Rheumatology Advisor: How can certain dietary choices affect symptoms?
Dana Pitman, MS, RD, CDN: Purines are found in many healthy foods so it’s important to note that it is not necessary to rid your diet of purines entirely. In general, dietary recommendations for gout management are similar to what we recommend to the general public: eat a healthy, well-balanced diet, limit processed foods as much as possible, and focus on whole foods including fruits, vegetables, whole grains, beans, legumes, healthy fats such as olive oil, and low-fat dairy products.
In general, foods to be cautious about consuming include most organ meats — liver, kidney, heart, and sweetbreads — other meats like beef, lamb, and pork; and shellfish, including mussels, scallops, shrimp, and clams. Foods made with high fructose corn syrup and other sugar-laden foods like white bread, cakes, candy, regular soda, juices, energy drinks, flavored yogurts, meal replacement bars, and breakfast cereals should also be avoided.
It’s incredibly important to read labels and know what to look for. Lastly, alcohol intake should be carefully moderated, and beer appears to be the worst offender. Alcohol not only acts as a source of purines, it appears to stimulate the reabsorption of uric acid and decreases the kidney’s ability to excrete it. Moderation is key.
On the flipside, choosing a wide range of foods may help keep gout attacks at bay. Low-fat dairy products, including milk, cheese, and yogurt, as well as eggs may actually play a protective role in the prevention of gout attacks. Other sources of lean protein to focus on include fish, skinless chicken and turkey, nuts, nut butters, beans, and legumes.
Complex carbohydrates are an important part of a healthy diet and include fruit, whole grains, and vegetables. While purines can be found in vegetables like spinach, cauliflower, mushrooms, asparagus, and legumes, these appear to be safe and should not be a concern for patients.
Lastly, adequate hydration is imperative. Dehydration can contribute to attacks so patients should focus on drinking at least 32 ounces of water daily — that’s four 8-ounce glasses per day.
Theodore R. Fields, MD, FACP: The American College of Rheumatology has reviewed the literature carefully, and in their 2012 guidelines for gout management include dietary recommendations.2 Although many foods contain purines, which are products of proteins that are further broken down into uric acid, dietary advice for patients with gout can be narrowed down to the big 4 items: alcohol — any type, beer in particular — red meat, shellfish, and high fructose corn syrup, especially sweetened sodas. Also, it is recommended they avoid organ meats and meat gravies.
Patients also sometimes ask, “If so much is bad for my gout, is there any food that is good for gout?” There are 2 replies to this. First, there is some evidence that low-fat dairy products are a good choice for patients with gout, and may mildly lower uric acid levels, possibly due to the effect of the casein on the excretion of uric acid.
Second, cherry juice — likely related to its vitamin C content —mildly lowered uric acid, but only when tested in people without gout.
In a small study of patients with gout no effect was seen. It may be that the genetic tendency to hold onto uric acid in the kidneys is too strong in patients with gout to be overcome by cherry juice. Even if the results from that small study are wrong, however, and cherry juice does have some effect on uric acid levels in patients with gout, patients should be aware that the effect is small and extremely unlikely to be enough to get them to their uric acid goal of less than 6. Cherry juice is not a replacement for medication for lowering uric acid levels.
There are 2 periods when people with gout should be especially careful with their diet. The first is when they are not yet on medication to lower their uric acid levels, because their levels are elevated, and eating foods that can set off gout can be a problem for them. The second time is during the first 6 months after starting a medication to lower uric acid. During those 6 months, with lower uric acid levels in the blood, crystals are being pulled out of the joint lining. While they are coming out, they can cause gout attacks. Watching the diet during that first 6 months can help prevent attacks.