Gout is a type of inflammatory arthritis that impacts 1-4% of the population in westernized countries. It most commonly occurs in men over the age of 30.

A root cause approach to gout looks for the exact cause of elevated uric acid levels and addresses any underlying conditions to prevent flares.

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What Causes Gout

Gout is caused when higher than normal uric acid levels in the blood cause monosodium urate monohydrate crystals to deposit into the joint space, causing inflammation and pain.

Uric acid is produced from the metabolism of compounds found in certain foods called purines. Levels can build up in the blood due to the body making too much uric acid or from ineffective breakdown. Usually, the kidneys filter out excess uric acid. However, uric acid can build up if the kidneys do not adequately eliminate the uric acid.

The body can make too much uric acid when consuming a high-purine diet or due to certain other health conditions.

Foods That are High in Purines

• alcohol
• organ meats
• conventionally raised grain-fed meat
• shellfish, sardines, and anchovies
• fructose such as in high fructose corn syrup sweeteners
• yeast

Health Conditions Associated With Increased Uric Acid

• diabetes
• dehydration
• recent surgery or trauma
• obesity which puts additional stress on the kidneys, making it more challenging to eliminate uric acid from the body.

Health Conditions That Impair The Elimination of Uric Acid

• reduced kidney function
• excess alcohol or coffee consumption that decreases uric acid excretion from kidneys
• imbalanced methylation
• hypothyroidism (under-active thyroid) which increases uric acid due to impaired kidney function
• imbalanced bacteria in the gut microbiome: dysbiosis or SIBO

Other Conditions That Cause Gout

• Certain medications may also increase the risk of gout by increasing levels of uric acid reabsorption and decreasing uric acid secretion
• Some individuals have an inherited enzyme deficiency or rare genetic disorder (Lesch-Nyhan syndrome, Kelley-Seegmiller syndrome) that causes excess production of uric acid‍
• Stress can also increase uric acid levels in the body
• Lead toxicity can cause a secondary type of gout known as saturnine gout

Gout Signs & Symptoms

Gout causes sudden onset of pain, usually in a single joint like the big toe. When the pathogenic urate crystals deposit in the joints, they create inflammation that causes intense acute attacks with pain and systemic inflammatory symptoms like fever. Gout is often preceded by alcohol ingestion, trauma, or consumption of purines found in foods like meats and oily seafood. When untreated over time, gout leads to irreversible joint damage.

The most commonly affected joint is the big toe (podagra). Other joints like the ankle, knee, wrist, and fingers can also be impacted.

Gout pain is usually severe and starts suddenly, often during the night. The pain is classically throbbing with warmth, redness, and tenderness over the affected joint. It usually subsides within a few hours to days.

When urate crystals build up in soft tissues like the ear, fingers, knee cap, toes, and elbow, they create collections called tophi that cause little lumps under the skin and trigger inflammation. Tophi nodules rarely occur in the eyes, but they can happen, contributing to vision changes. Due to inflammation, fever may also occur along with the pain.

Why Does Gout Attack The Big Toe?

The big toe is the most common site for gout flares in large part because uric acid crystals are more likely to form at the cooler temperatures that occur at the body's periphery. The big toe is also susceptible to factors like trauma (stubbing), mechanical irritation, and joint features that make it more likely to develop inflammation and arthritis, which makes gout flares more likely to occur.

Complications of Gout

If gout remains untreated, complications can occur, including:

• destruction of impacted joints
• secondary infections
• damage to the kidneys
• kidney stones
• damage to nerves

Functional Medicine Labs to Test for Gout Sufferers

Uric Acid

Uric acid can be measured in the blood, although elevated levels alone are not diagnostic of gout. Synovial fluid from the joints can also be examined under a polarized microscope and will reveal negatively birefringent, needle-shaped crystals, which are diagnostic for gout.

Measure Blood Sugar and Hydration Status

A complete metabolic profile provides a look at hydration status, blood sugar balance, and kidney function to assess these factors which can contribute to the risk of gout flares.

Small Intestinal Bacterial Overgrowth (SIBO)

Since SIBO can contribute to problems breaking down uric acid, a breath test can evaluate the overgrowth of bacteria that do not normally belong in the small intestine.

The 3-hour SIBO assessment is a non-invasive breath test that measures hydrogen and methane to evaluate bacterial overgrowth in the small intestine.

Digestive Function

Imbalanced gut bacteria can decrease the breakdown and clearance of uric acid from the body and lead to gout. The Gut Zoomer stool test evaluates microbes in the digestive tract to assess overall balance, conditions like SIBO, metabolic imbalances, and functional digestive status.

Thyroid function

A Complete Thyroid Panel including thyroid-stimulating hormone (TSH), T3 (free and total), T4 (free and total), and reverse T3 should be assessed using functional medicine ranges since thyroid hormone imbalances contribute to the build-up of uric acid in the blood.

Methylation Status

The C677T polymorphism of the MTHFR gene is a risk factor for hyperuricemia and can contribute to imbalances in inflammation that exacerbate gout flares.

Lead

When the level of lead in the blood reaches around 1.2 mcg/dL, there is an increased risk of gout. Lead levels can be assessed with a blood test.

Functional Medicine Treatment for Gout

Overall, the treatment of gout attempts to treat flares by reducing the resulting inflammation that causes joint damage in the shorter term and lowering levels of uric acid in the blood to eliminate the deposition of urate crystals in the joints in the long term.

A functional medicine approach to treating gout aims to reduce the length and frequency of attacks by addressing underlying factors such as imbalanced gut bacteria, SIBO, and nutrient deficiencies and lowering uric acid in the blood.

Eat a Low-Purine Diet

Foods like shellfish, organ meats, commercially produced red meat and poultry, beer, and yeast are high in purines which are metabolized to produce uric acid. Guidelines suggest limiting purine consumption to 150-300 g/day to reduce gout attacks.

Eliminate Alcohol

Alcohol reduces the excretion of uric acid and contributes to dehydration which increases the risk of a gout attack.

Focus on an Anti-Inflammatory Diet

Reducing overall inflammation in the body by consuming an individualized anti-inflammatory diet can help keep gut bacteria balanced and reduce the chance of arthritis.

A diet rich in whole foods like vegetables and plant-based proteins, as well as anti-inflammatory foods like wild-caught cold-water fish, nuts, seeds, and omega-3 fats, can keep inflammation in balance. Use natural sweeteners like stevia, monk fruit, or wild honey if needed. High Fructose corn syrup should be avoided.

Vitamin C

Studies have shown that vitamin C positively affects purine metabolism and can help reduce uric acid levels in the blood by increasing excretion in the urine, thus lowering the risk of monosodium urate crystal deposition in joint structures and soft tissue.

Celery

Celery (Apium graveolens) has anti-oxidant and anti-inflammatory properties and helps reduce uric acid levels in the blood since it contains the flavonoid apigenin. Since high urate crystals induce inflammation and free radical formation, celery can also help decrease these impacts and reduce joint damage.

Sour Cherry

Cherries contain vitamins A, C, and E and phenol compounds such as anthocyanins and quercetin that help to regulate inflammation and balance uric acid levels. Cherries lower blood uric acid levels by increasing kidney filtration and decreasing the reabsorption of uric acid. Regular consumption of tart cherry (Prunus cerasus) juice concentrate or extract over several months reduced the incidence of gout attacks.

Stay Hydrated

Individual hydration needs vary based on lifestyle, weather, activity, and diet, but staying adequately hydrated for your needs is essential to prevent gout flares. Water helps the body keep uric acid in solution and promotes excretion out of the body.

Summary

Gout is a metabolic disorder that causes inflammatory arthritis of the joints. This painful condition involves sudden swelling, redness, and pain in impacted joints when tiny needle-shaped uric acid crystals build up from too much uric acid in the blood. Uric acid levels can elevate in the blood due to too much consumption of foods rich in purines, like organ meats, fructose, some seafood, alcohol, and certain medications, or too little clearance from the body from issues like poor kidney function.

Often these attacks impact the big toe and can also involve the ankles, midfoot, knees, elbows, wrists, and knuckle joints. Over time the resulting inflammation can damage the joints.

A functional medicine approach to gout assesses and addresses the underlying causes. Treatment focusing on nutrition first, as well as lifestyle adjustments and supplements, can help provide pain relief, reduce inflammation in the short term, and prevent further attacks and chronic joint damage in the long term by reducing uric acid levels.