Gout is an inflammatory condition that occurs when crystals of uric acid form within certain joints or soft tissues. The popular image of gout is that it affects older males who over-indulge in large steaks, port and Claret. However, most uric acid is produced from the recycling of your own, worn-out cells and your diet accounts for only around a fifth of the uric acid that is formed in the body. Even so, strong evidence has pinpointed the foods to eat and foods to avoid if you have gout.
Gout signs and symptoms
When needle-like uric acid crystals form in joints, they trigger severe pain, redness and swelling. White blood cells swarm into the area to attack these crystals, and release a variety of powerful immune chemicals that contribute to the pain, swelling and tissue damage. Symptoms come on rapidly and reach maximum intensity within 24 hours.
An affected joint is exquisitely painful – it literally feels as if you have needles inside your flesh, or a rat trying to gnaw its way through. The overlying skin is taught, red and shiny, and it is often unbearable to have even a bed sheet covering the area. You may also have a mild fever. Symptoms tend to settle within a few days but recurrent attacks can reappear several months or even years later.
Acute gout typically affects a single joint, with the base of the big toe affected in 70% of first attacks. As gout has become more common, however, there is a trend towards experiencing symptoms in more than one joint in the feet and hands – especially the thumb – as well as larger joints such as a wrist, knee or ankle.
When uric acid precipitates in soft tissues, it forms firm, white, translucent nodules called tophi. These usually take at least 10 years to appear after the first attack of acute gout. Tophi most commonly form on the fingers, toes, forearms, elbows, knees, over the Achilles tendons or on the ears, but tophi can appear anywhere. Rarely, gouty tophi have developed in the wall of the intestines, on the heart valves, or deposited in the breast or organs such as the pancreas, where they are often mistaken for cancer or infection.
How common is gout?
Gout has become more common over the last 50 years and now affects 3.9% of adults in the US, with 21% having high blood levels of uric acid which puts them at risk. In the UK, gout affects 2.5% of the population.
Gout is nine times more common in men than women until the time of the menopause, when the incidence becomes similar in both sexes. This is because the female hormone, oestrogen, promotes the excretion of uric acid into the urine so it is less likely to build up in the circulation to a level that can precipitate out into the joints to form needle-like uric acid crystals.
What causes gout?
The risk of developing gout is linked with the level of uric acid in the blood. Some people with high levels of uric acid do not develop gout, however, and some people with low levels do. As shown in the following chart, the relative risk of developing gout is around 50% for men with high blood levels of uric acid (>8mg/dl) while for women the relative risk is less.
Relative risk of developing gout according to blood levels of uric acid in men and women
This underlines the fact that, even with high uric acid levels, you can avoid gout attacks if you’ve inherited the right genes, or if you follow a protective anti gout diet.
Gout has a strong hereditary component, based on the activity of enzymes involved in uric acid metabolism, and kidney function. Most uric acid (70%) is excreted via the kidneys, and researchers believe that in most cases, gout is due to a reduced ability to excrete uric acid into the urine, rather than any tendency towards producing too much.
The remaining 30% of uric acid is excreted into the intestine, where it is broken down by colonic bacteria to form a beneficial substance called allantoin. Only bacteria which possess an enzyme called uricase can do this, and latest research suggests that people with gout have a distinctly different population of bacteria living in their gut compared to people who do not develop gout. Your diet can help to influence the balance of bacteria within the gut.
Diet and gout
Uric acid is formed in the body from purines. Most purines (80%) come from the recycling of genetic material (DNA) and around one fifth come from your diet. By following a low purine diet, and eating foods that promote the excretion of uric acid formed from your recycled cells, you can significantly reduce your risk of another gout attack.
On average, 40% of people experiencing their first acute attack of gout will not have another attack within the following year. This figure can be greatly improved if you closely follow a low purine gout diet and take evidence based supplements that promote uric acid excretion.
Gout foods to avoid
Standard medical advice is to reduce your intake of uric acid forming foods such as liver, kidney, shellfish, game, meats and the flesh of oily fish – especially sardines and herrings. Omega-3 fish oil supplements are fine, however, as they contain no DNA and have a useful anti-inflammatory action.
These animal meats all contain cell DNA which, if eaten, will contribute to the level of purines you make.
Plant foods are also cell based, of course, and some vegetables such as asparagus, cauliflower, mushrooms, lentils and spinach are also naturally high in pre-formed purines. However, fruit and vegetables provide other components such as vitamin C, polyphenols and other antioxidants that promote uric acid excretion to protect against gout.
A recent large study, involving over 47,000 male healthcare professionals who were followed for 12 years, suggests that, after taking all other factors into account, moderate intakes of vegetable-based purines do not increase the risk of gout – those with the highest intakes were 4% less likely to develop gout than those with the lowest intakes which is a small but useful difference.
Their study also confirmed that high intakes of meat and seafood are associated with an increased risk of gout – those who ate the most meat were 41% more likely to experience gout than those with the lowest intake. For seafood, men with the highest intake were 51% more likely to have gout than those with low intakes.
This study also flagged up that total fructose sugar intake is an even more important risk factor. Men with the highest fructose intake were 81% more likely to develop gout than those with the lowest intakes (highest versus lowest quintiles):
Foods that increased risk of gout
|Total fructose||1.81 (81% increased risk)|
|Seafood||1.51 (51% increased risk)|
|Total meat intake||1.41 (41% increased risk)|
Total protein intake, animal protein and vegetable protein were not associated with the risk of gout, so you can continue to have your protein powder supplements.
Alcohol and gout
The link between a high alcohol consumption and risk of gout was noted in ancient times, when it was known as the Disease of Kings.
Victorian cartoons often show sufferers imbibing port or sherry, but it seems that much of this association was not so much to do with the alcohol, but to lead-poisoning.
Wine was initially sweetened with syrup derived from grapes that were boiled in lead vessels, and this so-called ‘saturnine gout’ was due to lead poisoning which, along with gout, also caused abdominal pain, nerve damage and kidney failure.
In the 12-year study involving over 47,000 men previously mentioned, those who drank one glass of wine a day were at no greater risk of gout than those who did not. In contrast, drinking half a pint of beer, or having one shot of spirit per day, significantly increased the risk as follows:
Drinks that increased risk of gout
|Total alcohol||50g per day or more versus none||2.53 (two and a half times increased risk)|
|Beer||2 or more drinks daily versus none||2.51 (two and a half times increased risk)|
|Sugar sweetened soft drinks||2 or more drinks daily versus none||1.85 (85% increased risk)|
|Spirits||2 or more drinks daily versus none||1.60 (60% increased risk)|
|Diet soft drinks||2 or more drinks daily versus none||1.12 (12% increased risk)|
|Wine||2 or more drinks daily versus none||1.05 (5% increased risk)|
So, it looks as if wine in moderation is okay for some people, as it does provide antioxidant polyphenols that will help to offset the effects of alcohol. Everyone is different however, and some people may find that even wine can trigger an attack, so whether or not to drink wine it is a personal decision that only you can make.
You should certainly avoid spirits and beer and soft drinks – especially those that are sugar-sweetened.
Anti gout foods to eat
Dairy products strongly protect against gout, so that men with the highest intake of dairy products have a 44% lower risk of developing gout than those with the lowest intake. Most of this protection appears to come from low-fat dairy products however, such as skimmed milk and low-fat yoghurt (relative risk 0.58, a 42% reduction), rather than from high-fat dairy products which have a neutral effect on gout risk (relative risk 1.00).
Dairy products are protective because milk proteins (casein and lactalbumin) appear to increase the excretion of uric acid through the kidneys, to lower blood uric acid levels. This is supported by another study involving 158 post-menopausal women who either followed a test diet providing 30g dairy protein a day, or a dairy free diet for four weeks. In those who ate no dairy foods, blood uric acid levels increased significantly, while in those eating dairy products, uric acid levels did not change.
Select lower-fat dairy products, and avoid sugar-sweetened yoghurts; stir in fresh berries for flavour instead.
Vegetables are slightly protective, overall, even those that contain pre-formed purines such as asparagus, cauliflower, mushrooms, lentils and spinach, as their antioxidant content neutralises the effects of the additional purines.
Select fruit and vegetables that have a high content of vitamin C, such as blackcurrants, berries, guava, kiwi fruit, citrus, mango, bell peppers and green leaves. High intakes of foods containing vitamin C promote uric acid excretion so that blood levels of uric acid fall, along with the risk of gout.
Protective food and drinks (reduced risk)
|Vegetable source purines||Highest versus lowest quintiles||0.96 (4% reduction)|
|Total caffeine||Highest versus lowest quintiles||0.83 (17% reduction)|
|Tea||4 or more cups per day versus none||0.82 (18% reduction)|
|Decaffeinated coffee||4 or more cups per day versus none||0.73 (27% reduction)|
|Low fat dairy products||Highest versus lowest quintiles||0.58 (42% reduction)|
|Total dairy products||Highest versus lowest quintiles||0.56 (44% reduction)|
|Total vitamin C (fruit, veg and supplements)||>1,500mg versus < 250mg/day||0.55 (45% reduction)|
|Coffee||6 or more cups per day versus none||0.41 59% reduction)|
So the good news here is that you can continue drinking tea and coffee as these promote uric acid excretion via the kidneys to protect against gout. Adding low fat milk will have additional beneficial effect.
The best anti-gout diet
Putting all the above together, the best anti gout diet is one that provides plenty of high-fibre, mainly plant-based foods that are rich in vitamin C – lots of berries, fruit and vegetables, with only small amounts of seafood, meat and sugars.
Low-fat dairy products (skimmed milk, low-fat yoghurt) offer strong protective effects against gout, so eat these regularly – aim for the equivalent of at least a pint (600ml) of milk per day and you will get good intakes of calcium and phosphorous, too.
Dark blue-red pigmented fruits such as cherries, grapes, blueberries and bilberries contain both vitamin C and antioxidant polyphenols that lower uric acid levels and prevent gout attacks. A study involving 633 people with gout found that those who ate cherries every day were 35% less likely to experience a recurrent gout attack than those who ate none. When cherry intake was combined with preventive medication (allopurinol) the risk of gout attacks was 75% lower than during periods without either. (See cherry extracts below).
Apples contain malic acid which helps to keep uric acid in solution so it is flushed from the body – I firmly believe that an apple a day does keep the doctor away!
Drink at least 2 litres of water per day to maintain hydration. This will help to dilute uric acid concentrations and keep it dissolved so it is less likely to crystallise out into joints or tissues. A good fluid intake will also help to reduce the formation of uric acid kidney stones.
Limit your intake of seafood, offal, game and other meats. If lobster and steak surf’n’turf is one of your culinary pleasures, then moderation is the key. A small indulgence every now and then – backed up with plenty of cherries and vitamin C – may not trigger an attack.
Avoid spirits and beer which increase uric acid production and reduces its excretion – especially beer which is particularly rich in purines. A little wine – even red wine – may be okay as long as you stick to just one or two glasses once or twice a week.
Indulge in as much tea and coffee as you like, with added low-fat milk.
Avoid all fizzy soft drinks and any other food or drink that is sweetened with sugar or fructose, as these have been shown to significantly increase the risk of gout even more than seafood and meat. Diet soft drinks also increase the risk of gout and are best avoided.
Food additives can trigger gout
Check labels of bought foods and avoid those that list the following additives which are metabolised to increase production of uric acid:
|Fructose||Disodium guanylate||Disodium inosinate|
|High fructose corn syrup||Guanosine monophosphate||Calcium inosinate|
|Fruit fructose||Calcium guanylate||Potassium inosinate|
|Crystalline fructose||Guanylic acid||Monosodium glutamate (MSG)|
|Isoglucose||Dipotassium guanylate||Sodium glutamate|
|Glucose/fructose syrup||Potassium guanylate||2-aminoglutaric acid|
|Table sugar (sucrose, which is 50% fructose)|
|Honey (whose sugar is 52% fructose)|
In the EU some of these may appear as additive numbers, so avoid foods listing any of the following: E620, E621, E622, E623, E624, E625, E626, E627, E628, E629, E630, E631, E632, E633, E634, E635.
MSG is also present in flavourings described as: hydrolysed vegetable protein (HVP), hydrolysed plant protein (HPP) and ‘Natural Flavour’.
Natural gout treatments
A number of food supplements can reduce gout symptoms, of which one of the most important is vitamin C.
Vitamin C protects against gout
High dose vitamin C mobilises uric acid from the tissues and increases its excretion via the kidneys.
In the large healthcare professionals study, a separate analysis was carried out to investigate links between vitamin C intake and the risk of gout in men. This showed that men who took vitamin C supplements at a dose of 1g up to 1.49mg per day were 34% less likely to develop gout than those who did not use them. Those who took doses 1.5g vitamin C per day, or more, were 45% less likely to develop gout.
If you are prone to indigestion, the form of vitamin C known as ester-C is best as it is non-acidic. Otherwise, a sustained release vitamin C will help to provide protection throughout the day.
Cherry extracts protect against gout
A one year study investigated the relationship between cherry intake and the risk of recurrent gout attacks among 633 people with gout. This showed that eating cherries or taking cherry extracts significantly reduced the risk of a gout attack during the following two days by 35% to 45% compared with no intake. The protective effect of cherries persisted regardless of gender, weight, purine intake, alcohol use, diuretic use or taking anti-gout medications. When cherry intake was combined with allopurinol use, the risk of a gout attack was 75% lower than when not taking either. The researchers concluded that cherry intake is associated with a lower risk of gout attacks.
Omega-3 fish oils may protect against gout
As you are probably eating little oily fish, because the flesh can increase gout attacks, it’s important to take an omega-3 fish oil supplement. These will ensure good intakes of the long-chain polyunsaturated fats, DHA and EPA, which do not increase purine or uric acid levels. Omega-3 fish oils has a beneficial anti-inflammatory action that can reduce joint pain, stiffness and swelling.
Researchers have found preliminary evidence that low omega-3 fatty acid levels are associated with more frequent gout attacks, so a supplement is a good idea if you are cutting back on fish protein intakes.
Krill oil which provides omega-3 DHA and EPA plus powerful antioxidants (astaxanthin, canthaxanthin) have even greater anti-inflammatory effects. These have not yet been investigated for their benefits in gout, but omega-3s do have proven benefits for the heart, circulation and brain.
Probiotics may help against gout
Interesting research suggests that people who experience gout attacks have a different population of bacteria within the bowel than those who do not. A preliminary study suggests that oral probiotic supplements containing the strain Bifidobacterium longum 5(1A) may reduce gout-related inflammation.https://www.ncbi.nlm.nih.gov/pubmed/26322542 Human studies have not yet been carried out to confirm this, but as probiotic supplements have other gut health benefits, they will not do any harm and may well do some good.
Supplements to avoid if you have gout
Avoid supplements containing more than the recommended daily amount (100% RDA, NRV or DV) of vitamin B3 (niacin) or vitamin A, as high doses can increase uric acid levels.
Medical treatment of acute gout
All the above measures can be used together with medical treatments for gout which usually involve high-dose non-steroidal anti-inflammatory drugs (eg diclofenac, indometacin, naproxen) which are started as soon as possible in an acute attack and continued until 48 hours after the attack resolves.
Paracetamol may be used for pain relief, but avoid aspirin as this raises uric acid levels further.
Sometimes, corticosteroid injections with a may be suggested if only one joint is affected.
Rest and elevation are important to avoid injuring the affected joint. Applying an ice-pack may help.
If you have two or more attacks of gout a year, prophylactic medication such as allopurinol or febuxostat may be prescribed to lower blood uric acid levels. As allopurinol can sometimes precipitate an acute attack of gout when first started, they are not used until at least 2 weeks after inflammation has settled down. In addition, these prophylactic drugs are usually prescribed together with a non-steroidal anti-inflammatory drug for at least the first 6 weeks of treatment.
Uric acid lowering medication is normally needed for life, with regular monitoring of blood uric acid levels and kidney function. If medication is stopped, there is no guarantee that further episodes of gout will not occur.
Always keep some NSAID anti-inflammatory medication available to start immediately if symptoms develop.
I hope you’ve found the above helpful. Please share your experience of diet and gout via the comments box below.