Does fasting cause gout? Or does it actually help gout because you eat less? Here you’ll discover the strange changes that take place in your body when fasting and how they affect your risk of gout attacks.
Fasting and Gout
“Fasting is the willful refrainment from eating and sometimes drinking.” Source: Wikipedia
But why would anyone choose to go without food and even drink? Perhaps the most common reasons are religious practice and to lose weight…
Many religions practice fasting, for example:
Although the timing and duration of fasting differs across religions and cultures, the basic tenets are much the same: to demonstrate sacrifice and cleanse oneself.
Self esteem and better health are perhaps the main drivers for people wishing to lose weight. And the pathways are often so-called ‘fad’ diets that involve fasting of some description, for example ketogenic (keto) diets, Atkins diet, Paleo diet and intermittent fasting like the 5:2 and 16:8 diets.
What Causes Gout?
The root cause of gout is high levels of uric acid circulating in the bloodstream, a condition called hyperuricemia. As uric acid levels increase, microscopic crystals of monosodium urate can appear out of the acid and lodge in the joints and surrounding tissue.
This occurs in the joint at the base of the big toe the majority of times but other joints, such as knees, ankles, elbows, wrists and hands can be affected too.
Uric acid is a byproduct of purine metabolism. Purines are natural chemical compounds found in the cells of all living things, including humans, animals and plants. As cells die the purines released are broken down by the body, producing uric acid in the process.
Around 70% of uric acid is produced by the body itself. Some 30% comes from the food we digest.
So how does fasting affect gout, if at all?…
Does Fasting Cause Gout or Actually Help It?
One could hazard a guess that fasting may have some beneficial effect on gout since, as there’s less food being consumed, less uric acid is being produced.
Except that it isn’t quite as simple as that…
Fasting and Uric Acid Excretion
The body needs fuel for energy but, when fasting, it doesn’t have access to its normal fuel source, i.e., glucose; from the breakdown of ingested carbohydrates. To compensate, the body switches to its glucose reserves stored in the liver and muscles in the form of glycogen. When called upon, these glycogen reserves break down and convert back into glucose.
The liver releases its glucose into the bloodstream where it’s transported around the body and converted into energy that all of the body’s cells can utilize. Glucose from muscle, on the other hand, only serves the muscle cells themselves.
However, these reserves — particularly in the liver — soon diminish and the body starts turning to its stored fat. This time the energy comes from ketones, a type of chemical produced by the liver as it breaks down fats in the bloodstream.
Unfortunately, as ketones build up in the bloodstream, they can impede the kidneys’ ability to excrete uric acid from the body because ketones are prioritized over uric acid. The result is higher blood uric acid levels and a corresponding increase in the risk of a gout flare.
But certain metabolic changes can help raise the risk too…
Fasting and Purine Metabolism
Some metabolic changes brought on by fasting may contribute to a raised risk of gout.
For example, the body’s cells are constantly dying and being replaced. As they die their purines are released, some of which are salvaged and participate in the creation of new cells, the rest are converted into uric acid.
However, during fasting, as the body converts proteins, carbohydrates and lipids from its own tissues into glucose for energy, tissue cells are breaking down faster than they’re being replaced. The result is that more purines are being produced and comparatively less being salvaged. More purine metabolism means more uric acid and a higher risk of a gout attack.
Dehydration is another major concern…
Fasting and Dehydration
Another key issue with fasting is that the body can become dehydrated, even seriously so. Uric acid becomes less soluble when the body is dehydrated making it much easier for urate crystals to form out of the acid and cause an attack.
But it’s not all bad news…
Fasting and Inflammation
On the upside gout is an inflammatory condition and at least one study at Yale, albeit using mice, has associated fasting with a reduction in inflammation. It should be noted, though, that this doesn’t necessarily translate into a reduced risk of gout attacks per se, but perhaps less severe symptoms during an attack.
But what does the science say?
Longer term fasting
Several studies over the years have associated fasting with an increased risk of gout but two, in particular, caught my eye…
According to Dr. Stephen Phinney, whilst fasting does cause an increase in serum uric acid this increase is temporary and blood uric acid eventually returns to pre-fasting levels. This may take a few days or even weeks depending on the type of fasting or diet being undertaken. Source: Virta
It isn’t known why this happens but it seems that the body somehow ‘learns’ to adapt to the new environment and the kidneys gradually start to excrete uric acid efficiently again whilst, at the same time, conserving ketones for the body’s energy needs.
And a paper by Dr. Irving H. Fox and colleagues illustrates similar results, with serum uric acid increasing significantly over the first 7 days of fasting then decreasing again over the next 21 days. Source: Metabolism: Clinical and Experimental.
Not all studies agree that fasting actually raises the risk of gout. For example, a study by George Habib and colleagues, found that there was “…no risk for a significant increase in gouty arthritic/renal calculi attacks or serum uric acid in patients with gout during Ramadan fast.” Source: Journal of Clinical Rheumatology.
Of course, this study concerned Ramadan which is an intermittent fast where adherents fast between dawn and sunset. They have a predawn meal, a 14+ hour fast, then a nightly meal, which is different from the fasts in the two studies mentioned earlier.
But other Ramadan studies found the exact opposite. For example K. A. Gumaa and colleagues associated intermittent fasting during Ramadan with an increase in uric acid. And an earlier study by S. S. Fedail and colleagues found a “significant increase” in serum uric acid during Ramadan.
So what are we to make of it all?
Whilst, for some, fasting may be largely discretionary, religious fasting isn’t, which can make things difficult for many gout sufferers, particularly when some of the science seems contradictory.
But it’s interesting to note that the British Islamic Medical Association, in its Ramadan Rapid Review Recommendations, advises that patients with uncontrolled gout should avoid fasting and even patients with well controlled gout should seek medical opinion before fasting.
As for using fasting for weight loss…
It’s true that weight loss in and of itself can help to reduce the risk of gout since being overweight is a major trigger for gout. But, paradoxically, using drastic or intermittent fasting to lose weight may increase the risk of a gout flare.
It’s also true that many, if not all, weight loss diets are hard to stick with long term so that you pile the pounds back on when you come off them.
And bear in mind that long-term fasting can lead to vitamin and mineral deficiencies.
So perhaps the best way for gout sufferers to get lasting results is to eat a healthy gout diet based on plenty of fruit and vegetables, whole grains, some lean protein, and low-fat dairy. And plenty of water to stay hydrated. I cover all of this in detail in my breakthrough guide: Gout Rescue.