“Preventing Gout Attacks with Diet” Over 2,000 years ago
Hippocrates described gout as a “disease of kings,”
primarily because it was the wealthy who could
afford the rich foods, which seemed to precipitate
gouty attacks. But now we can
all eat like kings and acquire some diseases
of royalty ourselves. Gout is caused by
needle sharp crystals of uric acid
in our joints, and uric acid comes from
the breakdown of purines. And purines are the breakdown
product of genetic material, DNA, the foundation of all life. So there is no such thing
as a purine-free diet, but foods do vary in
their purine content, and it was long thought
that people with gout just needed to stay away
from all high-purine foods, whether their from animals,
like organ meats, or plants like beans, but this strategy
proved ineffective. Yes, all uric acid comes
from the breakdown of purines, and so limiting
meat makes sense, but that means all
kinds of meat, and plant sources have
now been largely been exonerated. The association of gout
with both alcohol intake and increased dietary
purine consumption has been known since
ancient times, but there were no prospective
trials to back it up… until just a decade ago. The Harvard Health Professional’s
Follow-Up Study, about 50,000 men followed
for a dozen years, and alcohol intake was
strongly associated with an increased
risk of gout, and in terms of food, they
found an increased risk of gout with higher meat and
fish consumption, but NOT with higher consumption
of purine-rich plant foods, maybe because the purines
in plants are less bioavailable? So, though it’s been
suggested that gout sufferers should moderate both purine
rich animal and plant foods, their results suggest that
this type of dietary restriction may be only applicable to
purines of animal origin. Although it was not surprising
that meat and seafood had significant associations
with the incidence of gout, this lack of effect of
purine-rich plant foods was new. There don’t appear to be
any long-term studies showing purine rich
plant foods increase risk, though there are still some
guidelines out there continuing to disseminate these outdated
recommendations. Not only has the intake
of purine-rich plants not been associated
with high uric acid levels, but the vegetables gout
sufferers are specifically told to stay away from: mushrooms,
peas, beans, lentils, cauliflower were actually found
to be protective. This may be because foods rich
in fiber, folate, and vitamin C, appear to protect against
uric acid buildup and gout. For example, fiber has been
recognized as having a potential role in binding uric acid
in the gut for excretion. Lack of association between
purine-rich vegetables and urate could be due to the co-packaging
of these beneficial plant components (such as vitamin C, dietary fiber
or some phytochemicals), which may have masked an effect
of purine on uric acid. Vegetable intake, regardless
of purine content, may also be protective in terms
of getting rid of uric acid via excretion. By changing the pH
of our urine, we can change uric
acid clearance. Eating an alkaline diet,
a vegetarian diet in this case, was found effective for removing
uric acid from the body. Those eating the alkaline diet
excreted significantly more uric acid, than those eating
the acidic diet. As such, uric acid
levels in the blood of those eating the acid-forming
diet rose within days. So one would assume uric acid
levels are lower in vegetarians. And indeed, those eating
vegetarian long term were found to have significantly
lower levels their blood. To prove cause and effect, though, you need to do an
interventional trial, where you take people,
change their diets and see what happens. So they took ten guys
for a study of the build-up of uric acid
in the kidneys, kept them on a standard
Western diet for five days and measured their relative
super saturation for uric acid. Then they tried a vegetarian
diet for five days and got this. The intake of the vegetarian diet
led to a 93% decline in the risk of uric acid
crystallization, within days. Or you can do it
the other way: take a bunch of
people with gout, feed them a big
meal of meat and see if you can
trigger an attack. Seven patients were
put in a hospital, stabilized on a
low-purine diet, and then challenged with
a meat-laden dinner. In response, uric acid
levels shot up, and they started getting
gout attacks. Then they added alcohol and uric acid levels
shot up even further. In all, just with
single meals, they were able to
trigger gout attacks in six out of the
seven patients. Now some meat has
less purines than others. Superworms have particularly
low purine levels. Super, because they’re like
two to three inches long. Not all animal foods
increase gout risk, though, low fat dairy products were
found to be protective. If that’s the case,
we would predict vegans would be at a disadvantage, which is indeed
what was found, though these all were within
the normal range, which is like 3.5 to 7. Should gout patients add milk
to their diets? Well although drinking the
equivalent of ten cups of skim milk at a time appears to have an acute
lowering effect on uric acid levels, in the long term
over months, at the equivalent of
two cups a day, there was not a statistically
significant lowering effect. They gave skim milk powder
to gout patients for three months and it did not
appear to help. Though soy milk has also
been associated with a lower risk of uric acid buildup, but there are no interventional
trials to back that up. The bottom line is that
we now have good research on how to reduce risk of gout
without the use of drug treatments through modification of diet. That’s important, because
allopurinol is the drug of choice. It’s considered generally safe. But, what does it mean when doctors
talk about a relatively safe drug? Well, about 2% of patients develop
hypersensitivity reactions, which can sometimes be severe
and fatal with a mortality rate of 20%– and that’s the safe drug. The other leading drug,
colchicine, has no clear-cut distinction between the nontoxic,
toxic, and lethal dose.