Gout and Uric Acid

Gout is a kind of arthritis due to the accumulation of uric acid crystals formation inside and around the joints, causing sudden and severe burning pain, stiffness, swelling in joints, usually resulting in a big toe. 

Uric Acid (C₅H₄N₄O₃) heterocyclic organic compound. Condition of high or excess uric acid is known as Hyperuricemia, which is the root cause of development of gout, kidney stones, renal dysfunction, hypertension, hyperlipidemia, diabetes and obesity. Multiple studies have also associated hyperuricemia with the precursors of stroke, cardiovascular and coronary artery disease.

Hyperuricemia occurs due to the (1) increased uric acid production (2) the impaired renal uric acid excretion, or a combination of the above.

In modern medicine, you will be asked not to eat red meat, egg, fish {(high protein food) high protein foods are rich in Purine} in order to reduce the uric acid formation and also treated with medications like anti-inflammatory, steroids.

Are meat, eggs and fish the real cause of uric acid formation? Or the Excess carbohydrates and Fructose (fruit sugar) are the cause ?

Before that, Why body produces Uric acid? 

Uric acid is the end product (waste) of an exogenous pool of purines metabolism. (Also, its byproduct of protein digestion) Later, Uric acid dissolves in the blood and is excreted by the kidneys. That’s why you are advised not to consume protein rich food such as meat, egg, fish.  We will see how far it’s valid? 

Purines are the primary genetic material of our cells (Building blocks for DNA) Hence, its vital for our survival and found in all foods and drinks that we consume. Only the amount may differ from one to another. Foods like red meat, egg, and fish have concentrated levels of purines. Hence, production of uric acid is unavoidable.

Purines (a type of chemical compound) are digested/broken down thru purine metabolism, and uric acid becomes the end product or as a waste. Though it’s a waste, it’s a good antioxidant, which prevents the oxidation on the arteries. Kidneys are responsible to maintain the uric acid level in our blood stream and excrete the excess uric acid thru urine to prevent the uric acid crystals around the joints. 

So, How to control the excess uric acid production and what prevents the excretion of the (excess) uric acid?

Apart from purine metabolism and Protein digestion, Uric acid also produced by breaking down of Adenosine Tri-Phosphate (ATP).our body cells rely on ATP to survive (ATP is a fuel for our body cells)

When, we eat the high carbohydrates, especially Fructose rich (refined sugar) food, our body (Liver) converts the excess sugar into fat (and stores) thru a chemical process, by breaking down ATP, end up with uric acid! Fructose (available in fruit juices, Ice cream, processed food, bakery, sweet and confectionary) is rapidly depletes ATP and increases the amounts of uric acid.

ATP also breaks down, during Insulin secretes from pancreas. After all, insulin is a growth hormone. We know, pancreases release the insulin in order to bring down the blood sugar. The only reason for blood sugar rise is high carb food. Hence, High carbohydrates and Fructose can produce more uric acid than purine and protein. The most effective way to control uric acid is restricting the carbohydrates, not by restricting purine or protein rich food.

Apart from ATP breakdown, high carb food keeps the blood sugar above the normal range. (refer normal vs abnormal) this significantly reduces the kidney filtration efficiency to excrete the uric acid from blood.

Last, but not the least, alcohol plays major role in uric acid production and also prevent the excretion process. In order to breakdown/digest alcohol, liver undergoes to a special and complex process called alcohol metabolism, where more number of ATP broken down (uric acid production) and alcohol interfere with kidney function (filtrations) which results very high uric acid level.

Until the 20^th century, Gout was referred as "rich man's disease" because bread, sugar, alcohol were quite luxuries those days. Later, sugar, alsohol and refined carbohydrates were freely available to the common population and it becomes “common disease” in 21^st century.

The best way to control the uric acid is to thru HFLC. By limiting the carbohydrate consumption and totally avoiding the fructose and  alcohol is the only and more biological way to control / reduce the uric acid production also improves the the kidneys filtration ability.  Definitely not by restricting red meat, egg, fish (high protein and purine rich food) 

Remember, unlike carbohydrates, protein and purines are the vital for survival. As protein and purine the building blocks of the body and DNA respectively. Hence, it’s wise to restrict the carb's to get rid of hyperuricemia, to lead healthy life.

Carbohydrates

Are Carbohydrates the Real Villain?

It depends on how much you consume and its source. 

Are Carbs an essential nutrient for humans?

Carbs(glucose) are not a mandatory nutrient for human metabolism. We can survive without Carb but this is not the case with protein, fat. (macro nutrients) and Vitamins and minerals (micronutrients).  One can’t name any disorder or disease due to less or no carbohydrates. Also, there is no “term” like “carbohydrate deficiency”. But, there is long list of health issues due to over consumption of carb’s.

General fear is that, Carb (glucose) is the only fuel source for brain. But, the fact is brain is like a hybrid engine, it can run either on glucose (carb) or on ketone. (liver produces ketone only on HFLC diet or during fasting / starvation. High carb / SAD diet prevent the ketone production)  Ketones are the most preferred fuel for brain and its much efficient compare to glucose.

Even if we don’t consume carbs, our liver is capable of producing glucose (thru glycogenosis) from protein and fat. So, why to worry about carb ? 

Life begins at Very low carbohydrate environment!

We may need only about 50g of carbs per day. But, in a standard diet we were consuming around 300 – 400 g of carbs. This is where the whole problem starts to begin because; our body can’t handle such huge amount of carbs and leads to the high blood sugar that cause for all metabolic disorders and other life threatening diseases.

Also, the recommended 50g carb’s per day also should come from vegetables. Not from cereals, grains and fruits. But, in regular diet majority of carb we get from mostly from grains and fruits. 

Why only from Vegetable source?

From the vegetable source, we not only get carb, also cellulose.  Since, we do not have enzyme to digest the cellulose, it will be exerted as non-soluble fiber. Which help to pass smooth stool. Also, Vegetables helps to maintain the alkaline level in the gut which enables the perfect environment for the bacteria colony to ensure the gut health.

Why not from cereals and grains?

Whereas the Carb’s from the cereals and grains are doesn’t have much non-soluble fiber content. Carb form cereals and grains are high in starch (high glycemic index) hence, causes the blood sugar roller-coaster. Also, cereals and grains have high phytic acid which prevents the nutrition absorption. Certain cereals and grains have gluten. Also, while consuming cereals and grains we end up consuming very high calories than our daily need.

What about carbs from Fruits?

No, because fruits are rich in fructose and sucrose which triggers the insulin secretion very sharply (due to the sudden blood sugar rise) over the period of time our cells become insulin resistive. High insulin enables the fat storage. (Refer :Obesity)

In the modern world, the seasonal fruits are no more seasonal !  I mean seasonal fruits like melon are available now throughout the year!! Also, people start to consume fruits which are not at all related to their region. We consume different regional/seasonal fruits (Dates, Berries, Melons, Mango, Apple, etc) at the same time in the name of fruit salad ‼! 

Fresh fruit juices are even worst. Example if we consume apple as raw, you may end up eating one or two along with its fibers. If you make a juice, you remove all its fiber and easily take 1 or 2 glass of juice. Which is about 3 – 5 apples!! Result, your blood sugar shoots to its peak in response to that, Insulin spikes and blood sugar crashes!! (Refer :Human vs Food)

Finally, in order to increase the production (yield), sweetness, to grow all season and withstand the environment, cereals, grains and fruits are genetically modified, grown under chemical fertilizers and pesticides. Even, after the harvest, treated chemically and transported in the temperature controlled environment to reach its destination safe. They may reach the destination safe, but is it safe to eat? Are all its vitamins and minerals are intact? And is it safe to consume?

It is foolishness to say diabetic and obesity are an epidemic, after consuming 300g of carbs per day. This huge amount of carb’s results the increased insulin output from the pancreas, over the years, and leads to hyperinsulin, insulin resistance, diabetics, hypertension, dyslipidemia, atherosclerosis and heart disease. 

That’s why in HFLC, we restrict the carbs intake around 50g per day and we consume those 50 grams of carbs from vegetable source NOT from cereals, grains and fruits.

Vilifying the Fat

I have mentioned several times in various post that vituperation of fat was based on bad science and flawed research data. In this post, we will see how and who is behind the reviling of Good (old) Saturated fat.

The vilifying the fat has a very long story. Though it began in 1913, it become aggressive in 1952 and become officially declared by US government in 1977. 

In 1913, a Russian pathologist called Nikolai Anitschkow wanted to study the effect of cholesterol and health. He decided to feed the purified cholesterol to the rabbits and managed to elevate their blood cholesterol levels up to 1,000 mg/dl (nearly 26 mmol/L) then noticed the formation of “vascular lesions” closely resembling those of human atherosclerosis, forming in the arteries of the rabbits. 

Nikolai Anitschkow

There are two obvious flaws in the experiment. The first one was the subject “Rabbits” and they are strict herbivores. They do not eat animal products (cholesterol only derives from animal sources) hence, they don’t produce bile acids to digest fat. Thus, their digestive system is not equipped to handle cholesterol.

It’s like fueling the diesel engine with petrol and blaming the petrol is not a fuel or petrol damaged the engine.

The second flaw was the Blood cholesterol level, it was around 1000mg/dl. Even after eating very high amount of saturated fat (3 times a day) for two years, I wasn't able to touch 300mg/dl. (refer my lipid profile here)  It’s practically impossible to elevate 1000mg/dl in humans. 

Interestingly, similar such (cholesterol feeding) studies was done on rats and dogs (omnivores) and feeding cholesterol to these species failed to produce vascular lesions.

The demonization of saturated fat began in 1952 when Dr. Ancel Keys created a mythology in his paper linking saturated fat intake and heart disease mortality (Popularly known as Seven Countries Study) of different countries and published the below graph to prove his preconceived result. (Based on Nikolai Anitschkow rabbits study)

From the above graph Ancel Keys, could easily prove his preconceived idea of fat by associating or correlating the fat consumption and CVD.  But, the truth was he had around 22 countries data and he cherry-picked the data according to his preconceived idea. Find below the data’s he originally had.

Ancel Key intentionally left the data’s from other 16 countries, in order to prove his theory. He did not choose his countries randomly but instead selected only those likely to prove his beliefs – including Yugoslavia, Finland and Italy – while excluding countries with low rates of heart disease despite diets with a lot of fat – such as France, Switzerland, Sweden and West Germany. Just draw an imaginary line linking all the 22 country you can’t find any correlation between Fat consumption vs CVD.

The above graph shows the original data, the “real” correlation and Ancel key’s intentional correlation. Also, due to difficulties in collecting accurate nutrition data, Keys ended up sampling the diets of fewer than 500 men, far from a statistically significant sample.

There are many studies available to prove there is no correlation between high cholesterol intake with heart disease. Find below an another study result. 

Ancel Keys aggressive, persuasion personality managed to implanted his idea into the American Heart Association, National Institutes of Health (The McGovern Committee) and first-ever guidelines calling for Americans to cut back on saturated fats, as the best way to fight heart disease. The US government adopted this view, officially in 1977. As usual, rest of the world (BLINDLY) followed. 

However, (less fat, high carb) food guidelines received major criticism at the time from many respected scientists like John Yudkin (who insisted that sugar was to blame) and the American Medical Association. (will write an separate post later about Dr. John Yudkin) but all in vain. 

Ancel Keys flawed study produced the ‘Lipid Hypothesis’ and gained massive media attention and Times magazine honored (!) him by publishing his photo as its cover page. Media around the world spread the lie (along with medical associations) among the common people.  Times magazine took 57 year to realize the mistake and finally removed the saturated fat (butter) in 2014 from the prohibited list, by the time huge damage to the mankind already took place.

The above graph (plotted from the statistical data by the obesity research in US) is the self-explanatory the effect of High Carb (less or No fat) diet. Ancel key used to prove his theory ONLY by correlating the Fat and CVD. Association or correlation alone need not to be a causation. Major problem in (especially medical) science is by finding / deriving an association or correlation between the two different variable leaving the other (influencing) factors.

It’s not (always) possible to conclude something only based on an association or correlation factor. Such conclusions may be possible and accurate in other field, where there is no “other” factors involved. Whereas, in physiology (biology) it’s not that easy because of many “other” factors can alter or affect the end result. Here, the very important “other” factors are carbohydrates and hormone's, which plays a major role, just not only the Fat.

   Association or Correlation is NOT (necessarily to be a) Causation.

Here is an example……..The blow graph shows the very close correlation between atmospheric CO2 level and obesity levels. Based on this, If one can conclude, that atmospheric CO2 is the root cause of Obesity. Will you be accepting?

Observational studies can only establish associations. They cannot say that “A” (fat) causes “B” (heart block).  Ancel key study also an Observational study. May be later will write more about such studies.