Evidence-Based Dietary Recommendations for Gout Save

Gout, historically referred to as the “disease of kings,” was once associated with a lifestyle of excess, including ready access to alcohol and rich meats once reserved for society’s highest ranks. Today, it is more appropriate to refer to gout as a “disease of commoners,” as it is the most common inflammatory arthritis worldwide that affects >5% of the US general population. Nonetheless, the perception that gout is strongly associated with what we eat and drink remains pervasive.  

The modern gout epidemic has closely mirrored the global obesity epidemic, driven in large part by the rising prevalence of the Western lifestyle and dietary patterns. Therefore, this notion is not entirely wrong. However, misinformation about what constitutes evidence-based dietary recommendations for gout remain rampant. Patients are often left utterly confused after turning to online sources, or even their own healthcare providers, on what they should or should not be eating to reduce their gout risk. 

Typically, the most common recommendation is to follow a low-purine diet. While limiting alcohol is indeed beneficial (for gout and overall health), a low-purine diet otherwise amounts to a low-protein diet. In addition to concerns about the sustainability and palatability of such a diet in the long-term, it can lead to compensatory higher consumption of foods that are often rich in refined carbohydrates (including fructose, known to raise serum urate and trigger gout flares) and saturated fat. Such a diet can worsen the comorbidities of gout, such as type 2 diabetes or hyperlipidemia. Indeed, many patients express frustration at the seemingly conflicting dietary recommendations for their comorbidities. For example, they are told to follow a low-purine (i.e., low-protein) diet for gout but recommended to follow a high-protein diet for their diabetes. They throw their hands up in the air, wondering what they can eat other than chicken breast for the rest of their lives. 

The answer to this dilemma becomes clearer when we remember that, while the cardinal feature of gout is that of an inflammatory arthritis, gout (and its prerequisite precursor, hyperuricemia) can also be considered a metabolic disease. This is because insulin resistance, a key hallmark of metabolic syndrome, reduces the renal clearance of urate leading to hyperuricemia. Accordingly, any diet that helps improve insulin resistance will lead to improvements in metabolic syndrome (and its sequelae, such as cardiovascular and renal diseases) while also reducing serum urate and gout risk. Therefore, a diet that is good for gout and one that is good for diabetes (or whatever other cardiovascular-metabolic-kidney comorbidity one might be managing) are actually one and the same. 

The good news is that there are several evidence-based dietary patterns that fit this bill. 

This allows for some personalization based on food preferences and cultures, making it more sustainable. The most well-studied dietary patterns include the Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet. The DASH diet emphasizes the consumption of whole grains, fruits, vegetables, and low-fat dairy products with a high intake of plant protein from legumes and nuts in lieu of animal sources. As the name implies, this diet was initially developed and studied for the management of hypertension, one of the most common comorbidities of gout. The Mediterranean diet consists of a high intake of monounsaturated fat (primarily from olive oil), plant proteins, whole grains, and fish, accompanied by moderate intake of alcohol and low consumption of red meat, refined grains, and sweets. Both diets have been extensively studied and shown to benefit a myriad of relevant cardiovascular-kidney-metabolic endpoints, including type 2 diabetes, coronary artery disease, and mortality. They have also been demonstrated to reduce serum urate modestly and lower the risk of incident gout. 

One common question that comes up is the role of seafood, including shellfish. Seafood is prominently featured as part of the Mediterranean diet and can be enjoyed as part of the DASH diet as well. However, their consumption has been temporally associated with gout flares in case-crossover studies. Understandably, patients want to know if enjoying a lobster roll on the beach is going to trigger an excruciating gout flare. Indeed, seafood is the one food group where the long- and short-term effects related to gout risk are discordant. Typically, in these scenarios, if someone is experiencing frequent gout flares and has identified seafood as a potential trigger, it makes sense to temporarily limit its consumption. However, once their gout is better controlled, particularly if they start long-term urate-lowering therapy, chances are very high that they will one day be able to resume eating seafood without worrying about gout flares. 

Dietary counseling in gout remains an important pillar of comprehensive gout and comorbidity care, particularly in patients with mild gout not yet meeting indications for urate-lowering therapy. However, anyone providing dietary counseling for gout should be mindful of not reinforcing the stigma and shame that can be associated with this condition, due to its perception as a self-inflicted condition borne out of “being lazy” or “eating all the wrong foods.” 

We see plenty of patients who do all the “right things” with their diet and still get gout. Dietary counseling should be contextualized in a way that empowers patients to make healthy lifestyle changes that benefit both their gout and other comorbidities.