Dear Mark: Risk of Gout?

Every so often, a health malady arises that seems to clash with Primal living. And when a doctor brings it up, or a family member with intimate knowledge of the illness expresses concern, it can be intimidating and troubling. We’ve all heard how we’ll suffer heart attacks, diabetes, ketoacidosis, lowered marathon performance, kidney disease, and osteoporosis from “eating all that meat,” but that’s not what I’m covering today. No, today the subject is gout, which occurs when excess uric acid crystallizes and accumulates in the extremities. The jagged shards embed themselves in the joints, tendons, and other tissues, causing excruciating pain, inflammation, and swelling, particularly in the big toe. Suffice it to say, it is extremely unpleasant. Sounds great, right?

Let’s move on to the question that prompted today’s post:

Hi Mark, What’s your take on gout? It apparently runs in my family, and while I haven’t gotten an attack yet, I’ve heard that a “rich diet” is the cause, which as I understand refers to meat and animal fat. Does this mean I shouldn’t eat Primal? What does the science actually say? Thanks, Will

In previous centuries, gout was described as a “rich man’s disease” or “the disease of kings.” Ambrose Bierce called it “A physician’s name for the rheumatism of a rich patient.” Basically, it primarily affected the upper class, the royalty, the aristocracy – those who could afford “rich” foods like meat, sugar, and port. In the mid-19th century, uric acid was identified as the causative agent in gout. Where does uric acid come from? Purines.

Purines are in pretty much every cell – plant and animal alike – because they provide some of the chemical structure of both DNA and RNA. When cells are broken down and recycled (like in digestion – yum, love those delicious cells!), their purines get metabolized right along with everything else. Uric acid is a major product of purine metabolism, and this is a good thing; uric acid acts as an antioxidant in our blood, protecting blood vessels from damage. But if for some reason an excessive amount of uric acid (hyperuricemia) is produced, enough to crystallize and lodge in joints and other tissues, you might get gout.

And so the standard tale goes like so:

Since we get uric acid from breaking down purines, the natural solution is to reduce one’s intake of purine-containing foods – right? That seems sensible. Reduce purines, which turn into uric acid, and you reduce hyperuricemia, which causes gout. Boom. Problem solved.

The problem for a Primal eater given this advice, however, is that the richest sources of purines also happen to be some of our most treasured foods: organ meats like sweetbreads, kidneys, liver, and brain; seafood like sardines, anchovies, herring, mackerel, scallops, and mussels; and wild game meat. Even beef and pork are moderate sources of purines. In short, everything we talk about eating on MDA is apparently contraindicated for gout prevention. How do we reconcile without destroying our brains with cognitive dissonance?

Easy. We look for the real problem. What’s more logical? That purines, which appear in all foods and particularly in some of the most nutrient-dense foods (like organs and seafood), are the problem? Or that hyperuricemia, an excess of uric acid, is the problem?

Let’s table the purine talk for awhile, given the importance of purine-rich foods in the ancestral human diet, to look at some other causes of high uric acid. What else causes uric acid to rise?

Dietary Fructose

When the liver is loaded with fructose, whether by excessive intake or a lack of liver-glycogen-burning activity, purine metabolism is disturbed and uric acid spikes. One study (PDF) found that 0.5 g/kg body weight was enough to increase uric acid levels by this mechanism.

Fructose also decreases urinary excretion of uric acid, so it’s a double whammy: fructose both increases uric acid and decreases its excretion.

Insulin Resistance and Metabolic Syndrome

Elevated insulin levels, especially the chronically-elevated levels (hyperinsulinemia) seen with insulin resistance, also reduce urinary excretion of uric acid. It’s no surprise that gout patients often display the classic trappings of metabolic syndrome, too, including diabetes, vascular disease, and poor glucose tolerance.

Back to purines. Does the advice to drastically reduce purine intake hold up?

Not really, according to this 2002 review paper (PDF). And the fructose/alcohol connection is looking stronger. Among their findings:

“A diet rich in purines will produce only a small and transient (read: impermanent) rise of serum urate by about 60–120 ?mol/l (1–2 mg/dl).”

“Conversely, an isocaloric purine-free diet for 7–10 days will slightly lower serum urate by about 60–120 ?mol/l (1–2 mg/dl).”

“A dietary study of 61 men with gout and 52 healthy men showed that although the average daily intake of most nutrients, including total purine nitrogen, was similar in both gout sufferers and control subjects, the group with gout drank significantly more alcohol than the controls.”

“Alcohol intake, whether alone or with a purine-rich meal, produces greater effects on serum urate levels than a high purine diet.”

“There is growing evidence that a low energy, calorie restricted, low carbohydrate (40% of energy), high protein (120 g/day, or 30% of energy) diet, with unsaturated fat (30% of energy) and high dietary fiber, is more beneficial in terms of lowering serum urate, insulin, LDL-C, and triglyceride levels, and hence reducing CAD risk, than the conventional low purine diet…”

Furthermore, research shows that eating purines actually increases uric acid excretion in order to maintain balance, almost like the body knows what it’s doing or something. Nah, couldn’t be.

It’s also worth noting that dietary protein has also been shown to increase uric acid excretion and lower serum uric acid. Hmm. It’s starting to sound like a low-carb Primal eating plan might just help, isn’t it?

What else should people at risk for gout or showing high uric acid levels do, other than reduce/avoid fructose, clear out liver glycogen every once in awhile (maybe by occasionally sprinting, which I could have sworn I’ve heard someone recommend before), and avoid hyperinsulinemia?

You could make sure you’re getting enough vitamin C, which is inversely associated with uric acid levels. Vitamin C is known to be uricosuric (increases the excretion of uric acid), so this association is likely causal. While I don’t think the average person needs to megadose vitamin C, it is exceedingly safe, and it’s worth a shot for people at risk for gout or hyperuricemia. If you’re at risk, shoot for at least a gram or two a day.

Be careful with intermittent fasting, which has been shown to reduce uric acid excretion (PDF). This may not matter, as in one study, complete fasting by obese subjects did not increase incidence of gout, even in one individual who had previously suffered it. Just be aware of the possibility.

Stay hydrated. Dehydration (at least through exercise) can increase uric acid retention and concentrations.

I’ve also heard a number of anecdotal reports from gout sufferers who successfully staved off attacks with a quarter teaspoon of baking soda dissolved in water, supposedly by increasing alkalinity. There haven’t been any actual studies on it, though, so bear that in mind.

But perhaps the best way to avoid gout? Get healthy. Eat well. Exercise intensely from time to time. Avoid refined sugar. Avoid obesity, hyperinsulinemia, and metabolic syndrome. If what you’re eating and how you’re living are giving you those things – or moving you toward them – they’re also likely to reduce your chances of developing or exacerbating gout.

Gout sufferers, what have you experienced since going Primal? Has it helped, or has it made the problem worse? Let us know in the comment section!



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

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