Diet for gout: why common flavour enhancers and dietary salicylates are overlooked triggers

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I recently met a young man in Kathmandu, Nepal who said: “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”.  He was sitting in a restaurant with his foot on a chair and could barely hobble.

Gout is the most common inflammatory arthritis and is increasing.  In the United States, gout prevalence has approximately doubled over the last 20 years (Lee et al, 2006). A study in May 2017 found that risk for gout is increased by the Western diet (Rai et al, 2017).

This made me wonder: what was this guy eating in Kathmandu that could cause such an acute episode of gout?

I receive many reports from failsafers that their partner’s gout has improved dramatically when the family embarks on the RPAH elimination diet to change their children’s behaviour – but they don’t know why:

“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

So I had a look and was very surprised by what I found.

Four causes of gout

1. High purine diet: most people know that gout is due to high uric acid levels caused by consuming too many high purine food and drinks (in meat, seafood, beer and other alcohol),  foods that are mostly avoided on the RPAH elimination diet because they are also high in amines.

 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 … We have been doing the elimination diet for two weeks now … we enjoyed some beef and lamb … there has been no sign of gout at all!” - Carla from story [966]

2. Side effects of medication:  most people don’t realise that gout can also be caused by failure to excrete enough uric acid. Drugs that reduce excretion of uric acid include low dose aspirin, other salicylate-containing medications and some diuretics such as diazide medications for high blood pressure.

3. Food additives: most people have no idea that gout can be triggered by commonly used food additives called ribonucleotide flavour enhancers (E627, E631, E635, used to boost the effects of MSG; also listed as yeast extract or natural flavours) - although food regulators acknowledged this as long ago as 1974.

About six weeks ago I stopped all foods with 635 flavour enhancers. Within 48 hours my symptoms – including episodes of joint and bone pains that lasted 24-48 hours - had gone …”  – from story [569]

4. Dietary salicylates: very few people – except our readers – know that any effect of low-dose aspirin can also be caused by dietary salicylates. The RPAH elimination diet is a low salicylate diet. Salicylates are found in most fruit - especially berries, dried fruit and citrus; some vegetables - especially tomato sauce; and spices.

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]  

Kathmandu gout man

My guess is that this guy was affected by the MSG-booster flavour enhancers because, due to the influence of the Western diet, processed food in Nepal is now awash with these additives, most commonly eaten in instant noodles that nearly all contain ribonucleotides.  Next guess would be dietary salicylates in the curries, or a combination of both. He was probably not eating a lot of meat, or seafood, given Nepal is landlocked. And as he was youngish and fit, probably not low dose aspirin or blood pressure medication. But diuretics are a possibility because some trekkers take Lasix diuretics – against medical recommendations – to help with high-altitude acclimatisation.

What I learned from my investigation was that the diet we support on this website – free of additives, low in salicylates, amines and flavour enhancers (failsafe) - appears to work better for gout than most gout diets. People with gout need to know more about ribonucleotide flavour enhancers and dietary salicylates.

Ribonucleotide flavour enhancers 627, 631, 635

Failsafers avoid flavour enhancers that have been known to trigger gout since the 1960s.

MSG and ribonucleotides flavour enhancers - used to boost the effects of MSG - are some of the most commonly consumed additives in the western diet, although most people don’t realise when they are eating them. Flavour enhancers make food taste delicious and are usually in takeaways, ready meals, restaurant meals and many home cooked meals e.g. in gravies, sauces, stock cubes, meat extracts, soups, chicken salt, sausages, and many others.

People who must avoid purines for gout are advised to avoid these additives by the authorities (Joint FAO/WHO Expert Committee on Food Additives). They also thought it might be a good idea to put a warning on labels but this never happened, and as the food industry now plans to have these additives reclassified as “processing aids”, soon they won’t even have to appear on labels.  So the best way to avoid them is to avoid all processed foods, unless you know the exact ingredients.

People suffering from conditions such as gout which require the avoidance of purines should avoid this substance“ – Maurice Hanssen (1989)

Gout from low dose aspirin (salicylates in medications)

Low-dose aspirin (acetylsalicylic acid) is widely used to prevent heart disease. Surveys show that about one third of gout patients are or have used low dose aspirin. Yet aspirin is known to reduce uric acid excretion, thus contributing to high uric acid levels (hyperuricaemia). (Experts say: don’t stop taking your aspirin, talk to your doctor about it. For failsafers, RPAH recommends Clopidogrel instead)

low-dose aspirin use is associated with an almost twofold increased risk of recurrent gout attacks” - Zhang et al, 2014

Gout from dietary salicylates (salicylates in foods)

Anything low dose aspirin can do, dietary salicylates can do. (Swain et al, Salicylates in food 1995 )

So we were not surprised to find readers telling us that their gout could be triggered by high salicylates foods such as strawberries, tomato sauce and curries.

I was consuming half a punnet of strawberries a day in a strawberry growing area. After several days I was struck by severe excruciating gout, 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” – Tony from story [1131]

What you can do

For the strict version of the RPAH Elimination diet, we recommend seeing a dietitian.  See our list of experienced dietitians who specialise in food intolerance.
See our free failsafe booklet showing how manageable this diet is.
Request our free salicylate mistakes information sheet ( This email address is being protected from spambots. You need JavaScript enabled to view it. )
See our introduction to food intolerance
For support, join our facebook group

Read more and references

A low purine diet

Zhang Y et al, Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis. 2012;71(9):1448-53. “ … acute purine intake increases the risk of recurrent gout attacks by almost five times among patients with gout. The impact from animal purine sources was substantially greater than that from plant purine sources. Avoiding or reducing purine-rich foods intake, especially of animal origin, may help reduce the risk of recurrent gout attacks.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3889483/

A list of purines in foods and drinks  http://www.acumedico.com/purine.htm

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.

This observational study looked at more than 40,000 men over 26 years and scored their diets according to DASH and Western dietary patterns. Researchers concluded: "The main components of the DASH diet include fruits, vegetables, nuts and legumes, low fat dairy products, and whole grains, combined with a low intake of sodium, sweetened beverages, and red and processed meats. This pattern substantially overlaps with previous study findings of individual dietary risk factors for hyperuricemia and gout such as meat, seafood, alcohol, fructose-rich beverages, as well as protective (or neutral) factors such as low fat dairy intake, vegetables, legumes, nuts, and plant protein. This explains why the dietary pattern is associated with a lower risk of gout in a dose-responsive manner ... the Western diet is associated with a higher risk of gout." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5423545/

Ribonucleotide flavour enhancers

The safety of this entire range of flavour enhancers that are one of the most commonly consumed groups of food additives in the world was assessed by testing on just 3 “healthy male” volunteers. See our MSG-boosters factsheet

Hanssen Maurice, Additive Code Breaker: Everything you should know about additives in your food, 1989 “People suffering from conditions such as gout which require the avoidance of purines should avoid this substance “

JECFA,  CALCIUM AND SODIUM-5'-RIBONUCLEOTIDES, Eighteenth Report of the Joint FAO/WHO Expert Committee on  Food Additives Wld Hlth Org. techn. Rep. Ser., 1974, No. 557 FAO Nutrition Meetings Report Series, 1974, No. 54.

 “Ingestion of large amounts of these compounds (inosinate, guanylate and ribonucleotide flavour enhancers 627, 631, 635) … 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, 1974 http://www.inchem.org/documents/jecfa/jecmono/v06je02.htm

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 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.

Back in the 1960s, this substance was actually fed to normal subjects as a way of causing hyperuricemia, so they could be studied – now it is added to nearly every processed food in the Western diet.

Nugent CA. Renal urate excretion in gout studied by feeding ribonucleic acid. Arthritis Rheum. 1965 Oct;8(5):671-85. “normal  subjects fed a  urate precursor (ribonucleic acid, RNA) to produce hyperuricemia” - to  compare with  patients  with  gout.  http://onlinelibrary.wiley.com/doi/10.1002/art.1780080427/pdf

Low-dose aspirin

Zhang Y et al, Low-dose aspirin use and recurrent gout attacks. Ann Rheum Dis. 2014 Feb;73(2):385-90. “Our findings suggest that 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/

For those who must take low-dose aspirin but want to avoid salicylates, the RPAH diet recommends to ask your doctor about Clopidogrel

A low salicylate diet

Anything low dose aspirin can do, dietary salicylates can do. Swain AR et al, Salicylates in foods. J Am Diet Assoc. 1985 Aug;85(8):950-60.

This is the most comprehensive set of data on food salicylates yet published … Most fruits, especially berry fruits and dried fruits, contain salicylate. Vegetables show a wide range from 0 to 6 mg salicylate per 100 gm food (for gherkins). Some herbs and spices were found to contain very high amounts per 100 gm, e.g., curry powder, paprika, thyme, garam masala, and rosemary. Among beverages, tea provides substantial amounts of salicylate. Licorice and peppermint candies and some honeys contain salicylates.https://www.fedup.com.au/images/stories/Swain1985.pdf

Gout from diuretics

A combination of low-dose aspirin and diuretics (e.g. diazide medications for blood pressure) can cause even more problems.

 “Low-dose aspirin, up to 2 g/day has the potential to increase uric acid retention. The combination of low-dose aspirin and diuretics compounds this effect ..” – Jacobs and Stern 2007

Jacobs CL and Stern PJ, An unusual case of gout in the wrist: the importance of monitoring medication dosage and interaction. A case report Chiropr Osteopat. 2007; 15: 16.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174925/?tool=pubmed

 

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