Will Eating a Paleo Diet Cause Gout?

gout

This article is part of a special report on Red Meat. To see the other articles in this series, click here.

A common question I get from readers is whether a
Paleo-type diet will increase their risk for gout. Gout is a type of inflammatory arthritis caused by elevated levels of uric acid in the blood, forming crystal deposits in the joints, tendons, and surrounding tissue.

Gout typically affects the feet in general and big toe joint specifically, and causes severe pain and swelling. In the past, gout was referred to as a “rich man’s disease”, as it typically affected the upper class and royalty who could afford “rich” foods like meat, sugar, and alcohol.

Uric acid is a byproduct of the metabolism of purines, one of two types of nitrogenous bases that form the basic structure of DNA and RNA. While purines are present in all foods, they are typically higher in many of the foods emphasized on a nutrient-dense Paleo diet, such as red meat, turkey, organ meats, and certain types of fish and seafood. Patients with gout are often advised to reduce or eliminate these purine-rich foods with the goal of preventing excess uric acid production, thereby reducing the symptoms of gout. And research has confirmed the association between high purine intakes and acute gout attacks, suggesting that those diagnosed with gout would benefit from a reduction in purine-rich foods. (12)

So, do we need reconsider recommendations to eat foods like liver, sardines, red meat, mussels, and other traditional foods? Do these nutrient-dense, purine-rich foods really cause gout? Are those of us following a Paleo-style diet putting ourselves at greater risk for this painful, debilitating condition?

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Inflammation as a cause of gout attacks

While high purine intake is associated with gout attacks in those who already have hyperuricemia, or high levels of uric acid in the blood, purine intake alone is not enough to trigger these attacks. (3) In fact, uric acid levels are frequently decreased during gout attacks, sometimes to within the normal range. Another factor associated with gout flares is an increase in C-reactive protein (CRP) and interleukin-6 (IL-6), cytokines produced during numerous inflammatory conditions. (4) These inflammatory cytokines are increased in the joint fluid and serum of patients with acute gouty arthritis. (56)

Therefore, systemic inflammation is likely a key factor affecting the likelihood of developing gout flares, and as we know, diet plays a significant role in inflammation. While foods like grass-fed beef, sardines, and mackerel are high in purines, they are also higher in omega-3 fatty acids and low in omega-6 fatty acids. Since the omega-3 to omega-6 balance in your diet modulates the inflammatory response, a diet with sufficient long-chain omega-3 fats like EPA and DHA will reduce systemic inflammation and may reduce the risk of forming the uric acid crystals that cause joint pain.

Fructose: An important player in the development of gout

While fructose in naturally occurring amounts is relatively benign, research has shown that higher intakes of fructose may mediate many of the abnormalities seen in the metabolic syndrome, including elevated triglycerides, due to increases in uric acid production. (7) A recent study confirmed the uric acid–elevating potential of fructose ingestion, both by producing excess uric acid and reducing its excretion in the urine. (8)

While some uric acid in the blood is normal, providing a level of antioxidant protection, excess uric acid is a pro-oxidant and the major causative factor for gout. Some researchers even suggest that this excess uric acid in the blood is a major factor in the development of insulin resistance and metabolic diseases. (9) So if you’re avoiding excess fructose consumption from high fructose corn syrup and excess sucrose (table sugar), you’ll be at a lower risk for gout that someone who’s washing their burger down with a can of coke.

A word on the epidemiological correlation between meat and gout

A major reason that many conventional physicians and health professionals see red meat consumption as a significant risk factor for gout is that red meat is typically a component of an overall “Western diet pattern”, a pattern that is also high in sugar, vegetable oils, sweetened beverages, refined grains, and processed meats, while being low in fruits and vegetables. (10) It is nearly impossible for epidemiologists to separate meat consumption from this general pattern of eating when studying modern cultures — after all, most “health conscious” eaters in our generation believe that meat is unhealthy and typically eat less of it.

While most epidemiological studies attempt to control for these confounding factors, the truth is that most high consumers of meat are generally prone to other unhealthy habits such as smoking and drinking, and are typically more overweight than low meat consumers in these studies. Of course this doesn’t tell us anything about the active, health-conscious Paleo eater who avoids high fructose corn syrup and omega-6 fatty acids, as well as other inflammatory foods like refined grains, and doesn’t drink heavily or smoke.

Eating a Paleo diet won’t cause gout!

The next time your doctor or best friend says you’ll get gout from a Paleo diet, you can refer him or her to this article. Rest assured that a diet full of nutrient dense foods like grass-fed red meat, liver, shellfish, and fatty ocean fish is not putting you at risk for developing this painful condition. More likely to cause gout are the common American dietary staples such as sugar-sweetened beverages, industrial seed and vegetable oils, refined carbohydrates, and excessive alcohol (beer in particular). The Western diet pattern is a risk factor for gout; a nutrient-dense Paleo diet is not.

Now I’d like to hear from you. Have you experienced concern from a physician or family member over your diet and your risk for gout? Has this article helped calm your fears about your diet-related risk factors for gout? Share in the comments below!

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Comments Join the Conversation

  1. says

    I always love that you address that it isn’t the type of food but the quality of the food that is important. Another great article I can utilize the information for my own patients.

    • Harald Tilgner says

      The facts for gout are what they are, however the cause of these conditions is a Significant Biological Special program of Nature (SBS = commonly referred to as cancer), called a “refugee or hospital biological conflict”. When there is an unexpected, isolating sudden shock experienced, called a DHS, a ‘lesion’ becomes visible on a brain CT scan in the brain stem. This indicates an active biological conflict in the collecting tubules of the kidneys, designed to diminish the excretion of urine for survival purposes. The uric acid in the blood is being recycled to form protein. So the body is kept from dehydration and starvation until the biological conflict is resolved, at which time the small tumors in the collecting tubules are removed by tuberculosis bacteria, if the individual was fortunate enough to harbor them at the time of the DHS. http://learninggnm.com .
      This condition, called a Syndrome, is quite serious, if any other biological conflict happens to be in the healing (resolved) phase.

  2. Murray says

    I am 43 and have had two gout attacks. The doctor put me on Puricos until I discovered the paleo diet when I stopped taking it. I have been on the Paleo diet (albeit a little too loosely for my liking) for about six months now.

    In those six months I have almost cut gluten out, cut out chips and French fries and most other things that come in a packet or a box. I have substantially increased my intake of butter, cream and other healthy fats. Unfortunately I have very low cortisol so the results have not been as good as I had hoped, however both my bad cholesterol and my uric acid have dropped in the six month period. SO I would have to agree with your research through self analysis!

  3. Jen Houck says

    I have been eating low carb for 10 months now and am very close to losing 120 lbs. I have been reading about Paleo and have based many of our meals on the recipes I have found on various Paleo eating blogs. I too have been told by my doctor that I have elevated uric acid levels and given a huge list of foods to avoid – including most everything I eat! 2 years ago I did have a debilitating “attack” of some sorts that left me with curled and painful hands and severe joint pain that lasted for almost 2 weeks. He now thinks this may have been gout, although at the time nobody ever tested for it or mentioned it. I was treated with steroid shots. I began eating cleaner last May and have been basically ignored my doctor’s request to decrease eating foods that are high in purines and I am doing well despite. He is pleased with my weight progress but I have to admit going totally paleo has really scared me since his :”advise”. I really do believe that the elimination of grains from my diet has helped with my inflammation and think I will continue on course for now.

  4. says

    I had taken allopurinol for over a decade and still experienced occasional gout flares. In 2011, I eliminated sugar from my diet, stopped taking allopurinol and I stopped having gout symptoms. In 2012, I went full paleo and had no gout issues the entire year! January 2013, I did paleo auto-immune protocol to support my wife’s efforts to further figure out her sensitivities and in week 3 of strict AIP, I had my first gout flare in almost 2 years. I’m not sure why it flared during a more strict approach. I’d love to never have a flare again, but once in 2 years with no meds on a Paleo approach is much better than 6 times a year with meds on a standard American diet.

    • Sandy says

      Rick,
      It’s very interesting that you experienced a gout flare during strict AIP. I’ve been “paleo” for over a year, and I just had a flare in January (after not having had one in several years). I was dealing with some stressful situations in January, and as a result I was lacking an appetite and not eating as much as I normally do. During the flare, I started reading as much as I could about the possible causes, and I came to the conclusion that I needed to start eating more, especially carbs. My stressful events have passed, I’ve been eating more regularly, and my gout has resolved. Now that I know what gout is, I realize that I’ve been having these attacks since I was 13 or 14 years old. At that age I was not eating any red meat, but I was anorexic and underweight. I’ve read that sudden weight loss can cause gout, so perhaps my body was metabolizing my own tissues due to lack of proper nourishment, and perhaps the increase in stress hormones was affecting my ability to excrete the excess uric acid. Or something like that. Anyway, that’s just my unsophisticated interpretation. Since the AIP is so restrictive, perhaps you were experiencing something similar?

      • says

        Hard to say what my trigger was. In the past, my triggers were heavy sugar load, alcohol, shellfish, and asparagus. With AIP, I had none of those things. I definitely wasn’t under much stress and found AIP to be relatively easy to follow through on, although much less convenient than standard paleo. I did drop 9 pounds in the first 2 weeks, back to my pre-holiday weight, then leveled out. I tracked everything I ate over the month and I took in 53% fat, 25% protein, and 22% carbs. Normally, I’m probably running about 30% carbs.

      • Jan says

        I have been on the AIP diet for a couple of months, because I have a number of autoimmune diseases. I was a very clean gluten free, dairy free, organic eater before AIP. Since then, I have had extreme immune flares…worst I have ever had. I also have had a gout attack. Go figure! I am eating a lot of veggies, avocados, free range chicken, grass fed meats and wild seafood with a little added fruit. I am not sure why this is so. Perhaps I need to add something back in?

        • Rickus says

          Hi Jan,

          Gout and AI issues can exist for different reasons.

          The gout would most certainly flare-up with increasing protein consumption as it sounds like you have done. So, decreasing purine intake is important for you.

          The AI issues could improve over time with both dietary approaches you have taken. However, even on the AIP your probable leaky gut may be allowing some invaders in to your body. The invaders might be okay in someone with a healthy gut and could be considered ‘normal human food’, but when the gut is leaky the rules change. If your newer dietary approach has in fact increased your AI symptoms, not just the gout, then something in the diet could still be causing a reaction. Certainly, emotional stressors may increase AI symptoms or gout by increasing systemic inflammation. Looking at sleep, comfortable exercise and relaxation techniques may be useful. It may take months for AI issues to subside, but be persistent with the lifestyle changes!

          • Jan says

            Thanks for the response. I have been tested for leaky gut and do have it along with damaged microvilli. I am also nutrient deficient. I have been gluten free and dairy free, egg free, corn free for years and eat a clean diet. I also take great vitamins (Pure Encapsulations), but still am deficient. I’ve been on a gut healing protocol for months, with no real improvement…increasing joint pain etc. I think I am going to try and lessen the red meat intake and eat more wild salmon and free range chicken to see if that helps the gout anyway. I have celiac, AS and Sjogren’s and Morphea (localized Scleroderma). I am the healthiest, non healthy person on earth!! Thanks again for your insight. I will continue on AIP for the next few months to see what happens.

            • Jan says

              Also, I am studying to get a Masters in Nutrition and Functional Medicine and have made this my life’s work. I hope to work with people with difficult immune problems, so I continue to scour the literature. Maybe it will help me in the end.

  5. says

    Great article! I’m a Naturopathic and Chinese Medical student and I’ve had the best success with the paleo diet over everything I’ve learned in school. I was researching breast cancer this week and found that omega 3 has been found to be a causative factor in preventing breast cancer. Since that link has been made, it would be appropriate to get a study done on conventionally raised meat vs grassfed meat. What if we could change our agricultural practices through the link of omega 6: omega 3 ratios to breast cancer? We want a ratio of 4:1 or better – conventionally raised meat gets as high as 21:1 and grassfed between 1:1 and 3:1.

    • says

      Good point about the difference in grass fed red meat and grain fed red meat. There are so many differences in these meats it wouldn’t be surprising if they did all sorts of strange things to the body.

  6. says

    Couldn’t agree more Chris. I’d add that there is a reason why fructose in ”the complete package” is pretty harmless. Tart cherries will alleviate if not completely do away with the gout issue. Furthermore a paleo diet is not a meat heavy diet. One thing has always puzzled me though : why is it that gout so often happens to affect the big toe joints? Surely it cannot be gravity.

    • mhikl says

      So true, James. Even the black cherries, fresh or from the tin or as pure juice work. For health I use a black cherry pure juice, not from concentrate but from 2.5 lbs cherries from Super Store. Also celery water (and seeds) and pineapple juice work in this regard. I remember 3 members of a men’s organisation who were suffering gout and told them about these helpful foods and the suggestion they drink enough water and cut back on sugars and high starches, all being relieved of their pain by next meeting. As Chris suggests it is the processed foods including junk and high starch products that may be at fault. I know that the smell and taste (UT advocates attest to this) of urine is far different when junk, starch and sugar are included in the diet in comparison to pure goods low in carbohydrates.

    • Don Cross says

      James to your comment about gravity, I have seen many docs about mine and all of them have told me that it IS gravity. If you look at other comments in the post you will see other folks talk about different areas, but the majority of affliction is in foot and ankle. Me.. I get it every where but MOST severely in my right great toe first knuckle..

      • Linda says

        I have eaten low carb paleo for almost 2 years. I occasionally have achiness in left bunion area, but never diagnosed with gout – uric acid levels are normal. It does not seem to be associated with any particular foods. However, I recently found that I have a structural misalignment on one side which puts more pressure on my left foot heel and great toe. You can test it by standing in bare feet and seeing where you feel the pressure on the bottom of your feet. Perhaps this plays a part in the “gravity” issues- especially if the “gout” is one-sided and that joint is constantly taking the hit for the body’s weight.

    • Nichole K says

      Actually, I’ve read that the crystals tend to form at lower body temperatures, and because the big toe is so far from the body where the temperatures are lowest, the crystals form there first.

      I actually have just self diagnosed with gout. I’ve been following paleo for some time but have only recently begun having symptoms.I’m thinking dehydration and inclusion of more seafood and sardines, along with stress, may be my triggers.

      Do you think drinking way more water and taking 500mg of vitamin C will be enough to keep it at bay? I’d really hate to cut sardines and seafood from my diet. =(

  7. Brandon G. says

    My dad has a history of gout and, at 39, I have long felt very minor symptoms similar to gout in one of my big toes. My dad has cautioned me on the paleo diet, though I follow it contrary to him anyways. Having said that, I’ve always been a bit worried. Now I am less so, so thank you. :)

    It makes sense that it’s more the SAD to blame than the meat-component itself — seems like that’s mostly the case with other diet-related issues as well so why not gout?

  8. J says

    I eat monster amounts of spinach on Paleo and have had no problem. I’ve seen it as a major contributor to gout.
    I also got off BP and statins after adopting Paleo, talk about a trade off for some incremental propensity for gout. I’ll take it.

    • Honora says

      On the topic of delicious spinach…met an oxalate expert yesterday – a prof at our local agricultural university. He said most of the oxalate in foods is destroyed by boiling. We have a weird little South American pink shiny potatoey thing here in New Zealand, which we call yams and they’re very high in oxalates in the skin. He said baking them unpeeled is the worst thing to do as we love to eat them in this concentrated form. Off-topic but thought I’d pass it on.

      Oxalates are found in spinach, swiss chard (very popular here in NZ), rhubarb and the yam thingies. They can cause kidney stones in some folks. All things in moderation and plenty of fluids he says. The worst offenders are the Saudi folk who don’t drink enough for their climate – they get annual practice in Ramadan of going without water in daylight hours after all.

      • Beth says

        According to another oxalate expert and researcher, Susan Owens, oxalate content in some foods is so high that it cannot be cooked or soaked or boiled out of it to a degree sufficient enough to not cause problems for people who cannot handle oxalates well. She manages a free and open Yahoo group called Trying Low Oxalates where you can find lots of current info on oxalates, including a continually updated searchable spreadsheet of the oxalate content in foods.

  9. Heather H says

    My husband has a long history of gout which runs in his family. Since starting paleo two years ago he has not had an attack or needed to take his gout meds. He also had to decrease his blood pressure dosage though that is another post.

  10. Tucker says

    I have been 100% paleo for 2 years. I do not drink alcohol, soda, smoke or eat sugary snacks.

    Over the Christmas holidays I have a severe case of gout that lasted for about a month. It was in my big toe on one foot and then would move to my ankle on my other foot and then back again. The pain was a 9 out of 10.

    What is causing this to happen?

    • Andrew says

      I can sympathise with that 9 out 10 rating. Like walking on your eyeballs!
      Gout led me to Paleo, as I really didn’t want to go on meds. Persevered with fairly strict Paleo (with plenty of safe starches) for a year or so, but was still getting mysterious pains in my knees, and regular stiffness in my big toe. Finally gave in and went on the meds. That was about 6 months ago, and knees and toes better than they’ve been in years. I’m sure Paleo doesn’t cause gout, but I’m skeptical now that it alone cure it. Would really like to find a way to get off the meds though. Any suggestions?

      • Tucker says

        I am tweaking my diet to stay off any meds. Reduced bacon intake and eating more chicken. I am beginning to believe that it may be a hormone issue and am pursuing that angle.

    • says

      How about fructose intake? You didn’t mention this. Some people are very affected by fructose even the smallest amounts. Take a look at the FODMAP diet.

      • says

        You might like to try alkalized water (you don’t need to buy a electronic water ionizer for this) there are alternatives to getting this kind of water.
        I have seen seriously good results from people just drinking this kind of water.

      • Tucker says

        Very little. I only eat fruit occasionally and no sugary drinks of any kind.

        I will try out the alk water too. Anything to get my health and active lifestyle back.

        • says

          Fructose subsets – Fructans & Galactans (Oligosaccharides) are in some vegetables too.
          High Content Foods are:
          Beetroot, Asparagus,Cabbage,Broccoli,Onion, Garlic, Jerusalem Artichoke
          Could be worthwhile taking them out of you diet temporarily and reintroducing them one by one to see if you have a flare up.

  11. says

    After three days of anomalous and excruciating scapular muscle back pain I found some relief through massage. It was so bad I had to sleep sitting up and even that didn’t really help my labored breathing. That was rough enough but on day four, just as the back pain was subsiding, I awoke to find that my ankle was painful and swollen. My kinesiologist immediately sent me to a podiatrist who popped the most surprising question, “do you have gout in your family?” I was shocked. Not only was I not genetically predisposed, I eat cleaner than most (non-neurotic paleo plus grass-fed butter/cheese and occasional corn and rice). Tests for uric acid levels in my blood are pending but all signs point to my first-ever gout flare up. Now I wish we’d checked CRP and IL-6 levels too.

    The week prior to the flare-up hadn’t been particularly typical as I never normally consume fruit smoothies, gluten-free goodies, or drink that much. Such was that week. While not off the rails, it wasn’t picture perfect either. Regardless, there’s nothing like the remarkable pain of gout to inspire better habits. I wish I could do that week over just to see how much diet played a role versus the very real stress of back pain.

    I’m deeply curious to find out what exactly was the cause and am wondering what might be done beyond my normal good habits to never ever feel that pain again. Does having a gout flare-up make me more vulnerable to having another or can I chalk this up as a one-time deal provided I stay on the paleo path? I’m on the hunt! Are there any stricter paleo folks who have seen gout flare-ups do to pain alone?

    Thanks for what you do Chris.

  12. Anne G. says

    I started eating Paleo over a year ago to support my diabetic boyfriend. I haven’t had gluten or dairy for over a year, eat only organic veggies and grass fed beef, pork, free range, etc.
    I have had severe arthritis in my hands for over years. Cannot eat nightshade plants.
    By last summer, the gout flares in my hands and then feet were getting worse and worse. I was eating salmon 4-5 times/week, liver, tongue, tons of spinach and cauliflower as part of my diet. By December, I would cry because the pain was so severe in my hands. I finally went to a “Functional Medicine” doctor who picked up on it immediately. Have limited animal protein considerably and reduced eating other items that were on the list as contributors to “gout”. The severe pain is gone. I can eat the assorted aggrevators on occasion but stick more to chicken and white fish for animal protein. While I still eat beef, it’s once a month instead of once or twice a week. I rarely have major attacks unless I over do the foods that I shouldn’t. So while Paleo is still my eating style, have had to modify to deal with my gout issues.

  13. Jaime Kerns says

    I must respectfully disagree with the conclusion of this article with my husband’s experience as my proof.

    This past January 2nd, we began a nutritional challenge (friendly competition @ our local crossfit) that followed the Whole 30 food plan.

    Within a week, my husband’s right toe began to swell and cause discomfort, but we still maintained eating and exercising.
    By week 2, he could hardly walk and I demanded that he go to the local quick care. He had severe gout and was given a shot to help reduce inflammation as well as pills to take.
    It took him over 2 weeks to completely recover.

    All of our meat (except seafood) was from a local farm and was grassfed. That first week, we ate eggs and bacon w/ guacamole and salsa for breakfast, lunch was a variety of crockpot meals ( pork and beef from the farm), and dinner was seafood (shallots, fish, shrimp), cauliflower in some form, asparagus, and other veggies.

    I share this with you to say that the meals I provided him literally created the perfect storm. Every item on the list to avoid or limit we ate, and ate them everyday that week. (I buy in bulk.)

    In addition to the foods to be careful, he started out overweight and a study led by Dr. Hyon K. Choi, reported in the March 11, 2004 issue mentioned that being overweight and doing a ‘severe diet’ can raise the uric levels in the blood.

    So what I’m trying to say is, people considering paleo need to be mindful when creating their meal plans. We have chosen to continue eating paleo and we BELIEVE in eating this way but we have modified what we eat and when. Obese readers need to be careful in their exercise and eating so that they can avoid this very painful affliction.

    • says

      I would think that if it happened that quickly (w/i 1 week) after starting the Whole30, that your husband likely already had a higher level of uric acid in his blood and the change to a high purine diet triggered the acute gout attack. This would make sense in light of the study Chris referenced about high purine diets being associated with more frequent gout attacks in those with prior gout diagnosis.

      I think Chris’s point was that eating high purine foods should not directly CAUSE gout in an otherwise healthy person. But if you’re already at risk for gout symptoms from a past history of hyperuricemia, or have reduced kidney function for a variety of reasons, then a sudden and significant increase in purine containing foods could in fact raise your risk of gout symptoms.

      Definitely a good point to be aware of though, especially if you have a history of gout or other risk factors like obesity, metabolic syndrome, etc.

      • Alex says

        This is exactly correct.

        If you have gout, AND THEN, you get IBD, AID, Crohn’s, etc. etc. and begin a Paleo or SCD (Specific Carbohydrate Diet) your risk for a flare up is higher because those diets will make drastically shift your intake of purine. (SCD, is red meat, fish and chicken all day and night).

        I got a gout flare up battling Crohn’s with SCD.

        Really tough situation to be in, just gotta get more aggressive and careful with your intake, you have to… no other options or scenarios.

    • rumble says

      If you’re genetically vulnerable to gout, a Paleo diet high in purines will cause gout. I believe what Chris is saying is that the long-term cause of gout is over fructose consumption. But if you’ve already had gout attacks, are overweight, have high uric acid levelsand cannot excrete uric acid quickly enough, then you can get gout. But I don’t think a Paleo diet will cause gout in those who hasn’t developed it already. Check your uric acid but that’s not everything. I would also check my urine pH: make sure it’s above 6.5 or so. I drink a 1/2 tsp of baking soda everynight which causes my body to become alkaline at night when typically gout attacks occur. I rarely get gout attacks anymore. Two things are need to have gout attacks: (1) high uric acid and (2) acidity. There is plenty of people with one or the other who never get gout attacks. Only 1 in 10 of those with high uric acids have gout. 90% spend their lives not knowing what gout is.

  14. patty says

    How does the many high oxalate PALEO foods, wherein the oxalates can form crystals and accumulate in tissue, affect this gout discussion?

  15. Adam Skillin says

    Would the same logic apply to someone who gets oxalate-containing kidney stones? A good friend has chronic kidney problems and I keep telling him to cut fructose and added sugars while his doctors keep telling him to stay away from basically every nutrient-containing food due to purines.

    • Beth says

      There may be other relevant factors as well, but I suggest your friend transition slowly to a low oxalate diet. See my comment above for a source for very current info on oxalates.

  16. lance says

    I thought I had gout last month. I increased my walking and my big toe started hurting and the next day my foot swelled up. I cut way back on my walking and the condition went away in a week. I’m 63 now, so I cannot use the same gradient I use to when younger. Inches instead of yards now. Also I noticed my 3 year old (air-soled) sneakers were flat. So, no gout and just over doing it. I have to mention, I have read (online) the best of the best in alternative or natural health and nutrition over the past few years. There was too many different opinions, so I had to use my gut-instincts and pick a couple of what I thought were the leaders. Even so, there are still too many pieces of the puzzle that are not going together. I feel Chris, that you are starting to put the pieces together somehow, maybe through a mix of experience, intelligence and common sense. I appreciate this unique-perspective you show, so keep up the good work.

  17. Don Cross says

    Chris,
    I believe you are right on here with what you talk about but frankly I believe the culprit is even more deeply rooted in ALL the refined STUFF (beyond fructose) that we have in our diet. I am not a nutritionist nor doctor nor anyone with scientific credentials. I am in fact someone who has better credentials than that. I have been living with this condition for 40 years!! I get it in every lower Joint in my body! I never knew what it was, because one time I’d get it after eating too much Ham, then it was shell fish, then it was soup (ham stock) on and on. About 15 years ago (after I got intimate with Mr Atkins….) I didn’t get the gout in spite of all that purine based stuff. All the meats, all the organ meats, all the shell fish, spinach, mushrooms, none of that caused me ANY trouble. Then I decided to try out my assumption. I spent a week eating all sorts of the white things that are contrary to the (Atkins) Paleo way and by the fourth day I was limping and the 7th day I was in bed looking for something to remove my foot with. BTW this discussion also applies with many friends with Kidney stones…

    Since I have had a number of friends who have been on Allopurinol to manage the problem. Some of them have heeded my advice and Lo they have totally quite the drug and most of them have had few if any recurrences. Thanks for addressing this. Nice to know that my personal experience looks exactly what the clinicians suspect.

  18. Carrie says

    Thank you so much for putting this all together and giving the bigger picture…which you do so often and so well! It is much appreciated.

  19. Sharon says

    I eat Paleo but I do add grass fed and some raw dairy products.
    I never had a uric acid test, but I decided to get one a few months ago.
    The result was 5.5. I understand that the optimal level is 3-5.5, so I got concerned.
    I eased back on liver and sardines and just eat about once a month.
    I have no gout symptoms so I would appreciate if someone could put my mind at ease and let me know if these numbers are worrisome.
    Also, I don’t eat much fruit, just some berries or a little grapefruit a few times a month.

    • Michelle says

      I would ignore the numbers and go with how you feel! As a NP in emergency dealing with many people presenting in severe distress, uric acid levels don’t often correlate to pain or clinical presentation. They can be normal. If you have inflammation, then avoid the foods that cause it. If you have no pain, never had, then why be bothered by a set of textbook values that have no relation to how you feel? Don’t worry, that just adds needless stress. Just keep eating clean and no sugar! :)

      • Sharon says

        Thanks Michelle. Well..some time has passed and I took another UA test. Now, my number is 7.6!
        The doc’s people said to avoid red meat, but trust me, they are so undereducated it can make you cry.
        I came across Dr. Robert Su (www.carbohydratescankill.com). He also had a UA issue and he advised to use lemon and water, acv or cherries. He also found a correlation between coconut oil and this UA situation. He advised I dump the coconut oil and if I must cook with it..only tiny amounts. I am trying all of these and cutting severely back on my organ foods. I am trying to stave off prediabetes and I don’t want to just eat vegetarian now. I finally got my A1C to 5.2 and I’d love to go lower.

        I saw a video that uses Calcium Ion to ionize water. I may try that too.

        So far, no gout attacks, but I have read that even without an attack, high UA levels can cause stroke and heart attack. I also read that menopausal women and low thyroid (my profile) will also raise UA levels. Scary stuff!

  20. Bill says

    I believe that it can take more than 3 years to heal the damage. That’s my anecdotal experience.
    I seem to have suppressed my alopecia areata and osteo arthritis, but it did take time. I’ve been gluten/gliadin free for 7 years now. Also no industrial oils, only evoo and grass fed butter. My only carbs are basmati rice and potatoes. Never looked back.

  21. j says

    Adopting Paleo does not mean that we all somehow have the same genetic dispositions. Everyone will vary and have to navigate what works for them. Starchy rice and potatoes or dairy send me to the moon, but I can eat my weight in spinach. The real answer: pay attention!

  22. says

    I suffered with gout from the age of 24. I had terrible attacks. I remember one left me unable to walk properly for around three months as it just wouldn’t go. Since I have been studying nutrition etc i refused to take a pill for the the rest of my life so set about trying to fix it myself. High sugar, especially fructose is bad, beans and lentils unfortunately seem to trigger gout, especially black beans! Cooked spinach, I seem fine juicing it, alcohol bad, although I still drink from time to time with no problem…. now…. gluten bad. Too much organ meat and is start to feel it, but I think this is because I’m already broken. The most important things for me is, keep well hydrated, taking up juicing is great, lower sugar, lower alcohol especially beer, lower cooked spinach, rhubarb and others hight oxalate foods, and get plenty of naturAl anti inflammatory foods. I also made a concoction that literally made my gout disappear and has never been felt fully since. You can email me for that if you want the recipe

    • Linda Moody says

      Hi John, i’m interested in having your concoction recipe. Please email me. Thanks, very grateful. – Linda

    • J says

      John — I’d like the recipe. Thanks. Limiting alcohol and drinking tons of water has helped me. As well as tart cherry juice. I also supplement with magnesium (for other reasons) and have heard that may break up uric acid crystals.

      • says

        Ok, sorry for delay. The concoction. now remember that you need to increase fluids in general too (the most simple and important thing i believe helps).
        the recipe was one i modified from a guy (Tony Pantalleresco) from Youtube here is the link (not sure i am allowed? but ill try http://www.youtube.com/watch?v=bvGD6IvS97E )

        But this is what i done….

        chopped one whole pineapple, (Tony uses papaya in the video) then covered it in Cinnamon powder, ginger powder and Turmeric (lots of each) in a glass jar and let it sit for 7 to 10 days in the fridge. I then blended it with some aloe juice and enough pure water to get it started (I would use more fresh juiced pineapple/grapefruit when i do it again)

        I took it in small doses. I took 5 Serrapeptase tabs and a couple of ounces of this on a Friday night. I the same the next morning. I was unable to put smart shoes on to go out that night and i was going to get a taxi with the g/f because i could not walk. I knocked back my last 5 serrapeptase and the last two ounces or so of that concoction. A couple of hours later I felt a fizzing and and shortly after it was TOTALLY fine. I went out that night, in the tight shoes, walked a couple of miles to the bar and even had some beers to celebrate ( I know I know) and that was three years ago in July. Not had a bout since. Now I have learned some triggers (black beans in particular, and beans/lentils in general if consumed too much,) and the fact i don’t hardly ever eat bread or grains, or any fructose definitely all help. But I promise you I have never felt anything like this drink. I hope it helps even one other person. Now, I will have to make another batch and see if it works for Uveitis!!!! Good Luck

    • MARK HENISEY says

      I would be interested in that recipe that knocked out the gout if it is still available. I am a new introductee to the gout experience and can say I would really like to avoid it. Thanks

  23. Christine says

    Sometimes I wonder what would happen to any study, if two or three paleo eaters were amongst the participants. Would probably blow up the results ;-)

  24. ML says

    I have high uric acid, off the charts. It increased, nearly doubled, when I switched to low carb/LCHF, but decreased back to “normal” high levels in maybe six months. Never had gout.

    However, I have high levels of c-peptid, but low blood sugar (even before low carb). I have no results from blood tests in childhood, but I think my problem with insulin originates from being stressed since childhood.

  25. says

    Great gout reference article Chris. Having just done some reading around gout another aspect to the puzzle I hadn’t considered was sleep apnea. If anyone is interested in the biochemistry link between sleep apnea triggering a gout attack I’d read this and this.

  26. kat says

    I wish I knew these things while my mom was still alive. She suffered from gout flare ups quite often and always blamed seafood which was probably one of the few healthy things she ate. She ate a lot of sweets and ended up dying from heart and lung failure although she NEVER smoked!

    THANKS CHRIS for informing us of this often misunderstood condition! I will forward it to my husbands co-worker who also suffers from gout. Keep up the good work!

  27. Karl says

    I would frequently get gout a lot growing up as a teen. I rarely get it anymore. My diet definitely wasn’t paleo growing up but instead something along the lines of the typical American diet—high in vegetable oils, cereal grains, fast food/school lunches, etc. At the time I did eat a lot of meat though, and I also overate. Now I don’t strictly eat paleo as I consume a lot of dairy and other things like sweet potatoes and seldomly imported European breads that are pasteurized and don’t contain any wheat. I like lemons, and they reduce uric acid, so maybe that’s why I don’t get gout anymore? I’m betting my diet was just too acidic back then.

  28. ktb says

    My husband’s first disabling gout attack with massive swelling and pain that left him hobbling was the year we started buying our beef in bulk from Costco. We were also eating a lot of corn and other GF grains, as we all also live with Celiac disease. I did a ton of online research because I knew that medications to get rid of the symptoms without finding the cause was NOT what either one of us wanted. Even though all his family was telling him to go to the doctor and get on the medications. I found out the connection between inflammation and gout, and so we switched to grass fed beef and went grain free. He has not had another gout attack that severe since then. If he accidentally eats something that has some gluten in it, too much sugar or some grains—he will start to get the beginning pain of another gout attack in his big toe. Inflammation is definitely the MAIN factor in gout, and if you can remove the inflammation triggers, then you remove the gout triggers. Interestingly, though, the chicken we eat in abundance is corn/soy fed and he has not problems whatsoever with gout from that.

  29. sheila g says

    I suspect things may be more complicated than “eat this, experience that”. It is know that uric acid levels will climb in hypothyroidism. If your diet is inducing a lowering of your metabolism (most common when we decrease caloric intake), whether paleo, gluten free, vegan, or whathaveyou, then gout is a distinct possibility. This helps to explain why some do great on paleo/etc. while others do not. The most critical thing is the effect on the metabolism. Real food IS good, but when people change their diets and then experience weight loss they are intentionally under eating. While good for weight loss there is risk of damage to the metabolism. The key is to make these changes while preserving metabolic rate (the $64K question). As with everything, YMMV, and the role of your body constitution is critical.

  30. Phocion T says

    I’ve suffered gout attacks for 20 years, some bad, some minor. I’ve been “paleo” for about three years and have had minor flare-ups since but it was always due to falling off the wagon for a day or two. However, I had a seriously bad attack, the worst ever, during the summer of 2012; I was crippled for seven weeks. I actually had to buy a wheel chair plus I had to get my crutches out of storage. Man, it was bad.

    Eating paleo was, I believe, tangential to this attack. I had lost about 20 pounds fairly rapidly, thanks to paleo. When I was doing my initial research into the diet I came across a couple of papers indicating weight loss, or “rapid weight loss” was linked to gout. One study was a group of men having served in WW2 that had been on starvation menus as POWs, and another study was of a mix of adult men. Both studies were halted after some of the subjects suffered gout attacks.

    The theory is that rapid weight loss causes all the toxins in the fat cells to be dumped into the system too rapidly and too long for the body’s various filters to keep up with the onslaught. Why gout no one said but this theory makes sense until a better theory comes along.

  31. Sally says

    Very low-carb paleo (restricting all carbs) cured gout and other symptoms, not only in myself, but unrelated others. (Low-carb/high-fat diet, lots of meat and high fat dairy, otherwise all paleo.)
    I suspect it may have something to do with insulin resistance, as it responds so well to lowering carbs (and omega 6 fats).

  32. Pete says

    My brother in law has a uric acid problem ( gout) and struggled with it for a couple years with meat substitutes (all grains !!) and medication but finally tried paleo and now is gout free. It worked great for him and he’s still not even very omega 3/6 aware yet.

  33. Adam says

    I have suffered with month gout problems for a couple years. Pop a few indomethacin and go on with life. Since switching to a high protein primal/paleo diet I have not had a flare up in five months. Cheers

  34. says

    My Husband just had a bad episode of Gout that took him to the ER. The Doctor asked if he had been under a lot of stress because that triggers Gout as well. Has anyone else heard this theory? By the way – yes, he had been under a ton of stress, but really?

  35. Scott says

    Great article. I had gout constantly for 7 years from my early 30′s. All the medication I was given by “health experts” only relieved the pain but never got rid of the problem. I have been paleo for 1 year and have had no trace of gout yet I eat more red meat and seafood than I ever have. Paleo Rocks.

  36. pam says

    my mom in her 70 has had gout & mildly high blood pressure. otherwise, she is in reasonable health.
    she is slightly overweight (she looks more motherly than fat)

    she is not a big meat eater nor does she eat too much sugary junk or packaged food (compared with SAD), except she probably eats too much wheat (bagels, bread, pasta/noodle) & peanuts. she does not drink soft drink. she has about 2 servings of fruits. so not much fructose.

    every time she has thick chicken broth when eating out. it’s guaranteed she would have a severe attack.
    she insists it’s chicken. but i suspect it’s something else MSG? flour? HFCS? (i have asked her to try home made clear chicken broth so make sure it’s not chicken. but she does not eat chicken soup anymore)

    i suspect she is gluten intolerant & may have leaky gut. i have been trying to convince her to eat less wheat w/ little success.

    any idea?

    • Saytan says

      Gout is not normally understood as autoimmune. More likely is she’s genetically susceptible to gout. How high is her uric acid? It may not be all that high; those who’re genetically vulnerable have a problem excreting uric acid so even normal or mildly elevated uric acid could instigate gout. Another possibility is the acidity of what she’s eating. Fructose is not an immediate instigator of gout. Fructose is a long-term cause of gout and it’s usually seen in high uric acid. Like I said, short term, gout is definitely driven by purines and alkaline and acid imbalance in those who’re genetically vulnerable. I’d get her uric acid and pH tested (through urinalysis). If her UA isn’t high, she has no choice but to restrict purines. If her pH is low, she could increase that by eating more fruits and vegetables and possibly supplementing with baking soda / sodium biocarbonate.

  37. Rick says

    I’ve suffered from Gout for about 15 years. The frequency of my attacks has little to do with diet — that is to say that eating purine-rich foods do not, in and of themselves, cause an attack. What I HAVE seen is that following a period of major physical/mental stress — usually about a week — and low hydration, certain purine rich foods will act as a trigger to bring on an attack. So, the stress and dehydration are the precursors — probably dropping my resistance so that the purine is not being flushed from my system.
    Staying hydrated and focusing on breath will usually ward off an attack.

    • Andrew says

      Thanks for the advice. Kinda the conclusion I’ve been arriving at myself (first attack about 6 yeas ago now). I find having a couple of glasses of wine late at night is the surest way for me to get a stiff big toe the next morning, but I guess that’s probably just dehydration.

  38. TC says

    I recently came back to a Paleo diet last week. This week I have experienced my first ever bout of gout. The doctor has essentially ordered me to cut all animal protein until my symptoms subside and has all but said my body cannot tolerate animal protein. His belief is that I need to be on meds the rest of my life if I choose to continue eating meat. What I am wondering is whether or not I really need to be reducing my fruit intake?

    I don’t want to be on meds and I want to continue to eat meat, but I definitely don’t want to live with gout.

    Help.

    • Sharon says

      TC..from what I hear, the meds for gout are deadly and have very dangerous side effects.
      Do whatever you can to avoid them!

  39. craig pickles says

    first time commenting so sorry if I ramble a little. Anyway I am 47 and a diabetic for 12 years I have been experimenting with diets for years and have had success in curing all my metabolic syndrome issues except the blood sugar which is stubbornly high. Anyway to date I have lost a very slow 141 pounds in weight, now weigh 242 at 6 feet 1. OK to the point. The most effective diet for me is low carb high protein and good ie natural fats. The problem I have is everytime I begin to get good weight loss I get gout like symptoms! Not gout because no chrystals have ever been found but gout like. I think I have found the reason at long last as after a few months weight maintainance I went back on the low carb and tested both for blood sugar and keytones. It took a while but I went into keytosis finally and started to shed a few more pounds. After about 3 weeks the pains and feeling of inflammation began again. My blood sugar was now in a good range and I was in full keytosis. So after a lot of research I find that the excretion path for uric acid is the exact pathway shared by keytones! So I have an idea that when I get into keytosis this blocks my ability to clear uric acid from my body which eventually builds up and then triggers systemic inflamation to the point that I can no longer walk! The last time I had such an attack meds did not help but I eventually switched to high carb and it cleared up, but with high carbs stimulating the ensuing high blood glucose levels that I must avoid. Now I am testing this by blowing myself out of keytosis to clear the pathway in the hope that the signs will also clear. My plan is then to go back into keytosis for 2 weeks then back out for a few days to again free up the pathway. I hope this will enable me to continue to lose weight whilst balancing my uric acid and keytone excretion. Anyway I’ll see what happens. Any one else tried something like this and if so how did it work out? Is there an optimal number of days to clear out the uric acid? thanks

    • Sharon says

      Hey Craig, When I got my urine tested at the doc’s, they said I had 2.0 ketones which meant that I may have been in ketosis. Urine is really not the best indicator, blood tests are. Anyway, my uric acid level was 7.6.
      I have started adding some sweet potato a few times a week but not going overboard. I am trying to keep out of diabetes and I’m bummed that the LCHF diet may push up the UA levels.
      I need to find out what ‘s going on with my thyroid as that could be responsible for high UA too.

  40. Andre says

    Hi guys i suffer from gout and it drives me crazy , my knee flares up with fluid then goes to my ancles . Can some one plz help me with what food to avoid and im only 39 years old to youne for this but what can i do

  41. April says

    I stumbled across this post searching for gout caused by sardine consumption. I’ve been eating a paleo diet for 9 months now, but just recently introduced sardines (I’ve eaten them about 4 times in a couple of weeks). I woke up a few days ago with what I think is a gouty flare up in my knuckle on my hand. Have you heard of this happening from a few servings of sardines?

    • VT says

      I’d be interested too- have been eating relatively clean for most of the year, and have recently introduced sardines for the oils… Yesterday I ate pâté for the first time in years, and today I would appear to have gout. I can’t believe my levels would be so high to cause gout from one meal? I also can’t believe I ate sardine for lunch today. That was BEFORE I started googling around – grrr!

  42. Rumble says

    If you’re doing low-carb, high fat, your refuge is dairy. That is your refuge. But you don’t have to stay low-carb. You can be high carb Paleo and start eating yams, sweet potatoes, potatoes, taro, yuca, etc. Short-term, high purine foods definitely trigger gout. There is no question about that. So no bacon, organ meats, lots of redmeat, or sardines. I would eat flounders, pork chops, chicken, etc. that do not have as much purines per gram. Also, not too much spinach or vegetable sources of purines. Long-term, though, the cause is fructose. If you limit your fructose intake, your UA will go down.

    The other side of the equation is acidity: it’s your body’s acidity caused by highly acidic foods like sodas, juice, processed flour, etc. Especially sodas and including diet sodas, dip them in a pH strip and see how acidic they become. There are 2 triggers to gout: (1) uric acid volatility and (2) acidity. If you can keep your body alkaline, you will have less attacks. Drink a glass of water with 1/2 teaspoon of baking soda or mineral water before going to sleep and when you wake up. That will keep your body alkaline at night when gout attacks typically occur. When you have an attack, drink a glass of water 1/2 tsp baking soda every 15 minutes. That has about 5 times more effective than drinking water. Gout medications generally do not work. Your solution is to reduce your UA by reducing sugar/fructose and keeping your body alkaline by eating lots of vegetables and limiting organ meats and redmeat.

  43. Honora says

    I was talking to a rheumatology researcher today. The genes that cause some individuals to have higher levels of uric acid when they overconsume fructose have been identified. In her professor’s study, she is using a breath test to identify the individuals with this phenotype. I asked her if it was related to the gout issues I see in the Pacific Island community. She said that is a different genetic pathway and pathophysiology and was exhibiting before the introduction of the European diet but is now exacerbated by our diet. That issue for the Pacific Islanders is that they don’t get rid of uric acid to the same extent as normal folks. I’ll try to find out how common the fructose/uric acid genotype/phenotype is and report back.

  44. Matthew says

    While this article makes very plausible arguments for why the paleo diet doesn’t cause gout, this is a real problem with the diet. Perhaps the diet is miscalculating something? The paleo buff at our workplace who is 27, super fit, and has a popular paleo blog has been out all week with a nasty gout problem. All of us at work can’t stop laughing at the foolishness of overly extreme diets.

    • Chris Kresser says

      A sample size of one does not prove anything. That’s why we have research studies with hundreds or thousands of people. You can’t draw a conclusion like you have from a single person; doesn’t work that way.

  45. Phyllis Ursetta says

    I have started the Paleo diet and have been taking Allopurinol for a high uric acid condition. It isn’t acute and doesn’t affect me in any particular area. Since being on the Paleo diet I have noticed an increase in stiffness and soreness in my fingers and in every joint in my body. It reminds me of how I felt when I was first diagnosed with high uric acid. That is how I felt before I was prescribed Allopurinol. I think this way of eating has caused me some problems with Uric Acid. What do you think?
    Phyllis

  46. Tom says

    I had my first gout attack in 1983. After that I had several attacks per year each often lasting several weeks. Most doctors prescribe too small of doses of Allopurinal (i. e., 100 mg). I met a doctor in 1988 who put me on a 300 mg dose and I haven’t had a gout attack since. I did eliminate all organ meats ( the guts here in Wyoming). I didn’t change anything else even my beer. So I’ve been on a one/day 300 mg pill for over 25 years now. Allopurinal is cheap ($10-$15/quarter). I’ve never had any side effects from it, nor have I come across any studies showing adverse side efects. I’ve elimated the attacks and the dread of always worrying about what I’m about to consume.

    • Honora says

      Where I work, a professor of Rheumatology (Lisa Stamp) is doing a trial on higher dose allopurinol. She’s also been doing a study on the variant of gout induced by fructose. If I can catch up with the research nurse, I’ll add to what I’ve written here. The Prof is way too busy to talk to me!

      • Trundle says

        Allopurinol can be helpful if your UA is outside the reference range. But as your UA falls and approaches 6.0, you reach a point of diminishing return. I really don’t think it does anything if your UA is below 6.3. The reason why is easy if you understand how gout is triggered. It’s not the high uric acid. It’s the change in the uric acid caused by stress, purines, etc. So, let’s say you have a flower vase placed on a set of stairs. If it’s placed on 4th stairs, and there is some rumbling, the vase might fall and break into pieces. But on 1st and 2nd, it might survive the fall. The likelihood of breaking increases as you go high. But the fall is caused by the rumbling, not by being high up on the stairs.

        But if the vase already has a crack, then it might break from the 1st or 2nd stairs. These are the people with genetic vulnerability. These people get gout even when their uric acid is 4.5. It’s less frequent than when your UA was 14.0. But gout attacks still happen at that level of uric acid, which is a very low level for men. The reference range does not distinguish between men and women and the low limits of 3.5 is for women, who usually do not get gout unless they’re old.

  47. Dara says

    One thing, I believe, people on a paleo diet who have gout should watch out for is that a gout flare-up can be triggered by entering into ketosis. While I understand that a paleo diet does not necessarily result in ketosis, people who cut out all unnatural sugars, grains and dairy, and who are reducing intake of fruit and starchy tubers, probably are in ketosis. My understand is that the ketone bodies compete with uric acid for clearance by the kidneys, but this is much more pronounced during entry into ketosis, so going into ketosis can trigger a gout attack in those prone to get them, because temporarily, one’s uric acid levels are unusually high. (Lyle McDonald has some analysis of studies that sums up the effects of ketosis on gout.) Anecdotally, this has been the experience for me; when I eat a paleo diet that doesn’t push me deep into ketosis, I generally feel much better regarding flare-ups. When I severely restrict carbs for a couple of days, however, I have a pretty good chance of getting a really bad flare-up.

  48. Dara says

    This is a cut-and-paste of what Lyle McDonald writes about ketosis and gout:

    Phiney and Volek deal with gout in The Art and Science of Low Carbohydrate Living on pages 166-167 which are in Chapter 13, the section Biochemical Changes: A very predictable change in serum chemistry is a sharp rise in uric acid concentration in the first week or two of carbohydrate restriction. As noted above, this is due to competition between circulating ketones and and uric acid for renal tubular excretion. Put another way, uric acid rises in the blood not because the body is making more of it but because the kidneys temporarily clear less of it. Thus the blood level needs to rise in order for the same amount of it to be cleared by the kidney (because ketones are ‘getting in the way’). Subsequent to this abrupt early rise in uric acid, within 4-6 weeks the level then falls back to or below its pre-diet level even if the dietary carbohydrate restriction and ketonemia continue. This is part of the body’s ongoing adaptation to nutritional ketosis. In the vast majority of patients, this rise in serum uric acid is completely benign and requires no intervention. In the minority of individual predisposed to gout, however, wide swings in uric acid can trigger an attack. And this goes both ways – either the abrupt rise with diet initiation or the analogous abrupt fall if the ketonemia is reversed by breaking the carbohydrate restriction in the first few weeks, can act as a trigger. Most people with the genetic predisposition to gout know it long before they consider a low carbohydrate diet, so either preventative medication or prompt intervention at the first symptoms can usually preempt an attack. Also, because it is the rapid change in uric acid that is the primary trigger, once on a carbohydrate restricted diet, the patient with a history of gout should be counseled to avoid frequent cycling in and out of carbohydrate restriction (i.e., ‘going on and off the diet’).

    • Trundle says

      This is typical Phinney and Volek nonsense. They’re driven by an agenda to exonerate the VLC/ketogenic diet from being associated with gout. It could be true that temporary hyperuricemeia might result but the primary trigger here is the focus on puriner-rich foods, which naturally increase in proportion when you start VLCing. Phinney and Volek correctly note that it is the uric acid volatility that will trigger gout, not necessarily elevated uric acid. Only 1 in 10 people whose uric acid is above the reference range, that is, 7.0, will ever have gout. 9 out of 10 never get gout and have no reason to worry.

      For that 1 in 10, however, it’s the inability to excrete uric acid which is genetic in origin. That’s why these people have to avoid organ meast, redmeat, seafood, and other purine-high animal protein. For anyone with gout, you have to go on a high-carb Paleo, like the one advocated by Paul Jaminet or Chris Kresser. There is no other solution. You have to heavily start eating tubers, rice … in other words, safe starches. If you can tolerate dairy and eggs, indulge. I’m not saying completely restrict all meats: but eat meats that are relatively low in purines like poultry.

      But what’s alarming is these low-carbers still trying to preserve their low-carb agenda and trying to avoid gout from being implicated with their low-carb diets. Gout results from short-term uric acid volatility. And short-term UA volatility is triggered by heavy purine proteins. If you’re genetically vulnerable, you should avoid all organ meats, go easy on redmeat, bacon, and even certain vegetables like spinach, legumes, and lentils. Don’t listen to these low-carbers with an agenda. They’ll tell you to lose weight, lower UA even when you’re normal weight and have UA below 6.0. It’s the oldest trick in conventional medicine. When your patient starts having side effects, blame it on him, deny that the therapy (ketogenic/low-carb diet) is at fault. I have the lowest regard for peple like Phinney and Volek.

      • Dara says

        Thanks for the reply. I had no idea about anything regarding Phinney and Volek, I had just come upon that passage when it was referred to me by a friend who was a fan of Lyle McDonald (who is not necessarily an advocate of a very low-carb or ketogenic diet for all purposes). My understanding, however, is that even diets high in purine-rich foods don’t cause much of a change in circulating uric acid levels – I’ve seen the number quoted at about a 10% changes in uric acid levels at most can be attributable to diet, but who knows, maybe other studies say something different, or maybe that’s enough to cause the problems gout sufferers have. I was intrigued by this passage though, because looking back, going in and out of “deep” ketosis (not sure if that’s truly a thing, but I’ll assume now it is) seemed to be a more plausible trigger based on my experience than merely eating a low-carb diet. But I am merely a study of one.

        Also – and admittedly, this may be nitpicking, but I’d be interested to hear your thoughts if you’re so inclined – I don’t believe either Jaminet or Chris Kresser advocates a high-carb paleo diet. They do advocate, in slightly different ways, low-carb diets that include some carbs (enough to keep you out of perpetual, long-term ketosis, I believe), but they do tend to eschew very low-carb diets. For example, Jaminet advocates a diet that is about 65% fat calories with less or more carbs and proteins based on your goals (e.g., more carbs for athletes), which leaves carbs at about 200-400 calories/day, still pretty low-carb, I think. I know Chris Kresser, at least in the past, has cautioned against too much reliance on specific macronutient ratios, under the notion that we have seen healthy populations whose macronutrient ratios varied wildly. Still, I also understand that he doesn’t advise (or at least didn’t advise, maybe his thinking has changed) eating much at all in the way of carbs if a person has a weight problem and/or blood sugar issues, which many people who suffer from gout do have. Plus, even when discussing gout, neither Jaminet or Chris Kresser suggest avoiding many of the high-purine foods, particularly organ meats and shellfish; and neither would advocate eating much poultry, given the O3:O6 ratios. Do you think Jaminet’s specific recommendations (Chris’s are a little less specific, I believe) would be appropriate for those who have a propensity for gout attacks?

        • Trundle says

          Where do you get the 10% change? As I said, Volek and Phinney are right on this: it’s the change in UA, not the high UA level itself, which is a gout trigger. So if going in and out can induce this UA volatility, then it would trigger gout. But there are many other reasons why a VLC/ketogenic diet could induce gout, the biggest of which, as I said is purine-rich foods. This is simply indisputable. You eat a ton of organ meats/redmeat/sardines and you’ll come down with gout, I guarantee you. The blame game on fructose/sugar is really a smokescreen to divert attention from this. Sure, fructose will up UA long-term but unless it’s something incredibly acidic like sodas, fructose is not an immediate gout trigger; purines are. So if you have gout, I’m sorry, you will have to do low SaFA (except lacto-ovo SaFA) and higher carb Paleo, the kind done by those who may have defective ApoE4 genes and whose cholesterol skyrocket on a high SaFA low carb diet.

          By PHD and Chris, thieir diets are actually low carb compared to SAD, yes. But when VLCers look at it, they almost always consider it to be high-carb. I’m talking about 100-250 grams of all-natural carbs like tubers, plantains, white rice, etc. Yes, up to 250 grams if you have no blood sugar issues. But here’s the thing: neither Chris nor PHD believe in long-term ketogenic diets. This is off topic, but if gout is the only thing that you are suffering from after ketosis, consider yourself lucky. Many, many people are coming down with autoimmune diseases, gut dysbiosis, hormonal dysregulation, and immune deficiency after being on ketosis long-term. The effect is latent and stealthy so it might not be apparent. You start feeling it after a year, maybe 3 yeras. Your leptin, FT3, cortisol, and IGF-1 are dysregulated. You develop cold fingers and hands not just from hypothyroidism but Raynaud’s. There are plausible mechanisms where intestinal permeabilty will worsen and the autoimmune pathogenesis gets kickstarted. I know many people who became ANA-positive (that is, autoimmune antibody positive) upon ketoing. You will not know since it’s asymptomatic for years until you feel it. Check your WBCs. Leukocytopenia is an epidemic among VLCers and some of them end up developing severe immne deficiency syndrom. Check your WBCs before and after the diet. How much did it fall? Some fall as much as 50%. If your WBCs are into the 4-5s, you may be ok but I’ve seen some who fall to the 2s and their levels are not going back. Some of these people have to have immunoglobulins administered every month to battle infections. All of these are not mentioned in Lyle’s book, which was self-published, by the way. And Lyle is diligent and earnest but he does not fully understand the science behind many of the journal articles he cites. Also, my version is dated 1999, I don’t know if there was an update. But Lyle, impartial though he may be, misses a lot. There are huge health concerns emerging regarding VLC/ketogenic diets and it’s not just gout.

          anc

  49. says

    I am thoroughly confused after reading all of these posts and don’t have a clue what to do for the gout that has reared it’s ugly head for the first time in my life. I am trying hard to live the Paleo lifestyle and am so discouraged that I feel worse now that I did before I started. This along with the first two gout attacks I have ever had in my life is messing with my head and taking away my motivation to continue forward with trying to clean up my diet and my life.

    It seems as though no one really knows for sure the cause or the cure.

    I would to have answers from clinical studies that have been proven as fact. Everyone has opinions and everyone has a different case so I don’t want to depend on subjective opinions. HELP!!!

  50. Kathy says

    I have been paleo for 3 years, doing my annual Whole30. I have what I believe to be my first attack of gout. I really can’t tell anyone, because I can’t spout all these facts – it all seems twisted. Juicing? Reduce eating fruits? Caused by acidity? Eat lemons?

    My doctor is no fan of my diet! He is checking my cholesterol levels every three months and wants me to eat less beef and more chicken. I nod politely and disregard his directions. But I don’t know how I am going to handle telling him about this terrible pain in my big toe. He’s going to look down at my barefoot shoes and tell me to put my feet into some Nike boxes and cancel my grass-fed beef deliveries!

    So I will handle this myself. I do know that I have been eating too much fruit, for me it is the middle of fruit season. I also have reduced my water intake over the last 6 months. I am fixing that and I’ll see what happens.

    I have to ask my mother if she or my father have ever been diagnosed with gout. Shoot! There will be big family meetings about me and my “diet”, I can’t hear it now!

    • Trundle says

      Reduce eating fruit when you have gout? Why? You’re getting bad counsel from the low-carb camp, Cathy. Fructose is the problem. Fructose in excess quantity. You really cannot consume fruits in excess if you eat them raw; you can only do so via juicing. Soft drinks, cookies, sugary snacks … these contain excess fructose and raise your uric acid over the long term. There is nothing wrong with eating fruits in their natural state. That’s hardly gonna move your uric acid.

      The problem here is the uric acid volatility caused by purine rich foods; fructose is not a short-term trigger of gout. It is a long-term underlying cause of gout by elevating uric acid. But in the short-term, it’s purines, stress, hypothermia, over-exercising, etc. (Sodas can however often trigger gout by making your body extremely acid.) If you have gout, there is no other solution but to lower your uric acid and lower or avoid purine-rich foods. The low-carb camp has no answer for gout. They’ll hem and haw and act slippery, tell you to lose weight, lower UA. But you have to avoid those purine rich foods that are the mainstay of a VLC diet that are also gout triggers. You have to do higher-carb Paleo, incorporate dairy, tubers, and safe starches into your diet. Your food choices become unreasonable if you stay low-carb.

      • Honora says

        I noticed in my job as a phlebotomist that Pacific Islanders are prone to gout. Apparently as stated above elsewhere in the comments this category of gout sufferers genetically are unable to excrete the uric acid effectively – hence the build-up. We have another category that’s being studied at the moments using urea breath tests to diagnose the type of folks whose gout is due to a metabolic issue with fructose. I mean to learn more but it’s a matter of asking the right person at the right time. They’re all pretty busy…

  51. says

    Hi Chris.I have been paleo for 2years and always but particulary lately experiencing swollen finger and toe joints with hardening of the joint.I am confounded as I am strictly not touching any sugar in any form, no alcohol grains or any other carbs.Lately(2 weeks)I have taken eggs and dairy out as well to see if I would experience an improvement .The inflammation is worsening.I have increased my intake of fats(lard&coconut oil) and eat about 200gr of fish or meat/day fried or boiled in long cooked broths.Any thing jumps to your attention which I could try?Thank you so much for your guidance

    • Trundle says

      That’s not gout. You have rheumatoid arthritis symptoms. Young women hardly ever get gout. That has nothing to do with sugar, alcohol or grains. Go to a rheumatologist and get your antibodies checked out to make sure you don’t have any other connective tissue autoimmune diseases. There are some people around here who think that a Paleo diet will cure their autoimmunity. It will reduce your symptoms but not cure the underlying autoimmune attack. That immune dysregulation will persist and you’ll have to deal with that for the rest of your life, Paleo or not. Go see a rheumy and get diagnosed first. If it’s RA, you’ll need to go gluten/dairy and possibley nightshade free. Egg whites are a problem occasionally but not always.

      • Rickus says

        Trundle,

        You’re very Kurt Harrisesque in your writing style, smart, but abrupt:) ANYWAY, you make some good points. Clearly a leaky gut/gut biome dysfunction is a central problem. Just to add to your train of thought…If present, egg whites, gluten, meats, nightshades and more may cause inflammatory arthritis. So, BOTH gout and rheumatoid arthritis may indeed have something to do with sugar, alcohol and grains, which can effect intestinal permeability directly and indirectly via the gut biome. I suppose if someone removes that which has deteriorated the gut lining and increases gut biome diversity, they may indeed be able to stop food molecules/bacteria/viruses from entering the bloodstream and hence decrease the perpetuation of autoimmunity. As much as a rheumatologist might be great at checking antibodies, they haven’t yet gained ‘street cred’ for actually helping people with these problems:)

        One last thought. Is it possible that purines, oxalates, and more may directly cause autoimmunity in those with increased gut permeability? This may explain the confusing array of irritants and cures that people offer up.

        • Trundle says

          You’re mistaking gout to be autoimmune. It’s not, although it’s possible that a component of gout is autoimmune, just like atherosclerosis has an autoimmune component. But it’s not an autoimmune disease like RA is. Gout is actually closer to T2 diabetes/prediabetes, fatty liver, high triglycerides, and metabolic syndrome. RA has a genetic component that is more determining and an imbalance of gut flora (P. Copri), which may precede antibody attack. The “inflammation” underlying the two are different: in gout it’s systemic and largely metabolic. In RA, it’s specific and joint-related, although you could very well have metabolic issues and systemic inflammation.

          Plus, you almost never encounter someone who suffer from both RA and gout. The two do not travel together. If you’re diagnosed with both, it’s likely that you may not have gout or your arthritis may not be rheumatoid. These are not “fellow travelers” or what we call “co-morbidities.” They’re etiologically distinct, although their sufferers may both be replete with systemic inflammation. That’s why the food-based etiology that you mention misses the point.

          Sugar/fructose in gout, as I’ve said, is a long-term driver of hyperuricemia; sugar in itself, however, will not immediately trigger gout, as purines, alcohol, overexercise, and hypothermia, which induce sudden UA volatility, do. One possible exception is sodas but the mechanism may have as much to do with the acidity of soft drinks than with fructose. This is the point I keep hammering, since so many of you’re buying the Neanderthal line from these low-carbers that sugar is the driving force behind gout. Refined sugar is not good and it will raise your UA long-term. You should definitely avoid or limit it if you have gout or RA. However, you can still get gout at 5.0 UA. Only 1 out of 10 hyperuricemic (>7.0) people ever develop gout. Why is the 90% with high UA not getting gout? That’s because they’re not genetically vulnerable as the 10% is, who cannot excrete urate properly and must contend with sudden UA spikes or drops when they consume purines. The 90% is just as overweight, has metabolic issues and consume as much sugar as the 10%. However, they never develop gout. Doesn’t that tell you that sugar may be a component but not the primary driver of gout?

          The reason why these guys focus on sugar is because they want to promote their LC agenda while offering no solution for gout — sugar is a convenient scapegoat. But sugar is not implicated in an immediate gout attack; the real catalyst is purines that are in high doses in prototype LC foods: organ/muscle meats, bone broth, sardines, shrimp, lobster, lamb, veal, bacon, game meats, etc. If you already suffer from gout and do not restrict these foods, they will immediately trigger gout regardless of your UA level.

          As for purines and oxalates, these are gout triggers only in those that are genetically susceptible. They are not drivers of intestinal permeability. If you do not have gout, there is no special reason to restrict purines. But I would adopt a balanced diet with plenty of starchy carbohydrates, healthy fats, and animal protein. Low-carbing will solve metabolic issues short-term but is not a long-term solution health.

          • Rickus says

            Trundle,

            Your points are well taken. I think we’re on the same page. I don’t personally suffer from gout, but find this stream clinically useful. Gout is an interesting entity indeed, because folks can’t seem to pin down a cause in effect. However, purine triggers in folks with metabolic dysfunction and a genetic predisposition makes sense to me.

            Thanks for your feedback.

  52. Joe says

    This was a good read. It makes me feel more comfortable about my next paleo attempt. I got a really bad attack the last time I did “Paleo”, I quoted Paleo, because I wasnt really doing Paleo, I was faking it. I wouldnt eat carbs for 4 or 5 days, then i would have a cheat day, then resume. However, I was still drinking 2 or 3 Beers most days in my 4 to 5 day stints, and on my cheat day it was a whole different story. I lost about 15lbs in 4 weeks, then the gout attack came.

    I started Paleo the right way about a week ago. I go all week, and have 1 cheat day.. Saturdays. I do not drink any beer, and on Saturdays I will have a couple glasses of Red wine. I lost 7lbs my first week, and have a goal for 60lbs total. I plan to adopt a low carb lifestlye once I reach my goal weight. Have carbs for 1 meal every other day.

  53. Anna says

    I’ve been eating primal for 2 weeks (primal meaning gutting all grain and legumes, but consuming dairy). I have been considering sharing my new-found lifestyle with my family and encouraging them to go primal. My father already has acute gout episodes on occasion. What advice would you give to someone who already has gout in terms of starting a paleo diet?

    • Trundle says

      Add tubers, increase dairy if you can tolerate it, consider adding rice, plantains, lentils. Read Richard Nikoley’s Free the Animal Blog re resistant starch: potatoes, legumes, plantains, etc. You need higher-carb Paleo. The mistake is to eliminate all essential carbs thinking that you can avoid gout on a VLC diet. Your dad’s long-term plan is to cut out all processed foods and sugar to lower his Uric Acid. However, gout’s short term triggers are purine-rich meats, alcohol, sodas and overexercise. You’ll never be able to solve gout on a diet rich in organ meats, redmeat, sardines, and bacon. Those who claim that these foods don’t trigger gout do not suffer from gout. Fructose is the wool the VLC camp is trying to pull over your eyes to distract you from these gout triggers. If you don’t think organ meats and purine-rich foods trigger gout, serve your dad some liver and onions with spinach and legumes.

      • Daren says

        Hi Trundle,

        Regarding your post you said to add a bunch of carbs including legumes, yet in closing you said “If you don’t think organ meats and purine-rich foods trigger gout, serve your dad some liver and onions with spinach and legumes” — so are legumes in our out?

        Also, I’m wondering do you have personal experience with gout, and what is your background, as I noticed you said you were published in 1999.

        Your posts are informative and offer a great alternative perspective which is refreshing. From my experience as a gout sufferer I think you are spot on. I am currently paleo with higher carbs. I don’t have too many carbs but it enough to make sure I don’t get into ketosis. I find the things like sweet potatoes also offer a good quantity of vitamins like potassium to help with gout.

        • Trundle says

          Beans and lentils do have moderate amounts of purines. About 125mg per 100 grams or 3 oz servings. So do spinach, cauliflower and broccoli. However, it’s more like 50-80mg per 100g. There is no reason to completely avoid these foods, as they themselvs will not usually trigger gout.

          They’ll trigger gout when eaten with animal protein. For example, that cow liver from US Wellness Meast has 550mg per 100g. If you’re gonna eat animal protein, I’d look into chicken and turkey, which are around 150-175mg. Most dairy products, cheese, and eggs are virtually purine-free.

          What I wouldn’t do is have a purine orgy with organ meats, beans, lentils and spinach. If you’re going crazy and need a ribeye steak, have some white/brown rice, potatoes/yams, carrots, etc. as side dishes. Why go out of your way to pig out on purines when you know you’ll regret it later?

  54. says

    I had gout at the age of 26. My doctor did not believe that I had it. I went in with sever knee pain when I woke up and he couldnt believe that it was the gout. I told him to test my blood and see if it was. He prescribed me Colchicine and waited for the results. Of course the results came back with all signs leading to gout. I was 370lbs, ate like crap, drank a ton and have gout on both sides of my family. Since I started Paleo at 28 I havent had one single flair up. I eat a lot of lean meat and shellfish. I believe it was the SAD of highly processed foods and tons of beer that was giving me gout. I can honestly say Paleo has relieved me from my gout pain.

  55. Matt says

    I eat a low carb diet of things like poultry and eggs. No sugars or grains and I still get gout flareups.

    If you think that your safe eating a Paleo diet, you are sadly mistaken. Any rich diet has the potential and in the end it’s going to be more about how much you eat. If you have a very high protein diet, you are probably at risk if you are also genetically at risk. It’s about total protein processed at some point, not about which foods are rich in purine. If I pig out one night on chicken breast I can wake up with a gout flare up.

    The simple reality is the medical community doesn’t really have a handle on gout and the disease effects people differently. Some people are very sensitive to purine rich foods, like beef and they just can’t have them, while others can’t take supplements like creatine. In the same token different prevention methods work for different people, but in the end the one universe rule becomes… eat less. Fiber is always a good suggestions, but high protein of any kind can, in fact, set off some people’s gout and the quality of the food such as organic vs corporate farmed makes no difference.

    Who do you guys think your kidding on that. It’s not about how the food was produced at all, it is, and always will be about how your consuming in, particularly eating too much of it and not burning off calories enough.

    If you want to avoid gout you have to address the exact reasons you are getting it, not take general advice from the internet. A good diary and a doctor are your best bets, but a doctor alone isn’t going to do much for you other than prescribe drugs because they just don’t really know enough. They don’t know your diet and they don’t exactly know why this diet causes gout for one gout sufferer and not another. Like many other food intolerance issues, much of the effort is left up to the patient, but the one sure fire thing that will work is eating less. If X amount of eating purine and/or protein makes you have a flare up then eating less than X will always be an improvement. With so many different metabolisms and digestive property you can’t hope to give one set of advice to people.

    I can eat one healthy meal a day consisting of meat and veggies and plenty of fiber and still get gout if it’s just too much food at one time. Some simple to follow advice is to break your meals up and drink more water in between. More water is generally good advice for most people and eating less is good advice for most people, so you can’t go wrong with those. Breaking meals up into smaller servings is a fairly proven method for weight loss and healthy digestion in general.

    But, in the end the medical community really doesn’t know jack about gout.

  56. Anjum Pathare says

    You are talking about grass fed red meat. I do not get grass fed red meat so I usually eat grain fed red meat. If I avoid a diet high in sugar, vegetable oils, sweetened beverages, refined grains, and processed meats, do you think I still have a risk of gout due to the red meat I eat?

  57. Petrolene Le Roux says

    I have a client on Paleo. How long before gout effects should alleviate on such a diet or will it depends on the individual? He’s been on Paleo for about 2 months.

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