Uric acid is an organic chemical, which is produced in the body and broken down to substances called purine (found in body as well as foods). Uric acid dissolves in the blood, which is then taken to the kidneys and excreted in the urine. The kidneys excrete about 70% of uric acid crystals daily and intestines excrete the remaining 30%. When uric acid is not excreted in the urine, it gets accumulated in the blood. This leads to high blood levels of uric acid that is also known as Hyperuricemia. An imbalance between breakdown of purine and rate of uric acid excretion leads to Hyperuricemia.
Gout is a complex form of arthritis characterized by severe and sudden attacks of pain, redness and tenderness in joints, especially the big toe. It is a clinical condition in which uric acid crystals get deposited in the joints.
Stages of gout
There are four main stages of gout. These include.
Stage 1: Asymptomatic Hyperuricemia
During this stage, no symptoms of gout appear, but serum uric acid levels are raised, that is, above 6.0 mg/dL. A regular monitoring of serum uric acid levels and healthy lifestyle changes/modifications can help to reduce future gout attacks.
Stage 2: Acute gout attack
During this stage, episodes of severe pain and swelling of the joints appear. The deposited monosodium urate crystals activate and symptoms of gout appear. This pain may last for a week and then disappear. Treatment may or may not be required depending upon the severity of condition and intensity of pain.
Stage 3: Intercritical gout
During this stage, symptoms may appear suddenly and the attacks are more painful. However when the symptoms are absent, uric acid crystals still continue to accumulate.
Stage 4: Chronic Tophaceous Gout
This stage is also known as chronic arthritis and this may result in deformity and destruction of bone and the cartilage. There is increased inflammation and kidney damage could be a reason for chronic tophaceous gout. Patients in this stage require proper medical management and lifestyle modifications.
Symptoms of gout and Hyperuricemia
- Severe joint pain: Pain can occur in any joint but it mainly affects the big toe joint. Swelling and tenderness of the joints is also present. This symptom is known as ‘PODAGRA’. This pain usually begins at night, lasts for a few hours and then disappears. However, the intensity and duration of pain may vary from person to person.
- Redness of the joints: The color of the affected joints may change to purple or red.
- Decreased movement: The joint, which is affected, becomes stiff, loses flexibility and movement becomes very painful and difficult, thus limiting the overall movement.
- Peeling of the skin: The skin around the affected joint begins to peel off. Itching may or may not be present.
Causes of Hyperuricemia and gout
- Increased intake of purine rich foods, which may increase the production of uric acid
- Decreased excretion of uric acid, which in turn leads to increased accumulation in the blood
- Family history of gout
- Chemotherapy (drugs used to treat cancer)
- Kidney disease: Any disease that affects the kidneys decreases the ability to remove waste products from the body. This leads to build up of waste products such as uric acid in the bloodstream.
- Medications: Certain medications may increase the concentration of uric acid in the blood such as diuretics and immune suppressing drugs.
- Being obese or overweight
- Underactive thyroid or hypothyroidism
- Drinking excess alcohol
Complications of gout
Pain and restricted mobility: If gout is not treated properly, it may develop into a painful and disabling chronic disorder. It can also lead to destruction of cartilage and bones, which may cause permanent damage of joints. In some cases, walking or moving around becomes quite difficult whereas, in some other cases there is complete loss of motion. The joints become stiff and lose their flexibility. In serious cases, surgery may be required for the repair or replacement of the affected joint.
Tophi: Monosodium urate crystals get accumulated under the skin and form lumps, this is known as ‘tophi’. When gout is left, untreated tophi may develop about 8-10 years after the onset of gout. In older people, they appear much earlier. Women are at greater risk of developing tophi as compared to men. Tophi are usually seen on elbows, forearms, fingers, knees, heels and toes.
Renal stones: High serum uric acid levels may lead to formation of uric acid crystals in the urinary tract, which in turn leads to kidney stones. Medications and drinking plenty of fluids can reduce the risk of kidney stone formation.
Depression: Pain, restricted movement and loss of flexibility may affect the work as well as personal life. This may lead to depression and anxiety and deteriorates the quality of life.
Tests & Diagnosis
Blood test: Blood test is recommended to monitor the levels of uric acid in the blood. Not everyone with gout will have high serum levels of uric acid.
Joint fluid test: A sample of synovial fluid is taken from the affected joint. Synovial fluid is a viscous fluid found in the cavities of synovial joints. This test helps to determine the presence or absence of urate crystals in the fluid. People with gout do have urate crystals present in the fluid. In this test, the fluid is extracted with the help of a needle and examined under a microscope.
X-ray imaging: This is not a precise or an accurate method. It is used to rule out other causes of joint inflammation.
Ultrasound scan: This is a frequently used test to diagnose gout. An ultrasound scan of the affected joint helps to detect the presence of urate crystals within the cartilage.
Nutritional management of Gout
Drinking plenty of water
Drinking fluids, particularly water helps to flush out excess uric acid out of the body. Drink at least 2-3 liters or 10-12 glasses of water per day.
Avoid alcohol intake
Drinking beer is positively associated with gout attacks. Alcohol intake interferes with the elimination of uric acid from the body. Thus, uric acid is not excreted properly and excess of it gets accumulated in the blood. In addition to this alcohol also leads to dehydration, which further increases the risk of Hyperuricemia.
Restrict animal protein intake
Animal protein is rich in purine. Such foods with high purine and protein content are thought to be risk factors for gout. Rich sources of animal protein include poultry, meat and seafood. People with gout can easily replace animal protein with vegetarian protein sources such as low fat milk and milk products, nuts and tofu. Egg is considered to be one safe option for people with gout. Butter should also be limited.
Limit your intake of soft drinks and sugar-sweetened beverages
Soft drinks and fruit juices contain low purine content but these beverages are loaded with fructose. Fructose is the only carbohydrate that has the ability to increase the serum uric acid level rapidly. Fructose causes degradation of purine nucleotide and increases the purine synthesis. Such an increase in the purine content causes the serum uric acid levels to rise quickly. Therefore, people with gout or high levels of serum uric acid should strictly limit the intake fruits juices, sugar sweetened beverages and soft drinks or aerated drinks.
Increase your intake of vitamin C
Research has showed that increased intake of vitamin C lowers the risk of gout, particularly in men. Vitamin C increases the excretion of uric acid via urine and helps the body to get rid out of excess uric acid, which gets accumulated in the blood over a period of time. This effect of vitamin C is possible because it competes for renal reabsorption via an anion-exchange transport system. Foods rich in vitamin C include kiwi, grapefruit, dark green leafy vegetables, berries, citrus fruits and tomatoes.
The incidence of gout is greater in people who are obese or overweight. Increased waist to hip ratio, central or abdominal obesity and higher BMI (more than 25) have a significant linear effect on gout occurrence. Research has showed that a healthy and gradual weight loss of 5-10% may reduce the risk of gout. Following a healthy diet, which includes whole grains, low fat dairy products, fruits and vegetables may promote healthy weight loss.
Research suggests that cherry consumption plays an important role in lowering the serum uric acid levels and thus reduces the risk of gout. Cherries contain high levels of ANTHOCYANINS that possess anti-oxidant and anti-inflammatory properties. In addition to this research has also showed that cherry consumption can reduce the severity of pain and frequency of gout attacks. Therefore, eating 10-12 cherries 3-4 times a week may help in the treatment and management of gout.
List of various types of foods and their purine content
|Food items||Total purine in mg uric acid/100 grams|
|FOODS WITH HIGHER PURINE CONTENT (400 mg uric acid/ 100 grams and higher)|
|Organ meat (liver, heart, brain, spleen)||450-550|
|Pork (organ meat)||520|
|Sheep (organ meat)||773|
|MODERATELY HIGH IN PURINES (100-400 mg uric acid/ 100 grams and higher)|
|Bean, seed, white, dry||128|
|Bean, soya, seed, dry||190|
|Beef, muscles only||133|
|Black gram, seed, dry||222|
|Chicken, breast with skin||175|
|Chicken, leg with skin||110|
|Lamb (muscles only)||182|
|Lentil, seed, dry||127|
|Poppy seed, dry||170|
|Pork chop with bone||145|
|LOWEST IN PURINES (100 mg uric acid/ 100 grams and less)|
|Barley, whole gain||96|
|Wheat, whole grain||51|
|Breakfast||1 cup green tea/ tea/ coffee + 1 bowl fiber rich cereal grain with vegetables + 1 glass low-fat milk OR 1 bowl porridge with skimmed milk (porridge can be made out of oats, barley, quinoa, broken wheat) OR 2 egg whites with 2 slices of wholegrain or multigrain bread.|
|Mid-morning||1 fruit (vitamin C rich fruit or choose from the list of low purine fruits)|
|Lunch||1 bowl salad (lettuce, cucumber, tomato and spinach) / 1 bowl soup + 2 serving whole grain cereals + 1 serving tofu/ 2 egg whites/ ½ portion split dal/ 1 portion low-fat paneer + 1 bowl low-fat yogurt/ 1 glass buttermilk.|
|Mid-morning||1 cup green tea/ tea/ coffee + 1 serving of fiber rich cereal grain|
|Evening||1 glass unstrained vegetable juice/ 1 bowl unstrained soup/ 4 soaked almonds/ 1 walnut|
|Early dinner||1 bowl salad (lettuce, cucumber, tomato and spinach) / 1 bowl soup + 2 serving whole grain cereals + 1 serving tofu/ 2 egg whites/ ½ portion split dal/ 1 portion low-fat cheese + 1 bowl low-fat yogurt/ 1 glass buttermilk.|
|Bed-time||1 glass low-fat milk|
One-portion non-vegetarian food sources (except organ meat) can be consumed once in 10 days.