low purine diet…”

Furthermore, research shows that eating purines actually increases uric acid excretion in order to maintain balance, almost like the body knows what it’s doing or something. Nah, couldn’t be.

It’s also worth noting that dietary protein has also been shown to increase uric acid excretion and lower serum uric acid. Hmm. It’s starting to sound like a low-carb Primal eating plan might just help, isn’t it?

What else should people at risk for gout or showing high uric acid levels do, other than reduce/avoid fructose, clear out liver glycogen every once in awhile (maybe by occasionally sprinting, which I could have sworn I’ve heard someone recommend before), and avoid hyperinsulinemia?

You could make sure you’re getting enough vitamin C, which is inversely associated with uric acid levels. Vitamin C is known to be uricosuric (increases the excretion of uric acid), so this association is likely causal. While I don’t think the average person needs to megadose vitamin C, it is exceedingly safe, and it’s worth a shot for people at risk for gout or hyperuricemia. If you’re at risk, shoot for at least a gram or two a day.

Be careful with intermittent fasting, which has been shown to reduce uric acid excretion (PDF). This may not matter, as in one study, complete fasting by obese subjects did not increase incidence of gout, even in one individual who had previously suffered it. Just be aware of the possibility.

Stay hydrated. Dehydration (at least through exercise) can increase uric acid retention and concentrations.

I’ve also heard a number of anecdotal reports from gout sufferers who successfully staved off attacks with a quarter teaspoon of baking soda dissolved in water, supposedly by increasing alkalinity. There haven’t been any actual studies on it, though, so bear that in mind.

But perhaps the best way to avoid gout? Get healthy. Eat well. Exercise intensely from time to time. Avoid refined sugar. Avoid obesity, hyperinsulinemia, and metabolic syndrome. If what you’re eating and how you’re living are giving you those things – or moving you toward them – they’re also likely to reduce your chances of developing or exacerbating gout.

Gout sufferers, what have you experienced since going Primal? Has it helped, or has it made the problem worse? Let us know in the comment section!

You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. I had a co-worker of mine cure his gout through a 2 week fast. His case was really bad as I saw him limping in the hall for months, eventually he got tired of taking drugs and fasted. His fasting also made him think of his diet and he greatly reduced all fried foods. Not fast food fried, but traditional Chinese fried.

    As far as I know he is generally light on the meat and high on the salad/fruit. I have to check back in with him now to see how his gout is doing, but the long fast did the trick.

    I also fasted for 6 days after his episode to see if my persistent inflammation would go away, but it did not and I like the idea of IF a bit better.

    rkd wrote on April 23rd, 2012
    • I’ve also heard anecdotes of fasting helping gout, and will try my darndest to find some peer-reviewed papers that explore this issue.

      On a related note:

      One reason why “juice fasts” may help things is a minor uptick in blood alkalinity, from all the alkaline plant matter without any acid-producing grains/meats/etc.

      Fasting my also help with pain perception via sympathetic nervous system effects. If your body thinks it’s shutting down, sometimes it starts not caring about pain so much!

      Kamal Patel wrote on April 23rd, 2012
    • Careful throwing around terms like “cured”. Gout is a fairly odd disease in that acute flare ups are not always consistent with the body’s current Uric Acid levels. An acute flare up may dissipate (and possibly even be helped by his fast). That doesn’t mean at all that his uric acid levels had improved .

      E. Dale Christensen, M.D. wrote on May 24th, 2012
  2. I’ve had three flareups of Gout in my lifetime. All three times were related to intake of brown liquor (whiskey in specific)

    After cutting out the whiskey I’ve had no further issues. Beer is fine, and clear liquor is also fine. I’m not sure why whiskey specifically caused me problems.

    Chris McCoy wrote on April 23rd, 2012
    • Because nothing good ever comes out of consuming brown liquor ;).

      fritzy wrote on April 23rd, 2012
    • It really is amazing how similar fructose and ethanol are treated by the body.

      Fatty liver disease, high triglycerides, metabolic syndrome, impaired glucose tolerance, and now gout.

      I always knew, through intuition, that the “conventional wisdom” was wrong about gout, and I have always felt completely safe eating the foods I eat, knowing that it must be some modern source of food causing this problem.

      Thanks for cracking this one open, and exposing the truth again Mark.

      Matthew Caton wrote on April 23rd, 2012
  3. I’m pleased this subject has been tackled, as feels like it’s deliberately avoided by primal folk at times.

    Unfortunately, I do suffer from gout periodically, although the trigger seems to be exercise (impact exercise like running) rather than diet.
    I’ve been ‘primal’ for 17 months now. I think I did see an increase in the number (and severity) of attacks when I first started – I nearly stopped for this reason, however after about 7 or 8 months, they slowed and, touch wood, I haven’t had a visit from the gout fairy for nearly 6 months.

    High doses of Vitamin C (1400mg / day is optimum apparently) seems to help, and the other thing many people swear by is tart cherries. I buy concentrated cherry syrup, which is expensive but anybody who has experienced gout will attest that it’s worth trying anything!

    I like to conveniently skip the link with alcohol, but it’s probably true :(

    Stevemid wrote on April 23rd, 2012
    • My uncle had really bad gout. He started eating a 6-12 dried tart cherries a day and his gout disappeared. This was many years ago and he still eats his cherries faithfully every day. (As he lives so far away, I have no idea if the gout returned. Haven’t heard any mention of it for years so I just assume it’s been fine.)

      Happycyclegirl wrote on April 23rd, 2012
    • What about apple cider vinegar to ruduce the uric acid?

      Gary wrote on April 24th, 2012
    • Tart or BlckCherry juice works! So does applecider vinegar. I had my first episode in April and could barely walk. Had to use a cane. Then, becuase of improper lifting, had a back injury and becuase of the icing it triggered another episode in me hip joint. But in both cases the cherry and vinegar gave almost immediate relief. I have started taking daily doses of black cherry pills and applecider vinegar pills. It is so worth the money, as I never want to feel that pain again.
      On a side note, I think my first attack happened becuase I was loosing weight too quickly and mainly eating meat with limited vegetables and still consuming sode (high fructose) on a regular basis.

      neal wrote on September 14th, 2012
    • I’ve just started eating Primal and am totally sold, I’ve dropped 14 pounds in 10 weeks. I’m exercising regularly, lifting weights and running.
      However I have had intermittent flare ups of pain in my feet which has made it very hard to run.

      I previously had 2 bouts of gout in my ankles but this pain is around the metatarsal bone in my foot. I have been to see a Cardio who checked the bone and said it was fine and pain is muscular or gout.

      I’ve read multiple discussions about gout on the forum – eat red cherries etc, but would appreciate any other advice on how to manage uric acid levels?

      Hoffie wrote on October 21st, 2012
  4. This makes so much sense. My dad had terrible gout when I was a kid and he loved chicken livers and gizzards, and he also drank a lot of beer. When he cut back on both, his gout cleared up dramatically. We always assumed it was dropping the organ meats, not so much the alcohol. I am new to Paleo and not ready for organ meats yet, but good to know gout shouldn’t be a problem when I do start them.

    Shannon wrote on April 23rd, 2012
    • Half of my meat intake consists of organ meats now. I started to experience trouble with swollen painful joints after I tried limit meat and increase whole grain consumption 5 years ago. Going to low-carb diet eliminated that issue together with pre-menopause symptoms, allergies, infections and much more. I have been avoiding alcohol for last 15 years because it interfered with my asthma and migraines. On LC diet sometimes I could have a glass of wine without a problem.

      Galina L. wrote on April 23rd, 2012
  5. Eating primal is a gout suppressor for me.

    I was diagnosed with gout a year and a half ago at 32 years old. I was pretty bummed, and the information about it is so varied that it was tough to know what to do. I decided I wasn’t going to go on meds for the rest of my life. I changed my diet and lost a lot of weight. I started out doing the Slow Carb diet, but eventually transitioned to primal. My doctor advised against a “high protein” diet, but we agreed that I’d try it and quit at the first sign of gout symptoms recurring.

    I never had problems. The primal diet doesn’t trigger gout symptoms for me at all, quite the opposite. I’ve lost weight, and feel better every day.

    I’ve had over a year to play with this, and the only thing that will for sure trigger a gout twinge is excessive beer consumption. Beer is a weakness for me, and I can’t say I never give in to temptation, but I probably consume 1% of what I previously did.

    laz wrote on April 23rd, 2012
  6. I haven’t had a flare-up since going primal, circa 2010, that’s eating at least a pound of salmon a week, which is supposedly one of the highest contributors to an attack (purines).
    I think the biggest cause (anecdotal-based)is foods that cause inflammation – as gout is nothing more than an auto-immune disease. And we all know how to fight inflammation on this diet.

    Phil Bear wrote on April 23rd, 2012
  7. I constantly hear about how I’ll get skin cancer from not using sunscreen and being in the sun all the time. Everyone seems to have a story about a friend or relative who used to lay out tanning and/or spend lots of time outside without “protection” but ended up with melanoma. Anyone else get this? I don’t have much to respond with other than “I’m not really worried about it.”

    Kris wrote on April 23rd, 2012
    • my son’s high school class got a recent guest lecture by an oncologist-about skin cancer. apparently, sunscreen does not protect from melanoma,but only “milder” forms of skin cancer. the conculusion was to spend some time outdoors for vitamin D, but not long periods in the sun from 10 am -2 pm or whatever the “danger” times are.

      HopelessDreamer wrote on April 23rd, 2012
      • I tend to agree that we should stay out of the sun at it’s highest point.

        First of all most indigenous people avoid the sun during this time. Secondly, our circadian rhythm naturally provides more natural protection from the oxidative damage caused by UV rays during the morning hours, when we are also most active (or should be) because of increased cortisol levels. We usually get sleepy in the afternoon, and we would tend to seek shelter to nap or rest, out of the sun. Cortisol rises briefly later in the afternoon when the sun is lower and less intense.

        It seems to me that our circadian rhythm would have us be active in the sun when it is less intense, and to avoid it when it is most intense. UV rays can be very intense in the noon of summer.

        Matthew Caton wrote on April 23rd, 2012
        • They have found that UVB is the only kind of UV that makes vitamin D. The amount of UVB depends on the angle of the sun. Between 10 and 2 are the best times for UVB.

          Mike wrote on August 5th, 2012
      • Bad news. It doesn’t protect against that either. I haven’t attempted laying out since high school in the 80s. Pretty much have spent the rest of the time AVOIDING the sun. It’s too bright and I burn anyway. I don’t even swim in my pool until evening. Beach? Not until the sun is setting (and I’ve burned then too, WITH sunscreen 70 SPF).
        Last week? Squamous removed from my nose-a nose that has been smeared in sunscreen religiously since I had a precancerous lesion removed 7 years ago. And a melanoma off my leg. Nice. I might die from a stupid mole. On top of that, I’ve exercised every day for over a year, been on the SCD for almost 2 years. Did it help? Nope. Neither did avoiding the sun and wearing sunscreen.

        K wrote on April 12th, 2013
  8. Here is the chapter on gout not included in the “Good calories, bad calories” by Gary Taubes in order to keep his book at reasonable volume http://www.fourhourworkweek.com/blog/2009/10/05/gout/.
    Gout was a Medici curse, they even died of it(who was not killed).

    Galina L. wrote on April 23rd, 2012
  9. My coworker suffers from gout, and ever since I converted him to Primal he’s had far fewer flare ups. I don’t know if everyone would have the same success with it, but Primal definitely helps!

    Burn wrote on April 23rd, 2012
  10. Altering purine intake has made no difference for me. Fructose and alchohol do so very much, though.

    Nick wrote on April 23rd, 2012
  11. Almost five years ago, I was 231 lb (I’m 6’1″), eating mainly junk food, candy, soda, and an average of about 12 ounces of sugary alcoholic drinks with about 7% alcohol per night.
    And was diagnosed with gout. I didn’t like the doctor’s advice regarding dietary restrictions, so decided on my own to cut out sugar and alcohol immediately and go on a macrobiotic diet. The gout disappeared quickly and never returned.
    A year or so later I moved away from the macrobiotics, into Primal.
    Now at 175 lb (thinking about going down another 10 or so…), feeling good.

    Boo wrote on April 23rd, 2012
  12. Thanks for the writeup, Mark. I’ve heard many people pan primal/paleo due to “protein crystallizing your joints.” It’s uninformed and silly, but all too common.

    One other factor not mentioned in the article that can aggravate gout is rapid weight loss, believe it or not. Key things — keep hydrated, and talk to your doctor about something like allopurinol if your uric acid levels are elevated. I’d tried doing primal weight loss with a high uric acid level a few times, and it always kicked off gout flares. After getting on allopurinol, I’ve been able to lose weight primal style and not encounter flareups.

    Gout can be very frustrating, as many doctors adhere to the purine dogma and will advocate a diet of garbage to accompany any medicine.

    Sometimes a rapid change in some portion of your diet can trigger a gout attack even if you’ve never had one before — starting or stopping regular alcohol consumption, losing weight, changing diet makeup, etc. If this happens to you, I’d strongly encourage getting your uric acid level measured. Gout flareups are a warning sign that you’re getting crystallization, and that won’t happen in just your big toe. Fingers, elbows, knees.. most any joint can get gout. Be informed, and eat well! :)

    lynch wrote on April 23rd, 2012
    • I’ve been on a ketogenic diet for about 3 and a half months and lost 30 lbs. Recently I had a massive gout flare with pain in nearly all of my joints. uric acid was 7,7 a few days after the flare came up.

      My train of thought now is that I should slow down my weightloss with a higher carb intake (not being in ketosis all the time). Of Course I don’t want to eat pasta etc. again but instead fruit like bananas and apples. But if fructose also has a bad influence on uric acid levels, would you advise to stick to keto and take meds until I lost enough fat?

      I am a little lost right now. I know this way of eating is the right way for me to lose weight and live the rest of my life, but I never had problems with gout and it really sucks.

      Sadly my doctor advised me to eat less meat. She believes the higher meat intake is the cause of the gout flare and is not fond of the idea of giving me meds to lower the uric acid.

      I could need a little advice :)

      pat wrote on April 23rd, 2012
      • Suggest you include ‘safe’ carbs (sweet potatoes, white rice) rather than fruit – per Jaminet’s Perfect Health Diet.

        Sharyn wrote on April 23rd, 2012
      • To be honest, you may want to re-evaluate whether you want to be keto all the time. Being in ketosis has it’s benefits, but always being in ketosis has downsides.

        One being insulin resistance.

        http://jpet.aspetjournals.org/content/304/3/994.short

        I don’t bring this up to bash on anyone’s lifestyle, but I’m concerned that people making a lifestyle out of ketosis will one day regret that decision.

        Also, I don’t mean to confuse you more, but you don’t need ketosis to lose weight fast. In fact, I just helped a client lose ten pounds in ten days (not a program, just a coincidence). She was a low-carber, aka keto, but weight loss was stalling for her. We added some carb refeeds, and higher protein intake all around, and the weight started falling off. I’ve got to say she is my star client right now though.

        Matthew Caton wrote on April 23rd, 2012
        • yeah, I know you don’t have to be in ketosis to do that. Actually I already made the decision to not be in ketosis all the time and see how it affects the gout flares. but adding fruit to my diet to get out of ketosis might be a bad idea if fructose can mess with the uric acid level as well.

          so the suggestion of some sweet potatoes and white rice by Sharyn is something I will look into.

          pat wrote on April 24th, 2012
      • This is what I do to avoid gout, from which I suffer. First, be aware that any soreness/stiffness in the mornings, in the absence of pre-existing pathology in a relatively young person, is probably low level gout. Therefore do not exercise on those days of walk a lot because that will aggravate it.

        Go to bed well hydrated and stay well hydrated during the day. It is nearly always overnight that crystals grow, due to lack of movement and circulation.

        When I think it may be coming on I take cystitis remedy (urine alkalinizer) before bed. This works a treat, and, in combination with naproxen before bed will limit an acute attack to 3 days absolute max in my case, and will prevent an acute attack when it feels like it’s threatening.

        Most gout is due to problems with excretion, which is why the alkalinizer works. In my experience high fructose and alcohol are to be avoided if an acute attack threatens, but managing myself as I do currently (and (I eat a relatively large amount of meat) has meant not having to avoid alcohol.

        Result!!

        davoid wrote on May 6th, 2012
    • Thanks for posting this comment Lynch. I though I was the only one who would get gout attacks whenever I lost weight (always happened after I would lose 30lbs quickly). I mentioned this to a few of my primary care doctors over the last 20 yrs and they all had the same reaction…that I was making it up and that losing weight would prevent gout not cause it!!!

      jon o wrote on April 23rd, 2012
  13. Does me good to hear this info finally getting out. I still feel terrible for one of my first hospital patients as a newly minted RD. He was a truck driver suffering with gout and trying to eat as low purine and possible and getting no relief. I didn’t have any answers for him then.

    Real Food RD wrote on April 23rd, 2012
  14. Interesting! Overally, I’d say going primal has helped with my gout & my health in general. Gout runs strongly in my family & I got it at about age 25 (after an injury in my big toe joint). I did not fit the bill as a typical sufferer as I was young, in good shape physically, didn’t drink much alcohol, etc. The hereditary link with gout can be pretty strong though.

    I have to admit my last gout attack was the morning after eating beef liver. ;-) However, overall since eating primal I’ve had very few attacks. And I have eaten liver since then with no issues (although, it’s been chicken liver not beef).

    Great article! I’ve heard of the fructose connection before but never seen it explained so well!

    Sara wrote on April 23rd, 2012
  15. As a long time sufferer of gout, this was a concern of mine when I started going primal about 8 to 10 months ago. Turned out I had nothing to be worried about. I have had not attacks since, not even a peep. In addition I have dropped from 245 to 179 lbs (and counting), reduced my blood pressure and feel healthier than ever. Still fixing all the damage that the SAD diet caused, but I’ll be primal forever. Thanks Mark for the post and this site.

    Larry wrote on April 23rd, 2012
  16. My brother has gout and he doesn’t even come close to following a primal diet. If I had to guess I’d say alcohol is the biggest culprit– though he loves his dessert too…

    sqt wrote on April 23rd, 2012
  17. Went from vegan to primal a year and a half ago. Everything has gotten better —– EXCEPT for gout. Gout has flared up tenfold.

    Bob Crason wrote on April 23rd, 2012
  18. My first gout was in my knee, and it was so bad that I got referred to an orthoscopic surgeon who did some imaging. When it came back and he told me “go away, you just have gout”, he seemed almost disappointed that he didn’t get to cut my knee open.

    I had several more attacks, and I tried all the CW about cutting back on “good protein sources”. I tried less conventional wisdom about adding berries, dark cherries, and (to treat acute attacks) baking soda.

    At least the baking soda helped, some. The cherries and cherry extract, maybe. The fish oil, maybe.

    Over time, I came to discover an interesting correlation.

    Stress at work –> drinking more sugary soda –> Gout attack

    Some literature was connecting the fructose to gout, but I am not sure that the carbonation might not also be a factor. So I tried cutting out the soda, and that helped when I was consistent, but eventually I ended up on 300mg of Allopurinol. That really helped.

    Since going primal, (December 2011) I have not been as consistent about taking the allopurinol, and I have had none since returning from an international trip in early March. (I did take it on the trip because I knew that I was going to be eating more non-primal foods than normal, and a gout attack overseas would have been particularly bothersome.)

    Anyway, so far so good. At the first sign of trouble, I won’t hesitate to run back to the allopurinol, but I am not convinced that my body still needs it to get by.

    Philmont Scott wrote on April 23rd, 2012
    • PS: I also wanted to mention that I am also down 34.5 pounds since December 8, 2011 — my Primal birthday.

      Philmont Scott wrote on April 23rd, 2012
    • be careful going back and forth on/off allopurinol because I’ve heard that is a known gout trigger too.

      I agree with an earlier post saying that the change in stress, diet and alcohol can trigger an attack.

      I researched this about a year ago when I first went primal and was having more gout outbreaks. I ended up increasing my allopurinol to 200ml and no more outbreaks.

      Mike Gallagher wrote on April 23rd, 2012
  19. I have found Primal to help. I suffered from gout regular. I also did NOT drink alchol ever. I was oveweight and out of shape. I have been in shape before and still had an attack from time to time. The more out of shape and the more SAD I ate the more often the attacks came. I decided to get back in shape and I wanted a quick weight loss plan, so I started Atkins. That worked great as I read on I descovered MDA. Long story short, I have lost about 80lbs am in pretty good shape and have been gout free for several months now. I started Atkins-to-Primal Dec 26 2010. I still eat a junk meal a couple times a month, I think now my body can a piece of cake or a cookie twice a month. I do believe it was the fructose in store bought bread that was the culprit. Also Braggs Apple Cider Vinegar helps. It blocks some of the acid from forming, when I have something bad I always follow it with a 2tbsp/8oz of ACV and water.

    Jeffrey wrote on April 23rd, 2012
  20. Hey, Mark:

    Nice column. I’ve had gout for 15 years — at least — and over the last 18 months, it’s gotten to the point where I just can’t shake it. I have some joint affected by gout almost daily. When I first started having chronic gout, I thought losing weight my help and that’s how I found MDA. I lost about 60 pounds and stay on the paleo/primal diet at least 80 percent of the time. The diet hasn’t helped my gout, but it hasn’t gotten any worse.

    I am seeing a holistic doctor now and I’m taking supplements to treat a liver infection, which my specialist (a chiropractor who also does Nutrition Response Testing) said I had. He has me on a ton of supplements. In addition, he recommends a paleo diet, so I thought that was encouraging. The doctor said it could take three to four months to clear the infection naturally and get my liver back to 100 percent, which he believes will get the uric acid out of my system.

    My symptoms are lessening and there are days when I feel like I could almost sprint without too much pain.

    Bottom line – I believe the paleo/primal lifestyle will work once my body gets healthy on its own and starts doing what it should do.

    Thanks for everything you have done for me.

    I’m out.

    Rodney wrote on April 23rd, 2012
    • If I may be so bold why not go 100 percent Paleo for 1-2 months? The 80/20 rule doesn’t apply to people with auto-immune issues. Seems like it would be worth it to me if I had gout. You are saying that 20 percent of your diet is not Paleo so it seems like maybe going a 100 percent would give you a better baseline to see what if anything in your diet flares the gout.

      David Cole wrote on April 23rd, 2012
      • I don’t think gout is classified as an auto-immune disease. It’s caused either the over production of uric acid or the body’s inability to get rid of it fast enough. The body attacks the crystals during an outbreak but this is a normal reaction.

        Mike Gallagher wrote on April 23rd, 2012
    • Paleo/Primal may not be sufficient for someone with an existing auto-immune disorder. I’ve read posts here and on other paleo bloggers websites such as Robb Wolf and Chris Kresser about an Auto-immune Protocol diet to eliminate certain foods like nightshades that would otherwise be okay on a typical paleo diet.

      Josh wrote on April 23rd, 2012
  21. I used to suffer extremely painful gout flare-ups every summer (probably triggered by mild dehydration).

    Though I don’t drink alcohol, I was a moderate non-diet-soda drinker. I quit soda about 4 years ago have not had a recurrence.

    I never did give up red meat (even during symptoms), and this article makes me worry less about revisiting those days while living and eating primally.

    Thanks, Mark!

    Adam G wrote on April 23rd, 2012
  22. I have had gout and was on medicine to control it until just a few months ago. In September of last year I decided my way of losing weight wasn’t working and went primal. Since then I have lost 58 pounds and not surprisingly I don’t need the gout medicine any longer and have had no flare ups at all. Gout is related to arthritis and I can’t say my arthritis is totally gone, but it is a little better as well. Unless you are really gorging on the meat I can’t see that this diet is going to do anything but help a gout situation.

    Chuck P wrote on April 23rd, 2012
  23. I have hereditary gout. My first symptoms of it being in my early 40s after I injured the joint in one big toe. That seemed to trigger it. I suffered excruciating pain until I gave up alcohol and all forms of sugar, including grains. I basically went Primal before I knew what Primal was. I still like the occasional glass of red wine, but can only have it once or twice a month as I’m just too sensitive to it, in relation to gout.

    I would have to agree with a previous post that the 80/20 Primal rule doesn’t work for me. I need to be pretty much at 100% Primal to keep the gout at bay. Other than a little bit of arthritic stiffness in both big toe joints, I have no symptoms now that I’ve gone Primal. I also don’t need any medications.

    Sue wrote on April 23rd, 2012
  24. Hi Mark – “How do we reconcile without destroying our brains with cognitive dissonance?”

    This sentence alone was reason enough to read this article. I had to laugh out loud! Excellent!

    Gerhard wrote on April 23rd, 2012
  25. I’ve suffered gout for nearly 30 years. I actually thought it was turf-toe from football when it first reared its ugly head.

    While not fully primal, I have found gout to increase in two circumstances: While experimenting with IF and should I fall way off the wagon and subject myself to process foods – namely breads/buns multiple days in a row.

    I’ve not found any correlation with alcohol or meats.

    I limit breads/buns and have not done any IF and, knock on wood rapidly, I’ve not had any flairs in nearly a year.

    Dave

    Dave T wrote on April 23rd, 2012
  26. I had a couple of big toe issues before I went Primal. Funniest thing but cutting out grains, sugar and starchy stuff fixed many things, not just the gout problem. I have totally eliminated any gastric distress and ‘heartburn’ and my dry itchy skin patches cleared up. I even have not had any more problem with dry eye. Go figure !!

    Sitara wrote on April 23rd, 2012
  27. Mark,
    Interesting article but on what basis are you saying the average person does not need to megadose on vitamin C? what is megadosing? and on what basis are you saying 1-2 grammes should be ok?

    james wrote on April 23rd, 2012
  28. I suffered for about 5 years before I experimented on myself through diet.

    I cut protein to no effect, I never drink anyways, I cut high purine vegetables to no effect and cut table sugar to no effect.

    I cut fruit from my diet and haven’t had a flare up since (two years).

    Sam Van Horn wrote on April 23rd, 2012
  29. My gout definitely flared up after doing a primal diet. However, as mentioned earlier, its quite well known that weight loss can lead to acute gout attacks as the process for burning fat releases uric acid.

    I’m so far just depending on prescription drugs, i.e. allopurinol to prevent further attacks. I’m a little nervous to even attempt to go off of this as everybody that has gout knows how terrible the attacks can be.

    Trevor wrote on April 23rd, 2012
  30. I believe that my gout was caused by the diuretic Maxzide. Although their are postings online suggesting that it can cause gout, it’s not mentioned as a side effect. I suggested to my MD that I needed a change of meds to treat hypertension, which he did. Since then not gout and it’s been four years. This was pre-paleo.

    Mark Skvarla wrote on April 23rd, 2012
  31. How can you write a whole post about gout and not mention the chapter on gout that Gary Taubes deleted from his book GOOD CALORIES, BAD CALORIES? there’s a huge amount of info there as one would expect from Taubes, for instance the fact that dietary approaches to control of gout have largely been abandoned as ineffective.

    You can find & read the whole thing on Tim Ferriss’ fourhourworkweek dot com/blog/2009/10/05/gout/

    You’re welcome.

    cancerclasses wrote on April 23rd, 2012
  32. bill wrote on April 23rd, 2012
  33. Any time I went off my low carb primal diet, I would get gout in my right big toe, which tart cherry juice helped with a lot, but as soon as I was off the sugar/alcohol, the gout was gone. Can’t be purines in my case.

    Anon wrote on April 23rd, 2012
  34. I only ever got gout when I went off my low carb primal diet; tart cherry juice/supplements would help a lot, but the gout went away when I got off the carbs and wine. It can’t be purines in my case.

    Nan wrote on April 23rd, 2012
  35. Since being diagnosed with Gout, I’ve lost over 80 pounds going primal which I imagine has helped a lot. I do take a daily dose of Allopurinol with my vitamins and havent had any issues in over two years. Interestingly enough I had my first flareup of gout after increasing my fruit intake several weeks ago but was able to stop it with 100mg of indomethacin at the first signs.

    I am guilty of drinking a glass of red wine on most evenings. I certainly appreciate the article and will monitor my alcohol and fructose intake. I have not avoided any primal foods and thus far have had a lot of success on the primal diet. :)

    Kvalhion wrote on April 23rd, 2012
  36. Excellent post on a difficult subject. It does seem to always boil down to “Eat a healthy, real food diet!”

    Debra wrote on April 23rd, 2012
  37. Would drinking kombucha trigger gout? I have never had gout before. But had a recent bout of it about a month ago. I stopped all fruit and decided not to eat good grass fed bacon everyday. It’s better, but still some numbness on my big toe. I also haven’t drank kombucha everyday for the past month.

    Jenny wrote on April 23rd, 2012
  38. Man, make no mistake about it…going primal/paleo changed my life. Since having stopped eating fructose, whether fruit or High Fructose Corn Syrup, I have not had a gout attack. After having suffered three or four attacks per year for 20 years, life is pain-free. All the advice I followed over the years were for naught because I would continue to get attacks. (Hell, did you know caffeine is a purine?)

    Upon reading Sisson’s “Primal Blueprint,” gout has been a thing of the past. I’ve been eating a lot of meat with no problems.

    Got gout? Stop eating junk food but getting away from fructose is the biggest step one can take.

    Phocion Timon wrote on April 23rd, 2012
  39. I just read most of the comments before my post. Some mention gout attacks after startin a fast. A fasting/low calorie study was done after WW11 on returning soldiers. Many in the study had a gout attack after the study began. Several other low-calorie studies have also resulted in gout attacks. At the time, the researchers postulated the gout was caused by various chemicals reentering the system as the body drew upon the fat reserves in such abundance the body was unable to handle the influx.

    True? I don’t know but my first three fasts resulted in soreness in my thumb joints and big-toe joints. Not actual attacks but I knew from the discomfort that gout was definitely present.

    The last few fasts have been trouble-free.

    Phocion Timon wrote on April 23rd, 2012
  40. A scientific expert on uric acid told me that a mechanism of precipitating uric acid crystals (which is what causes the inflammatory arthritis of Gout) is dehydration. He thinks this is why gout is associated with alcohol use, especially beer, because people who chronicly consumption alcohol tend to not take care of their fluid needs.

    Thoughts on this anyone?

    Rebecca Schacker, DC wrote on April 23rd, 2012
    • My grandfather suffered gout, and my father has had a few gout attacks in the past 5-10 years. He drinks 4 liters of water a day (in addition to his 3 huge glasses of milky tea), and swears that he feels an attack coming on whenever he slacks off on the water intake. He doesn’t eat the best diet, however, so who knows how less water would affect him if he were eating Primal?

      Karen C. wrote on April 23rd, 2012
    • I was thinking the same thing. Both alcohol and sodas often lead to dehydration. Caffeine too for that matter. I wonder if dehydration might be a problem? The people I have known with gout are usually chronically dehydrated as well…it is a possibility…

      Nomad wrote on March 21st, 2013
      • I have a case of continuous minor gout, with tingling and stabbing sensations in many various joints and body parts. It started out with a high uric acid count which is now normal but I still have the tingling.

        I have found after 4 years of research and experience that gout is a problem of ph of the body. The purine theory has never improved my gout. What has and does improve it is decreasing the acid level of my body by eating a lot of vegetables and salads with my meat.

        I eat tons of meat – chicken, beef, bison, salmon, pork, all free range and/or organic. As long as I also take in lots of organic veggies I am fine. If I have eaten too much meat or “crap” with no veggies, the stabbing pains start up. I have found this to be alleviated almost immediately with a tall glass of good water with 1/2 to 1 whole fresh lemon squeezed in it. This is a testimony to the ph being involved because lemon water is extremely alkaline.

        My belief is take out junk food or any useless foods and drinks for the body and gout will improve or go away. Eat free range meats/wild salmon and tons of salads and veggies and healthy oils. Oh and eggs.

        Diane Marie wrote on November 9th, 2013

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