Although most cases of gout are hereditary, victims are often advised on lifestyle changes that can help reduce the frequency of attacks. Recently in these pages we published the standard dietary recommendations under the title "How to eat if you have gout" . For decades, gout sufferers have been advised to avoid high purine-containing foods. Examples of these are: kidneys, sweetbreads, liver, bacon, beef, pork, duck, shellfish, and venison. Purines are the chemicals that form uric acid in the body, which in turn causes painful deposition of urate crystals in the joints. A recent study, however, suggests it may be time to re-examine the recommendation for gout sufferers to avoid purine-containing food.

Investigators at Johannesburg, South Africa, noted the resemblance between some of the changes seen in gout and in patients with what is known as the insulin-resistance (IR) syndrome. These include obesity, high blood pressure, high blood sugar, high cholesterol levels, coronary artery disease, and increased uric acid levels. The investigators wanted to see if using a diet similar to one that is effective in the IR syndrome would also help patients with gout.

Thirteen men who had fairly frequent gout attacks (at least two in the previous four months), and who were not diabetic, undertook the following diet: calories were restricted to 1600 daily, 40% of food was derived from carbohydrate, 30% from protein and 30% from fat. Moreover, refined carbohydrates (like sugar, white flour products and snacks) were to be replaced by complex carbohydrates (rice, pasta, beans), and saturated fats (butter, lard, etc) by mono-and polyunsaturated fats (olive oil, deep-sea fish).

Weight (leading to calculation of the body mass index, or BMI) and blood tests were done at baseline. Also at baseline, and at visits 4, 10 and 16 weeks after being on the diet, the number of gout attacks was recorded, the composition of the diet during the last twenty-four hours was noted, and dietary counseling was given. Weight and blood tests were recorded at the final 16-week visit.

The average age of the subjects was 50, and BMI averaged 30.5 kg/m², which is borderline for obesity. Ten of the 13 subjects use alcohol, and 7 had high blood pressure. They had suffered from gout for an average of 7 years.

After 16 weeks on the modified diet, the average BMI was reduced by 2.7 kg/m², and blood uric acid levels were lowered by 18%. More importantly, the number of gout attacks fell from an average of 2.1 per month to 0.6 per month, a significant reduction of 67%. There were also improvements in the numbers of persons with raised cholesterol levels, high blood pressure and symptoms of coronary artery disease. Nine of the participants continued on the diet for further 3 to 14 months, and in 8 of these the reductions in blood uric acid levels and the number of gout attacks were maintained, or even improved.

There seems little doubt that the change in diet was responsible for the improvements in these subjects' symptoms and signs of gout. (Of course, a 1600 calories-a-day will result in weight loss in many persons.) Foods that are low in purines are often high in carbohydrates and saturated fats, so that the diet used here actually limited low-purine foods. On the other hand, the subjects were encouraged to increase their intake of fish and poultry, which are relatively high in purines. In this way, increased purine intake - classically avoided in managing gout - was associated with fewer gouty attacks.

These findings represent a challenge to the "low-purine, high-carbohydrate" diet usually advised for gout patients. Perhaps we need to re-think our recommendations regarding the most appropriate diet for gout patients. Certainly, further research should be done to substantiate these results. For those gout sufferers who want to try to follow the diet used successfully by the South African investigators, you can come close to it by following the dietary recommendations in "How to eat if you have cardiovascular disease"