Where do diet and lifestyle come in?
Both diet and lifestyle have a major role in the development of gout so you do have some control over how the disease affects you. Your food choices every day play a large part in this. There have been many studies done over the past couple of decades regarding this relationship; here are some of them.
A 2004 study found that alcohol intake is associated with an approximate 49% increase in the risk of gout. Beer confers the highest risk, followed by spirits. Moderate wine drinking does not increase the risk (22).
In 2011 a review study found that alcohol consumption (especially beer and liquor) along with meat and seafood significantly increases risk for developing gout. Sugar-sweetened drinks and high fructose foods also increase gout risk (26).
In 2004, researchers published data from the large Health Professionals Follow-Up Study that evaluated the relationship between the intake of purine-rich foods, dairy foods and protein with the incidence of gout. It was found that increasing meat ingestion by one additional daily portion resulted in a 20% higher risk of an attack of gout. Seafood was also associated with significantly increased risk. However, purine-rich vegetables did not increase the risk and low-fat dairy products were associated with reduced risk (4,24).
A study in 2012 confirmed this relationship. In this study, purine-rich food was separated into that from animal versus plant sources. It was found that there was up to five times more attacks of gout in the group with the highest consumption of animal sources of purine-rich food compared to those eating the lowest amount of animal sources of purine-rich foods. Purine-rich plant foods showed only an extremely small increase in gout (5).
In 2015 researchers studied 63,257 people and determined that those who consumed the most poultry and fish had the highest risk of gout while those who consumed the most soy protein and legumes experienced the lowest risk (27).
The newest study was just completed in 2017 and looked in particular at the DASH diet (Dietary Approaches to Stop Hypertension diet) in the prevention of gout in people with high blood uric acid levels. The DASH diet is low in red and processed meats, sugary drinks and salt and rich in fruit and vegetables, nuts and whole grains. This study found that the DASH diet reduces uric acid levels in the blood and also reduces the risk for cardiovascular disease, stroke and kidney stones. This study was part of the Health Professionals Follow-up Study and analyzed data from 44,000 men aged 40 to 70 years, following them for 26 years. Men whose diets were similar to the DASH diet showed a 32% reduced risk of gout. Those eating a more Western diet were at a 40% elevated risk for gout. These relationships held when the data was adjusted for other risk factors that may contribute to gout such as high alcohol consumption, high blood pressure, higher BMI and older age (28).
Further data from the Health Professionals Follow-Up Study revealed more associations between diet and gout;
Fructose, especially that found in sugar-sweetened drinks and in fruit juices, raises the serum uric acid level and increases the risk of developing gout by about 85% (14,15).
Body mass index of greater than 25 holds a 95% increased risk of gout compared to having a body mass index of 21 to 22 (15).
Vitamin C increases the elimination of uric acid through urine (16,17).
Drinking coffee but not green tea decreases the incidence of gout; this appears to be independent of caffeine (19,20).
Physical activity along with low BMI and healthy diets that include more fruit and less meat reduces the risk of gout (21).
Cherries – both delicious and beneficial for gout
Cherries are notably anti-inflammatory. One study found that healthy people eating a lot of cherries (about 45 cherries a day) achieved a 25% drop in C-reactive protein levels (a marker for inflammation) which lasted even a month after the cherry eating stopped (35). Another study noted that healthy women who ate just two servings of cherries decreased their blood uric acid levels (18).
In people suffering from gout, eating sixteen cherries a day produced a drop in inflammation plus a 35% drop in risk of attacks of gout (36).
A randomized controlled trial compared cherry juice concentrate with pomegranate juice concentrate and found that gout sufferers who consumed a tablespoonful of cherry juice concentrate twice a day reduced their gout flares by more than half. The pomegranate juice reduced gout flares by only 20%. In addition about half of those in the cherry group who were on prescription anti-inflammatory drugs were able to stop their medications within two months after starting the cherry juice, as opposed to none of the patients in the pomegranate group (37).
Eating cherries regularly appears to be another tactic that will decrease attacks of gout.
Let’s focus on plant sourced purine for a moment…
We know from Part One of this article that purines are at the root of the problem with uric acid blood levels. In the past the recommendation for people with gout has been to avoid all high-purine foods. This strategy has had limited effectiveness. It has been discovered that many of the purine-rich plants that people were once warned away from have turned out to be protective. These foods include mushrooms, peas, beans, lentils and cauliflower.
Part of the problem stems from the tables that list purine content of foods which base the amount of purine in beans on a 100 gm serving (just over a half a cup of dried beans). A 100 gm serving of meat is a reasonable size. However, a half cup of dried beans swells to 1 ½ cups once cooked – more like three servings. The purine content per serving of beans should be only 1/3 of the listed amount.
Another factor is that foods rich in fiber, vitamin C and folate tend to increase the elimination of uric acid from the body. Fiber can bind to uric acid in the stomach and carry it away before it has even been absorbed. Even the change in the pH of our urine from eating an alkaline plant-based diet is effective in removing uric acid from the body (23). Indeed uric acid levels are generally lower in vegetarians.
So, it appears that gout sufferers need to concentrate on avoiding or reducing only purine-rich animal food and need no longer worry about the purines they might get from in plant foods.
The bottom line – let’s boil all this down to the best advice for using diet and lifestyle to achieve decreased uric acid blood levels and reduced attacks of gout (6,30,31)
• Avoid very high purine foods (more than 200 mg per serving)
• Limit high purine foods (100 to 200 mg per serving) to not more than one small serving per day.
APPROXIMATE PURINE LEVELS IN SOME FOODS;
FOOD AMOUNT PURINE
Anchovies, sardines, herring 100 gm 400 mg
Pork kidney, pork liver, beef liver 100 gm 300 mg
Salmon, mackerel, ocean perch 100 gm 250 mg
Chicken liver, chicken heart 100 gm 250 mg
Shrimp, tuna, clams, squid 100 gm 150 mg
Chicken, lamb, steak, pork 100 gm 130 mg
Haddock, white fish 100 gm 115 mg
Lobster 100 gm 75 mg
Oats 75 gm 75 mg
Lentils, beans, peas, soybeans, tofu 100 gm 65 mg
(a serving of beans is actually 30 gm or about 20 mg purine)
Fruits and vegetables 100 gm 10 to 50 mg
Peanuts, flaxseeds, chickpeas 30 gm 25 mg
Almonds, walnuts 30 gm 10 mg
• Avoid rich, high-fat, meat-centered meals. Avoid processed meats – their content is so variable that their purine content is largely unknown. Rely on unprocessed plant-based foods as your primary sources of protein.
• Keep portions of meats and seafood small. A serving should be 75 g or less (smaller than a deck of cards). Since many people usually eat much larger portions, this step alone can significantly lower the amount of purine you eat. Remember that the average person needs a lot less protein than they probably are taking in.
• Avoid meat extracts, broths, bouillon and gravy because of their high levels of purines.
• Avoid organ meats (liver, kidney, sweetbreads, etc.) because of their high levels of purines.
• Avoid small fish such as anchovies, sardines and herring and larger fish such as salmon, mackerel and ocean perch because of their high levels of purines.
• Choose vegetable protein sources more often: beans, lentils, tofu, and unsalted nuts and seeds. Although some of these foods contain purines, they are not linked with increases in uric acid or risk for gout symptoms.
• Eat at least four servings of fiber-rich vegetables, whole grains and fruits every day. Their high fiber and vitamin C content can increase the elimination of uric acid from the body
• Choose vegetables as a snack
• Minimize intake of refined carbohydrates, including both starches (white flour products) and sugar. Avoid sugar-sweetened carbonated beverages, fruit juices, specialty coffee drinks, candy and sugary desserts like pastries, donuts, cake and cookies
• Choose whole fruit instead of juice. Aim to eat at least three servings of fruit a day.
• Eat 16 cherries a day or drink 1 tablespoonful of concentrated cherry juice twice a day. Studies show that cherry juice not only relieves inflammation and reduces uric acid level but can also drop the number of gout attacks by more than half.
• Limit alcohol. Even one or two drinks can increase your risk of a gout attack. One drink equals the following: 341 mL (12 oz.) bottle of 5% beer, cider or cooler, 142 mL (5 oz.) glass of 12% wine, or 43 mL (1.5 oz.) shot of 40% spirits
All alcohol, and especially beer, can increase your risk of gout attacks. Avoid all alcohol if you have painful gout or you are having a gout attack.
• Stay well hydrated. Aim to drink 2-3 L (8-12 cups) of fluids each day. Water is your best choice.
• Coffee may be helpful in decreasing the incidence of gout.
• Dairy products are low in purines and have not been found to increase risk. Some studies suggest that low-fat dairy choices can reduce uric acid levels. Use soy milk to replace dairy as it has been shown to lower uric acid.
• Keep your BMI below 24. If weight loss is a goal for you, choose a weight loss plan that encourages slow, steady weight loss (1 to 2 lb per week). Rapid weight loss or following a diet high in animal protein is not recommended because it could increase uric acid levels in your blood and the chance of a gout attack. People with a tendency toward gout are particularly vulnerable to attacks during times of dietary change, so medications should be continued through any dietary transition.
• Increase your physical activity. Do this gradually if you are currently not active.
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