What is Gout?
Gout is a common form of arthritis that has been recognized for centuries. Patients often will complain of experiencing recurrent episodes of pain and inflammation in a joint, particularly the large toe and usually lasts for 1-2 weeks. It is often associated with obesity and excessive alcohol consumption.
The incidence of gout seems to be increasing along with the incidence of obesity and diabetes in the U.S. Although men are affected more often than women, many women suffer from gout as well.
Pain and Inflammation
The pain of gout is due to an inflammatory reaction triggered by a buildup of uric acid in the joint. Uric acid (otherwise known as urate) is a normal waste product of protein metabolism. When concentrations of uric acid build up in the blood stream, they seep into the fluid of our joints and can trigger a painful inflammatory reaction. Why the reaction often occurs first in the joint of the large toe is generally unknown. It can also occur in the ankle initially and less commonly the knee.
The conventional approach to the treatment of gout is to provide medications that either reduce inflammation during an acute episode of pain or lower the level of uric acid in the blood. Both approaches help reduce the pain and frequency of attacks but neither addresses the underlying cause of gout.
Too Many Carbohydrates Cause Gout
For centuries, gout has been associated with obesity and overindulgence in alcohol. As I have discussed before, obesity is linked to development of insulin resistance which also causes elevated triglycerides, high blood pressure, diabetes, stroke, chronic kidney disease and heart attacks and elevated uric acid levels. The greater the degree of obesity, the more likely a person seems to be predisposed to develop gout.
Elevated insulin levels (hyperinsulinemia) are one of the hallmark signs of insulin resistance and have been shown to reduce the kidney’s ability to excrete uric acid as well as sodium (table salt) in humans. The reduction of uric acid excretion by the kidney leads to an increase of uric acid in blood stream.
Interestingly, uric acid levels seem to elevate before the onset of medical complications associated with insulin resistance (elevated triglycerides, high blood pressure, diabetes, stroke, chronic kidney disease and heart attacks). This is a tantilizing clue that at a basic level, uric acid may somehow fuel the complications of insulin resistance.
But as I discussed before in this blog, the increasing weight that leads to insulin resistance (and gout) is probably a surrogate marker for the true driving force of this disorder, carbohydrates. Weight often reflects the amount of carbohydrates consumed by an individual. The more an individual weighs, the more carbohydrates they tend to consume and visa versa.
Fructose and Gout
Fructose, an increasing common form of carbohydrate in our food supply has been shown to directly elevate uric acid in humans. Likewise, increasing or decreasing dietary fructose in a rat’s diet leads to a subsequent increase and decrease in the blood pressure, triglycerides and insulin levels respectively.
Because of this and other accumulating evidence, many scientists believe that gout is the direct consequence of excessive carbohydrate intake (fructose or otherwise) in our diet.
Reduction Gout Attacks By Reducing Carbohydrate Intake
If increased carbohydrate intake leads to more insulin resistance and insulin resistance seems to cause elevated uric acid levels and gout in patients, then does a reduction in carbohydrates seem to improve the outcome of gout? A recent study seems to suggest yes and remarkably so.
A recently performed study was conducted to evaluate the impact of a low-carbohydrate on the level of serum uric acid and the frequency of gout attacks. The study included 13 non-diabetic men who had experienced an average of 2 gouty attacks per individual over the 16 weeks preceding the diet study.
The subjects reduced their carbohydrate intake to approximately 160 grams per day. The average American male consumes between 300-350 grams of carbohydrates per day.
After 16 weeks, none of the patients had a single flair of their gout! Remember, each study subject had about 2 episodes of gout attacks in the 16 weeks before the study. Additionally, the subjects lost an average of 17 lbs as well ashad improvements of their triglyceride and cholesterol levels.
The reduction in uric acid with this mild level of carbohydrate restriction was almost 2 mg/dl. This is better that reduction seen with severe protein (low purine) diets and as good as standard medication therapy without the risks of side effects and expense of copays.
What Should My Goal Be For Carbohydrate Reduction?
Although the study mentioned above had subjects only reduce their carbohydrate intake to 160 grams per day, I recommend reducing the carbohydrates even further to help prevent or reverse the development of heart disease, diabetes and high blood pressure.
Studies have shown that reducing your daily intake of carbohydrates (sugars and starches) to 100-125 grams/day will lead to a consistent and steady reduction in blood sugar, cholesterol, triglycerides, blood pressure and uric acid levels in the vast majority of individuals.
Try to eliminate most of your carbohydrate from the least psychologically important meals of the day. For many of us, it’s breakfast and lunch. Don’t waste your carbohydrate “allowance” on fast food, sodas or a donut at breakfast.
Focus instead on eating more proteins and fats at these times and saving your carbohydrate allowance when you eat with family or friends. There is no metabolic importance to eating carbohydrates at dinner, it’s only a psychological trick that I have found has helped me as well as many of my patients.
By saving your carbohydrate allowance for this meal, the reduction in carbohydrates won’t seem so intrusive and difficult. You’ll still be able to enjoy some of your carbohydrate comfort foods and not feel as if cutting back on carbs is such a sacrifice.
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DR. I am suffering from Uric Acid , pain in toe , hand finger joins .. i follow LFCH ( KETO since 8 months i reduced weight from 75 kilogram to 65 kg .. but even the uric acid not reduce… if i eat carb 100 Gram , and continue with LCHF it will be useful for GOUT . and 100 gram Carb what i eat … whole grain Race , Wheat … or what kind of food kindly inform …. if i eat almond and walnut . it will increase uric acid ..
Read this more recent article.
A reduction in carbs but specifically fructose might be the ticket to get your uric acid levels to drop.
[…] sugar in the blood which encourages fat storage, and cause inflammation.Bonus: carbs also cause gout, acne (I can relate) and Acid […]
Well this is a very good and helpful article here !! Thank You.
By the way there is some evidences showing eating carb at dinner is metabolically better, check for John Kiefer and his Carb Nite solution.
Thank u for your advise. This article is very helpful.
Wow! Thank you! I permanently needed to write on my blog something like that. Can I include a portion of your post to my blog?
Sure. Go ahead and past in the link too.
After hours of searching, I’ve finally found an article on gout that makes sense. My own case: 6’2″ 180 pounds. Triglycerides, blood sugar, cholesterol all these things are wnl. The cause of my high serum uric acid is renal insufficiency and the resultant chronic anemia (anemia as a factor was news to me). I had my first gout attack a few months back and am still recovering from it. I tried Uloric but it raised my blood pressure to unacceptable level and produced a rash. My serum uric acid level at the time of the gout was 8.8. After 10… Read more »
On the carb reduction, remember for focus specifically on reduction of fructose.
Theoretically, dropping the uric acid and reducing inflammation could possibly reverse pre-existing crystal formation.
Good luck – Dr. N
I have chronic Gout and while I knew about Fructose I started to suspect all carbohydrates simply by trial and error so I started googling and found this article. While it is promising can you site those study? I’ve found most studies done in China and Taiwan to be a farce.
If you look at basic physiology studies, fructose is a required precursor for the production of uric acid.
I am a 70 year old 5′ 10″ 200 pound male who for 30 plus years have had gout attacks I have dealt with them by taking allopurinol, cholchine, protein reduction, alcohol reduction and predisone both oral and injections. Lately I am unable to control the gout attacks and have been told that I have diminished kidney function which probably is due to life long high uric acid and lately insulin resistance. My blood fats have been low my entire life and BP has been under control as well. I am stunned that carbs have been causing this, for years… Read more »
You are in a difficult situation as elevated uric acid associated with renal insufficiency has a different cause as compared to elevated uric acid without kidney problems.
Your carb reduction has clearly been effective in reducing the blood sugars but you need greater reduction of metabolic inflammation via reversal of gut bacterial overgrowth (SIBO), rebalancing of omega-6 and omega-3 fatty acids as well as possibly some vagus nerve stimulation.
Too much to discuss on line. I am available for phone or skype discuss you issues.
Contact our office next week if interested 623-208-4226.
thank u so much for this important knowledge..i have gout and i want to limit my carbs.im 33 and have gout for 5 years more..again thanks doc
After a month of taking 600mg Allopurinol daily I am still having to take prednisone to suppress inflammation (which I would very much like to discontinue). I am feeling generally more energetic and with improved mental clarity. I attribute this to the reduced carbohydrate intake. Just wondering how long to continue with the 600mg/day dosage and if it should be taken in a single dose or divided (or if it matters) for best results. I am aware that it may take several months to rid myself of uric acid deposits and am not giving up…JDP
JDP, The Allopurinol can be taken once daily. You might go to your PCP and have the uric acid levels checked again. Other conditions that fuel secondary gout such as hypothyroidism, renal insufficiency, chronic anemia (B12, hemolytic), hypoparathyroidism could be checked for as well. On rare occasions another form of arthritis can mimic gout, the is called Pseudogout and its the second most common for of crystal-induced arthritis. Pseudogout is inflammation caused by calcium pyrophosphate crystals and is sometimes referred to as calcium pyrophosphate disease (CPPD). The only way to discriminate between the 2 is by microscopic examination of a… Read more »
Thank you Dr. N for the encouragement and suggestions. I have already done 1,2, and 3 above and will try Allopurinol again at the 600mg daily dose. My prior dose was only 100mg daily. I don’t think my fructose consumption was particularly high but carbs were, as I was trying to avoid eating alot of protein at the time as per standard dietary recommendations. Thanks again and I will let you know what happens.
I have read your info with great interest and have found others to concur with your approach. I have tried the medical approach, allopurinol and NSAIDS (I am a pharmacist) to no avail. Traditional dietary recommendations have not helped either. My gout has progressed over the past 25 years from occasionally disabling episodes in my ankles and feet to now constant flares all over…knees, one hip, shoulders, one thumb, elbows, neck, etc. The only relief I get is from taking prednisone, usually 10-20mg per day but often have to ramp it up to 40mg to be able to continue to… Read more »
JDP, It might just be a bit early to notice improvement with your case of extreme, inflammatory arthritis. Points to remember to try to get you under initial control (which can require a lot more effort than to maintain it) are, 1. Eliminate as much fructose and sucrose (this is a dimer with half the molecule being made up of fructose) as possible. Completely cut out fruit and fruit juice. Considering your circunstances, these are no more healthy for you than high fructose corn syrup. 2. Reduction of carbohydrates to the 75-100 gram range. Starched from tubers (potatoes and yams)… Read more »
I have a question not a comment. Are uric acic kidney stones the same as gout and will a low carb diet be help him?
Uric acid deposits in the joint space and causes the painful, inflammatory condition called Gout. Uric acid crystals in the urine are the same type of substance. But I would say everyone with uric acid crystals will get gout and visa versa. An increase calcium intake seems to lower both oxalate and uric acid kidney stones but doesn’t help gout. A reduction of carbohydrates (<100 grams per day) along with complete elimination of fructose puts Gout in remission in the vast majority of patients.
I found a couple papers that suggest supplementation with potassium citrate will reduce kidney stone formation. Ask your doctor for more information.
I am 33 years old and in the past few years I have had a handfull of gout attacks. I have been reading on the internet “Don’t eay meat”. I am 6’5 325lbs, so yes I am overweight. I have recently started playing football again trying to lose some weight, but my gout came on with a vengance, so I had to stop playing. I find that everything seems to contradict itself on the internet. I am going to try your method to start, and I will keep you updated on my progress. I have unfortunatly have had gout in… Read more »
Carbohydrate reduction to about 100 grams per day will result in dramatic and rapid improvement.
Had roast beef the night before last with brocolli & mashed cauliflower. I put a good slathering of Worcestershire on it. It said only one gram of carbs per teaspoon. Well I woke up on the couch about 11pm with a low level ache in my knee. I’m thinking “Oh crap, here we go again!” Got up, pounded a glass of water and took an Ibeprofin and went to bed. When I woke up I was fine again. I have since looked closer to the label of the Worcestershire. Number two ingredient is corn syrup! Most condiments are loaded with… Read more »
Glad things are going so well. Yes it’s quite surprising how they put the HFCS in everything. There are brands of frustose-free catsups and worchester sauce available on the internet and at some local markets such as Whole Foods.
Avoiding the fructose is so important in gout as you have discovered.
Hang in there, you’ll get in a grove with the eating, the gout will stay in remission and you’re health in general will drastically improve.
Update: At the end of the third day I noticed a change in my breath. I call it yack mouth! This I have since found out is a sign that your body is now in Ketosis. Also a couple of bouts diarrea in the first few days of this diet I’ve since found out are related to Ketosis also. This is now my sixth day of almost zero carbs. I did enjoy a glass of dry red wine each night. I also had a small amount of dessert each night as well. Even with these two treats my carb intake… Read more »
I’m a 49 yo gout sufferer that hasn’t taken any meds. I tested your theory a few weeks ago, started felling better, got cocky and had some pizza then some pasta the following night. Woke up the next day and couldn’t walk again.
This time I’m on the third day of low to no carbs and I’m felling better and walking again. This time I’m sticking with it. I’ll report back my findings.
Great information Doc, I sent to a good friend suffering from Gout and he was blown away. He is eager to experience the change.