The Source Of Uric Acid

I’m often asked, “what causes uric acid?”

The simple answer is: “the natural breakdown of purines in the body.”

But this answer is too simple to be of any real value. In fact, because most people, including many professional medics, do not understand purines, there is an enormous amount of bad advice given to gout sufferers. The result of that bad advice is often a miserable low purine diet that is impossible to stick to.

Even worse, it does nothing (or in some cases very little) to help your gout.

This is a great opportunity to see how a simple question about causes of uric acid can lead to an immediate improvement in your understanding of gout. This is the starting point for you to learn how to control uric acid – the first step on your road to Gout Freedom.

As I’ve mentioned, purines cause uric acid. These are present in food, and released when cells breakdown during digestion. But they are also much more available in our own flesh. Every day, our body cells renew and regenerate our body tissues. We release many more purines as part of our natural metabolism than we eat in food. All these purines are a potential source of uric acid.

Do You Have Simple Or Complex Gout?

Read the rest of What Causes Uric Acid?

Gout Acid: How To Avoid 4 Ways To Pain

Surprisingly, uric acid by itself causes absolutely no pain. We often think of acid burns, and inflammation, e.g. when excess stomach acid causes heartburn. But uric acid is very weak. It causes no direct pain, but indirectly it can lead to the worst pain know to man. When you understand how it works, you are best placed to avoid all four types of gout acid pain.

1. Acute Gout Attack

The classic gout pain caused by uric acid crystals in the joints. This is not physical pain. It is an inflammatory reaction to invading uric acid crystals, when the immune system tries to kill the invaders in the same way that it deals with viruses and other infections. This pain is not permanent, and will go away naturally after a few days, though most of us need pain relief as the pain is very intense.

2. Gout Acid Kidney Stones

Uric acid is excreted by the kidneys, then substantially reabsorbed. High levels of uric acid can crystallize in the kidneys, causing painful kidney stones. In most cases, the stones are easily dissolved with sodium bicarbonate and plenty of fluids. Pain lasts until stones are passed or dissolved. Risk of permanent damage is low, but will increase if stones recur frequently.

Read more on Gout Acid

Increased Uric Acid – Increased Death Risk

Heart Risks Associated With Increased Uric Acid

Current thinking is neatly encapsulated in last year’s review by Gagliardi and colleagues [1]. Uric acid: A marker of increased cardiovascular risk, starts by telling us that uric acid has been linked with heart disease since the 19th century. At that time, there was no easy way to lower uric acid, though we now have effective gout treatments to avoid risks of high uric acid.

Over one hundred years later, we have a wealth of uric acid research relating to heart and associated risks. So common, that the review refers to “classical association of gout, hypertension, obesity and cardiovascular disease” [my bold]. It points out that, in addition to the well-known relationship between uric acid and deficiencies in purine metabolism, “increased uric acid is generally associated with important risk factors for atherosclerosis like hypertension, abdominal obesity, insulin resistance, the metabolic syndrome and renal failure.”

All these associations between uric acid and heart disease risks are reported in detail by Feig and colleagues [2].

More specifically, Car & Trkulja [3] have investigated uric acid levels in patients admitted to hospital with heart attacks. They have shown that increased uric acid is associated with increased risk of death in hospital, and death within 30 days. It is also associated with lower survival rates over five years following the heart attack.

Increased Uric Acid Conclusions

All these studies emphasize that whilst higher uric acid is associated with higher heart disease risks, nobody knows if there is any causal link. Neither do they show if heart disease problems are decreased if uric acid levels are decreased.

Although we do not know if increased uric acid might cause heart problems, or if undiagnosed heart problems cause high uric acid, several studies have shown that the risks are linked.

Increased Uric Acid Next Steps

If you have a personal or family history of high uric acid, it is important to see your doctor about your risks of heart disease.
Similarly if you have a personal or family history of heart disease, it is important to see your doctor about checking your uric acid level.

Leave Increased Uric Acid to browse the Gout Disease pages

Increased Uric Acid References

1. Authors: Gagliardi AC, Miname MH, Santos RD. Title: Uric acid: A marker of increased cardiovascular risk. Published: Atherosclerosis. 2009 Jan;202(1):11-7.
2. Authors: Daniel I. Feig, M.D., Ph.D., Duk-Hee Kang, M.D., and Richard J. Johnson, M.D. Title: Uric Acid and Cardiovascular Risk. Published: N Engl J Med. 2008 October 23; 359(17): 1811–1821. Uric Acid And Heart Risks
3. Authors: Car S, Trkulja V. Title: Higher serum uric acid on admission is associated with higher short-term mortality and poorer long-term survival after myocardial infarction: retrospective prognostic study. Published: Croat Med J. 2009 Dec;50(6):559-66. Uric Acid And Heart Attack Deaths

Diet & Gout: Fact & Fiction

I’m amazed at the number of questions I get about specific food items. A random selection from recent questions includes: tomatoes, beef, banana, fish, lemonade, salmon oil, potato chips, coconut, cherry juice, crab, tequila, and broccoli. This is in addition to associated requests for lists of good foods & lists of foods to avoid.

It is bad enough that gout sufferers are so obsessed with food, but even worse, is the way gout diet is approached. Looking for good or bad foods completely misses the point.

In fact, it misses two extremely important points. Foods only make sense in the context of a healthy balanced diet, and a gout diet only makes sense in the context of a good gout management plan.

Healthy Gout Diet Not Individual Foods

Although I publish several lists of foods for various purposes, these are not to tell you which individual foods are good, and which are bad for gout. They should be used to help you analyze your total food intake. After that, you might also use them to improve your overall diet.

Diet And Gout Table (click image for full size)

Terkeltaub & Edwards, two prominent rheumatologists, emphasize the need for overall diet management in their latest book, Gout: Diagnosis and Management of Gouty Arthritis and Hyperuricemia.

Apart from a few food groups, the emphasis is clearly on good balance of all nutrients. Important general diet advice includes:

• Maintain ideal body weight with a 40:30:30 carbohydrates:proteins:fats balanced diet.
• Moderate portion size and good hydration.
• Avoid binge eating and overeating.
• Eat plenty of vegetables in preference to starvation, fad, and strict low purine diets.

Interestingly, the book includes one of the best practical gout diet tips that I have used effectively. Reduce your plate size. They recommend a nine inch plate for main meals. Believe me, this really works, especially if you are born into a culture of “waste not, want not,” where lifetime habits mean you must clear your plate.
Read the rest of Diet And Gout: Fact And Fiction

Like any good website owner, I review statistics about topics that visitors are most interested in. I have listed some of these below, but they are far from the whole story.

The list of gout topics to improve is a fallback for me, if nothing more immediate needs doing. Quite often, I break from this list to investigate and summarize a gout news story. More often, I prioritize gout topics that arise in the gout forums. However, the topics that always get top priority are the ones that you ask me to write about.

More about your involvement in a moment, after the list.

Gout Topic Improvements

My current “hitlist” is in alphabetical order:

• alkaline foods
• arthritis facts
• causes of gout
• diet for gout
• febuxostat
• foods to avoid with gout
• gout
• gout cause
• gout diet
• gout pain
• gout pictures
• gout remedies
• gout symptoms
• gout treatment
• gouty arthritis
• high uric acid
• hyperuricemia
• indocin
• indomethacin
• joint inflammation
• low purine diet
• natural gout remedies
• protein rich foods
• pseudogout
• purine
• purine rich foods
• purines
• uloric
• uric acid crystals
• uric acid reduction

I tend to work on this list in the order that my statistics say is most important. But the overriding factor is what is most important to you.

I want you to feel that GoutPal gives you all the answers you need to give you your Gout Freedom. This can only happen if you tell me which gouty topics you want me to improve next.

It can be something on the list above, or a different gouty topic that means something to you. Either way, together we will continue to improve this unique gout support service.

Some reprieve for gout patients who cannot tolerate allopurinol arrived in recent years in the form of febuxostat. Sold as Uloric, or Adenuric, this was hailed as the first new gout treatment in 40 years.

Now, those patients who, try as they might, cannot get uric acid low enough, have a further option, but it is far from an easy one.

FDA approves new drug for gout

In a press release yesterday, the U.S. Food and Drug Administration announced the approval of Krystexxa (pegloticase) for gout in adults who do not respond to, or who cannot tolerate, conventional therapy.

They explain how gouty arthritis occurs

due to an excess of the bodily waste uric acid, which is eventually deposited as needle-like crystals in the joints or in soft tissue. These crystals can cause intermittent swelling, redness, heat, pain and stiffness in the joints.

Gout is strongly associated with obesity, high blood pressure, high cholesterol and diabetes, and occurs more often in men, in women after menopause, and in people with kidney disease.

“About 3 percent of the three million adults who suffer from gout are not helped by conventional therapy. This new drug offers an important new option for them,” said Badrul Chowdhury, M.D., director of the Division of Pulmonary, Allergy, and Rheumatology Products in the FDA’s Center for Drug Evaluation and Research.

They then explain how, Krystexxa differs from allopurinol and febuxostat, which blocks the enzyme (xanthine oxidase) that produces uric acid. The new gout treatment is an enzyme that lowers uric acid levels by metabolizing it into a harmless chemical that is excreted in the urine. The drug is administered to patients every two weeks as an intravenous infusion.

I will summarize the research that supports the license application when I update the gout treatments reference section with this newly approved treatment. For now, you need to be aware of the cautionary conclusion to the FDA Krystexxa press release:

Since one out of every four patients in the clinical trials experienced a severe allergic reaction when receiving an infusion of Krystexxa, health care providers should dispense a corticosteroid and an antihistamine to their patients beforehand to minimize the risk of such a reaction. Other reactions during the clinical trials included gout flare, nausea, injection site bruising, irritation of the nasal passages, constipation, chest pain and vomiting.

Physicians are also being warned to be cautious about administering Krystexxa to patients with congestive heart failure because the drug was not studied in this patient population.

Krystexxa is being approved with a Risk Evaluation and Mitigation Strategy that includes a medication guide for patients and materials for healthcare providers to communicate the risk of severe infusion and allergic reactions.

Sounds serious doesn’t it?

Let that be a reminder just how serious excess uric acid really is. If yours is high, you must do all you can to lower uric acid in your blood. If you do not know your uric acid number, please get it sorted. Today.

Traditional gout advice on protein rich foods has always been “Avoid them!”

High Protein Foods: How Do They Affect Gout?

But as awareness grows about nutrition in general, and proteins in particular, does this advice still hold true?

And if it doesn’t, what are the dangers of going too low on protein?

Protein Rich Foods: Contents

Protein Rich Foods: Introduction

I’ve experienced growing concern about the advice given to gout sufferers concerning protein. There appears to be confusion between purines and protein, and the advice on protein looks out-of-date in the light of gout research in the current millennium.

A quick look at the topic reveals little clear guidance from government or relevant professional bodies, so I started an in-depth study.

My research has led me down a few deep, dark, sometimes mythical alleyways.

To try to make sense of it all, I’ve decided to split this topic into at least 3 articles. This one looks at current American guidelines, or lack of them. I’ll look next at British guidelines, which in the absence of anything else are in danger of being adopted as a universal standard. Then, I will try and draw some conclusions.

Current Protein Guidelines For Gout Sufferers

High Protein Foods: Rheumatologist Advice

The first stop for gout guidelines should be the American College Of Rheumatologists (ACR). Their nearest thing to a guideline is a 2004 review of gout, diet and alcohol [1]. That document does mention the study into a 40:30:30 protein:carbohydrate:fats diet, but the recommendations are unclear:

Importantly, recent years have seen a surge in popularity of “low-carbohydrate, high protein diets” (e.g., Atkins, Zone, and South Beach diets). In a small, open study in overweight male gout subjects, a calorically restricted diet designed for IR management, with a 40/30/30 protein/carb/fat scheme and customized for high contents of seafood and mono-unsaturated fat as well as continued moderation in alcohol, achieved body weight lowering by ~17 pounds and also diminished hyperuricemia by 17 percent (3). But these results cannot be directly extrapolated to popular “low-carbohydrate” type diets, for which an adequately powered clinical trial in hyperuricemia and clinical gout has not yet been done.

The report is dismissive of evidence that milk protein may be beneficial to gout sufferers. This ignores Garrel’s 1991 investigation showing the acute effect of milk protein on uric acid levels. Also, it has not been updated to reflect Dalbeth’s similar 2009 investigation into milk and uric acid.
The report concludes with recommendations for gout patients, but these are not clearly defined. The protein advice is limited to:

concerns about the potential for ketosis and other effects of popular “low carb” diets heightened in animal protein and fat to exacerbate hyperuricemia and gout.
[and]
Consumption of vegetables with high purine content or a diet high in protein by themselves do not appear to raise the risk of developing gout.

There have been other studies since this recommendation, and I will review those investigations in a separate article. However, in the absence of clear guidelines, it is likely that nutritional and medical practitioners will seek guidance elsewhere.

High Protein Foods: Heart & General Advice

Guidance from the American Heart Association (AHA) is often quoted when health aspects of high protein foods are discussed. There are, in fact, two key protein-related guidelines from AHA, which refer, indirectly to nutrition advice from the Institute of Medicine.

The most authoritative reference, from a protein point of view is the second of their 2 guidelines, “Dietary Protein and Weight Reduction” [2] published in 2001. It is particularly likely to influence advisers to gouty arthritis sufferers, given the statement:

High-protein foods such as meat, poultry, seafood, eggs, seeds, and nuts are high in purines. Purines are broken down into uric acid, so excess consumption of these foods increases uric acid levels and may cause gout in susceptible individuals.

This is a very naive view of purine metabolism, and an unfortunate addition to the confusion that treats purines and proteins alike. Also, there is no reference to the, what was then, recent 2000 study on a 40% protein diet that appears to lower cholesterol as well as uric acid.

Anyway, they are strong recommendations in this AHA guidance to adopt a 15:55:30 protein:carbohydrate:fats ratio:

Total protein intake should not be excessive (average 50 to 100 g/d) and should be reasonably proportional ({approx}15% of kilocalories per day) to carbohydrate ({approx}55% of kilocalories per day) and fat ({approx}30% of kilocalories per day) intake.

It appears that in their haste to warn of the dangers of diets containing too high a proportion of animal protein and animal fat, they have adopted a low protein approach, primarily from the preceding year’s wider ranging “AHA Dietary Guidelines” [3].

I’ll confine myself to the protein part of these guidelines, and admit to some confusion, that might well arise from trying to analyze something from 10 years ago. The key point, echoed in my quote above from the later report, is the statement:

Although there are many conditions in which extra protein may be needed (growth, pregnancy, lactation, and some disease states), an average of 15% total energy or {approx}50 to 100 g/d should be adequate to meet most needs.

Note that the caution to recognize cases where extra protein is needed is lost between the two reports. Delving deeper, we can see how important this is. The AHA recommendations reference Advanced Nutrition and Human Metabolism (ANHM) by Goff, Gropper & Hunt (1995). Unfortunately, I only have access to the 2004 version, though the latest edition is 2008. This makes it difficult to understand if the dangers of low protein have been overlooked, or if they were not recognized when the 2000 Guidelines were published.

In a nutshell, the ANHM recognizes a 10% to 35% range for protein intake, noting that in some situations, especially where energy intake is restricted, 10% may be far too low, resulting in malnutrition. Where necessary, it might be more relevant to look at protein intake, which should be around 80g per day or 0.8g per kg body weight per day in normal circumstances.

The ANHM is a thorough explanation of nutrition issues and the main take-home is that cases need to be considered individually. Also, individual needs will change over time. Therefore fixed protein:carbohydrate:fats ratio’s might serve well as a starting point, but adjustments need to be made in the light of individual circumstances and test results.

Protein Rich Foods: Next Steps

I will continue this review of protein rich foods with an article on British Rheumatology Guidelines. Despite a focus on Great Britain, most of the issues affect every country, and the British guidelines are cited by many international gout studies.

To get a more complete view of current nutrition guidance for gout, especially with respect to protein, I have started the Protein Rich Foods Debate at GoutPal Interactive. If you have received specific nutrition advice from a professional advisor, please share it with us.

Protein Rich Foods: References

1. Author: Robert Terkeltaub. Titled: Health Professionals Follow-up Study on Gout: What Do We Now Tell Patients About Diet and Alcohol? Published: May 2004 Gout, Diet & Alcohol Guidelines
2. Author: St Jeor ST, Howard BV, Prewitt TE, Bovee V, Bazzarre T, Eckel RH; Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Titled: Dietary protein and weight reduction: a statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Published: Circulation. 2001 Oct 9;104(15):1869-74. Dietary Protein & Weight Reduction
3. Author: Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deckelbaum RJ, Erdman JW Jr, Kris-Etherton P, Goldberg IJ, Kotchen TA, Lichtenstein AH, Mitch WE, Mullis R, Robinson K, Wylie-Rosett J, St Jeor S, Suttie J, Tribble DL, Bazzarre TL. Titled: AHA Dietary Guidelines: revision 2000: A statement for healthcare professionals from the Nutrition Committee of the American Heart Association. Published: Circulation. 2000 Oct 31;102(18):2284-99.