Christine Peoples, MD: Gout management goals must include careful attention to patient education, weight management, smoking cessation, avoiding or limiting food and beverages containing high-fructose corn syrup, and a diet including protein sources such as low-fat dairy products and plant-based proteins — more than protein sources of red meat or fish.
The role of alcohol cannot be overemphasized. It is important to discuss how much alcohol and what type of alcohol — beer, wine, or liquor — a patient is consuming on a regular basis.
Rheumatologists should be comfortable discussing alcohol use and abuse with patients with gout. When these patients can abstain or greatly reduce their alcohol intake, the effects on gout control are profound. Gout flares cause significant pain, and many patients can use that pain as motivation to abstain from or limit their alcohol intake.
The benefits of weight loss, exercise, smoking cessation, and maintaining a healthy diet for gout will have an impact on serum uric acid levels and the frequency and severity of gout flares. It may also limit the amount of urate-lowering therapy needed. In addition, I emphasize to patients that all of these activities will improve other comorbidities such as hypertension, chronic renal disease, coronary artery disease, metabolic syndrome, obesity, diabetes, and hyperlipidemia.
Rheumatology Advisor: Do rheumatologists and dietitians typically discuss this issue with patients? If so, to what extent, and how is it best approached?
Dana Pitman, MS, RD, CDN: While I can’t speak for all rheumatologists, in my experience this is certainly a topic that is discussed. Dietitians play an important role in expanding upon the information provided by a patient’s doctor with regard to the role of diet in the setting of preventing gout attacks. As mentioned earlier, each patient is different and will come with various dietary needs, preferences, and a willingness to make changes. The most important thing to do when approaching this topic is to meet patients where they are and attempt small, incremental changes over time so that it never feels too overwhelming and can hopefully be more sustainable over time.
Theodore R. Fields, MD, FACP: Rheumatologists review dietary issues with their patients with gout and often give them handouts. This is important because there is so much on the internet about gout and diet that patients are often overwhelmed and feel there is almost nothing they can eat. It can seem that way because so many foods have protein, and protein breakdown leads to the development of uric acid. However, some foods are much worse than others and people need more practical guidelines. Fortunately, the diet for gout is also a heart-healthy diet, which is important because it is known that people with gout have a higher risk of heart disease.
Some people with gout benefit from a consultation with a nutritionist. At HSS, we had a symposium for patients with gout, at which I spoke about the diagnosis and medical management of gout and Dana Pitman, MS, RD, CDN, also spoke. She helped to simplify the gout diet and to emphasize an overall heart-healthy diet. She also emphasized that weight loss, when indicated, can help to lower uric acid levels.
Christine Peoples, MD: In my practice, I discuss the role of diet and nutrition with each of my patients with gout. I think the amount of time spent on patient education regarding gout itself and the role of diet varies a great deal, both among rheumatologists and primary care doctors. I cannot emphasize enough the importance of patient education regarding gout in terms of the disease itself, treatments for both acute and chronic gout, and the role of diet and nutrition.
I think is it key to recognize the connection between gout and other common comorbid conditions, such as hypertension, chronic renal disease, coronary artery disease, metabolic syndrome, obesity, diabetes, and hyperlipidemia. Many patients with gout are managed by their primary care doctors, so it is essential that primary care providers discuss the role of diet in gout.
Initially, I review the diagnosis of gout in great detail with patients. I discuss the role of diet and nutrition during the initial visit and at each subsequent follow-up visit. I often ask patients what typical foods and drinks they consume each week, and I review alcohol use at each visit.
I find that patients will start to become knowledgeable about their diet and gout, much like patients with diabetes understand the relationship between meals and blood glucose readings. I find it is often helpful to involve the patient’s spouse, partner, or caregiver in the discussion.
Rheumatology Advisor: What are other treatment implications for our audience of rheumatology clinicians and any additional relevant points they should know about the topic?
Theodore R. Fields, MD, FACP: Gout is the most common type of inflammatory arthritis. If people with gout get their uric acid levels below 6, over time the vast majority will achieve a “cure” as long as they stay on their medication. Unfortunately, only approximately 40% of patients with gout for whom a uric acid-lowering medication is indicated are actually taking it.
The main issue for rheumatologists in helping patients with gout with their diets is to recognize that the patient is likely overwhelmed and needs a simplified approach. The patient also needs to appreciate that diet is just one element in an overall approach to gout management, although it is an important element.
Our group at HSS recently published a study on education and monitoring in patients with gout.3 This study included a gout self-management examination, which patients filled out as they entered the study, before they were seen by the rheumatologist, nurse practitioner, or fellow. An RN then reviewed the questions and answers with them and taught them a standardized gout curriculum.
Pharmacists were involved in medication monitoring, but RNs addressed the dietary issues. Of the 12 questions in the self-management examination as published in this paper, 4 included references to diet and gout. [Rheumatology Advisor: The study demonstrated feasibility and acceptability of the patient education program.]
Christine Peoples, MD: I think it is important for rheumatologists and primary care doctors to work together to care for patients with gout. Since most patients with gout will be managed by their primary care doctor, it is important that primary care doctors know when to refer a patient with difficult-to-manage gout to a rheumatologist. The role of diet and nutrition can play a significant role in those patients whose gout is difficult to manage or refractory to other treatments. The use of cherry extract and vitamin C requires additional study.
Summary and Clinical Applicability
Dietary choices have significant implications for gout management.
- Gout. Centers for Disease Control and Prevention. https://www.cdc.gov/arthritis/basics/gout.html. Updated April 14, 2017. Accessed April 19, 2017.
- Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: Systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthrit Care Res. 2012;64(10):1431-1446. doi: 10.1002/acr.21772
- Fields TR, Rifaat A, Yee AM, et al. Pilot study of a multidisciplinary gout patient education and monitoring program. Semin Arthritis Rheum. 2016;S0049-0172(16):30277-3. doi:10.1016/j.semarthrit.2016.10.006