[Updated Jan 5, 2013]
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.
Gout is triggered by the presence of crystals of uric acid in your joints. Most but not all people with gout have high levels of uric acid in their blood stream.
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 Much Fructose Causes 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.
Historically, doctors and nutritionists have advocated the avoidance of foods high in purines (a component of cellular DNA and commonly found in organ meats and seafood) as an approach to prevent gouty outbreaks. Since purines are metabolized into uric acid, it was believed a reduction in purines would reduce the symptoms associated with gout. Science never believed gout was caused by eating too many purines, it only hoped eating less of these foods would reduce the problems of too much uric acid.
Unfortunately this approach has never been shown to substantially change the course of gout over the long term.
Modern studies indicate a strong association between the development of gout and fructose consumption, especially from soft drinks. We now understand a major factor in the production of uric acid is the metabolism of fructose. You see, fructose is metabolized much more differently than its cousin sugar molecule glucose. Fructose metabolism directly results in an increased production of uric acid.
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 tantalizing 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 metabolic disturbance that leads to insulin resistance (and gout) is probably a surrogate marker for the true driving force of this disorder, carbohydrates. The excess weight often found along with gout 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
As I stated before, fructose is an increasing common form of carbohydrate in our food supply and has been shown to directly elevate uric acid in humans. Prospective studies are also strongly suggesting that fructose (from corn syrup, fruit juice and sucrose) is responsible for the present epidemic of gout. 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, especially fructose, in our diet.
Common foods or ingredients that contain or are converted into fructose in our diet include:
- Corn Syrup
- High Fructose Corn Syrup (HFCS)
- Table Sugar
- Sugar Cane
- Cane Juice
- Rice Syrup
- Maple Syrup
- Agave Nectar
- Fruit Juices or Nectars
- Soda Pop
Anyone wishing to eliminate gout from their life should completely avoid these ingredients. One hundred years ago, the only individuals who developed gout were the rich. This was because they were the only ones able to afford the luxury of sugar (table sugar is 50% fructose) in the quantities required to develop gout. Gout was strictly a disease of affluence.
Now with sources of fructose so inexpensive and readily available, we all have the opportunity to feel the pain of affluence.
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 as had 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 copayments.
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.
My only warning is being too aggressive initially and reducing to Atkins levels of 20 grams or less per day. This will trigger ketosis which can cause a transient rise in serum uric acid levels and may worsen your gout for the first 2-4 weeks. Stay around the 75-100 grams of carbohydrate per day range, focus on eliminating all fructose and this won’t be a problem.