Jerry, a 32-year-old male, was diagnosed with gout in March 2015. So he booked an appointment with his doctor who gave him a cocktail of drugs, told him to lose some weight and stop eating red meat, legumes and full-fat dairy products. However, although Jerry adhered strictly to his treatment plan – he even loss his excess weight – he continued to suffer from gout flare-ups! So he decided to drastically change his diet and adopt a vegetarian diet. And guess what? The flare ups didn’t disappear! So what gives?
What if I told you that the general diet guidelines for gout management need some serious polishing? Keep reading to find out how to beat this debilitating condition for good.
What exactly is gout?
Did you know that in earlier centuries, gout used to be described as the ‘disease of kings’ or the ‘rich man’s disease’? In those days, gout was rampant in the upper class or among the royalties and aristocracies since they were the ones who could afford expensive foods such as port, meat and sugar. In the 1950s, uric acid was identified as the bad guy causing gout.
One important point to note here is that uric acid is an important antioxidant – it is responsible for the neutralization of over 50% of the free radicals in the bloodstream and thus protects blood vessels from damage. However, when uric acid levels rise beyond their limit of solubility, monosodium urate can begin to precipitate out of the blood. When this happens, needle-like crystals are formed mostly in cartilage and fibrous tissues where they can reside for years without causing issues. These crystals can either re-dissolve in body fluids and enter the circulation or they may enter joint spaces or bursa (the fluid-filled sacs that act as a cushion between tendons and bones around a joint). When they get into joint spaces or bursa, these crystals are engulfed by immune cells – this activates localized inflammation leading to excruciating pain and swelling characteristic of gout.
What are the risk factors for gout?
The primary risk factor for gout is hyperuricemia (high levels of uric acid in the blood). However, someone with hyperuricemia will not necessarily develop gout. The risks increase with:
- Age – gout is more common in men
- Renal insufficiency
- Excess body fat
- Early menopause
- The use of drugs such as loop and thiazide diuretics, antituberculous drugs, cyclosporin, and levodopa – effects are reversible upon discontinuation.
Why all the fuss about purine containing foods?
You’ve probably heard that individuals suffering from gout should avoid purine-rich foods such as:
- Organ meats like kidneys, liver, brain and sweetbreads
- Seafood like sardines, scallops, mussels, anchovies, herring and mackerel
- Red meat
Purines are substances present in pretty much all plant and animal cells – they provide some of the chemical structure of both DNA and RNA. When cells are broken down and recycled, the purines also get metabolized: one of the byproducts of purine metabolism is uric acid.
So here’s how the standard tale goes: if uric acid is obtained from the breakdown of purines, then the logical course of action would be to reduce one’s intake of purines. If you reduce purines which turn into uric acid, risks of hyperuricemia will go down and gout can be avoided. Problem solved! Or worsened?
My beef (no pun intended) with this logic is that it makes gout sufferers eliminate lots of traditional foods that are nutrient-dense only to replace them with more carbohydrate and fructose-rich foods. In one study, researchers reported that ‘the conventional low purine diet approach allowing fructose intake could potentially worsen the overall net risk of gout attacks.’ Plus only about one third of the body’s uric acid comes from dietary purines; the other two third is produced by the body itself. And guess what? Research shows that eating purines actually increases uric acid excretion in order to maintain balance. So doesn’t it make sense to normalize the amount of uric acid produced by the body first?
Then why do many health professionals see red meat consumption as a risk factor for gout?
Well, red meat is typically a component of the Standard American Diet, a diet that is also loaded with sugar, sweetened beverages, industrial seed oils, refined grains and processed meats while being low in naturally occurring antioxidants from fruits and veggies. As such, it is almost impossible for epidemiologists to isolate meat consumption from this modern pattern of eating. While it is true that most studies will try to control for these confounding factors, the truth is that, since red meat has been so constantly demonized, most individuals who consume a lot of meat often have other unhealthy habits such as smoking and drinking. They are also usually more overweight than low meat consumers who are often more ‘health conscious’ (many individuals still believe that meat is unhealthy and thus eat less meat). Plus, in Western countries, the most commonly consumed organ meats are gizzards and livers fried in industrial oils (which are often accompanied by a super-size sugary drink).
Disclaimer: There might be some people out there who would really benefit from a diet low in meat (whether it’s the purines or something else) so always talk to your doctor first – this article is not intended to act as a substitute for medical advice.
The REAL villain behind gout attacks: Inflammation
In my practice, I usually advise my patients to enjoy quality animal protein while switching to a real-food, anti-inflammatory diet and adopt healthy lifestyle practices. Of course, these are general guidelines which need to be tailored to the individual patient. For instance, many of them also have to adopt an autoimmune protocol or a specific-carbohydrate diet.
Although a high purine intake has been linked to gout attacks in those who are already suffering from hyperuricemia, research shows that purine intake alone is not enough to trigger gout flares. In fact, uric acid levels are often decreased during these attacks! Another factor associated with gout attacks is an increase in C-reactive protein (CRP) and interleukin-6, substances that indicate inflammation. These inflammatory molecules are increased in the joint fluid and serum of individuals with acute gouty arthritis.
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