I had heard of gout before I went into health care. I thought of it as an old man’s disease, caused by eating and drinking to excess, because that is how it was described in history books. In fact, they called it “rich man’s disease” because only the wealthy could afford to eat and drink the foods associated with this disease. While it is true that alcohol and food choices can play a role in gout, it is so much more complicated than that. Gout affects more than 8 million Americans—both men and women—and is a common type of arthritis that is extremely painful.
Gout is caused by uric crystals precipitating in the joint space and triggering immune activation with the release of inflammatory cytokines and neutrophil recruitment. Over time, the joint space can be irreversibly damaged, leading to chronic pain and disability with grossly deformed joints. Things that cause some level of dehydration increase risk of gout, because dehydration equals more concentrated blood equals higher undiluted concentrations of uric acid.
Gout usually begins by affecting one joint at a time, often the big toe, and causes swelling, pain, redness and heat. Doesn’t it seem odd that the big toe would be singled out? That is because the big toe is the location most distant from the heart in our bodies, and therefore, circulation is a bit more sluggish by the time it reaches the toe. Gravity complicates circulatory return. Gout occurs when there is a buildup of sharp uric acid crystals, carried by the blood, and the first place they often congregate is the big toe. Other common gout locations are the joints of the fingers. These sharp crystals create a lump called a tophus, and it can be extremely painful. Imagine a bump under the skin made up of sharp needles!
Paradoxically, there are people with high uric acid levels that don’t have gout, so it is not a universally causative factor. There is a familial link to gout. It is estimated that 20 percent of people with gout have a relative with the condition. Your risk is higher if it’s a first degree relative, such as a sibling or a parent.
Gout is a disease of flares and remissions. A flare is often called a gout attack.
Notable historic sufferers include Benjamin Franklin, Thomas Jefferson, Alexander the Great, Leonardo da Vinci, Martin Luther, Charles Darwin and Isaac Newton. William Osler, a famous early physician, had gout and stated: “I cannot take a glass of champagne without feeling it in my great toe.”
So why does what we eat and drink affect gout so profoundly? Well, as noted before, gout is an excess of uric acid in the bloodstream that is deposited in joints and becomes symptomatic. The body makes uric acid when it breaks down purines, which are found in food. High levels of purines are found in red meat, organ meat, anchovies, sardines, tuna, trout and certain other foods. Many types of alcohol, especially beer, are also high in purines. Additionally, any alcohol has an impact on kidney function, and kidney function dictates how the body rids itself of uric acid via urination. However, plants that are rich in purines have been found not to have a negative impact on gout and are safe to eat. These include mushrooms, nuts and asparagus.
An interesting note is that hyperuricemia can also cause kidney stones, so the two problems can be related. Also, people dealing with kidney conditions or diseases are at a higher risk of developing gout because around two-thirds of the body’s urate is excreted through the kidneys.
Other gout risk factors are male gender, obesity, congestive heart failure, high blood pressure, insulin resistance, metabolic syndrome, diabetes, reduced kidney function, certain medications (especially diuretics), alcohol, food and drinks high in purines.
Diet and Hydration
Nutrition can be very important in preventing gout attacks. Eating and drinking alcohol in moderation and lowering purine intake can help. The Mediterranean diet is often cited as also useful in preventing gout. Coffee and dairy products actually reduce the risk of gout because they increase uric acid excretion.
The easiest way to prevent gout attacks is to drink water. Remember that anything that increases dehydration increases risk of a gout attack? The opposite is also true—adequate hydration has a profound benefit in prevention. In one study, drinking eight 8-ounce glasses of water daily reduced the incidence of gout attacks by almost 50 percent! That is better than many prescription medications.
Targeting the microbiome may be a new treatment strategy for people dealing with gout. Researchers have found that when there are negative changes to the gut microbiome, the consequences include disruptions in uric acid metabolism, increased uric acid formation, and increased production of pro-inflammatory compounds. The microbiome is a huge player in the metabolism of purines and uric acid.
One study found that researchers could predict with almost 90 percent accuracy the people who had gout solely based on their microbiome patterns. Other research has found that the microbiome of people with gout contains a higher proportion of opportunistic and pathogenic bacterial species. Part of this may be explained by the chronic, low-grade inflammation that is induced by increased intestinal permeability, or “leaky gut.”
Another study found that Lactobacillus plantarum supplementation was able to decrease body weight and uric acid levels in animals that were fed a high-fat diet. Finding a good probiotic with guaranteed live bacteria counts at time of purchase that includes this species can be an effective part of a protocol to prevent gout and gout attacks.
Cherries have long been used for helping people with gout because they contain compounds that reduce uric acid. A large human clinical study from Boston University School of Medicine included 633 individuals with gout. People who used a cherry extract saw 35 percent reduced risk of gout attack after only two days of gout. In fact, when cherry intake was combined with the prescription drug allopurinol, the risk of gout attacks was 75 percent lower than during periods without either exposure. Tart cherry fruit extract (Prunus cerasus) is especially valued and effective if the anthocyanin content is verified more than 0.1 percent.
Grape Seed Extract
In an animal model, compounds found in grape seed called procyanidins were found to significantly alleviate pain and swelling associated with gout. The procyanidins were able to inhibit the NLRP3 inflammasome, one of the primary drivers of inflammatory processes. The researchers stated the human equivalent dosage used in the study is 300 mg per day. Plus, the oligomeric procyanidins (OPCs) works as well as colchicine, a drug commonly used for gout. One important note regarding grape seed extract is to make sure it is tannin-free. Tannins are the largest size OPCs and cannot be absorbed. Including only the small size OPCs leads to 100 percent absorbability.
In a scientific study, cells from patients in an acute gout attack or non-acute phase were compared to those of healthy controls. The acute gout group had significantly higher markers of inflammation, including NF-kB and IL-1. When berberine was added to the cells, there was a significant reduction in inflammatory markers. Other berberine research has shown that not only is it anti-inflammatory, but it also upregulates the production of our own antioxidants.
A clinical study involving men with high-normal uric acid were given 500 mg of quercetin per day or placebo for four weeks. Quercetin has been shown to inhibit the enzyme (xanthine oxidoreductase) involved in the final step of producing uric acid. The quercetin group experienced about an 8 percent reduction in uric acid levels whereas the placebo group experienced an increase in their uric acid levels. Plus, the quercetin group also experienced decreases in their average diastolic blood pressure. Quercetin is very poorly absorbed, so it is advantageous to use a quercetin with boosted absorption for more consistent benefits.
Downregulation of certain inflammatory pathways, such as COX-2 and 5-LOX, have been shown to significantly reduce urate crystal-induced inflammation. In fact, one of the inflammatory compounds produced by the 5-LOX pathway, called leukotriene B(4) [LTB(4)], has been indicated in the intensity and severity of gout through its pain and inflammation promoting activities. Finding a botanical that can reduce the activation of this inflammatory pathway is extremely useful, and boswellia is noted for its superior ability to downregulate the 5-LOX pathway. As a side note, not only does this help with gout, but other forms of arthritis as well.
When it comes to gout, it is not an either-or situation. You may need to use all these interventions to achieve your health goal! Healthy diet, drinking lots of water, and using quality dietary supplements will put you on the path to healing. VR
Some References Used:
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Cheryl Myers is an integrative health nurse, author, and an expert on natural medicine. She is a nationally recognized speaker who has been interviewed by the New York Times, Wall Street Journal and Prevention magazine. Her many articles have been published in such diverse journals as Aesthetic Surgery Journal and Nutrition in Complementary Care, and her research on botanicals has been presented at the American College of Obstetrics and Gynecology and the North American Menopause Society. Myers is the head of scientific affairs and education for EuroPharma, Inc.