FOOD INTOLERANCE NETWORK FACTSHEET

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Gout and diet

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Introduction

Why failsafe eating works better than most gout diets
7 foods/chemicals to reduce or avoid for gout                                                                                    
Why atrial fibrillation is associated with gout
Medications that can help or trigger gout

Reader reports

Notes, references, more info

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  Introduction

For 25 years, we have received reports about improvements in gout when readers try the RPAH elimination diet that we recommend.  For example

 “My husband’s gout has improved since our family went failsafe. He’s not really on the diet but eats a lot of our failsafe food” – from story [1531]

From the 1850s to the 1990s, the recommended gout diet was avoidance of purines in meat, seafood and alcohol. Since then studies suggest more foods are involved than previously thought.

Gout is changing

* gout used to be the “disease of kings” linked to rich food, but now it is linked to the Western diet (Rai, 2017).

* gout is increasing, especially in developed countries, the Pacific Islands, Māori people, and Southeast Asia (Kuo, 2011; Anneman, 2016) – and experts do not know why.

In men aged 65 and over, gout is estimated to affect 17 percent of non-Māori- non-Pacific people, 37 percent of Māori and 47 percent of Pacific people” (NZ Govt stats, 2019).

* traditionally, gout affects mostly older men but that is changing: in Nepal first attacks of gout are common in men under 40 (Pokharel, 2011) - and experts do not know why.

“I came here to do a trek. But now I have gout – it’s so painful I can’t even walk. My whole trip is wasted… ” – young American would-be trekker in Nepal, from story [1522]

* traditionally, gout is associated with dietary purines

“… acute purine intake increases the risk of recurrent gout attacks by almost fivefold among gout patients. Avoiding or reducing amount of purine-rich foods intake, especially of animal origin, may help reduce the risk of gout attacks …” (Zhang, 2012).

… but  tomatoes - low in purines - are the 4th most commonly reported gout trigger in New Zealand (Flynn, 2015) – so experts are starting to debate which other food chemicals are associated with gout.
          
* people with gout have a higher risk of Atrial Fibrillation (Singh, 2018) - and experts do not know why.

Why failsafe eating works better than traditional gout diets

1. Food additives approved 25 years ago can trigger gout


Commonly used flavour enhancers can increase uric acid levels and trigger gout attacks, yet these are ignored by most gout diets. Failsafe eating avoids these additives.

“Ingestion of large amounts of these compounds [inosinate, guanylate and ribonucleotide flavour enhancers E627 or GMP, E631 or IMP, E635 or I +G] … can increase the serum uric acid level and urinary uric acid excretion and this needs to be considered in relation to people with gout … and those taking uric-acid retaining diuretics. Hence specific mention of the addition of these substances on the label may be indicated” [… BUT IT DIDN’T HAPPEN] – JECFA (the WHO additive assessment committee), 1974.

These additives were approved for use (without the gout warning) in Australia and New Zealand in December 1994 and became widespread by 1999. Over the next ten years, the rate of hospital admissions for gout doubled (Robinson, 2013).

2. Low-purine foods can trigger gout. Failsafe eating avoids these foods.

In the NZ tomato study mentioned above (Flynn 2015), the top ten gout triggers were:

seafood/fish
alcohol
red meat
tomatoes
some vegetables
some fruits
sugar-sweetened drinks
poultry
dairy products
other

Five of these, including tomatoes, are low in purines. Their mention as gout triggers used to be dismissed as anecdotal, but is now being taken more seriously.

“Some people find that certain foods such as strawberries, oranges, tomatoes and nuts will trigger their gout even though they are not high in purines. Although there is no clear evidence to suggest why this happens, it is probably best to avoid them if you have had this experience.”- from the UK Gout Society diet factsheet, 2019, www.ukgoutsociety.org

Several studies have shown that consumption of tomato juice or sauce can increase uric acid levels and researchers suggest this may be due to food chemicals such as glutamates or others (Flynn 2015).

In the RPAH elimination diet, fresh tomatoes are listed as high in natural salicylates, amines and glutamates. Concentrates such as tomato juice, puree, paste and sauce are listed as very high. The science suggests there are good reasons for some people with gout to avoid these food chemicals:

Salicylates in foods (Swain 1985) can have the same effect as low-dose aspirin that has been shown to trigger gout (Zhang 2014). Although fructose is often blamed, other chemicals in fruit (Nakagawa 2019) such as salicylates would also account for the effects of high salicylate fruits, fruit juice, and soft drinks with flavour additives.
Amines are in the same foods as purines – meat, seafood, alcohol (RPAH’s Friendly Food; Kaneko 2014).
Glutamates (also often in amine foods) are in high-purine foods (Johnson 2013)

Failsafe eating sticks to low or moderate levels of these chemicals.

“My male partner (47) has suffered from medically diagnosed gout for three years … He undertook the failsafe diet as per the RPAH regime … When we undertook the challenges he passed the salicylate challenge and failed miserably with amines and glutamates; both bringing on gout. He avoids all amines and glutamates and he is now gout free“ – Susan, from story [1532], see full story below

“My partner's uncle tells me he used to be addicted to tomato sauce and had to give up because it was causing his bouts of gout … Now he longer gets it unless he goes to Fiji, which he does quite regularly, where he eats a lot of curry (so obviously salicylate related). He had no idea about the connection" - Cherie”  from story [965]

7 foods / chemicals to reduce or avoid for goutand why failsafe eating works

1. Meat (purines - and amines)

Gout diets avoid strongly flavoured meats such as red meat, game meat like venison, offal such as liver and kidneys and this has been confirmed by a 2014 Japanese analysis of purines in 270 foods (Kaneko 2014). The full list of foods analysed can be found at https://www.jstage.jst.go.jp/article/bpb/37/5/37_b13-00967/_article

Failsafe eating allows beef, lamb or chicken (no skin) only if fresh and additive-free; avoids cured meats, pork, strongly flavoured meats and all offal (see our shopping list). Or meat can be avoided. Studies suggest vegetarian diets are useful for gout prevention (Chiu 2019; Pokharel 2011).

My husband and I have been doing the elimination diet for two weeks now …  My husband can suffer with gout, if he has any red meat. There are also other triggers for him, but the red meat is really the big one. Over the past weekend … we enjoyed some beef and lamb (only seasoned with salt). I knew that we were pushing the boundaries, but I checked with my husband this morning, and there has been no sign of gout at all! – from story [966]

2. Seafood (purines – and amines)

Gout diets avoid seafood particularly shellfish, scallops, mussels, herring, mackerel, sardines and anchovies.

Failsafe eating allows certain fish and seafood if very fresh, best eaten within 12 hours of catch eg white fleshed fish, crab, lobster, oysters, calamari, scallops; no shellfish, oily fish, salmon, tuna, prawns, others; medications and supplements are also limited (see our shopping list)

“My husband is a gout sufferer and after a lot of trial & error we finally realized his trigger is shellfish … BUT - he kept having gout attacks even after eliminating it from his diet! Turns out there is shellfish in most multi vitamins, joint supplements, etc” – from https://www.fatsecret.com/Community.aspx?pa=fp&m=513117

3. Alcohol (purines – and salicylates, amines and glutamates)

Gout diets are conflicting. Some say beer is worst.

“Dad's not on failsafe diet, this is what he gets. All joints crystallised including his toes. Coconut and beer are the worst triggers for him” – Emily from [1531]

Research agrees.

"…beer drinkers increased their risk by 50% for every daily serving, while those who drank hard liquor increased their risk by 15% for each drink” (Choi 2004)

"Some local beer and high malt beers had a purine content 100-fold higher than a serving (40 ml) of whisky"…“Some local and low-alcohol beers were found to contain about 2.5 times more purines than regular beer“ (Kaneko 2009)

But it appears that all alcohol is implicated and reactions are related to the size of the dose:

“Results showed that a single serving of wine, beer or liquor (either straight or in a mixed drink) in a 24-hour period didn’t significantly increase the chance of repeat gout attacks. But consuming more than one to two drinks a day did – by 36%. With two to four drinks, the risk rose 50%, and it continued to rise with the amount of alcohol consumed.” (Neogi 2014)

Failsafe eating allows only gin, vodka and whisky.  For non-alcoholic drinks, water, decaffeinated coffee, still and sparkling mineral water, plain soda water and ice are all failsafe.

4. Yeast (purines and glutamates)

Gout diets say – if they say anything - avoid beer and Vegemite (Arthritis Australia) although yeast was identified as the 4th most important category of purines in the Japanese analysis (Kaneko 2014).

Failsafe eating avoids beer, brewers yeast, nutritional yeast, Vegemite, Marmite and any product containing yeast extract including all forms of MSG with MSG boosters (the 600 number food additives especially 627, 631 and 635). When these additives were assessed, it was suggested they have the following warning, but it NEVER HAPPENED …

WARNING: “People suffering from conditions such as gout, which require the avoidance of purines are recommended to avoid this substance” (JECFA 1974)

“I started getting gout attacks a few years ago. It took a while for me to realise it was the day after we ate in our favourite restaurant (Thai). We still eat there but I avoid the oyster sauce and we don’t take a bottle of wine” – story [1530]

Q. What’s in oyster sauce?

A. In Maggi brand, the main ingredients are water, sugar, salt and flavour enhancers 621,635. Oyster extract forms only 0.4% of the product https://www.maggi.com.au/products/asian-sauces/oyster-sauce

1530oyster


How to avoid MSG-boosting flavour enhancers?

These are used in processed foods such as fast food, ready meals, soups, stocks and stock cubes, gravies, seasonings, sauces, chicken flavoured salt, flavoured snacks and many more. Some people with gout - and some researchers - say the only way to avoid them fully is to cook for yourself at home, avoiding commercially available foods and restaurants (Insawang 2012).

"I have been battling with Gout since I was 27, now 40 … I knew there was a link between MSG and my gout attacks, but not until I got passionately strict and removed ALL MSG did I get my Gout under control … AVOID all MSG. Stay away from McDonald and ALL fast food. Fast Food has a lot of MSG. Stay away from Soups, unless you know it does not have MSG in it. Soup bases are loaded with MSG. Stay away from Seasonings that have MSG. You can still go to a Chinese restaurant, but make sure you ask for NO MSG. No Sausage ever, unless it says NO MSG. No sausage on your Pizza EVER because 95% of all Sausage has MSG … I can still drink beer and eat steak now and then. Just as long as I eat a lot of vegetables … drink lots of water, and exercise …from https://www.fatsecret.com/Community.aspx?pa=fp&t=36268

"I can confirm that MSG causes gout in me. After years of trial and error, it is the MSG that always causes it. It is in everything, and what initially clued me in was eating dried cuttlefish and Hot Fries in the same day that I also had a Cup of Noodles for lunch. I am from Hawaii and we love all of those things. That started my quest to eventually figure out it is the MSG. Now whenever I have a gout attack, I can ALWAYS trace it back to something I forgot had MSG, like a bag of BBQ Chips, Top Ramen (the flavor packet), sausage links (McDonald too!), some bacons, most flavored corn chips (nacho cheese, ranch), Campbells soups, Mexican packet soups, so many things. Read the labels and it could be affecting you too. Some restaurants you must ask also, because some put it in Kim Chee and their soup bases and sauces. Asian places LOVE to put it in their dips and sauces. I myself can eat any shellfish, drink beer, everything else is fine (except the concentrated fish sauces too as in Filipino food which I love), for the most part, just be careful not to STACK the items. A bag of Doritos is fine for me, but if I eat it, then eat a sausage burrito from McDonald's along with a hotdog that has it, the BOOM! Gout attack. Hope this saves you some time in figuring it out. Read the label and you'll be surprised how many things have MSG, even a lot of dressings, like Hidden Valley Ranch –  from https://www.fatsecret.com/Community.aspx?pa=fp&m=513117

And see our blog:  129 ways to add MSG and fool consumers

5. Salicylates (in fruit, vegetables, fruit juice, spices and others)

Gout diets say - at least, they should - avoid low-dose aspirin for heart attack prevention because low dose aspirin (salicylates) has been shown to impair excretion of uric acid from the kidneys. Paradoxically, the lower the dose, the higher the effect (Yu 1959, Zhang 2014).

“the use of low-dose aspirin on 2 consecutive days was associated with a 91% increased risk of gout attacks” – (Zhang 2014)

What none of these diets seem to recognise is: the effects of salicylates in low-dose aspirin and salicylates in foods such as tomatoes, strawberries and oranges are the same (Swain 1985, Fitzsimon 1978).

Tomatoes are 4th most commonly reported trigger foodbut experts don’t know why:

“Seventy one percent of people with gout reported having one or more gout trigger food. Of these 20% specifically mentioned tomatoes, the 4th most commonly reported trigger food (after seafood, alcohol and red meat). There was association between tomato intake and serum urate levels …” (Flynn 2015)

Failsafe eating avoids high salicylate foods especially tomato sauce, berries including strawberries, citrus including oranges and many more - see our Salicylate factsheet 

“I was consuming half a punnet [of strawberries] a day. After several days I was struck by severe gout, and it was excruciating, making walking from the car to the doctor almost impossible. Several passersby stopped to ask me if I had gout, and laughed at my affirmative saying "You've been into the strawberries, haven't you?"…  I ignored the pills and simply gave up the strawberries. Instant cure …  a few weeks later I tried some strawberries and the next day I had gout ..” – from story [1131]

6. Sugar-sweetened beverages, fruit juice and fruit  (fructose – or some other food chemical?)

Gout diets: Researchers found that sugar or corn syrup sweetened soft drinks were strongly associated with gout and that even some fruit juices and even some fruits can cause a problem. The mechanism – fructose or some other food chemical – is currently debated (Choi 2008, Merriman 2014, Nakagawa 2019).

Failsafe eating avoids these foods and products because they are high in salicylates or contain additives that can affect people who are sensitive to salicylates.

7. Dairy products

Gout diets say that dairy products are good for people with gout because they are low in purines (Hayman 2009). However, dairy products were listed as the 9th most common gout trigger in the NZ survey (Flynn, 2015).

Failsafe eating avoids dairy products for those who have identified a problem using the RPAH protocol:  avoid dairy products for 3 weeks during the elimination diet and drink 1-3 cups of milk or A2 milk every day for 7 days during the dairy challenge. Or if not doing the RPAH elimination diet, some people find switching to A2 milk makes a big difference https://www.fedup.com.au/factsheets/support-factsheets/how-to-start-failsafe-eating

“Spoke to you before about my husband drinking milk and him getting a pain like Gout in his foot. He had a Nestle Mocha one morning with Woolies Lite Milk (needed milk one night and that’s all he could get and left the A2 milk for the kids) still got a pain in his foot, next time tried with A2 and didn’t have any pain”. – from story [846] 

Gout and Atrial Fibrillation (AF)

Atrial fibrillation is increasing (Patel  2018).  Atrial fibrillation is also associated with gout – “a diagnosis of gout almost doubled the risk of incident AF in the elderly” (Singh 2018); the Western lifestyle (Hajhosseiny 2015) and MSG (Burkhart 2009). We suggest that for some people, the same foods/chemicals that can trigger gout can also trigger AF.

"From MSG, 635 flavour enhancer and metabisulphite preservatives I get very irregular pulse and atrial fibrillation. The atrial fibrillation settles down after 12-20 hrs depending on how much offending additive I have eaten (in a restaurant it is difficult to tell) - and my pulse settles down faster if I drink lots of water every hour to flush the toxins out of my system" – from story [117]

"Back around 1997 I was diagnosed with AF (atrial fibrillation) & TC (tachycardia) … I had a cardiologist who was great but neither he or any of the doctors or specialists I saw ever mentioned anything about diet … I was on medication …  somewhere along the line I heard about how MSG could be bad for your health … so I thought I’d strike it out of my diet ... WOW there went half my problems …  soon I had struck red food colouring from the list, sports drinks (when not exercising), high caffeine drinks (coke especially), energy drinks went too … highly fatty foods went out the window and through more experimentation (monitoring) I dropped anything with the preservatives starting with 22_ . I have also found that some of this stuff seems to build up in my system as if I don't have any for a long time I can cope with quite a high dose of it in one hit, if it becomes regular in my diet I quickly feel the symptoms after even the smallest amount" – from story [1118]

See more reader stories on our AF factsheet

Medications that can help or trigger gout

A rates of gout increase, and standard low-purine gout diets appear to be less effective, doctors are arguing over the use of long term medication to lower uric acid levels. On one side, the prestigious American College of Physicians issued new guidelines in 2017 calling for less aggressive drug treatment. On the other side, many gout specialists have created a new professional group - backed by drug companies —to promote long-term use of medication to lower uric acid (McFarling, 2017).

The commonest drugs to help with gout are colchicine (for acute attacks), allopurinol (to lower uric acid levels) and NSAIDs such as ibuprofen (for pain). Like all drugs, they can have side effects.

Colchicine: the commonest side-effect is diarrhoea often before pain relief, the  median time for which is 48 hours (Ahern 1987). A controlled trial showed that with high-dose colchicine(4.8 mg total over 6 hours), nearly 80% of patients had diarrhoea , 20% had severe diarrhoea, and 20% had vomiting. Low-dose colchicine (1.8 mg total over 1 hour) worked as well as the higher dose and only 23% of the patients had diarrhoea, none had severe diarrhoea and none had vomiting (Terkeltaub, 2010).

Allopurinol: on the doctor-run Rxisk.org website, there is a warning: “this is not an innocuous drug. It is not recommended for the treatment of asymptomatic hyperuricemia “. The most common side effect is skin rash but this drug has been associated with fatalities due to various causes from liver and kidney damage to toxic epidermal necrolysis that causes severe damage to the skin and mucous membranes, fatal in up to 50% of cases (Yang 2015, Pereira 1998). On Rxisk.org there is a long list: “call your doctor at once if you have the first sign of any skin rash, no matter how mild; flu symptoms, joint paint, easy bruising … and many more, see https://www.rxlist.com/zyloprim-side-effects-drug-center.htm#consumer

A man with gout for ten years wrote:

“I did the doctor thing for several years. Allopurinol made me scaly and I hate ‘Pharmaco-reliance’ for anything so I ditched it … I found [online gout diet info] to be more helpful than a doctor who never even suggested I cut back on alcohol” - from https://www.fatsecret.com/Community.aspx?pa=fp&t=36268

NSAIDs such as ibuprofen are not failsafe and some of our readers say their salicylate sensitivity was caused by these drugs:

"I am sensitive to salicylates as the result of overuse of Ibuprofen (chemically very similar to aspirin)" - from story [114]  http://fedup.com.au/stories/2001/114-paresthesia-numbness-august-2001

Medication that can trigger gout

Diuretics (water-pills) used to control high blood pressure are one of the most important causes of hyperuricaemia. Other drugs that can cause problems include immunosuppressants, vitamin B3 (nicotinic acid) used as a cholesterol lowering medication, low-dose salicylates as previously mentioned, and many others:

“Hyperuricemia and iatrogenic gout may also be encountered with many drugs, such as thiazide and loop diuretics, cyclosporine, tacrolimus, (immunosuppressants) pyrazinamide  and ethambutol (for TB) , nicotinic acid as well as low-dose aspirin (salicylates) and omeprazole . Other products may also be incriminated as: ticagrelor, topiramate, sildenafil, acitretin, L-DOPA, filgrastim, didanosine, and pegylated interferon.... “ (Ben Salem 2017)  

Conclusion

Gout is a lifestyle-related condition. Some people are more sensitive to various gout triggers than others.  In most cases gout can be prevented by a careful diet, reduced alcohol, regular exercise and staying well-hydrated. In our experience, the best way to deal with food intolerance is to find out exactly what the triggers are by using the RPAH elimination diet with challenges, supervised by one of our listed dietitians

Bernard from Wollongong was the first failsafer to recommend a dietitian-supervised trial of the RPAH elimination diet for symptoms of gout and psoriatic arthritis:

“By 33 years of age I was suffering pain under the base of the right big toe, which I thought was caused by a stone injury. This injury was subsequently diagnosed as gout … I have suffered with the pain and swelling of arthritis … for almost half of my adult life. At times my condition was so bad that I was only able to walk about 50 metres without a rest.… The constant pain I suffered was unbearable … I am still improving after eight and a half years on low chemical foods. NOTHING will make me eat the foods I once loved so much. “ UPDATE in 2019 at the age of 84: My wife and  I are doing fine we think,  thanks to being basically failsafe for nearly 23 years … I  now have had 23 years virtually without pain. [601]

Reader reports

[1532] RPAH diet works better for gout than prescribed medical low purine diet (June 2019)

My male partner  (47) has suffered from medically diagnosed gout for three years and has tried many things; prescribed medication, a low lectin diet (as per the Plant Paradox book by Stephen Grundy), the prescribed medical low purine diet to no avail. His gout was in his foot/ankle and when it flared he could not even stand the bedsheet touching his foot.

I had done the failsafe diet for my daughter 20 years ago with success and I encouraged him to try failsafe. He undertook the failsafe diet as per the RPAH regime (no dietician). We only challenged salicylates, amines and glutamates as we do not eat artificial additives. He is gluten free and only has A2 milk (prior to failsafe as these foods suit him better). When we undertook the challenges he passed the salicylate challenge and failed miserably with amines and glutamates; both bringing on gout. He avoids all amines and glutamates and he is now gout free – Susan

from [964] One-liners (October 2010)

My husband is an amine responder and reacts to chocolate with gout like symptoms - Rose

[966] Gout, red meat and the elimination diet (October 2010)

My husband and I have been doing the elimination diet for two weeks now. We are both feeling great, our tummies are not bloated, we are not sour in the stomach in the morning. Another thing that we are so pleased about! My husband can suffer with gout, if he has any red meat. There are also other triggers for him, but the red meat is really the big one. Over the past weekend, we were at friends, and enjoyed some beef and lamb (only seasoned with salt). I knew that we were pushing the boundaries, but I checked with my husband this morning, and there has been no sign of gout at all! Thank you. Things are really going well. – Carla

[1131] Gout from strawberries (September 2012)

The Sunshine Coast is a strawberry-growing area. My visiting daughter gave me a blender for Xmas and bought me daily supplies of bananas and strawberries. I was consuming half a punnet a day. After several days I was struck by severe gout, and it was excruciating, making walking from the car to the doctor almost impossible. Several passersby stopped to ask me if I had gout, and laughed at my affirmative saying "You've been into the strawberries, haven't you?"

Astonished, I told the doctor, who clearly was not impressed and prescribed some pills. I ignored the pills and simply gave up the strawberries. Instant cure. Testing the thesis , a few weeks later I tried some strawberries and the next day I had gout in, of all places, my left thumb. Just thought this experience might confirm for you your own conclusions - Tony (See more on gout and salicylates in Arthritis, joint pain and diet factsheet)

[965] Gout and salicylates (October 2010)

My partner's uncle tells me he used to be addicted to tomato sauce and had to give up because it was causing his bouts of gout. Now he longer gets it unless he goes to Fiji, which he does quite regularly, where he eats a lot of curry (so obviously salicylate related) …  - Cherie https://www.fedup.com.au/stories/2010/965-gout-and-salicylates-october-2010

[1531] Gout one-liners from our facebook group (May 2019)

Mango (high in salicylates) gives me gout in 1 foot  … Really sux cos I have two huge mango trees on my property! Lol – Tanya from facebook group

Dad's not on failsafe diet, gout is what he gets. All joints crystallised including his toes. Coconut and beer are the worst triggers for him – Emma from facebook group

My husband’s gout has improved since our family went failsafe. He’s not really on the diet but eats a lot of our failsafe food – Michelle

[1530] Gout from oyster sauce (May 2019)

I started getting gout attacks a few years ago - eventually I realised it was the day after we ate in our favourite restaurant (Thai). We still eat there but I avoid the oyster sauce and we don’t take a bottle of wine.

Sue’s comment:  What’s in oyster sauce?  Not oysters … in Maggi brand, one of the main ingredients is flavour enhancers (621,635) and oyster extract forms only 0.4% of the product. Flavour enhancer 635 is strongly linked to gout, see above.

[846] Pain like gout from milk (August 2009)

Spoke to you before about my husband drinking milk and him getting a pain like Gout in his foot. He had a Nestle Mocha one morning with Woolies Lite Milk (needed milk one night and that’s all he could get and left the A2 milk for the kids) still got a pain in his foot, next time tried with A2 and didn’t have any pain. – Tracey

[1522] 635: Kathmandu gout man due to flavour enhancers? (April 2019)

About five years ago in Kathmandu, Nepal, we met an American guy sitting in our hotel restaurant with his foot on a chair.  Aged maybe 35, he was barely able to hobble. He said sadly: “I came here to do a trek. But now I have gout – it’s so painful I can’t even walk. My whole trip is wasted”.  Both he and his doctor were mystified about the cause. Gout is usually associated with too much meat and alcohol in older age men - not the case here.

According to a local journalist, gout is common in Nepal, and attacks "seem to start at a younger age group ( less than 40 years) in Nepal than what is usually noted in Western medical  textbooks (over 60 years)", for unknown reasons. https://www.spotlightnepal.com/2011/08/09/gout-in-nepal/ - Sue Dengate

story1522

A ribonucleotide-containing noodle soup advertising blimp being towed through minor towns in Nepal

 

Sue's comment: I guess the culprit in both cases would be ribonucleotide flavour enhancer additives  These additives are heavily used in Nepalese food such as instant noodles, soups, sauces, fast food and snacks. These high purine additives are as strongly associated with increased uric acid and risk of gout attacks as high purine foods although, oddly, they are never mentioned in any medical gout diets or lists of high purine foods.

These additives can be called inosinates, guanylates and ribonucleotides (E627, E631 and E635) or  in America flavor enhancers Disodium Inosinate (DSI or IMP), Disodium Guanylate (DSG or GMP), and the combination of IMP and GMP (I&G). See JECFA reference below.

 


Notes and references

Gout linked to the Western diet

Rai SK et al, The Dietary Approaches to Stop Hypertension (DASH) diet, Western diet, and risk of gout in men: prospective cohort study, BMJ, 2017;357:j1794.

“A higher DASH dietary pattern score (based on high intake of fruits, vegetables, nuts and legumes, low fat dairy products, and whole grains, and low intake of sodium, sweetened beverages, and red and processed meats)  was associated with a lower risk for gout  … In contrast, a higher Western dietary pattern score(based on high intake of red and processed meats, French fries, refined grains, sweets, and desserts) was associated with an increased risk for gout …  Conclusion: The DASH diet is associated with a lower risk of gout …”   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5423545/

Gout is increasing

Kuo CF et al, Global epidemiology of gout: prevalence, incidence and risk factors, Nat Rev Rheumatol, 2015;11(11):649-62.

“distribution of gout is uneven across the globe, with prevalence being highest in Pacific countries. Developed countries tend to have a higher burden of gout than developing countries, and seem to have increasing prevalence and incidence of the disease. Some ethnic groups are particularly susceptible to gout …https://www.ncbi.nlm.nih.gov/pubmed/26150127

Annemans L et al, Gout in the UK and Germany: prevalence, comorbidities and management in general practice 2000-2005, Ann Rheum Dis, 2008;67(7):960-6.

“The prevalence rates [1.4%, same in the UK and Germany] observed are … fivefold higher than those observed (0.26%) in the survey by Currie in UK general practices 30 years ago …  There are other data which suggest that the prevalence of gout might have increased over the past 30 years. The annual prevalence of self-reported gout in the National Health Interview Survey in the USA trebled between 1969 and 1996, and the prevalence of gout and hyperuricaemia requiring urate-lowering drug treatment was observed to have increased by 80% between 1990 and 1999 in a managed-care population in the USA ….https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564789/

According to NZ government statistics:

“In men aged 65 and over, gout is estimated to affect 17 percent of non-Māori- non-Pacific people, 37 percent of Māori and 47 percent of Pacific people”  https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/gout/

Gout mostly affects older men but that is changing

Gout in Nepal, Spotlight Magazine, 2011,Aug  9;5(4).

“Gout attacks are common and seem to start at a younger age group (less than 40 years) in Nepal than what is usually noted in Western medical textbooks (over 60 years)”
https://www.spotlightnepal.com/2011/08/09/gout-in-nepal/

Pokharel K et al, Estimation of serum uric acid in cases of hyperuricaemia and gout, JNMA J Nepal Med Assoc, 2011 Jan-Mar;51(181):15-20.

“The mean age for gout was 47.49 and 56.65 years in males and females respectively. The mean age for the first gout attack was 42.1 +/- 14.0 years”  https://www.ncbi.nlm.nih.gov/pubmed/22335090

Traditionally gout is associated with dietary purines … but tomatoes (low in purines) are the 4th most commonly reported gout trigger

Zhang Y et al, Purine-rich foods intake and recurrent gout attacks. Ann. Rheum. Dis., 71, 1448–1453 (2012). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3889483/

Flynn TJ et al, Positive association of tomato consumption with serum urate: support for tomato consumption as an anecdotal trigger of gout flares. BMC Musculoskelet Disord. 2015 Aug 19;16:196.

“Tomatoes … have a very low purine-content“ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541734/

People with gout have a higher risk of Atrial Fibrillation

Singh JA1,2,3, Cleveland JD2. Gout and the risk of incident atrial fibrillation in older adults: a study of US Medicare data. RMD Open. 2018 Jul 13;4(2):e000712.

“A diagnosis of gout almost doubled the risk of incident AF in the elderly” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6045725/

Patel NJ et al, Global rising trends of atrial fibrillation: a major public health concern, Heart, 2018;104(24):1989-1990.

“Numerous studies have reported AF as a growing epidemic with an expected doubling of prevalence by 2030 …”.  AF is the most common arrhythmia and can be associated with strokes and heart attacks. https://heart.bmj.com/content/104/24/1989

Food additives that can trigger gout

Kojima K. Safety evaluation of disodium 5'-inosinate, disodium 5'-guanylate and disodium 5'-ribonucleotide.Toxicology. 1974 Jun;2(2):185-206.

“Three healthy volunteers (males) were given low purine diets containing 250-4000 mg DSRN [disodium 5’ribonucleotide] daily. The higher level raised the serum uric acid level and urinary uric acid output but the 2 g level did not raise serum uric acid level above the accepted range. No adverse effects were reported.“  

These additives were then assessed by the World Health Organisation as safe for use in food - if eaten in small amounts - with a possible warning for those with gout or taking diuretics, that never eventuated.  

JECFA Eighteenth Report of the Joint FAO/WHO Expert Committee on Food Additives, Calcium and Sodium-5’-Ribonucleotides, Wld Hlth Org. techn. Rep. Ser., 1974, No. 557.

“Ingestion of large amounts of these compounds (inosinate, guanylate and ribonucleotide flavour enhancers E627, E631, E635) … can increase the serum uric acid level and urinary uric acid excretion and this needs to be considered in relation to people with gouty diatheses and those taking uric-acid retaining diuretics. Hence specific mention of the addition of these substances on the label may be indicated. [but it didn’t happen- Ed] The changes in dietary purine intake from the use of flavour enhancers are no greater than those likely to be occasioned by changes in consumption of those dietary items, which are the main contributors of purine.”
http://www.inchem.org/documents/jecfa/jecmono/v06je02.htm

These additives were approved without evidence of safety in December 1994 in Australia and New Zealand, as described in our factsheet about MSG Boosters

Gout hospital admissions increased

Robinson PC, Hospital admissions associated with gout and their comorbidities in New Zealand and England 1999-2009, Rheumatology (Oxford), 2013;52(1):118-26. https://www.ncbi.nlm.nih.gov/pubmed/22989425

Low purine foods can trigger gout  

(Flynn as cited above)

Flynn TJ et al, Positive association of tomato consumption with serum urate: support for tomato consumption as an anecdotal trigger of gout flares. BMC Musculoskelet Disord. 2015 Aug 19;16:196.

“Tomatoes … have a very low purine-content. Instead tomatoes contain high levels of glutamate, an amino acid which is often found in foods with a high purine-content and is able to stimulate or amplify the synthesis of urate … tomatoes alter serum urate levels to an extent comparable to other established dietary risk factors for gout“  
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541734/

Effects of low-dose aspirin on gout

Zhang Y et al, Low-dose aspirin use and recurrent gout attacks. Ann Rheum Dis. 2014;73(2):385-90.

“the use of low-dose aspirin on two consecutive days is associated with an increased risk of recurrent gout attacks” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3902644/

Salicylates in foods can have the same effect as low dose aspirin

Swain AR, Salicylates in foods. J Am Diet Assoc. 1985;85(8):950-60.

“The values for salicylate in foods that we have obtained work out to a range from about 10 mg to 200 mg/day salicylate in Western diets. This is of the same order of magnitude as the challenge dose of salicylate used in clinical testing (60), usually a 300-mg aspirin tablet” https://www.fedup.com.au/images/stories/Swain1985.pdf 

Fructose – or salicylates in fruit?

Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ. 2008 Feb 9;336(7639):309-12.

"Prospective data suggest that consumption of sugar sweetened soft drinks and fructose is strongly associated with an increased risk of gout in men. Furthermore, fructose rich fruits and fruit juices may also increase the risk. Diet soft drinks were not associated with the risk of gout" https://www.ncbi.nlm.nih.gov/pubmed/18244959

Merriman TR et al, Sugar-sweetened beverages, urate, gout and genetic interaction. Pac Health Dialog. 2014 Mar;20(1):31-8.

“The evidence summarized here is of sufficient weight to recommend reduction of SSB consumption, particularly in Pacific Island and Mãori people, to reduce the burden of gout” https://www.ncbi.nlm.nih.gov/pubmed/25928993

Nakagawa T et al, The effects of fruit consumption in patients with hyperuricaemia or gout. Rheumatology (Oxford). 2019 Apr 19. pii: kez128.

“… the effect of fruits is complex … fruits should not be simply viewed as a source of fructose. The complexity of fruits is accounted for by several nutrients existing in fruits …” https://www.ncbi.nlm.nih.gov/pubmed/31004140

Amines are often in the same foods as purines

Compare the food lists
 
Swain et al, Friendly Food, Murdoch Books https://www.slhd.nsw.gov.au/rpa/allergy/resources/foodintol/friendlyfood.html

270 food stuffs were analysed for purines in a Japanese study

Kaneko K et al, Total purine and purine base content of common foodstuffs for facilitating nutritional therapy for gout and hyperuricemia. Biol Pharm Bull. 2014;37(5):709-21.

In Japan, gout and hyperuricemia are considered to be a life-style related disease that can be treated with nutritional therapy. A daily intake of less than 400 mg of dietary purines is recommended to prevent gout and hyperuricemia. Researchers observed that “patients with gout and hyperuricemia tend to have consumed a large amount of meat or giblets [hearts, livers, and gizzards of poultry, mainly chickens and turkey] over many years …”. 270 foodstuffs were analysed although some of the emphasis was on foods that are commonly eaten in Japan but not found in the west, such as chicken hearts and fish milt. The full list of foods analysed can be found at:  https://www.jstage.jst.go.jp/article/bpb/37/5/37_b13-00967/_article

Glutamates have been associated with the same effect as purines

Johnson RJ et al, Umami: the taste that drives purine intake. J Rheumatol. 2013 Nov;40(11):1794-6.

“All high purine foods are umami foods, and the overlap between the groups is significant.” http://www.jrheum.org/content/40/11/1794.long

Foods/chemicals to reduce or avoid: purines

Gout diets such as from Arthritis Australia https://arthritisaustralia.com.au/managing-arthritis/living-with-arthritis/healthy-eating/gout-and-diet/

Failsafe eating allows https://www.fedup.com.au/information/information/short-failsafe-shopping-list

Vegetarian diets are useful for gout prevention

Chiu THT et al, Vegetarian diet and risk of gout in two separate prospective cohort studies. Clin Nutr. 2019 Mar 27. pii: S0261-5614(19)30129-3.

“Taiwanese vegetarian diet is associated with lower risk of gout.” https://linkinghub.elsevier.com/retrieve/pii/S0261-5614(19)30129-3

Pokharel K et al, Estimation of serum uric acid in cases of hyperuricaemia and gout. JNMA J Nepal Med Assoc. 2011 Jan-Mar;51(181):15-20.

“Gout was more common in non-vegetarians (95%) and alcoholics (65.3%)” https://www.ncbi.nlm.nih.gov/pubmed/22335090

Alcohol

Choi HK et al, Alcohol intake and risk of incident gout in men: a prospective study. Lancet. 2004;363(9417):1277-81.

“…beer drinkers increased their risk by 50% for every daily serving, while those who drank hard liquor increased their risk by 15% for each drink”  https://www.ncbi.nlm.nih.gov/pubmed/15094272

Kaneko K et al, Determination of purine contents of alcoholic beverages using high performance liquid chromatography. Biomed Chromatogr. 2009 Aug;23(8):858-64.

Purine contents were as follows: spirits, 0.7-26.4 micromol/L; regular beer, 225.0-580.2 micromol/L; low-malt beer, 193.4-267.9 micromol/L; low-malt and low-purine beer, 13.3 micromol/L; other liquors, 13.1-818.3 micromol/L. Some local and low-alcohol beers were found to contain about 2.5 times more purines than regular beer. https://www.ncbi.nlm.nih.gov/pubmed/19353717

Neogi T et al, Alcohol quantity and type on risk of recurrent gout attacks: an internet-based case-crossover study. Am J Med. 2014 Apr;127(4):311-8.

“Results showed that a single serving of wine, beer or liquor (either straight or in a mixed drink) in a 24-hour period didn’t significantly increase the chance of repeat gout attacks. But consuming more than one to two drinks a day did – by 36%. With two to four drinks, the risk rose 50%, and it continued to rise with the amount of alcohol consumed” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991555/ 

How to avoid MSG-boosting flavour enhancers?

Insawang T et al, Monosodium glutamate (MSG) intake is associated with the prevalence of metabolic syndrome in a rural Thai population, Nutr Metab (Lond). 2012 Jun 8;9(1):50

“to be included in the present study families had to prepare their meals twice a day thus limiting the impact of commercially available food …  inhabitants of Thai rural areas rarely eat restaurant food compared to urban areas, thus minimizing this potential confounding factor” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583269/

Paradoxical effect of salicylates - high doses help, low doses – including aspirin for heart attack prevention - make it worse.

Yu TF, Gutman AB, Study of the paradoxical effects of salicylate in low, intermediate and high dosage on the renal mechanisms for excretion of urate in man. J Clin Invest. 1959;38(8):1298-315. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC442084/

 Zhang Y et al, Low-dose aspirin use and recurrent gout attack. Cited above.

Fitzsimon M et al, Salicylate sensitivity in children reported to respond to salicylate exclusion. Med J Aust. 1978 Dec 2;2(12):570-2.

12 children whose behaviour and sleeping improved on a low-salicylate diet took part in a double-blind controlled challenge with 40 mg of aspirin or placebo and significant changes were found. This was one of the first studies to demonstrate that dietary salicylates can have the same effects as low dose aspirinhttps://www.ncbi.nlm.nih.gov/pubmed/364260

Dairy foods

Hayman S, Marcason W, Gout: is a purine-restricted diet still recommended? J Am Diet Assoc. 2009 Sep;109(9):1652.

“Research has demonstrated that some foods and beverages may have protective effects against gout. High intake of dairy products seem to have an inverse relationship with hyperuricemia  … “ https://www.ncbi.nlm.nih.gov/pubmed/19699845

Atrial fibrillation

Patel NJ et al, Global rising trends of atrial fibrillation: a major public health concern, Heart, 2018;104(24):1989-1990.

“Numerous studies have reported AF as a growing epidemic with an expected doubling of prevalence by 2030” https://heart.bmj.com/content/104/24/1989

Singh JA, Cleveland JD, Gout and the risk of incident atrial fibrillation in older adults: a study of US Medicare data. RMD Open. 2018;4(2):e000712.

This American study reported “A diagnosis of gout almost doubled the risk of incident AF in the elderly.” https://www.ncbi.nlm.nih.gov/pubmed/30018808

Hajhosseiny R, Metabolic syndrome, atrial fibrillation, and stroke: Tackling an emerging epidemic. Heart Rhythm, 2015;12(11):2332-43.

The prevalence of atrial fibrillation (AF) and AF-related stroke is set to increase dramatically in coming decades …  It is in large part the result of unbalanced diet and sedentary lifestyle. These essentially modifiable risk factors are becoming more prevalent with the widespread adoption of so-called Western lifestyles … highlights the importance of addressing lifestyle-related risk factors to mitigate the trend toward increasing AF prevalence - https://www.ncbi.nlm.nih.gov/pubmed/26142297

Burkhart CG. 'Lone' atrial fibrillation precipitated by monosodium glutamate and aspartame. Int J Cardiol. 2009;137(3):307-8.

Over a period of months, a healthy 57-year old physician experienced sudden violent attacks of atrial fibrillation as confirmed by outpatient monitoring. When he eliminated monosodium glutamate and all artificial sweeteners from his diet, the arrhythmias stopped. Three challenges with Chinese food (with MSG) or diet soft drink(with aspartame)  resulted in development of atrial fibrillation within a few hours. http://www.afibbers.org/atrial_fibrillation/triggers/D89b.htm

Medications that can help gout

Usha Lee McFarling, Battle erupts over how to treat gout, no longer the ‘disease of kings’, January 25, 2017.

“It was once seen as the disease of kings, afflicting only the lazy and gluttonous. These days, however, gout is everywhere — and a bitter battle has broken out among physicians about how best to treat it… But the American College of Physicians, the nation’s largest specialty medical association, this month put out new guidelines that call for less aggressive pharmaceutical treatment. That’s angered many gout specialists, who in recent years have created two new professional groups — both backed by drug companies — one to bolster gout research and the other to promote long-term use of medication to lower uric acid …” https://www.statnews.com/2017/01/25/gout-treatment-doctors-battle/

Ahern MJ et al, Does colchicine work? The results of the first controlled study in acute gout. Aust N Z J Med. 1987;17(3):301-4.

“Two-thirds of colchicine-treated patients improved after 48 hours … All patients given colchicine developed diarrhea after a median time of 24 hours (mean dose of colchicine 6.7 mg) … This side effect occurred before relief of pain in most patients.” https://www.ncbi.nlm.nih.gov/pubmed/3314832

Terkeltaub RA et al, High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. rthritis Rheum. 2010 Apr;62(4):1060-8.

“Low-dose colchicine yielded both maximum plasma concentration and early gout flare efficacy comparable with that of high-dose colchicine …" https://onlinelibrary.wiley.com/doi/full/10.1002/art.27327

Zyloprim (allopurinol) Patient Information Including Side Effects https://www.rxlist.com/zyloprim-drug/patient-images-side-effects.htm#missdose

(Rxisk.org is described as "the first free, independent website where patients, doctors, and pharmacists can research prescription drugs and easily report a drug side effect--identifying problems and possible solutions earlier than is currently happening" and praised by Scientific American as “I hope that RxISK becomes a go-to source of information for patients and health-care providers. Ideally, the organization will also shame drug companies--and the researchers and institutions working with them--into acting more ethically.” https://blogs.scientificamerican.com/cross-check/e2809crxiske2809d-database-reports-side-effects-including-violence-undisclosed-by-pharma-firms/?redirect=1)

Yang CY et al, Allopurinol Use and Risk of Fatal Hypersensitivity Reactions: A Nationwide Population-Based Study in Taiwan. JAMA Intern Med. 2015 Sep;175(9):1550-7. https://www.ncbi.nlm.nih.gov/pubmed/26193384

Pereira S et al, [Fatal liver necrosis due to allopurinol]. Acta Med Port. 1998 Dec;11(12):1141-4.

Allopurinol hypersensitivity syndrome (AHS) is a severe reaction which is potentially lethal. Exanthematous rash, fever, eosinophilia, and other severe reactions such as toxic epidermal necrolysis, acute vasculitis, and severe hepatic and renal dysfunctions are manifestations of this syndrome … https://www.ncbi.nlm.nih.gov/pubmed/10192993

Medications that can trigger gout

Ben Salem C et al, Drug-induced hyperuricaemia and gout. Rheumatology (Oxford). 2017 May 1;56(5):679-688.

”Hyperuricaemia is a common clinical condition that can be defined as a serum uric acid level >6.8 mg/dl (404 µmol/l) … Diuretics are one of the most important causes of secondary hyperuricaemia. Drugs raise serum uric acid level by an increase of uric acid reabsorption and/or decrease in uric acid secretion. Several drugs may also increase uric acid production … “ https://www.ncbi.nlm.nih.gov/pubmed/27498351

More information

BLOG Diet for gout: why common flavour enhancers and dietary salicylates are overlooked triggers (2017)

BLOG Failsafe - best gout diet? (2019)

Introduction to food intolerance factsheet

How to start failsafe eating

www.fedup.com.au

The information given is not intended as medical advice. Always consult with your doctor for underlying illness. Before beginning dietary investigation, consult a dietician with an interest in food intolerance. You can see our list of experienced and supportive dietitians http://fedup.com.au/information/support/dietitians

© Sue Dengate June 2019

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