Author: David

Born in 1976, career is in technology sales, currently working for one of the big cloud compute companies (hyperscaler) and living in Northern Virginia. 10 yrs as a vegetarian with ever increasing uric acid and weight despite low purine diet. Heaviest weight 220 lbs, highest uric acid 7.8 mg/dL. Found Keto March 2018 and weight dropped from 200lbs to 150lbs by February 2019 (13 months). Steadily increasing meat and seafood consumption the entire time and transitioning to carnivore'ish in Fall 2021. Now focused on high protein (~200 to 215 g/day), moderate fat (~80-100 g/day), and incidental carbs (I like periodic asparagus). Uric Acid has been below 6.0 mg/dL since at least June 2021 (when I started regular testing). Weight is now ~145 lbs with visceral fat <1 lb and body fat percentage 15%.

Gut Microbes Causing Gout or is it Metabolic Syndrome?

Subtitle: Does it even matter which came first (the chicken or the egg)?

I’d like to thank u/jotii (Reddit User) for raising a very good point on a recent Reddit thread in r/gout.

I do believe that the metabolic factors is a part of the puzzle for sure, for some bigger than others. But it is obvious that there are yet some missing pieces that we don’t understand yet and are to be discovered in the future. I strongly believe in the microbiome as a potent factor (which is of course connected to metabolism), read more in this study about microbiome and gout and genes is probably another.
u/jotii, r/gout, Is allo for life?, 2/10/2022

Love the fact that u/jotii provided a link to a study that gave me another viewpoint to consider. It also gave me some evening reading. A few evenings actually, as I read it a few times.

The Study: Intestinal Microbiota Distinguish Gout Patients from Healthy Humans

The study itself was about a new way to clinically diagnose gout more accurately, and earlier, than testing uric acid, which may have its shortcomings.
There seems to be a role for specific bacteria in the microbiome in breaking down uric acid into urea so that it can be excreted in urine. These appear to be Faecalibacterium prausnitzii, Clostridium (which produce butyrate in the gut) and Bifidobacterium pseudocatenulatum.
If these bacteria are in short supply then the breakdown of uric acid to urea may fail to occur, resulting in high uric acid and gout.

Could a shortage of beneficial bacteria in the gut be preventing the breakdown of uric acid to urea?

This is what really caught my eye:

On the pathway of purine metabolism, the xanthine dehydrogenase which can degrade the purine to uric acid was enriched in the gout patients, whereas the allantoinase that degrades the uric acid to urea was depleted. Thus it is possible that in the intestinal microbiota of gout patients, a significant amount of purine were degraded to uric acid which however could not be further degraded to urea, leading to abnormal accumulation of uric acid in gout patients.
Guo, Z., Zhang, J., Wang, Z. et al. Intestinal Microbiota Distinguish Gout Patients from Healthy Humans. Sci Rep 6, 20602 (2016). https://doi.org/10.1038/srep20602

This is a tantalizing bit of information and drives me in two directions. First, does it matter? Second, can you do something to improve the gut microbiome futher?

Is it the Metabolic Syndrome or the Screwed Up Microbiome? Does the answer change the approach to curing gout?

My overarching theory is that most people (maybe not all) end up with gout because of a poor diet and the resulting metabolic syndrome. And that dumping the Standard American Diet and improving metabolic health will cure gout. Taking medication for gout is simply providing temporary coverage of symptoms. That relying on medication alone will still leave you with a constellation of other health problems down the road.

So on the one hand we have studies to show that metabolic syndrome is closely associated with gout (and Type 2 Diabetes, and Heart Disease, and and and…). Metabolic syndrome impairs the function of liver and kidneys and therefore impairs the ability of the body to properly handle and get rid of excess purines and uric acid.

On the other hand, the microbiome of gout sufferers may not have enough of the microbes necessary to break down uric acid to urea. But what causes a screwed up microbiome? It can be lots of things but, chief among them are alcohol, processed carbs and sugars. In other words, bad diet that pushes you further toward diagnosed metabolic syndrome. But it’s a spectrum, not an on/off. You likely just have a lesser degree of, but still worsening, metabolism until you are finally diagnosed with metabolic syndrome – usually at the same time you are told you have Type 2 Diabetes and need insulin for life. (Don’t believe this).

A meal of pork, asparagus, and tomatoes.

The microbiome is highly impacted by what we eat. Metabolic syndrome is highly impacted by what we eat. If we get rid of the highly processed carbs and seed oils and eat real food BOTH our metabolism and our gut microbiome improve naturally. So… while the distinction may be of interest to scientists does it change our approach? My vote is no!

Can You Improve Gut Microbiome to Improve Uric Acid to Urea Conversion?

Did you know the human body has 10 times the number of microorganisms than it has human cells (according to the U.S. National Institutes of Health)? They are all over our skin but even more live in our gut. If you think the quality of our diets is irrelevant, its time to rethink that assumption.

If you believe gut microbes can indeed be part of the solution to improving uric acid excretion (and I’m leaning that way) then what can you do?

A reminder, the single biggest thing you can do to improve your long term prospects for curing gout is to get to a truly healthy diet. But, next, it would seem there is case to be made for eating foods that help nourish Faecalibacterium prausnitzii, Clostridium, and Bifidobacterium pseudocatenulatum.

There are at least two studies showing that Faecalibacterium prausnitzii and Bifidobacterium pseudocatenulatum can be increased by adding certain types of fiber to the diet (See Notes 1, 2 at Bottom). Specifically, these studies highlight inulin. While you can get inulin by itself I’m not a fan of highly processed foods (e.g. a package of inulin).

Garlic Varieties - Might garlic help improve uric acid breakdown and excretion?

Turns out inulin is also available naturally in fruits and plants such as chicory roots, wheat, onion, banana, garlic, and leek. I’m still focused on improving my metabolic flexibility and reducing my overall insulin, gut permeability, and blood glucose so I’ll skip the wheat and banana. However, I’m all in to add onion, garlic, and leek to my diet. These foods *may* help my gut bacteria and they will also provide sources of beneficial nutrients that I hope will help my bone mineral density.

One last note for consideration… Yet another study with mice showed that Far Infrared Radiation exposure produced a significant increase in Clostridium, which like F. prausnitzii and B. pseudocatenulatum was found to be higher in non-gout patients (See 3 at Bottom). So, going for a Far Infrared Sauna with some regularity *may* also help the body better process and excrete Purines and Uric Acid. I’ve been doing it for several months now to improve recovery after strength training. Worst case it feels amazing!

Visceral Fat – The Core Value of a DEXA Scan

I’ve been getting a regular body composition measurements by DEXA Scan since December 2018 with a goal of less than 15% body fat and optimal visceral fat. At my latest scan, February 12, 2022, Rafi the tech who has witnessed our entire journey, made the comment:

Welcome to the 1% club. You’re in rarified air my friend.
Rafi, Composition ID Arlington VA

It took me a bit to internalize this. Looking closely at my DEXA I realized it means, after a starting point at the 57th percentile for my age as compared to the USA NHANES Database, I’m now at the 1st percentile for my age! This is pretty shocking to me but represents years of work to improve my diet, add strength training, and really dial in a way of eating that got me to 15% body fat! (What is NHANES ?)

DEXA Body Scan report showing total body fat, fat free mass, and comparison to USA NHANES database. — My Body Composition Over Time – As Compared to NHANES

A key take away is that the DEXA Body Composition Scan can be a very powerful tool to identify problems in body composition. Critically, it also can provide the motivation needed to continue adjusting diet and lifestyle. If you are serious about your health, you must ignore weight and BMI, and instead focus on body composition. To illustrate DEXA I’ll share some key parts of the report for me.

Visceral Fat – The Most Important Measure?

What upset me the most at my first DEXA scan was how many pounds of body fat I was walking around with. I think it was the psychology of the the number — 50 lbs! It was really the wrong number to focus on but it stuck in my head and initially became my “why”.

However, it was really the number on the last page which should have been the focus. That number was 2.41 lbs of visceral fat. Why? Visceral fat is the fat buries way under the skin. It’s the fat that lives in and around your organs. It’s the fat that disrupts the function of your internal organs. In short, its the stuff that will cause painful chronic disease and ultimately kill you off early.

DEXA is a great tool to track Visceral Adipose Fat. In my case I've dropped from 2.41 lbs to 0.65 lbs in 3 years. — Three Years of Visceral Adipose Fat Data

After I got over the “omg 50 lbs!” shock from my initial scan I realized that, more than anything, I needed to get my VAT down to less than 1 lb as quickly as I could. Less than 1 lb seems to be the key for minimizing risk of heart attacks and chronic disease.

Three years after my initial scan I’m well below 1 lb now. Rafi explained that while you can go lower, and some people are at 0 lbs, the ability to go that low may depend a lot on genetics. So getting to 0 may be the best but it also may not be practical or even possible.

Fat Distribution – Subcutaneous vs Visceral Fat

I’m not even sure I need to say much about this part of the DEXA Scan report. Look at the red coloration in my 2018 scan and you can clearly see the visceral fat where my organs live. Then see the 2022 scan where virtually all the remaining fat is clearly subcutaneous (under the skin) and far less important to metabolic health. You do need some amount of fat to live so this will never be zero.

DEXA can clearly show you where visceral fat vs subcutaneous fat lives on your body. — A Picture Speaks a Thousand Words (Fat Distribution)

Chart of the percentage body fat over time. Makes it real easy to see which dietary choices are working and which aren't.

Here is another graphic that’s been motivating to me. Using this chart I was able to easily understand which dietary changes I’ve made helped, and which didn’t. Early on (circa 2018-19) it was simply keto and low-carb but eventually I hit a plateau. Most recently (circa Fall 2022) I changed to carnivore’ish but with a focus on increased protein and decreased dietary fat. See the huge change October 2021 (20.6% body fat) to February 2022 (15.4% body fat).

Bone Mineral Density – Haven’t Found the Magic

Another feature of DEXA is tracking bone mineral density. In my case its trending the wrong way and I haven't quite figured out how to reverse it. — Bone Mineral Density – The one area I’m still trying to figure out.

The one area of my DEXA Body Composition report that continues to frustrate me is bone mineral density. I’m told I’m still in positive territory so that’s good. However, my BMD has steadily dropped over time. I had thought that the increase in protein would have reversed this trend. So far it has not. Supposedly strength training can help to reverse this. But I’ve been increasing the amount I can lift steadily to no avail. So this is still a work in progress as I look to identify what part of my diet may need a change.

If You Care About Health – Track Your Body Composition

There are several different options available for tracking body composition. Two of the better known are DEXA and Bod Pod. Regardless of what you choose be consistent and track your progress. Doing so once a quarter is a good starting point though you can go more often if you think there is value. Expect to pay out of pocket and if you think its expensive consider the future costs of monthly medication you will avoid if you get body composition in line.

Combine tracking of body composition along with select blood markers to understand and rapidly improve your health.

Are Aches, Pains, and Diabetes Really Inevitable as You Age?

(Before) David & Hillary 2015
Port Renfrew, British Columbia

While the focus of Gout DiY is obviously about curing gout, lets set that aside for the moment. Quite often my wife and I have people who have known us for a while approach and ask what we’ve been doing. We both look strikingly different from years ago.

We’ve both spent a number of years re-imagining what health could look like for us. As a result we’ve been experimenting with diet and exercise, informed by less well known doctors and researchers. For my wife it was initially about prevention of Alzheimer’s. For me it was about sustainable weight loss and curing my gout without medication.

We’ve had to be willing to ignore the mainstream health guidance, learn what our own bodies really needed, and track the results that matter. Those results are not about weight alone. Instead its about body composition and key blood markers that reinforce and provide the necessary motivation to continue forging ahead.

This is what we did. Admittedly, there have been internal struggles to give up the bad habits so common in society today. We’re a work in progress and there are slips as well as intentional splurges. But we pay attention to how our bodies feel when we slip and get back to plan quickly.

The changes we’ve made to our diet and lifestyle have led to massive improvements. We’ve both lost a large amount of body fat, weigh less now than we did in high school, yet have more skeletal muscle. A number of skin conditions, aches, and pains have also resolved.

Aches, pains, diabetes progression, and other chronic health issues are NOT inevitable but it’s up to you if you want to make the change necessary to train for the Centenarian Olympics.

Truly Changing Diet and Lifestyle

Easing In to a new Diet and Lifestyle

We stopped going out to eat (for the most part), eliminated processed carbs and grains, and increased dietary fat. This step got our bodies used to burning fat for fuel and reduced the blood sugar swings that drive being hangry between meals. We found the low-carb/keto recipes from DietDoctor.com to be hugely helpful. We also started walking regularly 30-60 minutes a day.

Regularly Measure Body Composition and Bloodwork

About every 3 months we get a DEXA body scan done to monitor changes to visceral fat, overall body fat, lean mass, and bone density. In the Metro DC area Composition ID is a great option. We also regularly (every one to three months) check HbA1c, Fasting Glucose, and Blood Lipids — especially the Triglyceride to HDL-C ratio. OwnYourLabs.com allows you to purchase these tests yourself and they are quite inexpensive.

Intermittent Fasting

We eliminated snacks and shifted to an eating window of 8 hours. This left 16 hours between our last meal of the day and our first meal the following day. This helped improve blood sugars further and allowed some of our body fat to be burned (this only happens when insulin drops and glucose from sugar or cabs keeps insulin up).

Refinements to Accelerate Health Improvements

Threw out all vegetable oils and shifted fats in our diet to Olive Oil, Coconut Oil, Butter, and Beef Fat. Eliminated most/all fruits and increased protein from meat. Added strength training 3 x week for 15-20 minutes each time. Reduced our eating window further to between 1 and 4 hours depending on the day.

Protein First, Fat for Fuel, and Carbs as Desired

We took inspiration from Dr. Ted Naiman and increased protein to 40% (higher some days) by calories with a goal of at least 1 gram per pound of desired body weight, no more than 1 gram of fat per pound of desired body weight, carbs are only coming from a small serving of vegetables if we want them, normally less than 60 grams per day.

Strength Training to Failure

We started doing indoor bouldering at a local gym three times a week and increased emphasis on lifting weights, as heavy as we can, doing enough repetitions each set to go to failure (here’s a way to start simple and at home)

The Future (Not There Yet)

We expect at some point to reach a body composition we are happy with. Ideally we are shooting for 20% body fat (my wife) and 15% body fat (me). At that point we expect to (a) allow for greater energy in our diet — a combination of more fat and carbs from whole foods (mainly vegetables) so that we maintain body composition and (b) continue to strength train with a goal of increasing muscle mass as long as possible and then maintaining it as we continue to age.

We fully recognize this is not a path everyone is willing to take. However, we found it to be the only approach where we aren’t constantly hungry and were able to make significant change to our body composition. As a result we’ve massively improved our long term health outlook. If you aren’t happy with the trajectory of your health maybe its time to try something different.

Before (2017 – Wuyishan, Fujian, China) and After (2022 – SportRock, Sterling, Virginia)

Making progress? Data to Track in Curing Gout

If you buy in to my hypothesis that metabolic syndrome is the real issue driving gout then it becomes pretty straight forward for most people to track progress. There are a million things you could track but at first don’t miss the forest for the trees. These are a short list of things that, if improved, will likely result in improvements to ton of other markers.

Body Composition
Select Blood Markers

Body Composition

The amount of visceral fat you carry around isn’t readily apparent but the presence of it is a telltale indicator of metabolic syndrome. For some people you can get a rough idea by measuring waist to height ratio. Ideally you don’t want the ratio to be over .5 (waist in cm divided by height in cm). BMI is not reliable.

A much better option is DEXA (or DXA) Body Composition Scan. Look for a company setup to use the DEXA to report on body fat, visceral fat, bone density, and lean body mass. Of most interest is the amount of visceral fat. This is the fat that’s highly correlated to many different chronic diseases including heart disease. Each scan should cost $100 to $200.

Get a scan soon to establish a baseline. Then do a follow-up every six months at least. I get them quarterly. When you go for your scan be consistent about time of day and if you have or have not consumed water. We want to know trends and water can be read as lean mass. Don’t over think it but just be consistent for each scan.

Do a Google search for DEXA or DXA. Expect to pay out of pocket. If you are in the Washington DC area I like Composition ID (no relationship to them at all).

The goals for your body composition over time is reduction of visceral fat below 1 lb, but it can and should be lower for optimal health. You should also see stable or increasing bone density, and stable or increasing lean mass.

Blood Markers

Again there are a million things you can track and you could spend a small fortune doing so. I believe for most people that’s a waste. Track a few key items, get those to improve and the others will likely fall into line, or you can make smaller adjustments later. Note that the goal numbers I propose are what I have gathered to be ideal. They are lower/tighter than the normal range provided labs (which skew towards doing lab work for people who are sick, not optimally healthy).

Uric Acid – Measure of Serum Uric Acid. Goal is at least 5.5 mg/dL, but optimal is 3.4 to 5 mg/dL (Why?)
HbA1C – A proxy measure for average blood glucose over roughly a 3 month period. Goal is 4 to 5.6 (Why?).
Triglycerides:HDL-C Ratio – another proxy measurement. The goal for optimal health is less than 1 – divide Trigs by HDL (Why? High TG to HDL-C Predicts Extensive Cardiovascular Disease and Triglycerides, LDL, and HDL on a Ketogetnic Diet).

As with a DEXA scan, expect to pay out of pocket, but these tests are cheap. You can buy from Quest or LabCorp but I love OwnYourLabs.com (again no relationship with them but what Dave Feldman and Siobhan Huggins do is amazing stuff). Plan to test quarterly or how ever often you feel you need to track your progress.

Top 10 Ways to Spot Snake Oil (Gout Edition)

In my opinion there are a huge number of snake oil salesmen out there. People who stand up an e-commerce business looking to sell a miracle cure to people desperate enough to try anything (and yes I’ve resembled that remark on occasion). So here is my top 10 list to help you spot dubious or fraudulent cures for gout. Did I miss anything you might look out for?

Spot a Snake Oil Salesman

Over the top claims their supplement (pill, elixir, whatever…) will immediately cure or relieve the pain of gout.
Lengthy posts outlining an individual back story, how this one simple change solved their problem forever, and finally after you have read seemingly forever, waaaayyyy at the bottom, you find a call to action to fill out a form for a free e-book.
Same as #2 but instead a call to action to buy their miracle cure right now for a low low price.
No actual evidence to support claims their product or solution works.
Purported evidence cited can’t be found if you Google it.
Supposed evidence cited is another website which itself provides no evidence.
Evidence is for a study where the compound studied was at doses no human would/should ever consume.
The lack of any credible researcher supporting the claim (note I said credible, not necessarily mainstream).
Product links directly to an e-commerce store (in addition to wild claims with no supporting evidence). Most of the time this means the author makes money by influencing you, the reader to buy said product.
The web page is peppered with ads and links to other articles with sensational headlines (hint, you have become the product being sold at this point).

Snakes really get a bad rap in the term snake oil. But we understand that snake oil salesmen are trying to con us.

Anything you would add to this list? Let me know!

For what it’s worth I do believe you can cure gout if you (really) want to. However, curing gout takes a willingness to change your diet and lifestyle. Nothing for sale here, just an approach that I feel is worthy to try unless you enjoy using medication to control flares for the rest of your life.