Don’t let gout get your goat

Niti Desai

Historically, gout has been associated with affluence and overindulgence of rich foods such as meat, seafood and alcohol. Traditionally, gout has been known as a problem of the wealthy or a first world’ problem, but we are seeing increasing number of  people with gout or raised uric acid levels in metros. It is one more of the lifestyle diseases which may soon reach alarming numbers. Gout is a vastly undertreated disease. Latest research suggests that elevated uric acid, by itself, even if you have no gout, is associated with higher rates of heart attack, metabolic syndrome and diabetes. It would be advisable to get uric acid levels under control, through diet or medication. Gout is a type of arthritis, which primarily occurs when high levels of uric acid in the blood get deposited as crystals and accumulate around a joint.

How do you get uric acid in the body? Uric acid is a waste product that is produced when the body breaks down purines. Purine occurs naturally in our bodies and these are also found in protein-rich foods. Generally, uric acid is eliminated from the body through urine.

A diet rich in purines from certain sources can raise uric acid levels, which sometimes leads to gout. The principle of a gout diet would therefore be to reduce the intake of purine-rich foods so that the body does not produce more uric acid.

Generally, treatment for gout focuses on eliminating all foods that are rich in purines. The list of foods to avoid becomes so long making the diet difficult to follow.

However, recent research on gout has given us a clearer picture of the role of diet in the treatment of gout. It is more important to follow healthy eating guidelines, rather than just eliminating certain foods.

Some foods should be avoided, but not all foods with purines need to be eliminated, and in fact, some foods should be included in the diet to control uric acid levels. The most important changes needed, dietary and otherwise, would be:

To lose weight if one is overweight or obese

This is perhaps the single most important factor.  Being overweight increases the risk of developing gout and vice versa. Even if you just lose weight without following a purine-restricted diet — the uric acid levels will drop and there will be a reduction in the number of gout attacks. Losing weight also lessens the overall stress on joints.

• Restrict fat intake: Limit the intake of high fat foods such as – fried foods, namkeen, sweets, mithai, cakes, pastries, red meat and full fat dairy products.
• Proteins: If you are a hardcore non-vegetarian, then you need to worry about limiting your protein intake.
• Organ meats: Completely avoid organ meats such as liver, kidney, brain, meat extracts and gravies which have high purine levels.
• Avoid some seafood: Avoid some types of seafood, which are higher in purines than others: herring, sardines, mackerel, tuna and shell fish such as mussels, crabs, shrimps, fish roe and caviar.
• Restrict yourself to 100 -150 gm of fish and chicken. 
• Avoid yeast extracts.
• Add protein to your diet with low-fat / fat-free dairy products, such as skimmed milk, skimmed milk curd and paneer. Low-fat dairy in fact is associated with reduced uric acid levels.
• Include dals and pulses: Surprisingly, you do not need to eliminate dals and pulses from your diet. Most of the times, our vegetarian diet is not meeting the daily protein requirements, so if you completely eliminate these foods from your diet, weight loss will be difficult, your sugar levels will rise and you may not see any significant lowering of your uric acid levels. You must include dals and pulses in moderate amounts.
• Eat more fruits and vegetables: Studies have shown that vegetables high in purines do not increase the risk of gout or recurring gout attacks. A healthy diet based on lots of fruits and vegetables can include high-purine vegetables, such as spinach, peas, cauliflower or mushrooms. There is some evidence that eating cherries, celery and leeks is associated with a reduced risk of gout attacks.
• Some people find that certain foods such as strawberries, oranges, tomatoes and nuts trigger their gout even though these are not high in purines. Although there is no clear scientific evidence for this, it is probably best to avoid them if you have had this experience. 
• Do not skip meals and keep a long interval between meals.
• Alcohol: Avoid alcohol completely or reduce the intake of alcohol. Drinking alcohol can increase your risk of developing gout and can bring on a sudden attack if you are already a gout sufferer. Beer is most associated with an increased risk of gout and recurring attacks, as are liquors to some extent. The effect of wine is not as well-understood. 
• Drink more water: Increase your fluid intake to 2-3litres, especially water intake. Drinking fluids flushes out uric acid from the body and prevents its deposition. An increase in water consumption has been linked to fewer gout attacks.  Making the above dietary changes will give you more relief than just following the list of foods to avoid. While a gout diet may not be a cure, it may lower the risk of recurring painful gout attacks and slow the progression of joint damage.

Foods to limit (very high in purines):

• Organ meats, such as liver, kidneys, sweetbreads, and brains 
• Meats, including bacon, beef, pork, and lamb
• Any other meats in large amounts
• Rawas, sardines, mackerel and shell fish
• Meat extracts and broths
• Beer
• Yeast( baker’s / brewer’s)

Foods to eat occasionally (moderately high in purines, but may not raise your risk of gout):

• Fish and seafood (other than high purine seafood)
• Chicken
• Oatmeal and wheatbran
• Peas / brinjal
• Spinach / mushrooms
• Cauliflower 
• Chickoo / custard apple

Foods that are safe to eat (low in purines)

Green vegetables and tomatoes

Fruits

Breads and cereals 

Butter, cheese and eggs

Chocolate and cocoa

Coffee, tea, and aerated drinks

Eggs

Nuts

Dairy products that may lower your risk of gout:

Skimmed milk

Curd

Paneer

Although you may have all the desire to manage your gout with lifestyle modification, if you have had more than two attacks of gout a year or if the condition has been present long enough, then there may be a clear need to be on medication.

— The writer is consultant nutritionist in Mumbai