Six years ago I awoke to a throbbing pain in the main joint of my right big toe. When I stood up I nearly fell, steadied myself with one hand on the wall, and winced. I could barely walk.
What is gout and how does a gout flare happen?
Gout is an extremely painful inflammatory condition that can happen if uric acid crystalizes in a joint–usually in the main joint of the big toe but other joints like the knees, elbows, and fingers can be affected.
A gout flare can happen if the uric acid is high (approx. 7 or 8 mg/dL), inflammatory conditions exist, and other metabolic contributors are present.
Gout is a metabolic disease that often co-exists with high blood pressure, high fasting blood sugar, a large waist line (waist to height ratio greater than 0.5), high triglycerides, and low HDL (metabolic syndrome). Quite often gout is a complication that is associated with diabetes, obesity, and cardiovascular disease.
One of the key factors in a gout flare is the consumption of sugar and refined carbohydrates. In particular is the molecule fructose that is metabolized almost exclusively in the liver. The result is fatty liver which drives insulin resistance (diabetes and cardiovascular disease) and uric acid which drives gout.
Gout is a metabolic disease and can be mitigated by diet. The question is, “what are the steps that I need to take in order to be free of gout?”
(1) How is uric acid measured and should I learn to do it my self?
Uric acid (UA) can easily be measure using a simple blood test (finger sticking). You simply prick your finger and use the UASure meter to analyze your uric acid. This allows you to monitor your uric acid at all times of the day, before and after meals, and when you first rise in the morning.
Monitoring UA is a really smart thing to do because it allows you to understand how UA fluctuates in your body over the course of the day, how UA rises and falls after meals, and what your personal levels are during a gout flare.
When combined with weight, blood pressure, fasting glucose, and ketones you will have a powerful way of evaluating your lifestyle journey to free yourself of gout.
(2) What are the other biomarkers that should be measured when you are first diagnosed with gout?
As mentioned above gout is a metabolic disease that often occurs with metabolic syndrome, diabetes, and cardiovascular disease. Therefore, when you are diagnosed with gout it makes sense to know your global markers. These include at the simplest level: waist to height ratio, weight, blood pressure, fasting glucose, and ketones (more on ketones later).
Additional blood work would include a basic metabolic panel with kidney and liver markers, hsCRP, a complete lipid panel, and the independent measure of fasting glucose, fasting insulin, and C-peptide.
Knowing these markers are vital to understanding your metabolic health and you can also discuss them with your doctor. Moreover, knowing these markers gives you the power to take control of your own health and the capability to track your progress as you start the ketogenic diet to be free of gout.
(3) What should your anti-gout dietary goals be?
The goal of the anti-gout diet is to (a) reduce systemic inflammation, (b) reduce uric acid, and (c) increase beta-hydroxybutyrate (BHB). BHB downregulates the NLRP3 inflammasome which plays a direct role in the gout flare.
Central to the gout diet will be the reduction in sugar, refined carbohydrates, and processed food which dominate the gout condition. Elimination of sugar, refined carbohydrates and processed food should be central to the anti-gout diet. This is for two reasons: 1) the generation of glucose in the blood with the corresponding expression of insulin drives systemic inflammation and 2) the metabolism of fructose in the liver drives non alcoholic fatty liver (NAFLD; insulin resistance and inflammation) and the formation of uric acid.
The ketogenic way of eating is the diet of choice because it eliminates sugar and refined carbohydrates and restricts complex carbohydrates.
(4) Why is the keto way of eating the best choice as the preferred gout diet?
The keto way of eating restricts carbohydrates and is the optimum way of eating for gout sufferers because 1) the keto diet reduces systemic inflammation because it lowers chronic insulin expression, 2) can reduce uric acid over time, and 3) the production of BHB downregulates the NLRP3 inflammasome which is needed for a gout flare.
(5) What foods can you eat on the ketogenic diet?
Whole food is the name of the game! The following list is not exhaustive:
All unprocessed meats including beef, pork, chicken, lamb, fish, and wild game.
Low carb vegetables including zucchini, yellow squash, asparagus, dark leafy greens, tomatoes, avocados, celery, cucumbers, radishes, etc.
Healthy fats including ghee, butter, beef tallow, and lard.
Dairy including heavy cream, high fat sour cream, half and half, cheese.
The full list of keto approved foods is linked here:
(6) What are the challenges of starting the ketogenic diet?
(1) You should measure your uric acid by finger sticking so that you know what your trends are. This is important because when you start the keto diet your uric acid initially rises. This is because in the fat burning mode you will be producing ketones and they compete with uric acid for excretion by the kidneys. Over time as you keto adapt (2-3 months) the UA should decrease.
During the UA spike you will be susceptible to a gout attack. It is crucial that you prepare for this possibility and speak with your doctor so that you can have anti inflammatory drugs on hand if you need them.
(2) When you shift from a diet that is high in sugar and carbohydrates to a ketogenic way of eating your kidneys respond by excreting water and salt. Therefore, you must increase the amount of salt that you eat to between 10-12 grams of table salt per day. If you do not increase the salt in your diet you will feel fatigued and may have headaches and generally not feel well.
Additionally it is recommended to drink a minimum of 3 liters of water per day to avoid dehydration.
Hydration and salt are the key reasons for the “keto flu” and is quite often the reason that is cited for ending the ketogenic diet. Drink water and eat salt and you can avoid this issue!
(3) A large number of people that try the keto lifestyle suffer from some form of carbohydrate addiction. It is imperative to understand that you must give them up. If not, “even a little”, will impede your ability to be successful in this lifestyle and to be gout free. It is our experience that most gout attacks that happen on the keto diet are the result of eating carbs. Cheat meals do not work!
(7) How long does it take to feel the benefits of the keto diet?
It takes 2-3 months to keto adapt. In my case it took a full year before I saw my uric acid drop fro 9.5av to 8.5av. In the time that I have been on the keto diet, I have not had a full gout attack. Other people that we work with or collaborate with communicate that their gout symptoms are far reduced than what they experienced before the keto diet. However, eating carbohydrates seems bring back the full symptoms of gout.
Its important to realize that the keto diet is not a pill or a short term cure of gout. If you want relief from gout you will need make a life long commitment to the keto lifestyle.
(8) What about medication to lower uric acid?
Keep in mind that I am not a doctor and this is not medical advice. Medications like allopurinol are a personal choice. I chose to take allopurinol after two years on the ketogenic diet. My average UA was 8.5 at that point and I wanted to lower UA into the middle of the “normal” range (4-8 mg/dL). I take 150 mg of allopurinol per day and my UA is now ~6 mg/dL.
My recommendation is to get consolidated in the keto lifestyle and then make the decision about UA lowering drugs later after you’ve had the chance to see what your UA levels settle to in the process of keto adaption.
The ketogenic diet can reduce or eliminate gout flares because of the reduction in systemic inflammation and direct inhibition of the NLRP3 inflammasome. Uric acid may also decline because of the reduction of fructose in the lifestyle.
Uric acid usually increases in the first months on the ketogenic diet because beta hydroxybutyrate competes with uric acid for excretion into the urine. Because of this increase a gout flare is possible at the beginning of the keto transition.
The most crucial aspect of this way of eating is to keep the carbs low and avoid excursions. In our experience usually gout issues arise when carbs come back into the eating plan. Even “just a little” matters.
“Keep the carbs low, down the road we go!”
For recipes and gout-keto beta find us here: https://www.youtube.com/c/DrPetesKetoKlub