Dear Mark: High Uric Acid and Gout; From Vegetarian to Primal Without a Gallbladder

Foot  PainFor today’s edition of Dear Mark, I’m covering two questions. First, what’s the deal with really, really high uric acid levels? Assuming a person is fit with good body composition, feels good, and has no complaints, are they still worrisome? Can they still lead to gout? Maybe. Read on. And then I cover a question on the best way to transition from vegetarian to Primal. If that seems fairly standard, there’s a little wrinkle: the potential convert has no gallbladder.

Let’s go:

Just read your article on 12 reasons to consume more protein. My uric acid levels are pretty high at 40 on the scale… Doctor says i’ts on the verge of becoming an issue and can develop into gout. I don’t have any gout problems now, but I also don’t want them. I have been eating a Primal Blueprint diet for the last 21 months, and have dropped 27 lbs and 6 inches off my waist. I am 47 years old, 6′ 1″ tall and weigh 187 lbs now! I look lean and fit with good muscle mass and feel good. Any advice on the protein and uric acids?



Given that vegans have higher uric acid levels than meat eaters, fish eaters, and vegetarians, the standard recommendation to reduce meat intake in the face of high uric acid doesn’t really apply to most Primal eaters. In fact, protein intake usually increases uric acid excretion and lowers uric acid levels. But 40 (mg/dL, I assume) is astoundingly high. The upper end of the reference range for males is 7.2 mg/dL, with anything above that qualifying a person for hyperuricemia. Severe hyperuricemia, or anything over 10 mg/dL for males, is very strongly associated with gout. If that’s a correct reading, something is impairing clearance and it very well could lead to gout if it’s a chronic, rather than transient, issue. Until you get it figured out, I would reduce foods high in purines (which break down to uric acid). That means red meat, shellfish, and organ meats.

But let’s explore some possibilities:

If you’re in the early stages of a ketogenic diet, your uric acid levels will spike because the kidney disposes of excess ketones and uric acid through the same pathway. People new to ketosis are hit with elevated levels of ketones and an inability to utilize them all; as time goes on and you become keto-adapted (with tissues prepared to utilize ketones), serum ketones won’t be high enough to interfere with uric acid disposal and serum levels should normalize. That’s one option. If you’re not transitioning to ketosis (either because you’re not eating a ketogenic diet or you’re already keto-adapted), that’s not it.

Intermittent fasting can impair uric acid clearance (PDF). In that study, however, long term fasting only got uric acid levels up to 22.5 mg/dL per 100 cc of blood. You’re at almost twice that, so I doubt that fasting is the only cause here. It could make the issue worse, of course.

You might be really dehydrated. Severe dehydration concentrates the serum and throws the uric acid measurement way off. In fact, the only reference I was able to find for uric acid levels approaching 40 mg/dL were in patients with “volume depletion.” These guys had no kidney issues; they were just really, really dehydrated. A few days of IV hydration normalized the uric acid levels.

Intense aerobic exercise spikes uric acid levels for several days. The more fast twitch muscles you utilize, the higher it spikes and the longer the spike lasts. Heavy squats and explosive power training also cause a “remarkable increase” in uric acid levels of trained weightlifters. Since both high-intensity metabolic conditioning (sprints, HIIT, etc) and strength training are healthy endeavors, any related elevations in uric acid are unlikely to be pathological. You’re a muscular guy, presumably exercising on a regular basis, right?

Insulin resistance and metabolic syndrome are strongly correlated with hyperuricemia. It doesn’t sound like you have either of those, though.

It’d also be worth trying out some dietary modifications that have been shown to reduce uric acid levels. Cherries (especially tart cherries), vitamin C, and mineral water with good sodium bicarbonate content can all lower serum uric acid.

And watch out for your alcohol and fructose intake, as both increase serum uric acid.

I wish I could tell you to ignore the numbers since you’re fit, strong, and feeling good – but I can’t do that. It could be a perfect storm of acute but otherwise benign serum uric acid modifiers. I hope it is, because acute, transient elevations in uric acid are actually protective against oxidative stress (uric acid is an antioxidant in the right doses, after all). But 40 mg/dL is high. You should follow up with your doctor, get re-tested, and see if it was just a temporary, transient fluctuation before brushing it off. Make sure you’re hydrated, don’t fast, and skip your intense workouts in the days leading up to a re-test.

Good luck, Chris, and keep me posted!

My husband & I switched to a Paleo lifestyle this past mid May. He has lost 23 lbs and I have lost 12 lbs with just changing what we eat. We love how we feel, plus the fact that we don’t get hungry between mealtimes.

Our son, who needs to lose around 100 lbs, has been watching and is showing interest in going Paleo. The short version of his health history is he has a blood disorder (spherocytocis) that caused him to have his spleen and gall bladder removed at the age of 8. After that he steadily gained weight over the years. He is 17 years old now and has been a vegetarian since last fall. My question is this: IF he chooses to go Paleo should he switch cold turkey or transition gradually? The reason he went vegetarian was IBS issues. Without his gallbladder he has a difficult time processing and digesting fat.



That’s a big change – going from vegetarian to paleo/Primal without a gallbladder – and he’ll have to make it carefully.

When you’re a vegetarian, your body reduces its production of specific animal protein-digesting enzymes. You don’t need them, so why make them? Just a month or so is enough to downregulate enzyme production. So he’ll need a few days or even a week to begin producing enough elastase (which breaks down connective tissue in animal foods – cartilage, tendon, fascia, the delicious gristly bits) and chymotrypsin (which breaks down protein in general) to handle regular amounts of meat. As long as he doesn’t start out with two pounds of lamb shanks for his first meal back, he’ll be fine.

He’s only been a vegetarian for less than a year, though. I don’t envision a huge transition. I’ve had longtime (10+ years) former vegan friends who throw up the first time they have steak. Totally normal for them. Also, the fact that he doesn’t seem to have an ideological or ethical issue with animal consumption should help smooth the transition. That’s often the biggest hurdle to overcome; the sensation that you’re a moral failure by ripping into a rare steak and relishing the juices running down your chin can be debilitating.

The good news for your son is that going Primal can be extremely protective against IBS. You know, I had IBS for years back when I was a grain-eating endurance athlete, and it was probably the first thing that cleared up once I gave up grains and started eating more fat and protein. Wheat famously (and infamously) exacerbates and even causes IBS in some patients; removing it (going Primal) makes for an effective, simple dietary treatment. The large amounts of insoluble fiber found in grains don’t seem to help IBS patients, either. Soluble fiber found in the roots, fruits, and vegetables your newly Primal son will eat does help, however.

He should be careful with FODMAPs, too, AKA fermentable, oligosaccharides, disaccharides, monosaccharides, and polyols. They’re a common trigger for people with IBS, and they appear in a lot of otherwise totally innocuous and downright beneficial foods (dairy, certain fruits and vegetables). Have him check out the post I did on FODMAPs. He might see some familiar faces from his vegetarian days. Luckily, even if FODMAPs are a problem for him, he can slowly reintroduce them and gradually increase the amount he eats, given sufficient time and gut health rehabilitation.

How about the gallbladder issue?

Since the gallbladder stores, concentrates, and releases bile to help break down dietary fat, his particular mode of Primal eating may have to be lower in fat than most. That’s okay; it’s not the deal breaker some would have you believe. While I find the higher-fat approach to Primal eating to be optimal for me and most people, it’s not necessary. Just stick to the basics – animals, plants, good fats – and avoid grains, refined sugar, and processed seed oils, and he’ll do great. The absolute ratios don’t matter as much as the quality of food you eat and don’t eat. Besides, as he loses weight he’ll be consuming his own body fat (a process which does not require a gallbladder). Once he’s lost the weight and is a bit more insulin sensitive, extra carbs shouldn’t pose any problems.

He’ll still be able to eat fat, of course, and his bathroom visits will tell him if he’s eating too much because undigested fat will show up in his stool. It’s more messy and annoying than dangerous. Coconut oil, MCT oil, and pastured dairy fat contain medium chain triglycerides that require less gallbladder input. These will be easier to digest and should be favored.

Ox bile supplements can help him break down fat. If you have access to an ox and its bile, that would probably be even better (if a bit more disgusting), but supplements can help the gallbladder-less digest fats.

Good luck to your son!

That’s it for today, everyone. Be sure to chime in with your experiences, insights, and comments!

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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42 thoughts on “Dear Mark: High Uric Acid and Gout; From Vegetarian to Primal Without a Gallbladder”

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  1. The cold turkey vs gradual transition argument seems to come up a lot. I think either way you’re going to fail a couple of times before you get to a point where your consistent model of eating is considered primal – the important thing is to understand that this is part of the process, and that you should jump back on the wagon as quickly as possible!

  2. My husband also had his gallbladder removed over 8 years ago and struggled with the IBS issues until we adopted a primal lifestyle almost 2 years ago. The biggest trigger for him were seed oils, and since removing those highly processed fats and other grains from his diet he rarely has any issues. Best wishes to your son on his transition to primal living.

    1. I started taking Ox Bile 125 mg supplement for the past few days to help with my bile production to overcome the problem with digesting foods moderate in fat, fried, and spicy. I still have my gallbladder but gallbladder disease run in my family. It also helped me a lot with my prostate pain in a form of BPH ( been dealing with this for years) and ED by getting rid of excess estrogen and more much better than many other supplements tried in the past. The other issue I have is problem with my body producing high levels (7.4) of uric acid. Does Ox Bile supplements cause for your uric acid to increase ( I read an short article from WebMD that it does)? If so do you have any recommendation in other forms of Bile Salts supplements to take? This stuff really helped with my BPH and ED but if it is going to increase my uric acid then I have to stop it.

      Truly looking forward to your feedback.

      Thank you in advance,

  3. While I can’t speak to the lack of gallbladder issue, a paleo diet has completely turned around a lifetime of IBS so I can see where a careful transition over to paleo would be really beneficial in that way. Great suggestions on the fat sources, love learning new things from this website!

  4. I haven’t had gout, but I have had multiple uric acid kidney stones. I had to give up all alcohol. Even a single glass of wine can cause a new stone. However, I have also discovered two GREAT cures for a uric acid kidney stone, even when the pain from a new one has started.

    1. 1 tablespoon of organic apple cider vinegar (must have ‘the mother’ in it) in 8 oz. of cold water. Drink it all. Twice a day, until pain is gone.

    or, or in addition to #1,

    2. tart cherries, like Mark mentioned, Tart cherries, tart cherry juice.

    Apple cider vinegar, and tart cherries,literally can dissolve the uric acid kidney stones, allowing them to pass pain free.

    I try to hold my urine for up to 2 hours after the apple cider vinegar concoction, just to allow the vinegar to do it’s magic on my urine.

    IT WORKS. 🙂

    Good luck!

    1. I have been drinking tart cherry juice for better sleep. Good to know it can be helpful for uric acid, too.

    2. My husband takes calcium carbonate after every meal to neutralize the uric acid–2000 mg. twice daily.

  5. I respect to transitioning form vegetarian to primal without a gall bladder, may I suggest starting with primal stews. Slow cooked chicken, beef and lamb with root vegetables are great sources of nutrition. The slow cooking “predigests” and releases nutrients into the broth. If one is fat sensitive, let the soup cool in the refrigerator and the fat will rise to the top and solidify. This may be removed prior to reheating. I just made a big batch of beef bone broth and used some of the fat cake to stir fry broccoli and shiitake mushrooms and it was amazing. I still have the reduced fat broth to enjoy on its own.

    1. I agree with this entirely. I had not had red meat since I went veggie at 14, & after a few very uncomfortable tries, truly thought I couldn’t digest it. But then starting with stews & other simmered meats, & small bits of meat with a lot of veggies in the same meal, helped my body make the transition. Now my belly can actually handle a serving of steak without misery!

      1. While being vegan and paleo would be tough as veganism is already so restricted, vegetarianism is quite compatible with paleo.

        I’ve been a vegetarian for 28 years now. Meat never did much for me and I felt better without it. But most would classify my diet as pretty darn close to paleo – No sugar, no grains except for special occasions (date night), tons of vegetables, very little fruit except for some berries and maybe a little melon or occasional apple, 4-6 eggs per day, plenty of nuts, sweet potatoes for my carbs, whey protein for supplementation, and I cook with only coconut oil,olive oil or butter. No seed oil ever. The only non paleo thing I eat regularly is sprouted organic tofu. Despite what many think, natural, organic, non gmo soy is not a crime against the body. It won’t kill you and it’s not poison.

        So my diet is probably more paleo than a lot of people who follow the paleo diet (I don’t follow paleo, I just do what makes sense for me and this is what I settled on).

  6. My gallbladder was removed over 14 years ago, when I was vegetarian (and very sick!) I have made the transition to Primal-ish eating over the last couple years (I would be Primal, if I could kill the sugar-demon that keeps pulling me back to SAD).

    I also have IBS, and it almost completely went away when I got off the grains. The only real trigger for it now is when I eat too many nuts.

    I keep falling of the wagon, by I also keep climbing back on…one of these times I’ll stay there!

  7. I’ve gotten my gallbladder out some years back, but haven’t had any issues with high fat intake. It’s probably rather individualized, for sure.


    1. Agreed – I had my gallbladder out at 17, started eating primal at 25 (though I have since fallen off the wagon and only recently restarted). I never really had any problems, although I tend to go for lean meats as I don’t like the texture of fat. Even now with my restart, I haven’t noticed any issues unless I have something very oily or non-primal.

  8. I have a comment about excessive uric acid levels. I personally experienced this problem and it was due to significant weight loss – in my case, more than 70 lbs. This, in and of itself, can substantially raise uric acid levels. When you lose weight, the body is actually breaking down and disposing of tissues, which creates lots of waste products that can lead to uric acid spikes. Once your weight stabilizes at the new level, the uric acid goes down.

    Beating Gout by Victor Konshin is the best book I’ve found on a subject that seems to attract a lot of unscientific nonsense.

  9. I suffered from gout for twenty years. I started Primal in early 2009 and my gout attacks ceased. I have had a few attacks since then but they have always been after I ingested a lot of High Fructose Corn Syrup or a lot of sugar. I did have one really bad attack but that was after losing 40 pounds in only three months.

    For me, fructose, in any amount, is dangerous. I do NOT eat fructose except that which is in a handful of blueberries once per week and I keep my ongoing weight loss to about three pounds per week (I’ve still got about 60 pounds to go).

    I do not avoid the high-purine foods such as offal and organ meat. I continue to drink my beloved coffee (caffeine is a purine), eat mushrooms (lots of purines) and so on. So far, as long as I avoid fructose from any of its sources, I stay gout-free.

  10. Wondering if Chris is from across the pond and missed a zero (400 mmol/L, or about 7mg/dL). At 40 mg/dL, a physician shouldn’t be worried about it being on the verge of becoming an issue, but should be seriously concerned about renal failure (I believe nephrologists become concerned when levels start to get above 10-12mg/dL). In any case, a few risk factors not previously mentioned:

    – Obesity
    – Hypothyroidism
    – Medications, most commonly diuretics such as hydrochlorothiazide (HCTZ) or
    loop diuretics like Bumex or Lasix
    – Salt restriction
    – Your parents (genetics)
    – Functional volume depletion, such as liver disease or congestive heart failure

    I’ve read the dietary recommendations for patient’s with gout. Personally, I’d rather have gout than diabetes.

  11. I had my gall bladder removed several years before I started to eat a LC diet , it took me a while to get used to higher amounts of fat. My doctor advised me against taking bile salts because he told me it would interfere with my body adaptation to higher fat intake. I think he was absolutely correct. My grandma was taking bile salt till the rest of her life or had a diarrhea after a meal. I consider myself to be perfectly adapted to eating fatty meals. I would advice against unusually big meals, like a Thanksgiving dinner to be consumed without bile salts at the beginning of the adaptation..

  12. My husband had his gall bladder removed about 7 years before we went primal. Although we were never vegetarians, we treated meat like a condiment & ate tons of “healthful” whole grains. We just couldn’t figure out why he was uncomfortable digesting our super-healthy-grainy-low-fat meals!
    After going primal, digestion issues became (mostly) a thing of the past.
    Wonder if his gall bladder would have had to go if we had figured out how to eat before he had a problem?

  13. Wow, what are the chances someone (or in this case, the parent of someone) with my condition would write in about eating paleo/primal without a gallbladder and get a response?! Like that person’s son, I too have spherocytosis and had my spleen and gallbladder removed when I was 7. The only times I have digestion issues are with some dairy, industrial seed oils and greasy processed/fast foods. I don’t eat things like that a lot, but every time I’m reminded why and it becomes easier to say no. Just keep it simple, try to make most of your meals and pay attention to how your body reacts when you eat certain things.

  14. Does anyone know where Todd Deusenberry (aka Primal Toad) is these days? I haven’t heard from him for a while.

  15. Honey is 40% fructose, so anyone with uric acid issues shoulf be avoiding honey, just like avoiding sucrose and HFCS.

  16. Definitely liver dysfunction can be a risk factor for gout. My fiance was diagnosed with AIH a few months ago, and the only s/s he experienced was gout. Definitely keep sugar and especially fructose to a minimum.

    Also, bile is one of the most foul substances of the human body with a very distinguishable smell. It only pales in comparison to respiratory secretions as being the nastiest.

  17. Hi Mark,

    You write: “mineral water with good sodium bicarbonate content can all lower serum uric acid.”

    The mineral water just needs to have good bicarbonate levels, not sodium bicarbonate specifically. (In fact, as you probably you know, each molecule of calcium or magnesium can bond to two bicarbonates, versus just one for sodium or potassium.)

    1. Interesting, gout led me to a primal life style.

      (primal for about a year now)

      I suffered from gout for about 10 years. In time the episodes were
      more frequent and more painful. I like being active but the gout, at times
      was debilitating. No point in telling you how painful it is, you have to be there.

      During those 10 years, my diet was mostly “anti-primal” that is I lived on
      mostly grains, legumes and starchy vegetables, very little red meat.

      The gout attacks, in time, led to weight gain, since I couldn’t walk very well. I became desperate to lose weight. I did a total 180 degree turn, and went Primal, lost 30 pounds and have not had a gout attack since, not one.

      But yes there’s a catch, at the same time I went Primal I stopped drinking beer, BEER! BEER! BEER! (and ALL shell food) I kept a diary of my gout
      episodes, noting the food I ate the previous 72 hours, beer and shell food were always the common denominator.

      Also worth noting here that there are medications out there that will lower uric acid levels, Allopurinol being the most popular. Word to the wise, the more attention you pay to your diet, the less medication you have to take, if diet alone does’t do it and you decide to take Allopurinol start at the lower levels, 100mg. (I’m not a doctor or anything close to one, just my experience)

  18. I had somewhat elevated uric acid levels for some years. I discovered that berries, tart cherry juice, and milk (some combination of these) seemed to help somewhat. However, after I started taking 1 or 2 teaspoons of baking soda a day, my uric acid levels decreased significantly more. I’d recommend supplementing with a teaspoon or so of baking soda (which is sodium bicarbonate, same thing as in one of the links Mark posted) a day and re-test.

  19. As a former vegetarian myself, I loved the answer to that question! Thanks for sharing!

  20. Like some others here, I read this post with great surprise and interest as a fellow spherocytosis sufferer. Likewise I had a splenectomy when I was younger, though somehow managed to retain my gallbladder.

    It’s difficult to know how much your son’s weight gain is down to his lack of gallbladder, as opposed to questionable dietary choices. I have met a fair few other sufferers and suspect the results are very individualized i.e. I’m not sure the removal of these organs inevitably leads to creeping weight gain even with the reduced ability to process fat. Either way, I hope for all of you that he embraces the primal way of life and that he enjoys the multitude of health benefits that will inevitably follow.

    For my own part the splenectomy operation made a massive difference to me and dramatically improved my quality of life and energy levels. That said, there were other longer-term health problems which I did not foresee at the time and which I and my parents were not warned against by doctors. I am convinced that ten plus years of taking penicillin on a daily basis (which I was prescribed to make up for the impaired immune function linked to not having a spleen) absoltuely destroyed my insides and ruined my gut health in particular. This caused me all sorts of other niggling health issues, which at the time I did not link to my massive antibiotic consumption. Unfortunately it is only recently that I have come to find out about the importance of gut health and am now doing my best to rebalance the equation. That is a different story however.

  21. My cousin has been suffering from gouty arthritis for over 3 years and it is very hard for him to cope because he has to avoid food that he used to enjoy. He also gained a few more pounds compared when he did not have the disease. He has been taking allopurinol 300mg every other day and colchicine every attack. Thankfully, the treatment makes his uric acid level on the normal side.

  22. For the no gall bladder issue. There is something I do not get yet .

    “Since the gallbladder stores, concentrates, and releases bile to help break down dietary fat, his particular mode of Primal eating may have to be lower in fat than most.”


    No gall, means it is harder to digest fat into energy. Too much fat will go into the stools and leave, so how come weight loss is slower when fat intake is too high?


  23. ” Without his gallbladder he has a difficult time processing and digesting fat.”
    Nope, that’s a crazy red-herring. He may have a hard time processing sudden huge intakes of fat, but that is all.
    Eat reasonable amounts of fatty meat and he’ll be fine.
    But … needing to lose 100 pounds … that’s a whole person! Are you sure?

  24. For those of us who lack gallbladders, there’s a very simple thing we can do.

    We can consume supplements containing oxbile and Betaine HCL before a meal that contains protein and fats. Simple and easy thing to do, is to take Now Super Enzymes. It’s not the best stuff, but it works. You could also get them separately or from another manufacturer.

    I take 3-4 of these capsules right before lunch, dinner, or breakfast. As I do bulletproof coffees every morning, I usually pop one or two of these to help break down the fats as well.

    If you’re not digesting fats, you’ll noticed ‘floaters’ when you, um, eliminate, or very rocky/clustered looking poops – in which case you need more oxbile throughout your day.

      1. I’m sorry, but this is false. I had my gallbladder removed in 1999. Until I went paleo in 2010 and also added oxbile supplements, I had many health issues despite trying to eat high fat.

        You don’t adjust to eating high fat if you don’t have a gallbladder. Perhaps some people do, but even then, it’s better to use the supplements so you can digest fat all the time instead of just randomly and in small amounts.

  25. I did adjusted slowly, right after a surgery any food would cause diarrhea, than it depended on a fat content, slowly I started to rise fat. Body is working around issues. My surgery took place approximately 10 years ago, my grandma was on bile salts till the rest of her life after the removal of her gallbladder, and she still had to run fast toward a bathroom on occasion. I started eating LC diet at 2007. I also have to add that consistency in the amount of fat is the key, my cooking fat is a coconut oil.
    I remember reading that it was reported that after a gallbladder removal some people developed enlarged bile ducts which store bile. I guess it was on Dr.Eades blog.

  26. Please help! Is gout related to beer as I have read beer is high in purines? If I drink moderate amount of wine on weekend, will that be fine or it will up my Uric Acid levels and flare up the gout attack? Without some advice, I am too afraid to try as it is painful. Thanks.

  27. I started taking Ox Bile 125 mg supplement for the past few days to help with my bile production to overcome the problem with digesting most foods. I still have my gallbladder but gallbladder disease run in my family. IT also helped me a lot with my prostate pain in a form of BPH ( been dealing with this for years) and ED by getting rid of excess estrogen much better than other supplements tried in the past. The other issue I have is problem with my body producing high levels (7.4) of uric acid. Does Ox Bile supplements cause for your uric acid to increase? If so do you any recommendation in any different forms of Bile Salts supplements to take? This stuff really helped with my BPH and ED but if it is going to increase my uric acid then I have to stop it. Truly looking forward to your feedback.