Gout and diet: what helps and what to avoid

Gout comes from urate (uric acid) building up in the blood and forming crystals in the joints. Bringing urate below a target level and holding it there is what prevents attacks, and for most people that takes a urate-lowering medicine, such as allopurinol, every day. NICE's guidance is that there is not enough evidence that any particular diet prevents attacks or lowers urate, and recommends a healthy, balanced diet. Most of the body's urate is made by the body itself rather than taken in with food, which is one reason diet can only do so much. So diet plays a supporting part: worth the effort, but no substitute for getting urate to target.

Four changes stand out:

• Bring excess weight down slowly. Excess weight is among the strongest risk factors for gout that you can change: in a large study of men, the risk rose steadily with body mass index, and losing weight was protective. Steer clear of crash diets and fasting, since losing weight fast can trigger an attack.
• Drink less alcohol, beer especially. The risk rises with the amount you drink, and beer carries the most, since it brings purines along with the alcohol; spirits carry less, and moderate wine drinking was not linked to a higher risk. Keep some alcohol-free days each week and stay within 14 units a week.
• Choose drinks without added sugar. People who drink the most sugar-sweetened drinks have about twice the risk of gout, and heavy fruit-juice drinkers a raised risk too. Whole fruit carries no such link, so keep eating it.
• Keep red meat, offal and shellfish for occasional meals. In a large study of men, those who ate the most meat or seafood had a higher risk of gout than those who ate the least.

Some changes are promising rather than proven, and reasonable on general health grounds:

• Dairy foods go with a lower risk: in a large study of men, those who ate the most had a little over half the risk of those who ate the least.
• Coffee is linked to a lower risk, more so at higher intakes, but a link seen in a study is no reason to take up coffee; tea was not linked either way.
• Cherries were linked to fewer attacks in one study. It is an encouraging finding that falls short of proof, so enjoy them alongside your treatment rather than in its place.
• Plenty of fluids, ideally water, help you avoid becoming dehydrated, which can trigger an attack. Vitamin C supplements have been studied, but a recent review found no solid evidence that they help; ask your GP before taking them.

Gout was once managed by avoiding anything rich in purines, but that advice has moved on. Vegetables high in purines, eaten in moderate amounts, show no link with gout in the research. The risk comes from meat and seafood, alcohol and sugar, not from a diet rich in plants. A healthy diet built largely around plants fits well with managing gout, and does you good in other ways too.

The size of the effect is small. In one study of people with high urate, which had no comparison group, two weeks of a low-purine diet lowered it by only about 34 micromol per litre (0.57 mg/dL), and changes to diet alone are often not enough to control gout. If you carry excess weight, losing it is the change that counts most. People with gout are more likely to have high blood pressure, raised cholesterol, diabetes or heart disease, which makes healthy eating worthwhile for reasons beyond the joints. When the aim is to stop attacks, diet works with urate-lowering treatment and cannot take its place.

Most gout attacks can be handled as you have agreed with your doctor. A few signs cannot wait, some of them because infection in a joint can be mistaken for gout, and for those the lists below name the service, the most urgent first.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• A rash that spreads across the body, skin that blisters or peels, or lips, mouth or eyes that turn sore or swollen, since this can be a severe reaction to a medicine, such as Stevens-Johnson syndrome, which needs treating in hospital straight away
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• The first attack in a joint, before gout has been confirmed; a joint worsening faster than your attacks usually do; or severe pain that your usual attack treatment does not control, even without a fever and even if you feel well, since infection can mimic gout and has to be excluded that day: an urgent GP appointment, NHS 111 or a specialist clinic that can see you that day
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day

If you take allopurinol or colchicine, the few side effects that need 999 or A&E, and those that need help that day, are listed in the gout guide, under When to seek help. An attack like the ones you already know can be treated as you have agreed and raised at your next planned appointment. If attacks come more often, book a routine appointment with your GP or rheumatology team so that your treatment can be reconsidered. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. If you cannot tell how urgent something is, asking is never a mistake.

If you already take a urate-lowering medicine, carry on with it exactly as prescribed, with diet in a supporting role. If you do not, and attacks keep returning, raise treatment at a routine appointment with your GP or rheumatology team; and the gout guide describes how the diagnosis is made and how urate-lowering medicines work. Anyone starting one of the newer weight-loss injections should read weight, weight-loss medicines and your joints, which explains why an early flare is worth planning for. Treatment that brings urate to target, with sensible eating and drinking beside it, is what keeps gout under control for good.

Can diet alone keep gout under control?

In most cases, no. Diet lowers urate only modestly, and NICE finds too little evidence that any particular diet prevents attacks or lowers urate. For most people whose attacks keep coming back, a urate-lowering medicine such as allopurinol, taken every day, is what reliably prevents them and protects the joints. Diet is a useful support to it, not a substitute.

Must I avoid every food that contains purines?

No. Advice to cut out purines across the board belongs to the past. Purine-rich vegetables, eaten in moderate amounts, have not been linked to a higher risk of gout. What matters most is meat and seafood, alcohol, beer in particular, and sugary drinks.

Can I still drink alcohol with gout?

The more you drink, the higher the risk of gout climbs. The type of drink matters too: beer carries more risk than spirits, while moderate wine drinking was not linked to a higher risk in a large study of men. Cutting down, especially on beer, keeping some days a week free of alcohol and staying within 14 units a week all help.

Are cherries good for gout?

Possibly. In one study, attacks were less likely in the two days after people with gout ate cherries than at other times, but that shows a link rather than proof, and cherries are not a treatment. Enjoy them if you like them, alongside your prescribed treatment rather than in its place.

Will losing weight get rid of my gout?

It can help a good deal, though it may not be enough by itself. Excess weight is a strong risk factor for gout, and losing it tends to lower urate and make attacks less frequent. Lose it gradually: crash dieting and fasting can bring on an attack in the short term. Keep taking any urate-lowering medicine while you lose weight.