Is Gout All About the Purines?
July 20, 2021 10:33 AM   Subscribe

With gout you're supposed to avoid red meat, cheese, and alcohol, because purines. However, looking at this chart, red meat has no more purines than chicken, and half as much as salmon, which is supposed to be okay; and Edam cheese is super low on purines. Is the red meat/cheese/alcohol advice just wrong? Is there some other factor? In 2012 folks were talking about fructose. Is there any more recent and more solid advice?
posted by musofire to Health & Fitness (10 answers total) 7 users marked this as a favorite
I drink a lot of water and I consume a fair amount of Naproxen (okay, 2-3 tablets a day) and my gout is under control. I do have a supply of Indomethacin in case I get an acute attack, but I haven't needed that for years unless I got into a new situation where stress and circumstances limited my water intake (i.e. a new job).

Basically, everybody's body is a little different in how it generates the uric acid and how having too much of it will congregate around your joints. It's not just ONE component of your food. The advice says to avoid purines because purines decompose into uric acid, and uric acid is a precursor to urate crystals, which actually gums up your joints in gout. Your kidney then filters out the uric acid and dumps it into your urine.

So there are basically two components to managing gout: 1) minimize food rich in purines (and thus, uric acid) 2) help your kidneys filter out the stuff from your blood.

Fructose-heavy drinks (along with alcohol) are believed to raise your overall uric acid level but I can't find any mechanism this is caused. However, given that diabetes is known to damage kidneys, it can be postulated that fructose can temporarily inhibit kidney functions as the kidney is working extra hard to pull sugar from the blood. But then, prolonged use of NSAIDs is also said to be potentially harmful to the kidneys. :-\
posted by kschang at 12:21 PM on July 20, 2021 [1 favorite]

Not sure how helpful this is but my doctor put me on allopurinol and I have not had an attack since then. I don't try to avoid anything specifically and just eat reasonably healthy.
posted by crocomancer at 12:33 PM on July 20, 2021 [3 favorites]

I was diagnosed with gout 11 years ago at the age of 31. I read a lot about what foods to avoid and/or specifically include, there is a lot of conflicting information and opinions out there.
I cut down a lot on alcohol, increased water intake and tried to reduce the "bad" foods, but would still have gout attacks every few months. The joints it affected varied, from ankles, toes, to knees and elbows.

About 2 and a half years ago, after a series of gout attacks, I started on Allopurinol, and haven't had any gout incidents since then, with diet and exercise being comparable.
I had known of this as an option, but always resisted as I didn't want to take a daily pill.

So yeah, if I went back in time, I would've started with Allopurinol earlier, as it has helped me a lot. IANYD etc.

(posted from a shiny new sockpuppet account as this is sharing more personal info than I'd otherwise feel comfortable with)
posted by PuppySocks at 2:08 PM on July 20, 2021 [2 favorites]

I had a prolonged gout attack after becoming dehydrated after a surgery. When I visited a rheumatologist, she told me it was highly likely my dehydration was the culprit (I was fasting, so couldn't blame it on foods) - that hydration 'flushes-out' the offending purines/ uric acid.
posted by mrmarley at 2:11 PM on July 20, 2021 [1 favorite]

One thing that I think is increasingly understood is that every body is a little different and treating the complex, interlocking systems of a human body as CHEM 201 mass balance equations regarding levels of chemicals misses a lot of fine details that can often make a big difference. And that studying diets are always fraught with difficulty.

The other thing is that your table shows purines per 100g of food; if you always eat exactly and only 100g of each food, then that's fine, but portion sizes vary culturally and for other reasons. 100g of steak, salami and mussel meat all have roughly the same amount of purines on your table, but: 100g of mussels would be maybe a pound or a bit more of in-shell mussels -- a nice hearty serving for one of moules frites. 100g of salami would be enough to top a two-person pizza; it'd be a lot to eat by itself in one sitting. 100g of steak would be 4 oz; you'd never see a steak this tiny served at a restaurant. Red meat in particular -- and especially in years past before health/climate awareness -- is often served in much larger portions than seafood or even chicken. A standard chicken breast is 6 oz; you can frequently see 16 oz steaks (and more!) on menus.

I've also found that dehydration is the key; if I catch it early enough, I can ward off a gout attack with plenty of water. A lot of the time, I ignore the initial indication, thinking I must have stubbed my toe, so I need to drink more water in general.
posted by Superilla at 2:43 PM on July 20, 2021 [7 favorites]

My husband has had gout since his late 20's, and it runs in his family on both sides. While he would agree that it's all about the purines, different foods trigger attacks for him than the ones that affect his other family members - he has no issue with red meat or limited amounts of alcohol, but can't have even a tiny bit of broccoli or cauliflower. His mother can eat all of those foods, but has issues with fruits and some other vegetables (I think turnips?). He takes Uloric and Febuxostat (Allopurinol didn't work for him), which keeps things under control, but he still needs to completely avoid some foods even with the medication.
posted by Mchelly at 3:09 PM on July 20, 2021

Just chiming in with gout seems to affect people completely randomly. I had a gout attack over 10 years ago. Doc put me on Uloric and the gout went away in 2-3 weeks. I took the pill daily but after 2 years just stopped. It took about 6 or so weeks but I had another attack. Back to Uloric. Same deal, went away completely, with no real change in diet. At some point I stopped again, and it's been 3, or 4 years and no gout.
posted by 922257033c4a0f3cecdbd819a46d626999d1af4a at 6:18 PM on July 20, 2021

Is Gout All About the Purines?

That is an excellent question. The big conundrum about gout for me is that if the body has all this uric acid it needs to get rid of, why not just dump it into the large intestine where it would easily and without much ado be gotten rid of, instead of into the joints where it causes such huge problems?

I couldn't find any evidence that there was a uric acid loving human pathogen of the large intestine that gout could be starving into submission, but I did find something else:
Gout May Be Associated With Protective Effect Against Colorectal Cancer

Over the 10-year study period, the prevalence of colorectal cancer was significantly lower in patients with gout compared with patients with OA (0.8% vs 3.7%; P =.0008). After adjusting for NSAID use, differences in colorectal cancer rates remained significant. Furthermore, within the gout cohort, use of allopurinol and/or colchicine did not influence the rate of colorectal cancer occurrence. In a subanalysis of patients who underwent diagnostic vs screening colonoscopies, the differences in colorectal cancer rates persisted with diagnostic colonoscopy (0.5% in gout vs 4.6% in OA; P .01) vs screening colonoscopy (0.9% in gout vs 1.1% in OA; P =1.00). There was no significant difference in the occurrence of nonmalignant colorectal polyps between cohorts (50.4% in gout vs 47.0% in OA;
People with gout had colorectal cancer at a rate better than four times less than matched controls. And note that allopurinol and colchicine treatments did not diminish gout's protective effect, and that gout did not significantly reduce numbers of polyps -- which would imply that gout was triggered by cells at least pretty far along toward being actually cancerous. rather than the early precancerous cells of most polyps

One rationale for this protective effect of gout is that uric acid can be metabolized into adenine and guanine, which a fast-dividing population of cells (such as a cancer) has a tremendous need for in order to manufacture new DNA.

And incidentally, if gout is not so much a disease in its own right as it is a remarkably effective weapon in the body's fight against colorectal cancer, but one which has unpleasant side effects, that might explain the role of fructose in triggering gout:
Fructose consumption and cancer: is there a connection?

Recent findings: Fructose intake is associated with increased risk of pancreatic and small intestinal cancers, and possibly others. Fructose promotes flux through the pentose phosphate, which enhances protein synthesis and may indirectly increase tumor growth.

Summary: Whereas glucose favors overall growth kinetics, fructose enhances protein synthesis and appears to promote a more aggressive cancer phenotype. Fructose has become ubiquitous in our food supply, with the highest consumers being teens and young adults. Therefore, understanding the potential health consequences of fructose and its role in chronic disease development is of critical importance.
posted by jamjam at 7:44 PM on July 20, 2021 [2 favorites]

Best answer: All humans have high serum uric acid levels (ie, uric acid in the blood). Some, due to genetics etc etc have that extra little bit that puts them over the top into gout-land.

Purines and all this other stuff is the final 0.1% on top of all the other. Yes, sometimes it can be the straw that breaks the camel's back, but that's all.

90% is the human genetic makeup, 10% is your own genetic makeup, and the remaining percent (OK, maybe it's not 0% as I have implied, but like 1-2% at most) is your diet and other such factors.

Gout is almost completely, 100%, curable. It is the only form of arthritis that is very close to 100% curable. Meaning that for most people it is 100% curable - there are few extreme outlier people out there who are resistant to treatment and so their horrible crippling disfiguring arthritis is only partially curable.

Your own horrible crippling disfiguring arthritis that goes by the ancient name "gout" is almost certainly 100% curable.

Gout has a cure; please take it.

Don't horse around with "maybe if I don't eat this one super-special magical thing maybe I'll never have gout again." That's just not how it works.

I've summarized what gout is, how it causes its crippling pain, what treatments are available and how they work in a few posts here.

Once you understand what gout is and how it works, you'll understand far better how to treat it.

Gout is not "my toe started hurting one day".

Gout is: Years to decades of high uric acid levels in your blood, leading to accumulation of uric acid deposits in all sorts of joints, tendons, and ligaments around your body. The uric acid deposits are mediate by your immune response, which "neutralizes" the uric acid by jamming into these deposits in various parts of your body.

So by the time you actually notice anything happening, this has been going on for years to decades. You have uric acid deposits all over the place. You finally just won the Evil Lottery and one of them reached the point were it triggered an extensive immune response in the wrong place and suddenly you can't walk.

All this can be completely reversed via the miracle medications that we now have available. It takes some years to reverse the deposits--just as it took years to decades to grow them. But they can be reversed and gout sufferers can be completely pain free and cured.

Hate to say it, but it's a little like the covid vaccine. You can be in vaccine denial and when you eventually get covid you might survive it. By why are you fooling around with that option when we have a pretty complete cure, in the form of a vaccine?

Just take the %$#$*$ cure and be done with it. Don't fool around.

We have a cure for gout, too. Or you can wear strings of garlic around your neck, keep your fingers crossed, etc. All the things that kind of work a little, but--not really.

The cure is to go to your doctor, or if the local doctor won't help, a rheumatologist (who specializes in conditions like gout), and get on one of the medications we now have that lowers your uric acid level. When you do that, over time, your existing uric acid deposits will gradually dissolve. You literally reverse the gout that you have with these medications--and given maybe 1-5 years for them to work.

It's a bit like high blood pressure--once you've got it you're likely to be on blood pressure meds for the rest of your life. But with those meds most people can keep their blood pressure entirely under control, halting all the damage high blood pressure can do to all kinds of sensitive areas of your body.

Same with gout and gout medications. The meds cure it, but it's a long-term cure. It's not one and done at all.

Summary of how gout causes inflammation & pain, and how various gout treatments work.
posted by flug at 8:56 AM on July 21, 2021 [4 favorites]

I asked my rheumatologist if I should change anything about my diet and he said no. I’ve heard that diet can only affect uric acid levels one point in either direction.
posted by soelo at 1:28 PM on July 22, 2021

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