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Plant vs. Animal Food Purines for Preventing Gout

More than 2,000 years ago, “Hippocrates described gout as a disease of kings primarily because it was the wealthy who could afford the ‘rich’ foods, which seemed to precipitate gouty attacks.” Today, however, we can all eat like kings and acquire some diseases of royalty ourselves. That’s why I produced my video Preventing Gout Attacks with Diet.

Gout is caused by needle-sharp crystals of uric acid in our joints. Uric acid comes from the breakdown of purines, which are the breakdown product of genetic material—DNA, the foundation of all life. So, “there is no such thing as a purine-free diet, but foods do vary in their purine content.” It was long thought that people with gout just needed to stay away from all high-purine foods, whether from animals, like organ meats, or plants, like beans, but this strategy proved ineffective. Yes, all uric acid comes from the breakdown of purines, so limiting meat makes sense, but plant sources “have largely been exonerated.”

“The association of gout with alcohol intake and increased dietary purine consumption had been known since ancient times, but there were no prospective trial data” to back it up until fairly recently. The Harvard Health Professionals Follow-Up Study, which followed about 50,000 men for a dozen years, found that alcohol intake was “strongly associated with an increased risk of gout.” In terms of food, they found “an increased risk of gout with higher meat consumption or seafood consumption,” but not with higher consumption of purine-rich plant foods. Perhaps this is because the purines in plants are less bioavailable? So, though it had been suggested that gout sufferers should moderate purine-rich animal and plant foods, their “results suggest that this type of dietary restriction may be applicable to purines of animal origin but not to purine-rich vegetables.”

Although it was not surprising that meat, including seafood, had significant associations with the incidence of gout, this lack of effect of purine-rich plant foods was new. There don’t appear to be any long-term studies showing purine-rich plant foods increase risk, though there are still some guidelines continuing to disseminate those outdated recommendations.

Not only has the intake of purine-rich plants not been associated with high uric acid levels, but the vegetables gout sufferers are specifically told to stay away from—mushrooms, peas, beans, lentils, and cauliflower—were actually found to be protective. This may be because foods rich in fiber, folate, and vitamin C appear to protect against uric acid buildup and gout. “Fiber,” for example, “has been recognized as having a potential role in binding uric acid in the gut for excretion.”

Lack of association between purine-rich vegetables and urate could be due to the co-packaging of these “beneficial plant components (such as vitamin C, dietary fiber or some phytochemicals), which may have masked an effect of purine on [uric acid]. Vegetable intake, regardless of purine content, may also be protective as it may increase [uric acid] excretion.”

By changing the pH of our urine, we can change uric acid clearance. Eating an alkaline diet, which was a vegetarian diet in the case of the study I profile in my video, was found “effective for removing uric acid from the body.” Those eating the alkaline diet excreted significantly more uric acid than those eating the acidic diet. As such, uric acid levels in the blood of those eating the acid-forming diet rose within days.

So, one would assume uric acid levels are lower in vegetarians, and, indeed, those eating vegetarian diets long-term were found to have significantly lower levels in their blood. To prove cause and effect, though, you need to do an interventional trial, where you take people, change their diets, and see what happens. Researchers took ten guys to study the build-up of uric acid in their kidneys, kept them on a standard Western diet for five days, and measured their relative supersaturation for uric acid. Then, they tried a vegetarian diet for five days. The result? Within days, the intake of the vegetarian diet led to a 93 percent decline in the risk of uric acid crystallization.

You can do it the other way, too: Take a bunch of people with gout, feed them a big meal of meat, and see if you can trigger an attack. Seven patients were put in a hospital, “stabilized on a low-purine diet and then challenged with a meat-laden dinner.” In response, their uric acid levels shot up, and they started getting gout attacks. Then they added alcohol, and their uric acid levels shot up even further. In all, the researchers were able to trigger gout attacks in six out of the seven patients with just single meals.

Now, some meats have less purines than others. For those who aren’t squeamish, inches-long superworms, for example, have particularly low purine levels.

Not all animal foods increase gout risk, though. Low-fat dairy products were found to be protective. Given that, we would predict vegans to be at a disadvantage, which is indeed what was found, though all groups tested—meat eaters, fish eaters, vegetarians, and vegans—were within the normal range of around 3.5 to 7.

Should gout patients add milk to their diets? Well, although drinking the equivalent of ten cups of skim milk at a time appears to have an acute lowering effect on uric acid levels, in the long term over months, at the equivalent of two cups a day, there was not a statistically significant lowering effect. Gout patients were given skim milk powder for three months, and it did not appear to help. Though soymilk has also been associated with a lower risk of uric acid buildup, there are no interventional trials to back that up.

The bottom line is that we now have good research on how to reduce risk of gout “without the use of drug treatments through modification of diet.” That’s important, because allopurinol is the “drug of choice.” It’s considered generally safe, but what does it mean when doctors talk about a relatively safe drug? Well, about “2% of patients develop hypersensitivity reactions, which can sometimes be severe and fatal with a mortality rate of ~20%”—and that’s the safe drug. The other leading drug, colchicine, has “no clear-cut distinction between nontoxic, toxic, and lethal doses.”


A better choice is through diet, and these videos show you how sweet that diet choice can be:

And, for alkalinizing your urine, see How to Treat Kidney Stones with Diet and Testing Your Diet with Pee and Purple Cabbage.

Uric acid is double-edged sword, as both high and low levels are associated with increased mortality. If our uric acid levels are too high, we can get gout; if they’re too low, it may increase our risk of neurodegenerative diseases such as Alzheimer’s and Parkinson’s. This is presumed to be because uric acid acts as a powerful brain antioxidant. See my videos Miocene Meteorites and Uric Acid and Parkinson’s Disease and the Uric Acid Sweet Spot for more on this.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Discuss

Michael Greger M.D., FACLM

Michael Greger, M.D. FACLM, is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, testified before Congress, appeared on The Dr. Oz Show and The Colbert Report, and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.


67 responses to “Plant vs. Animal Food Purines for Preventing Gout

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  1. I suppose that if we going to be painfully honest, we should concede that there is one class of plant foods that is strongly associated with gout – alcoholic beverages. And beer apparently does contain purines.

    1. Yes, beer is a problem. I had one patient with severe uncontrolled gout. I told him he needed to change his diet. He immediately said, “well, I’m not giving up my daily burger, coke or beer.” ( HFCS in soft drinks contributes to gout.) He refused to do anything different, and went on to have a heart attack. High uric acid levels are a risk factor for heart disease. It saddens me that so many people will not change their ways, and cause suffering for themselves and their families.

  2. Going off-topic again – apologies – but some of you may want to know about this.

    Following the recent announcements of more studies showing significant associations between low carb diets and increased mortality, a new study from Denmark seems to contradict all those low carb claims that grains are the invention of the devil and high fat diets are the way to fight type 2 diabetes:

    ‘It doesn’t matter if it’s rye, oats, or wheat. As long as it is wholegrain, it can prevent type 2 diabetes. This is the finding of a new study from researchers at Chalmers University of Technology, Sweden, and the Danish Cancer Society Research Center. The comprehensive study is a strong confirmation of previous research findings on the importance of whole grains for prevention of type 2 diabetes.’
    https://www.sciencedaily.com/releases/2018/09/180905083910.htm

    1. “Going off-topic again – apologies”
      – – – – – – –

      We all have our little frailties, TG. :-)

      Anyway, this thread will probably wander off to at least a dozen other off-topics before it’s done with.

      1. Yeah, like those “wheat belly” books that come on the scene every now and then.

        If I had my druthers, I’d much rather go for the whole grains than, say, lentils. For some strange reason, am not a huge fan of lentils. :-(

  3. I maintain a very high vegan purine diet with 4-8 ozs black cherry juice daily. When I added 2T of nutritional yeast daily I developed gradually worsening knee gout. Hydration, off the yeast and swelling gone in a fortnight.

    1. Morgan, that is really fascinating!

      You are the first vegan I have ever heard of with gout.

      You mention hydration, do you not drink enough water?

      In my family and friends the only ones who get gout are the beer drinkers and heavy meat eaters.

      You don’t drink alcohol?

      The nutritional yeast is fascinating, because it makes me think about beer having Brewers yeast, but even with that, it becomes interesting to me, because some vegans are using high amounts of nutritional yeast for their cheeses.

      Wondering if I Google, whether I will find other vegans pointing at Nutritional yeast.

      Anyway, thanks for sharing.

    2. #Morgan
      The question is, why do you eat 2T of nutrition yeast daily and drink 4 – 8 osz black cherry juice?
      In my thinking, nutrition yeast is not a natural food because there is no plant that build up a fruit called nutrition yeast and black cherry juice may be is fine from time to time but it’s not a hand full of black cherrys – also a glas of beer is not a hand full of barley and a glas of red wine is not a hand full of grapes. ;-)
      The secret is still “whole food”…

      1. Morgan, that’s great you found relief. I did too, years ago when I suffered gout in my big toe. I was in agony and searched the net for info to prepare for my doctor appt. I read that dehydration is a common cause and since I was slender and athletic, it made sense in my case. I declined the doctor’s pills, drank water, no cherry juice added and dumped the eggs, dairy and salmon I ate at the time. Cured. Today I eat purine rich foods in a wfpb diet and have never suffered an attack since.

        Several immediate family members continue to suffer attacks and do use medication.

        1. As a pesc-lacto-vegetarian for many decades, I had several gout attacks, even with lots of yogurt, possibly related to dehydration as in reality I ate very little fish (funny ambiguity :-). Going vegan about 2 years ago (slow learner), I have not had an attack and my uric acid level is routinely between 5.2 and 6.4. I try to stay hydrated but with all the veggies and fruit I eat this is not an issue. I eat 3 servings of beans/legumes per day and lots of nuts and seeds with no problem. On the other hand, I drink no alcohol.

  4. A Low Carb diet helped my 65 year old uncle with gout a few years ago. He lost 35 pounds too.

    Ketogenic diet may protect against gout – https://www.medicalnewstoday.com/articles/316111.php

    https://www.cell.com/cell-reports/fulltext/S2211-1247(17)30169-9?_returnURL=https%3A%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS2211124717301699%3Fshowall%3Dtrue

    Fish Oil might help – Do Omega-3 Fatty Acids Reduce Risk of Recurrent Gout Flares
    https://www.empr.com/acrarhp-annual-meeting-2015/do-omega-3-fatty-acids-reduce-risk-of-recurrent-gout-flares/article/452208/

    MaryAnn Zhang, MD, from the Boston University School of Medicine, in Boston, MA – “Dietary omega-3 fatty acid from fatty fish was associated with a lower risk of recurrent gout attacks,” Dr. Zhang said. “Supplemental omega-3 fatty acid alone appeared not to have a protective effect, though we were limited in our ability to adequately assess this.”

    1. Losing weight (fat) can reduce the risk of gout apparently, which might explain your uncle’s situation.

      https://ard.bmj.com/content/76/11/1870

      The ketogenic diet and fish consumption studiesyou referenced seem somewhat tentative, and further research would be necessary to substantiate those conclusions . Weight loss and eating fewer foods high in .purines seem to be the current standard lifestyle/dietary recommendations for treating gout.

    2. Greg,

      The sentence, which jumped out at me was this one:

      “It is caused by either an excessive production or insufficient excretion of uric acid.”

    3. Beta-hydroxybuterate is upregulated after exercise, even more so if done on an empty stomach. If BHB affects gout, exercise can be used instead of a keto diet.

  5. As for the beer drinkers though, they blame the vegetables and remember to avoid vegetables with high purines and cut back a little on meat, but none of them say, “I need to cut back on beer.”

  6. The ‘disease of kings’ is similar to the failure of success. This means that after wining one realizes that now they are losers. Is your success an inertia of cultural values? Some people eat a pile of shrimps in a buffet because of its high cost relative to vegetables. They think they are winning. Animals have a perceived higher value than plants since animals eat plants. A more expensive product is supposed to be better according with market values. And the king has all the money but with an unforeseen failure.

  7. I think this has already been discussed. As I recall there are a couple of others like me, but I’m WFPB, don’t drink, and have still gotten gout a couple of times (many years after I went WFPB and stopped drinking). They were short bouts (roughly only abou a day) but were very painful and I don’t look forward to repeat occurrences. My uric acid levels were high normal (whatever that means re. determination of current standards). So while going WFPB and not drinking is no doubt a great way to reduce the risk of gout, that’s still only a statistical property and isn’t a guarantee.

    1. I’ve had several attacks of gout in a big toe (fortunately, never that bad, no medicine taken) as a pesco-lacto-vegtarian before going entirely WFP several years ago. My ortho thought it was dehydration because I exercise a lot including hiking/jogging outside in the summer. So my first thought goes to hydration. Also my uric acid level has never been measured over 6.7 although those measurements were taken some days perhaps even a week after an attack. I also used to drink tons of caffeinated coffee, which could have been a problem.

      1. gengogakusha, your interesting post sent me looking for info about coffee and gout. I am happy to report that there have been some trials showing an inverse association between coffee consumption and high uric acid levels. https://www.hindawi.com/journals/jnme/2010/930757/
        Maybe part of the reason I have not suffered another gout attack is that I do not drink alcohol or soft drinks and I do drink coffee.

        1. Barb, Thanks very much for the link. It has a nice bibliography, including earlier articles I had previously read by Choi, et al. Since I only drink decafe, I was particularly interested in the section indicating agreement that chlorogenic acid, not caffeine, is the primary active ingredient. I lived on caffeinated coffee for decades when working and never had gout; only got into trouble after retiring when I drastically cut back.

    2. Karl, some people are triggered by fructose. Mostly that in prepared foods and soft drinks, but some by high fructose fruit. Not common, but keep a food diary.

  8. I have been eating a whole food plant-based diet for over one year. All my numbers have improved. However, I continue to suffer from pseudogout in one of my hips. I have repeatedly researched for dietary interventions for treating this condition but have not found any. Anybody have any recommendations?

      1. Gillian,

        Thanks for mentioning the Glutamate.

        “The authors found evidence that people with gout have elevated levels of glutamate and that it may play a role in high uric acid levels. MSG is also commonly used with additives that are converted to uric acid, like inosinates and guanylates.”

    1. Sorry. It is apparently quite different from real gout.

      Thare are no known food triggers for it and no accepted dietary treatment – at least according to the papers/sites I have seen ………… eg

      https://www.health.harvard.edu/diseases-and-conditions/pseudogout-cppd
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383522/

      The only advice I have seen thatis related to duet, is to avoid dehydration since this has been observed to increase the risk for flare-ups.

        1. Fred, read the second article TG posted. It does mention most patients have low magnesium levels. Have you tried a good magnesium supplement? Magnesium oxide is useless. I would try Magnesium Malate (1st choice) or Citrate. Threonate is good, but quite expensive. And you would need 400mg. of the magnesium (not total milligrams of supplement).
          Along with that, since this is a problem of improper calcium use, I would add vitamin K 2. ( not the same as K1.) except for natto, I don’t know of a food source.
          Important- This is not recommended however, if you are on blood thinners.
          Dose of K2 is 90 micrograms per day.
          Vitamin D, calcium, magnesium and K2 all need to be in balance for bone, joint and artery health.
          You could give this a try to see if it helps. Gentle exercise would also help mobility.

          1. Thanks Marilyn. I am taking all those supplements but it hadn’t been for treating CPPD. But I do need to check the doses. I believe the companies are reputable.

            Just curious about your experience with CPPD?

    2. Hi I’m a RN health support volunteer. Thanks for your great question. Congratulations on going plant based and improving your numbers.
      Have you had your hip pain examined by a Dr. to confirm that is is pseudogout? Hip pain is a less common presentation of it. If you have not, I would start with that so we know for sure what we are dealing with.
      If it is confirmed and you have already removed foods that trigger attacks, then focus on adding more of foods that may help with symptoms. Some were mentioned in this blog- mushrooms, peas, beans, lentils, and cauliflower. Cherries and cherry juice are another.
      https://nutritionfacts.org/topics/gout/

      If you are doing everything you can with diet and still having symptoms, then I would maybe consider a medication. You probably won’t need nearly as much of it as you would if you didn’t have such a good diet.

      All the best,
      NurseKelly

  9. I read your article about plant versus meat purines and have to disagree that plant-based purines are somehow protective from gout attacks. I am a long-time gout sufferer and have precipitated at least two gout attacks from eating lentils and one gout attack from eating black-eyed peas [I am a vegetarian – no meat, seafood or alcohol in my diet]. I am not a novice to gout, nor am I naive to potential bias in research methods as I am a research methodologist [in other words, I don’t believe that these attacks were simply due to chance]. So, at least for me, purines are dangerous to gout, no matter the source. Finally, allopurinol is far from benign as it changes both the androgen and thyroid hormone profiles of patients – some serious and potentially devastating side-effects especially for males.

    1. Interesting. I’ve had 3 attacks of gout in the 2000 – 2015 period as a pesco-lacto-vegetarian, and none since going 100% WFP after that. I eat at least 3 servings of beans/legumes per day, although I do not usually eat lentils or black-eyed peas. So it would seem, unless lentils and black-eyed peas are particularly problematic, that there are significant individual differences, which would not be surprising.

      1. Investigating a bit, I found that purines in beans/legumes vary from 16 mg per 1/2 cup serving (garbanzo) to 70 mg per serving (lentils). Solid,pea and soybeans are also at the higher end around 60 mg/serving, so bean choice could really make a difference. I almost always eat 1 serving of soy (tempeh or tofu), 1 serving of garbanzos and 1serving of some other bean per day, so I guess the average does not exceed my tolerance. Have to cut back on lentils and split peas, perhaps. Too bad.

  10. Cool that soy has an inverse association.

    Oh, I don’t think anybody has mentioned soda. The Daily Telegraph put that above alcohol.

    “Soft drinks ‘bigger gout risk than alcohol’” read the headline in The Daily Telegraph today. It reported that “drinking too many sugary soft drinks and fruit juices can substantially increase the risk of gout”.

      1. Is here indeed the perfect food? If it’s found to be good for us in one way, it’s lousy in other ways. Some claim eggs are the perfect food, but of course we know they’re not.

        Mother’s milk is also said to be “the perfect food,” but lots of luck in getting some of that!

          1. Laughing at it not being a perfect food.

            When people call Breast milk the perfect food, I always have wondered, doesn’t it depend on the diet of the mother?

  11. when you discuss gout, always worthwhile to add the point that some medications can contribute to gout. Examples are some bp medications eg – Diuretics, beta-blockers and alpha-1 blockers can reduce glomerular filtration rate and raise serum uric acid levels
    https://www.ncbi.nlm.nih.gov/pubmed/27643410
    Recently my dr prescribed beta blocker and diuretic and I got to experience my first gout toe – not a fun experience. What makes it interesting is the dr was not aware that beta blockers could raise uric acid levels – now she does (as I gave her the nih article). Thanks for the fantastic website and videos.

  12. I haven’t had meat or alcohol in years, the majority of my meals in that time have been unprocessed/low processed plant foods. Yet I still am plagued with a fairly large string of gout episodes. I haven’t “eliminated” sugar, but, sugar is a fairly low component in my diet. I’ve begun to wonder if the beans I eat are the culprit.

    1. With the sugars, make sure that they aren’t fructose because that is what they said was worse than alcohol. It is a different risk factor for males.

      “In this study, ingesting fructose was found to cause a sharp increase in serum uric acid. The rapid increase was exaggerated in individuals with a history of gout. Also, in a different study it was found that animal experiments and two National Health and Nutrition Examination Survey (NHANES) studies have suggested that the enormity of urate raising effect of sugar-sweetened sodas may be weaker among women than among men, extrapolation of data on this important risk factor for gout from men to women should be done with caution.”

      Have you looked at all the factors? Dehydration? Fructose? MSG? Any meds you are on? Seems like you need to evaluate risk factor by risk factor and then try different things.

      1. Harvard talks about high blood pressure and diuretics.

        “High blood pressure is another major risk factor for gout. It gets complicated, though, because the diuretics taken to lower high blood pressure increase uric acid levels, so the treatment as well as the disease are associated with the disease.”

        1. Do you do calorie restriction? “Blood urate levels rise dramatically when body proteins are broken down due to starvation or very low energy intake”

          The next thing would be to look for other health issues, such as kidney problems or things like Leukemia.

          1. Also, apples and oranges are associated with increase of uric acid, even though most fruits are not.

            “Certain fruits – which are a natural source of fructose – have also been linked with gout.

            This is a highly contentious area, because several studies have linked higher fruit intake with less incidence of gout. This is probably due to their high fibre content (9, 18).

            One study found that the consumption of apples or oranges – the most popular fruits in this study – was linked with an increased risk of gout compared to those who consume less than one serving of fruit per month. No link was found with other fruits however (12).”

            I am thinking that would mean checking apple juice and orange juice intake because you would would have the fructose without the fiber.

    2. You could also make sure to eat mostly low(er) purine beans, e.g. garbanzo (19 mg/serving), lima (49), small red beans (550, pinto (57).

  13. No one had mentioned even a bit exercise, perhaps as exercise with gout inflicted joints is a bad ide.
    But this study suggest a correlation with reduced incidence of gout with exercise. However the exercise is considered to have effect as probably a reduced body weight, and consumption of more fruits and veggies being typical of these peoples….https://academic.oup.com/ajcn/article/87/5/1480/4650681

    A good read nevertheless and a pretty good study though gout symptoms were self reported.
    I personally do not suffer this. I do eat large amounts of various beans most day every day at multiple meals and mushrooms as well. But my family seems to as well have no history in this specific.
    I have known peoples with healthy weight to have this and suspect alcohol meats body weight and such, exasperate a genetic tendency to the disease. Some seem to suffer it and some not, even though on the same approximate diet and equal for other factors.

    1. My family does have a definite tendency to arthritis, though I suffer only very minorly from this. Present in two hand joints as a consequence of heavy deadlifting without straps for 20 plus years and hitting a heavy bag without tape for many years as well. But is is not functionally limiting.

      Most powerlifters five or more years into the sport seem to develop joint problems of some sort, virtually all of them with 20 years or more of usually a disableing nature.

      But I wonder if there is perhaps a inverse correlation genetically between gout and arthritis?
      Peoples not presenting with both typically.

    2. Also nutritional deficiencies are linked.

      Vitamin D deficiency is probably a big one. Pubmed called it a “potential causal relationship”

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586492/

      The whole sodium / potassium / magnesium balance thing might be something to check. And with that would be calcium / magnesium and Vitamin D balancing act.

      A deficiency in calcium or magnesium leads to higher levels of uric acid in the blood.

      Dieting may also cause a loss of potassium, which can increase uric acid levels in the blood.

      “Investigators have found that supplementing vitamin C significantly lowers uric acid levels in healthy adults, according to a review of published studies.”

      Lowering glycemic index helps. If prediabetic or diabetic going low saturated fat and no oil might help https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586492/

      Alkalizing the diet helps, according to several sources.

      Sodium intake being higher helps with gout, but I say that with big flashing warning signs, because that doesn’t mean that salt is good for you.

      We discussed it a few blogs ago. If I am remembering properly, Sodium bicarbonate causes fewer endothelial problems than Sodium Chloride, but people who abuse Sodium bicarbonate end up dying.

      Yes, Alcoholics die from Baking Soda.

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