Gout: The Missing Chapter from Good Calories, Bad Calories

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Total read time (bolded sections): 2-3 minutes
Total read time (complete): 12 minutes

Last week, I had a wonderful conversation with Gary Taubes, my favorite science journalist and author of the incredible (and I consider definitive), Good Calories, Bad Calories. His ability to synthesize and recall research, both in writing and in speaking, is one of the most amazing feats I’ve ever witnessed.

It is with great pleasure, therefore, that I offer you the director’s-cut chapter that didn’t make it into the book.

The chapter addresses important misconceptions about diet, fructose, blood pressure, and diabetes through the lens of gout.

If you don’t know someone with gout, you probably will. It is common and becoming more so. The misguided prescriptions from misinformed doctors, which Taubes addresses, have affected my family, and I’d rather save you the trouble if I can.

But what the hell is “gout” anyway?

Like many, I’d heard it a million times but never knew. Here it is…

British physician Alfred Garrod, in the mid-19th century, identified uric acid as the causative agent; the idea being that uric acid accumulates in the circulation [and] crystallizes into needle-sharp urate crystals. These crystals then lodge in the soft tissues and in the joints of the extremities –- classically, the big toe — and cause inflammation, swelling and an excruciating pain that was described memorably by the 18th century bon vivant Sydney Smith as like walking on one’s eyeballs.

Sound like something to avoid?

Disclaimer as requested by Gary: This chapter is in draft form and has not gone through the same fact-checking as the rest of Taubes’ published work, even though there are 32 citations (some incomplete). I wanted to show the writing process at its mid-point. The only deletions I’ve make are “TK”, which–for unknown reasons–is traditional shorthand in publishing for indicating that something is “to come”.

I have bolded several sections for those who would like a 2-3-minute skim of content highlights before digesting the entire piece, which is 7 pages long.

Enter Gary Taubes:

—-

Gout and the condition known technically as hyperuricemia, or elevated levels of uric acid, are the most recent examples of this kind of institutional neglect of the potential health effects of fructose, and how pervasive it can be.

Gout itself is an interesting example because it is a disease that has gone out of fashion in the last century and yet the latest reports suggest it is not only as prevalent as ever, but becoming more so. Recent surveys suggest that nearly 6 percent of all American men in their fifties suffer from gout, and over ten percent in their seventies. The proportion of women afflicted is considerably less at younger ages but still rises over 3 percent by age 60.(1) Moreover, the prevalence of gout seems to have doubled over the last quarter century, coincident (perhaps not coincidentally) with the reported increase in obesity, and it may have increased five- or even six-fold since the 1950s, although a large portion of that increase may be due to the aging of the population.(2)

Until the late 17th century, when the spread of gout reached almost epidemic proportions in Britain, the disease afflicted almost exclusively the nobility, the rich and the educated, and so those who could afford to indulge an excessive appetite for food and alcohol. This made gout the original example of a disease linked to diet and over-consumption, and so, in effect, the original disease of civilization.

But once gout became easily treatable, in the early 1960s, with the discovery of the drug allopuranol, clinical investigators and researchers began to lose interest. And the pathology of gout has been understood since the British physician Alfred Garrod, in the mid-19th century, identified uric acid as the causative agent; the idea being that uric acid accumulates in the circulation to the point that it falls out of solution, as a chemist would put it, and so crystallizes into needle-sharp urate crystals. These crystals then lodge in the soft tissues and in the joints of the extremities – classically, the big toe — and cause inflammation, swelling and an excruciating pain that was described memorably by the 18th century bon vivant Sydney Smith as like walking on one’s eyeballs.(3) Because uric acid itself is a breakdown product of protein compounds known as purines – the building blocks of amino acids – and because purines are at their highest concentration in meat, it has been assumed for the past 130-odd years that the primary dietary means of elevating uric acid levels in the blood, and so causing first hyperuricemia and then gout, is an excess of meat consumption.

The actual evidence, however, has always been less-than-compelling: Just as low cholesterol diets have only a trivial effect on serum cholesterol levels, for instance, and low-salt diets have a clinically insignificant effect on blood pressure, low-purine diets have a negligible effect on uric acid levels. A nearly vegetarian diet, for instance, is likely to drop serum uric acid levels by 10 to 15% percent compared to a typical American diet, but that’s rarely sufficient to return high uric acid levels to normality, and there is little evidence that such diets reliably reduce the incidence of gouty attacks in those afflicted.(4) Thus, purine-free diets are no longer prescribed for the treatment of gout, as the gout specialist Irving Fox noted in 1984, “because of their ineffectiveness” and their “minor influence” on uric acid levels.(5) Moreover, the incident of gout in vegetarians, or mostly vegetarians, has always been significant and “much higher than is generally assumed.” (One mid-century estimate, for instance, put the incidence of gout in India among “largely vegetarians and teetotalers” at 7%.)(6) Finally, there’s the repeated observation that eating more protein increases the excretion of uric acid from the kidney and, by doing so, decreases the level of uric acid in the blood.(7) This implies that the meat-gout hypothesis is at best debatable; the high protein content of meats should be beneficial, even if the purines are not.

The alternative hypothesis is suggested by the association between gout and the entire spectrum of diseases of civilization, and between hyperuricemia and the metabolic abnormalities of Syndrome X. In the past century, gout has manifested all of the now-familiar patterns, chronologically and geographically, of diseases of civilization, and so those diseases associated with western diets. European physicians in World War I, for instance, reported a reduced incidence of gout in countries undergoing food shortages.(8) In primitive populations eating traditional diets, gout was virtually unknown or at least went virtually unreported (with the conspicuous exception of Albert Schweitzer who says he saw it with surprising frequency.) The earliest documented cases reported in Asia and Africa were in the late 1940s.(9) And even in the 1960s, hospital records from Kenya and Uganda suggested an incidence of gout lower than one in a thousand among the native Africans. Nonetheless, by the late 1970s, uric acid levels in Africa were increasing with westernization and urbanization,(10) while the incidence of both hyperuricemia and gout among South Pacific islanders was reportedly sky-rocketing. By 1975, the New Zealand rheumatologist B.S. Rose, a colleague of Ian Prior’s, was describing the native populations of the South Pacific as “one large gouty family.”(11)

Gout has also been linked to obesity since the Hippocratic era, and this association is the origin of the assumption that high-living and excessive appetites are the cause. Gouty men have long been reported to suffer higher rates of atherosclerosis and hypertension, while stroke and coronary heart disease are common causes of death.(12) Diabetes is also commonly associated with gout. In 1951, Menard Gertler, working with Paul Dudley White’s Coronary Research Project at Harvard, reported that serum uric acid levels rose with weight, and that men who suffered heart attacks were four times as likely to be hyperuricemic as healthy controls.(13) This led to a series of studies in the 1960s, as clinical investigators first linked hyperuricemia to glucose intolerance and high triglycerides, and then later to high insulin levels and insulin resistance.(14) By the 1990s, Gerald Reaven, among others, was reporting that insulin resistance and hyperinsulinemia raised uric acid levels, apparently by decreasing uric acid excretion by the kidney, just as they raised blood pressure by decreasing sodium excretion. “It appears that modulation of serum uric concentration by insulin resistance is exerted at the level of the kidney,” Reaven wrote, “the more insulin-resistant an individual, the higher the serum uric acid concentration.” (15)

These observations would suggest that anything that raised insulin levels would in turn raise uric acid levels and might cause gout, which would implicate any high carbohydrate diet with sufficient calories. But this neglects the unique contribution of fructose. The evidence arguing for sugar or fructose as the primary cause of gout is two-fold. First, the distribution of gout in western populations has paralleled the availability of sugar for centuries, and not all refined carbohydrates in this case. It was in the mid-17th century, that gout went from being exclusively a disease of the rich and the nobility to spread downward and outward through British society, reaching near epidemic proportions by the 18th century. Historians refer to this as the “gout wave,”(16) and it coincides precisely with the birth and explosive growth of the British sugar industry(17) and the transformation of sugar, in the words of the anthropologist Sydney Mintz, from “a luxury of kings into the kingly luxury of commoners.”(18) British per capita sugar consumption in the 17th century was remarkably low by modern standards, a few pounds per capita per year at the turn of the century, but the change in consumption over the next century and a half was unprecedented: between 1650 and 1800, following the British acquisition of Barbados, Jamaica and other “sugar islands”, total sugar consumption in England and Wales increased 20- to 25-fold.(19)

The second piece of evidence is much less circumstantial: simply put, fructose increases serum levels of uric acid. The “striking increase” in uric acid levels with an infusion of fructose was first reported in the Lancet in the late 1960s by clinicians from Helsinki, Finland, who referred to it as fructose-induced hyperuricemia.(20) This was followed by a series of studies through the late 1980s confirming the existence of the effect and reporting on the variety of mechanisms by which it came about. Fructose, for instance, accelerates the breakdown of a molecule known as ATP, which is the primary source of energy for cellular reactions and is loaded with purines. (ATP stands for adenosine triphosphate; adenosine is a form of adenine, and adenine is a purine.) And so this in turn increases formation of uric acid. Alcohol apparently raises uric acid levels through the same mechanism, although beer also has purines in it.(21) Fructose also stimulates the synthesis of purines directly, and the metabolism of fructose leads to the production of lactic acid, which in turn reduces the excretion of uric acid by the kidney and so raises uric acid concentrations indirectly by that mechanism.(22)

These mechanistic explanations of how fructose raises uric acid levels were then supported by a genetic connection between fructose metabolism and gout itself. Gout often runs in families, so much so that those clinicians studying gout have always assumed the disease has a strong hereditary component. In 1990, Edwin Seegmiller, one of the few veteran gout researchers in the U.S., and the British geneticist George Radda, who would go onto become director of the Medical Research Counsel, reported that the explanation for this familial association seemed to be a very specific defect in the genes that regulate fructose metabolism. Thus, individuals who inherit this defect will have trouble metabolizing fructose and so will be born with a predisposition to gout. This suggested the possibility, Seegmiller and Radda concluded, that this defect in fructose metabolism was “a fairly common cause of gout.”(23)

As these observations appeared in the literature, the relevant investigators were reasonably clear about the implications: “since serum-uric-acid levels are critical in individuals with gout, fructose might deserve consideration in their diet,” noted the Helsinki clinicians in The Lancet in 1967, and so the chronic consequences of high-fructose diets on healthy individuals required further evaluation.(24) Gouty patients should avoid high-fructose or high-sucrose diets, explained Irving Fox in 1984, because “fructose can accelerate rates of uric acid synthesis as well as lead to increased triglyceride production.”(25) Although none of these investigators seemed willing to define what precisely constituted a high-fructose or a high-sucrose diet. Was it 50 pounds of sugar a year? 100 pounds? 150 pounds? 300 pounds? And would high-fructose diets induce gout in healthy individuals or would they only exacerbate the problem in those already afflicted? In 1993, the British biochemist Peter Mayes published an article on fructose metabolism in the American Journal of Clinical Nutrition that is now considered the seminal article in the field. (This was in the special issue of the AJCN dedicated to the health effects of fructose.) Mayes reviewed the literature and concluded that high-fructose diets in healthy individuals were indeed likely to cause hyperuricemia, and he implied that gout could be a result, as well, but the studies to address that possibility had simply never been done. “It is clear,” Mayes concluded, “that systematic investigations in humans are needed to ascertain the precise amounts, both of fructose consumption and of its concentration in the blood, at which deleterious effects such as hyperlipidemia and hyperuricemia occur.”(26) Add to this Reaven’s research reporting that high insulin levels and insulin resistance will increase uric acid levels, and it suggests, as Mayes had remarked about triglycerides, that sugar (sucrose) and high fructose corn syrup would constitute the worst of all carbohydrates when it comes to uric acid and gout. The fructose would increase uric acid production and decrease uric acid excretion, while the glucose, though its effect on insulin, would also decrease uric acid excretion. Thus, it would be reasonable to assume or at least to speculate that sugar is a likely cause of gout, and that the patterns of sugar consumption explain the appearance and distribution of the disease.

Maybe so, but this hypothesis has never been seriously considered. Those investigators interested in gout have focused almost exclusively on alcohol and meat consumption, in part because these have historical precedents and because the implication that gouty individuals and particularly obese gouty individuals shy away from meat and alcohol fit in well with the dietary prescriptions of the 1970s onward.

More than anything, however, this sugar/fructose hypothesis was ignored, once again, because of bad timing. With the discovery and clinical application of allopurinol in the 1960s, those clinical investigators whose laboratories were devoted to studying the mechanisms of gout and purine metabolism – James Wyngaarden’s, for instance, at Duke and Edwin Seegmiller’s at NIH – began focusing their efforts either on working out the nuances of allopurinol therapy, or to applying the new techniques of molecular biology to the genetics of gout and rare disorders of hyperuricemia or purine metabolism. Nutritional studies were simply not considered worthy of their time, if for no other reason than that allopuranol allowed gout suffers to eat or drink whatever they wanted. “We didn’t care so much whether some particular food might do something,” says William Kelley, who is a co-author with Wyngaarden of the 1976 textbook, Gout and Hyperuricemia and who started his career in Seegmiller’s lab at NIH. “We could take care of the disease.”(27)

This exodus, however, coincided with the emergence of research on fructose-induced hyperuricemia. By the 1980s, when the ability of fructose and sucrose consumption to raise uric acid levels in human subjects was demonstrated repeatedly, the era of basic research on gout had come to an end. The major players had left the field and NIH funding on the subject had dwindled to a trickle. Wyngaarden published his last research paper in 1977 and spent the years 1982 to 1989 as director of the National Institutes of Health. Kelley published his last papers on the genetics of gout in 1989, when he became dean of medicine at the University of Pennsylvania. Irving Fox, who did much of the basic research on fructose- and alcohol-induced hyperuricemia in Kelley’s lab, went to work in the biotechnology industry in the early 1990s. Only Edwin Seegmiller remained interested in the etiology of gout, and Seegmiller says that when he applied to the NIH for funding to study the relationship between fructose and gout, after elucidating the genetic connection with Radda in 1990, his grant proposals were rejected on the basis that he was too old and, as an emeritus professor, technically retired.(28) “In the 1950s and 1960s, we had the greatest clinical scientists in the world working on this disease,” says Kelley. “By the 1980s and 1990s, there was no one left.”

Meanwhile, the medical journals would occasionally run articles on the clinical management of the gout, but these would concentrate almost exclusively on drug therapy. Discussions of diet would be short, perhaps a few sentences, and confused about the science. On those occasions when the authors would suggest that gouty individuals might benefit from low-purine diets, they would invariably include “sugars” and “sweets” as among the recommended foods with low-purine contents.(29) In a few cases – a 1996 article in the New England Journal of Medicine, for instance (30)– the articles would also note that fructose consumption would raise uric acid levels, suggesting only that the authors had been unaware of the role of fructose in “sugars” and “sweets.” Even when the New England Journal published a report from Walter Willett and his Harvard colleagues in March 2004, this same kind of nutritional illiteracy manifested itself. Willett’s article had reported that men with gout seemed to eat more meat than healthy men. But Willett, who by this time was arguably the nation’s most influential nutritional epidemiologist, later explained that they had never considered sugar consumption in their analysis because neither he nor his collaborators had been aware of the hyperuricemic effect of fructose. Willett’s co-author, Gary Curhan, a nephrologist and gout specialist with a doctorate in epidemiology, said he might have once known that fructose raised uric acid levels, but it had slipped his mind. “My memory is not what it used to be,” he said. He also acknowledged, in any case, that he never knew sucrose was half fructose.

The addenda to this fructose-induced hyperuricemia story may be even more important. When the New England Journal of Medicine published Willett’s gout study, it ran an editorial to accompany it written by the University of Florida nephrologist Richard Johnson. Over the past decade, Johnson’s research has supported the hypothesis that elevating the uric acid concentration in the circulation also damages the blood vessels leading into the kidneys in such a way as to raise blood pressure directly, and so suggests that fructose consumption will raise blood pressure.

This is another potentially harmful effect of fructose that post-dates the official reports exonerating sugar in the diet. And it is yet another mechanism by which sugar and high fructose corn syrup could be a particularly unhealthy combination. The glucose in these sugars would raise insulin levels, which in turn would raise blood pressure by inhibiting the kidney’s secretion of sodium and by stimulating the sympathetic nervous system, as we discussed in an earlier chapter, and the fructose would do it independently by raising uric acid levels and so damaging the kidney directly. If this were the case, which has never been tested, it would potentially explain the common association of gout and hypertension and even of diabetes and hypertension.(31) Johnson is only now looking into this possibility, however. Unlike Willett and his colleagues, Johnson had long been aware of the ability of fructose to raise uric acid levels, and so was studying that phenomenon in his laboratory. But it was only in the summer of 2004, he explained, three months after his NEJM editorial was published, that he realized that sucrose was half fructose and that his research of the past years was even relevant to sugar.(32)

A decade later, Thomas Benedek described the epidemiology of gout in The Cambridge World History of Human Disease this way: “Worldwide the severity and prevalence of gout have changed paradoxically since the 1940s. In the highly developed countries, as a result of the advent of effective prophylactic drug therapy, the disease is now rarely disabling. Elsewhere, however, it has become more prevalent, predominantly as a result of `improved diets.’”

###

Footnotes and endnotes:

The economist and historian Ralph Davis estimates that the supply of sugar from the Caribbean into Britain rose from three or four thousand tons a year in the late fifteenth century to over two hundred thousand tons by the 1770s, or an increase of over fifty-fold. (davis r, the rise of the atlantic economies, cornell university press, 1973, p. 251, 255)

1 Kramer hm, curhan g, the association between gotu and nephrolithiasis: the national health and nutrition examination survey III. 1988-1994. Am J Kidney Dis 2002;40:37-42

2 Arromdee E, Michet CJ, Crowson CS, O’Fallon WM, Gabriel SE. Epidemiology of gout: is the incidence rising? J Rheumatol. 2002 Nov;29(11):2403-6.

2Interview with choi, sept 16, 2004

2Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, Heyse SP, Hirsch R, Hochberg MC, Hunder GG, Liang MH, Pillemer SR, Steen VD, Wolfe F. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States.

2Arthritis Rheum. 1998 May;41(5):778-99.

3 gout, the patrician disease, p. 3

4

5 hydrick and fox, p. 748-749.

6 Duncan’s diseases of metabolism, p. 632.

7 Hydrick cr and fox ih, nutrition and gout, in present knowledge in nutrition, fifth edition, the nutrition foundation, Washington dc, 1984, p. 743

8 duncans diseases of metabolism, p. 638

9 Traut ef, rheumatic diseases, diagnosis and treatment, the C.V. Mosby Company, St. Louis, 1952 p. 303.

9benedek, in Cambridge history of diseases

9Trowel hc, a case of gout in a ruanda African, the east African medical journal, oct. 1947, p. 346-348

10 Beighton p et al, 1977, rheumatic disorders in th south African negro, part IV. Gout and hyperuricemia. South Af Med J. 51(26):969-72

11 Gout in the Maoris, B.S. Rose, Seminars in Arthritis and Rheumatism. Vol. 5, no. 2, (November) 1975, pg. 121-145.

12 duncan’s diseases of metabolism, 1947, p. 631

13 gertler mm, et al, erum uric acid in relation to age and physique in health andin coronary ehart disease, Ann Intern Med. 1951 Jun;34(6):1421-31. Reiser S, Uric Acid and Lactic Acid, in REISER S AND HALLFRISCH J, METABOLIC EFFECTS OF FRUCTOSE, crc press, boca raton fl, 1987 p. 113-134

13

14 duncan’s diseases of metabolism, p. 631

14 reaven gm, The Kidney: An Unwilling Accomplice in Syndrome X, Am J Kid Dis, Vol. 30, n0 6, December, 1997: pp. 928-931.

15 Facchini F et al, Relationship Between Resistance to Insulin-Mediated Glucose Uptake, Urinary Uric Acid Clearance, and Plasma Uric Acid Concentration, JAMA, December 4, 1991, vol. 266, no. 21, 3008-3011

16 Wyngaarden and Kelley p. ix

17 mintz

18 Sydney Mintz, Sweetness and Power, The Place of Sugar in Modern History, penguin books, ny 1985 p. 96.

19 mintz p. 64, 66

20 perheentupa j raivio k, fructose-induced hyperuricaemia, lancet, September 9, 1967, p.528531

21 emmerson bt, getting rid of gout

22 mayes pa, metabolism of fructose, ajcn, 1993

22hydrick c fox i, nutrition and gout, in modern reviews of nutrition

23 Seegmiller JE, Dixon RM, Kemp GJ, Angus PW, McAlindon TE, Dieppe P, Rajagopalan B, Radda GK. Fructose-induced aberration of metabolism in familial gout identified by 31P magnetic resonance spectroscopy.

23Proc Natl Acad Sci U S A. 1990 Nov;87(21):8326-30

24 peerheentupa ibid

25 hydrick and fox, p. 748-749.

26 Mayes pa, metabolism of fructose, ajcn 1993

27 Kelley interview

28 seegmiller interview

29 See for instance, fam ag, gout, diet and the insulin resistance syndrome, j. rheum. 2002;29, 1350-55

30 Emmerson BT. The management of gout.

30N Engl J Med. 1996 Feb 15;334(7):445-51

31 get citation from Richard Johnson articles on uric acid and hypertension.

32 Johnson interview, june 3, 2004

Posted on: October 5, 2009.

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236 comments on “Gout: The Missing Chapter from Good Calories, Bad Calories

  1. My father had gout in his knee often. It would swell up and he couldn’t walk on it. My friend had it in his big toe and could hardly walk on it. If I recall it’s a form of arthritis and can be common in young people. It used to be thought that all alcohol contributed to gout, but it appears beer has been ruled out and wine seems to be the worst culprit among the alcohols. I wonder if it’s a coincidence or not that wine, being made from grapes, and having fructose in it is a cause.

    Like

    • Fructose is converted to alcohol and CO2 during fermentation and therefore isn’t present in appreciable quantities in dry wines.

      Like

    • Alcohol or Ethanol, being a carbohydrate, like Fructose, has the same negative metabolic effects of fructose but includes the ones associated with the metabolism in the brain. A coke is like a beer without the buzz.

      Like

      • Alcohol is not a carbohydrate. Of it were, you would not have beers with 3g of carb or vodka, which has 0 g of carbs.

        Like

      • Disagree entirely.i gave up beer completely for 6 months along with all other alcohol drinks and my gout was no better.Only when I reduced fructose my gout dissapeared .Now I drink several pints a day and i have no problem at all with gout.

        Like

  2. Great post. Working in nutrition as I do I sometimes talk to friends and colleagues in the medical community and there’s a surprising level of ignorance, that said of course there is less of a fructose issue in the UK.

    Again it’s clear, if you’re going to eat fructose don;t eat too much and make sure you get a good amount of fibre with it, i.e. eat fruit.

    Of course info like the above is very useful but people need to step back and see the big picture; I now see people in clinic worried about the fructose in fruit! We focus on the nutrient and forget the food at our peril.

    Like

      • Both issues probably stem from same issue: acute fructose absorption/consumption. It will cause lots of other problems too, I have found.

        Like

      • Remember that acute fructose has same symptoms and causes same issues as Ethanol (alcohol) but without the ‘buzz’ (the symptoms caused by Ethanol metabolizing also in the brain where fructose metabolizes only in the liver). Both increase URIC ACID which INHIBITS INSULIN. Voila!

        CHECK THIS OUT:

        Like

  3. I’m reading this differently.

    It seems that besides possible genetic predispositions, the main culprit is once again resistance to insulin. Fructose (in excessive dosage) causes or worsens resistance to insulin by causing trans-fat buildups in muscle tissues (preventing proper sugar uptake). Other causes of resistance to insulin being insulin itself, secreted too often and in too high quantities due to a high sugar diet (fructose doesn’t cause any insulin reaction).

    This would mean that beer (GI of 120) should definitely have a worsening effect on gout, as it does on resistance to insulin.

    An interesting video on the topic if you missed it:

    Like

  4. Sucrose isn’t half fructose. Sucrose is sucrose and fructose is fructose. Table sugar is half fructose.

    ###

    From Tim – here is Wikipedia’s definition:

    “Sucrose, commonly called table sugar, is a disaccharide of glucose and fructose with the molecular formula C12H22O11. This white, odorless, crystalline powder has a pleasing, sweet taste. It is best known for its role in human nutrition. It is formed by plants but not by other organisms.”

    Liked by 1 person

    • Tim is correct. The wikipedia article you cite refers to sucrose as a disaccharide which is formed when two monosaccharides undergo a condensation reaction. In this case fructose and glucose.

      Like

    • YES IT IS. Sucrose is cane/granulated/table sugar. It is part GLUCOSE and part FRUCTOSE just like HFCS. With the Fructose being 50 to 60%. Glucose is the less sweet, good energy. Fructose is the much sweeter ‘toxin’.

      Check it out:

      Liked by 1 person

  5. I had one attack right after I opened one of my businesses. I swear stress has a part in gout also and everyone young who I know who has it agrees but I have never seen any discussion about that either.

    Like

  6. Aside: I’ve heard ‘TK’ is used as a marker in editing because it’s a letter combination rarely found in the English language. If you search your draft document for ‘TK’ your pending edits are easily surfaced.

    Like

      • Hi Tim,

        I wish that fructose were the main culprit behind gout, because then my problem would be solved. After all, I’m not overweight (I’m 5’11” and weigh 190 pounds, muscular and active, so BMI is skewed for me). Unfortunately in my case, I hit 40 this year and almost immediately developed gout in my big right toe joint. No fun, I can assure you. I’ve now had two attacks — the first much worse than the second. The only — and I mean only — causative factors that my wife and I have been able to discern has been wine and beer. Both of which I now avoid like, well, like the plague. I’ve never been a heavy drinker, always drink plenty of water, don’t drink a lot of soft drinks and generally skip desserts. My doctor pegged genetics and severe sleep deprivation (with a toddler who hasn’t slept well his entire young life) as being two other causes.

        Like

      • Damon, have you tried apple cider vinegar? I eat organic, including meat and chicken and eggs, am very active, yet have had several bouts with gout. I drink no soda and use no sugar in my diet. But, once I heard about apple cider vinegar, whenever I’ve woken with pain in my big toe, I drink about 1 or 2 tablespoons of organic apple cider vinegar in water and go back to sleep and it’s over. I don’t understand why I should have this problem, but it seems to be easy to at least remove the symptoms. I’ve also heard that bicarbonate of sodium also works. Just be sure to use a good quality one with no aluminum. (We use Red Mill.)

        Like

      • Probably shares similar roots as “OK”… which actually stands for “oll korrect” (all correct).

        Like

  7. THANKS for sharing this important information from Gary about gout, Tim. When I interviewed him on my podcast show last year, he noted that the final version of the book was less than half what he had actually written. At the time, I encouraged him to release the “other half” as another book that would be a GCBC 2 of sorts. He said he’s not opposed to doing that and it would be a great service. I appreciate all you are doing to spread the word! We gotta get YOU on my “Livin’ La Vida Low-Carb Show” podcast sometime. E-mail me!

    Like

  8. Hi Tim!

    We could’ve discussed gout at The Cellar the other night in SF! Ha! :)

    I’ve written a report about natural remedies for gout. Cherries, strawberries and blueberries work really well, as does 1/2 teaspoon baking soda mixed with 8 oz water.

    Cherries and berries have high levels of anthocyanins which have anti-inflammatory properties. They also quickly lower uric acid levels.

    There are bunch of other natural remedies that help as well.

    Hope this helps anyone suffering from gout!

    Joe Barton

    p.s. It was great meeting you the other day – glad you enjoyed the tattoo sleeve :)

    Like

    • I’ve had numerous gout attacks (42, 6’0″, 182lbs) and have always been told it was due to high protein foods like sushi and organ meats and exacerbated by beer… this by a doctor in Japan. Raw fish and beer… If that caused gout, the entire country would be in agony all the time.

      Ayway, I was prescribed anti-inflammatory pills and patch to combat the swelling but told to knock off beer when attacks hit and at if it became chronic, they would prescribe uric acid management drugs.

      I found the baking soda in a glass of water trick worked well to reduce my blood acidity (also works for intestinal gas) but I’ve found little actual correlation between my sushi and beer binges and the gout attacks.

      Sushi and beer I would not want to give up but I can live without fruit and sugar quite nicely. Thanks for the alternate view.

      Like

  9. Heya Tim!

    Very interesting. I think there is so much potential in just the food we eat. I think the majority of modernday complications and illnesses are all due to the food we do and do not eat, yet there is nobody to educate us on this properly, and if we do not research it ourselves, we may just be doing a lot of harm to our bodies.

    Personally I think nutrition is something that should be taught in school as a compulsory subject instead of all the other meaningless subjects we get forced to take.

    Great article!
    Cheers
    Diggy

    Liked by 1 person

  10. “The actual evidence, however, has always been less-than-compelling: Just as low cholesterol diets have only a trivial effect on serum cholesterol levels, for instance, and low-salt diets have a clinically insignificant effect on blood pressure, low-purine diets have a negligible effect on uric acid levels.”

    Add to that, low fat diets help you lose fat, high fat diets make you fat, cholesterol causes heart disease and statins are good for you, lol.

    This alone tells the sad story of health in America. The ONLY TRUTH is that there need not be much actual proof behind what you say, you just have to say it loud and often and everyone will start be believe it.

    AE

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  11. I wonder when the infectious component of gout will be discovered?

    The condition fairly screams of an infectious agent – a genetic component but no evidence of a direct, genetic cause. Sufferers with no family history. A waxing and waning of the commonality of the condition over time with no clear connection between, well, much of anything and that waxing and waning.

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  12. Interesting stuff…

    Hard to believe that this is a draft. Plenty of supportive evidence to go around. I always heard the blame on alcohol for gout but never saw any substantive scientific evidence. It’s been so long since I’ve read Good Calories, Bad Calories. Time to revisit Gary’s work.

    Mike

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  13. It is a great article. Too bad most doctors will never read it. It is another extension of lost nutritional knowledge. Since the 1920’s scientists know less and less about nutrition. Every disease that plaques our world now has a similar story as your gout article. Since research money is pumped into drugs and not nutrition most people will never get to read such cool stories. As he says in the article, there really is no one left to do the research. My guess is that you are going through your own transformation of knowledge. I like seeing articles like this on popular blogs. Until people get their diets changed, and eliminating sugars is an uphill battle, we use liquid phosphorous drops and some enzymes to help the kidneys detox and it works very well. I really like the line in there relating fructose to increases in lactic acid production. That has major implications for heart attacks. It is amazing how sugar is at the root of nearly all our health troubles.

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  14. Pizza – that’s interesting. Do these friends with gout drink a lot of beer, do they also drink wine or liquor?

    Tim – I wonder too if the rice-based beers like Budweiser (and Sake) are worse in this regard than the more traditional barley or wheat-based beers? In addition, doesn’t look like there is purine in rice, from a cursory google on the subject. So, depends on what beer you’re drinking…

    Also one thing that stuck out at me, has anyone ever considered that diseases run in families because they pass down the same (crappy) food traditions? It makes sense that the genes would show evidence of this, but our genes evolve, right?

    And I have to say, a lot of vegetarians indeed eat too much sugar, in particular the younger ones who use sweet stuff to fill their appetite. But don’t put all vegetarians in one bucket, I am personally very careful to get sufficient protein on a daily basis from whole food sources like nuts, beans & eggs (from a real farmer :)).

    Thanks!

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  15. Amazing! (I can’t wait for your next book!!!)

    I am only in my early 30’s and continue to fight against high blood pressure. I’m slim to medium build, somewhat active, and don’t indulge in addictive habits…yet, the doctor can’t figure out why my blood pressure is so high.

    The line drawn between sugars and high blood pressure makes sense to me. I have only recently decreased my sugar intake (my friend compared me to Will Ferrel’s character in Elf). My blood pressure is slowly falling to a normal level.

    You can bet that I’ll be looking more into this. Wish my doctors (multiple!) had known more about nutrition to have caught this. :(

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  16. Some doctors are paying attention, Dave. One doctor I know, a gynecologist, now mainly does nutritional counseling, prescribing Taubes’ book as the core lifestyle modification to obese, diabetic or insulin-resistant patients.

    She is also an anecdotal success, a hereditarily insulin-resistant Pacific Islander who fixed her own blood sugar levels through diet, with very little effort, simply by paying attention to glycemic index and fiber intake.

    This is going to turn. It just takes time, because many doctors are slow to change.

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  17. This is fascinating stuff, it’s like a modern updating of the book “Sugar Blues”. I’ll have to check out “Good Calories, Bad Calories”.

    As for doctors, all too often they willfully avoid learning any non-pharmaceutical treatments and cures.

    I’m far from alone in having the experience, even with doctors who are “open” to non-mainstream treatments, that telling them I’ve managed to cure something they said would be a lifetime disorder results in a “lala, glad it worked for you don’t-tell-me-how-you-did-it-I-don’t-want-to-know” response.

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  18. I find it particularily disturbing that so many medical researchers dont and didnt know that sucrose is about half fructose. It just goes to show how little consideration is put into the effects of carbohydrates in diseases of civilization.

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  19. I suffer from occassional attacks of gout. Luckily the attacks are getting fewer. I first suffered when I was in Taiwan. Possibly a result of eating a great deal of seafood (it’s really hard to resist) and tofu. Cutting down on these helps but the greatest improvement comes when I go on a no caffeine week. I do this when I gout attacks become more frequent and it works wonders. Okay the withdrawl headaches from no coffee or tea are tough, but I fond that I will be totally gout free for at least 6 months after and only have mild attacks for a year or so after.

    I have no idea if this just works for me, or if there is any science behind it. I suggest you try it out if nothing else works.

    Good luck

    M

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  20. Great article. I’ve been frequently told that meat intake is the primary cause of many inflammatory diseases. More and more I’ve finding that this is not the case. I think dave has it right, if we spent half as much time and money on nutrition as we do developing new drugs, we wouldn’t have disease. I highly recommend picking up a copy of the blue zones http://su.pr/31kBbF They study groups of people with longer than average life expectancy and have some interesting conclusions on diet and lifestyle (not all are vegetarian). BBC Horizon did a nice special that basically follows the book as well http://su.pr/1Vjeer

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  21. Unusual angle, gout.

    Tim will your next book include mention of the power of unconscious self-image beliefs?

    Positive affirmations about the body, letting go of unhealthy beliefs, are usually more important for a fat person than counting calories.

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  22. High uric acid levels may also play a role in formation of uric acid kidney stones. Kidney stones are associated with carbonated beverage consumption. Those drinks, of course, are sweetened with high fructose corn syrup. Perhaps certain kinds of kidney stones are also “diseases of civilization.”

    -Steve

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  23. Very interesting.
    It is really curious that we lost so much knowledge on nutrition.

    If you want to dig into wrong advice on nutrition I recommend a book called Bad Science where so called UK nutritionist are in trouble…

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  24. Tim, have you heard of Mark Sisson? I think you’d find his nutritional advice intriguing, as I have. His site, combined with many other sources have transformed my diet.

    In a nutshell, he encourages that we eat like our club-bearing ancestors, and cut out everything processed, prepackaged and/or man-made.

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  25. Thanks for this post Tim. A few years ago at the age of 23, I had my first “gout” attack, or at least that’s what doctor’s thought since I had all tell tale signs of it (but did not have fluid aspiration to verify uric acid crystallization). I was really confused about its origins since I lead a pretty healthy lifestyle and take my diet very seriously, except for my penchant for wine and beer. As I told my doctor, I’d rather go vegetarian than give up my wine and beer. After asking around, I discovered that my obese grandfather, who ate and drank like a king, only had 2-3 gout attacks in his whole life, the first one in his 20s (though his diet caugh up with him in the form of a heart attack that led to his death). I have not had an attack since, and while i did cut back my meat consumption, i remain a moderate drinker and very active. Reading about the dangers of sugar and fructose as they relate to gout for the first time (thanks for nothing doc) was eye opening and will definitely influence my diet and lifestyle. Thanks for pointing this out to me, and for wagging the finger at the medical community who is doing a disservice to millions by neglecting further study.

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  26. Tim:

    I generally open a window to my library catalog while reading posts on your site. Your blog and the library website are both in my favorites “Education” folder. Interestingly, the purchasing agent(s) for my local library system share your enthusiasm for the authors that you highlight in your posts. I most often find that your recommendations are interesting, well written, and thought provoking. Thank you.

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  27. For those who suffer from gout – I suffered for years – I “cured” it via the “baking soda” method (taking about 2 tablespoons of baking soda spread out over the day) – just google it. After two weeks, I stopped taking allopuranol and haven’t suffered from it since (going on a full year now).

    In support of this article though, I have also reduced drinking soda (fructose) to maybe 2 cans a week.

    Great article once again Tim. Thanks!

    Liked by 1 person

  28. Wow, thanks for this and for bring attention to Taubes and his work. Really looking forward to your next book.

    @Steve Parker. My youngest brother got kidney stones at age 19 and continues to battle them at 24. I’ve never seen such an unhealthy kid–his teeth are rotting out of his head too. His dietary staples are bread, sugar and salt. Interestingly, when people meet us they always assume he’s older than me. I’ve been trying to get him to change his diet but he doesn’t seem to care.

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  29. I love Dr. Weil, he rocks. It is funny to me that the more we dig into the science of dietary needs, the most popular view point is not the correct one. That is what scares me about the global warming issue. This type of bandwagon jumping for science is both dangerous and wasteful. I will stick with my high protein low sugar diet and keep driving my SUV.

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  30. My father, back in the 50s, was one of the few people who ventured to keep his gout under control through diet alone with minimal use of cortisone drugs. He ate a near-vegetarian diet with infrequent beef. I grew up on it, and that’s why I have fairly exotic food tastes for my age (nearly 60). He couldn’t drink wine, but he drank plenty of Haig and Haig pinch – it being before the days of single malts. Alas he was a heavy smoker, and he died before his 62nd birthday.

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  31. I heard a speaker talking about sugar intake and the idea that increased sugar intake caused increased joint pain just recently. I loved this comment because I, like most of you, like easy best practices that get results. This got me to thinking that my love for sugar based carbs may be causing me problems with my knee and hip (a mild to medium pain that occurs regularly with or without exercise). I did change my diet by reducing processed sweets and the pain is reduced. I think there is a definite correlation between processed sweets (and probably other processed foods) and joint pain (and other common health issues). I also recall reading similar diet related problems encounted by the author in the book Body by God.

    -God’s Blessings and Success to You and Yours!-
    Greg

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  32. This is so fascinating! I’m in my 50s and my much younger partner is currently suffering from insulin resistance, pre-diabetes, high cholesterol and non-alcoholic liver disease because (I’ve been arguing) of his high sugar, high fat, high-processed diet. At 24 years older than him, I’m fit and healthy and I believe it’s because I eat a lot of raw food including green smoothies, and I hate carbonated drinks.

    He’s now open to changing his diet but the so-called nutritionists are spouting the old story of low fat, high carb whereas I want to get him on high-raw. I’d love to know if eating whole fruits has the same detrimental effects as eating processed fructose.

    Thank you so much for highlighting this.

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  33. The obligatory video that often accompanies any mention of GCBC:

    Good Calories, Bad Calories is a wonderful (and I agree–definitive) work. But the reading is necessarily heavy. Expect to set aside a hefty block of focused time to get through it.

    The above video presentation is a good alternative to those who don’t have the time to read it–Gary Taubes condenses the book to about an hour-long talk.

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  34. “Discussions of diet would be short, perhaps a few sentences, and confused about the science. On those occasions when the authors would suggest that gouty individuals might benefit from low-purine diets, they would invariably include “sugars” and “sweets” as among the recommended foods with low-purine contents.”

    Yes, there is a bottom line link to gout and eating habits. Discussion of diets with not be short in this case. I love how we’re focusing on that.

    The over consumption of poor quality food; sugar and fructose does readily make itself apparent in physical symptoms such as gout and many others. A factor is to balance our diets to help manage the uric acid and insulin levels in the blood system

    Individuals can benefit from low-purine diets to help detox the body. Natural sugars such as Stevia, helpful sweets such as yams or fruits assist the body.

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  35. I’m not much of a calorie-counter or over-analyzer about what I eat on a day-to-day basis, though I am highly aware of how foods affect me and have a fascination in holistic nutrition and herbology. I do get OCD about menu planning, grocery shopping and kitchen organization. Yesterday I found nirvana through the Daily Burn menu planning functionality and the Grocery IQ iPhone app. Together, they streamlined my grocery shopping, making it easier for me to eat healthily while gaining satisfaction from cooking creatively at home. It’s the best, most re-usable menu-compiling, grocery list-building workflow I’ve found. It’s probably not exactly the use the Daily Burn founders had in mind (since when adding new foods I lazily put zeros across the board for calories, fat content, etc.)… but I’m happy to re-purpose their work for my own ends!

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  36. Interesting. Both myself and my father (now 85) get gout on and off on a fairly regular basis. We both drink wine and beer and eat meat, beer only seems to bring on symptoms if I really drink it to excess. Meat doesn’t seem to be a problem, however if we eat asparagus we get symptoms. In my case if I eat even a third of a stick of asparagus, I will be crippled within 3 hours.

    Through my own observations, it seems to be more the change in purine levels rather than the purine levels themselves that cause issues. for example if I eat meat and drink read wine on a regular basis THEN stop and say just drink water and eat vegetables, I’ll get gout, right when I would have thought my purine levels would be falling.

    I’ve never paid attention to fructose consumption, but I’ve always thought that fruit juice, especially clarified fruit juice was just like drinking a cup of sugar and regular consumption would be like drinking poison,

    It is interesting to note that high-fructose corn syrup is typically used as a sugar substitute and is ubiquitous in processed foods and beverages, including soft drinks, thick shakes, yogurt, industrial bread, cookies, salad dressing, and tomato soup. It is very interesting that these may have caused symptoms at times when I wasn’t expecting them.

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  37. After reading this, I see a potential correlation with some forms of kidney disease.

    The list of foods for people who have kidney disease to avoid is also similar to the list for gout and fructose is not on that list but probably should be. High blood pressure and diabetes are listed as causes of kidney disease which makes me suspect that there’s a common cause to a lot of these diseases (and it’s probably not just fructose even if that plays a key role – the quality of the food may also be a factor.) These aren’t the only similarities.

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    • @Franknol — Your answer certainly is short. And wrong. At least half wrong. Ethanol is a definite suspect, but dietary purines are a “red herring”. Dietary purines were just assumed to be a problem for gout sufferers, but no meaningful research was ever done to establish that.

      I used to have gout. But I have quit eating the stuff that causes it, and I’m off the allopurinol, and gout-free for over ten years now — on a diet that includes nuts, shellfish, and even a (very) small amount of wine. Gary Taubes’ answer is much closer to the mark than yours.

      Like

      • I have had gout since menopause, my mother had it at age 80. I have tophi on both my index fingers, and now a tophi on my big toe. All due to postmenopause which doctors are clueless about so I learn about gout from men, all overweight beer drinkers. My husband’s office mate, an engineer, heavy beer drinker, red-neck meat eater, wears a boot and is on allopurinol for life. I know that one tophi came from drinking a few dark lagers, and I am not much of a drinker, and another tophi, almost within a week, of eating a nutritional yeast supplement. If I do drink alcohol, more tophi. If I overdo protein, another tophi. God forbid I eat organ meat, another tophi. Now I am having trouble walking, can’t wear any shoes except flipflops. I use black cherry juice every day and I thought I had the gout under control because some of the tophi were shrinking. Not so. I have started eating according to the Perfect Health Diet by the Jaminets which makes more sense that any diet I have read which means limiting protein. I do not eat out, I do not buy any food containing more than 3 ingredients, cook from scratch. I started having tophi after eating according to the blood type 0 diet, then WestonAPrice guidelines with organ meats and nutritional yeast. And, yes, I can get a gout attack if I don’t eat and do a lot of exercise. I am researching right now, found your site, but I find that a lot of the conversation is not helpful because it appears to be an excuse to be a climate naysayer and let me shovel more meat into my mouth instead of an honest discussion to help those of us who want to help ourselves. My gout is spreading and I don’t want to end up in a wheelchair, otherwise being healthy, and people look at me and don’t realize that I am sick because I look healthy. I wish there were more honest discussions and I think now why doctors are not onboard which leaves many of us in trouble and on our own.

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  38. The statement that low salt diets having no effect on blood pressure does not mean that they don’t cause high blood pressure it just means that by the time the HBP develops it is often too late for low salt diets to work or they can take many years of strict avoidance to work. It has been proven by numerous studies that cultures who do not use salt have virtually no high blood pressure and those that do, have it and it correlates perfectly with amount of salt in the diet. This also correlates with the incidence of hemorrhagic stroke. Short term studies of salt avoidance it is true do not have much impact on blood pressure.

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    • It has long been believed that high sodium intake leads to a higher risk of hypertension and, by extension, cardiovascular disease. A recent study from Belgian researchers published in the Journal of the American Medical Association debunks this long-held belief.

      The researchers set out to test the theory that high sodium levels and hypertension are linked. They enrolled 3681 adults. Of those enrolled:

      • none (0%) had cardiovascular disease at the start of the study

      • 2096 (57%) had normal blood pressure at the start of the study

      • 1499 (41%) had their blood pressure and urine sodium level followed for the entire 7.9 year study period

      The study results may surprise you: over the study period, a higher percentage of people with low urine sodium levels died compared to those with moderate and high urine sodium levels. Furthermore, those study participants with the lowest urine sodium levels had a higher risk of dying of cardiovascular disease. The researchers were able to show that there was no correlation between high salt intake and high blood pressure.

      So what does this mean? It probably doesn’t mean that you should pile on the salt, but salt in moderation may not be as bad as it has been made out to be. People who are already hypertensive should continue to follow their physician’s recommendations on sodium intake until more research in this area has been done

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  39. Wow… first of all, I’m AMAZED by how many intelligent comments you get in your blog…. sound’s like the subject of the next book! ‘how I get intelligent comments in my blog’ haha…

    Secondy… yeah… Gout hurts bad!!! bottom line!!! I read a lot about the causes of gout in your post, but not much about the solutions to it. If you happen to have any kind of inside scoop on how a person can free themselves from the torture of this disease, it would be GREATLY appreciated… I’m sure a bunch of your readers would agree…

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    • I am by nature a very tiny person, always have been (it is genetic on my father’s side). After having breast cancer at 42, I have had to work like a dog to keep my weight up to at least 112 lbs.

      After my first attack of gout at 50, I immediately ate 10 cocktail cherries (the sickly sweet ones used in drinks) because they were in the fridge, the relief was almost immediate. The next day I baked cherry pies and ate a piece every day for a week, but realized that could not be a regular part of my diet because my husband has a serious weight problem (genetic on both sides) and pie in the house is not fair.

      Then I discovered Cherry Bits in capsule form and started taking them on a regular basis, but the expense was ridiculous. I then found a cherry juice (no sugar added) containing actual bits of cherries (it’s rather chewy, but just a couple of swallows in the a.m. does the trick), cheaper with same results, no gout attacks.

      I hope this helps you.

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  40. I have found that taking curcumin (turmeric extract) supplement daily is very helpful in keeping gout away and my large toe joint, where I had a severe attack a year ago, normal-feeling (devoid of inflammation).

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  41. Tim,
    Thanks for this! Taubes’ book is one of my favorites (I was actually re-reading part of it the other night), so this was a treat. I’m guessing this stems from research for the new book, so I like where you’re going.

    I must highly suggest then that you check out some of Art DeVany’s stuff. He’s an economist, you’d like him.

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  42. I have a feeling we are going to find that all to most disease is caused by sugar.

    Being sugar free for almost a decade has changed my life.

    Have you read: Sugar Blues, The Sugar Addict’s Total Recovery Program (fascinating research on alcoholics connection with sugar consumption), The UltraMind Solution (my new health bible), also watch the movie Sweet Poison to find out how much our government is really protecting us from harmful food.

    You are always inspiring, thanks for sharing this.

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  43. Getting a new (even draft) chapter from Gary Taubes’ GCBC is like finding a long lost manuscript from Aristotle, or a stash of newly discovered paintings from your favorite long-dead artist. Thanks so much for posting this, and like Jimmy Moore commented… if there is more draft material from GCBC, hopefully that can surface someday too!

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  44. Tim,

    Excellent post. There is a lot of weight to the theories being thrown around here. In my experience as an avid crossfitter, I have seen and felt not only personal results by eating paleo-zone but results of others at my gym benefiting from such an eating “lifestyle.” I’d recommend also Dr. Barry Spears. Gout, like diabetes, obesity and even MS can be brought on or elevated by a high starch, high sugar diet. In other words make sure you get your DV of a minimum 3g omega 3 a day. Fat is not all bad!

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  45. Go Taubes. This just drives another nail into the fructose coffin. Combine this with the fact that fructose forms AGEs 10 times more rapidly than glucose (see my blog for a post on this), and you have pretty good reasons to stay away from high-fructose foods.

    Now, whether we should include fruit in that category… I don’t know. I certainly don’t eat it as often as I used to.

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    • PUFA’s (polyunsaturated free fatty acids) are far worse at cause AGE’s than glucose/fructose. Dont get me wrong. Fructose is enemy number two……..PUFA’s are enemy number one as they are incorporated into every cell membrane in our bodies. As a clinician and surgeon I see disease every single day caused by both but the industrial seed oils loaded in omega 6 and 9’s cause nine times the AGE’s and ALE’s due to lipid peroxidation. If you have skin tags anywhere on youre body go get an omega 6/3 Index test, a cardiac calcium score and have your doc draw a ultra sensitive or cardiac CRP. Ironically, diabetics or those with evolving metabolic syndrome are the ones who harbor the most skin tags and this is a marker to clinicians that their patients are developing serious metabolic issues like hepatic insulin resistance and hypothalamic leptin resistance. Most of the symptoms in this comment section are the end result of the pathways I am mentioning. We need to advocate how to every get on this slippery slope to begin with. The ADA USDA AHA AMA and the federal govt all have it wrong. You have to be come your own health manager by doing your own research and talking to many folks. I learned all that I knwo about nutrition post medical school. Once you do this, then you will understand why most of america are walking time bombs. It can all be reversed but you need to know how based upon the latest data.

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      • Digital Surgeon – I am very interested in this topic about skin tags. Where can I get more information, and where can I find a doctor who knows anything about nutrition?

        I have had numerous skin tags most of my adult life. I have been obese since I was a child, and have had two gout attacks over the last two years. My doctor has had me on Probenecid for over 10 years due to elevated uric acid levels. About a year ago I read about uric acid on Dr. Mercola’s website and completely quit diet sodas. Over the last year I have been doing a lot of research and have lost over 100 lbs. I started out on Weight Watchers, and still track everything I eat, but I have changed my diet completely to a paleo-type mostly raw food diet. I got off the Probenecid after the 2nd gout attack – as I decided it wasn’t working and I didn’t want to be on the drug any more. I have been taking Juice Plus since January, and have quit eating fruit 6 days a week based on Tim’s slow-carb diet. The most amazing thing has happened – my nail fungus, or whatever that discoloration was on all my toes has almost disappeared. After reading your post, I just checked my skin tags, and I have only a few! I had no idea these had anything to do with my diet!

        I would love to find a doctor who can work with me nutritionally. And I want more information about the line of discussion you mention here. Thank you for your post.

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    • This may not be everyone’s experience, but I found that fruit could be addictive and therefore I ate too much of it. It didn’t help that I also ate a lot of dried fruit at various times. The result was not pleasant.

      Fruit in moderation may be ok, but if you are a person who finds it hard to moderate, it may be best to cut it out altogether. I know that in theory, the fibre is supposed to slow down sugar absorption, but has anyone actually tested this properly? Because I don’t believe that it does, significantly.

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  46. Thanks for this article.. I cut out all foods with non naturally added sugar about 2 years ago based on an intuition that most of the developed world’s degenerative illnesses were based on over consumption of refined sugar.

    I figured that given the lack of refined sugar in nature our bodies were probably not designed to process it.

    What’s interesting is that when you look at the labels of most food products they almost without exception contain added sugar. If you avoid refined sugar, it’s amazing how few food products you can actually eat.!

    I expect we’ll see a lot more research which links excess sugar consumption with illnesses and degenerative disease over the next decade – particularly cancer.

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  47. Yes, fructose (and naturally sucrose) may play a big role in gout.

    Perhaps one should also notice that uric acid is a powerful antioxidant. It has been postulated that it constitutes up to 2/3 of body’s total antioxidant capacity (Waring et al 2002). Much of uric acid formation is also endogenous, it’s not only what we eat.

    Thus, some researchers believe that elevation in uric acid level reflects, at least in part, body’s attempt to protect itself against oxidative stress prominent in hypertension, metabolic syndrome, atherosclerosis, aging and so.

    Dairy products, cherries and coffee may have an antiuric effect.

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  48. @Mayer

    What else do we know about cultures who do not have salt? More likely than not, they are less developed and therefore eat a less industrialized diet with delicious high fructose corn syrup.

    Salt increases blood pressure by increasing circulatory volume, causing the heart to pump harder. Although some effects are more permanent, because salt is readily moved in and out of the body most are short term. Once your arteries are clogged, lowering blood volume isn’t going to solve the problem. This is why if you have high blood pressure for a long period of time decreasing salt intake doesn’t have much effect (arteries are clogged). In a otherwise healthy individual, decreasing salt intake quickly decreases blood pressure, because arteries are not clogged.

    High blood pressure is definitely a problem, but that’s not why people are having heart attacks and strokes. HBP is a symptom of the real problem which is clogged/blocked arteries.

    Our current approach to heart disease seems to be well summed up by my grandfather. He would just skip the salt on his morning biscuits and gravy. Instead of fixing the problem, we fix the symptoms (HBP).

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  49. To me, the most important part of the video with the docs is when Weil interrupts Oz to say it’s not his DIET that keeps him thin, it’s his genetic makeup. It’s a critical point that is overlooked continually with regard to “what works,” and one of the main reasons why we can eat the same food as our peers/pursue a similar active lifestyle and still have issues with our body composition. We have to find what works for us as individuals. Trial and error, baby.

    I’m intrigued to learn more about the fruit vs. processed fructose argument yields as well…

    Cheers,
    D

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  50. Speaking of salt intake….is anyone familiar with salt making you sluggish, tired, similar to a hangover?
    I have not been able to find anything out there, other than talk of high blood pressure on the matter.

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  51. @Doc Kane

    To me, the most important part of the video with the docs is when Weil interrupts Oz to say it’s not his DIET that keeps him thin, it’s his genetic makeup. It’s a critical point that is overlooked continually with regard to “what works,” and one of the main reasons why we can eat the same food as our peers/pursue a similar active lifestyle and still have issues with our body composition. We have to find what works for us as individuals. Trial and error, baby.

    I’m intrigued to learn more about the fruit vs. processed fructose argument yields as well…

    Yeah Doc I gotta go with you on this one for as good as Taubes work is he misses out on your point. In speaking he seems to draw the nuances out when forced to (like when Weil on the video notes his disagreement), but his published work certainly lacks such nuances.

    And I would argue that while it is genetics for some that allows them to eat anything without apparent issue, it is not genetics that is the issue with carbs, but source and preparation. When properly sourced and prepared, which almost nobody does in modern society, then carbs become a non-issue. The modern Kitavans who were studied by Dr. Stephan Landberg is a case in point, but the most famous field researcher in this area is Dr. Weston Price.

    The Kitavans eat a high carb diet (69% of calories but none from grain) and do quite well. The Kitava study also answers the question of refined versus natural fructose. The Kitavans load up on fruit, but only seasonally. And by the way, tying in with a previous post Tim made about saturated fat, despite their high carb diet, the Kitavans saturated fat content is quite high, at least by western standards.

    You can read all about them … [on the site linked to via name – see comment rules]

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    • Re: Kitavans – Besides fruit, they also consume a lot of tubers such as sweet potato, yams, taro root and tapioca. They are also fish eaters. They do not consume legumes nor grains. Its like a high carb version of the Paleo Diet.

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  52. Tim, it’s increasingly known in Game and HBD circles that the primal diet is the way to go. And there are various health and nutrition movements advocating elimination of carbs, grains, starches, sugar, and eating lots of meat.

    It seems to me you’re posting scientific selections that flip the nutrition script without making any bold assertions backed only by your own authority. First the saturated fat post, then the gout post. Is this your way of laying a foundation for advocating a primal diet? I don’t blame you for being wary of the nutrition-industrial complex’s screaming Maenads.

    On the other hand, I see you eating plenty of milk, sugar and carbs on your binge days. What gives, are you yet to see the light?

    Frankly, I don’t think anyone can be superhuman who’s eating sugar once a week. If you haven’t already, try the one-week all-meat diet high.

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  53. Taube’s book is one of my favorites. It’s not a light read but definitely worth reading. I used to work with a guy who had gout (he’s only in his mid-20’s!) and he drank soda constantly. I’m gonna have to send him this article.

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  54. A very interesting chapter to leave out of the book. I wonder what else there is.

    I can see the disease complex in my Mom, but not from consumption of fructose. First it was high blood pressure in her late 30s. Then it was high cholesterol, next gout, and now it’s diabetes. Through it all Mom has eaten an almost perfect diet (4 or 5 fruits and veg., low fat meats, no salt, very little processed food), walked everyday and done yoga twice a week. She has never eaten a high fructose diet, and only rarely consumed wine or spirits, never beer.

    Then there was Dad. Lots of alcohol, lots of meat, no exercise, and no sweets (he just didn’t like sweet food). Low blood pressure, low cholesterol, no gout, no diabetes. The pharmaceutical industry is keeping Mom alive, but cigarettes killed Dad at the age of 64,

    I don’t know what conclusion to draw, but lifestyle does not seem to be the cause of the disease complex.

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  55. I’m totally confused, there are a number of excellent posts regarding nutrition but its too much info. Reading the comments section makes it twice as difficult due to conflicting opinions. How to consolidate all this information into some general rules of thumb for diet??

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  56. Ben-

    Your intuition may be correct. A dental professor, Philippe Hujoel, tends to believe the Cleave-Yudkin theory that excessive refined carbohydrates cause major degenerative diseases of civilization. I blogged about it at my NutritionData Heart Health Blog, if interested:

    [please do not put URLs in comment text — see comment rules]

    -Steve

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  57. This is a landmark book that will probably take western medicine 20 years to mainstream. I gotta tip my hat to Taubes! I would like to see someone correlate the use of HFCS and obesity rates. One day Congress will go after the Cargill’s and Coca-cola’s of the world as they went after cigarette-makers in the late 90’s.

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  58. The carbohydrate theory of chronic systemic disease was laid out in the mid-20th Century by Cleave and Yudkin. Taubes writes about both.

    Both Cleave and Yudkin (nutritional giants in my opinion) fingered refined sugar in particular, and refined carbohydrate in general as the problem. Neither pointed to carbohydrates per se as an issue.

    Michael

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  59. Through it all Mom has eaten an almost perfect diet (4 or 5 fruits and veg., low fat meats, no salt, very little processed food)

    and

    Then there was Dad. Lots of alcohol, lots of meat, no exercise, and no sweets (he just didn’t like sweet food). Low blood pressure, low cholesterol, no gout, no diabetes.

    While your assumptions about diet might not let you acknowledge such, your mom’s diet seems far from perfect and your dad was much closer to the truth. Read Taubes and Eades, both who have been featured on this blog as of late, and you will see demonstrable evidence that there is a fairly clear general consensus, in terms of evidence, of what the “perfect” diet might look like. It certainly would not include as a foundation low fat meats. The diet you describe predictably leads to the diseases you describe.

    Tim, I confused about your url policy. I counted seven in the posts above. With one gentleman you deleted his link and in the next post allowed his link to go through.

    Having accidentally run afoul of the url policy in my initial foray out of lurkdom here, I was going by what you told me then. Some clarification might be helpful. Thanks! And thanks for the diet posts. :-)

    Michael

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  60. Tim: as a fan of Taubes and his work, have you considered the idea of helping to get Taubes a higher profile venue then he has had so far present his material? As a TED presenter, I would imagine that you are in a position to recommend presenters and get his views heard by a large and influential audience.

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  61. Never had a problem with gout until I went on a low-carb diet (which, by the way, was inpsired by one of the posts on this blog). I lost about 30 lbs over a 6 month period, but had some recurring problems with gout in my big toe and ankle. Some of the episodes were crippling. I also experienced joint pain in my fingers on a regular basis while avoiding carbs. After falling off the low-carb wagon (about 6 months ago) I haven’t had any more problems with gout. Unfortunately, I also gained back the 30 lbs. This has caused me to reconsider the wisdom of following a low carb diet in my case; although, aside from the gout, I felt much healthier when I was 30 lbs lighter.

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  62. Also, while on my low carb diet i was drinking copious amounts of diet coke and coke zero – approx 6 cans/day (I noticed that someone else commented earlier on a possible relationship between caffeine and gout). Maybe that had something to do with it?

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  63. Anyone else see the big error at the beginning of the article? Uric acid is not a byproduct of protein metabolism, nor does it have anything to do with amino acids (unless you are a reptile). It is made from purines found in DNA, RNA, some signaling and energy storage/transfer molecules (GTP, ATP, NAD+ and FAD for example). That is quite important to the story here, as a high protein diet does not necessarily equate to a high purine diet.

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  64. I definitely have gout and it is horribly painful. And at times I could not even wear my shoes.

    A doctor’s visit didn’t help so while researching I read about the link between gout and uric acid levels. I also found that black cherries have a high level of anthocyanin which counteract the uric acid. I had to at least try it. Since I didn’t want to take in the calories required to eat the handful of cherries or drink the juice, so I found no-sugar, concentrated black cherries in capsule form. It works great! If I take 4 capsules a day, I experience absolutely no swelling and no pain.

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  65. @Rob
    Thanks for your excellent hint!

    Tim, could you elaborate on natural nitrate/nitrites in vegetables? I think there is fresh evidence on that naturally occuring nitrates might be cardioprotective (via nitric oxide pathway) – or perhaps cancer inducing. Cancer theory is now questioned due to inconclusive evidence. Are nitrates one of the key fytochemicals of veggies?

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  66. Curse my Finnish gout genes.

    I had my first gout attack in my mid 20’s but it took a few years for a diagnosis to confirm it. Fortunately I had a hunch that a strongly anti-inflammatory diet would to the trick. I went paleo and the gout (which was absolutely crippling – I would lose days at a time when I was immobilized) disappeared immediately. If you have a VERY strong pre-disposition to gout as I have, avoid excess sugar like the plague.

    Cheers, Paul

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    • Same here Paul, I had gout and went 80% carbs, 10% protein and 10% fat, basically a vegan diet/paleo and haven’t had an attack since and I feel great! I would also be immobilized with each attack for close to a week, it was frustrating Avoiding sugar is so key if you have gout, it can’t be emphasized enough, a good article http://goutandyou.com/sugar-fructose-high-fructose-corn-syrup-and-gout/ that talks about sugar, fructose and high fructose corn syrup is really enlightening to add to this thread!

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  67. Tim: Interesting article. As someone who has had gout attacks, “walking on your eyeballs” doesn’t even begin to describe it. More like driving a nail through the large joint at the base of the big toe, and soaking the result in vinegar.

    First draft? You might notify the author that he consistently misspelled allopurinol.

    Didn’t realize (at least not from your book) that you were so interested in diet. Guess I’ll have to go back and read it again.

    Cory: Cola beverages contain phosphoric acid, which, among other things, screws up the way your body handles calcium, potassium, and magnesium. I accidentally discovered that cola beverages were the principle cause of my restless leg syndrome. Would not surprise me a bit if that could be a contributing factor in gout.

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  68. @Mayer (thanks Allen for the backup) –

    Remember that correlation does not equal causation. If you actually slog through Taubes’ entire book, you can see that many of our current bad nutritional recommendations (low fat/cholesterol, et al) are chiefly because investigators abandoned true scientific research practices for dependence on correlations highlighted during observational studies. As Taubes demonstrates, actual science makes the causation pretty clear.

    Addidiont to Allen’s comment –

    Following a very low-carb diet causes the kidneys to dump sodium (&potassium), so avoidance is not only not required, it’s ill advised. Funny how the body falls into natural regulation patterns when carbohydrate poisons are eliminated.

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  69. I’ve had only one gout attack, after coming off a three-month liquid protein diet – a big success in terms of weight loss, but I also lost my hair and my gall bladder. My GP thought allopurinol forever was an easy solution, but once I checked the contraindications, I wasn’t about to take it. A very prominent weight loss doctor in Washington D.C. told me gout often accompanies weight loss (as in an earlier post here) and I would probably never experience another attack. I never filled my allupurinol prescription and he was exactly right. Subsequent low-carb dieting never produced another episode of gout.

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  70. This has provided some food for thought. I’m sending a relative with gout a link to this page.

    ….and another misspelled/phoenetic abbreviation: In industry compressed gas cyclinders, once they are empty, are marked with the letters MT.

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  71. @Cory

    Funny you mentioned Coke Zero. I have to limit my caffeine consumption to the equivalent of 4 cans of Coke Zero a day or I’ll get hit by a gout attack.

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  72. Eating “paleo”, ie. in the manner of our paleolithic ancestors, best captured by Loren Cordain and Robb Wolf (esp his website) is being shown across more and more parameters to be the correct way for us to eat. The evidence is available in all remaining hunter-gatherer societies, which have lower levels of almost all markers of poor health, and negligible cancers, heart disease and other “Syndrome X” markers. Eat a diet high in lean protein, healthy fats, all forms of vegetables and berries; and avoid all grains and beans.

    “The notions that:
    1-Vegetarianism is the best way for humans to eat.
    2-the earth is flat.
    3-the earth is 6,000years old
    Share some interesting characteristics:

    They do not reflect, research data, empirical findings, or offer any predictive value. Why? They are fantasies.

    In the case of vegetarianism from the China Study perspective, we should see a simple dose response curve with meat intake and cancer. We do not. In fact, we only need ONE (1) example of a conflicting finding to completely discredit the hypothesis. The Inuit Paradox is just such an example. Now the vegetarians will start back-pedaling and yamering a bunch of [stuff], but the fact is we have a well documented example of a society that consumes greater than 90% of it’s calories from MEAT yet suffers NO:cancer, diabetes, or heart disease until the introduction of neolithic foods. This fact is forgotten, ignored, dismissed…but it’s still a fact. The inuit, are BTW but one of hundreds of hunter gatherer cultures who represent this interesting “Paradox”.” (Robb Wolf)

    “In mature and well-developed scientific disciplines there are universal paradigms that guide scientists to fruitful end points as they design their experiments and hypotheses. For instance, in cosmology (the study of the universe) the guiding paradigm is the “Big Bang” concept showing that the universe began with an enormous explosion and has been expanding ever since. In geology, the “Continental Drift” model established that all of the current continents at one time formed a continuous landmass that eventually drifted apart to form the present-day continents. These central concepts are not theories for each discipline, but rather are indisputable facts that serve as orientation points for all other inquiry within each discipline…………..The study of human nutrition remains an immature science because it lacks a universally acknowledged unifying paradigm (11). Without an overarching and guiding template, it is not surprising that there is such seeming chaos, disagreement and confusion in the discipline. The renowned Russian geneticist Theodosius Dobzhansky (1900-1975) said, “Nothing in biology makes sense except in the light of evolution” (12)……All human nutritional requirements like those of all living organisms are ultimately genetically determined. Most nutritionists are aware of this basic concept; what they have little appreciation for is the process (natural selection) which uniquely shaped our species’ nutritional requirements. By carefully examining the ancient environment under which our genome arose, it is possible to gain insight into our present day nutritional requirements and the range of foods and diets to which we are genetically adapted via natural selection (13-16). This insight can then be employed as a template to organize and make sense out of experimental and epidemiological studies of human biology and nutrition (11).” (Prof. Cordain).

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    • @James Hardy,

      You’ve said that the Inuit consumed 90% of their calories from meat.

      Don’t forget that in their traditional diet they consumed a lot of fat. Maybe that should have read “90% of their calories from meat and fat”?

      In fact, as I think Gary says, most “primitive” societies always preferred the fatty parts of the meat (as well as the organs).

      Eating lean meat with no added fat may not be such a good idea. Of course the fashion for lean meat only came about as the result of the ill-advised campaign against saturated fat, brought about primarily by the mis-interpretation of diet studies across various different countries.
      Readers of GC, BC know exactly what I am talking about.

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  73. The best thing we can do for ourselves is simply to eat what nature makes and let the rest of it go. Fructose is fine along with the fiber, vitamins, etc. that comes along with it in its natural state; fructose syrup is not. I’m so sick of reading about diets and studies, just eat what is whole and natural.

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  74. Hello Tim, a really interesting article!!!

    This article has really shocked my since I am the father of a 3 year old daugther suffering form PKU (PhenylKetonUria). A rare genetic metabolic disorder characterized by the inability to process Phenylalanine. Therefore, patients should avoid, almost completely, proteins in their diets. Of course, sinde they need Aminoacids, they take supplements to avoid malnutrition. As a side comsecuence, they have a really high carbohydrate diet, almost purely based on vegetables (since pasta and bread also have proteins). Do you think that they would be more exposed to have high urine levels in blood? Don’t you think that they would be an good target study group to test the effect of high sugar/carbohydrates related to urine levels? Do no hesitate to contact me if you need more details.
    As I said, excellent article, blog and book ;)

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  75. When you eat a well constructed lower fat diet — one that is not excessive in fructose or polyunsaturates or protein — gout is basically non-existent.

    In fact, just because protein does not elicit much of a glucose response — does not mean it doesn’t increase insulin, in fact,it still increases insulin — just look at the insulin index. Some protein foods elicit more of an insulin response than carbohydrate foods. Just something to consider.

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  76. @Aaron

    In fact, just because protein does not elicit much of a glucose response — does not mean it doesn’t increase insulin, in fact,it still increases insulin — just look at the insulin index. Some protein foods elicit more of an insulin response than carbohydrate foods. Just something to consider.

    As far as protein affecting insulin, it should be noted that while protein does affect insulin, glucagon goes up as well, and it is the insulin-glucagon ratio which is important, not just the rise of insulin. Since glucagon rises with insulin when consuming protein and therefore the ratio does not change, it seems to me it is difficult to speak of insulin “rising” in a negative manner when discussing protein consumption.

    Michael

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  77. @ Aaron

    In fact, just because protein does not elicit much of a glucose response — does not mean it doesn’t increase insulin, in fact,it still increases insulin — just look at the insulin index. Some protein foods elicit more of an insulin response than carbohydrate foods. Just something to consider.

    As far as protein affecting insulin, it should be noted that while protein does affect insulin, glucagon goes up as well, and it is the insulin-glucagon ratio which is important. Since glucagon rises with insulin when consuming protein and therefore the ratio does not change, it seems to me it is difficult to speak of insulin “rising” in a negative manner when discussing protein consumption.

    Michael

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    • @Michael: Be careful: From the Wikipedia (yes, I know not definitive, but it’s a starting point) entry for Glucagon:

      “Glucagon causes the liver to convert stored glycogen into glucose, which is released into the bloodstream. Glucagon raises blood glucose levels.”

      So although glucagon can be regarded as the counter-hormone to insulin, this does not necessarily mean we can just ignore the various responses to the ingestion of protein.

      Personally, I would like to see Gary and others address this issue a little more closely. GC, BC was a great book, but it will leaves us with a myriad of questions.

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  78. Tim,

    Great post. While many like to blame “carbs” all around…it is still the “source” that matters.

    You can see high carb eating societies with low incidences of all diseases such as the Okinawa, Zulu, Kitavans and others….but what do they all have in common? The answers are simple as they:
    – eat in moderation
    – have NO sugar or processed foods (and the resulting fructose overload that can come from it via HFCS and Sucrose)
    – are active
    – have LOW fasting insulin (no insulin resistance brought on by excess fructose)

    High carb eating societies (like 65-85% of total daily calorie) that are lean and suffer little to no degenerative diseases of so called “old age”.

    As science seems to complicate matters with more and more diseases (and trying to blame it on generic factors), hopefully with articles like these the simple message we all need can get through.

    Mike OD

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  79. @ MIke OD

    From my own research what the high carb eating societies seem to have in common is eating a large amount of saturated fat as a percentage of their fat intake, even when overall fat intake is low. Some aren’t very active and some eat more than others, but this seems to be the common thread given that none of them eat a diet with what Weston Price described as the “displacing foods of modern commerce.”

    The Kitavans are a perfect example. Their overall fat intake is less than what we consume in the west but their saturated fat intake (which makes up 80% of their fat consumption) is about 10% higher than what we consume in the west. The amount of calories they consume is higher also and they are only moderately active.

    The Eades could have not been more right in an excerpt that Tim posted previously regarding saturated fat.

    Thanks for the comment about fructose. The Kitavans eat a lot of it without any ill effect but they do so seasonally, not all year around and certainly not any refined fructose, both practices which are characteristics of the standard American/Western diet (SAD).

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    • @Michael:

      Much of the saturated fat the Kitavans consume is from coconut. Other than that their only other source would be fish.

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  80. Dr Weil needs to practice his endoresment. He still writes about low-fat and doesn’t have the courage to step up and preach that fat is not the enemey in our diet. Money talks

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