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Dietary Management of Gout: What is the Evidence?

      To the Editor:
      We were interested to read the recent manuscript by Berl et al that “argues for the absolute importance of dietary counselling in gout and proves why this counselling may impact the long term well-being of a patient with gout.”

      Beyl RN Jr, Hughes L, Morgan S. Update on importance of diet in gout [e-pub ahead of print]. Am J Med. 2016 Jul 22.

      In support of this argument, the authors cite many observational studies showing associations of dietary factors in development of incident gout in the general population, and intervention studies reporting modest reductions in serum urate concentrations in healthy patients without gout.
      We note that only 3 randomized controlled trials have examined the role of dietary interventions for patients with established gout, and none have shown benefit. A Cochrane review published in 2014 reported, “there were no high quality trials to support or refute the use of lifestyle interventions for treating acute or chronic gout.”
      • Moi J.H.
      • Sriranganathan M.K.
      • Falzon L.
      • Edwards C.J.
      • van der Heijde D.M.
      • Buchbinder R.
      Lifestyle interventions for the treatment of gout: a summary of 2 Cochrane systematic reviews.
      Despite positive studies in healthy volunteers, a randomized controlled trial did not demonstrate that standard low-fat milk powder reduced serum urate concentrations or flare frequency in patients with gout.
      • Dalbeth N.
      • Ames R.
      • Gamble G.D.
      • et al.
      Effects of skim milk powder enriched with glycomacropeptide and G600 milk fat extract on frequency of gout flares: a proof-of-concept randomised controlled trial.
      More recently, a clinical trial of vitamin C showed no clinically significant urate-lowering effects in patients with gout, despite previous positive findings in healthy volunteers.
      • Stamp L.K.
      • O'Donnell J.L.
      • Frampton C.
      • Drake J.M.
      • Zhang M.
      • Chapman P.T.
      Clinically insignificant effect of supplemental vitamin C on serum urate in patients with gout: a pilot randomized controlled trial.
      Furthermore, a recent randomized controlled trial of comprehensive dietary advice has shown no benefit in serum urate control in patients with gout.
      • Holland R.
      • McGill N.W.
      Comprehensive dietary education in treated gout patients does not further improve serum urate.
      We entirely agree with the authors that counseling about the benefits of weight loss for overweight/obesity, avoidance of sugary drinks, and reduction of alcohol intake for hazardous drinking is important for all patients, including those with gout. However, excessive focus on unproven dietary management by health care professionals may reinforce negative stereotypes about gout
      • Lindsay K.
      • Gow P.
      • Vanderpyl J.
      • Logo P.
      • Dalbeth N.
      The experience and impact of living with gout: a study of men with chronic gout using a qualitative grounded theory approach.
      and contribute to ongoing underutilization of effective urate-lowering therapies.
      • Singh J.A.
      • Akhras K.S.
      • Shiozawa A.
      Comparative effectiveness of urate lowering with febuxostat versus allopurinol in gout: analyses from large U.S. managed care cohort.
      Given the current evidence, we challenge the concept that dietary management is proven to be of benefit for gout. Specifically, we caution about translating findings from observational and intervention studies of healthy volunteers without gout into treatment recommendations for those with established disease.

      References

      1. Beyl RN Jr, Hughes L, Morgan S. Update on importance of diet in gout [e-pub ahead of print]. Am J Med. 2016 Jul 22.

        • Moi J.H.
        • Sriranganathan M.K.
        • Falzon L.
        • Edwards C.J.
        • van der Heijde D.M.
        • Buchbinder R.
        Lifestyle interventions for the treatment of gout: a summary of 2 Cochrane systematic reviews.
        J Rheumatol Suppl. 2014; 92: 26-32
        • Dalbeth N.
        • Ames R.
        • Gamble G.D.
        • et al.
        Effects of skim milk powder enriched with glycomacropeptide and G600 milk fat extract on frequency of gout flares: a proof-of-concept randomised controlled trial.
        Ann Rheum Dis. 2012; 71: 929-934
        • Stamp L.K.
        • O'Donnell J.L.
        • Frampton C.
        • Drake J.M.
        • Zhang M.
        • Chapman P.T.
        Clinically insignificant effect of supplemental vitamin C on serum urate in patients with gout: a pilot randomized controlled trial.
        Arthritis Rheum. 2013; 65: 1636-1642
        • Holland R.
        • McGill N.W.
        Comprehensive dietary education in treated gout patients does not further improve serum urate.
        Intern Med J. 2015; 45: 189-194
        • Lindsay K.
        • Gow P.
        • Vanderpyl J.
        • Logo P.
        • Dalbeth N.
        The experience and impact of living with gout: a study of men with chronic gout using a qualitative grounded theory approach.
        J Clin Rheumatol. 2011; 17: 1-6
        • Singh J.A.
        • Akhras K.S.
        • Shiozawa A.
        Comparative effectiveness of urate lowering with febuxostat versus allopurinol in gout: analyses from large U.S. managed care cohort.
        Arthritis Res Ther. 2015; 17: 120

      Linked Article

      • Update on Importance of Diet in Gout
        The American Journal of MedicineVol. 129Issue 11
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          Gout is an inflammatory arthritis caused by deposition of monosodium urate crystals within synovial joints. Although it is most well-known for its arthritis, gout has an intimate relationship with many other cardiovascular and metabolic conditions. Current recommendations support aggressive medical therapy to treat gout, whereas dietary counseling has become less emphasized. This article argues for the absolute importance of dietary counseling in gout and proves why this counseling may impact the long term well-being of a patient with gout.
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