Rational approach to nutrition for patients with gout

Gout is a complex multifactorial disease associated with the deposition of crystals of sodium monourate in various tissues of the body and the emergence, in this regard, of chronic hyperuricemia, which is clinically manifested by acute recurrent arthritis and the formation of gouty nodes – tofus. Methods of treating gout can be divided into two groups: lifestyle modification / change in eating habits and pharmacotherapy. But, before drugs appeared, diet was the only way to treat the disease. Since ancient times, gout has been associated with excessive nutrition and excessive consumption of alcoholic beverages. In the Middle Ages, gout was often called the “disease of the kings”, explaining this, firstly, by constant plentiful meals without any measure, and therefore the kidneys of the “abusers” could not cope with the removal of a huge concentration of uric acid. And secondly, the high prevalence of this disease among male aristocrats. Ordinary people ate on a limited basis and could not afford food rich in purines, so they fell ill less often. However, in the last decade, wider knowledge has been gained about dietary factors associated with hyperuricemia and gout. Obesity, excessive consumption of red meat and excess alcohol have already been recognized as causative factors. Legumes and purine-rich vegetables have been justified after numerous studies. New risk factors have been described, such as fructose and sweetened drinks. Finally, protective factors such as low fat dairy products have been studied. Patients with gout are forced to follow a diet throughout their lives, and not only during periods of exacerbation, but now it has become easier to adhere to it, since the diet allowed for food has expanded significantly. Although most of the prerequisites for dietary recommendations have been assigned ratings of medium / low or very low quality, this article will provide the basis for changes in eating habits in patients with hyperuricemia and gout in accordance with large international studies.

gout, sodium monourate, uric acid, hyperuricemia, recommendations, diet, lifestyle, food, restrictions, treatment

1. Richette P., Bardin T. Gout. Lancet 2010;375(9711):318–28. DOI: 10.1016/S0140-6736(09)60883-7.

2. Nuki G., Simkin P.A. A concise history of gout and hyperuricemia and their treatment. Arthritis Res Ther 2006;8(Suppl. 1). DOI: 10.1186/ar1906.

3. Garrod A.B. On gout and rheumatism. The differential diagnosis, and the nature of the so-called rheumatic gout. Med Chir Trans 1854;37(1):181–220. DOI: 10.1177/095952875403700114.

4. Ebstein W. On the Regimen to be adopted in Gout. J Ment Sci 1886;32(138):255–6. DOI:10.1192/bjp.32.138.255.

5. Ebstein W. The nature and treatment of gout. BMJ 1846;Suppl. 1–10:114. DOI: 10.1136/bmj.s1-10.10.114.

6. Guyatt G., Cairns J., Churchill D. Evidence-based medicine. A new approach toteaching the practice of medicine. JAMA 1992;268(17):2420–5. DOI: 10.1001/jama.1992.03490170092032.

7. Shekelle P.G., Woolf S.H., Eccles M., Grimshaw J. Developing guidelines. BMJ 1999;318(7183):593–6. DOI: 10.1136/bmj.318.7183.593.

8. Nielsen S.M., Zobbe K., Kristensen L.E., Christensen R. Nutritional recommendations for gout: An update from clinical epidemiology. Autoimmun Rev 2018;17(11):1090–6. DOI: 10.1016/j.autrev.2018.05.008.

9. Richette P., Doherty M., Pascual E. et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2017;76(1):29–42. DOI: 10.1136/annrheumdis-2016-209707.

10. Qaseem A., Harris R.P., Forciea M.A. Management of acute and recurrent gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166(1):58–68. DOI: 10.7326/m16-0570.

11. Multidisciplinary expert task force оn hyperuricemia and related diseases. Chinese multidisciplinary expert consensus on the diagnosis and treatment of hyperuricemia and related diseases. Chin Med J (Engl) 2017; 130(20):2473–88. DOI: 10.4103/0366-6999.216416.

12. Hui M., Carr A., Cameron S. et al. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology (Oxford) 2017;56(7):1–20. DOI: 10.1093/rheumatology/kex156.

13. Kiltz U., Alten R., Fleck M. et al. Full version of the S2e guidelines on gouty arthritis: Evidence-based guidelines of the German Society of Rheumatology (DGRh). Z Rheumatol 2016;75(Suppl. 2):11–60. DOI: 10.1007/s00393-016-0147-6.

14. Sautner J., Eichbauer-Sturm G., Gruber J. et al. Austrian nutrition and lifestyle recommendations for gout and hyperuricemia. Z Rheumatol 2015;74(7):631–6. DOI: 10.1007/s00393-015-1580-7.

15. Graf S.W., Whittle S.L., Wechalekar M.D. et al. Australian and New Zealand recommendations for the diagnosis and management of gout integrating systematic literature review and expert opinion in the 3e Initiative. Int J Rheum Dis 2015;18(3):341–51. DOI: 10.1111/1756-185x.12557.

16. Sivera F., Andres M., Carmona L. et al. Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative. Ann Rheum Dis 2014;73(2):328–35. DOI: 10.1136/annrheumdis-2013-203325.

17. Sautner J., Gruber J., Herold M. et al. Austrian 3e-recommendations for diagnosis and management of gout 2013. Wien Klin Wochenschr 2014;126(3–4):79–89. DOI: 10.1007/s00508-013-0469-1.

18. Araújo F., Cordeiro I., Teixeira F. et al. Portuguese recommendations for the diagnosis and management of gout. Acta Reumatol Port 2014;39(2):158–71.

19. SER. Clinical practice guidelines for management of gout. Madrid. Spain: SpanishSociety of Rheumatology SER 2013. Available at: http://content. guidelinecentral.com/guideline/get/pdf/2948.

20. Manara M., Bortoluzzi A., Favero M. et al. Italian Society of Rheumatology recommendations for the management of gout. Reumatismo 2013;65(1):4–21. DOI: 10.4081/reumatismo.2013.4.

21. Engel B., Prautzsch H. Haufige gichtanfalle und chronische gicht in derhausarztlichen versorgung. DEGAM www.degam-leitlinien.de: Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin 2013. Available at: https://www.degam.de/degamleitlinien-379.html.

22. Bliddal H., Leeds A.R., Christensen R. Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons a scoping review. Obes Rev 2014;15(7): 578–86. DOI: 10.1111/obr.12173.

23. Yamanaka H. Japanese guideline for the management of hyperuricemia and gout: second edition. Nucleosides Nucleotides Nucleic Acids 2011;30(12):1018–29. DOI: 10.1080/15257770.2011.596496.

24. Woutersen-Koch H., Wiersma T., Janssens HJEM en and. Samenvatting van de standaard “Artritis” van het nederlands huisartsen genootschap. Ned Tijdschr Geneeskd 2009;153.

25. Ministry of Health Malaysia. Management of Gout. CPG Secretariat, Health Technology Assessment Section, Medical Development Division, Ministry of Health Malaysia, Putrajaya. 2008. Available at: https://journals.sagepub.com/doi/abs/10.1177/1010539509359535.

26. Moher D., Liberati A., Tetzlaff J., Altman D.G. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151(4):264–9. DOI: 10.7326/00034819-151-4-200908180-00135.

27. Tsurko V.V., Gromova M.A. General principles and guidelines for the management and treatment of patients with gout on the basis of updated European recommendations. Consilium Medicum 2017;19(12):20–4. (In Russ.).

28. Khanna D., Fitzgerald J.D., Khanna P.P. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: Systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 2012;64(10): 1431–46. DOI: 10.1002/acr.21772.

29. Choi H.K. A prescription for lifestyle change in patients with hyperuricemia and gout. Curr Opin Rheumatol 2010;22(2):165–72. DOI: 10.1097/bor.0b013e328335ef38.30.

30. Kalergis М., Leung Yinko S.S., Nedelcu R. Dairy products and prevention of type 2 diabetes: implications for research and practice. Front Endocrinol (Lausanne) 2013;4:90. DOI: 10.3389/fendo.2013.00090.

31. Choi H.K., Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ 2008;336(7639):309–12. DOI: 10.1136/bmj.39449.819271.be.

32. Jordan K.M., Cameron J.S., Snaith M. et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxford) 2007;46(8):1372–4. DOI: 10.1093/rheumatology/kem056a.

33. Clifford A.J., Riumallo J.A., Young V.R., Scrimshaw N.S. Effect of oral purines on serum and urinary uric acid of normal, hyperuricemic and gouty humans. J Nutr 1976;106:428–34. DOI: 10.1093/jn/106.3.428.

34. Zöllner N., Griebsch A. Diet and gout. Adv Exp Med Biol 1974;41:435–42. DOI: 10.1007/978-1-4757-1433-3_8.

35. Choi H.K., Atkinson K., Karlson E.W. et al. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med 2004;350(11):1093–103. DOI: 10.1056/nejmoa035700.

36. Choi H.K., Liu S., Curhan G. Intake of purine-rich foods, protein, and dairy products and relationship to serum levels of uric acid: the Third National Health and Nutrition Examination Survey. Arthritis Rheum 2005;52(1):283–9. DOI: 10.1002/art.20761.

37. Zgaga L., Theodoratou E., Kyle J. et al. The association of dietary intake of purine-rich vegetables, sugar-sweetened beverages and dairy with plasma urate, in a cross-sectional study. PLoS One 2012;7(6):38123. DOI: 10.1371/journal.pone.0038123.

38. Fam A.G. Strategies and controversies in the treatment of gout and hyperuricaemia. Baillière’s Clinical Rheumatology 1990;4(2):177–92. DOI: 10.1016/s0950-3579(05)80016-0.

39. Choi H.K., Atkinson K., Karlson E.W. et al. Alcohol intake and risk of incident gout in men: a prospective study. Lancet 2004;363(9417):1277–81. DOI: 10.1016/s0140-6736(04)16000-5.

40. Zhang Y., Woods R., Chaisson C.E. et al. Alcohol consumption as a trigger of recurrent gout attacks. Am J Med 2006;119(9):800.е13–8. DOI: 10.1016/j.amjmed.2006.01.020.

41. Choi H.K., Curhan G. Beer, liquor, and wine consumption and serum uric acid level: the Third National Health and Nutrition Examination Survey. Arthritis Care Res 2004;51(6):1023–9. DOI: 10.1002/art.20821.

42. Bhole V., de Vera M., Rahman M.M. et al. Epidemiology of gout in women: Fiftytwo-year followup of a prospective cohort. Arthritis Rheum 2010;62(4):1069–76. DOI: 10.1002/art.27338.

43. Chandratre P., Mallen C.D., Roddy E. еt al. “You want to get on withthe rest of your life”: a qualitative study of health-related quality of life in gout. Clin Rheumatol 2016;35(5):1197–205. DOI: 10.1007/s10067-015-3039-2.

44. Dalbeth N., Merriman T.R., Stamp L.K. Gout. Lancet 2016;388(10055):2039–52. DOI: 10.1016/s0140-6736(16)00346-9.

45. Kaneko K., Aoyagi Y., Fukuuchi T. et al. Total purine and purine base content of common foodstuffs for facilitating nutritional therapy for gout and hyperuricemia. Biol Pharm Bull 2014;37(5):709–21. DOI: 10.1248/bpb.b13-00967.

46. Eckel R.H., Jakicic J.M., Ard J.D. et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task force on practice guidelines. Circulation 2014; 129(25 Suppl. 2):76–99. DOI: 10.1161/01.cir.0000437740.48606.d1.

47. De Vera M.A., Marcotte G., Rai S. et al. Medication adherence in gout: a systematic review. Arthritis Care Res (Hoboken) 2014;66(10):1551–9. DOI: 10.1002/acr.22336.

48. Schumacher H.R., Taylor W., Edwards L. et al. Outcome domains for studies of acute and chronic gout. J Rheumatol 2009;36(10):2342–5. DOI: 10.3899/jrheum.090370.

49. Yin R., Li L., Zhang G. et al. Rate of adherence to urate-lowering therapy among patients with gout: a systematic review and meta-analysis. BMJ Open 2018;8(4):017542. DOI: 10.1136/bmjopen-2017-017542.

50. Sheng F., Fang W., Zhang B. et al. Adherence to gout management recommendations of Chinese patients. Medicine (Baltimore) 2017;96(45):8532. DOI: 10.1097/md.0000000000008532.