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TOMASZUK, Sebastian, WĄSIK, Karolina & WOJTUŚ, Magda. Nutritional factors in the prevention and treatment of gout.
Quality in Sport. 2023;9(2):29-36. eISSN 2450-3118. DOI https://dx.doi.org/10.12775/QS.2023.09.02.004
https://apcz.umk.pl/QS/article/view/42378

The journal has had 20 points in Ministry of Education and Science of Poland parametric evaluation. Annex to the announcement of the Minister of Education and Science of December 21, 2021. No. 32582.
Has a Journal's Unique Identifier: 201398. Scientific disciplines assigned: Economics and finance (Field of social sciences); Management and Quality Sciences (Field of social sciences).
Punkty Ministerialne z 2019 - aktualny rok 20 punktów. Załącznik do komunikatu Ministra Edukacji i Nauki z dnia 21 grudnia 2021 r. Lp. 32582. Posiada Unikatowy Identyfikator Czasopisma: 201398.
Przypisane dyscypliny naukowe: Ekonomia i finanse (Dziedzina nauk społecznych); Nauki o zarządzaniu i jakości (Dziedzina nauk społecznych).

© The Authors 2023;

This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland

Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium,
provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike.
(http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited.

The authors declare that there is no conflict of interests regarding the publication of this paper.

Received: 01.02.2023. Revised: 18.02.2023. Accepted: 18.02.2023.

Nutritional factors in the prevention and treatment of gout

Sebastian Tomaszuk1, Karolina Wąsik1, Magda Wojtuś1

1Medical University of Lublin, Aleje Racławickie Street 1, 20-059 Lublin, Poland
Sebastian Tomaszuk; sebastiantomaszuk@gmail.com;
ORCID 0000-0002-1572-5181;
Karolina Wąsik; wasik.karolina.0@gmail.com;
ORCID 0000-0003-2817-0848;
Magda Wojtuś; magdaawojtus@gmail.com;
ORCID 0000-0003-4299-2143

Summary:

Introduction and purpose:
Despite the fact that effective urate lowering therapy and anti-inflammatory drugs for the treatment of gout are
commonly available, there is considerable interest in novel treatment approaches. Gouty patients often have a
multitude of comorbidities, which lead to concern over drug–drug interactions and medication adverse events.
Thus, diet modifications are examined as a way of nonpharmacological treatment of gout. In this review, we
explore the potential impact of nutritional factors on hyperuricemia and clinical gout outcomes. A search was
conducted using PubMed and Google Scholarship databases.

Brief description of the state of knowledge:
Management in patients with gout should be holistic. Incorrect nutrition may lead to hyperuricemia. Studies to
date suggest that avoidance of certain foods and beverages can decrease the frequency of gout flares. Weight
loss may be beneficial for prevention as well as treatment of gout and its comorbidities. The impact of various
types of diet on the course of gout has been given particular attention and recent research suggests that
vegetarian, mediterranean and dash diets may be beneficial for gouty patients. Also, some vitamins and omega-3
PUFA have favorable effects and the potential clinical use in gout treatment.

Conclusions:
We propose that simple dietary regimens may be beneficial to complement therapeutic management or
contribute to the prevention of flares in gout patients. Although piecemeal modifications of various nutrients
often provide incomplete dietary recommendations, understanding the role of nutritional factors in gout
development would be helpful for patients in choosing their healthy diet.

Key words: gout; hyperuricemia; nutritional factors; non-pharmacological treatment; health

https://dx.doi.org/10.12775/QS.2023.09.02.004
https://apcz.umk.pl/QS/article/view/42378
http://creativecommons.org/licenses/by-nc-sa/4.0/)


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1. Introduction

Gout is a very common disease that is relatively very widespread around the world especially in developed
countries. In the USA approximately 3.9% of adults suffer from it and its occurrence is constantly rising. People
suffering from obesity, with metabolic syndrome and men over 40 years old are especially at risk to develop it
[1].
Most often, the clinical manifestations of gout might include: intense joint pain of the toe (usually affects the
first metatarsophalangeal joint, but any joint might be affected), lingering discomfort, inflammation and redness
of joints, and limited range of motion. Symptoms usually appear early in the morning. Gout manifests itself not
only in joints. In the course of gout also might be identified: tophi, kidney failure, kidney stones and
hypertension [2,3].
The pathogenesis of the gout is deposition of sodium urate crystals in the joints and in the subcutaneous tissue,
which causes the symptoms of the disease. Sodium urate crystals crystallize when uric acid level in the blood is
high. This is often due to triggers such as: alcohol, large amounts of purine-containing foods (especially meat),
exercise, injury, surgery, infections and medications (especially thiazide diuretics) [4]. First-line treatment of a
gout attack are non-steroidal anti-inflammatory drugs (NSAIDs) and after an acute attack of the gout the
allopurinol can be used in prophylaxis [5].

2. State of knowledge

2.1 The role of diet and dietary recommendations in gout.

Purines are molecules compounded by pyrimidine and imidazole rings.
They are converted to hypoxanthine by the xanthine oxidase enzyme (XO) after intake, and then to xanthine and
uric acid. Therefore, a special role in the gout pathogenesis is attributed to diet. It should be selected according
to the needs of the patient (age, weight, vitamin deficiencies) and should contain all the necessary macro and
microelements.
Healthy Eating Pyramid is the visualization of how a healthy diet should be well-balanced. There is a variation
that can be useful for patients suffering from gout. According to it, the diet should include whole grain foods
and plant oils at most meals. The least frequent group of products which should be consumed only sparingly are
red meat, sweets and refined carbohydrates [6]. Incorrect diet may contain excess purines leading to
hyperuricemia. Foods that are rich in purines are mainly meat and high protein vegetables. However, the
influence of the consumption of high protein vegetables on hyperuricemia in recent years is undermined.
A cross-sectional research made by Aihemaitijiang et al. studied the effect of a purine-rich diet in Chinese adults.
In the results purine-rich vegetables did not correlate with hyperuricemia [7]. Such outcomes can be explained
by other substances that are contained in plants. These compounds such as vitamin C might potentially increase
the excretion of uric acid from the body. Research in this direction is still needed, but they are increasingly
included in dietary recommendations.
As meta-analysis by Li et al. revealed the consumption of red meat, seafoods, alcohol or fructose was associated
with higher gout risk. Also in this study, the results indicated that the high-purine vegetables diet did not lead to
hyperuricemia [8]. Additionally cocoa, fish and yeast can contribute to the occurrence of an increased amount of
uric acid in the blood, and therefore their consumption should be limited.
Dietary recommendations do not apply only to solid foods, but also refer to liquids. The effect of drinking tea on
gout is not clear and depends on the type of tea. Nonspecific types of tea in study did not affect the higher risk
of gout [9]. However, the daily drinking of green tea increases the level of uric acid in the serum [10]. Alcohol,
due to the fact that it increases the conversion of purines to uric acid, is not recommended in the diet and people
suffering from gout should avoid it [11]. Also, fructose-sweetened beverages should be limited. It is worth
mentioning that from the 2021 meta-analysis made by Ayoub-Charette et al. sugar-sweetened beverages (SSBs)
increase uric acid levels in the blood, however consumption of 100% fruit juice decreased uric acid level [12].
Another drink that has shown a beneficial effect on reducing the amount of uric acid in the blood is water with
vitamin C. It happens as a result of vitamin C competing with urate for renal reabsorption [13,14]. In addition,
coffee, milk and yogurts also showed such an effect. All of them were associated with lower risk of gout [10].
Also drinking milk and yogurt have a lowering effect on uric acid levels in serum [15]. Diet should be
multifaceted and focused on the treatment of comorbidities such as hypertensive, dyslipidemia, metabolic
syndrome and especially obesity which often coexist with gout. Dietary recommendations should not only
contain qualitative advice. A caloric deficit should be considered and induce weight loss in patients with
increased BMI. The results from meta-analysis from 2022 which was focused on modifiable risk factors and
incidence of gout clearly show that increasing BMI was correlated with the higher risk of gout [16]. The diet
should consist of regular meals, adequate fluid intake and should be accepted and strictly followed by the patient
as the most important.



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2.2 Vegetarian diet in the treatment of gout

When it comes to the influence of the vegetarian diet on symptoms of gout, scientific data is composite.
Outcome of this diet strategy is dependent on the composition of the diet as it is known that some plant based
foods also contain high purine levels [17]. Siener et al. proved that vegetarian diet decreased the risk of uric acid
crystallization by 93% when compared to the standard western diet. The type of vegetarian diet was ovo-lacto-
vegetarian- it excludes not only meat, but also eggs [18]. This strategy is also supported by two prospective
cohort studies conducted by Chiu et al. In this paper lacto-ovo-vegetarians noted the lowest uric acid level out of
the three groups- other two were vegans and nonvegetarians [19]. Vegetarian strategy seems to be one of the
most beneficial as in a study made by Schmidt et al. serum uric acid level was the lowest in this group while
vegans noted the highest level followed by meat eaters [20].

2.3 Ketogenic diet in the treatment of gout

Ketogenic diet is based mainly on high-fat meals with moderate dose of proteins and very limited amount of
carbohydrates [21]. Currently, its possible health properties among many diseases are being investigated.
As stated by Goldberg et al. in their study proved that a ketogenic diet increases the production of β-
hydroxybutyrate (BHB). This molecule shows anti-inflammatory properties, therefore could potentially alleviate
the symptoms of gout [22]. Although it still remains unclear and questionable if ketogenic diet may be
considered as beneficial for patients with gout as ketosis that is induced by this way of nutrition may lead to a
higher uric acid level [23].

2.4 Dash diet in the treatment of gout

Dash diet is a proven health-promoting way of eating that is grounded on high consumption of vegetables and
fruits, legumes, nuts and seeds and low-fat dairy. There is also a strong emphasis on limiting the consumption of
sodium, sugar and saturated fats [24].This dietary pattern among many health benefits is associated not only
with the lower risk of gout as prospective cohort study conducted on men investigated [25], but its benefits were
also observed among patients who already have gout and were at a time not during pharmacological urate
lowering therapy (ULT). The outcome suggested that this strategy may be a useful tool to lower the urate serum
level [26].This evidence is also supported by another study which compared a dash diet to standard diet and one
with higher vegetables and fruits consumption, but without other restriction. Dash diet turned out to be the most
beneficial in reducing serum urate levels [27].
It is also known that gout is often part of the metabolic syndrome and is associated with insulin resistance. Dash
diet is proven to exert a positive impact on this condition and is profitable for patients who apart from metabolic
symptoms want to improve the tenor of gout [6].

2.5 Mediterranean diet in the treatment of gout

This model of nutrition concentrates on the higher consumption of antioxidant rich extra virgin olive oil, fruits,
cereals, nuts and legumes, moderate use of fish and other meat, dairy products and red wine with the determined
frequency [28].This diet pattern is widely recognised for its beneficial effects, therefore its impact on gout
disease is also being observed.It is known that long term usage of this model is connected with lover serum uric
acid level in elderly individuals, although Ikarian study demonstrated that only in male cases, therefore may be
considered as a part of preventative lifestyle [29].This model was also being investigated among patients who
already have gout and in a review published by Theodoridis et al. authors concluded that this diet may be
potentially helpful in the treatment of gout, because its components in a large part are proven to have positive
effects on serum uric acid level. It was noted that further research is still needed [30].

2.6 High-protein diet in the treatment of gout

The association between high protein intake and gout remains characterized as negative. As study by Xi et al
highlighted, incidence of gout increased in a group with this diet pattern [31].This consumption pattern
compounded not only serum concentrations of uric acid, but also renal function [32].Also in an animal model
high protein diet escalated the level of serum urate [33].Although, consuming more protein on a weight loss diet
has been shown as beneficial in a pilot study by Dessein et al. During this study participants who already had
gout attacks in the past have consumed 30% of calories from protein on a 1600 kcal. This strategy resulted in
fewer gout attacks and lower uric acid level [34].



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2.7 Vitamin supplementation in the treatment of gout

Although many epidemiological studies indicate a significant correlation between high vitamin C intake and
lower serum uric acid levels, data is still mixed and primarily related to the populations studied [35,36].
Pharmacologically, the uricosuric effects of vitamin C seem to have the highest impact on hyperuricemia. Both
uric acid and vitamin C can be reabsorbed in the proximal tube via anion-exchange transport. Vitamin C
overload can competitively suppress the reabsorption of uric acid in the filtrate [37]. The uricosuric function of
vitamin C is also connected with downregulation of URAT1 activity and/or Na+-dependent anion cotransporter
could promote uric acid excretion [35]. The reports about vitamin C-caused reduction in serum urate and
association between high doses vitamin C intake and a lower risk of gout have caused recommendations to add
vitamin C to the diet to reduce serum uric acid levels [35,38,39]. However, it should be noted that these studies
were conducted with high vitamin C doses among small numbers of participants without gout [38,39]. In
contrast, a small pilot randomized controlled trial revealed clinically insignificant effect of 500mg/d of
supplemental vitamin C placebo on serum urate in people with gout, regardless of concomitant allopurinol
administration [40]. In consequence, in 2020 the American College of Rheumatology’s (ACR) Gout Guideline
made a conditional recommendation against use of vitamin C in people with gout [41].
Just like vitamin C, vitamin A and vitamin E also show beneficial effects against oxidative stress and
inflammation, as well as effectively decreasing serum uric acid (SUA) levels [42]. The cross-sectional study
evaluated the association of dietary vitamin E intake with hyperuricemia in US adults. The results indicated that
it was negatively correlated with hyperuricemia, especially among males and participants aged ≥60 years [43].
Uric acid-lowering effect might be also observed in a vitamin D-rich diet. In provided by Charoenngam meta-
analysis of seven cross-sectional studies, individuals with vitamin D deficiency and insufficiency have been
shown to have increased serum uric acid in a dose-dependent manner compared with vitamin D-sufficient
individuals (pooled mean differences 0.45 and 0.33 mg/dL). These results are thought to be associated not only
with the fact both vitamin D deficiency/insufficiency and hyperuricemia share common comorbidities such as
obesity and metabolic syndrome, but also to a direct causal association between the two conditions [44]. These
conclusions were also supported by the study conducted on 71 participants with prediabetes randomized to
receive weekly doses of 20,000 IUs of vitamin D2, 15,000 IUs of vitamin D3 or no vitamin D. In this paper
vitamin D supplementation was associated with a reduction in mean serum uric acid level by 0.6 mg/dL in those
with baseline uric acid level of >6 mg/dL [45]. This effect is suggested to be caused by PTH suppression [46].
However, despite the causal link between vitamin D and uric acid, no association with gout has been
demonstrated [47].

2.8 Minerals supplementation in the treatment of gout

As it is commonly known dietary potassium intake has diuretic and natriuretic effects and even a minor
potassium insufficiency can trigger an impairment in the kidney’s capacity to secrete sodium chloride and retain
sodium [48], which results in renal dysfunction. Whereas long-term routine potassium replenishment causes
thiazide mediated by thiazide diuretic elevation of uric acid [49]. Moreover, a similar facilitation effect was
described by Martelin et al. when iron accumulation triggers increased XO activity. In this study ferric
ammonium citrate and FeSO(4) elevated intracellular iron levels and elevated XO activity in mouse fibroblast
and human bronchial epithelial cells [50]. However, the later analysis conducted by Cheng showed a significant
negative correlation between iron and magnesium with the risk of gout [51]. It should be also noticed that
minerals have a crucial role in maintaining acid-base balance and low urine pH predisposes to acid stone
formation. Hypercalciuria is a risk factor for calcium stone disease and in this light the level of calcium also
affects the serum uric acid concentration by causing a uric acid excretion disorder [52]. Normal calcium intake
can be beneficial because of decreasing the potential risk of kidney stone formation and conducting uric acid
elimination in renal tissue [53,54].

2.9 Omega-3 Fatty Acids supplementation in the treatment of gout

Omega-3 polyunsaturated fatty acids (PUFA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)
potentially have anti-inflammatory properties. They can inhibit NALP-3 inflammasome assembly and
neutrophil chemotaxis among other factors that lead to an inflammatory response to monosodium urate crystals
[55]. Yan et al. showed that stimulation of macrophages with omega-3 PUFA abolished NLRP3 inflammasome
activation and inhibited subsequent caspase-1 activation and IL-1β secretion. Through this mechanism omega-3
PUFA can repress inflammation and prevent inflammation-driven diseases, so its use may have the potential
clinical use in gout treatment [56]. Data regarding effects of omega-3 PUFA on serum urate are limited. A
randomized controlled trial conducted on 30 young healthy adults revealed that daily intake of fish oil (2 g;
primarily DHA and EPA) resulted in a significant decrease of SUA after 4 and 8 weeks of supplementation [57].

https://www.sciencedirect.com/topics/medicine-and-dentistry/inflammasome


33

A study with 112 men with gout noted a significant trend for a negative association between serum levels of
omega-3 PUFA and gout flares in the preceding 12 months, though other dietary factors were unable to account
[56]. Also in the online case crossover study among 724 participants with gout omega-3 PUFA-rich fish
consumption of at least 2 servings in the prior 48 hours was associated with a 26% lower risk of gout flares
compared with time periods of no consumption when adjusted for concomitant purine intake [58]. However,
there was no association between self-directed omega-3 PUFA supplementation such as with fish oil or cod liver
oil and a lower risk of gout flares, though few reported supplement use and doses may be too low for anti-
inflammatory effects [58]. Because of limited data regarding potential favorable effects of omega-3 PUFA in
gout, 2020 ACR guideline for the management of gout does not comment on omega–3 PUFA and gout [41].

2.10 Cherries supplementation in the treatment of gout

In traditional reputation consumption of cherries or cherry juice alleviates pain in arthritis and gout. A growing
body of literature shows that cherries may have anti-inflammatory, antioxidant and pain-mediating effects
because of their phenolic compounds [59]. Potentially cherries may also have a uricosuric effect [60]. Since
consumption of cherries or cherry juice decreased CRP and oxidative stress, and increased total antioxidant
capacity, it was suggested that such effects might provide symptom relief in patients with gout [59]. A crossover
trial with 26 overweight and obese participants without gout revealed a reduction in serum urate by 19.2% in the
tart cherry juice arm vs. an increase in the placebo group. The tart cherry juice intake resulted in an absolute
decrease of approximately 1 mg/dL serum urate, while at baseline its mean value was 6.3 mg/dL [61]. In
contrast, in the study conducted by Stamp et al. in patients with gout (half on allopurinol and half on no ULT),
who were given placebo or varying doses of tart cherry concentrate for 28 days, there was no significant effect
of cherry on serum urate levels [62]. Other work, evaluating the effects of cherry intake on gout flares among
633 individuals with gout, who consumed cherries over a 2-day period, revealed a 35% lower risk of gout flares
compared with periods of no cherry intake. The effect could be sustained thanks to adjusting for known risk
factors for gout flares and anti-gout medications [63].
However, due to insufficient data, the 2020 ACR guideline for the management of gout does not make a specific
recommendation regarding cherries/cherry juice concentrate intake [42].

3. Conclusions

Gout is a diet-dependent disease to a certain extent and science acknowledges that the nourishment pattern has
an impact on the tenor of it. Nutritional advice that may moderate the course of disease are mostly not very strict
and do not differ from the average healthy diet that every human should follow in order to stay healthy.
However, the degree of this dietetic influence remains unknown. Patients affected with gout should focus on
reducing nutritional risk factors for this disease and consider appropriate supplementation.

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