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Living With(out) Gout

Welcome

To find this story, Living With(out) Gout, you probably had to do a little work sifting through web pages. So now that you’re here, take a moment to read what I have to say. I'm not going to try to sell you anything. I'm just going to talk common sense about things like diet, lifestyle, and frame of mind.

As luck would have it, I've been happily (and unexpectedly) gout-free for several years, and I've been feeling a strong need to tell other people what happened—in particular, how diet and lifestyle changes (sorry, no magic remedies) essentially put me into remission.

I’m not looking for anything in return, other than perhaps an email if you have something to add, or if you think I'm nuts, which I very well might be. By the way, thanks to all those who have written already.

Ultimately, though, what you do is up to you, and all I can do is tell my story.

You can reach me using this site’s contact form.

Contents

Here's an outline of what I'm going to talk about:

Discovery

If you have gout, this will sound familiar.

One summer day back in 1995 when I was just getting ready to leave my apartment, I noticed that the big toe of my left foot seemed a bit stiff. I figured it was probably something I did while jogging (which I’d taken up a few years before to lose weight). So, I played with the toe a bit and stretched it, and it felt better for a time. But as the days, then weeks, then months passed the stiffness kept coming back.

Six months later, in what I initially thought was an unrelated incident, I woke up one morning and started heading for the bathroom, only to find the same toe all swollen up. It was so swollen, in fact, that I couldn’t walk right. Within a day I could hardly walk at all. Putting shoes on became a major ordeal and sleep, as the Bible says, "fled from my eyes," in this case because of the throbbing pain.

Somehow I managed to convince myself that it was nothing and that I’d just injured myself somehow jogging or coaching youth soccer, without realizing it. So I let my toe heal slowly on its own over the course of the next month.

It was around then that I went in for an annual physical. I almost didn’t mention the toe to my family physician, but while he was poking and prodding it occurred to me that the injury might be worth mentioning, so I did. He gently touched the toe and pondered ("it still looks a bit swollen"), and said I might have gout.

I laughed and said I thought the injury was related to something I’d done while jogging six months earlier, and let the matter go.

Progression

Over the next seven years I experienced on-and-off toe pain, plus several full blown attacks. I’d have followed up with my original family physician, but by then I’d moved twice and gone through two new family physicians. Both of the new physicians agreed with the first one that I probably had gout, but I’m stubborn and can deal with pain (albeit with plenty of complaining), and I never went in during an attack to get a real diagnosis.

Remission

To this day (a dozen years after my first attack) I still haven’t had a formal diagnosis of gout, mostly because I’ve stopped having attacks. All I get is slight, very occasional stiffness in my toes. And my family physician therefore doesn’t see the point in pursuing a diagnosis ("Even if we got you a diagnosis, since you're asymptomatic all I'd tell you to do is to keep doing what you're doing").

Commentary

If you have gout, you’re probably wondering how I got off so easy, i.e., how the attacks just stopped. In fact, though, they didn’t just stop. Rather, they slowed down over the course of five years while I, and my family, came to terms with the changes I needed to make. It was a struggle for me to get to where I am.

For me there was no magic pill, herb, or powder, I'm afraid (and yes, I tried them). What worked for me was this:

  1. Ease into things (diet, exercise, or otherwise)
  2. Stay active: Walk to work, bicycle, and play sports
  3. Drink enough water, especially during and after exercise
  4. Avoid meat and meat products; and eat them only with other things
  5. Avoid mushrooms, legumes, yeast; eat them only with other things
  6. Stay away from known gout triggers: alcohol, aspirin, niacin, sugar, etc.
  7. Avoid refined grains and sugar, especially on an empty stomach
  8. Eat lots of so-called pro-biotic foods like kefir, cheese, and real sauerkraut
  9. Avoid foods containing preservatives and other unnatural additives
  10. Eat out less frequently, and "eat fresh," as the Subway ads say

You could call these rules common-sense, but it took me years of trial and error to get to the point where I’d identified them and understood that if I was going to get better I needed to follow them all, whether I happened to feel like it or not.

In what follows here, I’ll explain how I basically stumbled onto these various rules, partly through reading and study, but mainly by just trying things out and learning the hard way.

Body Tissue

There is a link between body tissue and gout, and it’s easy to understand. The linkage isn't 100%, but generally what seems to happen is that the gout sufferer produces more uric acid than he or she can effectively eliminate. This uric acid gets produced primarily through the natural breakdown of tissue in the body. It doesn’t take any particular genius, therefore, see that if a gout sufferer reduces the amount of tissue in his or her body he or she reduces the chances of a gout attack. Put more simply: To reduce gout risk, lose weight if you're carrying extra.

Fat Guy on Beach (Me)

Age 30: 5'10" 205 lbs (93 kg)

You may wonder why I omit "lose weight" from the list of rules above. I omit it partly because losing weight has become kind of a panacea, and people are tired of hearing about it.

My main reason for omitting "lose weight," though, is that for most people losing weight implies temporary change, like a special diet. But gout is not temporary. It’s a chronic, progressive condition, and fighting it requires permanent changes. The thing is that these permanent changes are the kinds of changes that result, naturally, in weight loss.

So the weight will come off on its own. And as a result there’s no reason for me to list weight loss explicitly above. It’ll only put people off. Worse yet it may lead to more gout attacks, because one of the triggers for gout is rapid change in weight or diet. Whatever happens, the changes need to happen slowly and gently. They have to be eased into.

Exercise

Exercise is beneficial to gout sufferers for many, mostly indirect, reasons. For one thing, exercise—even simple activities like walking a few blocks—has a natural antidepressant effect. This is no small thing, given the role stress plays in some gout attacks. In my experience, exercise also helps maintain a healthy body weight, improves circulation, and strengthens stiff, damaged joints.

What I found, personally, was that on days when I woke up with a slightly sore foot or toe, if I made myself walk to work, by the time I’d walked three quarters of a mile the soreness usually had worked itself out and I felt pretty good.

One important footnote to this is that walking only worked if the pain was slight to moderate. I’ve tried hiking, biking, and playing racquet sports on more severely affected joints, and I can say, pretty definitively, that in that case exercise doesn’t do anything except give me a sort of defiant can’t-keep-me-down satisfaction. Also, note that any time a gout sufferer jumps into unaccustomed levels of hard exercise he or she is asking for trouble. Sudden stress, weight loss, or, as I'll discuss in just a moment, dehydration can all cause flare ups.

Drinking Enough of Water

Here’s how I learned that it’s important to drink enough water.

Less Fat Guy on Beach

Age 48: OK, lose more (81 kg)

When I was about forty two, a then seventy year-old acquaintance of mine asked me if I played tennis. She needed a fourth for doubles. I said I played a little, which was a bit of a stretch ("I have played" would have been more accurate). So she asked me to meet her and two others the following day. I did and played terribly. But we had fun, and I ended up playing now and then—eventually earning a place on her list of people she could call if the regulars, who actually did know how to play, couldn’t make it.

During the summertime our games typically happened outside in the afternoon, on an asphalt court where things could get quite hot. Despite this, I typically didn’t bother bringing any water along.

What I found was that one or the other big toe would sometimes stiffen up a few hours after I finished playing. Rarely, the stiffness would turn into a minor attack overnight. One time it turned into a major attack. The pattern wasn’t entirely consistent, but it happened often enough that eventually I grasped the larger pattern: Whenever I did things that dehydrated me and caused my body to stop producing as much urine, I put myself at an increased risk of gout.

Apparently I’m not the only one who has made this same discovery.

I now take a water bottle around with me, not only to tennis, but also to my office. And I drink it whenever I feel thirsty, and sometimes even when I don’t.

Incidentally, people with both gout and high blood pressure need to use care treating their high blood pressure with diuretics, which flush fluids from the body and can exacerbate the gout. Just keep this in mind.

Tissue (Again)

Correlation between body tissue and gout (see above) applies not only to one's own tissue, but to tissue that one ingests, i.e., to meat. Meats and meat products contain moderate-to-high levels of purine, which breaks down into uric acid, i.e., into the chemical that crystallizes in joints and causes gout.

Organ meats, other than brain, are particularly bad in this respect, as is nearly all seafood except oysters. Red meat doesn't seem to me to be any worse than "white," even though many people say it is. Lean meat also doesn't seem to me to be any worse than fatty meat, and in fact the fatty meat may often be better. The trick is not to eat a lot of meat, and to eat it with other things. Meat should never be the main dish.

Thai Food

Thai Food

I discovered the importance of eating meat in combination with other things while in Thailand on a trip with my wife to adopt our daughter, Jariya. When we first arrived I was having moderate pain in my foot and left toe. At the time I wasn’t yet vegetarian (which I am now). Wanting to fit in and experience the culture, we naturally ate whatever the locals did ("when in Rome").

When Thai people eat meat (although this is changing, especially among wealthy and middle class Thais), they traditionally eat small amounts of it—usually cut up into bits and mixed with noodles and vegetables, or taken with lots of rice.

After eating Thai food for a few days, I found myself feeling better. By the end of the trip I felt great. And after we returned, I learned to cook some Thai food myself. Although I’m (mainly) vegetarian now, I find that if I eat bits of meat mixed with other things, the Thai way, I don’t have problems. It’s when I have big hunks of meat, the way Americans typically like it, that I get into trouble.

Incidentally, stay away from the Atkins and other similar high-protein diets if you have gout.

Vegetarian No-No’s

Although being vegetarian will allow a gout sufferer to skirt a lot of trouble areas, there are key vegetarian foods that contain moderate amounts of purines. Foods that fall into this category include legumes (beans, peanuts, lentils, etc.), algae, and fungi such as mushrooms (some of which are sort of okay, and some of which aren’t). If you have gout and insist on eating these foods, eat them in moderate amounts, and try to do so in combination with other things, much as with meat.

It’s commonly said that gout sufferers should also avoid whole grains, cauliflower, spinach, cashews, asparagus, tofu, and certain other vegetarian foods containing moderate amounts of purine. I’ve never found these foods to cause trouble in reasonable amounts, especially when eaten in combination with low-purine foods. I’ve also never had any trouble with yeasts, which are very high in purines but are present in such small quantities, e.g., in breads, that they’re generally not an issue. One kind of vegetarian food I would steer well clear of, though, is mock meat ("mock duck," "mock chicken," etc.), which are typically made from wheat gluten or textured soy protein (TVP). Such foods have as much protein as meat, and don't taste as good.

If you’re ever in doubt about what’s OK and what’s not, there is a document listing the purine content of common foods that’s been circulating around the Internet for several years now. I keep a printed copy by my desk. To find it for yourself, just search for "purine boletus mushroom." Google it.

Incidentally, although I'm basically vegetarian, I'm not necessarily advocating that everyone else become vegetarian as well. Vegetarianism alone will not cure gout, and will only lower your uric acid levels a little. Also, there are a lot of important substances that come primarily, or only, from animal sources (such as vitamin B12). What I'm advocating people do is reduce meat consumption, buffer it with other foods, and steer clear of the main gout triggers. For those who want to become vegetarian, my advice would be to ease into it—and do it temporarily (e.g., for a few years), unless you're a real health scholar and are willing to learn how to compensate for what is, after all, a somewhat unnatural diet. If you look around the world, you'll find that even people who ideologically ought to be vegetarian (e.g., Hindus, Buddhists, etc.) generally aren't, and they find various excuses (e.g., "fish doesn't count as meat" or "I didn't kill the chicken, so it's okay") for being the omnivores that our physiology seems to want us to be. If you go the vegetarian route, therefore, talk with a dietitian or other knowledgeable professional, or find a good book and learn what you have to do.

One of the challenges all gout sufferers face, whether they go vegetarian or not, is getting enough protein on a gout-friendly diet. I get protein from egg whites, dairy products, whole grains, some legumes, and a bite of meat now and then. Also, it's important not to underestimate the challenges of getting any low-protein diet past friends and relatives. People with teenagers are likely to get a dim, self-centered response. One's spouse may balk at having to eat meals where meat isn't the main focus, or at always having to make sure there's something (in addition to the meat) that's acceptable to someone who's purine-averse. All you can do in this case is educate people slowly, and accommodate. I often cook meat for everyone, then eat only the side dish. And I try to make sure anybody who invites me to dinner knows I don't eat meat, right up front.

Word to the wise: Vegetarian men like me who hail originally from small, gun-toting, god-fearing Republican towns, should take particular care to stay in good physical shape, so that anyone inclined to make fun of their new "fruity" lifestyle will look kind of stupid.

Other Suspect Substances

There are also a number of substances that, although they don’t contain purines themselves, either promote purine production or suppress its proper excretion. The list of these substances is seemingly endless, and subject to much debate. Here are some common ones everyone seems to agree on:

  • alcohol
  • niacin
  • aspirin
  • spicy food
  • sugar, esp. high-fructose corn syrup

There are many articles in the medical literature about these and other substances. Try searching PubMed. Happy reading!

As for me, I’ve never had a problem with small amounts of alcohol. But then all I generally drink is a single beer at a party, or a glass of homemade cider or mead at home in the evenings. So I’m probably not the right person to ask. I've also never had problems with caffeine, which used to be considered a gout trigger (which makes sense, seeing as caffeine is actually a purine). Recent research has not only cast doubt on that notion, but shown that coffee, in particular, can reduce uric acid levels in the blood. As for niacin, I don't take vitamins, so I can't speak from personal experience.

I have had issues with aspirin. And because aspirin doesn’t seem to help me much with gout pain, my own advice is to go with ibuprofen instead.

I love hot, spicy food, and have never seen any personal correlation between eating it and having trouble with gout. The old wisdom, though, was that it was like alcohol. Too much could trigger an attack. There is some research to back this up now, so just be careful. As the geeks say: YMMV (your mileage may vary).

I’ve also never had problems with cake or candy, as long as I eat only a little and after a meal of "real" food. Soda pop, or "pop," as we call it in the Midwest, is a particular bugaboo because it typically contains high-fructose corn syrup, a particularly insidious form of sugar—and it’s often consumed on an empty stomach. I tend not to drink pop, partly because of this and partly because it’s so over-advertised. By abstaining I feel like I’m defying "the man" (i.e., other pudgy middle aged guys like me, but with nicer suits, expense accounts, and advertising budgets).

Part of what's going on here may be that the pH of sweet drinks like Coke and Pepsi is quite low, meaning that they're very acidic. I'd guess this would make it harder for the body to neutralize uric acids that result from purine metabolism. I'm not a biochemist, though, and frankly neither are most physicians (or others, like me, who often go on without knowing what they're talking about). So I can't say for sure whether the acidity of pop makes a difference. What I can say for sure is that recent research has confirmed that people who drink more than one sweet drink a day are at a significantly increased risk of gout. So just stay away from the stuff if you have gout, unless you're stuck drinking it at a party or something. Stick it to the man.

If you can't live without sweet, bubbly drinks, try a quarter teaspoon of baking soda in a glass of really good orange juice. The baking soda will neutralize some of the orange juice's acids and will carbonate the drink in a fun way. But don't go overboard with the baking soda. It contains lots of sodium. On the other hand, it may also neutralize some of the acid that's exacerbating your gout. Try it and see.

One other substance I want to mention is egg yolk. I found that when I ate a lot of egg yolks (five eggs between my son and me for breakfast every day), I was subject to a lot of mild attacks. Other gout sufferers don't report issues with yolks, so this may just be me. If you suffer from gout, and notice issues when you eat a lot of yolks, throw out most of the yolk and eat mainly egg whites. You can call this a resource waste, but it's a far greater waste to have you in bed with a gout attack taking expensive meds. And you need the protein.

Fresh and Wholesome Foods

Here’s where my friends and most of my family think I get a bit radical. You be the judge.

To me part of the trick to remaining gout free involves maintaining overall health, particularly digestive health.

In practical terms, this means eating a lot of fresh foods without preservatives. It also means eating foods containing "good bugs," i.e., foods like kefir, yogurt with live active cultures, homemade ciders and meads, cheese, kimchi, pickles, and sauerkraut (i.e., real, fermented pickles and sauerkraut, not the industrial kinds you normally buy in the store). Most of what I know about foods like these I learned either from my son, or from a book called Wild Fermentations, which I recommend.

Eating kefir, yogurt, and cheese may, simply by virtue of their being dairy products, mitigate gout risk. They also tend to be less acidic than other foods.

Something I’ve learned to do over time is look at the labels on foods I buy. If the ingredient list contains sodium benzoate, I generally don’t buy it. If I see potassium metabisulfite, I generally don’t buy it. If I see aspartame, I generally don’t buy it. Also somewhat disturbing is the catch-all ingredient artificial flavors. More disturbing still is the deceptively innocuous-sounding natural flavors, which covers a huge range of substances, not all of which you'd think of as "natural" (e.g., MSG). It’s amazing how much of the food we eat contains additives like these, and it can be disorienting at first to learn to cook with less of them.

I tend to frequent the local grocer's organic/whole food aisles.

I also go to organic or health food stores, but when I do that I see a certain grim humor in how they're set up. Health food stores contain mainly boxed, bagged, canned, jarred, or other processed food (plus a lot of pills and herbs). Go to a health food store some time and count the number of aisles devoted to processed vs. fresh foods and you’ll see what I mean. In reality, most health food stores would be more aptly described as premium food stores. And, ironically, the stuff they sell is mainly made by subsidiaries of the big food conglomerates their patrons so often complain about (e.g., General Mills, which owns Cascadian Farms and Muir Glen; ConAgra, which owns Healthy Choice; and so on). Again, YMMV.

Eating Out

The situation with restaurants is even worse. At a restaurant, food, no matter how pure they claim it is, nearly always has, in addition to sugar, bad fat, meat, and other gout no-no’s, plus lots of processed chemicals that don’t promote digestive health. Croutons, sauces, dressings, oils, etc. are particularly bad this way. Soups are bad not only because of this, but because—even if they’re made from scratch—they tend to have a meat or hydrolyzed vegetable protein base, neither of which is very good for a gout sufferer.

When I eat out I like places that serve lots of vegetables that are seasoned and cooked skillfully. Most Americans can’t cook a vegetable to save their lives. Thai and Indian restaurants, if authentic and not too westernized, are great places to start. Sub or sandwich places will almost always have vegetarian options, too, but go easy on the chemical-laden oils and dressings, and stick with plain white breads. In a pinch even a typical fat-ass American steak or rib joint will have a side vegetable, potato, appetizer, or salad that the hapless gout sufferer can live with until they’re able to get home and get something healthy. Again, though, watch the sauces and dressings.

Resources

The first and most obvious resource is one's family physician, who most likely will smirk (outwardly or inwardly) when a patient says he or she wants to try control gout naturally. Unfortunately there's a good reason for the smirk. Physicians know that most folks who set out to make deep changes to their lifestyle don't follow through and that ultimately what they need is a pill. Still, if you suffer from gout and your physician isn't helping you, or listening, then find another. My experience is that smart, middle-aged women with a wry sense of humor tend to be the best people to work with. All too often, medical professionals in the United States, typically men, don't see us whole people. (Sorry, guys, but it's your own fault. Get therapy. I've written about you elsewhere. My apologies go out, too, to all the excellent physicians to whom my comments do not apply.)

Some other really cool resources you should take a look at include:

Help me expand this list!

Conclusion

Whether or not you accept my thoughts about digestive health, spicy food, vegetarianism, or weight loss, the bottom line is that if you have gout, you need to make some serious changes to your life. Some of these changes will be forced on you, but some of them you can and should control.

If you’re not ready for those changes, that’s okay. But as you sit awake at night feeling sad about your aching joints, or worrying about whether you’ll be able to put your shoes on the next day, you’ll eventually reach a point where ribs and cheeseburgers don’t seem worth it. At that point, remember what I’ve said. See if you’re ready. Talk with your family. Talk with a sympathetic medical professional. See if they can commit to helping you, too.

Above all, though, don't feel sorry for yourself. The hand of fate deals far worse to people. If you are religious, think of this as a battle God has constructed for you, where your main opponent is yourself. Or think of it as a challenge you chose before you entered this life. Or think of it practically, as an opportunity to improve your diet and lifestyle. Even if, in the end, you find you have to take allopurinol or some other standard gout drug, you'll presumably have made changes to your life that will enable you to live better and longer than you would have otherwise.

However you think of it, though, don't get down on yourself. You're alive. You look forward to some things. You dread others. You still have the power to change your life, in big and/or little, ways.

And by the way, if you do embrace anything I’ve said here, or if you disagree and want to put in your own two cents worth, drop me a line. I’d like to know if I’ve made a difference for anyone one way or the other.