Monday, November 28, 2016
Importance of Diet in Gout
Gout is an inflammatory arthritis caused by deposition of monosodium urate crystals within synovial joints as a result of elevated serum uric acid (SUA) levels. 1 The classic symptoms described are recurrent “attacks” of severe pain, swelling, redness, and warmth in one or a few joints; in some cases it can become chronic and polyarticular. 2
In the United States the estimated prevalence of gout is 8 million individuals, which is an increase of approximately 1.2% over the last 20 years. 3 4 5 When comparing 2 incidence cohorts from 1977-1978 and 1995-1996 in Minnesota, the incidence of primary gout was shown to have increased from 42 to 62.3 per 100,000 ( P = .1) over the 20-year period. 6 Other studies have shown this trend to be worldwide. In New Zealand, where gout is especially common, the prevalence is estimated at 2.69% and rose as high as 25% in elderly men. 7
Because of new pharmacotheraputics targeting hyperuricemia, healthcare providers often start medical therapy sooner and give dietary counseling less emphasis. 8 With this approach comes the inherent risk of drug toxicity, interactions, and polypharmacy in patients who often have multiple comorbidities. However, if the approach to gout treatment included dietary therapy and lifestyle modification, it could lower uric acid levels as well as potentially mitigate the long-term consequences of the metabolic syndrome that often coexist with gout. 9 10
Although the current teaching is that health care professionals should concentrate on urate-lowering therapy, diet remains a very important part of gout management. More importantly than improving the arthritis associated with gout, diet gives the practitioner the opportunity to impact patients' risk for morbidity and mortality from consequences of metabolic syndrome.
Strong evidence supports weight loss through diet as a foundation of lifestyle changes needed in gout patients. Liberal intake of plant proteins, nuts, vegetables, legumes, whole grains, lower-sugar fruits, and plant oils is supported, and up to 2 servings daily of low-fat dairy products is recommended ( Figure 2 ). Although fish intake can increase serum urate, there may be greater overall cardiovascular benefit from the addition of moderate amounts of cold water, oily fish such as tuna, salmon, and trout, which are high in omega-3 fatty acids. 9 Eggs and poultry are lower-risk protein sources when used in moderation. One or less serving(s) of red meat or shellfish per week may be recommended. Avoidance of fructose-sweetened food, beer, liquor, and starchy carbohydrates is highly recommended. Wine in moderation is acceptable. Up to 6 cups of coffee daily has been shown beneficial but warn that new initiation of coffee may exacerbate gout flares. 9 Supplementation with vitamin C may be useful, but a dosing range and long-term safety recommendations have not been made. Cherry products may be beneficial, but better data are needed before making this a recommendation to patients. During an acute flare it is recommended to increase water intake to at least 8-16 cups per day and avoid alcohol or meat.