Uric acid (UA) is the new bad boy on the block… so move over, salt, sugar and cholesterol! High UA threatens the heart, the liver, the kidneys and the brain – not to mention my most favourite organ of all. So, what drives high uric acid, and what can we do to Drop Acid?
As mentioned in my blogpost #26 Uric Acid Part 1: Gouty Tales (see here), my recent uric acid (UA) blood test came back an optimal 4.7 mg/dL. That bodes well for me living long and strong, but what about my darling husband?
Fortunately, I found out that coffee lowers UA, and I told him so. It was the best news he’d had all year. Imagine, though, how miserably gouty he’d be if he wasn’t such a coffee-head.
My new UA Sure II uric acid monitor was delivered a couple of weeks ago, but at the time I started writing this blog I had not yet used it to test Roy. I was wondering how I would manage to pin him down and extract the necessary drop of blood from his craven finger.
Then came an unexpected stroke of luck! – he woke up a few mornings ago with a twinge of gout in one ankle, and immediately demanded that I test his uric acid levels. Right now! I hastened to comply: you don’t argue with a gouty husband.
So, I poked his finger with the lancet, applied a drop of blood to the test strip I’d inserted into the monitor, and waited a few seconds for the result. The result was interesting: within the manufacturer’s normal range, which was a relief to us both; but above what’s regarded as the optimal level of 5.5 mg/dL for both men and women.
I looked for signs of PTSD, but they were fortunately minor. Apart from joining a #metoo abuse group and refusing to be retested the next morning, Roy seemed to have survived the ordeal relatively unscathed.
In fact, after treating himself with colchicine – a herbal medicine that nevertheless requires a prescription – he called for a retest three days later. Though instructed not to state the exact number here, I can reveal that it dropped by 0.7 mg/dL. Good news, then!
Uric Acid – Why Should We Care about High UA?
If you’re not gouty, is there any reason to care about high UA levels? Absolutely! – and here’s why:
Briefly, hyperuricaemia (high UA) is linked with death from heart attack and ischaemic stroke, high blood pressure, diabetes, chronic kidney disease and non-alcoholic fatty liver disease, or NAFLD*.
(*As an aside, I see no point in developing NAFLD. If you were going to get fatty liver disease, wouldn’t you rather get it from champagne and cocktails than from Cokes and doughnuts?)
An internet search revealed a a distinct lack of attractive images of fatty livers, alcoholic or otherwise. So here are some images from my own archives to illustrate the festive champagne and cocktails route to NAFLD:
Wouldn’t you rather get a fatty liver from champagne and cocktails than from Cokes and doughnuts? – Verne Maree
To add insult to injury, high UA plays a role in erectile dysfunction – which in itself can be an early marker for cardiovascular disease. (For more about this, click here.)
As scientists like to say, association is not causality. But there’s increasing evidence that high UA is not simply a marker for all these diseases – it directly causes them!
Three Main Drivers of High Uric Acid – fructose, alcohol and purines
Now we why know we care about UA, and that Roy’s is a bit high, how are he and I scoring when it comes to the three drivers of high UA – fructose, alcohol and purines?
#1 Fructose
Fructose could be the biggest player in the rise of today’s chronic health problems.
And, as Dr David Perlmutter says in his revelatory book Drop Acid, The Surprising New Science of Uric Acid – the Key to Losing Weight, Controlling Blood Sugar and Achieving Extraordinary Health (2022) – sweetness appeals to us on many levels.
Sweetness tells us: eat this food because it’s safe and nutritious; and because it elevates uric acid that tells our body to store fat that will help us get through the coming winter, when food will be scarce. That worked in our favour when winters were hard. Nowadays, you and I never experience that sort of scarcity. It’s an evolutionary mismatch.
What’s more, unlike the fructose-rich treats such as honey and seasonal fruit that our ancestors occasionally enjoyed, most of our fructose is in the form of high-fructose corn syrup (HFCS) – a modern-era Frankenfood that’s neither safe nor nutritious. And HFCS is everywhere, all the time. Apparently, it’s added to 60 to 70% of the highly processed foods found in grocery stores – and that’s where most people get most of their fructose. Not from fresh, whole fruit.
How much fruit?
Of course you can eat fruit, just not too much. An apple has a reasonable 5 to 10 grams of fructose (of a recommended daily maximum of 25 to 55 grams, depending who’s doing the recommending). Berries and kiwis, too, are moderate; but pineapples and mangoes, for example, are overloaded with the stuff.
Roy and I try to stick to one-to-three servings of fruit a day: for example half-a-cup of wild blueberries (just 3.1 grams of fructose) in a smoothie, or a few strawberries, plus a kiwi-fruit, or half a mango or banana*, whatever happens to be in season.
(I used to laugh at old couples sharing a banana. Well, I’m not laughing anymore.)
I buy my frozen wild blueberries in 1kg packs at Farmer Jack supermarket (A$12.99 ). According to medicalmedium.com, the difference between these smaller, more intense berries and their cultivated cousins ($8.99/kg) is like the difference between farm-raised salmon and wild salmon; or between grain-fed, feed-lot beef and free-range, grass-fed beef. In fact, if you want to read a rousing paean to the frankly miraculous powers of wild blueberries, click here. (Certified organic would be even better, but cost at least twice the price.)
It’s not just the amount of fructose you ingest, either; it’s the time course involved. The slower, the better. That’s why drinking fruit juice is such a bad idea – it bombards the liver with naked fructose. (Unlike sucrose and glucose, which are dealt with in the digestive tract, fructose goes straight to the liver for digestion.)
The fibre, bioflavonoids, pectin and Vitamin C in whole fruit are protective against this; even to the point where moderate fruit consumption is associated with lower, healthier levels of uric acid.
Would you peel fruit for your spouse?
Speaking of fruit, I don’t know how it happened that I became a peeler of fruit for my husband.
I discovered soon after meeting him – 30 years ago – that he hated “fiddling with food”. He told me so. He would literally rather not eat prawns than have to peel them. I, on the other hand, will happily spend half an hour minutely dissecting a crayfish to get at the tiniest morsels from those skinny legs.
It’s the same with fruit. He’ll possibly skin a banana; but he simply can’t be arsed to cut up a cantaloupe or a watermelon, apportion a pawpaw, or peel an orange, a mandarin or a kiwi. It’s pathetic.
I swore I’d never start doing it for him, but somehow I did. Today, I cut up and peel fruit for him as if he were a five-year-old. Did it take 10 years of watching him literally never eat fruit except from a hotel buffet or a Singaporean cut-fruit stall? Or twenty years? All I know is that I’m doing it today, albeit with lingering astonishment and faint self-loathing.
#2 Alcohol
Alcohol – supremely unimportant to the people who can genuinely take it or leave it. How I wish I were one of them!… but I’m not. I really like it. Yes, I can go without for a day, a week, even a month if I put my mind to it. Otherwise, I’ll generally have a drink around dinnertime.
Roy, on the other hand, has no issue with skipping alcohol. Being able to take is or leave it was a huge help during the 18 months (March 2020 to September 2021) during which he lost 35kg on my my Low Carb, No Crap™ lifestyle plan.
Back to the question: How does alcohol affect uric acid? Interestingly, wine is neutral in men, and is actually associated with lower uric acid in women. Hurrah! Hard liquor such as gin, rum, whisky and brandy will raise uric acid levels to some degree.
But beer is by far the worst. Not only does it contain alcohol, but it also contains purines, the breakdown products of yeast cells. That might explain my late mother’s gout problem – beer having been her favourite tipple when she was younger. It explains the slow but steady weight gain that began in her 20s. With every beer, you’re making uric acid that tells the body: winter is coming, make fat.
Like mother, like daughter: I drank a lot of beer in my teens and twenties. (Horrifyingly, I largely subsisted on beer and cigarettes at one stage.) That’s no longer the case, fortunately – nowadays, I’m more likely to opt for wine, gin or whiskey. I don’t know where my love for beer went, but I’m glad it did!
#3 Purines
Before I go on, it’s worth noting that the purines you eat make up only one third of your total purine load. What’s more, some people simply tend to produce more purines than others do. Also, some people’s kidneys are more efficient at clearing the resultant UA out of the body.
Foods rich in purines include: liver, kidney and other organ meats; venison; certain shellfish such as scallops and mussels; anchovies and sardines. Not to say these foods don’t have huge nutritional benefits, but Dr Perlmutter advises eating them with an appreciation of their effect on your own UA levels. In other words, know your uric acid level so you can make appropriate choices.
Red Meat
As for us, we eat a fair amount of red meat on my Low Carb, No Crap™ eating plan. Not every day, but at least four days a week, the protein portion of our main meal will be something like grass-fed beef steak, mince or oxtail; roast pork belly or barbecued pork sausages; lamb chops, lamb shanks or roast shoulder of lamb. In-between, there may be droëwors (South African dried sausage), biltong or mortadella.
Organ Meats
Liver has some of the highest purine scores of all foods. Roy would eat lamb’s liver every week if he could, but I grew up eating chicken livers and far prefer them, especially the South African dish known as Portuguese peri-peri chicken livers. Nando’s does a pretty good version; but it’s never better than at home.
Lamb hearts are one of Roy’s favourite dishes. Every time we visited his late mother in England, she would prepare them specially for him, filled with a herby Pakco stuffing and and braised in the oven. I’ve cooked them for him, too, but admittedly with less enthusiasm. Here’s the evidence; the smile may be slightly fake, however.
Seafood
While anchovies are very high in purines, I prefer to see this in context. It’s largely due to their being semi-dried, which concentrates the purines. And how many anchovies are you likely to eat at a sitting, anyway? Five or 10 grams at most is my guess, especially if they’re on a pizza or in Caesar dressing.
Other Ways to Lower Uric Acid
Test, don’t guess
It’s a truism that what doesn’t get tested, doesn’t get treated – and that goes as much for UA levels as it does for anything else. It’s not that difficult, really. Not everyone is going to acquire their own uric acid monitor online, as I did, but it should be simple to order a serum uric acid test through your doctor.
Supplements – shake, rattle and roll!
If your level is higher than 5.5 mg/dL, but your diet is already rich in whole foods including lots of highly colourful veggies; you’ve already done your best to manage fructose and alcohol intake; and you’re not bingeing on liver and scallops (most people aren’t!) – you might want to consider a couple of additional supplements.
I must say, I expected a bit more gratitude from Roy the other morning when I handed him a bottle of quercetin 500mg tablets across the bathroom vanity. (I had one to spare, having stocked up on quercetin as part of our pandemic arsenal.) More pills, he grimaced. “I’m going to start rattling.”
More pills? I’m going to start rattling. – Roy Titchmarsh
I thought: surely you’d rather rattle a bit than suffer the agonies of gout?
Dr Perlmutter suggests adding these supplements to your diet: 500mg quercetin, 50mg Vitamin C, and 100mg luteolin. Luteolin has been shown to be on a par with the UA-lowering drug allopurinol! Best of all, to lower the rattle factor you can get it from herbal teas such as dandelion, chamomile and peppermint.
Round out your supplementation programme with the steroid precursor DHEA, suggests Dr Perlmutter. According to selfhacked.com, DHEA has been shown to increase insulin sensitivity and improve glucose tolerance. (Both good things, in case anyone was wondering… and both Roy and I have been taking it for years.)
Tart cherries have been shown to be very effective, being high in anthocyanins, which are highly antioxidant flavenoids. The same goes for other vitamin C-rich foods; but not fruit juice. Fruit juice is not part of our ancestral diet: it delivers a powerful fructose load that we are not equipped to thrive on.
Absolutely Optional Appendix: (without pictures)
More on the Science
Though uric acid (UA’s) association with gout (and kidney stones) is well-known – and that’s generally why your GP might suggest a UA blood test – high systemic levels of uric acid, or hyperuricaemia – are about a lot more than just these two agonising conditions.
In fact, it’s an independent risk factor for death in both men and women. Dr David Perlmutter spells this out clearly in Drop Acid. Here follow some possibly arbitrary and not entirely cohesive notes I made while listening to the Audible version, plus a couple of podcast interviews with this engaging author.
What Should Our UA Levels Be?
At or below 5.5 mg/dL (for both men and women) is optimal. Men generally have higher levels than women, and bear a higher overall risk of hyperuricaemia and gout; but that doesn’t mean they can’t achieve under this goal, even though they may have to work harder to do so.
(My recent test Pathlab result was 4.5 mg/dL.)
The Seminal Study
A large 2009 Japan study, following half-a-million healthy subjects aged 35 or more, looked at UA blood levels and all-cause mortality over eight years. It indicated that even a slight increase in UA – over 7 mg/dL in men and 5 mg/dL in women – was an independent risk factor for death in both men and women. It showed:
- a 16% increase in death from any cause over seven years;
- a 40% increase in cardiovascular (CV) death;
- a 35% increase in ischaemic stroke, caused by a blocked artery that leads blood to the brain.
Basically, you may not have high blood pressure, be obese or smoke; but even slightly high UA significantly increases your risk of death from all causes! The studies show that even asymptomatic hyperuricaemia (high UA levels with no other symptoms of disease) can predict the development of high blood pressure, diabetes, chronic kidney disease and non-alcoholic fatty liver disease (NAFLD), which has doubled in the past 20 years.
How it Works
High UA affects cardiovascular (CV) health in several ways, not least by damaging the vascular endothelium, i.e. the inner lining of the walls of blood vessels. Nitric oxide, or NO, mainly produced in the endothelial lining of blood vessels, works to relax the blood vessels, allowing them to dilate and thus increasing blood flow. Vasodilation involves relaxing the inner muscles of the blood vessels, one of the most powerful regulatory functions of the CV system. (Also vital in insulin sensitivity, as NO is needed for the uptake pathway of blood glucose into the cells for energy.)
First, UA compromises the production of NO; secondly, it hampers NO in doing its job. Both insulin function and CV health are compromised by high UA. Without NO, insulin cannot do its job.
So, elevated UA induces diabetes through more than one pathway. First is the simple activation of inflammation that it brings on, causing insulin resistance. UA is a powerful generator of oxidative stress that damages tissues and DNA and reduces NO function by harming the vascular endothelium. The cumulative damage can injure the pancreas and even affect the expression of the insulin gene, which causes a decrease in insulin secretion. Once insulin function is impaired, says Dr Perlmutter, metabolic trouble looms large.
To make things worse, a high level of UA suppresses autophagy, the form of cellular housecleaning which is vital for immunity and longevity, and in which pathogens and harmful zombie (senescent) cells are gobbled up. So, UA reduces autophagy and diminishes the anti-inflammatory capacity of cells – it prevents them clearing out dangerous clutter and calming down inflammation in cells.
As you might expect, high UA plays a role in erectile dysfunction (ED). ED is a well-known marker of vascular dysfunction and CV disease. Now we know that UA is a marker for CV, too; ED drugs like Viagra may work by increasing levels of NO.
Dementia and Cognition
Dementia and cognition in general are compromised by poor blood flow caused by high UA, which compromises blood supply.
People with high uric acid levels have 166% increased risk of “mixed dementia” and vascular dementia, and 55% increased risk of Alzheimer’s, and 80% increased risk of dementia of all types, all this related to mitochondrial dysfunction, inflammation, insulin resistance and oxidative stress being amplified by high uric acid. The brain is not happy with any one of those. There is no pharmaceutical intervention, unfortunately, so we may as well prevent it.
Conclusion
In conclusion, the effects of high uric acid go way beyond gout and kidney stones. And as it’s not just a marker of disease: it’s increasingly being recognised as a driver of these diseases. I wish I’d known this a long time ago, but better late than never, right?
