Rheumatology 2004;43:1054
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Heberden Historical Series/Series Editor: M. I. V. Jayson
A (very) short history of diets for gout
M. Snaith
Gout has been a relatively well-dened condition for centuries,
throughout which diet has featured in its treatment. In this context,
it is rather difcult to distinguish diet from medication. Medical
opinion, admixed with clinical observation and anecdotes, has
reected contemporary health beliefs up to and including modern
times (Fig. 1). For example, the Hippocratic school recommended
barley water, for which I can think of no particular virtue. How-
ever, white hellebore was also suggested. This may be because it
bears some of the characteristics of colchicum, to which it is related.
However, it may also have been because, by producing diarrhoea, it
equated with therapeutic gastrointestinal purging. Dehydration
and ketosis would have worsened hyperuricaemia, but dysentery
was said to be benecial for gout. To Hippocratic purging, Galen
added venesection and spring sea voyages, perhaps for some
therapeutic vomiting. Colchicine, discovered by the ancient Greek
and Islamic physicians, fell out of favour in the 18th century, with
the Sydenham-inspired abandonment of purging. When colchicine
was reintroduced, it was as much a treatment for dropsy as for gout.
Anecdotal observation, deductive reasoning and the power of
placebo all conspired in the development of medical treatments for
gout as much as other conditions.
Hippocrates, Sydenham and Galen advocated barley water and
barley bread for gout. Is there something undiscovered here? Their
health beliefs may have been misplaced by modern standards, but
Sydenham also urged that exercise should be taken and food and
drink moderated. He considered gout to be the product of humours
that had accumulated because of gluttony. The difference between
then and now is the social prole of gout. From Lord Stanhope
(gout is the distemper of a gentlemanwhereas the rheumatism
FIG. 1. Gout as a sociological stereotype in former times (with
acknowledgement to the Arthritis Research Campaign).
Shefeld Medical School, Division of Genomic Medicine, Shefeld, UK. E-mail: michael@mikesnaith.demon.co.uk
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doi:10.
is the distemper of a hackney coachman) to Ambrose Bearse in
his Devils Dictionary (Gout nA physicians name for the
rheumatism of a rich patient), gout was synonymous with wealth
and greed. The 20th century saw an end to that. The increase in
gout among South Pacic islanders when they became exposed to
Westernization is one of the best examples of the interaction of diet
and metabolic genetics.
The mid-20th century saw a rapid expansion in the understand-
ing of nucleic acid chemistry, including purine metabolism. A strict
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low-purine diet can lower plasma urate by around 20%. However,
the development of uricosuric drugs, then of xanthine oxidase
inhibition, encouraged enthusiasm for a pharmacological magic
bullet, and dietary advice was dropped from most standard medical
texts and practice. Now that the relatively health-conscious western
middle classes may be belatedly endeavouring to reverse the trends
towards ever more atherosclerosis, the less well-educated, wealthy
or motivated are certainly not. Contributors to internet chat rooms
on dietary treatments for their gout favour Montmorency cherries
and celery seeds over colchicine and allopurinol.
The sociological, dietary, metabolic and genetic aspects of
gout are now coming together with the recognition of the critical
role of insulin resistance in linking vascular disease, diabetes
and urate retention. A drug such as fenobrate is found to
have unexpected benets for urate levels; a diet high in protein,
restricted in calories but not specically in purine, is shown to
reduce urate. Rheumatologists should have regard for their gouty
patients cardiovascular status, not just because they are good
physicians but also because it may be good for the management of
gout. Diet is back.
Further Reading
Porter R, Rousseau GS. Gout: the patrician malady. New Haven: Yale
University Press, 1998.
Wyngaarden JB, Kelley WN. Gout and hyperuricaemia. New York:
Grune & Stratton, 1976.
Facchini F, Chen Y-D, Hollenbeck CB, Reaven GM. Relationship
between resistance to insulin-mediated glucose uptake, urinary uric
acid clearance and plasma uric acid concentration. JAMA 1991;266:
300811.
Dessein PH, Shipton EA, Stanwix AE et al. Benecial effects of weight
loss associated with moderate calorie/carbohydrate restriction, and
increased proportional intake of protein and unsaturated fat on serum
urate and lipoprotein levels in gout: a pilot study. Ann Rheum Dis
2000;59:53943.
Fam AG. Gout, diet and the insulin resistance syndrome [editorial].
J Rheumatol 2002;29:13505.
Yamashita S, Matsuzawa Y, Tokunaga K, Fujioka S, Tarui S. Studies on
the impaired metabolism of uric acid in obese subjects: marked reduc-
tion of renal urate excretion and its improvement by a low-calorie
diet. Int J Obesity 1986;10:25564.