Gout: is it the Meat or the Sugar

As You may be able to tell, we are taking a break from Why We Get Fat and What To Do About It, but I felt this was a worthwhile segway. Especially since what sparked me writing this post. Next week, however, will be the final conclusion of my book review, until then enjoy!

Recently at work, as I was prepping for my day, a friend of mine came up to me and asked me what I knew about gout since her husband was recently diagnosed with it. My first thought was: nothing. Which caused me to pull out my phone and type “gout” into the search bar. The search brought back “A form of arthritis characterized by severe pain, redness, and tenderness in joints[1].” After reading that I automatically thought about the pain in my wrists that happens when I eat sugar and the underlying inflammation that always followed it.

She then told me about the anti-meat, alcohol and seafood diet that was prescribed [2], she also mentioned that they stayed away from all of those things. Before responding I paused, told her that I had a few ideas, and I would get back to her. Before she left  I them typed “gout lchf” into the search box, I skimmed a few articles, and there seemed to be a reoccurring theme that cutting the sugar helped. I mentioned this find to her and told her I would do more digging and follow up later. That is what led me to write this article.

During my search, I found a lost chapter of “Good Calories, Bad Calories” by Gary Taubes[3]. This chapter proved to be an invaluable resource on not just what would help out, but also why the anti-meat, alcohol, and seafood diet was not the panacea you would think it was. I have both summarized his chapter and added some extra bits that I have learned along the way.

What is “Gout”?

A 19th-century British physician, Alfred Garrod, identified uric acid as the causative agent of gout[4]. You can think of gout like this: uric acid accumulates and crystallizes into sharp urate crystals. These crystals become lodged in the soft tissues and joints of the extremities (most notably the big toe) this causes inflammation, swelling and excruciating pain[5].

How do we treat gout?

Like mentioned above, it is caused by chronically elevated uric acid levels which ultimately lead to excruciating pain, but what causes the elevated uric acid? If you go with common wisdom, you will be told that it is caused by an overconsumption of seafood, red meat, and alcohol, and physicians may tell you that when you remove or limit those foods you will start to feel relief. Also, many physicians may prescribe you medication[5]. However, if we take a look at what the studies say, we find a different dietary culprit, which may lead us to a different dietary change to help manage gout.

When patients undertake a low-purine diet, often times there is negligible effect on their uric acid levels. In fact, taking a quote from Gary Taubes newest book “The Case Against Sugar”:

As it turns out, a nearly vegetarian diet is likely to have only a very modest effect on uric acid levels—at least compared with a typical American diet—rarely sufficient to return high uric acid levels to normality, and there’s little evidence that such diets reliably reduce the incidence of gouty attacks in those afflicted. This is why purine-free diets are no longer prescribed for the treatment of gout, as the physician and biochemist Irving Fox noted in 1984, “because of their ineffectiveness” and their “minor influence” on uric acid levels…. This implies that the meat/gout hypothesis is very debatable; the high protein content of meats could be beneficial, even if the purines are not.

How should we treat gout?

Before I answer that question I want to mention that diabetes is commonly associated with gout. This begs the question: Could gout be triggered but the same things that trigger diabetes?

In type 2 diabetes, we have insulin-resistance from too much sugar and grains[6]. Do these food trigger a similar response in gout sufferers? I’m glad you asked; Let’s take another long quote from Gary Taubes unpublished gout chapter[3]:

In 1951, Menard Gertler, working with Paul Dudley White’s Coronary Research Project at Harvard, reported that serum uric acid levels rose with weight, and that men who suffered heart attacks were four times as likely to be hyperuricemic as healthy controls.(13) This led to a series of studies in the 1960s, as clinical investigators first linked hyperuricemia to glucose intolerance and high triglycerides, and then later to high insulin levels and insulin resistance.(14) By the 1990s, Gerald Reaven, among others, was reporting that insulin resistance and hyperinsulinemia raised uric acid levels, apparently by decreasing uric acid excretion by the kidney, just as they raised blood pressure by decreasing sodium excretion. “It appears that modulation of serum uric concentration by insulin resistance is exerted at the level of the kidney,” Reaven wrote, “the more insulin-resistant an individual, the higher the serum uric acid concentration.” (15)

So… these observations seem to point to anything that raises insulin could, in turn, raise uric acid? If that be the case, is it too much of a leap to suggest that a high carbohydrate diet may be the cause of gout? Afterall, last I checked meat does not raise insulin. Then, could it stand to reason that a low carbohydrate or ketogenic diet may help reverse gout symptoms; much like a low carbohydrate or ketogenic diet can, in most cases, reverse type 2 diabetes[6].

The answer seems to be pointing towards yes, especially since a recent study found that, “Inflammation and joint pathology during gout flare is prevented by ketogenic diet[7].” To be fair, this was a rat study, however, the results do seem to be promising.

With all this talk about low carbohydrate diets, this begs a further question:

Are certain carbohydrates more likely to cause gout?

Well, the little voice in my head, I’m glad you asked, and yes there are! It seems that fructose is the linchpin that triggers a gout outbreak[8]. To further understand that, let’s look at the most famous breakout of gout. To do that we need to have a little history lesson. During the 17th-century, England started to have a large increase in the number of people with gout outbreaks. To illustrate this point, let’s look at a review article that looks at the sweet connection to gout in England from 1650 and 1900:

[Over the years] many have ascribed this rapid increase in gout to the introduction of wines that were laced with lead. In this article, we suggest another likely contributor, which is the marked increase in sugar intake that occurred in England during this period. Sugar contains fructose, which raises uric acid and increases the risk for gout. Sugar intake increased markedly during this period due to its introduction in liquors, tea, coffee and desserts. We suggest that the introduction of sugar explains why gout was originally a disease of the wealthy and educated, but gradually became common throughout society[9].

Science talk aside, what the data seems to suggest is that a low-carbohydrate diet (more specifically a low fructose diet) should help fight and may even eliminate gout symptoms. Again this is very similar to type 2 diabetes, both of these diseases are triggered by the wrong combination of carbohydrates and other inflammatory foods. This does not mean, however, that every person with type 2 diabetes can or will ever end up with gout.

If there are similar triggers, why is diabetes more common than gout?

This is because gout has a strong genetic component to it. In fact, a 1990 scientific study reported this very thing, saying, “the hyperuricemia [abnormally high level of uric acid in the blood] responsible for the development of gouty arthritis results from a wide range of environmental factors and underlying genetically determined aberrations of metabolism[10].” In less science speak most of the time those with gout will have family members that also suffer from gout.

The same study goes on to say, “studies of children with hereditary fructose intolerance revealed a readily detectable rise in phosphomonoesters with a marked fall in inorganic phosphate in their liver in vivo and a rise in serum urate in response to very low doses of oral fructose[10].” This seems to suggest that gout comes from a defect in how our body metabolizes fructose. This further points a finger to sugar instead of red meat and the trigger for gout.

What are the actionable steps to take?

First off, try and kick the sugar, it is poison and it should not be part of a healthy lifestyle. Check out any of Gary Taubes books (Good Calories, Bad Calories; Why We Get Fat; and The Case Against Sugar) he has argued for taking sugar out of your diet in each of his books.

Second, you could either kick sugar out cold turkey (which may cause withdrawal-like symptoms,) or you can slowly take sugar out of your diet. You can do this by cooking most of your meals at home, eat less junk food, kicking out sodas/juices, by limiting your fruit intake, and finally stop using sugar in cooking.

If you want a template for this way of eating check out the Healthy Lifestyles portion of the blog where I break down 3 of the most popular eating styles that will limit the amount of sugars you get. You can also check out the Recipe section where I break down a quick and simple meal that can take as little as 30 minutes. I also add new recipes from time to time.

Lastly, stay the course cutting out sugar is hard; especially if you are new to this. For more guidance sign-up for my newsletter, as a “Thank you” I will send you a PDF that is a 7-day start-up guide to get you started, in the appendix I have also included a more in-depth talk about sugars as well as a bunch of sneaky names food manufacturers use for sugars on food labels.

This is a lot of information… I still don’t know where to start!   

This can be overwhelming I know, I am learning along with you. Here are a few steps to help you on the way:

  1. The research points to sugar (specifically fructose) being a contributing factor for gout.
  2. Try and limit your sugar intake, only keeping in some whole food sources of sugar (like fruit)
  3. Check out the Healthy Lifestyles and Recipes part of my blog to help you enact change.
  4. Read any of Gary Taubes books: Good Calories, Bad Calories; Why We Get Fat; or The Case Against Sugar
  5. If you want my help you can email me, or sign-up for the newsletter where I send out periodic emails to help you switch into a healthier lifestyle.
  6. Remember that change is hard; it may take you awhile to fully embrace this way of eating. All we can do is stay consistent. If you remain consistent it will become a habit; habits allow you to excel in anything you put your mind to.

Resources

[1]: https://g.co/kgs/VM1WJJ

[2]: https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897

[3]: https://tim.blog/2009/10/05/gout/

[4]: https://www.ncbi.nlm.nih.gov/pubmed/19937040

[5]: https://www.arthritis.org/about-arthritis/types/gout/what-is-gout.php

[6]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633336/

[7]: http://www.cell.com/cell-reports/fulltext/S2211-1247(17)30169-9

[8]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073537/

[9]:https://www.researchgate.net/publication/233750937_Sack_and_sugar_and_the_aetiology_of_gout_in_England_between_1650_and_1900

[10]: http://www.pnas.org/content/pnas/87/21/8326.full.pdf

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