The role of diet in hyperuricemia and gout

Abstract

Purpose of review: Although gout's cardinal feature is inflammatory arthritis, it is closely associated with insulin resistance and considered a manifestation of the metabolic syndrome. As such, both gout and hyperuricemia are often associated with major cardiometabolic and renal comorbidities that drive the persistently elevated premature mortality rates among gout patients. To that end, conventional low-purine (i.e., low-protein) dietary advice given to many patients with gout warrant reconsideration.

Recent findings: Recent research suggests that several healthy diets, such as the Mediterranean or Dietary Approaches to Stop Hypertension (DASH) diets, in combination with weight loss for those who are overweight or obese, can drastically improve cardiometabolic risk factors and outcomes. By treating gout as a part of the metabolic syndrome and shifting our dietary recommendations to these healthy dietary patterns, the beneficial effects on gout endpoints should naturally follow for the majority of typical gout cases, mediated through changes in insulin resistance.

Summary: Dietary recommendations for the management of hyperuricemia and gout should be approached holistically, taking into consideration its associated cardiometabolic comorbidities. Several healthy dietary patterns, many with similar themes, can be tailored to suit comorbidity profiles and personal preferences.

Figure 1.

Stages of Gout and Role of Lifestyle Interventions CV = cardiovascular; ULT = urate-lowering therapy

Figure 2:

Persistent Premature Mortality Among Patients with Gout Remains Higher than Premature Mortality in Rheumatoid Arthritis in Recent Decades Panel (a) compares the cumulative incidence of death from 1999 to 2006 (red lines) to that from 2007 to 2014 (blue lines) among patients with gout (solid lines) and without gout (dotted lines), with the difference between the solid and dotted lines remaining unchanged during the two time periods, indicating persistent premature mortality. Conversely, panel (b) compares the cumulative incidence of death from 1999 to 2006 (red lines) to that from 2007 to 2014 (blue lines) among patients with RA (solid lines) and without RA (dotted lines). The difference in mortality between the two blue lines is substantially smaller than that between the two red lines, indicating an improvement in the mortality gap among patients with RA in the latter time period. Adapted from: Fisher et al. Ann Rheum Dis 2017 & Zhang et al. Ann Rheum Dis 2017. RA = rheumatoid arthritis

Figure 3:

Causal Pathway Linking Lifestyle Factors with Gout and CV-Metabolic Disease CVD = cardiovascular disease; T2DM = Type 2 diabetes mellitus; CKD = chronic kidney disease

Figure 4:

Evidence-Based Healthy Eating Pyramid for Gout *Fish is the only exception where recommendations for gout (short-term) and cardiometabolic health may be contradictory. In the long-term, patients with gout would still benefit from moderate fish consumption if their gout/hyperuricemia is controlled by other measures.

Figure 5:

Serum Urate Change at 6 Months Among Participants with Baseline Hyperuricemia in Ancillary Analysis of Dietary Intervention Randomized Controlled Trial Adapted from: Yokose et al. Diabetes Care 2020.

Figure 6:

Potential Personalized Approaches Based on Comorbidity Cluster Profiles