Let me tell you how it all began – my strange interest in something called uric acid, that is.
I awoke in the middle of the night with a dull pain in the back. I got up, thinking maybe I had to pee or maybe it was just one of those weird things that happens and disappears with a little movement. But nothing seemed to relieve the pain. And as the minutes and then hours went by, the pain grew more and more excruciating.
It was unlike anything I had experienced in my life. And let me tell you, I’ve experienced lots of weird and painful shit. But this took the cake – a cake of pain. I couldn’t stand, sit, lie down, or roll over for that matter for more than a few seconds without having to move to another position. I was literally writhing for hours.
I’ll spare you all the drama and cut to the chase. After many failed attempts to relieve the pain with heating pads, water, and herbs, I finally discovered the secret that gave relief: lots of watermelon. Thankfully, it was summer and watermelon was in season. After eating a few of them and peeing like a racehorse, the pain subsided.
Nearly a month later I had a repeat episode. Once again, watermelon saved the day.
Then, a year later, yet another episode. Same as before, only twice as excruciating and twice as long to improve. After the third watermelon I passed a bunch of small, yellow stones that I’m 99.9% sure were uric acid stones. I did not have them tested, but my theory is substantiated by the following: for one, I had purchased some of those pH strips sold for the purposes of testing urine pH, and my urine was testing consistently very acidic, which is the condition in which uric acid stones form (versus oxalic stones, which only form when urine pH is consistently alkaline). For another, over the course of the year I had symptoms of gout – including the classic symptom of pain in the big toe – which is a condition thought to be caused by deposits of uric acid in the joints, and gout and uric acid stones are commonly seen together.
Anyone who has ever experienced kidney stones or gout will know that once having had the experience one is highly motivated not to have a repeat. So understandably, I have been researching the matter for a while now. And what I have found is that much of the common advice is?unhelpful, perhaps even counterproductive, and certainly restrictive. Let me explain.
The common advice available on the internet and from health care providers is as follows: avoid anything and everything that might possibly elevate uric acid levels. Avoid alcohol. Drink a shit load of water.
The first point is the one that I want to focus on: avoid everything that can elevate uric acid levels. This sounds like reasonable advice until one understands what can raise uric acid levels. If we believe the experts then we are to believe that all?meat (including fish and seafood) and especially organ meats raise uric acid levels. But the list doesn’t stop there. Also included are asparagus, cauliflower, most beans and legumes (such as peas), oatmeal, and spinach. And the Mayo Clinic even recommends (apparently still toeing the line that most of us have long since abandoned as bad science) restricting saturated fat because it claims that saturated fat reduces the body’s ability to eliminate uric acid (yet they fail to cite anything to back this claim).
We?re not quite done with that list yet, though. All the sugar haters are practically peeing their pants in delight right now because sugar has just racked up another tally on the evils of sugar tally board. That’s right. Sugar increases uric acid. The worst sugar of all is…wait for it…fructose! Fructose makes up half of sucrose, so cane sugar, beet sugar, and maple syrup (all sucrose) are all guilty. Honey is extremely high in the poison. And then there’s fruit, which is often teeming with the stuff. Sure, some fruits have relatively low amounts of free fructose, but then they often have a lot of sucrose, which, as we have already learned, is fructose hiding behind glucose. So many health advisers actually warn against eating fruit because of the dangers it poses. The worst offenders? Apples and oranges.
So when we put this all together, what we’re left with (if we want to be ultra conservative) is an extremely restricted diet consisting of low fat dairy, grains, and a small handful of vegetables. First of all, yuck. I mean, really. Yuck. And secondly, a substantial reduction in calories is one of the known causes of high levels of uric acid in the blood. So any dietary restrictions that are likely to produce significant caloric decreases will probably increase uric acid. I don’t know about you, but if all I’m allowed to eat is skim milk and rice then I’m probably going to have a caloric deficit, and so I’ll probably have increased uric acid.
Now, I don’t know about you, but it’s starting to look a bit like maybe the body likes uric acid just a little bit. I mean, if just about anything one does seems to create uric acid, then what’s up with that? Stupid evolution must have failed big time, right?
Well, I’m betting on no. I’m willing to wager that uric acid isn’t the devil it’s been made out to be. So let’s have a looksee. Normally when we hear about uric acid, we hear about how terrible it is. We hear that uric acid is implicated in metabolic syndrome, cardiovascular disease, and even diabetes! Sounds like uric acid really is bad!
But wait just a second. Because, you see, despite the bad rap that uric acid has gotten, it turns out that it is an antioxidant. Yeah. You heard that right. Uric acid is one of the good guys! So what’s going on here? You see, all that has ever been demonstrated in each of these cases is that these conditions happen to be correlated with higher uric acid blood levels. But considering that each of these conditions also correlates with increased oxidative stress, we shouldn’t be surprised to see higher levels of uric acid. Maybe, just maybe, uric acid is helping.
So is there any evidence that uric acid is helpful in any conditions? Uh, yeah, there is. Where to begin? First, there’s the little matter of multiple sclerosis. Turns out that people with MS have low levels of uric acid. [study: http://www.ncbi.nlm.nih.gov/pubmed/11985629] And some people with MS show improvement when uric acid levels increase. [study: http://www.ncbi.nlm.nih.gov/pubmed/17121380] Then there’s the matter of idiopathic (which is the usual sort of) Parkinson’s disease. One study concluded that uric acid may protect against the disease. [study: http://aje.oxfordjournals.org/content/144/5/480] Next, there’s schizophrenia. A study found that uric acid levels are low in cases of schizophrenia. [study: http://www.ncbi.nlm.nih.gov/pubmed/9727961] There’s also a study that shows that uric acid may be helpful in type 1 diabetes and for heavy smokers. [study: http://www.ncbi.nlm.nih.gov/pubmed/17065352] Granted, these studies were all fairly small, and so larger studies would be needed to confirm the outcomes. But thus far, uric acid is looking pretty good, not bad. Which isn’t to say that more uric acid is always better or that uric acid might not be problematic in certain contexts, but it sure seems far from the devil that you’d think it was if you read the recommendations to avoid producing the stuff at all costs.
So in light of this new information, let’s revisit the suggestion to eliminate foods that increase uric acid levels. On the one hand, it may sometimes offer some relief to some people who otherwise have a tendency to deposit uric acid crystals in joints or kidneys. But with the information we’ve just looked at, hopefully this suggestion to reduce uric acid formation in the body starts to look more like a band-aid than a real solution. It may sometimes help, but it certainly isn’t addressing the real problem, because uric acid isn’t likely to be the real problem.
What is the real problem? Well, that’s the million dollar question. And I’m not willing to state that I have all the answers. But with a little digging around I’ve got some good leads and insights that provide much more useful, realistic ideas as to what the problems may be in most cases of gout or uric acid kidney stones.
Both conditions are associated with low pH. In the case of uric acid kidney stones, they can only form when urine pH is consistently acidic. Urine pH has a fairly sizable range that is considered to be normal – from 4.6 to 8. You can test your urine pH using test strips sold in a lot of pharmacies and natural food stores. If your urine is consistently quite acidic (let’s say lower than 6) and you have a history of uric acid kidney stones then probably the very best thing you can do is get your urine pH closer to the 6-7 range. I’d caution against trying to get the pH too alkaline since that would be potentially very unpleasant. When my urine pH was 7.2 I found the experience to be quite unpleasant. So more isn’t always better.
Interestingly, gout also seems to be predicted by low urine pH. So much of what applies to addressing uric acid kidney stones also applies to gout. Namely, if your urine pH is consistently low then raising the pH can probably help.
Now the next million dollar question is: what the hell does one do to raise urine pH? And again, I don’t have all the answers. This is a complicated matter. Perhaps the single most influential regulator of pH in the body is the breath since carbon dioxide is the primary acid found in the body. In the blood carbon dioxide is balanced by bicarbonate, which is alkaline. So when the breath is too rapid or too deep (called hyperventilation) the kidneys will start dumping bicarbonate from the blood into the urine in order to prevent the blood pH from rising too much (blood pH is tightly regulated to stay in the narrow range of 7.35 to 7.45). What this means is that chronic hyperventilation (which is more common than you might think) actually raises urine pH. This is a mixed blessing. On the one hand, it can prevent uric acid kidney stones and gout. But on the other hand, it comes at a cost, which is that hyperventilation has a bunch of unpleasant side effects, including being correlated to a whole bunch of disease states and unpleasant conditions.
As it turns out, I got my first kidney stone event after I began practicing reduced breathing exercises to correct chronic hyperventilation. Looking at it now this makes perfect sense. My urine pH probably dropped because I was no longer dumping so much bicarbonate. It could very well be that hyperventilation is often an automatic compensatory measure designed to offset low urine pH. And even though I still think that correcting chronic hyperventilation by way of reduced breathing exercises can be a very good thing, I think it pays to also correct other imbalances.
So far we’ve seen that one possible way to increase urine pH is to hyperventilate. This may work, but it comes at a cost, and I don’t recommend it. Instead, I recommend finding other ways to improve urine pH.
In the medical world, one of the common ways in which uric acid conditions are treated is to prescribe alkalizing mineral supplements. Because of the general fear of sodium and also because potassium supplementation seems to be moderately more effective [study: http://www.nature.com/ki/journal/v30/n3/full/ki1986201a.html], the go-to supplement is potassium citrate. In some cases potassium isn’t tolerated, so then the fallback is either sodium citrate or sodium bicarbonate (baking soda). These supplements often work very well. But they can also have powerful effects that aren’t always pleasant. So they might be a good fallback plan, but they wouldn’t be my first choice on a daily basis. Many people report that half a teaspoon of baking soda in water a few times a day helps tremendously during a kidney stone or gout episode. For my part, though, I think they are powerful enough that I’d much rather find a less heroic means to regulate urine pH if possible and only rely on those supplements as necessary.
To begin with, do foods affect urine pH? Not surprisingly, they do, though generally not as strongly as strong alkalizing supplements. Generally-speaking meats tend to lower urine pH while most fruits and vegetables raise the pH. Fats don’t have much effect that I am aware of. Of course, there is a lot of nonsense out there on the internet with charts describing which foods and beverages are alkalizing and which are acidifying. But by and large, those claims are not backed by any real studies. They seem to be pulled out of thin air. However, there are a handful of studies showing that fruits and vegetables generally have alkalizing effects on urine. [see studies: http://www.jissn.com/content/5/1/20, http://www.ncbi.nlm.nih.gov/pubmed/15569332, and http://www.ncbi.nlm.nih.gov/pubmed/18042305. Note that some of the claims made by these studies are bogus, however. Specifically, the claim that acidic diets are detrimental to bone health are incorrect.] Otherwise, there’s not a lot of good information on the subject, at least not as it applies to humans. There are some studies showing that in non-human animals, grains tend to decrease urine pH. Whether this translates to humans, we don’t know. And the few human studies that use any forms of dairy suggest that most dairy probably has a neutral effect, but some fermented dairy such as yogurt may have a slightly acidifying effect.
I’ve already mentioned this, but it’s worth mentioning again; more is not better – a higher urine pH is not better than a balanced value somewhere in the 6-7 range. I mention this because some people take this alkaline-acid balance thing to the extreme and give up all meat in favor of eating all fruits and vegetables and dairy. That is a mistake because overly alkaline urine creates conditions for oxalate kidney stones and urinary infections. So don’t overdo it.
But on the other hand, it might start to be clear why low carbohydrate/high protein diets can produce uric acid stones and gout more reliably than just about anything else. In fact, though I can’t find the study off hand, I recall that in some populations low carbohydrate diets produce stones 50 times more often than other diets! Low carbohydrate/high protein diets are really the perfect storm for uric acid stones and gout because they tend to decrease urine pH while also increasing uric acid production, leading to what is known as supersaturation, which is the ideal condition in which uric acid crystals can form.
So the idea then is to eat a balanced diet that includes both acid-forming and alkaline-forming foods. Eat meat. Eat dairy. Eat vegetables, including starchy vegetables like potatoes. And eat fruit, lots of fruit. If you tend toward low urine pH then increase the fruit and vegetable to meat ratio.
Eating enough is important. Some of the literature about gout and uric acid stones suggest that obesity is a risk factor. That may be, but I suspect that in this case obesity is actually a stand in for low metabolic rate. So remaining in a state of semi-starvation and maintaining a sluggish metabolic rate is a bad idea. Instead, eat enough of everything in order to get your metabolic rate up. It can take some time, but based on a bunch of studies starting with the Minnesota Starvation Experiment it has been demonstrated over and over again that once the metabolic rate increases with consistent, adequate caloric and nutrient intake, the weight set point will lower and the body composition will naturally and effortlessly shift toward less fat and more lean mass. In other words, eating more may, in the long run, lead to less obesity. And therefore, it is at least plausible that eating more (as in enough) will lower risk of uric acid crystallization.
Hypothyroidism correlates very strongly with gout and uric acid kidney stones. And hypothyroidism can be worsened or produced by restrictive eating. So again, eating enough is likely essential for improving the condition.
What about beverages? To begin with, as Matt Stone has repeatedly pointed out, the advice to drink so much water that you start to pee clear is bad advice. That just means that you’re diluting your fluids and creating electrolyte imbalances. But on the other hand, particularly for those who have a history of kidney stones or gout, overly-concentrated urine is also a problem. So be sure to drink fluids when thirsty. Don’t make the mistake of avoiding fluids entirely in an attempt to increase metabolic rate (as I see some people doing). Drinking enough fluids so that urine doesn’t become saturated is important, and including adequate dietary salt can help to protect against electrolyte imbalance.
What fluids? Well, fruit juice is good. Orange juice may be a double win because not only does it provide overall alkalizing effects, it also provides citrate, which as we’ll see in a moment, is beneficial. Cherry juice is particularly good as well – though perhaps expensive. But cherries and cherry juice have been shown in numerous studies (here’s just one: http://www.ncbi.nlm.nih.gov/pubmed/12771324) to help with gout and uric acid kidney stones.
Despite the fact that many acid-alkaline diet proponents claim otherwise, coffee does not seem to affect urine pH. [study: http://www.sciencedirect.com/science/article/pii/0306460380900131] In fact, numerous studies demonstrate that coffee (though not the caffeine) consumption is inversely correlated to serum uric acid levels (though it is important to note that serum uric acid levels are not always a good predictor of problems related to uric acid crystalization). More importantly, coffee consumption is inversely correlated to gout. Personally, I am not a coffee drinker. I just don’t care for it. But if you like coffee then it’s probably just fine and maybe even protective against gout and uric acid kidney stones.
Alcohol is strongly positively correlated with gout. The evidence is that it would be best to avoid it for anyone who has a tendency to form uric acid crystal deposits.
What about soda? I’d strongly recommend skipping it. I’m sorry to jump on the anti-soda bandwagon, but it doesn’t look good when it comes to matters of uric acid complications. Not all sodas are equal in this regard, of course. So let me specify. In particular, I suggest avoiding any soda containing phosphoric acid because it will significantly decrease urine pH. And although the jury is still out on high fructose corn syrup, there is some evidence that the free (unbound) fructose content in corn syrup acts differently than either bound fructose (in sucrose, for example) or fructose occurring naturally in fruit. For anyone with a history of uric acid crystallization, I’d avoid it.
Some water is probably okay, but most water isn’t very mineralized, and as a result over consumption of water leads to electrolyte imbalances. So don’t drink a bunch of highly filtered water. Or, if you do, at least add some minerals to it. There are some notable historical accounts exist of the use of natural mineral water in treatment of kidney stones and gout. For example, the Italian mineral water, Fiuggi, has long been used to treat these conditions, and Michelangelo is said to have been cured of kidney stones from the water. As it turns out, the efficacy of mineral water – specifically Fiuggi water, has been tested and shown to be a valuable aid in improving urinary markers. But before you buy a bunch of expensive Italian mineral water, you might consider merely increasing fruit intake and possibly ensuring adequate salt intake with your water and possibly some of the supplements suggested next.
The substance citrate, which is a derivative of citric acid, found in (not surprisingly) citrus fruits among other foods, has positive effects in regard to improving renal (kidney) health. The best documented of these benefits is that it protects against calcium stones that can occur when pH of urine is alkaline. But there is also some evidence that citrate may help dissolve uric acid crystals. One possible source of citrate is from supplements such as potassium citrate or sodium citrate. But another source is (again, not surprisingly) citrus fruits. Orange juice is the most palatable of citrus fruit juices, and it contains some citrate, but lemon juice is the most concentrated source. In fact, one study showed that lemon juice worked nearly as well as potassium citrate supplementation for increasing urine citrate levels. [study: http://www.ncbi.nlm.nih.gov/pubmed/18946667]
Magnesium may also be involved in uric acid disorders, though I cannot find any human studies on the matter. Anecdotally, magnesium supplementation sometimes helps. And epsom salt (magnesium sulfate) baths have long been known to be helpful for gout. Also, gout is generally accompanied by high blood pressure. Magnesium can normalize high blood pressure, which may reduce the likelihood of uric acid crystallization. And finally, at least one study showed that of various supplements tested, magnesium potassium citrate proved the most effective in reducing urinary risk factors for stone formers. [study: http://www.ncbi.nlm.nih.gov/pubmed/15117041] So although magnesium supplementation isn’t as well studied as other possible ways to improve uric acid disorders, it shows some promise. Magnesium citrate is commonly available, relatively inexpensive, and less likely to cause unwanted side effects when compared to magnesium potassium citrate. Plus, potassium is pretty easy to get from foods when eating fruits and vegetables, but magnesium is a little trickier. Just don’t overdo the magnesium supplementation. It can have unpleasantly explosive results, if you know what I mean.
In summary, for those who have a history of uric acid stones or gout, I’m suggesting that the standard recommendations to restrict or eliminate large categories of foods, including meats (including fish and seafood), sugar, and fruit are misguided. Uric acid is not inherently bad. In fact, uric acid seems to have lots of really positive effects in the body. The problem arises when uric acid crystallizes and deposits in the joints or in the kidneys. And these problems seem to be averted or corrected by eating enough, correcting hypothyroidism, including enough fluids (without diluting bodily fluids and causing electrolyte imbalances), and increasing urine pH to the 6-7 range. The last point can generally be achieved by including adequate fruits and vegetables (including starchy vegetables) in the diet. Don’t forget to salt food to taste. Supplementing with cherries, citrus, and possibly magnesium citrate may be helpful. And in extreme or acute cases, supplementing with potassium citrate, sodium citrate, or sodium bicarbonate (baking soda) can be very helpful. However, if using these latter supplements, please use caution as they are very strong alkalizers, and they can easily lead to overly alkaline conditions that are just as undesirable as gout or kidney stones.
Oh, and just for the record, there isn’t any evidence that most people will benefit from any of this stuff. This probably only applies to people who have a history of gout or uric acid kidney stones. So if that’s not you then don’t stock up on cherry juice and pH strips. It probably won’t improve your life much. Though, admittedly, peeing on a strip of paper and having it turn colors (other than yellow) is strangely fun. But not that fun. Still, this information may come in?handy one day after you or someone you know makes the bad decision of trying a low carb diet or moves to the kidney belt.
Well, that’s all for now. Until next time, pee safely.