Gout and Metabolism: A Case Report on the Impact of “Healthy” Fruit & Juice

By Abigail Oswari and Dr. Andrew Oswari

In the case report discussed we present a patient who was making “healthy choices” which had a negative impact on his gout and metabolism. This led to a flare up of previously controlled symptoms. Dietary choices are powerful tools for reducing inflammation and reversing metabolic syndrome. At the Chung Institute, we have achieved success in reversing diabetes, insulin resistance, psoriasis, nephrolithiasis, gout, irritable bowel syndrome, and many other diseases related to inflammatory conditions.

Case Report

A 67-year-old male with a history of gout had successfully reversed his insulin resistance over the past two years, lost weight, and resolved his gout attacks. He presented at our office one month after experiencing a severe gout attack. On review of recent lifestyle changes, he reported incorporating a cup of “Mom’s Pomegranate juice” and an orange in his breakfast routine due to perceived antioxidant benefits. Further investigation revealed this juice contained 34 grams of sugar per cup—around 8 ½ teaspoons. Subsequent blood work results showed an increase in uric acid, insulin, triglycerides, and C-peptide (an insulin precursor). All in response to this drastic increase in fructose intake.

Relevant laboratory results are shown below.

The image depicts the patient described previously, showing severe inflammation in the left foot due to the gout attack.

What is Gout?

Gout is the most prevalent form of inflammatory arthritis, increasing annually and affecting over 40 million people worldwide [1, 6]. The most common symptom includes painful joint inflammation in the lower extremities, with a classic picture showing an inflamed, painful big toe [7]. The cause of gout is believed to be elevated serum uric acid levels that have crystallized in the joint space [2]. 

What is Uric Acid?

Uric acid is a natural waste product your body creates when it breaks down certain substances, like purines (found in foods such as red meat, shellfish, and some fish) and fructose (a type of sugar in fruits, honey, sodas, and processed foods like fruit juices). Think of uric acid as the leftover “junk” after your body processes these foods.[2] Normally, it dissolves in your blood, gets filtered by your kidneys, and leaves your body through urine.

Problems start when your body makes too much uric acid or your kidneys can’t remove it fast enough. This causes uric acid to build up in your blood, where it can form tiny, sharp crystals, especially in your joints. These crystals are what cause the intense pain, swelling, and redness of gout, often in the big toe or other joints.[2]

High uric acid levels don’t just cause gout—they can also put stress on your kidneys, potentially leading to kidney disease, and may even affect your brain, increasing the risk of conditions like Alzheimer’s or Parkinson’s over time [4]. 

How does fructose fit in the picture?

Fructose is found naturally in fruits, honey, and some vegetables, but it’s also added to many processed foods like sodas, fruit juices, candies, and desserts in the form of high-fructose corn syrup or table sugar. While natural sources are fine in moderation, too much fructose from processed foods can harm your health.

Your liver processes fructose, producing uric acid, which can build up and cause gout. Studies link high fructose intake, especially from sugary drinks, to increased gout risk. Several studies suggest that the more fructose one eats/drinks, particularly fruit juice or sugar-sweetened beverages (SSB), the higher the risk of gout [2, 3]. 

Fructose can also reduce insulin sensitivity, raising the risk of diabetes and weight gain, and increase blood fats (triglycerides), which can harm your heart. It can also increase fat in your blood (triglycerides), which increases your cardiovascular risk [5]. We observed this effect in the case study noted. 

But doesn’t meat cause gout?

Organ meats, shellfish, and canned fish are high in purines, which are often limited in gout management, but evidence on their impact is weak. [1]. Fructose, a sugar in many processed foods, can worsen gout by lowering energy (ATP) in the liver and increasing purine production, which leads to more uric acid buildup. This uric acid can trigger gout attacks, especially when high-purine foods are eaten with high-fructose foods like sodas, juices, or alcohol. However, more research is needed to confirm this connection. [2]. 

Why is it important to avoid high-fructose products?

Fructose raises uric acid levels, which can cause inflammation, disrupt energy balance, and increase the risk of chronic diseases. [8] High uric acid can also cross into the brain, potentially causing inflammation linked to neurodegenerative diseases like Alzheimer’s and Parkinson’s. [4]

Concerning the 67-year-old male patient, the sole dietary change was the addition of high-fructose fruit juice. Subsequently, uric acid levels, insulin, C-peptide, and triglycerides increased, shifting toward insulin resistance or a pre-diabetic state. This is extremely dangerous as it poses potential health risks. Keeping fructose intake low, especially from sugary drinks and processed foods, can help prevent these issues [2,4,5].

The key is to enjoy natural fructose from whole fruits in moderation but avoid processed foods and drinks loaded with added sugars. Choosing water, unsweetened teas, or homemade options can keep your body healthier.

Fructose is found in numerous products. Here are some common foods and a healthy alternative:

1. Danve A, Sehra ST, Neogi T. Role of diet in hyperuricemia and gout. Best Pract Res Clin Rheumatol. 2021 Nov 19;35(4):101723. doi: 10.1016/j.berh.2021.101723. PMCID: PMC8678356.
   
2. Zhang Y, Chen C, Choi H, Chaisson C, Hunter DJ, Niu J, et al. Fructose intake and risk of gout and hyperuricemia: a systematic review and meta-analysis of prospective cohort studies. BMJ. 2016 Oct 18;355:i6557. doi: 10.1136/bmj.i6557. PMCID: PMC5073537.
   
3. Choi HK, Willett W, Curhan G. Important food sources of fructose-containing sugars and incident gout in men. JAMA Intern Med. 2019 Apr 1;179(4):486–494. doi: 10.1001/jamainternmed.2018.7663. PMCID: PMC6502023.
   
4. Motlagh Asghari K, Zahmatyar M, Seyedi F, Motamedi A, Zolfi M, Janbaz Alamdary S, et al. Gout: global epidemiology, risk factors, comorbidities and complications: a narrative review. BMC Musculoskelet Disord. 2024 Dec 19;25:1047. doi: 10.1186/s12891-024-08180-9. PMCID: PMC11544450.
   
5. Abdelmalek JA, Suzuki M, Guyton JR, Hossain MA, Peixoto AJ, Huang L, et al. High fructose feeding increases kidney uric acid transporter expression and disrupts uric acid homeostasis in rats. Am J Physiol Renal Physiol. 2019 Oct 1;317(4):F1099–F1109. doi: 10.1152/ajprenal.00272.2019.
   
6. Motlagh Asghari K, Zahmatyar M, Seyedi F, Motamedi A, Zolfi M, Janbaz Alamdary S, et al. Gout: global epidemiology, risk factors, comorbidities and complications: a narrative review. BMC Musculoskelet Disord. 2024;25:1047. doi: 10.1186/s12891-024-08180-9. PMCID: PMC11660718.
   
7. Hainer BL, Matheson E, Wilkes RT. Diagnosis, treatment, and prevention of gout. Am Fam Physician. 2014 Dec 15;90(12):831–836.

8. Johnson RJ, Sanchez-Lozada LG, Nakagawa T. The effect of fructose on renal biology and disease. J Am Soc Nephrol. 2010;21(12):2036–2039. doi:10.1681/ASN.2010050506