Gout - a Natural Approach

Part I: What is Gout?

Gout is a severely painful inflammatory joint condition that most commonly affects the large toe, and (more rarely) the knee. Up to 4% of western populations are affected, making this the most common inflammatory arthritis.⁽¹⁾ Gout attacks are acutely painful, and although they resolve rapidly on treatment with anti-inflammatory drugs, they may recur frequently; up to 60% of patients with gout will have recurrent attacks within one year or suffer from chronic gout.⁽²⁾ Clearly, such outcomes are less than ideal, and considerably limit patients’ quality of life. In addition, gout signals an underlying metabolic disturbance that may impact the risk of other chronic diseases. This series will discuss the implications of gout and natural approaches to management.

Gout is caused by deposits of urate crystals within the joint space.⁽³⁾ When blood levels of uric acid become elevated, urate crystals precipitate and deposit in joints as well as soft tissues, where they produce masses called tophi. Urate crystal may also deposit in the kidney, causing kidney stones and urate nephropathy.⁽²⁾ Elevated levels of uric acid in the blood, also called hyperuricemia, are defined as serum uric acid greater than or equal to 7.0 mg/dl in males and greater than or equal to 6.0 mg/dl in females.⁽⁴⁾ Drugs such as allopurinol, which is the mainstay of gout management, act to inhibit the synthesis of uric acid.⁽²⁾ Gout has traditionally been regarded as a simple disorder of purine metabolism in which purines (found in certain foods) are converted in the body to excess uric acid. As a result, the mainstay of gout treatment is the drug allopurinol in combination with a low purine diet. A low purine diet entails avoidance of meat and seafood, yeast and yeast containing foods such as beer and alcohol, as well as select purine-rich vegetables including beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, and mushrooms.⁽⁵⁾ Despite these well established treatment strategies, there is a growing recognition that gout is not simply a disorder of purine metabolism, but may represent a more pervasive metabolic problem with long term health implications. Most recently, research has linked gout to a condition called metabolic syndrome, which leads to elevated risk of cardiovascular disease and pre-diabetes. In light of this new knowledge, therefore, the underlying factors contributing to gout deserve re-examination and careful management. The link between gout and metabolic syndrome will be further discussed in Part II of this series.

Gout - a Natural Approach
Part II: Gout and Metabolic Syndrome
In Part I we discussed the fact that gout is usually viewed as a benign condition without repercussions for long-term health. In this section we show that, on the contrary, gout is strongly associated with a number of chronic diseases that also have metabolic components, most notably, metabolic syndrome and its components; hypertension; and cardiovascular disease.⁽¹⁾ These conditions appear to share common underlying metabolic links that can be addressed in concert to reduce symptoms of gout as well as future disease risk. In particular, the researchers Saag and Choi have proposed that obesity and insulin resistance, which are the driving factors behind metabolic syndrome, are also key factors in contributing to elevated uric acid (hyperuricemia) and gout.⁽¹⁾

Obesity is defined as a body mass index (BMI) over 30. BMI is calculated based on height and weight using the formula below, and quick calculators can easily be found online, such as this one: http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm.

_BMI= (Weight in Kilograms)
(Height in Meters)²

Insulin resistance refers to a state in which the body no longer responds appropriately to the hormone insulin. Insulin is responsible for telling the cells to take up sugar, called glucose, from the blood. This prevents blood sugar from rising too high, and drives the storage of sugar inside the cells. In people with insulin resistance, the cells stop responding to insulin properly, and in response the body starts producing more and more insulin. This state is also considered pre-diabetes. Two important factors contribute to insulin resistance. One is a diet high in sugar or refined carbohydrates. The second is being overweight or obese. Metabolic syndrome is a constellation of three or more of the following: overweight, borderline elevated blood sugar; borderline low levels of good cholesterol, called HDL; borderline elevated triglycerides, which is part of a cholesterol blood test; and borderline elevated blood pressure. The concept of metabolic syndrome is important because it tells us that even if these markers are not actually “abnormal,” even slight increases very powerfully predict elevated risk of cardiovascular disease down the road. With respect to gout, research indicates that there is significant overlap between gout and metabolic syndrome. People who are overweight or who have metabolic syndrome are much more likely to also have elevated levels of uric acid or gout, compared to people of normal weight, and vice versa.^(2,3) Even among young, healthy people, those with higher BMI, insulin levels, triglyceride, or lower good cholesterol had higher blood levels of uric acid.⁽⁴⁾ In fact, in one study, being overweight was the single most powerful predictor of having elevated uric acid levels.⁽⁵⁾ On the other hand, even moderate weight reduction reduces serum uric acid.^(6-8) Obesity can increase production and decrease renal excretion of urate while weight loss decreases uric acid by increasing excretion through the kidneys.⁽⁸⁾ One study found that among very obese patients, even a 5% reduction in body weight was associated with reduced serum uric acid, such that uric acid decreased 5.7% with weight loss of between 5%-9.9% of initial body weight, and decreased 16.6% with weight loss of 20% of body weight or greater.⁽⁹⁾ Again, another study found that among 53 moderately overweight women, caloric restriction (1200 kcal/d) resulting in between 5-8 kg weight loss led to significant reductions of serum uric acid.⁽¹⁰⁾ These studies suggest that the most appropriate way to manage gout is through diet and lifestyle strategies that promote healthy weight loss and addressing the metabolic factors identified by metabolic syndrome. This will be discussed in detail in Part III.

Gout - a Natural Approach
Part III: The Gout Pyramid

In Part II we showed that management for gout should focus on healthy weight loss and reduction of cardiovascular risk factors as identified by metabolic syndrome. Gout researchers Saag and Choi have created a “food pyramid” to outline dietary recommendations for patients with gout, taking into consideration not only high purine foods, but also foods that exacerbate insulin resistance and contribute to metabolic syndrome.

Saag and Choi have pointed out that following a “rigid purine restricted diet” ⁽¹⁾ must be weighed against the fact that a low-purine diet is often high in refined carbohydrates and saturated fat, which may actually aggravate the underlying metabolic factors. In the long run, following a diet that promotes weight loss, improves insulin sensitivity and lipid levels, and lowers uric acid is also crucial in controlling gout symptoms as well as in managing cardiovascular risk. The resulting “food pyramid” incorporates both moderate restriction of purine intake, as well as strategies to improve insulin resistance that are characteristic of the diet used to control metabolic syndrome.⁽²⁾ An adaptation of this pyramid is shown in Figure 1. There are some notable inclusions in this dietary plan, namely, moderate amounts of purine rich legumes and vegetables, as well as fish and poultry. Choi states that plant source purines do not increase risk of gout.⁽²⁾ In a large observational study of over 47 thousand men, consumption of meat and seafood increased risk of gout by 40-50%, but intake of purine-rich vegetables and legumes did not.⁽³⁾ Another inclusion is low fat dairy products; in the same study, intake of dairy products was associated with approximately 50% reduced risk of gout.⁽³⁾ Fish is another inclusion that is recommended in moderate amounts considering its cardiovascular benefits,⁽²⁾ however, given the high-purine content of fish, a fish oil supplement (no protein content) seems an even better strategy for patients with gout. Soft drinks and sweetened juices are discouraged since they contribute to insulin resistance and obesity, however regular consumption of coffee in moderate amounts is allowable. Caffeine is a natural xanthine oxidase inhibitor; this means that it slows down the conversion of purines to uric acid. Therefore as long as intake is consistent on a day-to-day basis, coffee may help lower uric acid levels.⁽⁴⁾ If intake is variable, however, coffee may in theory worsen gout, since this pattern results in unstable changes in serum uric acid which may actually precipitate an attack.⁽²⁾ Of course adequate water intake is necessary to ensure uric acid excretion.

Finally, it is crucial to note that the base of the pyramid (the most important recommendation) is daily exercise.⁽²⁾ This benefits metabolic parameters independently of weight loss, and when added to moderate weight loss and appropriate dietary strategies, the effect is even more powerful. We advise readers to consult a licensed naturopathic doctor for guidance on how to safely and effectively implement these diet and lifestyle changes.

Gout - a Natural Approach
Part IV: Use of Natural Health Products (NHPs) and “Prescription Foods”
In Part III we discussed dietary guidelines for the management of gout and associated metabolic risk factors. In Part IV we discuss how use of select natural health products (NHPs) and/or “prescription foods” can further augment the benefit attained through these diet strategies. We consider “prescription foods” to be those foods that we specifically ask our patients (in a clinical setting) to consume regularly at a specific dose because they possess unique therapeutic properties.

Conclusion : Gout strongly impacts quality of life in affected patients. Because hyperuricemia is associated with the metabolic syndrome and cardiovascular risk factors, dietary strategies for gout need to be balanced in order to reduce purine intake but also reduce risk of cardiovascular disease. Weight loss is key in lowering uric acid levels. Therapeutic foods and nutritional supplements for gout include low fat dairy, black tea/ coffee, cherries, EPA, citrate, and vitamin C.