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 more than three decades 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 flavorful and delicious kitchen staples crafted with premium ingredients like avocado oil. With over 70 condiments, sauces, oils, and dressings in their lineup, Primal Kitchen makes it easy to prep mouthwatering meals that fit into your lifestyle.

If you'd like to add an avatar to all of your comments click here!