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. (1, 2)
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?
Does eating meat and fish increase your risk for gout?
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. (5, 6)
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.
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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.
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What a rich dialogue. Really appreciate it. @Trundle, thanks especially.
I have to say I’m surprised/frustrated to not have seen any commentary on how (if it’s possible at all) to reduce steady-state/base uric acid levels over time.
I am 30. I have experienced 5-6 episodes of gout over the last 1.5 years, with increasing frequency — despite being by and large Paleo for the last 2.5 years. I’ve lowered pain & inflammation since my first attack with acute use of prescription “Indomethacin” — but would obviously prefer to have fewer attacks. Some context — I have a genetic predisposition (via father), was on a VLC initial diet (for ~1.5 years) followed by PHD over the last 4 months, but am sadly seeing no drop in gout episodes (rather, an increase since PHD). I have allowed myself cocktails/wine and some low-sugar chocolates, and think this could be a major cause. I’ve also continued to eat purine-rich foods, in what I thought was an appropriate balance with safe starches. All that’s stopping now, though — I’ll be fully eliminating alcohol and processed fructose, and I’m going to be significantly limiting my consumption of purines. Curious if I should expect to be able to reduce my *base* uric acid blood levels to <5 ever again in my lifetime. Overly optimistic? Any suggestions for how to start?
Also — thoughts from the forum on gout-impacts of:
– Dry Kombucha
– Cherry extract *pills*
– Natural sources of Vitamin C (bell peppers?) vs supplements
– Animal fats (grassfed tallow, grassfed butter)
– Permissible levels of wine consumption (eg 1 day/week?)
For 20 years I was misdiagnosed with stress fractures in both feet (many MRIs) so was in excruciating pain and often on crutches. As I got older, it got worse and more frequent. My uric acid level was never higher than 7 so gout was never suspected. I ended up in a wheel chair for several months and on crutches afterwards. After many specialists, I finally found a rheumatologist who was an expert on gout. When she stuck the needle in my deformed foot, the microscope revealed millions of uric acid crystals. Because I had been misdiagnosed for 20 years, all joints in my feet were severely damaged and that is why the “stress fracture” error was diagnosed throughout the years. BTW–at several points over the years I had gone to multiple holistic practitioners and had tried their recommendations of cherry juice, celery seeds, cider vinegar, supplements, etc. in case it was gout. Nothing worked. What I discovered is gout flare ups have to be nipped in the bud within 24 hours or it has to run it’s course whether it will be days, weeks or months. Gout is hereditary and some bodies are missing the enzymes to eliminate uric acid crystals caused by purine. (See Mayo clinic study). Although I was reluctant to take medication daily, I succumbed to Allupurinol and closely monitored my kidney function which have been fine. I am thrilled to report my feet have been gout free for 14 months….the longest time in 20+ years. Because it went on for so many years, the joint damage is severe but at least I am thrilled not to have any further flare ups. When I review my life, I was an active exercise fanatic so from 30 to 55+ consumed a high protein low carb diet. As later discovered, prolonged high protein-low carb diets are not healthy for the liver and kidneys especially as one ages. I’ve tried just about every food plan. After seeing an aryuvedic practitioner, I have stopped eating a high protein low carb diet, rarely have raw foods, and have begun eating cooked gluten free grains, lots of ghee, fresh green drinks several times a week instead of daily as they can create havoc on the thyroid which I also experienced, small portions of low saturated fat proteins, seasonal root veggies and a glass of warm organic milk nightly with turmeric, cardamon and cinnamon. Time will tell. I believe clean, conscious eating free of gmo and pesticides is the best.
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.
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?
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.
Agree! I am 58 yo white male. I have had gout attacks since age 23. Some years multiple attacks and some years no flare ups. At its worst I have had 6 flares in a year and al joints wth the longest episode lasting more than a month. It is an insidious disease. I have tried everything and monitored Moyer diet over my lifetime. I have come to the realization that the medical community knows still has much to learn about this ancient disease. And it is clear everyone is different. For me… My triggers: Dehydration (particularly after excessive), sugar (particularly corn syrup), stress, and surgery! I have had three surgeries over the past four years and each set off the worst gout attacks. As far as meat or alcohol I haven’t seen a link. But everyone is different!
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.
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?
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.
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.
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?
Fructose gave me gout this is my story http://www.youtube.com/watch?v=lbFhlTP-wsQ
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.
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
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.
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.
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.
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.
I’ve read that taking a round of antibiotics can temporarily interfere with the bodies ability to eliminate UA. I have experienced a few(3-4)flair ups in my big toe over the last 5 years and they seem to coincide with when I’ve taken antibiotics for lymes, sinus infections. Could there be something about a healthier gut flora that protects those susceptible to gout from building up UA?
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!
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.
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…
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!!!
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’).
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.
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?
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
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.
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.
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!
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.
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
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.
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.
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.
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.
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?
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!
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