What dietary recommendations can help manage uric acid levels in a patient with a history of gout or kidney stones?

Foods High in Uric Acid: What to Avoid and Encourage

Patients with gout or hyperuricemia should strictly limit purine-rich meats, seafood, alcohol (especially beer), and sugar-sweetened beverages, while strongly encouraging low-fat dairy products and weight loss if overweight. 1

Foods to Limit or Avoid

High-Purine Meats and Seafood

• Organ meats (liver, kidney, sweetbreads), red meat, and game meats should be limited as they raise serum uric acid levels through increased purine metabolism 1, 2
• Shellfish and seafood increase gout risk significantly (relative risk 1.51) and should be consumed sparingly 1
• The Japanese dietary guidelines recommend consuming less than 400 mg of dietary purines per day for patients with gout or hyperuricemia 1

Alcohol

• Beer and spirits must be avoided or severely restricted as they raise uric acid through adenine nucleotide degradation and lactate production that impairs renal uric acid excretion 1, 3
• Consuming more than 1-2 alcoholic beverages in 24 hours increases flare risk by 40% with a clear dose-response relationship 1
• Complete alcohol abstinence is mandatory during active gout flares, especially when medical control is inadequate 1
• Wine consumption did not increase serum uric acid levels in cohort studies, distinguishing it from beer and spirits 1

Sugar-Sweetened Beverages and Fructose

• Sugar-sweetened beverages and energy drinks containing high-fructose corn syrup should be eliminated as they raise uric acid levels through increased production and/or decreased excretion 1, 2
• Fruit juices (particularly orange and apple juice) should be limited due to their high fructose content 1
• Foods rich in fructose, including certain sweet fruits, should be moderated 1

Foods to Encourage

Dairy Products

• Low-fat or non-fat dairy products (skimmed milk, low-calorie yogurt) are strongly encouraged as they are associated with lower gout risk and may have antihyperuricemic effects through uricosuric properties 1, 2

Other Beneficial Foods

• Cherries or cherry juice may help reduce serum urate levels and decrease the frequency of gout attacks 1
• Regular coffee consumption is negatively associated with gout 1
• Vegetables, nuts, legumes, and whole grains are healthy choices that may help prevent gout by reducing insulin resistance 4

Weight Management

• Weight reduction through daily exercise and limiting excess calories is essential for overweight/obese patients 1, 3
• Weight loss greater than 5% BMI is associated with 40% lower odds of recurrent gout flares and reduces serum uric acid independently of purine restriction 1, 3

Critical Limitations and Pitfalls

Dietary Modifications Have Limited Impact

• Dietary modifications typically provide only 10-18% decrease in serum uric acid, which is therapeutically insufficient for most patients with sustained hyperuricemia substantially above 7 mg/dL 1
• Pharmacologic urate-lowering therapy is required for most patients to achieve target serum uric acid <6 mg/dL, with dietary modifications serving as important adjuncts 1
• A unit of beer raises uric acid by only 0.16 mg/dL, and healthy diet patterns have even smaller effects 1

Avoid Patient-Blaming

• Providers should be mindful that gout has important genetic contributions, and dietary discussions should not be misinterpreted as "patient-blaming" as patients frequently feel stigmatized 1
• Dietary factors serve more as flare triggers than primary causes of sustained hyperuricemia 1

Don't Eliminate All Purines

• Eliminating all purine-rich foods is not recommended, including those that may have cardiovascular benefits such as fatty fish with omega-3 fatty acids 1

Management of Kidney Stones

For patients with uric acid kidney stones specifically:

• The most important risk factor for uric acid stone formation is low urine pH (below 5.5) rather than increased urinary uric acid excretion 5, 6
• Treatment consists of hydration (urine volume above 2000 ml daily) and urine alkalinization to pH 6.2-6.8 using potassium citrate or sodium bicarbonate 5
• Potassium citrate is the treatment of choice for prevention of recurrent uric acid calculi 5
• Dietary changes such as reduction of animal protein, sodium, refined sugars, oxalate-rich foods, and excessive calcium intake, along with increased oral fluids and dietary fiber, may benefit patients with recurrent calcium oxalate stones 7
• The KDIGO guidelines recommend limiting intake of foods rich in bioavailable potassium (e.g., processed foods) for people with CKD G3-G5 who have a history of hyperkalemia 8