Managing Gout without many dietary restrictions – Is it possible ?
I recently met a gout patient in the clinic. He was having poor gout control. He loved beer and was having a good amount daily. Obviously, the discussion moved towards possibly cutting that down. He was also not taking his medicines regularly and his uric acid was still higher than the target we desired to meet. He asked me a question which many have and what this article will be about. He asked, ” Tell me, doctor. I have a friend, who sits across the table in the same pub we have visited for ages. He probably drinks 5 large glasses of beer every time we end up there. Why doesn’t he have gout? Why do I have it and I am always asked to cut down on my beer, diet etc ?”
The patient asked me” Tell me doctor. I have a friend, who sits across the table in the same pub. He probably drinks 5 large glasses of beer every time we have visited for ages. Why doesn’t he have gout? Why do I have it and always asked to cut down on my beer, diet etc ?”.
Read following article to understand everything about gout by a simple picture and analogy
Gout causes, attack and treatment explained – by simple ‘matchstick’ analogy
The following discussion should help you break many myths and get many answers on gout.
The risk of developing gout is partly genetic
Gout doesn’t develop in everybody who drinks too much alcohol or eats too much non-vegetarian food. One has to have a combination of genes that make them build up uric acid and give it a tendency to deposit into organs. There should also be genes to cause inflammation in joints of gout patients. When we say that it is genetic, it doesn’t mean that somebody in your family should have gout. The genes can be newly acquired during birth.
Gout doesn’t develop in everyone who has bad eating habits, eats meat and has too much alcohol (unhealthy lifestyle). One has to have some genes for it. The genes don’t necessarily come from someone in family. One can get totally new genes not passed from parents at birth.
Unhealthy lifestyle might build up your uric acid, but it won’t necessarily give somebody gout. One should not have unhealthy lifestyle due to obvious reasons. Its like diabetes where everybody having sugars and unhealthy life doesn’t have diabetes. But, once someone has diabetes, one has to work to eat healthy, exercise and avoid sugars. Similarly, when someone develops gout, one needs some restrictions. Remember, if you start early with proper gout medications, the restrictions are much lesser.
Unhealthy lifestyle (like bad eating habits and less exercise) can increase risk of having gout in people who have the genes. It is difficult to say who has these genes. Not all gout patients necessarily has someone in family with gout. Also, these genes are complex and there is no advantage in testing them routinely.
Some people might have really strong genes which may be passed on to many members of the family. We do get gout patients at very young age (<30-40 years of age). There are a lot of gout patients in countries like India, who are pure vegetarian (they eat no meat, no fish or seafood) and haven’t touched alcohol in their life. There are families where multiple members of the family have gout at very young age. But these scenarios are uncommon.
So to make it short, for somebody to have gout genes always play a role. These genes might be a strong part in some, who will develop gout at a young age without much to with their lifestyle. However, most people with gout are usually above 40-50 years who have some genes which increase their risk in addition to their poor diet and exercise habits.
Most gout patients have gout because = Genetic factor (almost around 50%) + one or more of poor lifestyle factors (less exercise, obesity, unhealthy diet, excessive alcohol etc)
A few young gout patients have gout because = Very strong genetic factor + possibly one or more lifestyle factors
Once gout starts, it doesn’t go back
Once gout starts, even if you control everything in diet, it won’t stop it’s progress (except in rare cases). This is because multiple factors have led to somebody developing gout. It’s not only diet but many genes which cause uric acid to build in the body, deposit into joints and finally cause inflammation. Yes, controlling diet might help, but one cannot take the gene factor away. One has to usually take medicines to control uric acid and only that can prevent gout progression.
Gout patients often feel stigmatised
There is this conception that if somebody develops gout, they must be living unhealthy, having too much alcohol etc. The gout patients have to face this stigma daily. A gout patient is always surrounded by people who have the same lifestyle like him/her and don’t have gout (like the patient at the start). They start feeling bad, miserable and start asking why me? The answer is because you have some genes dear.
The internet is filled with how to control gout naturally, don’t have this and that. The gout patients try to avoid everything thinking that his/her gout will be controlled without medicines. But because of such a strong genetic component, they will have to take medicines anyway. If they start medicines early, usually they don’t have to have severe dietary restrictions, which make them feel more miserable and stigmatised.
The general perception is that gout happens due to poor diet and alcohol which gives stigma to the person. However in reality, its at least partly due to genes. Because of the genes, a gout patient will have to usually take medicines to control uric acid. If one starts treatment early in gout, they can manage their life without the list of painful restrictions mentioned on internet and possibly with much lesser dose of medicines in the future.
Gout medication is usually lifelong – why shouldn’t one delay medication as long as possible?
Everybody wants gout to be treated naturally. In initial gout phase, the attacks are very painful but infrequent. Every attack at the start is followed by a period of silence. The uric acid accumulates in the body during this phase. Many patients don’t take medications during this phase and will try everything natural. This is the phase when gout attacks are anyways uncommon and a patient feels that natural therapy is working. If the patient doesn’t take medications to meet the uric acid target in the early phase, they will progress. Later, gout starts giving continuous problems (not just intermittent attacks) and starts damaging joints permanently. If one starts taking proper medications early (with target achieved), uric acid doesn’t accumulate. One can then have a reasonable diet without miserable restrictions. They are also far less likely to go on higher doses of medications or develop complications in the future.
In initial stages of gout, after a few attacks, the disease goes silent for months to sometimes years. If some patient starts natural therapy during this silent stage, they feel that therapy is working and won’t take medicines. But in that case, the uric acid keeps depositing into body and their gout will come back with more severity in the future. If these patients start medicine early after first or initial few attacks, they are very unlikely to develop gout damage and complications.
| Common misconceptions or myths or about gout. | True facts | What should a patient do? |
| 1) I can try natural foods and healthy diet, that will control uric acid and help me take fewer medications. | True fact: Healthy diet and lifestyle are good for gout patients as these patients are more prone to blood pressure and heart problems. There is no clear-cut evidence that it can lower uric acid and control gout on its own, as it’s caused partially by genes. Fewe medicines will be required if you start taking them early, not if you try natural things at the start. | A patient should start uric acid-lowering drug as soon as advised by a rheumatologist. Usually, a rheumatologist will definitely recommend starting gout medicines after the second gout attack, especially if there is no other major contributory factor which can be modified (eg blood pressure drugs like chlorthalidone, metolazone, hydrochlorothiazide etc). |
| 2) I should follow a gout diet. | The real truth : There is no specific diet required except that one should eat healthily. Eating healthy means – more fruits, low-fat dairy, veggies, less fried foods, less sugary stuff ( sugary colas, sugar-laden fruit juices, canned sugary foods) less junk, reasonable alcohol and meat If you start medications early moderate meat and alcohol is easily possible and does no major harm. Also, if things are controlled, one can comfort self with very occasional junk food | Eat healthy, stay hydrated, be active. Get a proper education about gout. Consult rheumatologist, ask for authentic resources on gout. Discuss, follow their advice and if prescribed, take medicines properly. Always be prepared to treat a gout attack, have pills ready (‘pill in pocket’) for any sudden attacks. Check and keep uric acid below 6mg/dl (or < 375 umol/L). (#Reachforsix) |
| 3) I should avoid meat, seafood, alcohol, colas etc. | A gout patient can have everything in moderation as long as things are controlled well at the start. Only sometimes very high purine meats like sweetbreads, kidney etc may be avoided. Occasional beer should be fine and alcohol intake < 2 units/day for men & < 1 unit/day for females should be fine. Alcohol needs to be avoided only in those with poor gout control and during acute attacks. High fructose corn syrup sweetened sodas (most sodas, many sweetened drinks, canned foods etc) should be ideally avoided. Occasional sugary colas (though not really recommended) should do not much harm. Diet colas are ok. | Do as above. Avoid junk and sugar, especially drinks with fructose added in them. Avoid alcohol during acute attacks. Limit beer. Keep uric acid controlled below target and enjoy life by having everything in moderation. Complete restriction of very few things is required then. If uric acid is controlled really well, a gout patient can have things which used to cause gout attacks in past. All gout patients might have occasional attacks due to many reasons. Do not live in fear. Be prepared for the attack, have ‘pill in the pocket’ – consult your doctor for same. |
| 4) I should eat cherries and cherry supplements. | Cherries may lessen gout attacks, but it doesn’t lower uric acid in gout patients. It will keep progressing.Cherry supplements sold on amazon or other places are marketing trick (costly and every gout patient has very few attacks at start, doesn’t mean they are working). By logic, one has to eat a healthy diet with whole fruits anyways and take some medicines. Why then take extra tablets of costly cherry supplements? If you take them one might have a false sense of security and avoid proper medicines.Things will get worse eventually as already explained above. | Eating whole fruits can be helpful. Fresh cherries might help to have slightly lesser attacks, but they won’t lower uric acid, stop progression or decrease your dose of medicines in the long run. Don’t burn money on cherry supplements and concentrates sold on the internet. Cherries and cherry juice have been associated with a decrease in gout attacks. There are not many studies which show that these supplements sold on the internet do the same. |
| 5) Gout drugs are marketed by companies over natural treatment to make profits | Most gout drugs are among cheapest drugs in rheumatology for any long-term disease. They are cheaper than so-called natural diets and amazon cherry supplements. | Take a proven, mostly safe, cheap and effective therapy. Don’t waste money on other things. Later, you might end up taking same allopathic drugs you wanted to avoid in much higher doses. |
| 6) My uric acid is high. I should start uric acid-lowering medicines early to prevent gout. | There is no proven benefit of taking medicines just for high uric acid without gout.Most people with high uric acid won’t develop gout. Just eat healthily and keep fingers crossed :-). Even if one develops gout later treatment can be started when it happens. No sense in taking medicines without any benefits or actually having gout. | High uric acid is very common due to blood pressure drugs, less exercise, junk food etc. Higher uric acid is just an extra sign of something else. It will lead to gout only in very few. Discuss with rheumatologist to see if you have gout and then only medicines are required. High uric acid only, no gout = no uric acid medicines required. Look for blood pressure drugs (might increase uric acid), junk in diet, thyroid etc, change things accordingly – exercise and decrease food junk. High uric acid + If gout has developed = Consult rheumatologist and mostly need to start uric acid-lowering medications. |
| 7) I should stop eating all lentils (beans, dals, chana, moong, chickpeas (chole), red gram (masoor) , green gram (moong), black gram etc), gobhi (cauliflower, cabbage), dairy etc. | Plant foods high in purine do no harm. There is no acid in them as commonly thought. Low-fat dairy is healthy for gout patients. | Gout treatment will anyways need medicines. Plant sources of foods even if high in purine content, do not increase uric acid much. They have many health benefits in gout patients. |
| 8) I cannot have any fish or seafood in gout. | Seafood can be taken in moderation. Among fish, salmon is probably better. But as long as uric acid is below target any seafood in limitation should be fine. | Remember taking medicines, achieving uric acid target is most important. A gout patient can have a not so boring life then :-). |
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Author: Dr Nilesh Nolkha, Rheumatologist
Dr Nilesh Nolkha is a rheumatologist who strongly believes in patient education and empowering patients to make rational treatment decisions. He is a practicing rheumatology consultant in Wockhardt hospital, Mumbai.
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