The prevalence of gout has been steadily increasing, more than doubling between the 1960s and 1990s, so it is currently estimated to affect over eight million American adults (16). This painful inflammatory arthritis inflicts acute discomfort and significantly impacts the long-term joint health and overall quality of life of those afflicted. Addressing this condition requires a comprehensive understanding of its causes, risk factors, and the interconnected factors contributing to its development. In this article, we explore the multifaceted nature of gout and how functional medicine plays a role in successfully treating it.
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What Is Gout?
Gout is a type of inflammatory arthritis that develops due to the accumulation of uric acid crystals in the joints. Uric acid is a normal waste product that forms when the body breaks down purines, substances found in certain foods and produced by the body. Under normal circumstances, uric acid dissolves in the blood and is excreted through the kidneys. However, in people with gout, the body either produces too much uric acid or has difficulty eliminating it, leading to elevated uric acid levels in the blood. When the concentration of uric acid becomes too high, it can form crystals that settle in the joints, particularly in smaller joints of the extremities, such as the big toe, ankle, or knee. These crystals trigger an inflammatory response by the immune system, causing intense pain, swelling, redness, and warmth in the affected joint. (2, 19)
Gout Signs and Symptoms
Gout progresses through four clinically distinct stages (2):
- Asymptomatic Hyperuricemia: The patient is asymptomatic, but serum uric acid levels are greater than 7 mg/dL
- Acute Gout: The patient experiences a single gout attack, most commonly affecting the big toe. The episode is followed by symptom resolution.
- Recurrent Gouty Arthritis: Acute attacks involve more joints and become more frequent
- Chronic Tophaceous Gout: Characterized by the formation of tophi (deposits of urate crystals in the joint) that cause constant pain and marked limitation in joint range of motion
The big toe is the most commonly affected joint by gout, but it can also affect other joints, such as the ankle, knee, wrist, and finger joints. These are the key signs and symptoms of a gout attack (10):
- Sudden pain, described as severe, sharp, and throbbing
- Swelling and inflammation of the affected joint
- Limited range of motion of the affected joint
- The skin over the affected joint may appear shiny and stretched due to swelling
- Low-grade fever
During a gout flare, symptoms typically last several days to a week. After the attack resolves, the joint may return to normal; however, gout attacks can become more frequent when left untreated, leading to joint damage and degeneration. (7)
What Are the Possible Causes of Gout?
Hyperuricemia, elevations of uric acid in the blood, arises due to imbalances in the metabolic processes involving purines and uric acid. Various factors can lead to overproduction or underexcretion of uric acid.
Diet
Uric acid is a metabolic breakdown product of purines, molecules consisting of carbon and nitrogen that are found both inside the human body and in the foods we eat. Consuming foods that are high in purines can increase the production of uric acid in the body. Purines are naturally occurring compounds in certain foods, such as red meat, organ meats (like liver and kidney), seafood (particularly shellfish), and some types of beans. Eating these foods in excess can lead to higher uric acid levels. (7)
Alcohol, especially beer and spirits, can contribute to hyperuricemia by increasing uric acid production and reducing excretion. Additionally, dehydration can lead to higher uric acid concentrations in the blood, increasing the risk of crystal formation. (7)
Genetics
Gout tends to run in families, suggesting a genetic predisposition. Some people are genetically more prone to developing hyperuricemia and gout due to differences in how their bodies produce and eliminate uric acid (9). The C677T polymorphism of the MTHFR gene is a risk factor for hyperuricemia and can contribute to imbalances in inflammation that exacerbate gout flares (19).
Medical Conditions
Gout is considered a metabolic disease because it involves disturbances in the body's metabolic processes related to purines and uric acid. Gout also often coexists with other metabolic conditions like obesity, hypertension, and diabetes. These conditions are linked to disturbances in insulin sensitivity, glucose metabolism, and lipid metabolism. Metabolic syndrome and insulin resistance contribute to the development of gout by decreasing uric acid excretion. (7, 10)
Some medications, particularly diuretics used to treat conditions like high blood pressure and heart failure, can interfere with the excretion of uric acid, leading to higher levels in the blood. (10)
Functional Medicine Labs to Test for Root Cause of Gout
When managing patients with gout, it is essential to consider ordering specific functional medicine labs to gain a comprehensive understanding of their metabolic and overall health status.
Uric Acid
An elevated serum uric acid (SUA) level is one of the diagnostic indicators for gouty arthritis, per the American College of Rheumatology's 1977 diagnostic criteria. However, it is important to note that this marker has limited diagnostic value because up to 49% of patients with acute gout will have normal SUA. Therefore, joint aspiration to identify urate crystals in the synovial fluid is the preferred method of diagnosis. (14)
Cardiometabolic Profile
Gout often occurs alongside metabolic conditions like obesity, high blood pressure, abnormal cholesterol levels, and insulin resistance, a constellation of comorbidities called metabolic syndrome. Screening for cardiometabolic issues in gout patients can detect these comorbidities early. This is crucial because gout patients are at a higher risk of cardiovascular diseases, like heart attacks and strokes, due to shared risk factors like obesity and hypertension (18). Typical components of a comprehensive cardiometabolic screening include measuring blood pressure, waist circumference, lipid panel, comprehensive metabolic panel (CMP), diabetes panel, hs-CRP, and thyroid panel.
Heavy Metals
Mercury exposure is associated with hypertension and kidney dysfunction. A secondary type of gout, saturnine gout, can result from lead toxicity. A heavy metals panel screens for recent exposure to and measures the body's total burden of these heavy metals.
Comprehensive Stool Analysis
Dysbiotic changes from the normal diversity and abundance of the gut microbiota negatively impact purine and uric acid metabolism, resulting in increased SUA (20). A comprehensive stool test analyzes the intestinal microbiome and helps uncover dysbiosis as a root cause for increased uric acid production.
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Conventional Treatment for Gout
The goals of gout treatment include alleviating acute pain and inflammation during acute gout attacks and long-term prevention of future attacks by lowering SUA levels. To achieve these goals, standard treatment algorithms rely on dietary modifications (discussed below), nonsteroidal anti-inflammatories, corticosteroids, colchicine, and urate-lowering medications. (11)
Integrative Medicine Protocol for Gout
An integrative medicine protocol for gout combines conventional short-term interventions for acute symptomatic relief with complementary therapeutic modalities that function to correct underlying metabolic imbalances causing hyperuricemia for improved long-term flare prevention and joint preservation.
Therapeutic Diet for Gout
A low-purine alkaline-ash diet is often recommended for individuals with gout as part of their treatment plan. This diet serves a dual purpose: reducing purine intake and fostering an alkaline internal environment.
The low-purine aspect focuses on minimizing the consumption of foods containing purines, predominantly high-protein sources like red meat, organ meats, seafood, and some legumes. When purines are metabolized, they are converted into uric acid. Hence, a low-purine diet restricts these purine-rich foods to curb uric acid production. (12)
While some forms of alcohol are lower in purines than others, all alcohol consumption raises uric acid levels (12). Similarly, fructose metabolism results in purine byproducts and elevations in SUA. Therefore, all alcohol and fructose-sweetened food products should be eliminated from the diet.
The alkaline-ash component revolves around the notion that certain foods can impact the body's pH, promoting acidity or alkalinity. Advocates of this diet propose that creating an alkaline internal environment can increase uric acid solubility and deter the crystallization in the joints. Foods typically considered alkaline-promoting include fruits, vegetables, nuts, seeds, and legumes. (13)
The effectiveness of this diet also lies in its ability to promote overall health by encouraging the consumption of nutrient-rich fruits and vegetables, potentially mitigating inflammation and other chronic conditions linked to gout, such as cardiovascular disease. (20)
Best Supplements for Managing Gout
Integrative protocols for treating gout commonly involve using dietary and herbal supplements to complement traditional medical approaches. Individuals with gout often explore these supplements to reduce symptoms, manage inflammation, and support overall joint health in conjunction with medical guidance.
Vitamin C
Vitamin C, or ascorbic acid, has been researched for its potential role in gout management. Studies indicate that it may be beneficial for reducing uric acid levels in the blood by improving uric acid solubility and excretion and increasing kidney filtration. (6)
Dose: 200-2,000 mg daily
Duration: 2 weeks-6 months
Fish Oil
Omega-3 fatty acids EPA and DHA, concentrated in fish oil, limit the production of leukotrienes, chemical mediators that contribute to inflammatory processes. A large cohort study found that consuming omega-3-rich fish was significantly associated with a lower risk of recurrent gout attacks.
Dose: 3,000 mg combined EPA & DHA daily
Duration: 1-6 months
Cherry Fruit Extract
Cherry fruit extract, often derived from tart cherries, is gaining attention as a natural remedy for managing gout. It is believed to be beneficial due to its rich anthocyanin content, which has antioxidant and anti-inflammatory properties. This extract may help reduce inflammation, lower uric acid levels in the blood, and prevent gout flare-ups, making it an excellent natural treatment option for gout. (17)
Dose: 500-1,000 mg three times daily
Duration: at least one month
When To Retest Labs
In addition to monitoring the frequency and severity of gout attacks, repeating labs within 3-6 months of initiating a treatment protocol can help monitor the protocol's efficacy and guide modifications based on the patient's response.
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Summary
Adopting an integrative and functional medicine approach to treating gout holds significant promise in improving the lives of individuals suffering from this painful and debilitating condition. By recognizing the complex interplay of metabolic factors, dietary choices, lifestyle, and genetic predisposition, healthcare practitioners can offer a more holistic and personalized approach to gout management. This approach includes dietary modifications, natural supplementation, stress reduction, and exercise, all tailored to each patient's unique needs. By addressing the root causes of elevated uric acid levels and inflammation, such an approach not only alleviates gout symptoms but also promotes long-term joint health and overall well-being.
The prevalence of gout has been steadily increasing, more than doubling between the 1960s and 1990s, so it is currently estimated to affect over eight million American adults (16). This painful inflammatory arthritis can cause significant discomfort and may impact long-term joint health and overall quality of life. Addressing this condition requires a comprehensive understanding of its causes, risk factors, and the interconnected factors contributing to its development. In this article, we explore the multifaceted nature of gout and how functional medicine may play a role in managing it.
[signup]
What Is Gout?
Gout is a type of inflammatory arthritis that develops due to the accumulation of uric acid crystals in the joints. Uric acid is a normal waste product that forms when the body breaks down purines, substances found in certain foods and produced by the body. Under normal circumstances, uric acid dissolves in the blood and is excreted through the kidneys. However, in people with gout, the body either produces too much uric acid or has difficulty eliminating it, leading to elevated uric acid levels in the blood. When the concentration of uric acid becomes too high, it can form crystals that settle in the joints, particularly in smaller joints of the extremities, such as the big toe, ankle, or knee. These crystals may trigger an inflammatory response by the immune system, causing intense pain, swelling, redness, and warmth in the affected joint. (2, 19)
Gout Signs and Symptoms
Gout progresses through four clinically distinct stages (2):
- Asymptomatic Hyperuricemia: The patient is asymptomatic, but serum uric acid levels are greater than 7 mg/dL
- Acute Gout: The patient experiences a single gout attack, most commonly affecting the big toe. The episode is followed by symptom resolution.
- Recurrent Gouty Arthritis: Acute attacks involve more joints and become more frequent
- Chronic Tophaceous Gout: Characterized by the formation of tophi (deposits of urate crystals in the joint) that may cause constant pain and marked limitation in joint range of motion
The big toe is the most commonly affected joint by gout, but it can also affect other joints, such as the ankle, knee, wrist, and finger joints. These are the key signs and symptoms of a gout attack (10):
- Sudden pain, described as severe, sharp, and throbbing
- Swelling and inflammation of the affected joint
- Limited range of motion of the affected joint
- The skin over the affected joint may appear shiny and stretched due to swelling
- Low-grade fever
During a gout flare, symptoms typically last several days to a week. After the attack resolves, the joint may return to normal; however, gout attacks can become more frequent when left unaddressed, potentially leading to joint damage and degeneration. (7)
What Are the Possible Causes of Gout?
Hyperuricemia, elevations of uric acid in the blood, arises due to imbalances in the metabolic processes involving purines and uric acid. Various factors can lead to overproduction or underexcretion of uric acid.
Diet
Uric acid is a metabolic breakdown product of purines, molecules consisting of carbon and nitrogen that are found both inside the human body and in the foods we eat. Consuming foods that are high in purines can increase the production of uric acid in the body. Purines are naturally occurring compounds in certain foods, such as red meat, organ meats (like liver and kidney), seafood (particularly shellfish), and some types of beans. Eating these foods in excess can lead to higher uric acid levels. (7)
Alcohol, especially beer and spirits, may contribute to hyperuricemia by increasing uric acid production and reducing excretion. Additionally, dehydration can lead to higher uric acid concentrations in the blood, increasing the risk of crystal formation. (7)
Genetics
Gout tends to run in families, suggesting a genetic predisposition. Some people are genetically more prone to developing hyperuricemia and gout due to differences in how their bodies produce and eliminate uric acid (9). The C677T polymorphism of the MTHFR gene is a risk factor for hyperuricemia and may contribute to imbalances in inflammation that exacerbate gout flares (19).
Medical Conditions
Gout is considered a metabolic disease because it involves disturbances in the body's metabolic processes related to purines and uric acid. Gout also often coexists with other metabolic conditions like obesity, hypertension, and diabetes. These conditions are linked to disturbances in insulin sensitivity, glucose metabolism, and lipid metabolism. Metabolic syndrome and insulin resistance may contribute to the development of gout by decreasing uric acid excretion. (7, 10)
Some medications, particularly diuretics used to manage conditions like high blood pressure and heart failure, can interfere with the excretion of uric acid, leading to higher levels in the blood. (10)
Functional Medicine Labs to Test for Root Cause of Gout
When managing patients with gout, it is essential to consider ordering specific functional medicine labs to gain a comprehensive understanding of their metabolic and overall health status.
Uric Acid
An elevated serum uric acid (SUA) level is one of the diagnostic indicators for gouty arthritis, per the American College of Rheumatology's 1977 diagnostic criteria. However, it is important to note that this marker has limited diagnostic value because up to 49% of patients with acute gout will have normal SUA. Therefore, joint aspiration to identify urate crystals in the synovial fluid is the preferred method of diagnosis. (14)
Cardiometabolic Profile
Gout often occurs alongside metabolic conditions like obesity, high blood pressure, abnormal cholesterol levels, and insulin resistance, a constellation of comorbidities called metabolic syndrome. Screening for cardiometabolic issues in gout patients can detect these comorbidities early. This is crucial because gout patients may be at a higher risk of cardiovascular diseases, like heart attacks and strokes, due to shared risk factors like obesity and hypertension (18). Typical components of a comprehensive cardiometabolic screening include measuring blood pressure, waist circumference, lipid panel, comprehensive metabolic panel (CMP), diabetes panel, hs-CRP, and thyroid panel.
Heavy Metals
Mercury exposure is associated with hypertension and kidney dysfunction. A secondary type of gout, saturnine gout, can result from lead toxicity. A heavy metals panel screens for recent exposure to and measures the body's total burden of these heavy metals.
Comprehensive Stool Analysis
Dysbiotic changes from the normal diversity and abundance of the gut microbiota may impact purine and uric acid metabolism, resulting in increased SUA (20). A comprehensive stool test analyzes the intestinal microbiome and helps uncover dysbiosis as a potential factor for increased uric acid production.
[signup]
Conventional Treatment for Gout
The goals of gout management include alleviating acute pain and inflammation during acute gout episodes and long-term support for reducing the frequency of future episodes by managing SUA levels. To achieve these goals, standard management strategies may include dietary modifications (discussed below), nonsteroidal anti-inflammatories, corticosteroids, colchicine, and urate-lowering medications. (11)
Integrative Medicine Protocol for Gout
An integrative medicine protocol for gout combines conventional short-term interventions for acute symptomatic relief with complementary therapeutic modalities that may help address underlying metabolic imbalances associated with hyperuricemia for improved long-term support and joint preservation.
Therapeutic Diet for Gout
A low-purine alkaline-ash diet is often considered for individuals with gout as part of their management plan. This diet serves a dual purpose: reducing purine intake and fostering an alkaline internal environment.
The low-purine aspect focuses on minimizing the consumption of foods containing purines, predominantly high-protein sources like red meat, organ meats, seafood, and some legumes. When purines are metabolized, they are converted into uric acid. Hence, a low-purine diet limits these purine-rich foods to help manage uric acid production. (12)
While some forms of alcohol are lower in purines than others, all alcohol consumption may raise uric acid levels (12). Similarly, fructose metabolism results in purine byproducts and elevations in SUA. Therefore, it may be beneficial to limit or avoid alcohol and fructose-sweetened food products.
The alkaline-ash component revolves around the notion that certain foods can impact the body's pH, promoting acidity or alkalinity. Advocates of this diet propose that creating an alkaline internal environment may increase uric acid solubility and deter the crystallization in the joints. Foods typically considered alkaline-promoting include fruits, vegetables, nuts, seeds, and legumes. (13)
The effectiveness of this diet also lies in its ability to promote overall health by encouraging the consumption of nutrient-rich fruits and vegetables, potentially supporting inflammation management and other chronic conditions linked to gout, such as cardiovascular health. (20)
Best Supplements for Managing Gout
Integrative protocols for managing gout commonly involve using dietary and herbal supplements to complement traditional medical approaches. Individuals with gout often explore these supplements to help manage symptoms, support inflammation management, and promote overall joint health in conjunction with medical guidance.
Vitamin C
Vitamin C, or ascorbic acid, has been researched for its potential role in gout management. Studies indicate that it may be beneficial for supporting uric acid management in the blood by improving uric acid solubility and excretion and increasing kidney filtration. (6)
Dose: 200-2,000 mg daily
Duration: 2 weeks-6 months
Fish Oil
Omega-3 fatty acids EPA and DHA, concentrated in fish oil, may help limit the production of leukotrienes, chemical mediators that contribute to inflammatory processes. A large cohort study found that consuming omega-3-rich fish was significantly associated with a lower risk of recurrent gout episodes.
Dose: 3,000 mg combined EPA & DHA daily
Duration: 1-6 months
Cherry Fruit Extract
Cherry fruit extract, often derived from tart cherries, is gaining attention as a natural option for managing gout. It is believed to be beneficial due to its rich anthocyanin content, which has antioxidant and anti-inflammatory properties. This extract may help support inflammation management, promote healthy uric acid levels in the blood, and support joint health. (17)
Dose: 500-1,000 mg three times daily
Duration: at least one month
When To Retest Labs
In addition to monitoring the frequency and severity of gout episodes, repeating labs within 3-6 months of initiating a management protocol can help monitor the protocol's efficacy and guide modifications based on the patient's response.
[signup]
Summary
Adopting an integrative and functional medicine approach to managing gout holds significant promise in supporting the well-being of individuals experiencing this painful condition. By recognizing the complex interplay of metabolic factors, dietary choices, lifestyle, and genetic predisposition, healthcare practitioners can offer a more holistic and personalized approach to gout management. This approach may include dietary modifications, natural supplementation, stress reduction, and exercise, all tailored to each patient's unique needs. By addressing the factors associated with elevated uric acid levels and inflammation, such an approach not only supports gout management but also promotes long-term joint health and overall well-being.
1. Calder, P. C. (2013). Omega-3 polyunsaturated fatty acids and inflammatory processes: nutrition or pharmacology? British Journal of Clinical Pharmacology, 75(3), 645–662. https://doi.org/10.1111/j.1365-2125.2012.04374.x
2. Cloyd, J. (2022, August 17). An Integrative Medicine Approach to Rheumatology. Rupa Health. https://www.rupahealth.com/post/6-common-types-of-arthritis
3. Cloyd, J. (2023, April 10). A Functional Medicine Hypertension Protocol. Rupa Health. https://www.rupahealth.com/post/functional-medicine-hypertension-protocol
4. Coburn, B. W., & Mikuls, T. R. (2016). Treatment Options for Acute Gout. Federal Practitioner, 33(1), 35–40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366613/
5. Collins, S. (2013, December 11). Alkaline Diets. WebMD. https://www.webmd.com/diet/a-z/alkaline-diets
6. Dan, L. (2022, March 31). What is Gout?: Top Natural Strategies for Preventing Gout Attacks. Fullscript. https://fullscript.com/blog/gout
7. Fenando, A., & Widrich, J. (2022). Gout. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK546606/
8. Fructose and Gout: What's the Link? (2016, February 15). Arthritis Foundation. http://blog.arthritis.org/gout/fructose-sugar-gout/
9. Gout. MedlinePlus. https://medlineplus.gov/genetics/condition/gout/#causes
10. Gout. (2019). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897
11. Hainer, B. L., Matheson, E., & Wilkes, R. T. (2014). Diagnosis, Treatment, and Prevention of Gout. American Family Physician, 90(12), 831–836. https://www.aafp.org/pubs/afp/issues/2014/1215/p831.html
12. Harris, S. (2018, July 26). Foods to eat and avoid on a low-purine diet. Medical News Today. https://www.medicalnewstoday.com/articles/322590#overview
13. Kanbara, A., Miura, Y., Hyogo, H., et al. (2012). Effect of urine pH changed by dietary intervention on uric acid clearance mechanism of pH-dependent excretion of urinary uric acid. Nutrition Journal, 11(1). https://doi.org/10.1186/1475-2891-11-39
14. Leiszler, M., Poddar, S., & Fletcher, A. (2011). Are serum uric acid levels always elevated in acute gout? https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/6010JFP_ClinInq1.pdf
15. Poór, G., & Mituszova, M. (1989). Saturnine gout. Baillière's Clinical Rheumatology, 3(1), 51–61. https://doi.org/10.1016/s0950-3579(89)80035-4
16. Quick Facts: Gout and Chronic Kidney Disease. (2018, January 10). National Kidney Foundation. https://www.kidney.org/atoz/content/gout/patient-facts
17. Rath, L. (2022, December 14). Cherries May Help Gout Symptoms. Arthritis Foundation. https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/are-cherries-cure-for-gout
18. Saito, Y., Tanaka, A., Node, K., et al. (2021). Uric acid and cardiovascular disease: A clinical review. Journal of Cardiology, 78(1), 51–57. https://doi.org/10.1016/j.jjcc.2020.12.013
19. Weinberg, J. L. (2022, July 20). 7 Natural Treatments For Gout That You Can Start Today. Rupa Health. https://www.rupahealth.com/post/natural-treatments-for-gout
20. Yoshimura, H. (2023, May 26). Integrative Approaches to the Treatment of Gout: A Comprehensive Review. Rupa Health. https://www.rupahealth.com/post/integrative-approaches-to-the-treatment-of-gout-a-comprehensive-review
21. Zhang, M., Zhang, Y., Terkeltaub, R., et al. (2019). Effect of Dietary and Supplemental Omega‐3 Polyunsaturated Fatty Acids on Risk of Recurrent Gout Flares. Arthritis & Rheumatology, 71(9), 1580–1586. https://doi.org/10.1002/art.40896
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