Key Points for Discussion with Patients (adapted from Choi 2010)
Wine --> GOUT
- Alcohol predisposes to gout. This is due to the generation and turnover of ATP, diuresis and dehydration, production of lactic acids and ketoacids, and the amount of purines in the alcoholic beverage.
- Beer and ale have a high purine content and their ingestion is strongly correlated with hyperuricemia and gout.
- Spirits/hard liquor are also associated with increased sUA and an icnreased risk of gout.
- Wine on the other hand is more complex and contains antioxidants and phenols. Data suggests that wine has little or no effect on serum urate or the risk of guot.
- Recommend sensible moderate drinking, 1-2 drinks/day for men and less than/equal to 1 drink/day for women.
Surf 'N Turf
- Meat, especially red meat and organ meat, and seafood (including oily fish and shellfish) have a high purine content and are associated with increased uric acid levels and a risk of gout.
- Recommend that the intake of red meat and organ meat be limited.
- Oily fish may be allowable while implementing other diet and lifestyle changes.
- Recommend that patient use plant-derived omega-3 fatty acids or supplements of eicosaspentaenoicacid (EPA) and docosahexaenoic acid (DHA)
The Pepsi Generation fructose the new evil
- Fructose intake and fructose containing soft-drinks and beverages have been linked to increased serum uric acid levels and increased risk of several metabolic disorders including gout, obesity, and type 2 diabetes. Fructose shares ethanol's urate raising mechanism, inducing uric acid production by increasing ATP degradation.
- In the case of fructose, minutes after an infusion of fructose, plasma uric acid concentrations are increased.
- Recommend that patients reduce or eliminate sugary soft drinks and juices from their diet. The intake of sweet fruit (apples, melons) should also be limited as they too have been linked to the elevated uric acid levels. 20,27
Physical Activity daily, reduce weight
- Adiposity is associated with higher uric acid levels an increased future risk of gout and other metabolic disorders. Weight loss reduces uric acid levels and risk.
- Recommend gradual caloric restriction as rapid weight loss through dieting may cause ketosis, resulting in hyperuricemia and precipitate an acute gouot flare.
- Encourage patients to aim for their ideal body weight through gradual weight loss and to avoid crash dieting. Ensure they understand that high protein/low carbohydrate (Atkins-type) diets should be avoided as they can raise sUA levels.
- Encourage moderate exercise to improve cardiovascular and metabolic health.
Milk - benefits beyod the bones!
- Diets high in dairy products have been shown to reduce sUA levels by nearly 30mol/L more than low dairy diets. Proteins commonly found in milk and dairy products increases urinary urate excretion (uricosuric effect).
- Of note, while dairy products are low in purine, soy products/proteins are high in purine. 28
- Recommend that patients drink skim milk or consume other low-fat dairy products up to 2 servings daily.
- Vegetables, nuts, legumes and even purine-rich vegetables do not appear to increase the risk of gout. They are also excellent source of protein, fibre, vitamins and minerals.
- Recommend an increased consumption of vegetables and 1-3 portions of nuts and legumes daily.
Coffee - protective effect?!
- Coffee, both regular and decaffeinated, were shown to be associated with a lower uric acid level and risk of gout. Caffeine is an xanthine and likely exerts its protective effect through inhibition of xanthine oxidase.
- Allow coffee drinking if a patient already drinks coffee, however recommend fewer than 4 cups per day.
- Note that intermittent use of coffee or acute introduction of large amounts of coffee may trigger gout attacks similar to urate lowering therapy. 29,30
Vitamin C - protective effect
- Vitamin C supplements have been found to reduce serum uric acid levels and the future risk of gout in clinical trials.
- Vitamin C is thought to have a uricosuric effect by interfering with uric acid reuptake in the proximal tubule and possingbly by increasing the glomerular filtration rate.
- Recommend that patients take a supplement of at least 500mg/day (but not more than 2000mg/day) 20,31
When discussing diet and lifestyle adjustments with your patients they need to clearly understand the goal, to prevent gout attacks, prevent the deposition of urate crystals, prevent complications of gout and its comorbidities including cardiovascular-metabolic issues.
Reference: Choi HK. A prescription for lifestyle change in patients with hyperuricemeia and gout. CurrOpin Rheumatol 2010;22:165-72