Low Carb

Gout and Low Carb

GoutIt’s occasionally claimed that low-carb diets high in meat often cause gout. This does not appear to be true (nor does a low-carb diet have to be high in meat).

However, there may possibly be a temporary increase in risk of gout during the first six weeks on a strict low-carb diet. After this initial time period, a low-carb diet is likely neutral, or even protective, when it comes to gout.

Keep reading to find out what gout is and how to avoid 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).1 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, avoiding meat seems to have little effect on the risk of gout, and even vegetarians get gout much more often than would be expected if this was the main cause.

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.

Sugar and gout

As there is a very strong connection between 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.

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.

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).

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

Alcohol and fructose are metabolized in similar ways in the body, and alcohol increases uric acid levels in the same way as fructose.

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.

Almost all of my patients who are successful on low-carb diets eventually become gout-free and have low uric acid levels…
Studies show no significant change in uric acid levels in people doing a low-carb diet over several months or years.2 After dozens of high-quality studies comparing low-carb diets to other diets, there seems to be none noticing any 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 apparently do not notice an increase in gout episodes even during the first time period. So if there exists an increase in risk during the first few weeks it is likely small or moderate.

Long-term uric acid levels tend to become low on low carb, along with other markers of metabolic syndrome3 and even patients that used to suffer from gout can potentially become gout free. However, it might take months or even years to completely reverse their insulin resistance and achieve normal levels.

 


 

How to avoid gout

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

  1. Minimize intake of sugar.4
  2. Reduce intake of alcohol. Particularly avoid beer and other high-carb alcoholic drinks.5
  3. Lose excess weight and reverse metabolic syndrome. Low carb is a good treatment, as is intermittent fasting.6

As a bonus, these lifestyle modifications have many other positive effects on weight and health. However, if they are not enough, the drug allopurinol is highly effective in preventing gout.7

Given that there may be a temporary rise in uric acid during the first few weeks on a strict low carb diet, people who’ve previously had troublesome gout attacks may want to consider using the drug allopurinol during that time period, to minimize any risk of a new gout attack.

 
 

Meat or no meat?

Avoiding meat should not be necessary or effective when it comes to gout prevention.

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

A well-formulated low-carb diet (i.e. a low-carb, high-fat diet) likely reduces the risk of gout long term.

Do you have anything to add?

Do you have anything to add to this guide? Have you experienced any change in gout problems on low carb? Are you aware of further studies regarding gout and low carb?

Feel free to leave a comment below, we’ll read them all.

More about gout

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


Improve this page

Do you have any suggestion – big or small – to improve this page?
Anything that you’d like added or changed? Any other problems you’d like to see addressed?

Comment below or e-mail me at andreas@dietdoctor.com.

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

  2. NEJM 2003: A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obesity

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

  3. E.g. triglycerides, liver enzymes, blood pressure, glucose, abdominal circumference, and weight.

  4. Sugar is worse than other carbohydrates, even refined carbs, because of the high concentration of uric acid-raising fructose.

  5. 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.

    If you want to drink alcohol, ideally choose options low in carbohydrates. This will still raise uric acid levels and the risk of gout, but not by as much:

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

  6. The American Journal of Medicine: Update on Importance of Diet in Gout

  7. Wikipedia: Allopurinol

18 Comments

  1. Derick
    Andreas. Derick here in Denver. Met you in Capetown and Denver. So is there a chance someone who has been on Allopurinol can go off the meds if on LCHF ?
    Reply: #3
  2. Pete
    More people are certainly looking more closely at fructose causing high uric acid. Have a look at this press release from my local university 'Fructose and gout' http://biochem.otago.ac.nz/our-people/academic-teaching-staff/tony-me...
  3. Any chance? Sure. Uric acid can eventually end up normal even without it, as all metabolic risk factors often tend to normalize on low carb. But this can take months or years depending on where you start, even if you're successful.
  4. Patrick Kenyon
    I suffered gout in my ankles and knees for a couple of years. So I am very pleased you have written this article.
    I am very keen to reduce my allopurinol dose (500mg a day), I think this high dose makes me thirsty. My blood glucose seems normal.
    Until I gave up sugar and cut out a lot of carbs (most), late last year and joined Diet Doctor, I had no idea that sugar was such a big player in Gout (I blamed my Dad for passing it on! along with the slightly iffy prostate). I tried cutting down Allopurinol, but too much too soon and got a bad knee. Ow!
    I wonder if excess weight is an added cause or a symptom? As I loose weight do extra purines get released into my blood from the fat I am burning and should I get down to my target weight before trying to reduce allopurinol again. I am a couple of Stone over weight. Not sure how to tackle the Gout Monster! HFLC Gouters almost need theit own section lol.
  5. Bodil
    Just saw an interview with Dr. Veech on ketosis. He recommends taking Potassium Citrate when in ketosis, 50 mg once or twice a day. This to prevent formation of both kidney stones and deposits in joints. Now I want to find out if I excrete sufficient in the urine, so should I measure urine as well as blood for uric acid? Our doctor says, blood levels should be enough, but now I have asked also to be measured in a 24 hour urine. What is the optimal glucose level in mmol/L, when in nutritional ketosis? Should it just be lower than the ketone mmol/L reading?
  6. Tim H
    If in real nutritional ketosis, higher levels of uric acid may be expected. This is because ketones and uric acid compete for excretion in the kidneys. The ketones force the retention of uric acid.

    This is all to the good since uric acid provides the most anti-oxidant power in the body, way ahead of vitamin C. Primates have higher levels of uric acid than non-primate mammals, 10X in the case of humans, because primate evolution has lost the enzyme that degraded uric acid. Evolution would not have selected for it if it wasn't good.

    In the case of calcium oxalate kidney stones, chelation of calcium by proteins expressed in the kidneys of healthy individuals prevents stones despite super-saturation of the urine by both calcium and oxalate. The problem starts when those proteins are not expressed properly or are glycated upon expression. I would imagine there is a similar mechanism operating in the case of gout. I have enjoyed uric acid levels well above reference values for at least 4 years now without the slightest sign of gout. The literature says that centenarians typically have higher than normal uric acid levels.

  7. RICHARD BENSON
    HAVING BEEN OVERWEIGHT FOR MANY YEARS AND THEN DIAGNOSED TYPE2 DIABETIC, I SUFFERED FROM GOUT QUITE SEVERELY, ALTHOUGH NOT USING ALLOPURINOL, BUT RATHER COLCHICINE AS MEDICATION.
    CHANGE TO LOW CARB, HIGH FAT DIET ANDWEIGHT LOSS SAW THE DIABETES OFF, BUT I STILL SUFFERED GOUT, WHICH I THEN IDENTIFIED WITH FRUIT CONSUMPTION. EVEN2 OR 3 STRAWBERRIES WOULD TRIGGER AN OUTBREAK OF GOUT. SINCE THEN I HAVE GIVEN UP ALL FRUIT AND THE GOUT HAS NOW DISAPPEARED. I REGARD THIS AS A VERY DIRECT RELATIONSHIP, WHICH IS UNFORTUNATE, BECAUSE I LOVE FRUIT
  8. dv
    The ONLY time I get gout is when I'm strict low carb high fat. Make no mistake, high fat/high protein diets trigger gout flare ups, not sugar.
  9. Wendy
    Gout is related to Arthritis, I'm hoping a LCHF diet will alleviate my Arthritis, is this possible?
    Reply: #13
  10. Terri F.
    dv, that may be your experience, but many others find relief on LCHF, especially if they cut down on fructose in fruit. I've known a few people that are low carb, yet they eat a lot of fruit and some starches, so perhaps their idea of low carb is much different than mine.
  11. Lesley Robertson
    My hubby suffers badly from gout, prior to LCHF diet it was related to white wine and high fat foods , pate, rilettes. He went through a bad spell in week 6-7 of LCHF and we discovered it was cauliflower that was the problem, we had been having a lot of it cooked in various ways. Now even a couple of spoonfuls and he is in extreme pain.
  12. IMB
    Well, dv, unless I am missing something, I'm pretty sure that you're elucidating the old "causation vs. correlation" fallacy here. From what I have read, fat burning, which indeed can be caused by a LCHF diet, can trigger elevated levels of uric acid. These levels could, in turn, cause a gout flare-up. It's the fat-burning that's the culprit in this case, not the diet per se. I'd appreciate if someone more knowledgeable chimed in here, actually. Also, I have read that drinking lemon water can have a good effect on uric acid levels, lowering them.
  13. IMB
    Wendy, when I eliminated sugar from my diet, my arthritis disappeared. I now have joint pain only after I've eaten sugar.
  14. Paula
    I started a keto diet the end of January this year 2017 and was having great success by March 1st I lost close to 40 pounds but then the unthinkable happened! I started have severe pain in my joints of my feet and then in my stomach and then the weight started coming back on.....I was trying to get even stricter with my diet by adding intermittent fasting. But whatever the heck was happening inside my body.....was like an avalanche. The more I tried to press through it the worst the pain got. I then decided to take a break from ketosis for a few days and the pain went away. I was heartbroken because this diet was the first diet in my life to get me such great "initial" success. I guess I have to place this weight problem, and diabetes in the hands of God....who knows more than us all.
    Reply: #18
  15. MerryKate
    I was diagnosed with gout 20 years ago and took allopurinol daily until this year. After reading Gary Taubes' research on the subject, which indicates that gout attacks are triggered by fructose intake, I cut all fructose sources from my diet and went off the allopurinol. 3 months later, no gout attacks. I have always had them when I stopped taking the meds for 3 weeks or more. I've got a bottle of allopurinol handy "just in case" but it's looking like the fructose hypothesis is the right one.

    Paula, I would encourage you to give ketosis another try, this time avoiding any fructose sources (which includes cauliflower and asparagus). If you have a flare up, cherry pills can get you past the problem. Skip ADF if it isn't working for you. Its been known to increase cortisol levels in women which could lead to the other issues.

  16. Louisa
    Thank you for this very interesting article. Late last year I had a very large kidney stone that blocked off my kidney, it became infected and very swollen. After 3 months of treatment I found out that it was from uric acid, not calcium. I have not been given any advice or reason for it, but have been put on allopurinol. Do you think I will be able to get off the medication eventually, if I stay on LCHF ?
  17. George
    Great article!
    I'm a 67 yo hypertensive, obese male, with a big gut at 178cm & 110kg (5'10~240 lbs). I had a horrible gout episode last year for the first time, which took 6 months to diagnose, which left me almost unable to walk and in chronic pain in my legs and ankles. I was prescribed Colchicine for ten days along with long-term Allopurinol, which seemed to do the trick mostly, although walking was still a bit painful.

    I have been LCHF and below 20g carbs for almost five weeks now and am in ketosis if the urin Ketostix strips are working as advertised. I am now able to walk to the local shops without pain and have even taken to doing the shopping and walk home up a hill with over 10kg of shopping in my backpack without huffing and puffing or pain. Extreme perhaps but I'm trying to strengthen my legs so I can hike again. I've already eliminated one of my Blood pressure meds, Natrilix a diuretic and now plan to suspend the Allopurinol and see if any gout symptoms return.

    I'll repost in a few weeks so please wish me luck...

  18. Ann
    So sorry for you. Kind of puts me off trying this diet.
    Have you had any advise or response regarding this situation from one of the keto experts?
    How are you doing now?

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