The Gout: what you need to know and 7 things you can do about it.

  1. Gout is an auto-inflammatory disease caused by a disorder in purine metabolism and the resulted chronic elevation of blood (serum) uric acid (i.e., hyperuricemia)
  2. Men have a higher risk of gout at a lower given blood level of uric acid, and at a lower age than women – generally 10 years earlier.
  3. Women who go through early menopause, or have estrogen deficiency are at higher risk than women who progress through menopause at a normal age, due to oestrogen’s role in increasing uric acid excretion.
  4. Insulin resistance increases risk of gout, as insulin reduces uric acid secretion. The relationship between insulin resistance and gout is more pronounced in women than in men.
  5. There is a bi-directional relationship between high blood pressure and gout: ie if you have high blood pressure, your risk of gout goes up (independent of diuretic medication that is taken), and if you have gout, your risk of developing high blood pressure also increases. High blood pressure can result in damage to kidney and a reduction in uric acid excretion, and the inflammation associated with gout can stiffen and damage arterial walls, and reduces production of nitric oxide – which helps widen arteries.
  6. Genetics play a role in determining risk associated with gout – and people with a particular genetic profile (such as those of European descent with the SNP sequence SLC2A9 as an example) have an increased risk, as do those with ABCG2 rs2231142. However, as with any genetic risk factor, lifestyle determines if these genes are switched on or off, so while this information could be useful (and more people are starting to find out their genetic profile and determine what it means for their health), it is your lifestyle habits predominately regulate overall risk
  7. Triglycerides increase in the bloodstream when people overeat refined carbohydrate foods, and recent research suggests a reduction in serum uric acid occurs when triglycerides decrease.
  8. Alcohol intake is associated with an increased risk of gout – beer more so than wine.
  9. Overall fructose load in the diet is the only type of carbohydrate that is known to increase uric acid levels, potentially because when metabolised, it depletes phosphate and therefore doesn’t help produce ATP (energy) in the body and instead increases uric acid production. Fructose from processed food (and particularly sugary sweetened beverages) can elevate insulin levels and increase risk of insulin resistance. There may be a genetic element to this also, with people who have polymorphisms in SLCA9 and ABCG2 genes responding unfavourably to a load of fructose.
  10. A large cross sectional survey found that people following a vegan diet had the highest serum uric acid concentrations compared to fish eaters, meat eaters and vegetarians, independent of smoking status or alcohol intake.
  11. While seafood is often cautioned against for people who experience gout due to its purine content, a number of studies have failed to find a relationship between seafood intake and serum uric acid levels. Those that have found a relationship may not have adjusted for body mass index (BMI), which can confound the relationship as it did in this study. Indeed, those populations who are at greater risk today (such as Maori and Pacific among New Zealand population) enjoyed a traditional diet of predominantly seafood, vegetation, tubers and gout was non-existent.

What to do?

  1. Look after your gut. Bacteroides caccae and Bacteroides xylanisolvens are increased, and Faecalibacterium prausnitzii and Bifidobacterium pseudocatenulatum depleted in the gut of people who experience gout, suggesting a strong correlation with the presence of gout. F prausnitzii is one of the most abundant bacterium in the gut of a healthy individual, helping produce short chain fatty acids butyrate, which is fuel for our gut bacteria, and the provision of B pseudocatenulatum improves markers of gut wall integrity. So these are pretty important! While this doesn’t necessarily mean that the provision of certain bacteria through probiotics will reduce gout attacks, it does suggest that inflammatory processes of the gut play a role in the presentation of gout and provides further evidence of the importance of a diverse population of bacteria in the gut for overall health.
  2. Supplementing with 1500mg vitamin C reduces serum uric acid and its antioxidant functions may also help kidney function by reducing inflammation.
  3. Like your coffee? You don’t have to go without if you have gout and in fact, 4-5 cups per day have found to decrease serum uric acid that isn’t seen with green or black tea, or total caffeine intake. Decaffeinated coffee has afforded similar benefits, leading investigators to suggest the phenol content (phytochemicals) might increase insulin sensitivity and decrease serum insulin, as discussed above insulin levels have a positive correlation with uric acid due to decreased renal excretion. Furthermore, xanthines, either in caffeine or in coffee itself, could inhibit xanthine oxidase – an enzyme that increases reactive oxygen species (and inflammation).
  4. Magnesium intake is associated with a decreased serum uric acid level in males, and marginal intakes is associated with higher levels of markers in the body indicative of inflammation. Magnesium is low in soil which makes dietary sources of the micronutrient not as high as they once were, therefore supplementing with magnesium of 300-600mg/day (depending on bowel tolerance) is likely a good idea. (To be honest, I’m a big fan of magnesium supplementation for pretty much anyone male or female, given it’s a co-factor in over 300 processes in the body).
  5. Tart cherry extract – not just useful for sleep – is found to reduce the prevalence of gout flare ups in cross sectional studies, potentially due to the presence of polyphenols including anthocyanins, and vitamin C found in the fruit, which have anti-inflammatory and antioxidant affects.
  6. The consumption of low fat dairy products is linked to a lower risk of gout in larger population studies.*
  7. Anecdotally (as in, I didn’t find any study on pubmed to support this), baking soda is used to increase pH level of the blood (¼ teaspoon in water), thus making uric acid in the blood able to be excreted. If you know of any studies around this that I’ve missed, let me know!)

The take-home?

While a low purine diet is often recommended as a dietary prescription for people with gout, many purine-containing foods (such as seafood and vegetables) do not contribute to hyperuricemia or gout and may in fact be protective. The effects of red meat consumption on serum acid levels are arguably hard to disentangle from other elements of the modern dietary pattern, and are often in conjunction with higher alcohol intake, lower fruit and vegetable consumption and higher fast-food intake – all contributors to inflammation in the body. In addition, the agricultural practices of the cattle industry in countries such as the US where many of the epidemiological studies that associate red meat with poor health (including higher serum uric acid levels) include the use of antibiotics, poor farming practices and animals that are grain and not grass fed, altering the fatty acid profile of the meat to be higher in omega 6, pro-inflammatory fats. Furthermore, processed and fresh meat is often grouped together – thus a steak is viewed the same as a hamburger from a fast-food outlet – the latter often being in the company of a bun, fries, mayonnaise made with industrial seed oils and a sugar sweetened beverage – the adverse effects which many, myself included, argue cannot be adjusted away by a statistician when determining risk.

*I don’t think you need to start consuming low fat dairy if right now you’re enjoying the benefits of full-fat dairy in the context of an awesome diet. I think this could well be indicative of overall lifestyle patterns. I’d be surprised if there were studies showing that risk of gout is increased in a diet that is whole food, minimally processed, an abundance of vegetables that also incorporated full-fat dairy products.

 

Raise your glass: a toast to Dry July.

Well, we’ve made it. It’s 2/3 of the way through calendar winter and, for Auckland at least, the climate starts to feel a lot more like spring (despite the deluge of rain this morning). Along with that, we can all raise a glass to those who participated in Dry July. A month without a drop of alcohol is, for some, a big deal. Earlier in the month there was an opinion piece in the Herald regarding Dry July, questioning the utility of it – asking what the point of going one month alcohol free when actually people should look to having a few alcohol free nights per week instead. For those who follow my Facebook page, you’d have seen my initial comments about it. There’s no dispute that choosing to drink moderately throughout the week and including alcohol free nights per week is important; certainly the toxic effects of excess alcohol consumption on inflammation and our organs that contribute to chronic disease are well established. But to my mind, the editorial missed the point. Yes, Dry July is an exercise in abstinence that isn’t a long term approach to alcohol consumption for most. However some people who undertake the challenge, sponsored or not, choose to do it because they are curious as to the impact that not drinking will have on their wellbeing. And these aren’t people who you might consider would ‘need’ it.

A client of mine is just that person. She wasn’t close to the maximum of two standard drinks per day, 14 in total across a week. She enjoyed just one on most nights throughout the week, perhaps two at the most on the weekend. The last time she drank what she would consider ‘too much’ was back in 2008 on a girls night out. And it wasn’t that one drink made her feel drunk – or feel anything other than relaxed – however there was a nagging thought in the back of her mind that the attachment to the glass of wine wasn’t a good thing. She didn’t hang out for the wine from 8am in the morning but it was a little oasis of relaxation in an otherwise busy day that started before 5am with an ironman training session, to move swiftly into her role in a busy insurance firm to another training session to finally arrive home for dinner at around 8pm. It was the only thing that helped her wind down and there was nothing she enjoyed more than that glass of wine as she prepared dinner. We had a discussion about this. While she enjoyed the glass of wine with her partner, she would also take pleasure in drinking it by herself. Her main fear centred less around the physical damage of her drinking but the psychological pull. Her parents are heavy drinkers and have been for years, so alcoholism is something that runs in her family. For her, going alcohol free was as big a deal as the person who has a drink or three after work and then one with dinner four or five nights a week.

What she noticed across the course of the month was interesting. As she reflected back to me this week, she said that the first week was eye opening. She realised that she had been waking up feeling slightly groggy and dehydrated for years without realising it. It wasn’t until she decided to go cold turkey that she discovered it wasn’t a natural state for her to be in. Even the seemingly small amount that she drunk had that effect on her. While the first week was a little strange – as the habit of a glass of wine after work has been ingrained for years – it became easier across the course of the month to go without. In fact, by the end of week four, with just a few days remaining, she realised the main issue for her giving up the wine was the question as to whether or not she would go back to drinking it. The exercise in abstinence proved that she could go without – however to reintroduce it suddenly put her in a conundrum. Would that attachment still be there? Yes, likely – it’s only been a month. The question of whether or not she should drink alone also came up. For some, this type of drinking is a red flag for a more serious drinking problem. However, this isn’t the case for everyone, and I didn’t see it as an issue with this client particularly. The association of guilt here is a lot like guilt around food – I think that in itself can be problematic. If you feel guilty for the drink that you have, you are more likely to drink quickly (almost like it didn’t happen) and not enjoy it. For some, this could also increase the amount being consumed as ‘this is the last time I’ll have a drink by myself.’

The thoughts going around her head were largely related to her family history – which is why she decided to do Dry July in the first place. The one thing she was most concerned about was the possibility that the first drink could open the flood gates and she would be on a slippery slope from one drink a night to two bottles of wine. You’d probably agree this seemed extremely unlikely. She’d been drinking this way for at least 10 years and it hadn’t cascaded into more problematic behaviour. We bandied about ideas that could help her enjoy her wine without the associated (and unnecessary) guilt – but this put rules on it which also didn’t make her feel comfortable. In the end we decided that, if she felt like a glass of wine, she would first have a sparkling water to satiate her thirst, then pour a glass if she felt like it. This solution may mean the end result wouldn’t look any different from what she was doing before Dry July, but it might at least offset the dehydration she felt. Also, for anyone who drinks, this is a good way to slow down how quickly you consume alcohol, especially those who neck the first drink due to thirst. I also always recommend to clients they back up every alcoholic drink with a non-alcoholic, sugar free option. That way they would drink only half as much as they would normally. I’d say I have about a 30% hit rate with that little gem. Those who do it though report feeling a lot better the next day, heavy drinkers or not.

So, raise your glass (of your drink of choice – alcoholic or not) to Dry July, as it creates an awareness around drinking behaviour – for heavy and light drinkers alike. Cheers.