What Causes Gout, and Does Eating Meat Really Trigger It? 

Why does gout matter so much?

Gout plagues millions of people with severe joint pain. In my years as a family doctor, gout is one of only three things women have told me is worse than childbirth. If a woman says that, you definitely don't want it.

I'm a board-certified family doctor licensed in Tennessee, and at the time I made this video I had been practicing for 20 years. I've seen lots of people with gout. I've seen patients who followed the standard diet advice and took the standard pills and still had severe, debilitating attacks. I've also seen patients who bucked the trend, didn't follow the standard advice, didn't take the standard pills, and had almost no flare-ups at all.

What are you usually told about gout and diet?

Most of us were taught that to avoid gout flare-ups you need to eat low fat, eat a low-purine diet, avoid red meat and avoid seafood. In my view, these are just not true.

Do the purines you eat really cause gout?

We're taught that eating lots of purines raises your uric acid and leads to gout attacks. Here is the problem. Your body makes purines itself. Anytime a cell breaks down ATP or GTP for energy, a purine is created. Anytime you break down DNA or RNA, a purine is created. These are called endogenous purines because you make them yourself.

In my view, your body makes far more purines from this breakdown than you could ever eat, even on a high-purine diet every day of your life. Telling someone to avoid dietary purines is like telling them not to pour a cup of water in the ocean because it might flood the world.

Does high uric acid always mean gout?

No. I've checked uric acid levels on thousands of patients, and I've found many people with an elevated uric acid level in their blood who have never had a gout attack. If high uric acid causes gout, why don't they have it?

Do uric acid crystals in a joint always cause pain?

Uric acid crystals look like broken shards of glass under a microscope. That's true. But researchers have found urate crystals in the big toe joints of people with gout between attacks, when the joint had no symptoms (see the 1979 Annals of Internal Medicine report below). In my view, if I drew fluid from your big toe, knee or ankle joint right now, there would probably be a few crystals in there, and you have no pain and no gout attack. If the crystals alone caused the pain, you should hurt.

Is uric acid always bad for you?

Your body uses uric acid as an antioxidant and has multiple uses for it. Uric acid is excreted by the kidneys, but your kidneys also reabsorb a large share of the uric acid that first goes into your urine. In my view, if uric acid were really bad and dangerous, your kidneys wouldn't be doing that.

Which gout beliefs can you forget?

In my view, these are myths you can forget because they don't prevent gout or flare-ups:

• A low-purine diet. Many people eat a high-purine diet and never get gout. Many people with gout eat a very low-purine diet and keep having flare-ups. It has to be something else.
• Lots of fruit, vegetables and juices. Lime juice, lemon juice, celery juice and cherry juice are often promoted for gout. In my view the research for this is weak, and our ancestors never made juices from any of these things.
• A daily prescription pill for life. You don't have an allopurinol deficiency or a Uloric deficiency. In my view, if you eat the proper diet you may not need these pills, and you don't need anyone's gout supplement, powder or protein shake.
• Your blood is too acidic. I've worked thousands of hours in the emergency department and drawn arterial blood gases on thousands of patients. You cannot meaningfully change a human being's blood acidity by eating celery or cherries.
• You need to eat very low fat. In my view, eating fat, saturated or unsaturated, has nothing to do with uric acid production or joint inflammation.

What really drives gout attacks?

Is gout caused by inflammation?

Yes. Gout is inflammatory in nature. Someone having a gout attack has inflammation in that joint, and remember, in my view, even normal joints can have uric acid crystals. When you come to me with an acute gout attack, I don't give you something to quickly flush the uric acid out. I give you an anti-inflammatory, either a steroid or a non-steroidal anti-inflammatory, because getting rid of the inflammation is what relieves your pain quickly. So it stands to reason that a diet and lifestyle that are not inflammatory make gout much less likely.

Does fructose cause gout?

Drinking lots of fructose is a terrible idea if you want to avoid gout attacks. Stop drinking fruit juices, and stop drinking any soft drink or beverage sweetened with high fructose corn syrup or sucrose, because sucrose is made of glucose and fructose. In my opinion, if you've been diagnosed with gout you should also cut down on fruit, even raw organic fruit. The research linked below found that sugary drinks and fruit juice were tied to more gout, but it did not find the same link for whole fruit, so that part is my clinical opinion.

Does high insulin play a role?

In my view, a big part of the cause is being chronically hyperinsulinemic, meaning a chronically high insulin level, from eating too many carbohydrates every day. That greatly increases your risk of a gout attack.

Does alcohol cause gout?

Alcohol works on both ends of this equation to raise your risk of gout. Beer is the absolute worst. Wine and spirits come in a close second. If you've been diagnosed with gout, stop the alcohol. I promise you, not having a gout flare-up is much more fun than anything you could get from drinking.

Should people with gout avoid coffee?

No. You may hear online that coffee makes your blood acidic and causes gout attacks. That's complete rubbish. There is research linking long-term coffee drinking to a lower risk of developing gout (see the 2007 study of men below). Coffee is your friend. Alcohol is not.

What are 9 steps to help prevent another gout attack?

1. Stop drinking alcohol. If you have elevated uric acid, have had a gout flare-up or have been diagnosed with gout, alcohol is not your friend.
2. Lose body fat. Research links being overweight or obese to gout. The way to lose fat is to follow the diet, which is free, and you can buy the food at the grocery store.
3. Decrease inflammation by getting rid of industrial seed oils like canola, margarine, soybean, corn and peanut oil. In my view, their bad omega-6 to omega-3 ratio causes inflammation in your body.
4. Cut the fructose. Stop high fructose corn syrup and sucrose sweetened drinks and any fruit juice, even organic or non-GMO. Some occasional raw fruit and berries are okay, but too much will set you up for a flare-up.
5. Cut sugars and grains. Rice, wheat, oats and corn break down quickly and raise your blood sugar, which raises your insulin, which in my view raises your risk of a flare-up.
6. Keep your insulin level low by eating low carb, keto or carnivore. Remember the patients I mentioned with almost no flare-ups? That is how they ate. When they came in, I'd ask if they needed a refill on their allopurinol, and they'd say no, they ran out six months ago and didn't come back because they hadn't had a single attack since changing their diet. That makes me very happy as a doctor. Don't stop any medicine without talking to your doctor.
7. Get plenty of magnesium and potassium, from magnesium and potassium rich foods or a liquid supplement. If you have kidney disease or take certain blood pressure medicines, check with your doctor before you take a potassium supplement. In my view, getting enough of both lowers your risk of a gout attack.
8. Make as many of your own ketones as you can. Beta-hydroxybutyrate is an excellent anti-inflammatory. I don't want you to drink exogenous ketones. Make your own by eating a ketogenic or carnivore diet.
9. Don't be afraid of coffee. One cup a day or five cups a day.

Put it all together. Stop the alcohol, the fruit juices, the soft drinks and the things that raise your blood sugar and insulin, and stop the seed oils that raise inflammation. Then gout can become something you talk about in the past, not something you fear in the future.

What does the old gout painting on my thumbnail show?

The image on the thumbnail is an old painting of a British army officer. To me it is a picture of what to avoid if you don't want gout. What is he eating? Lots of fruit. What is he drinking? Alcohol. What is his body like? He's obese.