Gout

Gout is a form of inflammatory arthritis that develops suddenly, in some individuals who have high levels of uric acid in their bodies.  High uric acid in the blood is also called Hyperuricemia.  Purines are substances in plants and animals that the body converts to uric acid. 

High uric acid results from the body not breaking down or metabolizing purines or, from the body retaining uric acid.   Serum urate turns into crystallized deposits of monosodium urate.  The sharp crystal deposits in joints, deposits of uric acid (called tophi) that look like lumps under the skin and kidney stones from uric acid crystals in the kidneys. (National Institute of Arthritis and Musculoskeletal and Skin Diseases).  While a Gout attack may only last for a few days or up to a few weeks, stones in the kidneys are much more dangerous and they can eventually cause kidney damage.  Additionally, recurring gout can also damage bones and joints in the affected areas, causing deformities, stiffness and lack of mobility.

The first stage of gout is called Asymptomatic Hyperuricemia – this is prior to the first gout attack when symptoms are not present however blood uric acid levels are high and crystals are forming.  The second stage of gout is when the attack actually happens.  The next stage is Interval Gout during attacks when the pain is gone but inflammation is setting in causing damage to joints.  The last stage is Chronic Gout where there is long standing high levels of uric acid in the body and the attacks become more frequent and more damaging to both the kidneys and the joints.

Gout often presents itself quickly, without any warning.   This is why it’s known as an “attack”. It is characterized by acute pain, redness, swelling, warmth in the affected joint.  For many people, the first attack occurs in the big toe, however it can also affect the instep, ankles, heels, knees, wrists, fingers and elbows.(National Institute of Arthritis and Mucoskeletal and Skin Diseases).  Removing and examining the fluid, under a microscope in the affected joint, can diagnose gout.  If urate crystals are present, then a positive gout diagnosis is confirmed.  Subsequent attacks do not necessarily require fluid examination.  Typically, the symptoms of a gout attack are similar to previous attacks and individuals are able to self-recognize it for what it is.

Gout is also called gouty arthritis and is therefore categorized as an Arthritic disease or disorder of the joints, along with Rheumatoid Arthritis, Osteoarthritis, Septic Arthritis and Bursitis.  These types of disorders categorized under the Arthritis umbrella, all have one thing in common, which is inflammation.  Diet therefore, will have a huge impact on helping to relieve this disease, both from the perspective of creating a dietary program loaded with anti-inflammatory foods but also a diet that is low in foods that elevate uric acid levels (foods high in purines).  Vitamin supplementation, stress reduction and exercise will also be key to preventing future gout attacks.  Gout attacks will typically relieve themselves with or without prescription medication, however even though the gout may seem to be gone (asymptomatic), there can still be elevated uric acid levels causing inflammation and damage.  Chronic Gout can lead to kidney damage as a result of kidney stones.

Causative Factors

Unfortunately, the cause(s) of gout are not known. Gout used to be considered a disease of kings, which dates back to stories told of King Charles I of Spain.  Through his excessive drinking and eating rich meats and saturated fatty foods, King Charles I developed Gouty Arthritis.  It has been said that his acute gout has changed history in that he eventually had to abdicate the throne to his son Philip II.(Kay)  Back in the 1500’s, commoners or those without wealth certainly would not have had the financial means to consume alcohol or eat rich meals. So historically, Gout seems to have been confined to those of wealthy socioeconomic stature.  

Today, the prevalence of gout among US adults in 2007–2008 was 3.9% (8.3 million individuals) using nationally representative data (NHANES) from 2007–2008.  The prevalence of Gout among men was 5.9% (6.1 million), and the prevalence among women was 2.0% (2.2 million).  The prevalence of gout increased over the past 2 decades by an estimate of 1.2 percentage points.(Centers for Disease Control and Prevention).  Those over the age of 60 seem to be the most affected by gout.  For women prior to menopause, estrogen seems to have a protecting effect, which accounts for why men seem to have a greater prevalence towards Gout.

This seems to suggest that it is neither a disease of kings nor is it even a rich man’s disease.  Gout is growing in our society for the same reasons that it was in the 1500. The difference is that our socioeconomic status allows the majority of people to consume foods bereft in nutrition, high in bad fats (altered, saturated), white flour and high fructose corn syrup.  The Standard North American Diet (SAD) or more broadly speaking the affluent Western diet is certainly a contributing factor in the increased incidence of gout.  That being 40%+ hard and altered fats, 40% refined carbohydrates and 6% complex carbohydrates.  

Gout appears to be related to improper metabolism of proteins, specifically, purine which is a component of nucleic acid.  It is also related to abnormal retention of uric acid.

Foods high in purines contribute to gout attacks.  Eating a lot of purine-rich foods – like red meat, organ meat, certain fish and vegetables – over a short period of time increased the risk of a gout attack almost fivefold compared to the risk when eating fewer purine-rich foods.  A study cited by the Arthritis Foundation showed that risk of recurrent gout attacks increased almost 40 percent if intake of purine went from less than 1 gram to 1.75 grams over two days. The fivefold increase in gout-flare risk came at purine ingestion levels about twice that level – and the risk persisted even in those taking the uric acid-lowering agent allopurinol.

Stress can also bring on gout attacks because it raises uric acid levels.  When stressed the body is depleted of B5 and pantothenic acid which helps remove uric acid.  Additional stress causes the body to release cortisol, which depletes the body’s ability to deal with the gout issue because it’s too busy dealing with the other side effects of too much cortisol like muscle breakdown and high blood pressure.  Vitamin C may help lower uric acid levels.  In a 2009 study published in the Archives of Internal Medicine, Hyon K. Choi, MD, of the Boston University School of Medicine, showed that the more vitamin C men took, the less likely they were to get gout.  In fact, individuals taking 1500 mg of Vit C daily had a decreased risk of having gout by 45%.  

Alcohol is also a contributing factor to gout.  The metabolism of alcohol in your body is thought to increase uric acid production, and alcohol contributes to dehydration. Beer is associated with an increased risk of gout and recurring attacks, as are distilled liquors to some extent. The effect of wine is not as well understood. (Mayo Clinic).  Those suffering from alcoholism certainly are more likely to suffer from gout.

Hypertension has also been described as a risk factor for hyperuricemia or gout, partly due to decreased renal urate excretion. Diuretic use, lead exposure, and cyclosporine immunosuppressive therapy also affect urate renal excretion.(Bates)

Obesity is another significant causative risk factor for Gout.  Overall, Gout onset is 3 years earlier (on average) in those who were obese compared with those who were not obese.  Additionally, gout onset was 11 years earlier on average in those who were obese in early adulthood compared with those who were not obese in early adulthood. The relative risk of gout was nearly double in those who were obese compared with those who were not obese, even after accounting for other risk factors for gout. (Kelly)

Overall, gout has several significant causative risk factors including; 

• Retention of uric acid 
• Improper metabolism of proteins (purines)
• Lack of nutrition 
• Lifestyle (obesity) 
• Gender (more prevalent in males)
• Age (60 +)
• Too much alcohol consumption 
• Hereditary 
• Hypertension and well as taking diuretics (as part of hypertension treatment)
• Stress  
• Westernization (due to diet)

Nutritional Recommendations 

Diet is key to both preventing Gout and staving off recurring Gout attacks. Essentially, a Gout prevention diet is a complete lifestyle change, not just during attacks.  Outlined below are nutritional, diet and lifestyle recommendations to support prevention and recurrence.  The key will be to eat a diet low in purines, get good amounts of Essential fatty acids and avoid saturated and altered fats, good fluid consumption, and to generally avoid gout triggering foods and activities.  

1. Change the fats consumed from “bad” fat to “good” fats

• Essential Fatty Acid (EFA’s) will generally benefit the nutritional support required to deal with Gout.  EFA’s produce secretions that lubricate joints.  You want to get 15-20% of calories as fats (1/3 to ½ of that EFA’s) and a balanced W6:W3 ratio.  Animals fats especially those from organ meat (also high in purines), cheese and butter are poor sources of EFA.  EFA to include:  flax, hemp, fish oils are good choices of balanced EFA’s.  EFA’s are good at reducing inflammation as well.
• No altered or saturated fats.  “Bad” fats such as margarine, (toxic and partially hydrogenated), butter, animal fats or fats that have been damaged though high temperature frying techniques should be avoided altogether.  These fats interfere with EFA function and can increase stone formation in the body.
• No processed foods.  These types of foods have no nutritional value to the body (lacking in essential vitamins, fiber, minerals and are all too often high in sodium and high in “bad” fats)
• Avoid dairy products due to its saturated fats
• Reducing saturated and altered fats will help prevent kidney stones.
• Dose:   1 tbsp cold pressed oil, 3 x/dy.  (one that has a balance of w3:w6) or a tablespoon of ground seeds 3x/dy.  (can be sprinkled on foods)

2. Eat foods low in Purines. This is probably one of the most important elements to preventing Gout attacks.  A low purine diet will reduce uric acid levels in the body.  Note: High purine legumes have not been shown to increase the risk of gout or gout attacks.(Mayo Clinic).  Examples of low purine foods (0-50 mg purine per 100g): most fruits and veggies, most nuts (except for peanuts, cashews), herbal teas, good fats, olives. 

For a complete listing of foods ranked by highest to lowest purine levels go to:  http://www.n1health.com/Media/Corporate/McHenry/Documents/Purine Table.pdf

3.  Slightly Alkaline Body pH.

Sudden drops in body pH (making the body more acidic) have been shown to bring on gout attacks. Sodium urate crystals will not dissolve in water or alcohol; however, they do dissolve in some alkaline solutions. Therefore, consuming large amounts of acid-forming fruits and vegetables can make a gout flare-up worse. (Dr. David Williams)

Alkalizing foods:  mostly all fruits and veggies including their juices, except for blueberries, plums, prunes, and cranberries.  Unprocessed, cold pressed oils, herbs, spices, grains (flax, quinoa, millet), sesame seeds, nuts (almond, pine nuts). 

Acidic foods (avoid):  coffee, alcohol, sweeteners, meats, rice, grains (cornmeal, oats, rye, spelt, wheat, bran), nuts (walnuts, pecans, cashews), seeds (sunflower, pumpkin) table salt, condiments (ketchup, mustard, mayonnaise)

4.  Fluid Recommendations

• Avoid chronic dehydration – Drink water because it helps in the elimination of uric acid from the body as well as preventing kidney stones.  Water should be filtered to avoid chlorine and other potentially toxic impurities.

Dose: Aim for 8 ounces of water/hr during the day.  

• Avoid alcohol consumption.  The metabolism of alcohol increases uric acid production, and alcohol contributes to dehydration. 

• Avoid caffeine because it is a diuretic as well as converts to uric acid.

• Avoid sugary drinks altogether.  High Fructose corn syrup contained in most sugary drinks increases the risk of gout attacks and depletes the body of Vitamin B.  Vit B is needed to cope with stress.

• Drink tart cherry juice every day.  The concentrated form is available in health food stores and can be added to the daily water consumption.  This may help to reduce the recurrence of a gout attack.  Plus, tart cherry juice helps with pain and inflammation, as they are a rich source of anthocyanins, which are anti-inflammatory.

Dose:  1 tbsp of concentrate tart cherry juice, 2 X/day.  Dilute in an 8-ounce glass of water.  This is equivalent to eating 100 cherries, which you wouldn’t want to do due to gastric upset.

5.  Protein Sources

• Limit protein from lean meat, fish and poultry to 4-6 ounces of protein per day.  There is approximately 7 grams of protein in 1 ounce of cooked meat.  Balance of daily protein requirements can be from bean and legumes and nut sources (except those high in purines).  Sweet potatoes are a good accompaniment with protein because it contains proteases, which help break down protein.

Daily recommended intake 0.8 grams of protein per kilogram of body weight

• Avoid liver, kidneys and sweatbreads, anchovies, mackerel, sardines, scallops, mussels, shrimp and lobster due to high purine content

6.  Vitamin and Mineral Supplements

• B5 (Pantothenic Acid) When stressed the body is depleted of B5 and pantothenic acid helps remove uric acid. 
• B6  – helps with protein metabolism
• Zinc – helps with protein metabolism
• Calcium/Magnesium – 3:2 ratio with Magnesium.  
• Vitamin C  Vit C reduces gout risk and is a very good antioxidant.  Plus, it helps make collagen keeping bones and joints firm and strong.  Take the ascorbate form because it is mildly alkaline. 

7.  Exercise and Weight Loss 

Exercise to reduce stress and lose weight.  Do not engage in excessive exercise as it raises cortisol levels and can lower immune function.  Also engaging in a weight loss program should involve slow gradual weight loss.  Rapid weight loss can increase uric acid levels in the body.  Suggestions:  walking, low impact activities like swimming; tai chi and yoga (which is also good for stress). Low impact will be less stressful on already painful and potentially damaged joints due to Gout.  Exercise will also have a heart health benefit, which will help reduce blood pressure.

Daily recommendations:  30-45 minutes of exercise.  Start out at whatever feels comfortable without overexertion and build up slowing to the daily recommendation.

 

8.  Natural Remedies to combat Gout

Anti-inflammatory Herbs:  Black Willow, Meadowsweet, Devil’s Claw, White Poplar, Wild Yam and Frankincense.  Helps to reduce inflammation and pain.  

Diuretics and Antirheumatic Herbs:  Burdock Root, Celery, Boneset, Wild Carrot, Yarrow. 

During a gout attack, Thuja can be added to the tincture to help with pain.  Dose: A tincture of 5 ml, 3-4 x/day, away from food, taken with a small amount of water.

9.  Fruits and Vegetable consumption

• Fruits and vegetables are the ideal items in a low purine diet.  Additionally, they are full of fiber to help increase satiation and keep elimination regular, essential vitamins, minerals and antioxidants.  Eating whole fruits and vegetables is a good way to keep the fiber content vs. juicing.
• The key will be to eat low acid fruits to keep the body in a slightly alkalized state. (ie – apples, berries, melons, bananas).  Note – most fruits and vegetables are alkalizing to the body.

Recommendation:  No limit on Vegetables (except for carrots, potatoes and squash limit to 2 servings/dy,) Fruits 3 servings/dy.

Limit (2 servings/week)– spinach, cauliflower, mushrooms and asparagus because they are higher in purines.  

10.  Gluten Free Grain consumption

• Grain consumption must be gluten free to avoid potential allergic reactions.  Reducing allergies and helping to reduce inflammation is beneficial for arthritic conditions such as Gout.
• Grains that contain gluten: wheat (all), couscous, kamut, faro, spelt, semolina
• Grains that are gluten free: millet, quinoa, brown rice, buckwheat, sorghum, teff, amaranth, oats* (*some controversy)

Recommendation: 2 servings/dy 

11.  Other things to consider

• Reduce salt intake to a maximum of 1500 mg/day to prevent kidney stones and water retention.  Eating less processed foods will help in reducing “hidden” salts as well as bad fats.
• Obtain at least 8 hrs of sleep/night
• Reduce stress

For more information contact us at info@nutritiondispensary.ca