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Association of dietary fiber intake with

hyperuricemia in U.S. adults
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Cite this: DOI: 10.1039/c8fo01917g

Yongye Sun, †a,b Jianping Sun,†c Peipei Zhang,a Feng Zhong,a Jing Caia and
Aiguo Ma *a

Received 30th September 2018,
Accepted 4th July 2019
DOI: 10.1039/c8fo01917g
rsc.li/food-function
Current evidence on the relationship between dietary fiber intake and risk of hyperuricemia is limited. The
aim of the present study was to examine their associations in the U.S. general adult population. Data from
the National Health and Nutrition Examination Survey (NHANES) 2009 to 2014 were used. Dietary fiber
intake was extracted through two 24 h dietary recall interviews. Hyperuricemia was defined by cut-off
values of 7.0 mg dL−1 for men and 6.0 mg dL−1 for women. Multivariable logistic regression models and
restricted cubic spline models were applied to explore the associations between dietary intakes of total,
cereal, fruit and vegetable fiber and the risk of hyperuricemia. A total of 12 869 participants aged 20 years
or older were included in the present study. The multivariable odds ratio (OR) and 95% confidence interval
(CI) of hyperuricemia for the highest vs. lowest quartile intake of total fiber were 0.58 (0.46–0.74), 0.61
(0.52–0.74) for cereal fiber, 0.94 (0.76–1.16) for fruit fiber and 0.95 (0.76–1.18) for vegetable fiber. The
inverse associations between dietary intakes of total fiber and cereal fiber and the risk of hyperuricemia
were observed in men. In stratified analysis by age (<45 years, ≥45 years), the inverse association between
total fiber intake and the risk of hyperuricemia was consistent, while cereal fiber intake was only inversely
associated with hyperuricemia among participants <45 years old. Dose–response analyses showed that
the risk of hyperuricemia was associated with dietary intake of total fiber in a nonlinear manner, whereas
the relationship was linear for cereal fiber intake. In conclusion, dietary intakes of total fiber and cereal
fiber were inversely associated with the risk of hyperuricemia in the U.S. adult population.

Introduction Apart from genetic16,17 variations, several lifestyle or dietary

Uric acid is an ultimate product of purine metabolism and is
considered as one of the major endogenous antioxidants.
Hyperuricemia occurs from urate overproduction or impaired
urate excretion through the kidney and gastrointestinal tract.
Elevated serum uric acid can lead to gout and may be an etio-
logical factor for multiple chronic diseases, including
diabetes,1,2 hypertension,3–5 cardiovascular disease6–8 and
chronic renal disease,9,10 all of which are prevalent all over the
world. Over the past several decades, the prevalence of hyper-
uricemia increased greatly,11–13 which has been perceived as
an emerging public health problem. The reported prevalence
rate of hyperuricemia ranges from 8.9% to 24.4%11,14,15 in
different populations. Therefore, it is necessary to find the
potential modifiable factors to suppress the increase of the
serum uric acid concentration.
a
Department of Nutrition and Food Hygiene, School of Public Health, Qingdao
University, Qingdao, China. E-mail: sunnyleaf@qdu.edu.cn
b data from two large cohorts of homogeneous ethnicity but
Basic Medical College, Qingdao University, Qingdao, China
c
Qingdao Municipal Center for Disease Control and Prevention, Qingdao, China
† These authors contributed equally to this work.
factors have been linked with hyperuricemia, which is
regarded as a modifiable condition.18 Intakes of purine-rich
foods, alcohol, and fructose-containing foods have been
reported to be related to the increased risk of
hyperuricemia,19,20 whereas an inverse association was
observed in dairy, coffee, vegetable and fruit intakes with the
serum uric acid concentration.21–23 Dietary fiber is a group of
food components derived mainly from vegetables, fruits and
cereals. Previous studies have indicated that dietary fiber may
play a significant role in prevention or treatment of several dis-
eases, such as type 2 diabetes,24,25 hypertension,26 cardio-
vascular disease,27 and metabolic syndrome.28,29 An experi-
mental study by Takashi Koguchi revealed that dietary fiber
could suppress the increase of the serum uric acid concen-
tration induced by feeding rats with a yeast RNA diet.30 In
addition, two epidemiological studies have examined the
association between dietary fiber intake and hyperuricemia.
Svetlana’s study20 explored the relationship between macro-
and micronutrient intakes and serum uric acid by comparing
different food traditions (Australia and Norway). Results of this
study showed that dietary fiber intake had a strong beneficial

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association with the serum uric acid concentration in the

Australian subjects but not in the Norway participants whose
maximal daily fiber intake was at least twofold lower than that
of the Australian participants. Another cross-sectional study31
performed among American adults mainly to evaluate the
relationship between dietary fructose and hyperuricemia indi-
cated that a higher total dietary fiber intake was associated
with lower hyperuricemia rates. To date, information about the
relationship between dietary fiber intake and hyperuricemia is
limited. In particular, no study has investigated the association
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between different sources of dietary fiber (cereals, fruits and

vegetables) intake and hyperuricemia. Furthermore, few
studies have explored the dose–response relationship between
dietary fiber intake and hyperuricemia.
In view of limitations and conflicting outcomes of previous
studies, the present paper examined the associations between
dietary intakes of total, cereal, fruit and vegetable fiber and
the risk of hyperuricemia in the U.S. general adult population
using data from the National Health and Nutrition
Examination Survey (NHANES) 2009 to 2014.
Fig. 1 Flow diagram showing the process for the selection of eligible
subjects.

Methods
Study population
Cross-sectional study data from 3 cycles of NHANES (2009–2010,
2011–2012 and 2013–2014) were combined for analyses. The
response rates were 79.4%, 72.6% and 71.0% for the interviewed
sample and 77.3%, 69.5% and 68.5% for the examined sample
for 2009–2010, 2011–2012 and 2013–2014, respectively. The
2009–2014 NHANES included 30 468 participants, and our ana-
lyses were limited to 17 547 participants aged 20 years or older.
We excluded pregnant women (n = 149) and individuals who did
not provide dietary fiber intake information and those with
missing uric acid information (n = 2762). Participants with unreli-
able or incomplete dietary recall data (n = 1629) were also
excluded. In addition, individuals whose total daily energy
intakes > mean + 3SD (4630 kcal) or <mean − 3SD (0 kcal) were
excluded (n = 138). Finally, 12 869 individuals (6158 men and
6711 women) were included in our analysis (Fig. 1).
Serum uric acid measurement
The key outcome of interest was the serum uric acid concen-
tration which was detected on a Beckman Synchron LX20 or
Beckman UniCel® DxC800 Synchron after oxidization with the
specific enzyme uricase to form allantoin and H2O2.
Hyperuricemia was defined by the cut-off values of 7.0 mg dL−1
for men and 6.0 mg dL−1 for women.32
Dietary fiber intake
The data of dietary fiber intakes were obtained through two
24 h dietary recall interviews. The first dietary recall interview
was conducted in person in the mobile examination center, and
the second interview was conducted via telephone 3 to 10 days
later. Dietary fiber intakes were calculated according to the US
Department of Agriculture (USDA) Food and Nutrient Database
for Dietary Studies (FNDDS 2009–2010, 2011–2012 and
2013–2014).33 Average dietary fiber intakes from the two 24 h
recalls were used if an individual completed both 24 h recalls.
Otherwise, we used the single dietary recall data.34 Among all
participants, 99.68% completed both the 24 h recalls. Different
sources of dietary fiber intake were identified by food codes.
Study covariates
Based on the previous literature, factors that had been proved
to be correlated with hyperuricemia and intake of dietary fiber
were included in regression models to control for potential
confoundings. Demographic characteristics included age
(20–44 y, 45–59 y, 60–74 y, and ≥75 y), sex, race (Mexican
American, other Hispanic, non-Hispanic White, non-Hispanic
Black, and other race), and educational level (lower than high
school, high school diploma, and higher than high school).
Other covariates included body mass index (BMI), total energy
intake, smoking status (smoking at least 100 cigarettes in life
or not), alcohol consumption status (having at least 12 alcohol
drinks per year or not), vigorous recreational activity, diabetes
status (yes or no), and hypertension status (yes or no).
Diabetes was defined as the fasting plasma glucose level
≥7.0 mmol L−1, or the 2 h plasma glucose level (OGTT)
≥11.1 mmol L−1, or the glycohemoglobin level ≥6.5%, or
taking diabetes pills or insulin, or self-report diabetes
diagnosis.20,35 Hypertension was defined as the mean systolic
blood pressure ≥130 mm Hg, or the mean diastolic blood
pressure ≥80 mm Hg, or self-report hypertension diagnosis.36
Statistical analysis
Statistical analyses were conducted using Stata 15.0 to account
for the complex sampling design. To perform a nationally

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Table 1 Baseline characteristics of the participants by hyperuricemia, U.S. adults aged ≥20 years, NHANES 2009–2014

Hyperuricemia (total) Hyperuricemia (men) Hyperuricemia (women)

Characteristic No Yes p value No Yes p value No Yes p value

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Number of participants (%) 10 257 (80.65%) 2612 (19.35%) 4761 (77.68%) 1397 (22.32%) 5496 (83.33%) 1215 (16.67%)
Age group (n, %) <0.001 0.044 <0.001
20–44 years 4514 (83.8%) 832 (16.20%) 1971 (76.25%) 584 (23.75%) 2543 (83.89%) 248 (8.92%)
45–59 years 2669 (81.86%) 616 (18.14%) 1221 (79.57%) 318 (20.43%) 1448 (83.89%) 298 (16.11%)
60–74 years 2196 (76.04%) 743 (23.96%) 1098 (79.09%) 315 (20.91%) 1098 (73.39%) 428 (26.61%)
≥75 years 878 (69.53%) 421 (30.47%) 471 (75.04%) 180 (24.96%) 407 (65.34%) 241 (34.66%)
Race (n, %) <0.001 0.006 <0.001
Mexican American 1545 (86.75%) 244 (13.25%) 724 (82.28%) 155 (17.72%) 821 (91.59%) 89 (8.41%)
Other Hispanic 1054 (86.25%) 183 (13.75%) 442 (81.72%) 102 (18.28%) 612 (90.18%) 81 (9.82%)
Non-Hispanic White 4607 (79.97%) 1265 (20.03%) 2166 (77.15%) 673 (22.85%) 2441 (82.55%) 592 (17.45%)
Non-Hispanic Black 1949 (77.26%) 648 (22.74%) 909 (76.31%) 305 (23.69%) 1040 (77.96%) 343 (22.04%)
Other race 1102 (80.89%) 272 (19.11%) 520 (75.75%) 162 (24.25%) 582 (85.71%) 110 (14.29%)

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Educational level (n, %) 0.4358 0.2959 0.0343
<High school 2325 (80.61%) 614 (19.39%) 1130 (79.87%) 314 (20.13%) 1195 (81.32%) 300 (18.68%)
High school 2237 (79.61%) 594 (20.39%) 1094 (77.76%) 321 (22.24%) 1143 (81.42%) 273 (18.58%)
>High school 5682 (80.98%) 1401 (19.02%) 2533 (77.07%) 760 (22.93%) 3149 (84.42%) 641 (15.58%)
Smoking status (n, %) <0.001 0.8529 0.003
Yes 4429 (79.34%) 1231 (20.66%) 2513 (77.80%) 720 (22.20%) 1916 (81.16%) 511 (18.84%)
No 5824 (81.65%) 1380 (18.35%) 2246 (77.57%) 676 (22.43%) 3578 (84.67%) 704 (15.33%)
Alcohol drinking status (n, %) 0.2236 0.1391 <0.001
Yes 7101 (80.76%) 1809 (19.24%) 3868 (77.44%) 1148 (22.56%) 3233 (84.59%) 661 (15.41%)
No 2535 (79.55%) 680 (20.45%) 697 (80.30%) 188 (19.70%) 1838 (79.24%) 492 (20.76%)
Vigorous recreational activity (n, %) <0.001 0.0151 <0.001
Yes 2283 (85.09%) 420 (14.91%) 1275 (80.07%) 318 (19.93%) 1008 (91.86%) 102 (8.14%)
No 7974 (79.2%) 2192 (20.8%) 3486 (76.67%) 1079 (23.33%) 4488 (81.21%) 1113 (18.79%)
Hypertension (n, %) <0.001 <0.001 <0.001
Yes 3203 (69.69%) 1403 (30.31%) 1589 (71.64%) 634 (28.36%) 1614 (67.90%) 769 (32.10%)
No 6819 (86.04%) 1128 (13.96%) 3090 (80.79%) 727 (19.21%) 3729 (90.84%) 401 (9.16%)
Diabetes (n, %) <0.001 0.4708 <0.001
Yes 1698 (70.24%) 732 (29.76%) 917 (76.54%) 308 (23.46%) 781 (64.03%) 424 (35.97%)
No 8543 (82.44%) 1874 (17.56%) 3840 (77.87%) 1088 (22.13%) 4703 (86.52%) 786 (13.48%)
BMI (kg m−2) 28.15 ± 6.31 32.46 ± 7.68 <0.001 28.15 ± 5.56 31.35 ± 6.45 <0.001 28.15 ± 6.86 33.80 ± 8.80 <0.001
TC (mg dL−1) 192.54 ± 39.88 199.72 ± 43.79 <0.001 188.62 ± 40.08 197.28 ± 43.29 <0.001 195.85 ± 39.41 202.69 ± 44.18 <0.001
HDL (mg dL−1) 54.22 ± 15.98 48.65 ± 14.96 <0.001 48.48 ± 13.65 45.03 ± 13.18 <0.001 59.07 ± 16.19 53.03 ± 15.81 <0.001
Uric acid (mg dL−1) 4.95 ± 1.02 7.42 ± 0.98 <0.001 5.57 ± 0.86 7.79 ± 0.79 <0.001 4.42 ± 0.83 6.96 ± 0.99 <0.001
Daily total energy 2075.19 ± 725.99 2022.55 ± 779.55 0.008 2397.06 ± 749.35 2310.41 ± 782.32 0.002 1803.30 ± 583.78 1673.17 ± 600.60 <0.001
intake (kcal d−1)
Total fiber intake 17.81 ± 9.19 15.88 ± 8.58 <0.001 19.63 ± 10.24 17.24 ± 9.32 <0.001 16.26 ± 7.89 14.25 ± 7.16 <0.001
(mg d−1)
Cereal fiber intake (mg d−1) 8.02 ± 5.35 7.02 ± 4.80 <0.001 9.16 ± 5.96 7.85 ± 5.18 <0.001 7.06 ± 4.58 6.00 ± 4.01 <0.001
Fruit fiber intake (mg d−1) 3.28 ± 3.12 2.97 ± 2.84 0.003 3.42 ± 3.41 3.20 ± 3.13 0.110 3.17 ± 2.89 2.73 ± 2.45 0.001
Vegetable fiber intake (mg d−1) 3.71 ± 3.63 3.60 ± 2.85 0.268 3.89 ± 4.24 3.77 ± 3.02 0.423 3.57 ± 3.03 3.40 ± 2.60 0.164

BMI, body mass index; TC, total cholesterol; HDL, high density lipoprotein cholesterol. Data are presented as mean ± standard deviation (SD) for continuous variables or participants
(percentage) for categorical variables.
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representative estimate, appropriate sampling weights,
primary sampling unit, and strata information were con-
sidered in our analyses. Following the NHANES analytical
guidelines,37 2-year sample weights for NHANES 2009–2010,
2011–2012 and 2013–2014 are provided on public-use files. To
combine these cycles to produce 6-year estimates, a new 6-year
weights can be calculated by dividing the 2-year weights by
3 (the number of 2-year cycles). The detailed command to
create new weights is available in https://wwwn.cdc.gov/nchs/
nhanes/tutorials/module3.aspx. The approach to get weighted
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and 95% confidence interval (CI) were calculated from logistic
regression models. Dose–response relationship was evaluated by
using restricted cubic spline functions with three knots located
at the 5th, 50th, and 95th percentiles of the exposure distribution
in the multivariate-adjusted model 2. All p-values were two-sided,
and p ≤ 0.05 indicated statistical significance.
Results

ORs is available in https://wwwn.cdc.gov/nchs/nhanes/tutor- The comparisons of baseline characteristics between hyperuri-

ials/module9.aspx. All descriptive data were presented as mean
± standard deviation for continuous variables, and frequency
and percentage for categorical variables. In order to compare
the differences in means of continuous variables between
hyperuricemia group and non-hyperuricemia group, Student’s
t-test (normally distributed data) or non-parametric test (non-
normally distributed data) was applied as appropriate.
Differences in categorical variables were evaluated by chi2 tests.
Intakes of dietary fiber were categorized based on quartiles (quar-
tile 1: <25th percentile, quartile 2: ≥25th to 50th percentile, quar-
tile 3: ≥50th to 75th percentile, quartile 4: ≥75th percentile).
Logistic regression models were used to investigate the associ-
ation among intakes of total, cereal, fruit, and vegetable fiber
and hyperuricemia, separately, and the lowest quartile was used
as the reference category. Model 1 was adjusted for age and sex.
Model 2 was further adjusted for BMI (continuous), race, edu-
cational level, smoking status, alcohol consumption, total energy
intake (continuous), recreational physical activity, hypertension,
diabetes, TC and HDL levels (continuous). Then, stratified ana-
lyses were conducted by sex and age to determine the associ-
ations between fiber intake and hyperuricemia. Odds ratio (OR)
cemia group and non-hyperuricemia group according to
gender are presented in Table 1. Among 12 869 participants,
the overall prevalence of hyperuricemia was 19.35% (22.32% in
men; 16.67% in women). Compared with controls, both men
and women with hyperuricemia tended to be older and non-
Hispanic Black, to have hypertension, and to have higher
levels of BMI and TC. Daily total energy intake, vigorous rec-
reational activity, HDL and dietary intakes of total and cereal
fiber were significantly lower in subjects with hyperuricemia.
The female participants with hyperuricemia were more likely
to have a higher prevalence of a lower education level,
smoking at least 100 cigarettes in life, not having at least 12
alcohol drinks per year, diabetes, and a lower level of fruit
fiber intake (all p value < 0.05).
The weighted ORs (95% CIs) of hyperuricemia based on
quartiles of dietary intakes of total, cereal, fruit, and vegetable
fiber are presented in Table 2. In univariate logistic regression
analyses, for the highest quartile vs. lowest quartile, intakes of
total fiber (0.57 (0.47–0.68)), cereal fiber (0.53 (0.44–0.65)) and
fruit fiber (0.81 (0.66–0.98)) were associated with a decreased
risk of hyperuricemia. After adjustment for age and sex (model 1),

Table 2 Weighted ORs and 95% CIs for hyperuricemia according to the quartiles of dietary fiber intake

Crude Model 1 Model 2

OR (95% CI) OR (95% CI) OR (95% CI)

Total fiber (g d−1)

<10.75 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
10.75 to <15.30 0.81 (0.69–0.94** 0.77 (0.66–0.89)** 0.77 (0.65–0.92)**
15.30 to <21.50 0.66 (0.57–0.76)** 0.61 (0.52–0.70)** 0.65 (0.55–0.78)**
≥21.50 0.57 (0.47–0.68)** 0.50 (0.41–0.61)** 0.58 (0.46–0.74)**
Cereal fiber (g d−1)
<3.90 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
3.90 to <6.40 0.82 (0.69–0.96)* 0.81 (0.68–0.96)* 0.80 (0.66–0.96)*
6.40 to <10.00 0.76 (0.66–0.88)** 0.76 (0.65–0.89)** 0.82 (0.68–0.99) *
≥10.00 0.53 (0.44–0.65)** 0.55 (0.45–0.67)** 0.61 (0.52–0.74)**
Fruit fiber (g d−1)
<1.10 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.10 to <2.35 1.07 (0.90–1.27) 1.03 (0.87–1.22) 1.02 (0.86–1.21)
2.35 to <4.40 0.89 (0.73–1.07) 0.83 (0.69–1.01) 0.87 (0.71–1.07)
≥4.40 0.81 (0.66–0.98)* 0.76 (0.62–0.93)** 0.94 (0.76–1.16)
Vegetable fiber (g d−1)
<1.40 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.40 to <2.80 1.02 (0.87–1.20) 1.00 (0.85–1.18) 0.94 (0.79–1.13)
2.80 to <4.75 1.09 (0.92–1.29) 1.05 (0.88–1.25) 1.03 (0.84–1.27)
≥4.75 0.98 (0.82–1.16) 0.93 (0.79–1.10) 0.95 (0.76–1.18)

CI, confidence interval; OR, odds ratio. Model 1 adjusted for age and gender. Model 2 adjusted for age, gender, race, BMI, educational level,
smoking status, alcohol consumption, daily total energy intake, hypertension, diabetes, physical activity, TC and HDL. The lowest quartile of
dietary fiber intake was used as the reference group. Results are survey-weighted. * p < 0.05; ** p < 0.01.

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the results were similar to the crude ORs (95% CIs). Further
adjustment for race, BMI, educational level, smoking status,
alcohol consumption, recreational activity, daily total energy
intake, hypertension, diabetes, TC and HDL (model 2), total and
cereal fiber intakes were inversely associated with the risk of
hyperuricemia, whereas the association of fruit fiber intake with
hyperuricemia was no longer statistically significant. The corres-
ponding ORs (95% CI) of hyperuricemia for quartile 4 of total,
cereal and fruit fiber intake were 0.58 (0.46–0.74), 0.61 (0.52–0.74),
0.94 (0.76–1.16), respectively. However, no significant association
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the highest vs. lowest quartile, the OR of hyperuricemia was
0.52 (0.38–0.72) for total fiber intake and 0.52 (0.41–0.67) for
cereal fiber intake in multivariate analysis (model 2) for men.
For women, after adjustment for multiple covariates, com-
pared with quartile 1, the ORs of hyperuricemia for quartile 2,
quartile 3 and quartile 4 of total fiber intake were 0.82
(0.67–1.01), 0.73 (0.59–0.91) and 0.77 (0.55–1.07), respectively.
However, no significant association was found between cereal
fiber intake across quartiles 2 to 4 compared with quartile 1.
In the stratified analyses by age, for participants younger than

was observed between vegetable fiber intake and the risk of hyper-
uricemia with or without adjustment for confounders.
We also conducted analyses for relationship between
dietary fiber intake and hyperuricemia risk stratified by sex
(Table 3) and age (Table 4). In the stratified analyses by sex, for
45 years old, the OR (95% CI) of hyperuricemia was 0.53
(0.35–0.79) for total fiber intake and 0.45 (0.33–0.62) for cereal
fiber intake for the highest quartile versus lowest quartile in
multivariate analysis, and the corresponding results were 0.68
(0.48–0.97) and 0.78 (0.61–1.00) for subjects aged 45+ years.

Table 3 Weighted ORs and 95% CIs for hyperuricemia according to the quartiles of dietary fiber intake, stratified by gender

Crude Model 1 Model 2

OR (95% CI) OR (95% CI) OR (95% CI)

Male
Total fiber (g d−1)
<11.65 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
11.65 to <16.80 0.76 (0.60–0.97)* 0.76 (0.60–0.97)* 0.73 (0.55–0.97)*
16.80 to <23.71 0.62 (0.50–0.76)** 0.63 (0.51–0.77)** 0.63 (0.48–0.83)**
≥23.71 0.48 (0.39–0.60)** 0.49 (0.39–0.61)** 0.52 (0.38–0.72)**
Cereal fiber (g d−1)
<4.35 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
4.35 to <7.40 0.74 (0.59–0.91)** 0.74 (0.60–0.92)** 0.71 (0.55–0.91)**
7.40 to <11.45 0.74 (0.61–0.91)** 0.75 (0.61–0.91)** 0.78 (0.62–0.98)*
≥11.45 0.51 (0.40–0.65)** 0.50 (0.39–0.65)** 0.52 (0.41–0.67)**
Fruit fiber (g d−1)
<1.05 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.05 to <2.43 1.11 (0.84–1.47) 1.11 (0.83–1.47) 1.08 (0.80–1.45)
2.43 to <4.65 0.78 (0.63–0.98) * 0.79 (0.63–0.98)* 0.85 (0.66–1.11)
≥4.65 0.91 (0.70–1.18) 0.92 (0.71–1.19) 1.09 (0.83–1.43)
Vegetable fiber (g d−1)
<1.45 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.45 to <2.95 0.91 (0.70–1.18) 0.91 (0.70–1.18) 0.90 (0.68–1.19)
2.95 to <4.95 1.02 (0.80–1.30) 1.03 (0.81–1.31) 1.03 (0.79–1.34)
≥4.95 0.93 (0.74–1.17) 0.94 (0.75–1.19) 0.93 (0.71–1.21)
Female
Total fiber (g d−1)
<10.10 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
10.10 to <14.15 0.81 (0.68–0.96) 0.74 (0.62–0.88) 0.82 (0.67–1.01)
14.15 to <19.50 0.63 (0.52–0.76) 0.58 (0.47–0.70) 0.73 (0.59–0.91)*
≥19.50 0.56 (0.42–0.75) 0.51 (0.37–0.69) 0.77 (0.55–1.07)
Cereal fiber (g d−1)
<3.60 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
3.60 to <5.75 0.91 (0.72–1.15) 0.89 (0.70–1.15) 0.96 (0.74–1.26)
5.75 to <8.75 0.78 (0.61–0.99)* 0.77 (0.60–0.98)* 0.90 (0.68–1.19)
≥8.75 0.56 (0.43–0.72)** 0.59 (0.45–0.77)** 0.80 (0.60–1.07)
Fruit fiber (g d−1)
<1.10 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.10 to <2.35 1.03 (0.81–1.32) 0.94 (0.73–1.22) 0.98 (0.76–1.26)
2.35 to <4.29 0.99 (0.75–1.29) 0.84 (0.64–1.10) 0.89 (0.67–1.17)
≥4.29 0.70 (0.51–0.97)* 0.58 (0.41–0.83)** 0.79 (0.54–1.15)
Vegetable fiber (g d−1)
<1.40
1.40 to <2.70 1.16 (0.91–1.47) 1.10 (0.85–1.44) 0.99 (0.74–1.33)
2.70 to <4.50 1.18 (0.92–1.50) 1.08 (0.84–1.39) 1.08 (0.80–1.44)
≥4.50 1.04 (0.84–1.28) 0.91 (0.74–1.12) 1.03 (0.77–1.36)

CI, confidence interval; OR, odds ratio. Model 1 adjusted for age. Model 2 adjusted for age, race, BMI, educational level, smoking status, alcohol
consumption, daily total energy intake, hypertension, diabetes, physical activity, TC and HDL. The lowest quartile of dietary fiber intake was
used as the reference group. Results are survey-weighted. * p < 0.05; ** p < 0.01.

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Paper Food & Function

Table 4 Weighted ORs and 95% CIs for hyperuricemia according to the quartiles of dietary fiber intake, stratified by age

Crude Model 1 Model 2

OR (95% CI) OR (95% CI) OR (95% CI)

<45 years
Total fiber (g d−1)
<10.75 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
10.75 to <15.30 0.90 (0.71–1.13) 0.81 (0.64–1.03) 0.79 (0.61–1.03)
15.30 to <21.50 0.68 (0.52–0.90)** 0.60 (0.45–0.80)** 0.61 (0.44–0.85)**
≥21.50 0.68 (0.51–0.92)* 0.50 (0.37–0.69)** 0.53 (0.35–0.79)**
Cereal fiber (g d−1)
<3.90 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
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3.90 to <6.40 0.83 (0.65–1.07) 0.83 (0.65–1.06) 0.77 (0.59–0.99)*

6.40 to <10.00 0.66 (0.51–0.85)** 0.65 (0.51–0.84)** 0.63 (0.49–0.83)**
≥10.00 0.51 (0.39–0.67)** 0.49 (0.37–0.64)** 0.45 (0.33–0.62)**
Fruit fiber (g d−1)
<1.10 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.10 to <2.35 1.26 (0.92–1.72) 1.26 (0.92–1.71) 1.28 (0.97–1.70)
2.35 to <4.40 0.88 (0.65–1.20) 0.87 (0.64–1.17) 0.86 (0.63–1.18)
≥4.40 1.06 (0.76–1.46) 1.06 (0.76–1.44) 1.26 (0.92–1.73)
Vegetable fiber (g d−1)
<1.40 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.40 to <2.80 0.97 (0.76–1.23) 0.93 (0.73–1.19) 0.90 (0.69–1.16)
2.80 to <4.75 1.10 (0.85–1.43) 1.10 (0.84–1.44) 0.99 (0.72–1.37)
≥4.75 1.05 (0.79–1.40) 1.01 (0.77–1.33) 1.00 (0.72–1.40)
≥ 45 years
Total fiber (g d−1)
<10.75 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
10.75 to <15.30 0.73 (0.59–0.90)** 0.73 (0.59–0.90)** 0.77 (0.61–0.99)*
15.30 to <21.50 0.60 (0.48–0.74)** 0.60 (0.48–0.74)** 0.72 (0.55–0.94)*
≥21.50 0.48 (0.37–0.61)** 0.48 (0.37–0.61)** 0.68 (0.48–0.97)*
Cereal fiber (g d−1)
<3.90 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
3.90 to <6.40 0.80 (0.64–0.99)* 0.80 (0.64–0.99)* 0.85 (0.66–1.10)
6.40 to <10.00 0.82 (0.68–0.98)* 0.82 (0.69–0.98)* 1.00 (0.80–1.25)
≥10.00 0.56 (0.44–0.71)** 0.56 (0.44–0.71)** 0.78 (0.61–1.00)
Fruit fiber (g d−1)
<1.10 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.10 to <2.35 0.94 (0.77–1.15) 0.94 (0.77–1.15) 0.91 (0.72–1.13)
2.35 to <4.40 0.83 (0.66–1.05) 0.83 (0.65–1.05) 0.88 (0.68–1.14)
≥4.40 0.66 (0.52–0.83)** 0.66 (0.52–0.83)** 0.84 (0.65–1.10)
Vegetable fiber (g d−1)
<1.40 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.40 to <2.80 1.03 (0.82–1.28) 1.02 (0.82–1.27) 0.95 (0.75–1.20)
2.80 to <4.75 1.03 (0.83–1.28) 1.03 (0.83–1.27) 1.08 (0.84–1.40)
≥4.75 0.88 (0.72–1.07) 0.88 (0.72–1.07) 0.93 (0.72–1.20)

CI, confidence interval; OR, odds ratio. Model 1 adjusted for gender. Model 2 adjusted for gender, race, BMI, educational level, smoking status,
alcohol consumption, daily total energy intake, hypertension, diabetes, physical activity, TC and HDL. The lowest quartile of dietary fiber intake
was used as the reference group. Results are survey-weighted. * p < 0.05; ** p < 0.01.

In the restricted cubic spline model, a nonlinear inverse
association ( pfor nonlinearity < 0.01) between total dietary fiber
intake and hyperuricemia was detected (Fig. 2). The risk of
hyperuricemia dropped with an increasing intake of total fiber
and reached a plateau approximately at 27 g d−1 (OR: 0.4; 95%
CI: 0.29–0.56).
The dose–response relationship between cereal fiber intake
and hyperuricemia is shown in Fig. 3. Cereal fiber intake was
inversely associated with the risk of hyperuricemia in a linear
manner ( pfor nonlinearity = 0.71). The OR of hyperuricemia
decreased as cereal fiber intake increased. Cereal fiber showed
significantly protective effects on hyperuricemia when intake
of cereal fiber reached 8 g d−1 (OR: 0.78; 95% CI: 0.61–0.99).
Because no significant associations were observed among
dietary intakes of fruit and vegetable fiber and the risk of
hyperuricemia, we did not analyse the dose–response relation-
ship between fruit and vegetable fiber and the risk of
hyperuricemia.
Discussion
In the large sample, nationally representative cross-sectional
study, we explored the relationship between dietary fiber
intake and the risk of hyperuricemia. After adjustment for
multiple potential confounders (age, sex, BMI, race, edu-
cational level, smoking status, alcohol consumption, total
energy intake, physical activity, hypertension, diabetes, TC and
HDL), total dietary fiber intake was inversely associated with
the risk of hyperuricemia in general U.S. adults. When strati-

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Food & Function
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Fig. 2 Dose–response relationship between total dietary fiber intake
and hyperuricemia by the restricted cubic spline model. The lowest level
of total fiber intake (3 g d−1) was used as the reference group. The
association was adjusted for age, gender, race, BMI, educational level,
smoking status, alcohol consumption, daily total energy intake, hyper-
tension, diabetes, physical activity, TC and HDL. The solid line and
dashed line represent the estimated ORs and the corresponding 95%
confidence intervals, respectively. OR, odds ratio.
Fig. 3 Dose–response relationship between cereal fiber intake and
hyperuricemia by the restricted cubic spline model. The lowest level of
cereal fiber intake (1 g d−1) was used as the reference group. The associ-
ation was adjusted for age, gender, race, BMI, educational level, smoking
status, alcohol consumption, daily total energy intake, hypertension, dia-
betes, physical activity, TC and HDL. The solid line and dashed line rep-
resent the estimated ORs and the corresponding 95% confidence inter-
vals, respectively. OR, odds ratio.
fied by sex and age, the inverse associations between total
dietary fiber intake and hyperuricemia were statistically signifi-
cant in men, women, 20 to <45 y group and older than 45 y
group.
Several studies have also examined the association between
total fiber intake and hyperuricemia. A cross-sectional study
found an inverse correlation between dietary fiber intake and
hyperuricemia among 9384 adult subjects without diabetes,
cancer and/or heart diseases.31 Another cross-sectional ana-
lysis of nutrition and serum uric acid in two Caucasian
This journal is © The Royal Society of Chemistry 2019
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Paper
cohorts showed that the consumption of fiber was significantly
inversely related to the serum uric acid concentration in the
Australian cohort but not in the Norway subjects.20 It was
suggested that dietary fiber possibly present the beneficial
effect on serum uric acid when associated with a higher intake
of fats and that fiber was not significantly related to serum
uric acid in the Norway cohort probably due to the relatively
low intake of fat. In the analysis of Korea population, Ryu KA
et al. found that hyperuricemia subjects had a significantly
lower intake of fiber compared with controls.38 Our finding of
the inverse association of total dietary fiber intake with hyper-
uricemia was consistent with most of the aforementioned
studies. However, previous studies did not explore the relation-
ship between hyperuricemia and different sources of dietary
fiber intake.
In our study, we further examined the association between
intakes of cereal, fruit, and vegetable fiber and the risk of
hyperuricemia. Our findings suggested that cereal fiber intake
was associated with the decreased risk of hyperuricemia in
men, whereas no significant association was observed between
hyperuricemia and consumption of dietary fiber from fruits
and vegetables. To our knowledge, this is the first population-
based study to explore the possible relationship between
various sources of dietary fiber intake and hyperuricemia.
Available studies on the association between cereal fiber
intake and hyperuricemia are very limited. Based on published
studies, the exact explanation for the differences of cereal fiber
intake on hyperuricemia between males and females is not
clear. Further studies are needed to clarify the gender differ-
ence. No significant association was observed between fruit
fiber intake and hyperuricemia, and this might be partly
caused by the low proportion of dietary fiber intake from
fruits. Another hypothesis is that most of the fruits contain
fructose,39 and the deleterious effects of fructose may counter-
act the protective effects of fiber in fruits to some extent.40
We also found a nonlinear relationship between total fiber
intake and the risk of hyperuricemia. When total fiber intake
was up to 27 g d−1, the risk of hyperuricemia was reduced 60%
in comparison with 3 g d−1. Moreover, cereal fiber intake had
a linear inverse association with the risk of hyperuricemia.
Although the underlying mechanism of the association
between fiber intake and hyperuricemia has not been fully elu-
cidated, several hypotheses have been suggested. A possible
mechanism could be that the viscosity and bulkiness of
dietary fiber interfere with the absorption of purine or adenine
in the digestive system.30,41 Moreover, fiber was proposed to be
able to enhance the intestinal motility and have a potential
effect on binding uric acid in the gut for excretion.42
There are several strengths in this study. First of all, the
large sample size (12 869 subjects included) increased the stat-
istical power; therefore, the results would be more reliable.
Second, the inverse association of total fiber intake and cereal
fiber intake with hyperuricemia remained statistically signifi-
cant after adjustment for potential confounders, which auth-
enticated the associations. Third, we assessed the dose–
response relationships between dietary intakes of total fiber and
Food Funct.

Paper
different sources of fiber and the risk of hyperuricemia.
Moreover, the association between various sources of dietary
fiber intake and hyperuricemia was examined for the first time.
However, our study has some limitations to acknowledge.
First, this is a cross-sectional study which is difficult to make
causal inference, and prospective longitudinal studies and
trials are needed to establish a causal association between
dietary fiber intake and hyperuricemia. Second, dietary data
were calculated by the average of two 24 h recalls. Although
the data of the two dietary recalls were significantly correlated,
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they might be influenced by recall bias and cannot represent
an individual’s usual intake. In addition, there may be residual
confusion caused by incomplete adjustment for dietary
factors.
Conclusions
In conclusion, intakes of total and cereal fiber were inversely
associated with the risk of hyperuricemia in the U.S. general
adult population.
Conflicts of interest
The authors declare no conflicts of interest.
Acknowledgements
This work was supported by the grant from the Natural
Science Foundation of China [No. 81703206] and China
Postdoctoral Science Foundation [No. 2017M622146].
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