Gout is one of the common forms of inflammatory arthritis. It affects about 1 to 2% of the western population and is increasing in frequency in association with the increase in obesity and diabetes. It is mostly an acute intermittent condition characterised by the sudden onset of red, painful, tender and swollen joints. It can occur in any joint but most commonly in the toes or ankles. It is due to the formation of uric acid crystals within the joint which results in an acute inflammatory response.

Crystals form when there is an elevated level of uric acid in the blood. There are both genetic and dietary factors that result in the accumulation of uric acid in the blood.

Gout can also occur as a chronic ongoing condition in which there is persisting inflammation in multiple joints. It may also result in tophi, kidney stones, or urate nephropathy.

Gout is a common, recurrent form of arthritis and the prevalence in Australia continues to rise.

Men are more likely to present with gout, although the rates in women are increasing. Prevalence also increases with age, and Australian men older than 70 years have the second highest rate of gout in the world (16.5%), just behind New Zealand.

Australian Aboriginal populations also experienced a rise in gout prevalence from 0% in 1965 to 9.7% in males and 2.9% in females in 2002.

Patients with gout often have other illnesses.

– 74% of patients with gout have hypertension,
– 71% have chronic kidney disease,
– 53% are obese,
– 26% have diabetes,
– 24% have kidney stones,
– there is an increased risk of myocardial infarction, and heart failure.
–  There is a strong correlation between sleep apnea and gout.

 

How to reduce the risk of gout?

Weight loss reduces the risk.
Substances from coffee to cherries may help reduce risk, too.
In general what’s good for gout is probably good for overall health.

Risk factors for gout include :·

Increasing age
Poor diet including a high grain and fructose intake.
Alcohol/beer consumption
Genetic predisposition
Hyperuricaemia ( high blood uric acid level)
Diuretic use
Increased weight especially if the BMI is greater than 30

FOODS TO AVOID

Purines
For many years dietary recommendations have included reducing dietary purine intake since the last step of purine metabolism generates uric acid.
Purines are found in all animal tissues and these increase the level of uric acid in the blood. Eating these foods increases the risk of a recurrent attack of gout by up to 5 times.

Eating meat and fish
With each additional daily serving of meat, the risk of gout increases by 21%. Each additional weekly serving of seafood increased risk by 7%. Consumption of purine-rich vegetables did not seem to be associated with gout, and a strong inverse relationship with the consumption of dairy products was observed.

Red meats such as beef and lamb contain the highest amounts of purines.
Turkey and duck contain the highest purines from the poultry family.
Organ meats such as liver heart and kidney should be eliminated.
Pork and chicken have lower levels of purines and can be eaten in moderation.

Some types of fish are particularly high in purines eg haddock, anchovies, trout, hearing and codfish

Shellfish, mussels and skillet should be avoided completely.

Other fish such as salmon, crab, shrimp, oysters and lobster have lower levels of purines.

Small portions of purine-rich foods may be tolerated.

Sweetened soft drinks
A US study found the risk of gout was 85% higher in men who drank more than two sweetened soft drinks per day.

In the US, soft drinks are sweetened with high fructose corn syrup, which is not used in Australia. However, fructose is found in fruit juices, and this was
linked with a higher risk of gout.

Alcohol

Alcohol converts to glucose triggering uric acid production
The more alcohol consumed the greater the risk of recurrent gout attacks in the following 24 hour period, with beer showing the strongest association.
Two or more beers a day increase the risk of gout by 2.5 times, and two measures of spirits a day by 1.5 times when compared with those who don’t drink alcohol.
Moderate wine consumption, however, does not increase the risk of gout.

So what to do;

Limit the intake of purine-rich meat (eg, beef, lamb, and pork) and seafood (eg, shellfish and sardines).

Avoid organ meat (eg, sweetbreads, liver, and kidney) altogether.

Reduce fructose-rich diets. eg high fructose corn syrup content and to avoid consumption of naturally sweet fruit juices, desserts, and table sugar.

Alcohol consumption has long been recognised as a risk factor for gout.
The risk is higher in women than men.
It is recommended that patients with gout avoid alcohol overuse (defined as more than 2 drinks for men and 1 drink for women), especially beer.

During periods of active arthritis or in those with advanced gout and poor control, no alcohol should be consumed.

Plant protein is not linked to an increased risk of gout despite some plant proteins containing purines. Eating tomatoes may trigger an attack in some people.

 

FOODS AND FLUIDS THAT REDUCE GOUT RISK

Dairy and calcium
Dairy, calcium and lactose intake is associated with lower urate concentrations. Milk and soy increase uric acid excretion. This effect may be related to an increase in urinary pH causing greater uric acid excretion.

Vegetables
High purine vegetables may not increase the risk of gout as once thought. One analysis found high purine vegetable intake in over 2000 participants was not linked to gout risk – although the average serving size was just two tablespoons. Purines may be lost in cooking water, which may help explain this effect.

Cherries.
Cherries have urate lowering properties.  There is upto a 35% reduction in acute attacks in patients who consumed cherries or cherry extract.   Cherries are combined with allopurinol the reduction in attacks was up to 75%.

Vitamin C
Vitamin C supplementation trials found that an average dose of 500mg/day for approximately 30 days reduced blood uric acid levels.

Whether or not this can reduce the risk of gout is yet to be determined. This amount of vitamin C intake cannot be achieved through diet alone.

Fluids
Water – Drinking 2L of water per day is necessary, especially if taking xanthine oxidase inhibitors. ( allopurinol -Progout)

Coffee/caffeine
Both coffee and caffeine have been shown to reduce the risk of gout. Greater than 950ml of coffee a day or around four cups reduced the risk of
gout by half in one study.
Drinking green tea may lower serum urate levels.

Quercitin
Quercetin, a flavonoid found in high levels in onions, tea and apples, inhibits xanthine oxidoreductase
Dose : 500mg per day

 

For more detail about foods.

List of Purine-rich foods

200–500mg purines per 100g

Anchovies, brains, gravies, kidneys, legumes, lentils, liver, salmon, sardines, sweetbreads, yeast extracts.

5–100mg purines per 100g*

Asparagus, bacon, beef, bluefish, bouillon, calf tongue, carp, cauliflower, chicken, chicken soup, codfish, crab, duck, goose, ham, kidney beans, lamb, lima beans, lobster, mushrooms, mutton, navy beans, oatmeal, oysters, peas, perch, pork, rabbit, shellfish, snapper, spinach, tripe, trout, tuna, turkey, veal, venison.

Summary and the bottom line

1. Limit rich sources of purines
For most people suffering from gout, medication is usually very effective, and dietary purine restriction has little influence on symptoms. However, there are some people who benefit from restricting purine – rich foods.

Avoid these foods whenever possible.

Meat Sources :

  • Heart
  • Kidney
  • Liver
  • Meat extracts e.g. Oxo
  • Sweetbreads (pancreas)

Fish Sources :

  • Anchovies
  • Crab
  • Fish roe
  • Herring
  • Mackerel
  • Sardines
  • Shrimps
  • Whitebait

Other Sources :

  • Asparagus
  • Beans and peas (green)
  • Beer
  • Cauliflower
  • Mushrooms
  • Spinach
  • Yeast and extracts e.g. Vegemite
  • Fruid juice and fructose

2. Moderate alcohol intake
Excessive alcohol can aggravate gout. Keep intake to 2 standard drinks per day, with several alcohol-free days per week.

3. Fluid
If you do not have a fluid restriction, a high fluid intake (3L/day) is recommended.

4. Weight Control
If you are overweight, gradual weight loss of about ½ kg per week is recommended. Quick loss of weight will result in tissue breakdown and a rise in blood uric acid levels.

5. Sugar / Fat / Fibre
High blood fats (hypertriglyceridaemia) are associated with high levels of uric acid and gout. Reduce carbohydrates and sugar will reduce triglyceride levels. Eating Health fat Avocados, olive oil, butter and other full cream dairy prodicts is helpful as part of a diet plan to reduce triglycerides.

A low carbohydrate high Fat ( LCHF) is an effective eating plan. ( www.lowcarbdownunder.com.au )

6. Eating Well It is always important to make sure your diet is varied and contains food from all the food groups – dairy foods, fruit and vegetables,and meat, fish, poultry or legumes/lentils.

Rapid changes in nutritional advice is occuring as personalised medicine becomes the norm. Now is the time to know and monitor your circumstances and eat a diet that is right for you.