Can we blame gout’s resurgence on ketosis?

Gout , Rheumatoid arthritis

“My toe hurts so bad, even looking at it is painful!” I was a third year medical student when I heard the obese 50ish-year-old man screaming in the emergency room about his pain. At first I thought he must be overreacting to get better pain medicines. But then I remembered all the textbooks mentioning how incredibly painful gout is. My attending confirmed that, yes, this was a common presentation for gout and I have never forgotten that. Gout hurts!

Traditionally, gout has been associated with the “opulence” and “indulgence” of the upper class aristocrats. Now, however, gout is an equal opportunity offender striking individuals of all socioeconomic classes.

The Cut: Why gout is making a comeback

In fact, the article in The Cut suggests a resurgence of gout not just in obese Americans, but also in young, otherwise healthy individuals who start a ketogenic diet:

Doctors largely attribute this rise to the increasing prevalence of obesity and hypertension. But Dr. Leigh Vinocur, an emergency physician, said she has also noticed a new crop of young, trim people coming into the hospital with symptoms of the disease; patients who don’t have pre-diabetes, or high blood pressure, or hypertension. She believes that this, in part, has something to do with fad diets like keto, which calls for low-carb, high-protein consumption. “Quick-fix diets like keto and paleo, where your intake is very high in fat and proteins, those can lead to gout,” she says. “It’s ironic: modern living — from the food industrial complex to those brand-new diets like keto — have led to an uptick in one of the world’s earliest diseases.”

Could this be true? Does a ketogenic diet cause gout attacks?

For starters, there are no good studies looking specifically at the incidence of gout after starting a keto diet. In fact, most nutritional studies on gout focus on the blood level of uric acid, the main component of gout crystals found in affected joints. As we have written previously, ketogenic diets may cause a short term rise in uric acid levels which may correspond with an increased risk of gout. Over the long term however, it appears that low-carb diets may reduce uric acid levels and therefore may be beneficial for preventing gout rather than causing it.

Instead, gout is most likely associated with metabolic syndrome, alcohol consumption, high fructose intake, and less likely associated with meat consumption. What did wealthy aristocrats with gout have in common besides high meat intake? They were overweight, they drank alcohol, and they ate plenty of sugar and simple carbs. Sounds a lot like our standard American eating our standard American diet.

What can conclude from the limited data we have?

  1. In large scale trials, gout is rarely if ever reported as a side effect of a low-carb ketogenic diet.
  2. There may be a very small increase in the risk of gout in the early stages of transitioning to a ketogenic diet.
  3. There is likely a beneficial long-term effect of preventing gout while on a ketogenic diet.
Based on what we know, concerns of gout should not deter someone from pursuing the multiple potential benefits of a ketogenic diet. But if your toe starts to hurt just by looking at it, be sure to let your doctor know right away!

Thanks for reading,
Bret Scher MD FACC

Earlier

Low-carb case report: Patrick

The keto diet: “My health has never been better”

I don’t call this a diet, but a new beginning

Diabetes

22 comments

Top comments

  1. Domenick V Doran
    A ketogenic diet does not call for high protein, as mentioned in the article. In fact, too much protein can actually take one out of ketosis. The diet typically calls for 20 percent of one's calories be from protein. This is comparable, and actually a bit lower, than the protein intake prescribed by the Mediterranean diet.
    Replies: #2, #9
    Read more →
  2. mike
    I suffered from pain in my big toe from gout as well as having metobalic syndrome. I started a ketogenic lifestyle 2 weeks after my diagnosis. 1 year in and my uric acid is normal, no more toe pain. I've also lost 40 lbs. and stopped needing medication for high bp, cholesterol, triglycerides, and diabetes. I've also never felt better. It should be a lifestyle change not a short term diet.
    Read more →

All comments

  1. Domenick V Doran
    A ketogenic diet does not call for high protein, as mentioned in the article. In fact, too much protein can actually take one out of ketosis. The diet typically calls for 20 percent of one's calories be from protein. This is comparable, and actually a bit lower, than the protein intake prescribed by the Mediterranean diet.
    Replies: #2, #9
  2. Wanda Yarbrough
    Great response!
  3. Brenda
    A great read and great infro. My mom just got over a bout with Gout. She was in very bad pain and her toe was swollen and red and she was already in pain with her bunion. When I read this it brought to my attention that I had strated us on a low carb diet. Thanks again. Gave a fresh insight.
    Brenda
  4. Elizabeth
    I realized by the end of the article that I am paranoid about anyone that writes against Keto. Well written. The article isn’t against Keto it just says to be aware of a possible side effect. I think the sugar and carb companies are giving out misinformation making me think “are they paying you for this article”. I should be aware of side effects. Thank you
  5. mike
    I suffered from pain in my big toe from gout as well as having metobalic syndrome. I started a ketogenic lifestyle 2 weeks after my diagnosis. 1 year in and my uric acid is normal, no more toe pain. I've also lost 40 lbs. and stopped needing medication for high bp, cholesterol, triglycerides, and diabetes. I've also never felt better. It should be a lifestyle change not a short term diet.
  6. Charlie
    You would have to eat your body weight in meat to be kicked out of ketosis. Infact if you go visit carnivore keto groups on FB you'll get a better understanding of why.
    Reply: #20
  7. Charlie
    Kudos to diet doctor for not jumping on the keto bashing bandwagon.
  8. Miles
    I would really appreciate some help here from guys who are well acquainted with the keto diet !
    Please tell me what you'd eat on a normal day snd how much of what so I have a clue if I'm overdoing anything 🙏🏻
    Reply: #16
  9. Mike
    Actually 20% protein is considered a high protein diet. On keto most people have 75% from fat and 5% carbs. So mathematically they have 20% of protein and medical professionals will classify that as a high protein diet but it really is not. 20% of protein will not nock you out of ketosis. You have to watch out though. If you go much higher your body will convert protein into energy and not fat, that’s how you can get knocked out of ketosis.
  10. Bruce
    I have been diagnosed with gout for the last 30 years I’m 56. The keto diet doesn’t cause gout. High consumption of foods high in purines combined with dehydration seem to cause most gout attacks. I’m doing keto right now 70 to 80 percent fat 20 to 30 percent carbs and 20 grams or less carbs. And I’m fine.....deer meat,Organ meats (sweetbreads, liver, tongue) and drinking will then cause dehydration concentrating the uric acid in your blood bringing on an attack
  11. Merv
    Once you have used the keto calculator to determine how much protein, fat, 20 gm carbs. You know exactly what you should consume per day. Initially, I monitored it closely with a food scale and a fitness app which allow me to track the nutritional facts in my food until I became comfortable with knowing my numbers. I have lost 40 pound and holding. I don’t use the breathelizer or strips but weigh myself every morning if I weigh less than the day before or weigh more. Based on the scale, I know if stayed below my carb limit or exceeded my carbs limit.
  12. Lorena
    I first saw the article on Business Insider, and the headline and first part of it certainly sounds biased against Keto. As someone else pointed out, Keto is moderate protein, not high protein, but the article refers to it as a high-protein diet. Yes, many people tend to go overboard with protein, but speaking as someone who's been eating moderately low-carb since I first went on Atkins in about 2000, I've never had any gout symptoms. In fact, the only people I know with gout are those who eat lots of sugar and starchy carbs (with one exception for someone who takes a diuretic blood pressure pill).
  13. Lynnette R.
    Good article, and I appreciate the viewpoints brought out in everyone's comments. I'm 58, diabetic, have heart disease and am facing another heart surgery due to developing blockage. I'm just getting started on the ketogenic way of eating AT MY CARDIOLOGIST'S RECOMMENDATION. He's eaten this way for over 10 years and is one of the healthiest, fit and energetic people I've met. He says keto isn't for everyone but is worth a try if other diets haven't worked. Wise counsel I am heeding! Wish me success...
    Reply: #17
  14. Anne
    My husband suffered for years from gout and was on daily allopurinol until he had to stop because he developed a bad rash to it. I started the keto diet more than 3 years ago, and he was slow to join me. I dove in; he took about 2 years to slowly, slowly cut carbs. But now he is almost completely keto, with no gout flares for a year -- which is amazing to him. The biggest impact is that he now rarely has any fructose -- he used to drink juice daily by the gallon -- and he has no sugar or foods that convert to sugar. (He has also lost 17 pounds.)He thinks these two things - no fructose, no sugar -- are what has prevented further gout attacks.
  15. Andrew
    I suffered from gout for about 15 years on and off - usually about 3 to 4 attacks a year. I haven't had an attack in the last 9 months... about the same time I gave up sugar and started the keto diet. My toes and feet which were always sore and swollen are now back to normal. No swelling - no pain. Coincidence?
  16. Kristin Parker Team Diet Doctor

    I would really appreciate some help here from guys who are well acquainted with the keto diet !
    Please tell me what you'd eat on a normal day snd how much of what so I have a clue if I'm overdoing anything 🙏🏻

    I'm afraid your question is going to get buried here!

    You can check out our free 2 week challenge with meal plans and shopping list. Also make sure and check out our other articles linked from the header!
    https://www.dietdoctor.com/low-carb/get-started

  17. Allison
    Good luck Lynnette - switching to keto can be a challenge at first but it gets easier. It's all about rediscovering real food - quite a pleasant adventure! Best of luck with your surgery.
  18. PAUL
    Hi DD,
    I love your responses to these articles in the press. Please can I ask if you send the response to the publications where the articles appear?
    Many thanks
  19. Brenda Odle
    I believe the keto diet is solely responsible for my son not having any gout symptoms since our family started eating keto. No inflammation of any kind. My other son and daughter have no more gut issues. And last but not least I’ve lost 52 lbs since June 2018. We are believers!
  20. Mike
    To much protein will definitely kick you out of ketosis an it doesn’t take that much.
  21. Jeff
    I had a gout flare up not long after starting a keto diet. I got some meds from my doctor and it was gone in a few days, but I kept with the keto and over a year later, I have not had any more gout problems.
  22. Peter
    clearly Dr. Leigh Vinocur shows her ignorance at several levels. She is an emergency room physician, not a specialist, and she should know better than to claim any kind of causal connection based on "she has noticed..." as if that is scientifically valid. She is also clearly ignorant on what a keto diet is and its history by calling it a fad diet.

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