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.

 

Got a headache?

Ever get a headache?  I would say that most people I talk to have experienced a headache in the last couple of weeks. Indeed, a 2014 telephone survey found that headaches were one of the top five symptoms reported on a weekly basis, with over one-third of those questioned experiencing an episode. Increasingly, it is more than an infrequent occurrence that can be put down to an occasional late night (lack of sleep), being dehydrated or too much alcohol the night before. In fact, I think that headaches have come to the point where we’ve normalised them so much we barely see any reason to pay them much credence. Everyone gets a headache – what’s the point in worrying about it? Nothing ibuprofen can’t fix.

In my opinion, this normalisation of pain is how we’ve addressed (or not) the chronic stress, tiredness, bloating, inability to wake up properly or the slight malaise we might feel on a day to day basis. For a lot of people what I’ve described is just ‘life’. There’s no point complaining because this is what everyone is experiencing so we may as well buck up and get on with it. Like all of the conditions I’ve mentioned above, frequent and recurring headaches impact massively on quality of life. While obviously migraines are a type of pain that would cause more disruption to everyday life, a headache shouldn’t just be dismissed either. It’s a sign that something is out of balance in your life that you should probably address. That said, a closer look at your diet might reveal elements which could be changed or optimised to reduce the likelihood ot these occurring, Specifically, there are nutrients which have been found (in addition to an awesome diet) to be useful for reducing severity and frequency of headaches or migraines occurring. While the jury is out on both omega 3 fatty acids, and vitamin D (with some research suggesting that too much vitamin D may have the opposite effect), there is fairly good evidence to suggest that these may be useful:

Magnesium: in powder form, along with a citric acid or as an amino chelate – up to 600mg per day over three months (this might equate to 2.5g – 5g of powder from a brand such as Bioceuticals Ultraeaze). Studies have shown that many experience a reduction of attacks by up to 41%. Now that is significant.

CoQ 10: not just as part of face cream, in doses of up to 300mg/day (which is fairly substantial) has been found to reduce frequency of attacks and also symptoms of nausea associated with headaches.

Riboflavin: this amino acid in doses of 400mg/day over four months have also been found to reduce severity and frequency of attacks – people of European background are more likely to respond than others due to genetic differences.

A well balanced whole food/paleo diet contain substantial amounts of these nutrients. Magnesium is abundant in vegetables, animal products and fruit; CoQ 10 present in salmon, sardines, red meat, nuts such as almonds, and seeds such as sesame   seeds; and riboflavin is found in substantial amounts in cheese, beef, pork, eggs and oily fish. However if you are consuming such a diet and not experiencing relief, it might be worth considering supplementing in addition to this.

Now people who experience migraines are likely to know which foods trigger an attack. A well studied group of amino acids have been found to trigger headaches and migraines in susceptible people: tyramines, histidines and arginine.

  1. Tyramines: are found in fermented foods (such as sauerkraut, kimchi), blue cheese, broad beans, beer and sulphate-containing wine, dried fruit, grapes, cured meat and fish (not a complete list). Some people lack the enzymes to inactivate these and it can lead to a build up in the blood, causing temporary nausea, increase in blood pressure, sweating and migraine headaches. Tyramines are found in fermented foods (sauerkraut, kimchi, yoghurts), blue cheese, broad beans, in beer, wine that contains sulphates, other sulphur-based dried fruits, grapes, cured meat and fish.
  2. Histamines: are a result of the conversion of an amino acid histidine by two enzymes diamine oxidase and histamine N-methltransferase. People who have low levels of these enzymes have a build up of histamine in the body as they are unable to metabolise it. Histamines, like Tyramines are found in fermented based foods, along with all alcohol and vinegars. Other sources are fruits such as strawberries, avocado, and bananas, vegetables (tomatoes, spinach, eggplant) and nuts including walnuts, peanuts and cashews.
  3. Arginine: is an amino acid that causes vasodilation of the blood vessels by increasing the amount of nitric oxide in the blood. Great if you’re an athlete wanting to go at higher intensities, not so great if it causes pain through vasodilation and expansion of the cranial blood vessels. Avoiding these foods can minimise this, and nuts and chocolate have the highest amount of arginine in them. (As a side note, people who might experience break outs in the herpes virus have been recommended minimising these foods in their diet).

Not all of these groups of food are going to affect everyone, and not all foods within the different groups are going to trigger a migraine or tension headache, but it’s a process of figuring out which ones do by eliminating them from the diet for one to three months to see if there is respite from frequent migraine headaches, then reintroducing them (as you would any food).

There are many things which affect frequency and severity of headaches and migraines. Like other stressors, the effects of these (or anything) that might trigger an attack can be made worse depending on overall stress load. If you are lacking in sleep, relying on sugar or coffee for energy, have a lot on your plate at work, drinking too much alcohol (etc) then you may well experience more of an effect compared to other times where you feel a little more on top of things. So while you can remove certain foods from your diet and optimise others to minimise attacks in the short term, looking at the root cause of what is causing the headaches is clearly the best option long term.

Snapshot of the brain 2 (and a bit of a related, but slightly off topic vent).

Now… where was I? Oh yes. The brain. As I said in my brain post three weeks ago, it’s not just calories and energy required to fuel it – in fact, if that’s all that you relied on, your cognitive function would diminish, brain fog would ensue and overall brain mass would reduce. Seriously. The importance of a nutrient-rich diet cannot be overstated when it comes to a healthy body and mind, at which the brain is at the centre of. The myriad of reactions and interactions of nutrients in the brain is too involved for me to adequate write up here, and as you know, scientific scribe is not how I roll, so this is a very brief overview, combined with a bit of a vent (my favourite).

In order to convert the calories provided (either by glucose, fat or lactate) into ATP for the mitochondria to use (energy to be produced), riboflavin and niacinamide (B vitamins), Co-enzyme Q10 (not just good as part of a skin cream) and magnesium are required to enable reactions at various stages of the process. Antioxidants are also required to scavenge free radicals so they do not damage cellular tissue through oxidation. The B vitamins and amino acids are important as neurotransmitters to send messages from the brain to various parts of the body. Magnesium is like a super mineral – involved in over 300 processes in the body – it has a really important role in the brain, acting as a ‘guard at the gate’ if you like, blocking excess calcium and glutamate from entering the cells. Both of these can increase cellular damage due to their excitatory effects in the brain. Magnesium also exerts control over the hippocampus, preventing it from stimulating the release of adrenocorticotropic hormone, or ACTH. ATCH instructs our adrenal glands to pump out both cortisol and adrenaline in times of stress, and magnesium inhibits these hormones from entering the brain and causing additional cellular damage. Thank you, magnesium, you’re not just good for relieving constipation and regulating insulin sensitivity.

Vitamin D has a neuroprotective role, promoting their survival and reducing damage – hence its association with the preservation of cognitive function in the brain. It helps reduce inflammatory factors related to neurological disorders such as multiple sclerosis and there is an association between vit D levels and depression – with receptors for the active form of Vitamin D found in the hippocampus.

Vitamins C and E are antioxidants, and clinical trials have shown that adults who supplement these two vitamins improve their cognitive function when compared to a placebo group. Iodine has been found to be particularly important in the development of the brain, and if a pregnant women has an insufficient intake of iodine, their baby may be born with a low birth weight, cognitive impairment and their physical development impaired. Sulfur is another component that contributes to antioxidant activity and acts as a neuroprotector in the brain.

Docohexanoic acid (DHA) is a long chain fatty acid that is found pre-formed in fatty fish such as salmon, sardines and mackerel. It may be the most studied nutrient with regards to the brain and is the most abundant omega 3 fat found in the cell membranes of the brain. Our body is not good at synthesising it and the conversion of it from plant-based sources such as alpha-linoleic acid is poor. It’s important for ensuring membrane fluidity, protects membrane integrity and is involved in the development of synapses. Indeed, archaelogists suggest one of the pertinent factors in humans having an encephalisation quotient as big as we do is largely due to early populations living close to the shore line and having access to marine life. Associations have been drawn between fish consumption and neurological function. In addition, in health older adults, more essential fats , vitamins and minerals present in bloodstream is associated with bigger brain, better cognitive test. Higher intake trans fats and processed food – smaller brains, lower cognitive function.

So when you do hear ‘a calorie is just a calorie’ as is often touted, particularly in the weight loss arena where the argument of a calorie restricted diet versus the nutrient-focused diet is often played out, you can see that this just isn’t true. A calorie restricted diet is often too restrictive, not only making fuel availability questionable at certain times, but not focusing on the right macronutrient calories – given that carbohydrate is much less calorie dense than fat. In addition, the focus on calories shifts attention away from the all important micronutrients I’ve listed above (among others) which are essential for brain functioning and (importantly) overall mood and wellbeing. No wonder those on a 1200 Calorie diet counted by adding up the numbers on the back of their cereal boxes, muesli bar wrappers and diet yoghurt containers don’t get the same feeling of calm and nourishment that comes when following a real food approach. The addition of nutrients to cereals by way of fortification doesn’t help – particularly if the delivery vehicle is a cereal that has additional gluten added to bump up the protein content (i.e. Special K; a topic deserving a blog post all on it’s own). Unfortunately when we consider all of the elements that promote and preserve brain health in light of what people are actually buying, then it doesn’t make for a pretty picture. Take this for example – the top 10 foods sold by volume in supermarkets in 2009. Bar the bananas, all foods on the list are nutrient devoid.

ANCESTRAL HEALTH 19 Jun]

Thanks, Jamie for this info.

In NZ currently, we have children who are over-represented in both the low academic achievement rates and the lower socioeconomic sections – these are interlinked obviously. Further, these children tend to have a poorer diet – with less fibre, less calcium, less fruit, cheese and milk than their school-aged peers. As these foods are important contributors to the aforementioned nutrients above, is it any wonder that those most disruptive in class, less likely to achieve academically are less likely to finish high school? There are clear links between diet and hyperactivity, concentration, and even cognitive development – the available nutrients include those delivered from the mother prenatally. How are these children supposed to further themselves if they don’t have the right start in life.

Yes, in NZ we have the Fonterra breakfast in schools programme (Kickstart) – now funded and widely available to those less privileged in decile 1 schools. Is it better than nothing at all – yes? Are weetbix and milk the best we can do? I don’t think so. What about government funded school based gardens/kitchens? What about attention in the curriculum to teach children the fundamentals of good nutrition, perhaps through an integrated curriculum? Teach them the importance of it in an environment that supports it – not in one where all attention is pushed towards ‘energy out’ physical activity model. School Food and Beverage guidelines? Bring it. Much better than the voluntary system that is in place now in schools. All of these take time, resources, investment – the government has a $40 million healthy lifestyles initiative which looks at supporting communities to make healthier choices, which – if included the above – could be promising. However the first sentence on the website doesn’t fill me with much hope: “Encouraging families to live healthy lives – by making good food choices, being physically active, sustaining a healthy weight, not smoking and drinking alcohol only in moderation – is part of the Government’s approach to promoting good health.” Not because I don’t think the government should be doing this – but this is no different from what they’ve always said. People need more than encouragement – they need infrastructure to make it easier. Anyway, let’s see.