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

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:

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. 6’4″ 225 and can bench 200 lbs15 times and have a 34″ waist. Former athlete and avid skier, hiker, and hunter. A my big toe will knock me flat on my back once a year. It always happens to me during a change of seasons. I am talking a week at a time unable to wear a shoe. I am 41. I don’t drink. Body chemistry. First, never fast! Second, cook your meat well done. When you start burning fat instead of sugar (ketosis), the ketones prevent you from expelling uric acid. Once you get here, it is too late. There is nothing you can do but hydrate and let it run its course. Naproxen (anti-inflammatory) sometimes cures it for me but is never prescribed by doctors. I found it quite by accident as it was the only thing we had in the house and my wife used it for her back. Your daily maintenance is HIGHLY important. Potassium and Vitamin C and multi-vitamins, combined with magnesium (blood flow) are crucial. No processed fructose. Organic raw cherry juice (shudder) helps. Then, if it ever hits, you MUST give in and have dairy. Yogurt, smoothies, and broccoli, Brussel sprouts all are good. Even then, be prepared because if like me, it is hereditary, grit your teeth, ice your foot, and cuss a lot, because it hurts like hell.

    Pete wrote on September 18th, 2015
  2. I have an occasional flare up in the big toe, usually after wine and or junk meats like hot dogs. I have excellent results with tart cherry capsules. A couple for 2-3 days takes care of it, plus staying away from alcohol. Beer and wine seem to cause my flareups, not spirits.

    Digby wrote on October 1st, 2015
  3. Gout like symptoms can also be caused, from personal experience, by Leaky Gut Syndrome in turn caused by inflamed stomach lining which allows toxins to be dumped into ones bloodstream. Be that as it may be, the cure is essentially the same. Cut down on grains, particularly wheat, sugars and refined products (worst offender is HFCS, which in turn is made from GMO corn), and all GMO products.

    When one changes diet don’t expect a magic bullet response, but watch the trend. Be satisfied with a gradual improvement in health and reduced occurrences of gout like symptoms. You will have ups and downs as you refine yr diet thru trial and error – stick with the trend!! My personal improvement over 6 months can only be described as amazing – from not being able to walk to running 2-3 miles in 12 months, now almost completely pain free and without taking any medication or a single pill.

    The other point here is that the medical and pharmaceutical industries are not your friends. They want to treat symptoms not causes, so you keep coming back for more medications. In fact the medications in almost all cases are toxic to you.

    Gotta take personal responsibility for your own health and not outsource it!

    Ted Daniels wrote on November 20th, 2015
  4. Gout like symptoms may be caused by Leaky Gut Syndrome where certain foods irritate the stomach lining so toxins leak thru to the bloodstream. In my case I cured my gout completely by cutting down on bread and boosting veggie intake. Never had high uric acid but would be crippled with pain in knees or ankles or toes. 12 month of revised diet got rid of it all and have gone from not being able to walk to running 2-3 miles – all in 12 months.

    One has to take personal responsibility for ones health – the medical and pharmaceutical industries are not one’s friends. Watch the trend for improvement as diet changes are not magic bullets or feel good solutions. Go with the trend and experiment.

    Ted Daniels wrote on November 20th, 2015
  5. I had about 4 gout attacks in my life (at the rate of once a year). Going through all the websites to find the cure was very frustrating since I tried to avoid beer, tart cheery juice and organ meat but the gout flareups revisited once a year or so. After the last attack, I realized that the diet soda could be the trigger of my attacks. Looking back, I had very little knowledge about how diet soda contained the sweeteners that were bad for your body. Ever since cutting down carbs and eliminating sugary drinks (regular and diet) I have been gout free for about 2 years.

    As far as I know, everyone’s trigger is different. Generally I learned that Fructose, Alcohol and insulin resistance contributes to gout attacks. Diet soda doesn’t contain Fructose but I don’t know what sweetener like Aspartame can do to my body.

    I suggest:

    -Avoid sugar at all cost including artificial sweeteners (Eat low carb/primal etc)

    -Avoid fruit juices because of their Fructose content (Whole fruit may be okay because you are having fibers also)

    -Try intermittent fasting to reduce insulin resistance

    -Reduce your alcohol intake

    These are nothing that you haven’t learned from this site but researching the cure for gout can be very frustrating.

    Please note that I heard you may get “healing” gout attack during rapid weight loss or fasting. I don’t have knowledge on this subject. It may be due to your body trying to get rid of toxins from the breakdown of your fat cells.

    Zaw Htut wrote on March 5th, 2016
  6. Hi Mark. I’ve been mostly Paleo for a year now, drink some wine and fruit smoothies every morning. Is there a link between paleo for a sustained period of time and now fruit and wine now becoming inflammatory for me? I’m considering reintroducing white rice and totally eliminating fruit and wine for a period of a month to see if that helps? Thoughts?

    Claire wrote on April 24th, 2016
  7. “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.”

    Basic misunderstanding of gout. The problem is caused by the immune system attacking microscopic crystals, not the crystals themselves.

    Hugo wrote on July 3rd, 2016

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