Gout Diet Category

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 There appears to be confusion between purines and protein, and the advice on protein looks out-of-date in the light of gout research in the current millennium.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.

Milk Diet For Gout: Contents

Uric Acid Percent Change After Milk

Milk Diet For Gout: Introduction

The 1991 investigation claiming milk is beneficial for gout appears to be somewhat ignored by the medical profession. Now, almost 10 years later, a similar investigation reports similar findings. I have not done a full comparison of the two milk and uric acid studies. For one thing, I do not have full access to the latest study. However, you should find plenty of useful information in this summary taken from the American College of Rheumatology (ACR) press release.

Please note that I’ve paraphrased the original press release to make it more readable and relevant to us non-medical people. The full gout and milk report has subsequently been published in the British Medical Journal [1].

Milk Diet For Gout: Overview

The ACR’s press release, ‘Got Gout? Get Milk’, promotes the research presented at their Annual Scientific Meeting in Philadelphia, Pa.

It describes gout as a painful and potentially disabling form of arthritis with symptoms usually consisting of intense episodes of painful swelling in single joints, most often in the feet (especially the big toe).

They note that treatments are already available to prevent or control the arthritis associated with gout, but managing this disorder can be difficult, and treatment plans often have to be tailored for each person. I believe it is vital that treatment is planned individually, which is a key point in the Gout Freedom campaign.

They note that previous studies indicate that individuals who drink a lot of milk have a lower risk of developing gout. Though not specifically referenced, this is almost certainly Choi’s statistical analysis linking high dairy consumption with lower gout incidence.

Milk Diet For Gout: Research Report

The presentation is titled: “The Acute Effect of Skim Milk On Serum Urate Concentrations: A Randomized Controlled Cross-Over Trial” and it’s authors are listed as:

• Nicola Dalbeth, FRACP , Department of Medicine, University of Auckland, Auckland, New Zealand
• Sumwai Wong, Department of Medicine, University of Auckland, Auckland, New Zealand
• Greg Gamble, Department of Medicine, University of Auckland, Auckland, New Zealand
• Anne Horne, Department of Medicine, University of Auckland, Auckland, New Zealand
• Barbara Mason, Department of Medicine, University of Auckland, Auckland, New Zealand
• Lynette Fairbanks, Guy’s Hospital, London, United Kingdom
• Fiona M. McQueen, Department of Medicine, University of Auckland, Auckland, New Zealand
• Jillian Cornish, Department of Medicine, University of Auckland, Auckland, New Zealand
• Ian R. Reid, University of Auckland, Auckland, New Zealand
• Kate Palmano, Fonterra Research Centre, Palmerston North, New Zealand

Uric Acid Research Purpose

Recent observational studies have highlighted the beneficial role of skim milk in prevention of gout. The aims of this study were to determine the acute effects of intact skim milk on serum urate concentrations, and to examine the mechanisms of the urate-lowering effects of skim milk.

Uric Acid Research Method

This was a short-term randomized controlled cross-over trial of skim milk in 16 healthy male volunteers. The following products were tested (each 80g protein):

1. soy control
2. early season skim milk
3. late season skim milk (containing high concentrations of orotic acid, a naturally occurring uricosuric agent)
4. MPC 85 skim milk (an ultra-filtrated skim milk containing very low concentrations of orotic acid, purines and lactose)

Each participant received a single dose of each product (each containing 80 grams of protein) in random order. Researchers collected samples of blood and urine immediately before each participant drank one of the beverages and then hourly over a three-hour period. They completed this with each participant for each of the four beverages with a week in between each session.

Uric Acid Research Results

After drinking the soy milk, uric acid in the blood increased by about 10 percent. In contrast, all skim milks led to a decrease in serum uric acid by approximately 10 percent. All products (including the soy milk) rapidly increased the ability of the kidneys to remove uric acid from the body.

Additionally, researchers found that late season skim milk led to a greater increase in the removal of uric acid by the kidneys when compared to the other skim milks. Late season skim milk is primarily available from countries where milking is seasonal and cows are grass-fed, such as New Zealand and Australia, and is known to contain higher levels of orotic acid, a substance that promotes uric acid removal by the kidneys.

There were no significant differences over time or between groups in changes in serum oxypurines (xanthine and hypoxanthine) or purines (guanosine and inosine). However, all products led to an increased excretion of xanthine.

Uric Acid Research Conclusion

The press release concludes that the study showed that skim milk has a specific acute uric acid-lowering effect. The authors suggest long term studies for further proof that it might be a good dietary way to assist in the prevention and treatment of gout.

“This study has shown that skim milk can significantly reduce the serum uric acid concentration in the short term,” explains Nicola Dalbeth, MD, FRACP; senior lecturer, clinical medicine, University of Auckland, Auckland, New Zealand, and lead investigator in the study. “The results suggest that increasing the amount of skim milk in the diet may help with preventing the development of gout, and also assist with treatment for those with the disease. We are now continuing this work by studying the longer term effects of milk in people with gout.”

Milk Diet For Gout: Next Steps

Now is a good time to seriously consider improving your diet with skim milk. Do not forget that even the lowest fat skim milk still has some energy, so if you are counting the calories make sure you plan this diet change properly.

More importantly, you must realize that the uric acid lowering effects of skim milk, though significant, may not be enough to reduce you uric acid to a safe level. You must continue to check uric acid levels regularly to ensure that you remain safe.

If you are used to drinking full-fat whole milk, I found that by gradually reducing the fat content, I was soon happy with the taste of skim milk. In fact, I now find full fat milk far too creamy for my palate.

Milk Diet For Gout: References

1. Dalbeth N, Wong S, Gamble GD, et al. Acute effect of milk on serum urate concentrations: a randomised controlled crossover trial. Ann. Rheum. Dis. 2010;69(9):1677-1682.

To put it another way.

When most medics practicing today were in med school, the dietary control of gout was very simple: no high purine foods; limited medium purine foods; and unlimited low purine foods.

Then research in the 1970s and 80s began to question the simplicity of this view. In 1985, Zöllner[1] noted:

purine sources differ in their absorption rates, a fact not taken into account in our food tables.

[...] In summary it can be concluded that dietary purines are absorbed to a variable extent, depending on the degree of hydrolysis to nucleosides and/or nucleotides, and that they are oxidized to uric acid in the gut and excreted as uric acid, which is bad for gout but without influence on purine metabolism.

He concludes:

Supplements of dietary purines produce dose-proportional increases in plasma uric acid concentrations, uric acid pool size and renal uric acid excretion. The magnitude of these increases depends on the type of purine compound administered, which may limit the value of food tables for human dietetics. Purine content of food must be related not only to weight but also to energy and to protein, particularly if new foodstuffs or a vegetarian diet are ingested.

It is worth noting at this point, that foods never contain uric acid. Many do contain purines, which are a source of uric acid, but as Zöllner points out, there are different type of purine, and they metabolize to uric acid at different rates. He also points out that we do not really need to digest purines for uric acid, as we can make our own by reprocessing dead cells.

A turning point in our understanding of food high in uric acid came about in 2004. Choi and colleagues compiled statistics from a 12 year study of over 40,000 men. Though this statistical review adds nothing to our knowledge of how different purines affect gout in different ways, it certainly changed the way gout experts view diet.

Their conclusions set the foundation for today’s more effective gout diet plans:

Higher levels of meat and seafood consumption are associated with an increased risk of gout, whereas a higher level of consumption of dairy products is associated with a decreased risk. Moderate intake of purine-rich vegetables or protein is not associated with an increased risk of gout.

Though not the total story, as they do not factor in risks such as obesity and excess iron, those words should be tattooed on the hearts of all gout nutritionists. My simple view of purine control is to balance small portions (up to 4 oz) of meat or fish with low-fat dairy products. Fill the plate with whatever vegetable foods you enjoy. Simple and effective.

Finally, though we can see that some form of purine control may help gout, it is absolutely pointless to attempt this if you do not monitor your uric acid numbers. There is no correlation between gout pain and purines. You might still experience gout pain when uric acid is lowering because old urate crystals can cause a gout reaction before they dissolve completely. Make sure that you know and understand your uric acid level.

Food High In Uric Acid References

1. Author: Zöllner N . Title: Purine and pyrimidine metabolism. Published: Sep 1985.
2. Authors: Hyon K. Choi, M.D., Dr.P.H., Karen Atkinson, M.D., M.P.H., Elizabeth W. Karlson, M.D., Walter Willett, M.D., Dr.P.H., and Gary Curhan, M.D., Sc.D. Title:Purine-Rich Foods, Dairy and Protein Intake, and the Risk of Gout in Men . Published: March 2004.

See more articles related to food high in uric acid in the Gout Diet section.

Myth 1: Alkaline Foods Turn Red Litmus Blue

Alkaline Foods Image

Despite my best efforts to explain otherwise, people still believe that you can measure the power of alkaline foods by testing their pH. There are even lists of alkaline foods touted round the Internet that show the pH value for common foods. But these have nothing to do with the alkalizing effect, so why do they exist?

They stem from a US government table of pH values produced for the canning industry. Whilst they might help food packagers determine what balancing agents they need to avoid food reacting with it’s container, these values have absolutely nothing to do with the effect of food on our bodies.

The science of alkaline foods recognizes that elements and compounds in food cause different reactions in our body when digested. Some elements, e.g. proteins and phosphorous produce acidic salts. Other elements, e.g. potassium, magnesium and calcium, produce alkaline salts. These salts end up at our kidneys, where they alter the pH environment. This process has resulted in the Potential Renal Acid Load (PRAL) calculation, which is an approximate estimate of the effect of foods on the acidity/alkalinity of our bodies. Or more specifically, of urine, as this is the measurable result.

Still, people remain confused as to how an acidic food item, like lemons or vinegar, can have an alkalizing effect on urine and the kidneys. As I explained recently: Read the rest of Alkaline Foods: More Myths Exposed

Stop Gout Triggers

In gout treatment you begin by removing any obvious triggers, such as diuretics or dehydration. Gout diets need the same planning and must stop irregular eating times and other bad eating habits. They should not classify high purine foods as forbidden – this is where most so-called gout diets fail. Food avoidance is fatally flawed; balanced food is vital, and will allow you to make the first steps in managing pain.

Manage Gout Pain

Food is not a painkiller, however gout and diet plans must recognize that pain relief is completely separate from reducing uric acid. Some foods, with anti-inflammatory properties, will reduce the severity of gout pain. Increase these foods and you will improve your natural defenses against gout pain. This puts you in a stronger position to manage the all important uric acid lowering.

Manage Uric Acid

Most uric acid in your body does not come directly from food – it comes from your own body tissue as cells die. Though excess animal protein can slightly raise uric acid levels, your body produces much more from poor diet. Irregular eating and poorly balanced meals cause your body to produce more uric acid than a plate of purine rich food.

Gout and diet starts with understanding the three phases of gout management. Your diet must stop gout triggers, help with gout pain and lower uric acid. It is also vital that the diet supports good general health, as many gout sufferers also suffer from heart disease, high blood pressure and other conditions. Specific diet guidelines only make sense when you can relate them to the three phases of gout management.

Please discuss your gout and diet experiences and problems on the GoutPal Forum.

Read more about gout and diet in the Gout Diet section.

The table below lists foods high in uric acid first with purine concentration reducing as you move down the list. Many advisers tell gout sufferers to avoid anything over 400mg and restrict foods in the 100-400mg range, but you should treat this advice with caution.

Firstly, you must realize that typical portion sizes vary enormously.
Be sure to calculate the amount that applies to your typical serving size from the value shown for 100 grams.

Secondly, the effect of foods high in uric acid depends on direct absorption through the digestive tract. Most uric acid derives from the breakdown of your cells as part of normal metabolism. The overall contribution of foods high in uric acid is debatable – figures of between 5% and 15% are common.

Purines Warning

Please be careful about getting obsessed with the purine content of food. Though purines in food can have a slight effect on uric acid, there are many other factors to consider.

Foods High In Uric Acid Table

You should use the information in the table below only as a guideline. Many other factors, besides foods high in uric acid, affect the risk of gout attacks.
If you do feel that it is important to manage foods high in uric acid, then you should measure your total intake. Multiply the weight of your food (in grams) by the value from the table and divide this by 100 to give your uric acid intake in milligrams. In this way you can calculate a total intake from the list of foods high in uric acid for every meal. You need to find the level that you can tolerate best by trial and error.

I took the data in this table from Food Composition and Nutrition Tables by Souci, Fachmann, Kraut. Their notes for the purine data states

Purines

The total of free and bound compounds is given for each component. The “total purines” column contains the total of all individual components calculated as uric acid.
The exact calculation of this is beyond the scope of this article, but you can easily see the relative purine count in the table. Remember, the table of foods high in uric acid shows the number of milligrams per 100 grams, so intake will depend on portion size.

GoutPal warns against taking these types of analysis too seriously. Firstly, gout food research indicates that vegetable purines do not increase the risk of gout, and dairy foods can actually reduce it. More importantly, people digest foods differently – a food that causes gout in one person might be tolerated by another, and different food combinations have significantly different effects. There is more information about dealing with foods high in uric acid in my Gout Diet section.