Gout is on the
Rise
by John McDougall
Over the past
20 years the incidence of gout�a debilitating arthritis caused by eating
rich food�has doubled in the USA (1). Not surprisingly, this is
an increase that parallels the growing epidemic of obesity(2).
Although gout is the most common form of inflammatory arthritis in men, affecting 1 to 2 % of men in Western countries and as many as 5
million men in the United States (3)
�this painful arthritic condition is essentially unknown in parts of the
world where people consume a diet based on starches
(4-6).
The Diagnosis
I see many
people who believe they suffer with gout, but they don�t. They may have
joint pains, and some may have an elevated blood uric acid level, but
their problem is usually degenerative arthritis (osteoarthritis). Gout
is suspected if a joint�classically, the base of the big toe�becomes
suddenly swollen, red, and painful. However, the definitive diagnosis
is made by examining, under the microscope, fluid extracted from a
painful joint and finding uric acid crystals (monosodium urate
crystals).
The Cause
The
inflammatory process in gout is caused by the accumulation of uric acid
crystals in a joint. Excess uric acid in the body can be caused by an
increase in production by the body and by under-elimination by the
kidneys. However, the most important cause is an increase in the intake
of rich foods, which are high in uric acid precursors, known as purines.
These molecules are the building blocks of genetic materials�DNA and
RNA. The muscles of animals�meat, poultry, fish and seafood�are the
most important sources of purines. Vegetable sources of purines do not
contribute to the risk of having an attack of gout. According to an
article in the New England Journal of Medicine, �Higher levels of
meat and seafood consumption are associated with an increased
risk of gout�Moderate intake of purine-rich vegetables or
protein is not associated with an increased risk of gout.�7
Other lifestyle habits, like alcohol consumption are also
believed to encourage the deposition of uric acid crystals in the
joints.
Weight Loss
from Any Cause Can Start Gout
I have seen a
couple of my patients develop gout after changing to our diet.8
This is caused by the release of uric acid from their dissolving body
fat. These molecules can move to the joints where they may form
crystals. I worry about this happening only with patients with a
history of previous gout. Even for these people, the risk of an attack
is very small. However, for some patients any risk is too much and they
may choose to add a further measure of protection by taking a
time-honored gout medication�colchicine .05 mg daily for about 6
months�in order to eliminate the possibility of an attack while losing
weight.
Not
surprisingly, gout attacks have been seen more frequently since the
popularity of high protein diets (Atkins, South Beach, etc.).3
The foods recommended by these low-carbohydrate diets are very high in
purines.
Second, these diets cause rapid weight loss and thereby facilitate the
release of uric acid from the body fat. Lastly, these diets cause
dehydration and place added stress on the kidneys, which might make
people more sensitive to the rise in uric acid.
The Medical
Treatments
Early treatment, within 24 hours, is the key to resolving an episode of
acute gouty arthritis. Colchicine, the traditional agent used, is more
specific for gout than are the NSAIDs, which are also effective.
Although elevated levels of uric acid in the blood are a major risk
factor for the development of gout, acute gouty arthritis can occur in
the presence of normal serum uric acid levels. Patients suffering with
on-going damage from elevated uric acid levels may need treatment with
medication that lowers uric acid in the body (like allopurinol). Just
having an elevated uric acid level without chronically active arthritis
(or recurrent kidney stones) is not a cause for treatment
with medication (you still need to change your diet).
The Cure
All dietary
recommendations for the prevention of gout attacks strongly recommend
avoiding the use of muscle foods. Some authorities also warn against
high protein vegetable foods, like beans, peas and lentils. Actually,
higher intake of vegetable protein is associated with a lower risk of
gout.3 Therefore, if a patient avoids the animal foods,
including some of the higher protein vegetable foods mentioned above
will cause no trouble. Based on population studies and the
well-established cause-and-effect mechanisms between animal muscles and
gout, I believe the common form of diet-caused gout cannot occur in
people who follow a McDougall-type diet. However, most people have
large storages of uric acid in their tissues which may take months of
healthy eating and associated weight loss to dissolve away.
References:
1) Arromdee
E, Michet CJ, Crowson CS, O'Fallon WM, Gabriel SE. Epidemiology of
gout: is the incidence rising? J Rheumatol. 2002
Nov;29(11):2403-6.
2) Lyu LC,
Hsu CY, Yeh CY, Lee MS, Huang SH, Chen CL. A case-control study of the
association of diet and obesity with gout in Taiwan. Am J Clin Nutr.
2003 Oct;78(4):690-701.
3) Lee SJ,
Terkeltaub RA, Kavanaugh A. Recent developments in diet and gout.
Curr Opin Rheumatol. 2006 Mar;18(2):193-8.
4) Torralba
TP, Bayani-Sioson PS. The Filipino and gout. Semin Arthritis Rheum.
1975 May;4(4):307-20.
5) Johnson
RJ, Titte S, Cade JR, Rideout BA, Oliver WJ. Uric acid, evolution and
primitive cultures. Semin Nephrol. 2005 Jan;25(1):3-8.
6)
Roberts-Thomson RA, Roberts-Thomson PJ. Rheumatic disease and the
Australian aborigine. Ann Rheum Dis. 1999 May;58(5):266-70.
7) Choi HK,
Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy
and protein intake, and the risk of gout in men. N Engl J Med.
2004 Mar 11;350(11):1093-103.
8) Antozzi P,
Soto F, Arias F, Carrodeguas L, Ropos T, Zundel N, Szomstein S,
Rosenthal R. Development of acute gouty attack in the morbidly obese
population after bariatric surgery. Obes Surg. 2005
Mar;15(3):405-
�2006
John McDougall All Rights Reserved
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