Treating the disease of kings with diet

Gout has long been termed the “disease of kings” because hundreds of years ago in Europe, it was the royalty who were primarily impacted by the disease.

I’ve personally seen how gout can impact not just a person’s life but also all of those around them. I have a family member who suffers from it and have seen how he has struggled with the disease for years, much to the dismay of his wife and children. My grandfather also had it, and I remember when I was young how some days he was essentially bed-restricted from the pain.

Now neither my grandfather nor any other family members are royalty (despite how we may sometimes act). But as it turns out, it’s has nothing to do with royalty, but more often than not is commonly found in overweight and obese people who consume rich foods and drink alcohol. Historically only the very wealthy could afford to eat such foods with such frequency which is why the disease has the reputation it does, but today nearly everyone has access to these debilitating foods, and as such, gout now affects nearly 1-2% of the American population at some point in their lives, and as high as 5% of men over the age of 65. This makes it the most common inflammatory arthritis in men and older women.

For some time we’ve know that foods high in purines tend to trigger and set off gout. Purines are a compound found naturally in certain foods that form uric acid. Gout accrues when that uric acid crystalizes in our joint fluid, causing a very painful form of inflammation. As such, when a person suffers from gout they are told to avoid foods that contain a high level of purines.

Seafood and organ meats are among the highest purine-containing foods (chicken and other meats are high on that list as well). However beans are also surprisingly high on that list of foods with purine.

However a study published in the Annals of the Rheumatic Diseases found that the risk for a gout attack increased five times with the consumption of animal protein when compared to those consuming plant-protein.

So then why are beans always excluded from a gout-prescribed diet? Well Brenda Davis, R.D. figured it out. Most lists of purine containing foods, display the amount of purines found in 100 grams of a food. Now 100 grams of beans is roughly half a dry cup, which when cooked is closer to 1.5 cups. The average serving size for a portion of beans is 1/2 cooked cup.

This means that most lists of high-purine foods are measuring triple the recommended serving size for beans. Imagine if we tripled the serving size of chicken? Most beans fall in the moderate range, and have a purine count of  20-75 mg per serving. 

Diets typically suggest avoiding the highest purine foods which have over 200 mg purines per serving or more (these are typically seafoods and organ meats), greatly reducing foods that contain 100 mg purines per serving (this is where white fish, pork, steak and chicken all fall) and eating no more than one portion  per day of moderate foods, or those that have between 50-100 mg per serving (hello beans!). 

The authors of the above study also cited other studies which found that long-term, habitual consumption of purine-rich vegetables was not associated with an increased risk of gout. That means eating beans may not be a bad thing, even for those suffering with gout.

I would be remiss if I didn’t mention that a different study from the EPIC-Oxford group found that vegans actually had the highest levels of blood uric acid compared to vegetarians, fish eaters, and meat eaters, but the authors did not look specifically at gout, and even still they found that the vegans had the lowest scores for other risk markers of gout, including Body Mass Index. They attributed the high level of uric acid to consumption of soy protein, and a lack of dairy, which may have some benefits for uric acid - although it could have many other serious health risks (see: here, here, here, here, here).

At first this paper seems contradictory from what we normally know. However, this is in fact, one of those papers where they actually over adjust, skewing the end result. They adjusted for BMI, which is the problem. It's problematic because we know that meat consumption leads to weight gain (In fact, according to one EPIC study, chicken is the biggest offender!) Weight gain tends to go hand and hand with higher levels of uric acid, which is why overweight and obese people have much higher incidence rates of gout, so when they adjust the studies statistics, they take the majority of meat eaters out, in favor for the minority whose bodies seem more adapt at processing heavy animal products. Also exercise was not added into the equation, and it remains possible that some of the patients included in the study switched to a vegetarian or vegan diet after they first got gout.

Finally, there may be one fruit that seems uniquely helpful when dealing with this painful disease. The same research team that published on animals vs plants proteins, uric acid, and gout incidence, published a second paper that same year which found that cherries seem to be a particularly protective when trying to control gout. But unlike the EPIC-OXFORD research, this one specifically examined patients suffering from gout.

They studied 633 individuals who were suffering from gout, and found they had a 35% decreased occurrence rate of gout when consuming just 1/2 cup of cherries per day - they did not change anything else (including any medications they were taking) - but simply ate cherries. The other fruits they tested did not have the same benefits.

When patients who were taking medications to help control their attacks added cherries, the researchers saw even greater benefits, reducing attack occurrences by 75% compared to an untreated control. 

Another paper found that fresh, frozen, and even cherry juice all worked well. As little as 1 tablespoon of concentrated cherry juice per day could decrease the flare ups. The cherry juice decreased flare up occurrences by as much as 50%, and nearly 50% of all the patients in the study were able to stop taking their medication for the crippling disease. 

So if you suffer from the disease of kings, you may be able to greatly reduce or completely stop your flare ups by simply making some small changes in your diet, namely minimizing or eliminating alcohol and meats, while increasing your consumption of fruits and veggies (potentially beans as well) and especially by adding cherries (in almost any form - although I haven't been able to track down a study showing the benefits of cherry pies yet!). While all the studies recommended more research be done on treating gout with diet, the only know side effects of eating cherries or even adopting a plant-based diet is better health. 

*** 

Schlesinger, N. et al. “Previously reported prior studies of cherry juice concentrate for gout flare prophylaxis: comment on the article by Zhang et. al” Journal of Arthritis 2013 April. 

Schmidt, J et al. “Serum Uric Acid Concentrations in Meat Eaters, Fish Eaters, Vegetarians and Vegans: A Cross-Sectional Analysis in the EPIC-Oxford Cohort.” PLoS ONE 8(2): e56339.

Vergnaud, A.C. et. al. “Meat consumption and prospective weight change in participants of the EPIC-PANACEA study” American Journal of Clinical Nutrition. 2010 August 92 (2).

Zhang, Yuging et al. “Cherry consumption and decreased risk of recurrent gout attacks” Journal of Arthritis 2012 64 (12).

Zhang, Yuging et al. “Purine-rich foods intake and recurrent gout attacks” Annuals of Rheumatic Diseases Sept. 2012, 71 (9).

As always the information presented in this blog is for educational purposes only. It should not be considered as specific medical, nutritional, lifestyle, or other health-related advice.

12 Tips for Healthy Weight Loss… with Benefits Beyond the Scale

By Michelle McMacken, M.D.  

(In case you missed it, here is Michelle on the recent RRP)

As an internal medicine physician and director of an obesity program, I am all too familiar with the struggle that many people face when it comes to weight loss. The statistics in my primary care practice mirror the U.S. national numbers: more than 70% of us are overweight or obese.[i] I’ve seen many people attempt to lose weight, become frustrated and disheartened, and turn to supplements, pills, meal replacements, unhealthy fad diets, and surgery. Unfortunately, most of these are short-term solutions without long-term weight-loss benefits (often accompanied by troubling health consequences).

The mechanisms that regulate our body weight are highly complex – neurologic, genetic, hormonal, environmental, social, and even microbiologic factors are at play. But these factors do not necessarily determine our destiny! We have the power to override them with the food and lifestyle choices we make every day.

Here are twelve of my favorite weight-loss tips:

1.   Start “crowding out” animal products, high-fat foods, and processed foods.

Gradually add more whole plant foods to your diet. You can begin with plant foods you already like and build from there. Eat a whole plant food (such as a piece of fruit) or a dish made from whole plants (such as a vegetable or bean soup or a salad) before one of your usual meals, so that you won’t have as much room for the less-healthful foods.

If you are ready to make the full leap to a whole-food, plant-based diet, you will likely see benefits even faster. Consider trying one of the many plant-based/vegan “kickstart” programs available online or in print.

2.   Focus on the positive—the nutrient-dense, high-fiber foods you are adding to your diet—instead of what you are taking away.

Enjoy experiencing new flavors (this is what I call “taste-bud rehab”), rather than focusing your mental energy on the unhealthy foods you are trying to remove from your diet.

3.   Choose the right kind of carbs!

Avoid processed carbs, such as white bread, white rice, and white pastas, even if they are vegan/plant-based. Stick to whole plant foods in their most natural form—brown or wild rice, quinoa, barley, oats, sweet potatoes, beans, lentils, and of course, an abundance of colorful vegetables and fruits.

4.   Remember that oil is a processed food.

Oil is very dense in calories, so it can easily sabotage your weight-loss efforts. Oil-based salad dressings, for example, dramatically increase the calories in a salad.

5.   Avoid liquid calories.

Don’t drink your calories, especially in the form of sports drinks, sodas, other sweetened beverages, and alcohol. The calories in these drinks add up fast and don’t fill you up. And for weight loss, in my experience, eating whole fruit trumps drinking fruit juice. Water is the only beverage we actually need.

6.   Have conversations with your family and/or close friends.

Talk to the people you live with about how they can best support your weight-loss efforts. Many of us have cravings for certain junk foods and/or sugary desserts, and when these items are readily available in the kitchen, it’s pretty challenging to resist them. Ideally, family members should be on board with not bringing these foods into your house. In my practice, I encourage my patients to bring their partners and other family members to their appointments with them, so we can talk about behavior changes together.

7.   Track positive behaviors (such as taking a walk at lunch, trying a new vegetable, or avoiding a sugary coffee beverage).

Keep track of the positives, so that you can look back and see the progress you are making. Many of these changes have important health benefits, independent of weight loss. Also, keep in mind that losing just 5% of your body weight can have significant health benefits if you are overweight or obese.

8.   Aim for at least 30 minutes of physical activity most days of the week.

Your daily activity can be as simple as walking. Although dietary changes tend to be more effective than exercise for weight loss, exercise is key to preventing weight regain and has numerous other health benefits.

9.   Eat as mindfully as you can.

Whenever possible, avoid reading or using technology (television, computer, phone, gaming, etc.) while eating. Savor each bite and focus on the experience of tasting your food.

10.  Be aware of your hunger cues.

Rate your hunger on a scale of 1 to 10, where 1 is very full and 10 is extremely hungry. Don’t let yourself get to a 9 or 10. This requires some planning. Eat something when your hunger level reaches 7 or 8, so that you won’t become ravenous later and make a desperate, unhealthy food decision.

11.  Don’t worry if you don’t lose weight right away.

The rate at which people lose weight depends on many factors, including activity level, age, muscle mass, health conditions and medications, and of course caloric intake. I don’t encourage setting goals around the rate of weight loss. Rather, focus on behavior and health goals, such as cooking at home more often, eating more servings of whole plant foods, and increasing physical activity. For most people, this approach will result in safe and sustainable weight loss. I’m not a fan of fasting for weight loss, meal replacement programs, weight-loss pills/supplements, or other practices that are not durable and do not promote long-term health.

12.   What if you are already eating plant-based but not losing weight?

Examine whether you are eating refined carbohydrates and other processed foods on a regular basis. Look out for added oils and sugars in your food. Are you eating out at restaurants and/or getting take-out regularly? These meals tend to be much higher in calories than similar meals prepared at home. Finally, consider reducing portions of calorie-dense foods such as dried fruits, nuts, olives, seeds, and avocados.

So what is the best way to eat for weight loss and overall health?

We’ve known for a long time, from large-scale observational studies, that vegetarians and vegans consistently have lower body mass indexes and significantly lower rates of obesity compared with omnivores.[ii],[iii],[iv],[v],[vi] Research also shows that animal products are linked to weight gain[vii],[viii],[ix],[x],[xi],[xii] and that plant-based diets are effective for weight loss, [xiii],[xiv],[xv],[xvi] without calorie counting or measuring portions. [v],[xv],[xvi] This is likely due in part to the high fiber content, which promotes satiety without excess calories.

Research aside, thousands of personal anecdotal reports and years of clinical experience attest to the fact that people who begin following a whole-food, plant-based diet almost always lose weight, and sometimes dramatically!

Probably the most important benefit of following a plant-based diet for weight loss is that it also decreases the risk of heart disease, high blood pressure, high cholesterol, diabetes, dementia, certain cancers, and even death.[xvii],[xviii] I know of no other “weight-loss diet” that can make such a claim. As a physician, I don’t think we should be separating weight issues from other health risks. I question the wisdom of following a diet (high-protein, low-carb, for example) that might help you lose weight in the short term but increases your chance of having significant health problems later on.

Michelle McMacken, M.D., is a board-certified internal medicine physician and an assistant professor of medicine at NYU School of Medicine.  She practices primary care at Bellevue Hospital Center in New York City, where she also directs a medical weight-loss program.  An enthusiastic supporter of plant-based nutrition, she is committed to educating patients, medical students, and doctors about the power of healthy eating and lifestyle modification. Be sure to connect and follow Dr. McMacken on Twitter.

This article was previously published on Forks Over Knives.

  

Sources:

[i]Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults: United States, 1960–1962 Through 2011–2012. 

[ii] Rizzo NS et al. Nutrient profiles of vegetarian and nonvegetarian dietary patterns. J Acad Nutr Diet 2013 Dec;113(12):1610–9.


[iii] Spencer EA et al. Diet and body mass index in 38 000 EPIC-Oxford meat-eaters, fish-eaters, vegetarians and vegans. Int J Obesity 2003;27:728–734.


[iv] Tonstad S et al. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care 2009 May; 32(5): 791–796.


[v] Berkow SE et al. Vegetarian diets and weight status. Nutr Rev 2006 Apr;64(4):175–88.


[vi] Wang Y et al. Meat consumption is associated with obesity and central obesity among US adults. Int J Obes 2009 Jun;33(6):621–8.


[vii] Vergnaud AC et al. Meat consumption and prospective weight change in participants of the EPIC-PANACEA study. Am J Clin Nutr 2010;92:398–407.


[viii] Rosell M et al. Weight gain over 5 years in 21,966 meat-eating, fish-eating, vegetarian, and vegan men and women in EPIC-Oxford. Int J Obes 2006 Sep;30(9):1389–96.


[ix] Halkjær J et al. Intake of total, animal and plant protein and subsequent changes in weight or waist circumference in European men and women: the Diogenes project. Int J Obes 2011 Aug;35(8):1104–13.


[x] Hernández-Alonso P et al. High dietary protein intake is associated with an increased body weight and total death risk. Clin Nutr 2015 Apr 7. pii: S0261-5614(15)00091–6.


[xi] Vergnaud AC et al. Macronutrient composition of the diet and prospective weight change in participants of the EPIC-PANACEA study. PLoS ONE 2013;8:e57300


[xii] Vang A et al. Meats, processed meats, obesity, weight gain and occurrence of diabetes among adults: findings from Adventist Health Studies. Ann Nutr Metab 2008;52(2):96–104.


[xiii] Turner-McGrievy G et al. A two-year randomized weight loss trial comparing a vegan diet to a more moderate low-fat diet. Obesity 2007 Sep;15(9):2276–81.


[xiv] Turner-McGrievy GM et al. Comparative effectiveness of plant-based diets for weight loss: a randomized controlled trial of five different diets. Nutrition 2015 Feb;31(2):350–8.


[xv] Barnard ND. The effects of a low-fat, plant-based dietary intervention on body weight, metabolism, and insulin sensitivity. Am J Med 2005 Sep;118(9):991–7.


[xvi] Barnard ND et al. A systematic review and meta-analysis of changes in body weight in clinical trials of vegetarian diets. J Acad Nutr Diet 2015 Jun;115(6):954–69.


[xvii] Fraser GE. Vegetarian diets: what do we know of their effects on common chronic diseases? Am J Clin Nutr2009;89(suppl):1607S–12S.


[xviii] Tuso et al. Nutritional update for physicians: plant-based diets. Permanente Journal 2013;17(2):61–5.

As always the information presented in this blog is for educational purposes only. It should not be considered as specific medical, nutritional, lifestyle, or other health-related advice.