Journal of Human Nutrition and Dietetics

The Official Journal of The British Dietetic Association

Journal of Human Nutrition and Dietetics

RESEARCH PAPER
The role of diet in the management of gout: a comparison
of knowledge and attitudes to current evidence
P. Shulten,* J. Thomas,* M. Miller,* M. Smith  & M. Ahern 
* Department of Nutrition and Dietetics, Flinders University, Adelaide, SA, Australia
  Rheumatology, Flinders Medical Centre and Repatriation General Hospital, Adelaide, SA, Australia

Keywords
aged, diet, disease management, evidence-
based medicine, gout.
Correspondence
Michelle Miller, Department of Nutrition and
Dietetics, Flinders University, GPO Box 2100,
Adelaide, SA 5001, Australia.
Tel.: +61 08 8204 4715
Fax: +61 08 8204 6406
E-mail: michelle.miller@flinders.edu.au
doi:10.1111/j.1365-277X.2008.00928.x
Abstract
Background: Evidence supports dietary modifications in the management of
gout. Despite this, the degree of implementation of this evidence by nutrition
professionals and rheumatologists and those affected by gout is unknown. The
present study aimed to compare usual dietary practices of patients with gout to
evidence for dietary management of gout and to investigate whether the knowl-
edge and attitudes of nutrition professionals and rheumatologists reflects cur-
rent evidence.
Methods: A food frequency questionnaire was used to determine usual dietary
intake of patients with gout, a separate questionnaire examined gout-related
dietary modifications (n = 29). Online questionnaires to examine attitudes
towards dietary management of gout were completed by nutrition professionals
and rheumatologists.
Results: Proportions of participants whose reported intakes were inconsistent
with current evidence for the dietary management of gout were: alcohol,
n = 14 (48%); beer, n = 18 (62%); seafood, n = 29 (100%); meat, n = 7
(24%); beef/pork/lamb, n = 24 (83%); dairy products, n = 12 (41%); vitamin
C supplementation, n = 29 (100%). Of the 61 rheumatologists and 231 nutri-
tion professionals who completed the online survey, the majority considered
that weight loss and decreased alcohol intake were important or very important
outcomes. Proportions were lower for decreased purine intake. Thirty-four
(56%) rheumatologists do not refer patients with gout to dietetic services and,
of those who do, the majority refer less than half.
Conclusions: Overall, patients with gout in the present study were not imple-
menting evidence for dietary management of their condition and complex die-
tary issues were evident.

more men than women suffering from gout (Kramer &

Introduction
The therapeutic goal of serum uric acid (SUA) lowering
therapy in individuals with gout is to promote crystal dis-
solution and prevent crystal formation by achieving a
SUA level of £6 mg dL)1 or £360 lmol L)1 (Zhang et al.,
2006). Among other factors, obesity and increased age
have been associated with an increased risk of gout and
hyperuricemia (Choi et al., 2005a; Peronato, 2005; Saag &
Choi, 2006). Gender differences are also evident, with
Curhan, 2002; Wallace et al., 2004).
Recent evidence-based recommendations for the man-
agement of gout state, ‘Patient education and appropriate
lifestyle advice regarding weight loss if obese, diet and
reduced alcohol (especially beer) are core aspects of man-
agement’ (Zhang et al., 2006). There is evidence to support
that dietary factors, including consumption of alcohol and
purine-rich foods such as seafood and meat, increase the
risk of gout. This evidence does not extend to purine-rich

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ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 3–11 3
 Nutrition and gout P. Shulten et al.

vegetables (Choi et al., 2005b). In contrast, low-fat dairy
products and vitamin C have been shown to be potentially
protective (Choi et al., 2005b). Table 1 highlights the mag-
nitude of the effect for the range of dietary factors. In sum-
mary, it has been found that an increased intake of meat
(particularly beef, pork, lamb) increases the risk of gout by
40–50%, seafood increases the risk of gout by 35–45% and
that alcohol (particularly beer and spirits) increases the
risk of gout by 30–250% (Choi et al., 2004a,b). Low-fat
dairy products, although not as extensively studied as
other dietary factors, have been found to potentially
decrease the risk of gout by 33–42% (Choi et al., 2004a)
Correspondingly, studies have found that increased intakes
of meat, seafood and alcohol were associated with higher
SUA levels (Choi & Curhan, 2004; Choi et al., 2005b) and
one study showed that adherence to a low-purine diet
resulted in a decrease in SUA level that was comparable to
that of Allopurinol administration of 150–300 mg daily
(Peixoto et al., 2001). In addition, there is evidence dem-
onstrating that increased dairy product intake (regardless
of fat content) and supplementation of 500 mg per day of
vitamin C result in a decreased SUA level (Choi et al.,
2005b; Huang et al., 2005).
Studies examining the medical but not dietetic manage-
ment of gout have been conducted amongst rheumatolo-
gists and physicians (Fang et al., 2006; Schlesinger et al.,
2006). Despite the evidence for dietary management of
gout, the implementation of this evidence by nutrition
professionals and rheumatologists and those affected by
gout is unknown.
The present study comprised an investigation of the
usual dietary practices of patients with gout, how these are
influenced by their condition and how their intake com-
pares to evidence for dietary management of gout. Further-
more, whether the knowledge and attitudes of nutrition
professionals and rheumatologists who are regularly
involved in the dietary management of patients with gout
reflects current available evidence, and any perceived barri-
ers to implementation of the evidence, were investigated.
Materials and methods
This study was registered with the Australian New Zea-
land Clinical Trials Registry (ANZCTR) on July 5, 2006
[ANZCTRN012606000282583].
Usual dietary practices of patients with gout
The investigation was a cross-sectional study, with ethics
approval from and conducted in accordance with the eth-
ical standards of the Repatriation General Hospital
(RGH) Research and Ethics Committee, was implemented

Table 1 Magnitude of effect for the range of dietary factors found to be associated with gout

Author Study design

(year) (sample) Exposure (serves) RR (95% CI)

Choi et al. Cohort Meat <0.81; 0.81–1.12, 1.13–1.46, 1.47–1.9, >1.92 day)1 Q1 versus Q5: 1.41 (1.07–1.86)
(2004a) (47 150 men) Beef, Pork, Lamb (main dish), <1 month)1, Q1 versus Q4: 1.50 (1.04–2.17)
1–3 month)1, 1 week)1, ‡2 week)1
Seafood <0.15, 0.15–0.28, 0.29–0.36, Q1 versus Q2: 1.35 (1.05–1.74)
0.37–0.56, >0.56 day)1 Q1 versus Q3: 1.45 (1.13–1.87)
Q1 versus Q4: 1.38 (1.06–1.79)
Q1 versus Q5: 1.51 (1.17–1.95)
Canned tuna fish ‡1 week)1 versus <1 month)1 1.28 (1.03–1.60)
Dark meat fish ‡1 serve per week versus <1 month)1 1.32 (1.06–1.64)
Other fish  1–3 serves per month versus <1 month)1 1.52 (1.17–1.97)
Other fish  ‡1 serve per week of versus <1 month)1 1.55 (1.18–2.02)
Low-fat dairy <0.2, 0.2–0.56, 0.57–0.99, 1.00–1.67, >1.67 day)1 Q1 versus Q4: 0.67 (0.53–0.85)
Q1 versus Q5: 0.58 (0.45–0.76)
Choi et al. Cohort Alcohol 0, 0.1–4.9, 5.0–9.9, 10.0–14.9, 15.0–29.9, S1 versus S5: 1.49 (1.14–1.94)
(2004b) (47,150 men) 30.0–49.9, >50.0 g day)1 S1 versus S6: 1.96 (1.48–2.93)
S1 versus S7: 2.53 (1.73–3.70)
Beer <1 month)1, 1 month)1 to 1 week)1, 2–4 week)1, Q1 versus Q3: 1.27 (1.00–1.62)
5 week)1 to 1 day)1, >2 day)1 Q1 versus Q4: 1.75 (1.32–2.32)
Q1 versus Q5: 2.51 (1.77–3.55)
Spirits <1 month)1, 1 month)1 to 1 week)1, 2–4 week)1, Q1 versus Q5: 1.60 (1.19–2.16)
5 week)1 to 1 day)1, >2 day)1
 
Refers to fish other than canned tuna fish and dark-meat fish.
CI, confidence interval.

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4 ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 3–11
P. Shulten et al.
using patients registered over the previous 2 years in the
department of rheumatology database. Individuals, who
had a confirmed diagnosis of gout (Wallace et al., 1977)
recorded in medical records and whose primary language
was English were invited to participate in the study. They
were contacted via telephone and a time was arranged in
which one of the investigators (PS) visited those inter-
ested. Informed written consent was obtained. A face-to-
face interview with duration of approximately 1 h was
then undertaken.
Demographic information, medical history, anthropo-
metric measurements, dietary intake, and information
regarding awareness of diet and gout associations were
collected. Gender and age were obtained from medical
records. Participants were weighed using calibrated porta-
ble digital scales (BF-681; Tanita, IL, USA). Knee height,
measured using a sliding broad-blade calliper (Ross Labo-
ratories, Columbus, OH, USA), was used to estimate
height in accordance with standard protocol (Chumlea
et al., 1998). Where knee height was unable to be
obtained, demi-span, measured using a flexible steel tape
(KDS Corporation, Chicago, NJ, USA), was used to esti-
mate height in accordance with standard protocol (Bas-
sey, 1986). Weight and estimated height were used to
determine body mass index (BMI) (Garrow & Webster,
1985). Dietary intake data was collected using a 74-item
semi-quantitative food frequency questionnaire (FFQ)
developed specifically for Australian adults by the Anti-
Cancer Council of Victoria, and previously validated in
Australian adult populations (Giles & Ireland, 1996;
Hodge et al., 2000; Xinying Xie et al., 2004). This instru-
ment was selected because it was likely to be culturally
appropriate with regard to food preferences, provides a
large range of food items and allows respondents to select
from seven portion sizes, which were used to calculate an
individualized portion size factor for adjustment of the
standard portion sizes used in the FFQ. Questions regard-
ing frequency of seafood intake and total daily fluid con-
sumption were asked in addition to those on the FFQ.
Two additional open-ended questions about dietary mod-
ifications and a series of open-ended questions regarding
food avoidances were asked. The same investigator (PS)
conducted all dietary interviews and obtained all anthro-
pometric measurements.
Frequency and amount of alcohol consumed (standard
drinks per day) were compared with national guidelines
and the current evidence regarding alcohol intake for
patients with gout (Australian Government Department
of Health and Ageing, 2006). Intakes of seafood, meat
and dairy products were calculated from frequencies of
consumption and portion size factors from the FFQ,
intakes were compared with evidence for consumption of
these foods by individuals with gout.
ª 2009 The Authors. Journal compilation.
ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 3–11
Nutrition and gout
Attitudes of nutrition professionals and rheumatologists
regarding the dietary management of gout compared to
current evidence
A cross-sectional study of nutrition professionals and
rheumatologists in Australia, approved by and conducted
in accordance with ethical standards of the Flinders Uni-
versity Social and Behavioural Research Ethics Commit-
tee, involved administration of two online profession
specific questionnaires, which sought demographic infor-
mation and information regarding the attitudes surround-
ing the dietary management of patients with gout by
these health professionals. Nutrition professionals and
rheumatologists were invited to complete the correspond-
ing online questionnaires via their respective national
association e-mail distribution service (Australian Rheu-
matology Association and Dietitians Association of Aus-
tralia). A total of three e-mails were distributed to the
membership group of each profession.
All members of these associations were eligible to par-
ticipate. The questionnaires were developed following
review of other questionnaires directed towards general
practitioners and nutrition professionals (Collins, 2003;
Nicholas et al., 2003). Demographic information collected
included age, gender, years of practice, geographic area
and setting of practice. To investigate whether nutrition
professionals and rheumatologists were translating evi-
dence into practice, using a five-point Likert scale, both
groups were questioned, in relation to perceived effective-
ness of dietary treatment in gout and perceived impor-
tance of specific diet-related outcomes. The diet-related
outcomes were weight loss, improved food and exercise
habits regardless of weight loss, decreased purine intake
and decreased alcohol intake. Response options for per-
ceived importance of diet-related outcomes were: very
important, important, undecided, not important, not
important at all. Responses were collapsed into three cate-
gories for statistical analysis (very important–important,
undecided, not important–not important at all). For per-
ceived effectiveness of dietary treatment the response
options were: strongly disagree, disagree, undecided, agree
and strongly agree, collapsed into these three response
categories for statistical analysis (strongly disagree–dis-
agree, undecided, agree–strongly agree).
Rheumatologists were questioned about the proportion
of patients that they refer to dietetic services with five
response categories: none, one quarter, half, three quar-
ters, all, and collapsed into three categories for statistical
analysis (none-one quarter, half, three quarters-all). An
open-ended question regarding barriers in referring to
dietetic services was also asked. Nutrition professionals
were independently asked from which source gout
patients were predominantly referred (closed-ended),
5
 Nutrition and gout
what the referrals request (open-ended) and their level of
satisfaction with the current available information
(closed-ended) and, where relevant, how this could be
improved (open-ended). Questionnaires were reviewed by
two clinical dietitians and a rheumatologist prior to ques-
tionnaire distribution.
Statistical analysis
All de-identified data was entered into SPSS, version
12.0.1 (Chicago, IL, USA). Continuous data were checked
for normality and presented accordingly as mean with
95% confidence intervals or median with interquartile
range (IQR). Chi-square analysis was used to determine
whether there were any significant differences between
nutrition professionals and rheumatologists regarding the
perceived effectiveness of dietary strategies and the per-
ceived importance of diet-related outcomes for patients
with gout.
Results
Recruitment and demographics of study participants
with gout
Of 78 eligible persons, 29 (37%) provided their informed
written consent and complete data for analysis. The age
range of the participants was 50–91 years, with a median
(IQR) age of 74 (59–81) years, 25 (86%) were male and
the median (IQR) BMI was 28.0 (25.7–32.1) kg m)2.
Twenty (69%) participants were classed as overweight or
obese based on definitions by the World Health Organi-
zation (1998).
Dietary intake of study participants with gout
Twenty four (83%) participants reported having received
dietary advice regarding management of gout. Most fre-
quently reported sources of dietary advice included rheu-
matologists (n = 11, 28%), dietitians (n = 9, 23%),
general practitioners (n = 6, 15%) and the Internet
(n = 4, 10%).
Of the 27 (93%) participants who consumed alcohol,
the total average intake was in the range 0.2–10.6 stan-
dard drinks per day, with a median (IQR) intake of 0.9
(0.3–3.9) standard drinks per day. Results regarding pat-
terns of alcohol consumption are displayed in Table 2.
No participants reported complete avoidance of sea-
food. More than half of participants (n = 16, 55%)
reported consuming shellfish never to less than once per
month, 10 (35%) and one (3%) reported consuming
shellfish one to three times per month and once per week
respectively. Eight (28%), 15 (52%) and six (17%)
reported consuming fish (other than shellfish) one to
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P. Shulten et al.
three times per month, one to two times per week and
three or more times per week respectively. Twelve (41%)
participants avoided shellfish and four (14%) reported
avoiding fish as a result of having gout.
Average daily consumption of meat products was
greater than 1.9 serves per day for seven (24%) and con-
sumption of beef/pork/lamb was ‡2 serves per week for
24 (83%). Five (17%) participants reported having
decreased their portion size of meat as a result of having
gout.
Average daily consumption of dairy products was less
than 1.7 serves for 12 (41%). Eight (28%) reported con-
sumption of solely reduced fat or skim milk and four
(14%) reported consumption of low-fat cheese as
opposed to full fat varieties. Two (7%) participants
reported consuming both low-fat or skim milk and low-
fat cheese. Four (14%) reported daily consumption of
multivitamin supplements; however, none reported con-
sumption of vitamin C supplements.
Additional foods reported to be avoided secondary to
gout included offal, Vegemite/Promite, citrus fruit, toma-
toes and tomato products, wholemeal bread, cauliflower
and lentils. Eighteen (62%) reported avoiding one or
more foods as a result of gout.
Recruitment and demographics of nutrition professionals
and rheumatologists
Nutrition professionals
Two hundred and thirty-one out of 2995 nutrition pro-
fessionals responded to the survey, giving a response rate
of 8%. Of these, 132 (57%) worked in a metropolitan/
Table 2 Alcohol consumption behaviours among participants (n = 29)
Alcohol behaviour n %
Met gender specific national recommendations 12 41
for daily alcohol intake 
Complete avoidance of all alcohol 2 7
Alcohol consumption of <1.5 standard drinks per dayà 12 46
Beer consumption <2 standard drinks per weekà 8 31
Spirit/liqour consumption £1 standard drinks per dayà 24 92
Wine consumption £2 standard drinks per dayà 24 92
Met gout-related recommendations for beer, 7 27
spirits/liqours, wineà
Alcohol consumption on ‡6 days per week § 14 54
Recommended that males consume no more than an average of no
more than four standard drinks per day and that females consume a
average of no more than two standard drinks per day (Australian
Government Department of Health and Ageing, 2006).
à
Results do not include those who abstained from alcohol consump-
tion.
§
Two alcohol free days per week recommended for both men and
women (Australian Government Department of Health and Ageing,
2006).
ª 2009 The Authors. Journal compilation.
P. Shulten et al. Nutrition and gout

urban location, 78 (34%) worked in a regional/rural or Table 3 Perceived importance of diet-related outcomes for individu-
remote location and 14 (6%) worked across all locations als with gout by nutrition professionals (n = 154) and rheumatologists
(n = 61) who participated in the online survey
listed. Of those who responded, 175 (76%) were involved
in the dietary management of patients with gout. Of Nutrition
these, 154 (88%) provided complete data and were there- Perceived importance of Rheumatologists professionals
advice provision n (%) n (%) P value
fore included in subsequent analysis.
Weight loss
Rheumatologist Not important at all/not 4 (7) 2 (1)
Sixty-one of 266 eligible rheumatologists, responded to important
the online survey, giving a response rate of 24%. Of the Undecided 7 (11) 21 (14) 0.103
Important/very important 49 (82) 129 (85)
rheumatology respondents, the majority (n = 45, 74%)
Improved diet and exercise habits regardless of weight loss
worked in the metropolitan/urban location. All rheuma- Not important at all/not 4 (7) 2 (1)
tologist respondents were involved in the management of important
gout patients. Undecided 5 (8) 7 (5) 0.053
Important/very important 51 (85) 144 (94)
Decreased alcohol consumption
Perceived effectiveness of dietary strategies and impor- Not important at 0 (0) 0 (0)
tance of diet-related outcomes for patients with gout by all/not important
nutrition professionals and rheumatologists Undecided 3 (5) 5 (3) 0.518
Important/very important 58 (95) 148 (97)
For the question regarding the degree to which rheuma- Decreased purine intake
tologists and nutrition professionals agreed with the state- Not important at all/not 11 (18) 21 (14)
ment ‘dietary strategies are effective in the management important
of gout’, a significant difference was observed in perceived Undecided 6 (10) 47 (31) 0.007
effectiveness between nutrition professionals and rheuma- Important/very important 43 (72) 85 (55)
tologists (P < 0.0001). Subsequent analysis revealed that
the significant difference was between those nutrition pro-
fessionals and rheumatologists who disagree/strongly dis-
agreed that dietary strategies are effective (P < 0.0001) respondents reported perceived barriers in referring to
with no significant difference between those who agreed/ dietetic services. The main barriers detailed by these
strongly agreed or were undecided. Fifty-nine (97%) respondents were: expense of private dietetic services
rheumatologist respondents reported that they consider (n = 23, 64%), inadequate availability and access (n = 21,
diet in the management of their patients with gout. 58%), long waiting times (n = 12, 33%) and poor compli-
Table 3 reports the perceived importance of diet-related ance or motivation of patients with gout (n = 11, 31%).
outcomes for individuals with gout reported by nutrition The sources of referral of gout patients as reported by
professionals and rheumatologists. Chi-square analysis nutrition professionals were: general practitioners (n = 84,
indicated a significant difference in perceived importance 55%), medical officers (n = 11, 7%), nurses (n = 7, 5%),
of decreased purine intake for patients with gout nephrologists (n = 6, 4%), rheumatologists (n = 3, 2%)
(P = 0.007), and that the difference lay between nutrition and self-referral by gout patients (n = 41, 27%).
professionals and rheumatologists who were undecided
regarding the importance of this dietary outcome, with a
Discussion
greater proportion of nutrition professionals being unde-
cided. There was no significant difference in perceived Results from this cross-sectional study indicate that
importance for the other outcomes. Sixteen (10%) nutri- patients with gout are not following evidence-based die-
tion professionals added that they thought adequate fluid tary strategies to manage gout. The attitudes of nutrition
intake was an important outcome for patients with gout. professionals and rheumatologists appear to be consistent
with the evidence for managing patients with gout; how-
ever, improvements could be made to optimize attitudes
Referral of patients with gout to dietetic services
and thus potentially improve dietary management within
Thirty-four (56%) rheumatologists reported not referring this patient group. Barriers to optimizing services were
any patients with gout to dietetic services. Twenty-four identified by nutrition professionals and rheumatologists,
(39%) reported referring either a quarter or half and three highlighting that further investigation is necessary to
(5%) reported referring three quarters to all of their explore the barriers and formulate strategies to overcome
patients with gout. Thirty-six (59%) rheumatologist or manage them.

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ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 3–11 7
 Nutrition and gout
The higher proportion of male than female participants
in this study is expected given that gout occurs more
frequently in men than women (Kramer & Curhan, 2002;
Wallace et al., 2004). The likely explanation offered for
the increased prevalence in men is that of the uricosuric
effect of oestrogen in women (Saag & Choi, 2006). The
evidence base for dietary management of gout is based on
male subjects and, although no literature was located
identifying differences in efficacy of treatment between
men and women, caution should be taken when extrapo-
lating the evidence to the female population.
In this sample, beer consumption was particularly con-
cerning because the majority of participants consumed
more than two standard drinks of beer per week. Evi-
dence for restriction of specific types of alcoholic bever-
ages is reasonably recent, possibly explaining a lack of
awareness amongst patients with gout and inconsistency
with the evidence. Other factors that may contribute to
the inconsistency include the relaxation and social effects
that can accompany consumption of alcohol (Common-
wealth of Australia, 2006) and the potential awareness of
evidence suggesting an inverse relationship between mod-
erate intakes of alcohol and the risk of cardiovascular dis-
eases (Goldberg et al., 2001).
All participants consumed seafood; however, the intake
was infrequent. Frequency of fish intake was higher with
consumption as high as five to six times per week for
some participants. Persistent high intakes of fish may be
explained by knowledge of potential cardiovascular health
benefits of the consumption of the omega-3 fatty acids
eicosapentaenoic acid and docosahexaenoic acid found in
fish (Hooper et al., 2004). Evidence based dietary prac-
tices for total daily meat intake were met by the majority
of participants; however, it is unlikely that adherence to
this guideline was intentional by all of these participants
because less than one quarter of participants reported that
they had intentionally decreased their portion size of
meat due to presence of gout. In addition, the majority
reported an intake of beef/lamb/pork that was greater
than that recommended (Choi et al., 2005b).
Evidence for low-fat dairy product intake was not fol-
lowed by the majority of participants. Only two (7%)
participants reported the consumption of both low-fat or
skim milk and low-fat cheese consistent with guidelines
for low-fat dairy consumption in gout. Figures for com-
pliance with this guideline may alter depending on the
type of yoghurt consumed because data were not col-
lected regarding low-fat versus full-fat for yoghurt; how-
ever, yoghurt consumption was less than once per week
for the majority (75%) of participants. Evidence for the
protective effect of low-fat dairy products is very recent
and thus it is possible that the participants surveyed in
the present study have not received any guidance regard-
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P. Shulten et al.
ing dairy product consumption for prevention of gout. A
similar explanation could be used for vitamin C because
all participants were inconsistent with evidence regarding
daily supplementation.
Some food avoidances reported by participants are not
supported by the current evidence: tomatoes and tomato
products, citrus fruits, lentils, wholemeal bread and vege-
tables. Unsubstantiated modifications to the diet without
appropriate monitoring may result in suboptimal nutrient
intake and adverse consequences. Additional reasons why
patients may not comply with the evidence include: high
efficacy of anti-gout preparations, lack of up to date
knowledge of appropriate dietary behaviours, disbelief of
effectiveness of dietary alterations, patients being unaf-
fected by gout for a substantial period of time and food
preferences, such as the traditional meat and vegetable
style diet that is common in the elderly Australian popu-
lation. In addition, there is evidence to support poor
recall and incomplete adherence to nonpharmacological
advice in elderly patients (Lainscak et al., 2007).
Although both nutrition professionals and rheumatolo-
gists reported that specific diet-related outcomes (weight
loss, alcohol, purines) were important, nutrition profes-
sionals were more likely than rheumatologists to suggest
that dietary strategies could be effective. The availability
of potent, more effective uric acid-lowering medications
or perceived poor compliance with dietary therapy (Fam,
2002, 2005) may be a potential explanation. Secondary to
strong evidence for moderation of dietary purine con-
sumption, the proportions of nutrition professionals and
rheumatologists who reported that decreased purine
intake was an important outcome for patients with gout
was lower than expected. Possible explanations for this
may again be that the effect of dietary alterations in low-
ering serum uric acid levels is smaller compared to the
effect of uric-acid lowering medications and the tradi-
tional rigid low-purine diet can rarely be sustained long-
term, secondary to it being unpalatable and impractical
(Fam, 2002, 2005). Moderation in dietary purine con-
sumption rather than the traditional strict low-purine diet
is more feasible (Fam, 2002).
Despite existing evidence-based guidelines that reinforce
the importance of dietary education and appropriate die-
tary advice and evidence that hyperuricemia is associated
with other diet-related conditions including hyperlipida-
emia, hypertension, diabetes and insulin resistance and
obesity, approximately half of rheumatologists reported
not referring any of their patients with gout to dietetic ser-
vices (Zhang et al., 2006). Poor referral rates may be
related to the finding that approximately half of rheuma-
tologists who responded reported being undecided or dis-
agreeing with the overall concept that dietary strategies are
effective in the management of this patient group. How-
ª 2009 The Authors. Journal compilation.
P. Shulten et al.
ever, an additional explanation for low referral rates could
be that rheumatologists themselves may be providing die-
tary advice to patients with gout. Reported barriers to
referring to dietetic services may be another explanation
for the low referrals rates observed. Diet-related pamphlets
or group education sessions for patients with gout may
help to overcome barriers reported by nutrition profes-
sionals and rheumatologist in the present study. Interest-
ingly, over half of the nutrition professionals who
responded reported that general practitioners were their
main source of referral of patients with gout, with only a
very small number reporting that rheumatologists were
the main source of referral. This is consistent with general
practitioners being the primary medical contact for most
patients with gout, indicating the need for similar research
involving general practitioners (Wortmann, 2006).
The limitations of this study are: (i) a small sample of
participants with gout (n = 29), which limits the extent
to which the results may be generalized and made sub-
group analyses difficult; (ii) the response rate of 37% for
patients with gout was less than desired; however, this
may be expected given the age group used and that the
database used for recruitment was 2 years old and thus
contact details may not have been current; (iii) patients
with gout in the present study may represent a biased
sample because they were recruited from a rheumatology
database and the management of these patients is likely
to be more complex than for those attending their general
practitioner; and (iv) the response rates of nutrition pro-
fessionals and rheumatologists 8% and 24%, respectively,
are less than desirable, but remarkably similar to that seen
in previous studies of nutrition professionals and rheu-
matologists (Barnard & Kerruish, 2006; Schlesinger et al.,
2006). It should also be noted that one participant pro-
vided self-reported data for height and weight because
they were from a regional area. Although errors may have
been introduced as a result of this, it is unlikely that the
data from one participant would greatly influence the
findings of the study. Further research should ensure that
dose of vitamin C from multivitamin supplements is col-
lected to ensure accurate determination of consistency
with guidelines.
In summary, it is evident that patients with gout
within this sample are not following evidence-based
practices, particularly for alcohol, purine intake (includ-
ing seafood and certain meats), vitamin C supplementa-
tion and low-fat dairy product intake. Inappropriate
food-avoidances also need to be addressed. Although the
evidence for medications is stronger than that for diet,
the present study has indicated that this patient group
have complex, often unaddressed dietary issues, indicat-
ing the need for dietetic input. Appropriate current pro-
motional materials located in rheumatology clinics may
ª 2009 The Authors. Journal compilation.
ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 3–11
Nutrition and gout
help to raise awareness and access to information
regarding diet and gout. In general, nutrition profession-
als and rheumatologists reported attitudes in line with
the current evidence for the dietary management of
patients with gout. Although it is likely that attitudes
would be reflected in the practice of nutrition profes-
sionals and rheumatologists, it is our belief that
increased research regarding actual practices in provision
of diet-related education and specific strategies used in
the dietary management are required to form sound,
specific evidence-based recommendations that result in
an improved service provision to this patient group.
Despite this, barriers will need to be addressed to fur-
ther improve dietetic services to patients with gout.
These results also suggest that general practitioners are
an appropriate target for similar future research.
Acknowledgments
The authors would like to thank the patients with gout,
nutrition professionals and rheumatologists who took
time to participate in this study. The authors also wish to
acknowledge the group of Flinders Nutrition and Dietetic
students who were involved in some preliminary planning
of the study.
Conflict of interest, source of funding
and authorship
The authors declare that they have no conflicts of interest.
We did not receive any funding for the project, which
was conducted as part of a honours project for a Bachelor
of Nutrition and Dietetics student (PS).
PS contributed to the planning of the project, conducted
all data collection and analysis and prepared the first draft
of the manuscript. JT contributed to the planning of the
project, supervised data collection and provided intellec-
tual input into the preparation of the manuscript. MM
contributed to the planning of the project, supervised
implementation of the project, provided support for data
analyses and intellectual input into the preparation of the
manuscript. MS provided infrastructure and access to
project participants and provided intellectual input into
the preparation of the manuscript. MA contributed to the
planning of the project, supervised implementation, pro-
vided infrastructure and access to project participants and
provided intellectual input into the preparation of the
manuscript. Work should be attributed to Flinders Uni-
versity Department of Nutrition and Dietetics and Flin-
ders University Department of Rheumatology and
Clinical Immunology. All authors critically reviewed the
manuscript and approved the final version submitted for
publication.
9
 Nutrition and gout
References
Australian Government Department of Health and Ageing:
Population Health Division. 2006. Australian Alcohol Guide-
lines [Homepage on the Internet]. Updated 2006 April 5
[cited 2006 Dec 18]. Available from: http://www.alcohol.
gov.au/internet/alcohol/publishing.nsf/Content/guidelines.
Barnard, J. & Kerruish, K. (2006) Report for DAA Board 2005
Membership Survey. Australia: Dietitians Association of
Australia.
Bassey, J. (1986) Demi-span as a measure of skeletal size. Ann.
Hum. Biol. 3, 499–502.
Choi, H.K. & Curhan, G. (2004) Beer, liquor, and wine con-
sumption and serum uric acid level: the third national
health and nutrition examination survey. Arthritis Rheum.
51, 1023–1029.
Choi, H.K., Atkinson, K., Karlson, E.W., Willett, W. & Cur-
han, G. (2004a) Purine-rich foods, dairy and protein intake,
and the risk of gout in men. N. Engl. J. Med. 350, 1093–1103.
Choi, H.K., Atkinson, K., Karlson, E.W., Willett, W. & Cur-
han, G. (2004b) Alcohol intake and risk of incident gout in
men: a prospective study. Lancet 363, 1277–1281.
Choi, H.K., Atkinson, K., Karlson, E.W. & Curhan, G. (2005a)
Obesity, weight change, hypertension, diuretic use and risk
of gout in men: the Health Professionals Follow-up Study.
Arch. Intern. Med. 165, 742–748.
Choi, H.K., Liu, S. & Curhan, G. (2005b) Intake of purine-rich
foods, protein and dairy products and relationship to serum
levels of uric acid- the third national health and nutrition
examination survey. Arthritis Rheum. 52, 283–289.
Chumlea, W.C., Guo, S.S., Wholihan, K., Cockram, D., Kucz-
marski, R.J. & Johnson, C.L. (1998) Stature prediction equa-
tions for elderly non-Hispanic white, non-Hispanic black,
and Mexican-American persons developed from NHANES
III data. J. Am. Diet. Assoc. 98, 137–142.
Collins, C. (2003) Survey of dietetic management of over-
weight and obesity and comparison with best practice crite-
ria. Nutr. Diet 60, 177–184.
Commonwealth of Australia. (2006) National Alcohol Strategy
2006–2009. Canberra:Commonwealth of Australia. ISBN: 1
74186 051 2. Sponsored by the Ministerial Council on Drug
Strategy.
Fam, A. (2002) Gout, diet and the insulin resistance syndrome
[editorial]. J. Rheumatol. 29, 1350–1355.
Fam, A.G. (2005) Gout: excess calories, purines, and alcohol
intake and beyond. Response to a urate-lowering diet [edi-
torial]. J. Rheumatol. 32, 773–777.
Fang, W., Zeng, X., Li, M., Chen, L.X., Schumacher, H.R. &
Zhang, F. (2006) The management of gout at an academic
healthcare centre in Beijing: a physician survey. J. Rheuma-
tol. 33, 2041–2049.
Garrow, J.S. & Webster, J. (1985) Quetlet’s index (W/H[2]) as
a measure of fatness. Int. J. Obes. Relat. Metab. Disord. 9,
147–153.
10
P. Shulten et al.
Giles, G.G. & Ireland, P.D. (1996) Dietary Questionnaire for
Epidemiological Studies (Version 2). Melbourne: The Cancer
Council Victoria.
Goldberg, I.J., Mosca, L., Piano, M.R. & Fisher, E.A. (2001)
AHA Science Advisory: Wine and your heart: a science advi-
sory for healthcare professionals from the Nutrition Com-
mittee, Council on Epidemiology and Prevention, and
Council on Cardiovascular Nursing of the American Heart
Association. Circulation 103, 472–475.
Hodge, A., Giles, G.G., Patterson, A., Brown, W. & Ireland, P.
(2000) The Anti-Cancer Council of Victoria FFQ. Relative
validity of nutrient intakes compared with diet diaries in
young to middle-aged women in a study of iron supplemen-
tation. Aust. NZ J. Public Health 24, 576–583.
Hooper, L., Thompson, R.L., Harrison, R.A., Summerbell,
C.D., Moore, H., Worthington, H.V., Durrington, P.N.,
Ness, A.R., Capps, N.E., Davey Smith, G., Riemersma, R.A.
& Ebrahim, S.B.J. (2004) Omega 3 fatty acids for prevention
and treatment of cardiovascular disease (review). Cochrane
Database Syst. Rev. 4, CD003177.
Huang, H.Y., Appel, L.J., Choi, M.J., Gelber, A.C., Charleston,
J., Norkus, E.P. & Miller, E.R. (2005) The effects of vitamin
C supplementation on serum concentrations of uric acid:
results of a randomized controlled trial. Arthritis Rheum. 52,
1843–1847.
Kramer, H.M. & Curhan, G. (2002) The association between
gout and nephrolithiasis: The National Health and Nutrition
Examination Survey III 1998–1997. Am. J. Kidney Dis. 40,
37–42.
Lainscak, M., Cleland, J.G., Lenzen, M.J., Keber, I., Goode, K.,
Follath, F., Komajda, M. & Swedberg, K. (2007) Nonphar-
macologic measures and drug compliance in patients with
heart failure: data from the EuroHeart Failure Survey.
Am. J. Cardiol. 99, 31–37.
Nicholas, L.G., Pond, C.D. & Roberts, D.C.K. (2003) Dietitian-
general practitioner interface: a pilot study on what influ-
ences the provision of effective nutrition management.
Am. J. Clin. Nutr. 77, 1039–1042.
Peixoto, M.R., Monego, E.T., Jardim, P.C., Carvalho, M.M.,
Sousa, A.L., Oliveira, J.S. & Neto, O.B. (2001) Diet and
medication in the treatment of hyperuricemia in hyperten-
sive patients. Arq. Bras. Cardiol. 76, 468–472.
Peronato, G. (2005) Purine metabolism and hyperuricemic
states: the point of view of the Rheumatologist. Contrib.
Nephrol. 147, 1–21.
Saag, K.G. & Choi, H.K. (2006) Epidemiology, risk factors and
lifestyle modifications for gout. Arthritis Res. Ther. 8, 1–7.
Schlesinger, N., Moore, D.F., Sun, J.D. & Schumacher, H.R.
(2006) A survey of the current evaluation and treatment of
gout. J. Rheumatol. 33, 2050–2052.
Wallace, S.L., Robinson, H., Masi, A.T., Decker, J.L.,
McCarty, D.J. & Yü, T.-F. (1977) Preliminary criteria for the
classification of the acute arthritis of primary gout. Arthritis
Rheum. 20, 895–900.
ª 2009 The Authors. Journal compilation.
ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 3–11
P. Shulten et al.
Wallace, K.L., Riedel, A.A., Joseph-Ridge, N. & Wortmann, R.
(2004) Increasing prevalence if gout and hyperuricemia over
10 years among older adults in a managed care population.
J. Rheumatol. 31, 1582–1587.
World Health Organization. (1998) Obesity: Preventing and
Managing a Global Epidemic. Report of a World Health
Organization consultation on obesity. Geneva: WHO.
Wortmann, R.L. (2006) The management of gout: it should be
crystal clear [editorial]. J. Rheumatol. 33, 1921–1922.
Xinying Xie, P., Noakes, M. & Keogh, J. (2004) Can a food
frequency questionnaire be used to capture dietary intake
ª 2009 The Authors. Journal compilation.
ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 3–11
Nutrition and gout
data in a 4 week clinical intervention trial? Asia Pac. J. Clin.
Nutr. 1, 318–323.
Zhang, W., Doherty, M., Bardin, T., Pascual, E., Conaghan, P.,
Gerster, J. et al. (2006) EULAR evidence based recommen-
dations for gout. Part II: management. Report of a task
force of the EULAR Standing Committee for International
Clinical Studies Including Therapeutics (ESCISIT).
Ann. Rheum. Dis. 65, 1312–1324.
11