Gout and low carb

GoutDo low-carb or keto diets high in meat cause gout? We are not aware of any evidence proving this, and this guide will explore why, or why not, this may be true.

First of all, a low-carb diet is not necessarily high in meat, and even those that are high in meat are markedly different from the standard American diet high in meat.1

Instead, since all low-carb diets are low in sugars and refined carbohydrates, there is a potential for them to reduce the risk of gout rather than increase it.2

Keep reading to find out what gout is, how to avoid it, and how a low-carb diet may affect it.

What gout is

Gout is a sudden and painful inflammation of a joint, most often at the base of the big toe (see image). It may also affect other joints, like heels, knees, wrists and finger joints.

The cause of gout is elevated levels of uric acid in the blood, resulting in crystals depositing in the affected joint.

Gout is more common in people who are overweight and have metabolic syndrome, and have thus become more common in recent decades, affecting about 6% of adult men and 2% of women (it’s even more common in older people).3 Historically, it was known as “the disease of kings” or a “rich man’s disease”, but now everyone can afford… sugar.

Meat and gout

Gout has often been blamed on excessive consumption of meat. This is because the uric acid that causes gout is a breakdown product of purines, a building block of protein, that is highly concentrated in meat.

However, as with all nutritional epidemiology studies, it is impossible to separate eating meat from observational healthy user bias, or from associated refined grains or alcohol intake.4 Therefore, epidemiology studies cannot prove that meat causes increased gout risk. In fact, one study showed that vegans had higher uric acid levels that meat eaters and fish eaters, thus potentially placing them at the highest risk for gout attacks.5

Eating more protein (like meat) seems to increase the excretion of uric acid from the kidneys, through the urine, thus not having much of an effect on the blood uric acid levels… or the risk of gout.6

Some weak observational studies, especially those in the United states, show an association between meat intake and elevated uric acid levels.7 Others, such as one in Taiwan, show no such association.8 Why the difference? We don’t know for sure, but one explanation could be the prevalence of metabolic syndrome or the consumption of sugar. Therefore, the rest of the diet may matter more than the consumption of meat itself.

Sugar and gout

As there is a very strong connection between hyperuricemia, gout, obesity, type 2 diabetes and metabolic syndrome, it’s possible that they are all primarily caused by the same thing: sugar and other refined carbohydrates.9

In fact, high blood levels of insulin – a consequence of a diet high in refined carbs – has been shown to increase uric acid levels, probably by decreasing the excretion of uric acid by the kidneys.10

There is a striking history of gout suddenly becoming common in populations just as sugar consumption started to rise sharply (e.g. in Britain during the eighteenth century, paralleling the birth of the country’s sugar industry).11

There’s also experimental evidence, showing that consuming fructose (a main component of sugar) increases levels of uric acid in the body.12

Since alcohol and fructose are metabolized in similar ways by the liver, it is possible that they also increase uric acid levels in the same way.13

Low carb, uric acid and gout

Short term studies show a temporary rise in uric acid during the first few weeks when starting a strict (i.e. keto) low-carb diet. This effect seems to disappear after about six weeks, with uric acid returning to baseline or even lower.14

Studies show no significant change in uric acid levels in people doing a low-carb diet over several months or years.15 The exception is one study that actually showed uric acid going down significantly after 6 months on low carb, suggesting it may decrease the risk of gout.16  

After dozens of high-quality studies comparing low-carb diets to other diets, there seems to be none noticing any obvious difference in the risk of gout, although no study has focussed on this specific question in detail.

Doctors regularly treating patients with low-carb diets do not notice a sharp increase in gout episodes even during the first time period.17 So if there exists an increase in risk during the first few weeks it is likely small.

 

 

How to avoid gout

Here’s how to avoid gout long term, using only lifestyle modifications:

  1. Minimize intake of sugar.18
  2. Reduce intake of alcohol. Particularly avoid beer and other high-carb alcoholic drinks.19
  3. Lose excess weight and reverse metabolic syndrome. Low carb is a good treatment, as is intermittent fasting.20
  4. Avoid dehydration.21

As a bonus, these lifestyle modifications have many other positive effects on weight and health.

Given that there may be a temporary rise in uric acid during the first few weeks on a strict low carb diet, some recommend that people who’ve previously had troublesome gout attacks may want to consider using the drug allopurinol while starting low carb.

However, rheumatologist Dr. Edward Skol from Scripps Clinic warns against temporary use of allopurinol for this purpose as its known to initially increase the risk of an acute attack when started (and when stopped) without the use of additional medication. This is supported by the American College of Rheumatology official guidelines, which strongly recommend only starting allopurinol with a medication like colchicine or ibuprofen to decrease this initial risk.22 In Dr. Skol’s practice, if medication is desired to prevent gout attacks at the start of a low-carb diet, he most commonly uses just colchicine or ibuprofen without allopurinol. He also summarizes, “The best advice is probably just avoiding dehydration when starting a ketogenic diet.”23

 
 

Meat or no meat?

Avoiding meat should not be necessary when it comes to gout prevention, especially if someone is otherwise following a low-carb diet.

Furthermore, please note that a low-carb diet is not supposed to be especially high protein or meat anyway. An effective low-carb diet should be moderate in protein.

A well-formulated low-carb diet (i.e. a low-carb, high-fat diet) could potentially reduce the risk of gout long term.24

More about gout

Gout and ketosis sometimes get mentioned in the media. Here’s an example from 2019:

Can we blame gout’s resurgence on ketosis?

Here’s an entire chapter about gout, from the award-winning science journalist and low-carb expert Gary Taubes:

Tim Ferriss: Gout: the missing chapter from Good Calories, Bad Calories

 
 

More low-carb side effects & how to cure them

Common early issues

Less common issues

 

Low-carb myths

 

More

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  1. It’s even possible to eat a vegan low-carb diet:

    How to eat low carb as a vegan

    Low-carb diets studied in the literature usually include less than 30 grams of carbohydrates per day.

    Nutrients 2020: Impact of a ketogenic diet on metabolic parameters in patients with obesity or overweight and with or without type 2 diabetes: A meta-analysis of randomized controlled trials [systematic review of randomized trials; strong evidence]

    Observational studies of the Standard American diet, on the other hand, estimate an average of 250 grams of daily carbs.

    JAMA 2019: Trends in dietary carbohydrate, protein, and fat intake and diet quality among US adults, 1999-2016 [nonrandomized study, weak evidence]

  2. Observational studies have found an association between sugar intake and risk of gout. More evidence is needed to show a cause and effect relationship.

    BMJ Open 2016: Fructose intake and risk of gout and hyperuricemia: a systematic review and meta-analysis of prospective cohort studies [nutritional epidemiology study; very weak evidence]

    Seminars in Nephrology 2011: The epidemiology of uric acid and fructose [nutritional epidemiology study; very weak evidence]

  3. Arthritis & Rheumatology 2011: Prevalence of gout and hyperuricemia in the US general population: The National Health and Nutrition Examination Survey 2007–2008

  4. The following study showed a very weak association between animal protein intake and risk of gout. However, those who had gout also drank alcohol more, were more likely to have hypertension, and ate more total calories.

    Arthritis and Rheumatology 2015: Food sources of protein and risk of incident gout in the Singapore Chinese health study [nutritional epidemiology study; very weak evidence]

  5. PLOS One 2013: Serum uric acid concentrations in meat eaters, fish eaters, vegetarians and vegans: A cross-sectional analysis in the EPIC-Oxford Cohort [observational study, weak evidence]

  6. Advanced Experimental Medical Biology 1980: The uricosuric action of protein in man. [randomized trial; moderate evidence]

  7. Arthritis and Rgheumatism 2005: Intake of purine-rich foods, protein, and dairy products and relationship to serum levels of uric acid: the Third National Health and Nutrition Examination Survey. [observational study, weak evidence]

  8. Seminars in Arthritis and Rheumatism 2008: Dietary factors associated with hyperuricemia in adults. [observational study, weak evidence]

  9. American Journal of INternal Medicine 2007: Prevalence of the metabolic syndrome in individuals with hyperuricemia [observational study, weak evidence]

    Arthritis and Rheumatology 2015: Risk of incident diabetes in patients with gout: a cohort study [observational study, weak evidence]

  10. Journal of Clinical and Diagnostic Research 2013: Correlation of the serum insulin and the serum uric acid levels with the glycated haemoglobin levels in the patients of type 2 diabetes mellitus [observational study, weak evidence]

  11. Rheumatology 2013: Sack and sugar, and the aetiology of gout in England between 1650 and 1900 [overview article; ungraded]

  12. Lancet 1970: Fructose-induced hyperuricaemia.[non-controlled study; weak evidence]

    In addition, observational studies show a correlation between fructose consumption and increasing risk of gout

    BMJ 2008: Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. [observational study, weak evidence]

  13. The following observational study suggested a link between alcohol intake and gout risk

    American Journal of Medicine 2014: Alcohol quantity and type on risk of recurrent gout attacks: an internet-based case-crossover study [nutritional epidemiology study; very weak evidence]

  14. Nutrition 2012: Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes. [randomized trial; moderate evidence]

  15. NEJM 2003: A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obesity [randomized trial; moderate evidence]

    Obesity reviews 2012: Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors [strong evidence]

  16. American Collage of Rheumatology 2014: High-Protein Diet (Atkins Diet) and Uric Acid Response [non-controlled study; weak evidence]

  17. This is based on clinical experience of low-carb practitioners and was unanimously agreed upon by our low-carb expert panel. You can learn more about our panel here [weak evidence].

  18. Sugar is likely worse than other carbohydrates because of the high concentration of uric acid-raising fructose.

    This study showed lowering the glycemic index of carbohydrates improved uric acid levels

    Arthritis and Rheumatology 2017: Effects of lowering glycemic index of dietary carbohydrate on plasma uric acid: The OmniCarb Randomized Clinical Trial[randomized trial; moderate evidence]

  19. Beer not only contains alcohol, but also rapidly digestible carbs, raising insulin and thus lowering excretion of uric acid. Of less importance, beer also contains purines.

    This study showed most types of alcohol, even in moderate amounts, increased risk of gout. However, it is likely that none of the participants were on a low-carb diet.

    American Journal or Medicine 2015 Alcohol quantity and type on risk of recurrent gout attacks: An internet-based case-crossover study [anecdotal report; very weak evidence]

    If you want to drink alcohol, ideally choose options low in carbohydrates. This may still raise uric acid levels and the risk of gout, but possibly not by as much (this is not based on evidence but on potential mechanistic thinking):

    1. Low-carb alcohol
    2. Low-carb beer

  20. The American Journal of Medicine: Update on Importance of Diet in Gout [overview article; ungraded]

  21. PLoS One 2017: Triggers of acute attacks of gout, does age of gout onset matter? A primary care based cross-sectional study [observational study, weak evidence]

  22. Arthritis Care Research 2020:
    2020 American College of Rheumatology guideline for the management of gout
    [overview article; ungraded]

  23. This is based on clinical experience. [weak evidence]

  24. Although we are not aware of any long term studies specifically on low-carb and gout, it makes empiric sense that reduction in sugar and improvement in metabolic syndrome would reduce the future risk of gout