Dear Mark: Risk of Gout?
Every 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:
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!
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Posted By: Mark Sisson
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.
Celery seed extract cured my gout.
http://www.myhealthmybody.com/trellis/ADM4515%20Celery%20Seed
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.
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.
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.
Excellent post on a difficult subject. It does seem to always boil down to “Eat a healthy, real food diet!”
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.
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.
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.
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?
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?
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…
Uric acid is a toxic metabolite of yeast and fungus, Dr. A.V. Costantini, former head of the World Health Organization believes that high levels of uric acid is a result of mycotoxicosis not a ‘metabolic disorder’.
“Nearly every medical school in the country teaches its students gout is caused by uric acid. They teach that when uric acid reaches critical levels that it forms crystals in the joints causing gout. These schools teach that uric acid is created by the body itself and not from outside sources.
Dr. Costantini, retired head of the World Health Organization (WHO) Center for Mycotoxins in Food 1994, concluded from the work of he and fellow researchers, that it can’t be proven that the body creates uric acid. They found that uric acid is more than likely of fungal origin, and entered the body from the outside.
Further studies revealed that urate crystals found in patients with gout occurred days after the the inflammation became present. So he stated that uric acid was not the cause of pain experienced by gout patients. He offerred a $1000 reward to any one that could prove him wrong. To this day no one has collected.” http://goo.gl/RzY32
“The unified concept of a fungal etiology and an anti-fungal mode of action of anti-gout drugs provides a clinically meaningful therapeutic drug and dietary approach not only for the physician, but, most importantly, for the patient afflicted with gout, particularly those who are beer drinkers and are consuming other yeast-fermented beverages and foods such as wine, bread and cheese.” http://goo.gl/baq53
Never had another case of gout after I increased my water hydration daily to 8 glasses per day. The water flushes everything away.
I am a student in chiropractic school and we, in our pharmacology class talked about how it is the fructose that causes gout and not animal products…glad to see this topic becoming more popular and the truth coming out!
Which chiropractic school do you go to? I was just about to forward this to the person who taught our clinical lab class at the University of Western States.
For me, alcohol=gout. I have had no gout issues while eating primal (and keeping my alcohol in check).
Hi Mark,
Great article on gout! I wish I had read this fifteen years ago.
Prior to going on a primal diet I suffered from severe gout for fifteen years. During the last couple years I spent literally 50% of my time limping, and that’s if I could walk at all. Since going primal 6 months ago my gout has completely disappeared.
As for background information; I’m a 47 years old male, 6’1” @ 175lbs. I have always been athletic and exercised regularly – when I wasn’t laid up with gout. My mother had suffered from gout for many years until she had a successful kidney transplant, which ended her problems with gout, among other things. My guess is her kidney failure may have been linked to gout or her daily gout medication (allopurinol) of thirty years. My nineteen year-old son also has gout, so it’s likely there’s a genetic component at work here.
I first began having gout symptoms around the age of 30 and it got progressively worse each year. I tried every “natural” remedy I could find (cherry juice, apple cider vinegar, baking soda, lemon juice, garlic pills, fish oil, ground ginger, berries, etc. etc. etc.) and all the standard pharmaceutical recommendations from my doctor (allopurinol, uloric, colchicine, colcrys, indomethacin, etc.). Nothing worked and things only got progressively worse as time went on. Surprisingly, doctors have no idea what causes gout and I spent countless hours researching gout on my own and never heard about fructose being the cause until after I went primal. A quick Google search on gout cures will produce an amazing array of web sites and forums devoted to gout related quackery. I say “quackery” because I tried it all systematically and nothing came close to working. As much as I like cherries and apple cider vinegar, I am now convinced that there is nothing you can eat, drink or rub on yourself that’s going to prevent or cure gout. Forget about grandpa’s magic gout elixir. If you don’t want to get gout, don’t eat anything with fructose. Period. It’s all in the studies Mark cites in this post. And although I haven’t experienced a correlation myself, I think there’s some evidence that alcohol may play a role in amplifying gout, especially when combined with fructose. If you’ve got a serious case of gout it probably wouldn’t be a bad idea to also consider giving up booze for while in order to establish a baseline for yourself. If all goes well you can add alcohol back in gradually and see what happens.
My diet had always been pretty decent, at least according to conventional wisdom. I didn’t consume much sugar, fat, red meat, purines or excessive alcohol. I was fit, I exercised, I didn’t smoke, I got plenty of sleep and I wasn’t stressed out. What I have since learned is that I am particularly sensitive to fructose and even relatively small amounts of sugary food will bring on an acute gout attack. I could have saved myself a lot of trouble if someone had told me to just cut out the sugar fifteen years ago. I don’t understand why something so simple is so entirely unknown in the medical community.
I hope a lot of people who are suffering from gout find this post and give the primal diet a try. In addition to gout, I had chronically painful foot and knee joints that I thought were the result of residual damage caused by repeated gout attacks over the years. Whatever those arthritic-type problems were, they were eliminated along with the gout and my feet and knees are virtually pain free now. I also experienced the total disappearance of irritable bowel symptoms and heartburn. When I think back on it I’m amazed at how much discomfort I was putting up with on a regular basis. I think I just chalked it up to getting older. I think if I didn’t make the move to a paleo style diet I could have ended up with some very serious health problems before too long. I’ve also been able to drop 25lbs almost effortlessly along with improving my body composition. Moving to a more high intensity training program has allowed be to get better results while spending a lot less time doing it. My wife and several family members have had some great results as well. I’ve been able to glean a lot of good information from the MDA web site and I thank you for all the good work you are doing.
Best regards, *LB
I have had gout for 20 years. I have been primal for the last two. It has not caused me to have any flare ups. I have learned to combat gout entirely through nutrition. Folic acid and VItamin E help suppress the uric acid. I also read in Poor RIchards Almanac that cherries will help as well. So when I start to feel it I drink a swallow of pure organic black cherry juice. Also if you do get a flare up capsaicin will actually null the pain.
I have found that monitoring my intake of sugars to be far more important that purines. I eat steak and chicken almost every day.
Also stress has been linked to outbreaks. Not sure if this is anecdotal or what. But exercise helps with gout and stress so it seem fairly obvious.
I find that as long as I am exercising, watching sugar, taking folic acid and vit E everyday I nearly never get it. It is only when I fail to do these thing that I get flare ups.
Hope this can help somebody.
I love living primal. I will never stop eating and living this way.
It’s been about a year since my last gout attack, which happens to coincide with eliminating sugar from my diet. I had started with a 6 days clean/1 cheat day per week to drop weight, and found that after most cheat days, I would suffer from a gout attack. The relationship between sugar and gout was painfully clear, and the science solidified in my mind after watching Dr. Lustig’s lecture on “Is Sugar Toxic?” I decided to go sugar-free for the entire summer to see if I could eliminate gout as well as the daily intake of allopurinol. I get the 80/20 rule, but for some conditions, 80/20 just isn’t worth the pain. I’ve continued to refine my diet and now eat on the paleo/primal spectrum 95% of the time – although I don’t eat organ meats because I’ve never liked the taste. In 1999, I had noticed a clear relationship between alcohol and gout and stopped drinking completely. Just last week, I had my first beer since 1999 (gluten-free, of course), and had no ill effects. Eliminating sugar was the key for me.
Another great benefit from going primal and one that I can use to help more of my clients, thanks for the article. Also, I’ve haven’t noticed any incidences of gout or flareup in clients. It’s easy to overlook the simple advice in the post… “Stay Hydrated” but so important during workouts on IF.
My husband suffers from gout, and while we have done a great deal of research his 2 main triggers appear to be yeast in bread and prawns. If he eats a lot of bread, or prawns twice in a week, he gets an attack. Other friends have gout attacks and all seem to be linked to yeast. Vegemite, brewers yeast (especially in beer) sometimes red wine. Cherries and cherry juice, water (adequate hydration) and gluten free all seem to help. Gout is a form of arthritis, and there is also a genetic and sex-linked (hormonal) component. Women tend not to get gout until after menopause. Doesn’t really seem to be any reason why primal eating would hurt, unless it includes your personal triggers.
Alpha Lipoic Acid completely normalizes my uric acid level.
Don,
Did ala drop your uric acid level below 6 mg/dL? Do you recall the before and after?
First of all great post.
I’m much like Adam G, I will get flare ups every summer, usually from mild dehydration. I would play ball 3-4 nights a week, and usually have a few beers by the pool to finish the night off. (Might have been a little more than mild dehydration)
I usually spent about a week not drinking/re-hydrating and getting a few more vitamins in my diet (the vitamin c is a good hint).
I’ve definitely noticed reduced flare ups since I’ve started the diet and as I’ve grown up some and had a child I tend to not drink as often and don’t quite have as much time to play ball as often.
I love knowing the way I eat is not attributing to it!!
Interesting. Didn’t know much about Gout before reading this. Nice to know that the PB doesn’t cause Gout and seems to actually be anti-Gout. Cool
Funny you should mention this, I’ve got an uncle who has the occasional outbreak of gout from eating too much cauliflower. He’s a vegan and doesn’t drink.
I am going to start using baking soda. My Dad had gout and he always put baking soda in his tomato soup and had soup about 3 times a week. I do all the other things. I have gout but I keep healthy and have not had an attack for years. I am diabetic and eat right. I eat low cholesterol, etc. I have lost weight but gained some back and will try to lose it again. I water exercise, bike, etc. I am a retired nurse of 69 years young. Thanks for the ideas. I do eat meat in moderation, green vegetables, no cheese or milk but I do tolerate yogurt. Tonight I went out for Chinese and had sweet and sour pork and boxed up half of it for another time. Be happy and healthy and move-Ever Onward!
I am using vitamin C. I do believe it is an auto-immune disease. Do not eat over 4 oz. of meat at a meal, do not eat rich banana splits, do not eat excessive any thing-nuts gave me a flare up once, chocolate once. All things in small amounts. Take care.
Try a couple capsules 3x/day of quercetin with bromelain. Knocks down gout quickly for me.
One important aspect of the disease which this article misses is that Gout is an auto-immune disease or it is a manifestation of auto-immune disorder.
I doubt gout is a single disease. I believe all the diagnosis “gout” defines are the consequences of high levels of uric acid.
An effective “home remedy” may treat the cause. Allopurinol likely only removes uric acid. One theory is that high levels of uric acid may be acting as an antioxidant to deal with an underlining metabolic disorder. What are the long-term consequences of using Allopurinol?
I agree that Gout can be caused by anything that causes excess uric acid deposition. I think the reason why primal diet and vitamin C helps and the reason why fructose increases problem is that it is associated with underline auto-immune disease.
And you could be right that uric acid is produced by body to deal with the inflammation or oxidative stress.
My husband suffers from gout attacks about 4 times a year… the doctor of course told him that the cause was purines and to avoid those foods containing high levels of purines. Then prescribed the pills. Funny he never told him NOT to drink so much beer.
Still can’t get him on board to change his lifestyle.
My husband has familial gout, and when his flares up, I simply adjust his plate from 50/50 meat and produce to 75/25 produce and meat. It’s the calcium in the greens that helps him most.
He still eats meat–even crab and beef–but he gets less of it when an attack is happening or about to happen.
For quick relief, he drinks a glass of water with 1T. calcium carbonate powder in it. Diet takes care of the rest.
Wish I could have read this article 5 years ago! Outstanding article Mark.
I suffered from gout for 5+ years with attacks becoming worse and occurring more often. I searched for answers, followed eating recommendations, even went as far as going vegan for 6 months while searching for a cure. The only help I ever found was drinking dark cherry juice (which helped immensely in reducing the pain quickly) and a few other antioxidants (acai, blueberries) seemed to help. Had a very bad attack after drinking a liter of freshly made carrot juice, started digging for info in different directions.
That is when I came across an unpublished Gary Taubs chapter / article posted by Robb Wolf at his site. It connected fructose intake with gout and explained the theory that for most people it wasn’t the purines but the clogging up of the kidney and it’s ability to clean out Uris acid that was the problem.
I began a primal diet and lifestyle almost 18 months ago, had a couple minor gout attacks in the first 2-3 months, but have been gout free since. I drink alcohol moderately, enjoy lots of red meats and shellfish, and have more energy than I’ve had since my early twenties…
I firmly believe that excess fructose was the primary driver of my gout attacks and I was probably getting lots of it from all of the ‘healthy’ fruit juices I was consuming.