Ketosis and gout. What's the ketosis effect ?

Page 9 of 10 about the Atkins diet for gout

Referenced studies and study abstracts, the numbers in brackets, are listed on page 10 of the gout and the Atkins diet section

The Gout and the Atkins diet articles are across ten pages.

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This page about ketosis and gout was first uploaded or reviewed on 13 April 2015.


Lipolysis means fat burning, and ketosis is the generation of ketone bodies caused by lipolysis. A central feature of the Atkins diet is that when the body is starved of glucose from carbohydrates, after a couple of days or so, it turns to burning fat for energy as its primary source of fuel. Hence the weight loss.

The human body, and the brain, use ketone bodies for fuel too. Ketones circulate in the blood and they are eventually excreted in the urine, (mainly) but also in perspiration and in breath. The lipostix or ketostix you can purchase from pharmacies (chemists) or online, measure the amount ketones your burning fat produces by indicating the amount in urine. The greater their volume of  in urine, the more fat you are burning. The ketosis test is easy to do. 

The beauty of the stix is that they tell you whether you really are limiting your carbohydrates sufficiently, and they should tell you in advance whether you're losing weight. They would also warn if you are "burning" too many ketones. If so they would be at their maximum purple colour (color), and you would probably be losing weight too quickly on Atkins, which may trigger a gout attack. They aren't expensive. 

Do ketones raise uric acid?

One criticism of ketosis is that, like elevated insulin, ketones inhibit uric acid excretion which causes raised uric acid (UA). So are ketosis and gout connected?  A study did demonstrate raised uric acid among women on a fast, but the Atkins diet is not about fasting. In a low carb study where the uric acid level rose, the dieters were on less than 10 grams of carbs daily for eight weeks (18), figures shown in (19). Ten grams of carbs daily is not the Atkins diet.

However, one of the co-authors of A New Atkins For A New You *, Dr. Steve Phinney, has noted that blood uric acid rises with the rise in ketones on low carb diets. But he has observed in over 2,000 patients, that the blood uric acid level will fall again in 6 - 12 weeks back to its pre-diet start line. And in 4 - 6 months, below it in some people, presumably caused by weight loss.

So this rise is temporary, but it might just trigger a gout attacks in some, possibly until uric acid falls to below 6.0 mg/dL (about 5.5 in women). Discuss with your doctor - taking allopurinol or febuxostat to lower uric acid may be the answer if this is a concern.

You can read an interview with Dr. Steve Phinney about this here at The interview also features Dr.Rick Johnson, who is in the forefront of research into fructose and uric acid.

The Atkins website says that studies show the Atkins diet does not raise uric acid levels (presumably in the long term) so if ketones raise uric acid, perhaps the rise is offset by some other factor such as falling weight or the amount of protein. 

Dr. Atkins did not report the blood uric acid level always rises. He thought it fell or remained the same. (See page 2 of our gout and Atkins section, link below). To make those statements he would have measured his patients' uric acid level. He reported doing this in his SuperEnergy diet book (1977) - see page 2 of our gout and Atkins section. 

If rising uric acid on the Atkins diet happens to you, another answer could be to increase carbohydrate intake. i.e. a modified Atkins. And never use the Induction phase. Make sure you work closely with your doctor.

What seems to be clear from all this, is that a low carb diet does not lead to permanently elevated uric acid, and that some or most will lower their uric acid on this diet.

If you have had a gout attack discuss using allopurinol (which Dr.Atkins recommended if you have gout) or febuxostat (Uloric, Adenuric,Feburic). He did not recommend allopurinol if you don't have gout and in most countries allopurinol and febuxostat will not be prescribed merely  for raised blood (serum) uric acid. The use of allopurinol and febuxostat with the Atkins diet has not been studied, but it has been used by gout sufferers on the diet. See page 8 of our Atkins for gout section where their is a link to the Atkins diet and gout forum at the Atkins website.

Bad breath

Here's another criticism of ketosis. Ketones give you bad breath because ketones are expelled in the breath too. Well, if that does happen to you, what a small price to pay it is, if the diet is working ! There are plenty of ways of dealing with bad breath. If you want a natural way, chew parsley or take parsley supplements.
Parsley is an good food for a gout sufferer, but watch its purines.


Another criticism. Ketones, which enter the bloodstream, cause ketoacidosis - over acidic blood. They have a low pH so the pH of blood falls too low. For ketosis to turn into ketoacidosis, which is serious, you would have to be an undiagnosed Type 1 diabetic unable to burn glucose and who therefore uses fat for energy. So you see your doctor before starting the Atkins diet.

In at least the over fifty studies of low carb diets, ketoacidosis has not been found in anyone. The reality is that hundreds or thousands of Atkins dieters are not rushed to hospital daily suffering it. There was supposed to have been a case of ketoacidosis on the Atkins diet in 2006, which was highly publicised by the U.S. media.

If you wish to know more and decide for yourself, read this judgement of that case. There is much med-tech language, but enough plain English to get the gist.

You can read about another case of ketoacidosis on a low carb diet here. But in this case, the patient had remained frequently on less than 20 carbs a day for four years. This is not what Dr.Atkins says you should do. Atkins dieters stay at this level for two weeks at the start of the diet. And gout and atkins dieters on 35-40. In ketoacidosis there are ten times the number of ketones in the blood as in ketosis,* so something exceptional must happen for ketoacidosis to occur.

The Atkins website says that ketones produced by burning fat do not change the pH balance, (aka the acid/base balance), but stay within a safe blood pH level as long as sufficient vegetables are eaten. Vegetables are usually alkaline. i.e. they raise pH levels (desirable). You can purchase alkaline boosting supplements.One study found that after 24 weeks blood pH fell slightly on a low carb diet. It also fell on a low fat diet(13).

Dr.Atkins was adamant that ketosis is safe and natural. He called it benign dietary ketosis (or BDK). Burning our stored fat is natural because it's how humankind evolved. In times of food scarcity we needed this mechanism, and the stored fat, to keep going - at least for a while. Over a 40 plus years' career, he dealt with thousands of diet cases. From all this experience he did not report any difficulties with ketosis. 

Other criticisms of ketosis

It causes heart problems; it depletes muscles and it causes breathing problems. Keep visiting your doctor on the Atkins diet if you have had a gout attack in the past (just one is enough), and obviously if there's any sign of these s/he will stop the diet. I can't find any studies confirming any of these. If you can, please let this website know using 
the Contact us form

Exercise boosts ketones

From my own experience of the Atkins diet on 
this Gout and Atkins page I learnt the lipostix/ketostix change of colour (color) is given a boost (i.e. more ketones are produced) when you exercise. 

This makes sense. Exercise means burning more calories and those calories on this diet will mainly come from burning fat, not using glucose. More fat is used, and more ketones are produced. And moderate exercise is good for gout. This is because the better the blood circulates, especially at body extremities like the big toes (where gout so often first flares), the less likely it is that crystals will be deposited. Exercise boosts blood circulation.

Furthermore, when I lost weight (90 lbs in 18 months, witnesses included) my ketones never turned the stix to its maximum purple. I usually found my stix'scolour (color) somewhere in the middle of the range. i.e. I wasn't burning nearly as many ketones as I could if I had been on a lower number of carbohydrates. I was on about 35-40 net carbs a day. So I wasn't in ketosis that much - middle of the range - and I wasn’t told I had bad breath.

* The New Atkins For A New You. Publishers: The Fireside Division of Simon and Schuster Inc., New York 2010.

Related pages 

Go to page 1 of 10 about the Atkins diet and gout. Includes a gout quote by William Banting, the first low carb dieter in the 19th century about gout

Go to page 2 of 10 about the Atkins diet and gout. What Robert Atkins said about his diet and the uric acid level.

Go to page 3 of 10 about the Atkins diet and gout. More about what Robert Atkins said about his diet and gout.

Go to page 4 of 10 about the Atkins diet and gout where I explain our modifications to the Atkins diet for gout sufferers.

Go to page 5 of 10. The Atkins diet and the insulin resistance cause of gout.

Go to page 6 of 10  My Atkins diet success

Go to page 7 of 10   Meat and gout on the Atkins diet

Go to page 8 of 10 for free Atkins diet resources

Go to page 10 of 10 which lists the gout studies, study abstracts, other relevant studies and books used as background whilst preparing the pages on the Atkins diet and gout.

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