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IMPACT OF DIET COUNSELLING ON PATIENTS

SUFFERING FROM GOUT

A DISSERTATION
Submitted To The Indira Gandhi National Open University
In Partial Fulfillment of the Requirement for the Degree of

MASTER OF SCIENCE IN DIETETICS


AND
FOOD SERVICE MANAGEMENT
2013

Submitted by:
SANGITA SLARIA
Enrolment Number: 092458763

SCHOOL OF CONTINUING EDUCATION


INDIRA GANDHI NATIONAL OPEN UNIVERSITY

STUDENT CERTIFICATE
The work embodied in this dissertation entitled "Impact of Diet Counselling On patient
suffering from gout" has been carried out by me under the supervision of Mrs. Neeru . This
work is original and has not been submitted by me for the award of any other degree to this or any
other university

Date:
Place:

Sangita Slaria

CERTIFICATE OF DISSERTATION COUNSELLOR


This is to certify that the dissertation work entitled Impact of Diet Counselling on patient
suffering from gout submitted to Indira Gandhi National Open University in partial
fulfillment of the requirement for the degree of Master of Science in Dietetics and Food
Service Management, is a bonafide research work carried out by Sangita Slaria under my
supervision and no part of this dissertation has been submitted for any other degree.
The assistance and help received during the course of investigation has been fully
acknowledged.

Date:

COUNSELLOR

Place:

Mrs. Neeru
IGNOU Study Centre
Govt. Medical College & Hospital
Sector-32 Chandigarh

ACKNOWLEDGEMENT
In the first place I would like to record my sincere and deep gratitude to my supervisor
Ms Neeru for her cooperation, encouragement, interest and stimulating suggestions,
without whom I would never have been able to bring this work into present shape.
My sincere thanks to Dr. Nandini Kapoor, coordinator, IGNOU Study center, GMCH-32,
Chandigarh for her valuable advice and infinite understanding.
I convey my special acknowledgement to faculty and staff of Government Medical
College and Hospital, sector-32, Chandigarh for their constant help, support and
cooperation.
I am very grateful to all the respondents of my study for co-operating with me in giving
frank and valuable information for this investigation. Without their co-operation, this
study could not have been realized.
The love, moral support, motivation and good wishes bestowed upon me by my parents,
brother, sister were a source of inspiration, encouragement and co-operation received
from them. I dedicate this work to them, to honor their love, patience and support.
Last but not the least, thank you GOD for everything.

Date:

Sangita Slaria

CONTENTS

Sr. No.

Contents

1.

Introduction

2.

Review of literature

3.

Material and Methods

4.

Results and Discussion

5.

Summary and Conclusion


6.

References

7.

Appendix-I

Page No.

ABSTRACT
The present study was conducted to observe the impact of diet counseling on patients
suffering from Gout. The gout has increased in prevalence and incidence in recent years
and the clinical pattern of gout is becoming more complex.The greatest increase has been
observed in primary gout in older men and it affects women more commonly after
menopause.During the study it was found that gout patients were having more of purine
rich diet,consumption of excess alcohol,use of diuretics,chronic renal failure and genetic
factor which predisposed them for obesity,hypertension,hyperlipidemia and insulin
resistance.Diet counseling was imparted to the patients were encouraged to follow a low
purine and low fat diet The present study was aimed at evaluating the reduction in uric
acid level in gout patients through diet counselling. Significant reduction of uric acid level
has been observed in patients who are on low purine and low fat diet.

INTRODUCTION
Gout is a painful and potentially disabling form of arthritis that has been around since
ancient times. The first symptoms usually are intense episodes of painful swelling in
single joints, most often in the feet, especially the big toe. The swollen site may be red
and warm. Hyperuricemia is a metabolic disorder marked by an excess of uric acid in the
blood, which is the product of a disorder in purine metabolism. Urates, deposited in tophi
in joints, and tissues produce state called gout (inflammatory arthritis or tophaceous gout).
This term "gout" should not be used when referring to isolated hyperuricemia. For a
reason yet unknown, some individuals have difficulty in eliminating uric acid, the final
product of purine metabolism.
Gout is sometimes referred to as the disease of kings. This is because people long have
incorrectly linked it to the kind of overindulgence in food and wine only the rich and
powerful could afford. In fact, gout can affect anyone, and its risk factors vary.
Fortunately, it is possible to treat gout and reduce its very painful attacks by avoiding food
and medication triggers and by taking medicines that can help. When the blood level of
urate, the end-product of purine metabolism,reaches its physiologic limit of solubility,it
may crystallize into monosodium urate (MSU) in the tissues and cause gout. Gout affects
at least 1% of the population in Western countries and is the most common inflammatory
joint disease in men older than 40 years of age.
There are two different types of gout:

Primary hyperuricaemia refers to an increased level of uric acid in the blood. This
type of gout is usually caused by a hereditary abnormality in the kidneys, which renders
the body incapable of excreting uric acid fast enough.

Secondary hyeruricaemia is the more common form of gout seen in most doctors'
surgeries. It can be a result of some other medical condition. It can also be caused by
diuretics (fluid tablets) or alcohol. Some people experience gout when they eat certain
foods.

Nearly all cases of primary gout cases are idiopathic. This means that the cause of
the hyperuricemia cannot be determined. Primary gout is most likely the result of a

combination of genetic, hormonal, and dietary factors. Secondary gout is caused


by medicines or by medical conditions other than a metabolic disorder. Lifestyle factors.
Drinking excessive amounts of alcohol can raise your risk of gout. Beer is the kind of
alcohol most strongly linked with gout, followed by spirits. Moderate wine consumption
does not appear to increase the risk of developing gout.
Alcohol use is highly associated with gout in younger adults. Binge drinking particularly
increases uric acid levels. Alcohol appears to play less of a role among elderly patients,
especially among women with gout.
Alcohol increases uric acid levels in the following three ways:

Providing an additional dietary source of purines (the compounds from which uric
acid is formed)

Intensifying the body's production of uric acid


Interfering with the kidneys' ability to excrete uric acid . Choices you make in your
everyday life may increase your risk of gout. Excessive alcohol use generally more
than two drinks a day for men and more than one for women increases the risk of gout.
Medical conditions. Certain diseases and conditions make it more likely that you'll
develop gout. These include untreated high blood pressure (hypertension) and chronic
conditions such as diabetes, high levels of fat and cholesterol in the blood
(hyperlipidemia), and narrowing of the arteries (arteriosclerosis).
Certain medications. Thiazide diuretics are "water pills" used to control hypertension.
The drugs are strongly linked to the development of gout. A large percentage of patients
who develop gout at an older age report the use of diuretics.
Several other medications can increase uric acid levels and raise your risk for gout. These
include:
Aspirin -- low doses of aspirin reduce uric acid excretion and increase the chance for
hyperuricemia. This may be a problem for older people who take baby aspirin (81 mg) to
protect against heart disease.

Niacin (used to treat cholesterol problems)

Pyrazinamide (used to treat tuberculosis)


Family history of gout. A family history of gout is present in close to 20% of patients
with this condition. Three genetic locations have been associated with the body's uric acid
handling and gout. Some people with a family history of gout have a defective protein
(enzyme) that interferes with the way the body breaks down purines.
If other members of your family have had gout, you're more likely to develop the disease.
Age and sex. Middle-Aged Adults. Gout usually occurs in middle-aged men, peaking in
the mid-40s. It is most often associated in this age group with obesity, high blood
pressure, unhealthy cholesterol levels, and heavy alcohol use.
Elderly. Gout can also develop in older people, when it occurs equally in men and
women. In this group, gout is most often associated with kidney problems and the use of
diuretics. It is less often associated with alcohol use.
Children. Except for rare inherited genetic disorders that cause hyperuricemia, gout in
children is rare. en. Men are significantly at higher risk for gout. In males, uric acid levels
rise substantially at puberty. In about 5 - 8% of American men, levels exceed 7 mg/dL
(indicating hyperuricemia). However, gout typically strikes after 20 - 40 years of
persistent hyperuriceMmia, so men who develop it usually experience their first attack
between the ages of 30 and 50.
Women. Before menopause, women have a significantly lower risk for gout than men,
possibly because of the actions of estrogen. This female hormone appears to facilitate uric
acid excretion by the kidneys. (Only about 15% of female gout cases occur before
menopause.) After menopause the risk increases in women. At age 60 the incidence is
equal in men and women, and after 80, gout occurs more often in women
Gout occurs more often in men than it does in women, primarily because women tend to
have lower uric acid levels than men do. After menopause, however, women's uric acid
levels approach those of men. Men also are more likely to develop gout earlier usually
between the ages of 40 and 50 whereas women generally develop signs and symptoms
after menopause.

Obesity. Researchers report a clear link between body weight and uric acid levels. In one
Japanese study, overweight people had two to more than three times the rate of
hyperuricemia as those who maintained a healthy weight. Children who are obese may
have a higher risk for gout in adulthood.
Lead Exposure. Chronic occupational exposure to lead is associated with build-up of uric
acid and a high incidence of gout.
Organ Transplants. Kidney transplantation poses a high risk for renal insufficiency and
gout. In addition, other transplantation procedures, such as heart and liver, increase the
risk of gout. The procedure itself poses a risk of gout, as does the medication
(cyclosporine) used to prevent rejection of the transplanted organ. Cyclosporine also
interacts with indomethacin, a common gout treatment.
Eating too many foods rich in purines can cause or aggravate gout in some people.
Sign and Symptoms. The signs and symptoms of gout are almost always acute, occurring
suddenly often at night and without warning. They include:
Intense joint pain. Gout usually affects the large joint of your big toe, but it can occur in
your feet, ankles, knees, hands and wrists. The pain is likely to be most severe within the
first 12 to 24 hours after it begins.
Lingering discomfort. After the most severe pain subsides, some joint discomfort may
last from a few days to a few weeks. Later attacks are likely to last longer and affect more
joints.
Inflammation and redness. The affected joint or joints become swollen, tender and red.
Prevalence of Gout. According to the Centers for Disease Control and Prevention
(CDC), gout affects approximately 3 million people in the United States each year.
Overall, more than 6 million American adults have had gout during their lifetime. The
condition is more common in men between the ages of 40 and 50, and in women,
incidence increases after menopause. Gout is rare in children and young adults.
The study shows that a diet low in purine should be the first therapeutic option for
controlling hyperuricemia in patients with similar characteristics to the once presented in

study. The study also shows that a reduction in the intake of food sources of purines, fat
and an increase in the intake of liquids have been just as efficient in decreasing serum uric
acid level.
An apparent increase in the prevalence of gout over the last 23 decades has been
compounded by limitations in largely antiquated strategies for treating gouty
inflammation and lowering serum urate levels. As a result, there remain substantial gaps
in the capacity to manage subsets of refractory disease. In this review, we focus on how
recent advances can pave the way to translational research targeted toward enriching
current management options for gout.
The prevalence of gout appears to be increasing. This is partly a reflection of changes in
diet, increases in longevity, hypertension, metabolic syndrome, and advanced renal
disease, and the broad use of diuretics in clinical practice. Management of gout in the
elderly, in organ transplant recipients, and in patients with renal insufficiency and
allopurinol intolerance can be particularly challenging. As reinforced by a recent study
(160), diagnosis and management could certainly be enriched in part by optimizing
medical and patient education efforts related to the disease.

RESEARCH OBJECTIVES
The present study as conducted with the following objectives :
1. To study the dietary pattern, life styles and risk factors
2. To study nutritional profile of gout patient consuming high purine and high fat diet
3. To educate the community about healthy choices of food and food groups.

REVIEW OF LITERATURE
Defination
Gout is a common form of inflammatory arthritis, often causing recurrent episodes of pain
and swelling of certain joints. Although the pathophysiology of gout is well understood
and clinically efficacious therapies are available, recent studies have shown that the
prevalence and incidence of gout in the United States are increasing( 1,4).When the blood
level of urate, the end-product of purine metabolism, reaches its physiologic limit of
solubility,it may crystallize into monosodiumurate (MSU) in the tissues and cause
gout.Gout affects at least 1% of the population inWestern countries and is the most
common inflammatory joint disease in men older than 40 years of age(5,6)
Hyperuricemia is a metabolic disorder marked by an excess of uric acid in the blood,
which is the product of a disorder in purine metabolism. Urates, deposited in tophi in
joints, and tissues produce a state called gout (inflammatory arthritis or tophaceous gout).
This term "gout" should not be used when referring to isolated hyperuricemia. For a
reason yet unknown, some individuals have difficulty in eliminating uric acid, the final
product of purine metabolism (7,8).
The clinical spectrum ranges from the classic presentation of episodic, acute inflammation
of the first metatarsophalangealjoint (ie, podagra) to tophaceous gout, chronic
polyarticular arthritis, urate nephrolithiasis, and interstitial nephropathy.Historically a
disease of affluent, middle-aged or older men with overindulgent lifestyles, gout has now
become more democratic by affecting more women and a wider range of
socioeconomic groups.
Cause
High levels of uric acid in the blood (hyperuricemia) is the underlying cause of gout. This
can occur for a number of reasons, including diet, genetic predisposition, or
underexcretion of urate, the salts of uric acid.[9] Renal underexcretion of uric acid is the
primary cause of hyperuricemia in about 90% of cases, while overproduction is the cause
in less than 10%.[10] About 10% of people with hyperuricemia develop gout at some point
in their lifetimes.[11]The risk, however, varies depending on the degree of hyperuricemia.

When levels are between 415 and 530 mol/l (7 and 8.9 mg/dl), the risk is 0.5% per year,
while in those with a level greater than 535 mol/l (9 mg/dL), the risk is 4.5% per year.[12]

Lifestyle
Dietary causes account for about 12% of gout,[13] and include a strong association with the
consumption of alcohol, fructose-sweetened drinks, meat, and seafood.(14,15) Other triggers
include physical trauma and surgery(16) Recent studies have found that other dietary
factors once believed associated are, in fact, not, including the intake of purine-rich
vegetables (e.g., beans, peas, lentils, and spinach) and total protein. [17][15] With respect to
risks related to alcohol, beer and spirits appear to have a greater risk than wine.[18]
The consumption of coffee, vitamin C and dairy products, as well as physical fitness,
appear to decrease the risk.[19[20][21] This is believed partly due to their effect in
reducing insulin resistance[21]
Genetics
The occurrence of gout is partly genetic, contributing to about 60% of variability in uric
acid

level.[22] Three genes called SLC2A9, SLC22A12 and ABCG2 have

been

found

commonly to be associated with gout, and variations in them can approximately double
the risk.[23][24] Loss of function mutations in SLC2A9 and SLC22A12 cause hereditary
hypouricaemia by reducing urate absorption and unopposed urate secretion. [24]A few rare
genetic disorders, including familial juvenile hyperuricemic nephropathy, medullary
cystic kidney disease, phosphoribosylpyrophosphate synthetase, superactivity, and
hypoxanthine guanine phosphoribosyltransferase deficiency as seen in Lesch-Nyhan
syndrome, are complicated by gout[22]
Medical conditions
Gout frequently occurs in combination with other medical problems. Metabolic
syndrome,

combination

of abdominal

obesity, hypertension, insulin

resistance and abnormal lipid levels, occurs in nearly 75% of cases.25] Other conditions
commonly

complicated

by

gout

include: polycythemia, lead

poisoning, renal

failure, hemolytic anemia, psoriasis, and solid organ transplants.[24][26] Abody mass
index greater than or equal to 35 increases a male's risk of gout threefold. [15] Chronic lead
exposure and lead-contaminated alcohol are risk factors for gout due to the harmful effect

of lead on kidney function.[27] Lesch-Nyhan syndrome is often associated with gouty


arthritis

Medication
Diuretics have been associated with attacks of gout. However, a low dose of
hydrochlorothiazide does not seem to increase the risk. [28] Other medicines that increase
the risk include niacin and aspirin (acetylsalicylic acid).[14] The immunosuppressive drugs
ciclosporin and tacrolimus are also associated with gout,[16] the former more so when used
in combination with hydrochlorothiazide.[19] Gout presenting in the metatarsal-phalangeal
joints of the big toe.Note the slight redness of the skin overlying the joint.

Signs and Symptoms

Gout can present in a number of ways, although the most usual is a recurrent attack of
acute inflammatory arthritis (a red, tender, hot, swollen joint).[13]The metatarsalphalangeal joint at the base of the big toe is affected most often, accounting for half of
cases[25] Other joints, such as the heels, knees, wrists and fingers, may also be
affected[25] Joint pain usually begins over 24 hours and during the night.[25] The reason
for onset at night is due to the lower body temperature then. [12] Other symptoms may
rarely occur along with the joint pain, including fatigue and a high fever.[12]20]
Long-standing

elevated uric

acid levels

(hyperuricemia)

may

result

in

other

symptomatology, including hard, painless deposits of uric acid crystals known as tophi.

Extensive tophi may lead to chronic arthritis due to bone erosion.[5] Elevated levels of uric
acid may also lead to crystals precipitating in the kidneys, resulting in stone formation
and subsequent urate nephropathy.[29]

Prevalence
Gout affects around 12% of the Western population at some point in their lifetimes, and
is becoming more common.[13][10] Rates of gout have approximately doubled between 1990
and 2010.[5]This rise is believed due to increasing life expectancy, changes in diet, and an
increase in diseases associated with gout, such as metabolic syndrome and high blood
pressure.[15] A number of factors have been found to influence rates of gout, including age,
race, and the season of the year. In men over the age of 30 and women over the age of 50,
prevalence is 2%.[30]
In the United States, gout is twice as likely in African American males as it is in European
Americans.[31] Rates are high among the peoples of the Pacific Islands and the Mori of
New Zealand, but rare in Australian aborigines, despite a higher mean concentration of
serum uric acid in the latter group.[32] It has become common in China, Polynesia, and
urban sub-Saharan Africa.[10] Some studies have found attacks of gout occur more
frequently in the spring. This has been attributed to seasonal changes in diet, alcohol
consumption, physical activity, and temperature.[33]
Comparing epidemiologic studies of gout is complicated by the lack of a standard case
definition for gout (eg, self-reported vs physician-diagnosed), varying methods of
calculating prevalence and incidence, and the different populations studied. For example,
relying on self-reports likely overestimates the true prevalence and incidence.
The American College of Rheumatology(ACR) Classification Criteria for gout have not
been well-validated in different populations, and confirming the diagnosis by
arthrocentesis to demonstrate the presence of MSU crystals in synovial fluid or tophi is
not practical at the population level[34]
Nevertheless, a recent review of studies from Western countries suggests that both the
prevalence and incidence of gout have been increasing over the past 4 decades [35].The

Table summarizes these incidence and prevalence studies. Two studies in the United
Kingdom, one in the 1970s and the other in 1993, showed that overall gout prevalence
increased from 0.26% to 0.95%[36,37]. In a US managed care population, the prevalence of
gout in a population aged older than 75 years (ascertained by pharmacy claims for gout
medications) doubled from2.1% to 4.1% between 1990 and 1999 [38]. In the National
Health Interview Survey, the overall prevalence of self-reported gout rose from 0.5% in
1969 to 0.9% in 1996[39,40]. In New Zealand, the gout prevalence in Maori men rose from
4.5% in 1956 to 13.9% in 1992, and from 0.7% to 5.8% in European men [41] The
prevalence may also be increasing in developing countries in the Far East.[42,43]
A number of factors have been proposed to explain the increasing prevalence of gout in
the United States. This increase may be a result of increased longevity, because
prevalence is a function of both disease incidence and disease duration. Other
contributing factors may be the increased prevalence of hypertension and metabolic
syndrome, increased use of diuretics and low-dose aspirin, dietary trends, change in
demographics (eg, increased African American and Hispanic populations, in which the
metabolic syndrome is more common), increased prevalence of endstage renal disease,
and increases in organ transplantation[35]
Table1. Increased Gout in the Overall Adult Population in Western Industrialized
Countries over the Past 4 Decades as Evaluated by Different Survey Approaches
Author/study (ref)
Currie (Ref 37)

Year
1978

Population
Great Britain

Gout statistics
Prevalence 2.6/1000 (physician
diagnosis)

Harris, et al (Ref 38)

1995

Great Britain

Prevalence 9.5/1000 (physician


diagnosis)

Klemp, et al (Ref 41)

1956-1966

New Zealand

Prevalence 7-20/1000

1992

New Zealand

(in Caucasians, ACR criteria),


Prevalence 58/1000

National Arthritis

1969

US

Prevalence 5/1000 (self-report)

1996

US

Prevalence

Data Workgroup (Ref 39)


National Health
Interview Survey (Ref 40)

report)

9.4/1000

(self-

Wallace, et al (Ref 31)

1990, 1999

US

Prevalence 2.1/1000 (age >75


years, drug codes) Prevalence
4.1/1000 (age >75 years)

Mikuls, et al (Ref 44)

1990-1999

Great Britain

Incidence 14/10 000 patientyears


(physician diagnosis, drug
codes)

Campion, et al (Ref 7)

1963-1978

US veterans

Incidence 14/10 000 patientyears


(physician diagnosis, drug
codes)

Arromdee, et al (Ref 45)

1977-1978 ,

US (Rochester,

1995-1996

MN)

Incidence 4.5/10 000 patientyears (ACR criteria), Incidence


6.2/10 000 patient-years

MATERIAL AND METHODS


The Principle Objective of present study was to assess the effect of low Purine and low fat
diet on patients suffering from gout . The other objective was to collect information &
data of the factors that leads to risk of gout. The third aim was to assess eating habits and
type of lifestyle they adopted which may be involved in gout. After assessing the various
factors, the objective become to create awareness among the community and to educate
them about dietary modification and change in life style to prevent or delayed the onset of
the disease.
The systematic methodology adopted for study is discussed under the following headings:
1) Preliminary Steps:i) Locale of study
ii) Size & Selection of the subject
iii) Method of investigation

iv) Formulation of questionnaire

v) Presenting the questionnaire


2) Collection of data: i) General information
iii) Biochemical assessment
v) Miscellaneous information
3) Statistical analysis:i) Arithmetic means
4) Nutrition counseling.
i)

ii) Information relevant to disease.


iv) Dietary survey
vi) Anthropometric measurements.
ii) Standard deviation

1. PRELIMINARY STEPS:
Locale of the study: The present study was confined to GMSH Sector-16, Chandigarh
only. The study was conducted on patients visiting OPD. For the second part of the
investigation, the subject was taken from different sections of society working in various

ii)

capacities at different institutions.


Size and selection of the subjects: A discussion was carried out with the doctors at
various levels in order to explain the objectives of this study and to explore the
possibilities of carrying out this investigation. A sample of 57 patients was selected who
were undergoing treatment.

iii)

Method of investigation: The method used for present investigation was questionnairecum- interview method.

iv)

Formulation of questionnaire: Two separate questionnaire-cum-interview schedules


were prepared. The questionnaires consisted of an exhaustive list of questions, which

were prepared and arranged in a systematic order to facilitate smooth communication and
conversation for collection of data. These include both Yes/ No and multiple choice
questions. These were framed to general & dietary information from the subjects.
Ambiguous words and personal questions were avoided. Data of biochemical and
anthropometric measurement were recorded in the questionnaires.
v)

Presenting the questionnaire: Before the actual administration schedules they were
pretested on a pilot sample of 5 subjects each. This was done in order to check any flaws
in the questionnaires. After pretesting, the questionnaires were appropriately modified for
final information.
2. COLLECTION OF DATA:
The data was collected by questionnaire- cum- interview schedules formulated for the
purpose. Questionnaire-I was filled up by the investigator and questionnaire- II was
personally handed over to each of 55 respondents. The respondents were briefly explained
about the nature and purpose of study. The subjects were explained that the results
depended on their cooperation and help in responding to the questions.

i)

General information: Information regarding the name, age, occupation, address,


educational qualification, type of family, family income and family composition of the
subjects was obtained.

ii)

Information relevant to the disease: This part of questionnaire include information


regarding type of gout, its diagnosis, type of treatment and time of starting the treatment.
Activity pattern of the individuals is closely linked to incidence of gout. Information
regarding activity pattern at work place and at home i.e. sedentary, moderate or heavy,
any exercise or walking undertaken by the patients and regularity in doing so was
obtained.

iii)

Biochemical assessment: The reports of various tests related to uric acid levels, and
blood glucose levels were examined to know their correlation with the incidence of the
disease.

iv)

Dietary information: It contained questions pertaining to food habits, dietary pattern,


quantities of various food items (from various food groups) consumed and type of protein

used by the subjects. The daily dietary intake of respondents was recorded for a period of
three consecutive days by 24 hour recall method. Energy, protein, total fat, iron, calcium,
vitamin A, thiamine, riboflavin, niacin, folic acid, ascorbic acid, vitamin B12 and fiber
content were calculated on the basis of raw foods consumed by using standard food
composition tables(Gopalan et al, 1989)
In questionnaire-II, the information about the type and quantity of protein used by the
subjects was recorded. The information about the intake of fast food and fried food was
also recorded.
v)

Miscellaneous information: Information about the drinking and smoking habits and
other addiction habits of the subjects was recorded.

vi)

Anthropometric measurements: Anthropometric measurements of height, weight and


BMI were taken.
Height(cms.): Non stretchable steel measuring tape was used to take the
measurement in centimeters. The subjects were asked to stand on flat cemented floor
without shoes with heels together and toes apart, buttocks, shoulders, and back touching
the wall. The head was comfortably erect and subjects were asked to look straight at eye
level. Slight pressure was applied on head to reduce the hair thickness and height was
then recorded in centimeters up to 0.5 cm accuracy (Jelliffe, 1966).
Weight (kg): The total body weight of the individual respondents was recorded in
kilograms using portable weighing machine (Krupps) with zero adjustments. The subjects
were asked to stand on the weighing machine without shoes, with minimum clothing and
without any support. The weight was recorded up to 0.2 kg Accuracy (Jelliffe, 1966)
BMI (Kg/m): Measured height was converted into meter a and using the weight
measurements, the BMI of the subjects was calculated by using the following formula:
BMI= weight (kg)/height (m)
3. STATISTICAL ANALYSIS
The following statistical measures were taken for the interpretation of quantitative data:

i)

Arithmetic mean: It refers to central value of the distribution. It is defined as sum of


individual values divided by total number of observations.
Arithmetic Mean (Xm) =
Where

X/N

X = sum of observation

N= Total number of observations


ii)

Standard Deviation(SD): Standard Deviation gives the numerical expression of the


extent of deviation of observed data from the arithmetic mean.
=

( X X m )2 /N

Where Xm is the actual mean value & X is standard value.


The investigation has been aimed to study the incidence of gout, analysis certain dietary
and personal habits of patients, which are regarded to be predisposing to gout. Food
intake was assessed in order to compare the actual nutrient intake of subjects with
recommended allowances. The study was conducted on gout patients visiting OPD in
Hospital. Observations of the study reveal following results:
1. Age of the Subjects
Table-2 Distribution of subjects according to their ages:

Age (Years)

Respondents(N=50)
Number

Percentage

Below 18

nil

Nil

20-30

10

30-40

23

46

40-50

22

44

In the present investigation it was found that the incidence of gout is highest among age
group of 30 40 i.e. 46%, followed by in the age group 40 50 i.e. 44%. Thus it shows
that risk of gout is higher among the age group between 30-40years.
2. Occupation of subjects:
Table -3 Distribution of subjects according to occupation:
Occupation
Students
Working
Retired
Housewives

Respondents (N=50)
Number
Percentage
2
4
25
50
Nil
Nil
15

30

Table 3 clearly
indicates

that

incidence

of

gout

is

same

among working
class (50%) and non- working class (50%)
3. Sex of Patients:
Table -4 Distribution of subjects according to Sex :
Sex
Male
Female

Respondents (N=50)
Number
Percentage
15
30
70
50

Table -4 shows
that out of 50

patients, 30% were Females while the remaining 70% were Males.
4. Habitation of Subjects:
Table -5 Distribution of subjects according to their habitation:

Habitation

Respondents (N=50)
Number

Percentage

Urban

30

60

Rural

20

40

Table 5 indicates
that

there

difference

is
of

only 20% in urban and rural patients for gout incidence. The incidence of cancer in urban
was found to be 60% whereas in rural was 40%. The increasing incidence of gout in rural
areas can be attribute to adoption of urban lifestyle, modernization and consumption of
alcohol, tobacco and excess use of fertilizers in fields.
5. Type of Family:

Family type i.e. nuclear or joint affects the nutritional status of respondents
Table -6 Distribution of subjects according to their type of family:

Types of Family
Nuclear
Joint

Respondents (N=50)
Number
Percentage
35
70
15
30

The incidence of gout found to be higher i.e. 70% in subjects with nuclear family, 30% in
subjects with joint family.
6. Family history:
The respondents were asked about their family history regarding the disease to know if
their ancestors or siblings were suffering from any type of gout disease.
Table -7 Distribution of subjects according to their family history:

Family history of
respondents
Yes
No

Respondents (N=50)
Number
Percentage
5
45

10
90

Thus the investigation revealed that 10% of the subjects had positive family history of the
disease while 90% of the subjects developed gout disease due to their faulty eating habits
and sedentary lifestyle.
7. Economic status of the patients:
The patients were categorized into Group I, II and III according to their monthly income:Up to
10, 000
Group I
10,000 20,000 Group II
Above 20,000 Group III

Table -8 Distribution of subjects according to their economic status:


Economic Status
Group 1
Group II
Group III

Respondents (N=50)
Number
Percentage
20
40
10
20
20
40

As shown in above table, most patients i.e. 40% fall in Group I and Group III. The
incidence was found to be 20% in Group II. So, it is clearly seen that with increasing

income and standards of living, the incidence of gout also increases due to more
expenditure on refined foods and tendency to eat outside. And gout risk increases in low
socio- economic Group as the people become addict to drinking.
8. Type of gout:
Table -9 Distribution of subjects according to their type of gout:
Type of Gout
Primary Gout
Secondary Gout

Respondents (N=50)
Number
Percentage
20
40
30
60

9 Activity pattern of the Respondents:


Inactivity adds not only to energy imbalance but also to mental stress, anxiety and sleep
disturbances, Research has shown that poor diet and not being active are 2 key factors that
can increase a gout risk. The evidence for this strong .
Table -10 Distribution of subjects according to their activity pattern:
Activity pattern
Sedentary
Moderate

Respondents (N=50)
Number
Percentage
40
80
10
20

The above table shows that the maximum incidence of gout was found in non- working or
less active class The gout is prevalent in the sedentary and moderate working class i.e.
80% in sedentary and 20% in moderate working class. The incidence may be due to less
physical activity in non working class.

10 Physical Activity under taken by the subject:


Table -11 Distribution of subjects according to their activity pattern:
Physical Activity
No Exercise
Irregular
Regular

Respondents (N=50)
Number
Percentage
25
50
15
30
10
20

Table 11 clearly indicates that incidence of gout was more in subjects who did not
perform any exercise i.e. 50%, while 30%, subjects who used to do irregular exercise and
only 20% subjects performed regular exercise. Research has shown that poor diet & not
being active are 2 key factors that can increase a persons gout risk.

11 Weight Status of the subjects:


Weight of the subject i.e. whether he/she is normal/ overweight/ obese is determined by
comparing his/her weight with standards according to the heights. If the person is having
a standard weight within a given range, he/ she is normal but if he/she is 5- 10% above
standard weight then he/she is overweight while if he/she is more that 10% above his/her
standard weight, then he/she is considered obese.
Table -12 Distribution of subjects according to WHO (2000) Criteria of BMI:
Classification
Under weight
Normal
Overweight
Grade I
Grade II

Respondents (N=50)
< 18.5
18.5 22.9
23 24.5
29.9
>30

Number
10
12
15
10

Percentage
20
30
30
20

The table 12 shows that 30% of the subjects were overweight, 50% were obese whereas
20% were of normal weight. Being overweight or obese can have, far reaching health
consequences. According to the US center for disease control & prevention (CDC), excess
body weight increases the risk for number of diseases includes ; Heart diseases, Blood
pressure, Diabetic and Gout.

12 Nutritional Knowledge of the Subjects:


Table 13 depicts the nutritional knowledge of subjects i.e. whether the patients were
aware about the role of nutrition in the incidence or prevention of the disease.
Table -13 Distribution of subjects according to their nutritional knowledge:
Awareness
Nutritionally aware
Unaware

Respondents (N=50)
Number
Percentage
15
30
35
70

35 out of 50 patients did not have any nutritional information. Only 15 patients were
aware about the importance of nutrition in their life. This indicates that incidence of gout
is more prevalent among who are ignorant about the diet they had. So, education about
low purine and low fat diet should be imparted to community to lessen the incidence of
gout.

13 Uric Acid level of the subjects:


Table -14 Distribution of subjects according to their uric acid levels
Range of uric acid
(in mg/dl)

Respondents (N=50)
Number
Percentage

2.4-7.0(Males)
2.4-5.5(Females)

--------

---------

7.5- 8.2(Males)
5.5-6.1(Females)

27

54

7.5 8.5(Males)
5.5 - 6.5(Females)

23

46

54% of the subjects were having uric acid levels ranging between 7.5-8.2(Males) and
5.5-6.1(Females) mg/dl while 46% of subjects were having levels between 7.5
-8.5(Males) and5.5-6.5(Females)mg/dl. These levels come back to normal after the diet
counseling and medication.

14 Creatinine level of the subjects:


Table 15 Distribution of subjects according to their Creatinine levels

Range of Creatinine
(in mg/dl)

Respondents(N=50)
Number

percentage

--------

---------

0.8-1.6

15

10

0.8-1.0

45

90

0.8 1.4(Normal)

10% of the subjects were having slightly increased creatinine levels ranging between 0.81.6 mg/dl while 90% of subjects were having normal levels i.e between 0.8-1.0 mg/dl.

15 Urea level of the subjects:


Table -16 Distribution of subjects according to their urea levels

Range of Blood Urea in


mg/dl

Respondents(N=50)
Number

Percentage

--------

---------

10-51

27

54

10-46

23

46

10 50(normal)

54% of the subjects were having urea levels ranging between 10-51 mg/dl while 46% of
subjects were having levels between 10-46mg/dl.

16 Fasting blood Glucose:


Table -17 Distribution of subjects according to their blood glucose levels:

FBS (mg/dl)
<110
70-110
>110

Respondents(N=50)
Number

Percentage

28
14
8

56
28
16

The investigation shows that 56% of the respondents had normal blood glucose
levels(i.e. <110 mg/dl), 28% had normal levels i.e. 70-110 mg/dl and 16% of the subjects
had poor control on diabetes and their fasting blood glucose levels were > 110 mg/dl.

17 Medication:
Types of Medication Non-steroidal anti-inflammatory drugs (NSAIDs) are a type of painkiller usually
recommended as an initial treatment for gout. They work by reducing the levels of pain
and inflammation.

NSAIDs often used to treat gout include:

Diclofenac

Indometacin

Naproxen
Colchicine
If NSAIDs are ineffective, colchicine can be used instead. Colchicine is derived from the
Autumn crocus plant. It is not a painkiller, but works by reducing the ability of the urate
crystals to inflame the joint lining (synovium), which reduces some of the inflammation
and pain associated with a gout attack.
Colchicine can be an effective treatment for gout. However, it should be used at low doses
since it can cause upsets, including:

nausea

abdominal pain

diarrhoea
Colchicine can cause major gut problems if taken in too high a dose. It is important to
follow the recommended dose. For most people, this means taking no more than two to
four tablets a day.
Corticosteroids
Corticosteroids are a type of steroid sometimes used to treat severe cases of gout that do
not respond to other treatment.

18 Smoking Habits:
Table -18 Distribution of subjects according to their smoking habits:

Smoking habit
Smokers
Non-smokers

Respondents(N=50)
Number

Percentage

11
2

84.61
15.38

Table 18 shows that out of 13 males, 84.61% were smokers while 15.38% did not smoke.

19 Alcohol Consumption:
Table -19 Distribution of subjects according to their alcohol consumption:

Alcohol Consumption
Drinkers
Non- drinkers

Respondents(N=50)
Number

Percentage

9
4

69.23
30.76

Table 19 reveals that 69.23% males were consuming alcohol while 30.76% did not
consume alcohol.
Studies have shown that alcohol consumption increases the level of serum uric acid[4447] and that excess intake of alcohol is associated with an increased risk of initial
occurrence of gout[.48-52] Results from the Health Professionals Follow-up Study
showed that the risk of incident gout attack increased as the amount of alcohol consumed
increased and that this risk varied according to the type of alcoholic beverage consumed.
Beer conferred a larger risk than spirits, whereas moderate wine drinking did not increase
risk.[53]
An Internet-based case-crossover study has shown the relation of amount and type of
alcoholic beverages to the risk of recurrent gout attacks.The approximate time interval in
which a recurrent attack would occur after alcohol consumption is also estimated in this
study.
A website for this study (https://dcc2.bumc.bu.edu/GOUT) on an independent secure
server within the Boston University Medical Center domain was constructed. A
rheumatologist reviewed all medical records and the checklist information. Information
abstracted from medical records or the checklist, and data collected from the
questionnaires submitted by the participant to confirm the diagnosis of gout according to
American College of Rheumatology (ACR)Criteria for gout[.54] A subject was
considered as having aconfirmed history of gout if his/her medical record showedthe
presence of characteristic urate crystals either in thejoint fluids or in tophus, or presence
of at least 6 of the 12 clinical, laboratory, and radiography phenomenon listed in ACR
Criteria.[54].Of 197 subjects who completed both Hazard-period and Control-period

Questionnaires, 179 subjects (91%) fulfilled the ACR Criteria for gout.[54] Gout
diagnosis was confirmedby the presence of the crystal in only 37 subjects (19%). A total
of 186 subjects (94.4%) returned a signed Medical Record Release Form. Of those, we
obtained 172 subjectsmedical records or physicians checklists from their physicians,and
164 (95.3%) met ACR Criteria for gout.[54]
Although many studies have found that alcohol consumption increases the levels of uric
acid[,44-46] its relation to the risk of incident gout attack has not been
consistent.Hochberg et al[.55] found no association between alcohol useand risk of
development of gout among participants in two cohort studies. Recently, Choi et al.[53]
showed a strong dose-response relationship between the amount of alcohol consumed and
the initial gout attack.

FOOD AND NUTRIENT INTAKE


Your diet plays an important role in both causing gout and reducing the likelihood of
suffering further painful attacks of gout. If you already suffer from gout, eating a diet that
is rich in purines can result in a five-fold increase in gout attacks. Losing weight alone
can reduce blood uric acid levels, and the number of acute attacks suffered. Weight-loss
will also help to reduce the stress on weightbearing joints e.g. hips, knees, ankles and
feet. However, it is important to avoid any type of crash dieting, as going without food for
long periods and rapid loss of weight can increase uric acid levels and trigger painful gout
attacks. A combination of balanced healthy eating and regular physical activity is the best
way to lose weight safely and
maintaining a healthy diet.
Cereals: The cereal intake by males ranged from 160g to 280g with a mean of (22927)g.
The mean cereal intake in the diet by females ranged from 160g to 260g with a mean of
(22121)g but the suggested intake is 250g.so the nutritional inadequacy was 91.6% &

88.4% for male & females respectively. Majority of the subjects were consuming wheat
flour(Chapattis, parantha, bread),rice . Most of the subjects were consuming 3-4 chapattis
per meal and frequency of rice consumption by most of the subjects was twice and thrice
in a week.
Pulses and legumes: The mean daily intake of pulses and legumes by males and females
was(36.612.5)g & (32.67.7)g respectively. Compared with suggested intake (20g), the
nutritional inadequacy for male & females was 183% & 163% respectively. It was
observed that 70% subjects were consuming pulses & legumes regularly while others
were consuming on alternate days or twice a week. All the respondents were using
mixture of whole and split pulses. Bean shaped dals are consumed more than whole dals
Milk and Milk products: Majority of the subjects were consuming milk in tea only.
Curd was also consumed daily but paneer, buttermilk or ice- cream were consumed
weekly or occasionally. Whole milk was consumed by majority of the objects while only
30-20% subjects were consumed skimmed milk. The daily average intake of milk and
milk products by males& females was (36170.9) g & (29322.6)gm respectively. When
compared with the suggested intake is 400-500g, the nutritional inadequacy for males and
females comes out to be 72.2% & 58.6% respectively.

Fruits and vegetables: The daily consumption of fruits & vegetables ranged from150 g
to 300g. The mean consumption of fruits and vegetables by males and females was
(25654.3)g & (28361.3)g respectively. The suggested intake is 500g/ day. So the
nutritional inadequacy for males was 51% while for female was 57%. Only 56% subjects
were consuming fruits regularly, remaining 44% were consuming twice a week or
irregularly. Mostly consumed fruits were seasonal fruits like: apple, banana, mango etc.
All the respondents consumed all the vegetables (roots, tubers, leafy vegetables & others).
Majority of the subjects were consuming vegetables twice a day. The subjects who
consumed pulses & legumes weekly or irregularly, preferred vegetables instead of pulses.
Being available seasonally, green leafy vegetable like spinach & mustard leaves were
mostly consumed by number of subjects.
Fats and Oils: The average intake of fats & oils by males was (25.84.3)g with
nutritional adequacy of 26% while females was (22.13.6)g with nutritional adequacy of

22%. the suggested intake is 10/ day. All the respondents were using combination of oils
& fats. It was found that 65% subjects were using mustard oil for deep frying while 25%
subjects used refined oil for the same purpose. Ten percent subjects were not consuming
paranthas at all while out of 35 who were taking, 25 were using desi- ghee while 10 were
using refined oil. Butter or desi- ghee were used by some subjects in dals or vegetables
while majority of subjects were not taking any additional fat in vegetables or dals.
Meat and poultry: All the respondents were not consuming non- vegetarian foods. The
result revealed that 80% subjects were not consuming non-vegetarian food while 20%
subjects were consuming these foods once a month. The average daily intake of meat and
poultry by meals was (113.628.6)g while by females was (81.512.3)g. with the
suggested intake of 75g, the nutritional adequacy for male and females was 151.5% and
109% respectively. All the respondents were consuming fish while chicken was consumed
by very less number of subjects.
Sugar and jaggery: The average daily intake of sugar and jiggery by male subject was
(22.33.8)g while by female subjects was (20.95.1)g. As compared to the intake (10)g,
the nutritional adequacy for males & females was 223% and 279% respectively.

Table20:

Food group

Suggested
intake(g)*

Average SD

%Adequacy
/inadequacy

Males

Females

Males

Females

Cereals

250

229.327

22121

91.6

88.4

Pulses & Legumes

20

36.612.5

32.67.7

183

163

500ltrs

36170.9

29322.6

72.2

58.6

Fruits & Vegetables

500

25654.3

282.861.3

51

57

Fats & oils

10

25.84.3

22.13.6

26

22

Meat & poultry

75

81.512.3

113.628.6

151

109

Milk &Milk products

Sugar & jaggery

10

22.33.8

20.95.1

223

279

Figure 1: Average Daily Food Intake By Male And Female subjects.


500
450
400
350
300
250
200
150
100
50
0

Suggested Intake
Avg.Intake of Male
Avg.Intake of Female

NUTRIENT INTAKE OF THE SUBJECT


Energy: The average daily intake of energy by male subjects was (2960532) Kcal as
compared to the recommended allowance of 2875 kcal, but the decreased suggested
intake for gout patient is 2375 kcal .So, the nutritional adequacy of RDA & decreased
suggested intake was found to be 295% & 124.6% respectively. Average daily intake of
energy by female subjects was 2618164 Kcal as compared to the recommended
allowance of 2225 kcal,but the decreased suggested intake for gout patient is 1725kcal
Thus, nutritional adequacy of energy by RDA & Increased suggested intake comes out to
be 176.6% and 517.6% respectively. Generally patients suffering from gout are obese so
energy should be reduced.

Figure 2: Average Daily Energy intake chart

3500
3000
2500
2000

Suggested Intake
RDA

1500

Avg.Intake

1000
500
0

Male

Female

Proteins: The average daily intake of proteins by males and female subjects was
(5020.6)g and (358.8)g which are more than the Suggested decreased intake. The RDA
value of proteins for male and females are 60g and 50g respectively in normal or other
cases but in gout moderate protein is recommended i.e. 30g and 25g. the nutritional
adequacy was in males is 83.3% and 166.7%and 79% & 140% in females respectively.

Figure 3 describe the average daily intake of proteins by males and females when
compared with RDA and Suggested increased intake.

Figure 3: Average Daily intake of Protein Chart

60

50

40
Suggested intake
RDA

30

Average intake
20

10

0
Males

Female

Carbohydrates: The average daily intake of carbohydrates by male subjects was


(331.445.9)g while by female subjects was (311.442)g. The intake of carbohydrates
were more as compared to suggested intakes i.e. 300g for both male and female
subjects.The RDA value for males and female are 350 . Complex carbohydrates should be
given such as whole wheat products like bajra, ragi etc. So, the nutritional adequacy of
RDA & decreased suggested intake in males 946 and 110.5 & In females were 103.7 and
889.7

Figure 4 Shows The Average Daily Intake Of Carbohydrates By Male


And Female Subjects

350
340
330
320

Suggested intake

310

RDA
Average intake

300
290
280
270
Male

Female

Fats and Oils: The average daily intake of fats by male subjects was (33.36.5) Kcal as
compared to the recommended allowance 20g, but the decreased suggested intake for
gout patient is 10g & The average intake of fats by female was 30.96.9g So, the
nutritional adequacy of fats for females was 154.5% and the nutritional adequacy of fats
for male was 166.5% .

Figure 5 Explains The Average Daily Intake Of Fats By Male And


Female Subjects As Compared To Suggested Values.
35
30
25
Suggested intake

20

RDA

15

Average intake

10
5
0
Males

Females

Dietary Fiber: The average daily intake of dietary fiber by male and female respondents
was (29.35.1)g (28.85.2)g respectively. The intake of fiber was found to be low as
compared to suggested intake of 60 g/day .The nutritional adequacy of fiber for male and
female respondents was 48.8% & 48% respectively.Intake of fibre should be increased as
it helps in lowering uric acid level.

Figure 6: Average Daily Fiber Intake Chart.

60
50
40
Suggested intake
30

RDA
Average intake

20
10
0
Males

Females

Ascorbic Acid: Higher vitamin C intake is independently associated with a lower risk of
gout. Supplemental vitamin C intake may be beneficial in the prevention of gout. The
intake of Ascorbic acid ranged from 10 30mg. The average daily intake of ascorbic acid
by male and female subjects was 23.95.8mg and 22.85.4 mg respectively. The
recommended value for ascorbic acid is 40 mg/ day, but suggested intake is 60 mg/day.
The nutritional adequacy was found to be 39.83% for males & 38% for females.

Figure 7: Average Daily Ascorbic Acid intake chart


60
50
40
Suggested intake
RDA

30

Average intake
20
10
0
Males

Female

Despite previous studies touting its benefit in moderating gout risk, new research reveals
that vitamin C does not reduce uric acid (urate) levels to a clinically significant degree in
patients with established gout. Vitamin C supplementation, alone or in combination with
allopurinol, appears to have a weak effect on lowering uric acid levels in gout patients
according to the results published in the American College of Rheumatology (ACR)
journal, Arthritis & Rheumatism. "While current treatments are successful in reducing the
amount of uric acid in the blood, there are many patients who fail to reach appropriate
urate levels and need additional therapies," explains lead author, Prof. Lisa Stamp, from
the University of Otago in Christchurch, New Zealand. "Vitamin supplementation is one
such alternative therapy and the focus of our current study, which looked at the effects of
vitamin C on urate levels in patients with gout."

The study showed that a modest dose of vitamin C (500mg/d) for 8 weeks had no
clinically significant urate lowering effect in patients with gout despite increasing plasma
ascorbate. These results differ from findings in hyperuricaemic healthy controls. The
uricosuric effect of modest dose vitamin C appears less in patients with gout both as
monotherapy and in combination with allopurinol.
"Though vitamin C may reduce risk of developing gout, our data does not support using
vitamin C as a therapy to lower uric acid levels in patients with established gout,"
concludes Prof. Stamp.

Table 21- Average daily nutrient intake of the respondents:

suggested

RDA

intake

Nutrient

Average intake SD

% adequacy

Male

Female

Male

Female

Male

Female

Male

Female

2375

1725

2875

2225

2960532.22

2618404.40

124.6

151.8

30

25

60

50

502.6

358.8

166.7

140.0

300

300

350

350

33145.9

311.441.99

110.3

103.8

Fat (g)**

10

10

20

20

33.66.5

30.96.9

336.0

309

Fiber (g)*

60

60

40

40

29.35.1

28.85.20

48.8

48

Ascorbic
Acid(mg)*

60

60

40

40

22.925.16

22.85.54

38.2

38.0

Energy(Kcal)*
Protein (g)**
Carbohydrate
(g)**

NUTRITION COUNSELING:
A nutrition counseling program was planned. Dietary Knowledge was imparted to each
subject through a pamphlet/ leaflets. General guidelines for maintaining good health were
given to the subjects. All the queries regarding diet were taken care of by the investigator.
The respondents were informed about the following aspects of nutrition & health:

Maintain ideal weight

Avoid High Purine content food

Restrict alcohol

Increase Dietary fiber intake

Take a low fat diet

Exercise for healthy life style

Take moderate protein


The thumb rule for dietary management is to advice the patient to try to cut down or
avoid:

Red meats

Organ meats such as brain, Kidneys, liver and heart.

Shellfish such as mussels, oysters, sea eggs.

Peas and beans.

Alcohol.especially beer and wine

Lentils, Spinach, Oatmeal, Cauliflower, Mushroom

Table22:Purine Content of Different Foods

Avoid foods highest in


purine(150-825
mg/100gm)
Brain

Limit foods containing moderate Consume foods lowest in


amount of purines

(50-150) purines (0 - 50 mg/100 gm

mg/100gm)
Whole grain bread or cereals

Kidney
Liver
Gravies

Cauliflower
Spinach
Legumes (beans,peas and lentils

Beverages
(coffee,tea and soda)
Refined cereals
Cheese
Eggs

Herring

Meat soup and broth

Fruits

Mushrooms
Asparagus
Oatmeal
Chicken
Spinach

Milk (low fat)


Nuts- Almonds

Sardines
Broth
Meat Extracts
Minced meat

Summary And Conclusion

The present investigation was undertaken to study the effect of low purine diet on patient
suffering from gout. The study include the presence of risk factors of gout and the
representative group of 50 respondents attending OPD, at GMSH sector-16, Chandigarh.
General information and information regarding their occupation, dietary habits, family
history about the disease and life style aspects was recorded with the help of interviewcum- schedule. Detailed information on food intake was recorded for three consecutive
days by using 24 hour recall method. The foods consumed were converted to their raw
equivalent and an average daily intake of Energy, Protein, Fats, important minerals and
vitamins were calculated on raw weight basis (ICMR, 1989). The relevant data regarding
type of treatment, nutritional awareness and activity pattern of respondents was collected.
Data regarding physical activity like walking and exercise or yoga was collected. Reports
of RFT like;uric acid, urea, serum creatinine, sodium; fasting blood sugar were collected.
Majority of the subjects i.e. 70% were Male and 30% were Females. The results revealed
that majority of the subjects came under age group of 30 40 years and 40- 50 years and
most of the subjects (30%) were non- working,50% were working and 4% were
students.60% of the subjects were urban and 40% belonged to rural areas.
The study showed that according to type of family, 30% respondents were from joint
families & 70% from nuclear families. 40% subjects belong to group III i.e. above
20,000 per month, 20% belonged to group II (
were from group I

10,000 20,000) and remaining 40%

10,000 and below).

The investigation revealed that most of the patients suffered from secondary gout.
The results showed that 50% respondents performed no physical activity (exercise/ yoga/
walking) while 30% were doing it irregularly. Only 20% subjects were doing exercise or
yoga or for a walk regularly. Many patients (50%) were obese while 30% were
overweight. Only 20% subjects were maintaining their desirable body weight.
The subjects showed that out of male subjects, 15.38% were non- smokers while 84.61%
were smokers. Out of 13 male respondents, 9 were consuming alcohol regularly or on
weekly basis while 4 subjects were not consuming alcohol at all.

Majority of the subjects i.e. 70% were not nutritionally aware and dietary advice was
being provided by the doctor while 30% subjects had nutritional knowledge.
Some of the subjects were vegetarian and other were non vegetarian and consumed egg,
chicken, fish, meat etc. Usual practice among most of the subjects was to consume
partially skimmed milk or whole milk (buffalo). Majority of the subjects used refined oil,
desi -ghee and vanaspati -ghee.
Consumption of fruits was irregular by most of the subjects while most vegetables (roots,
tubers, green leafy vegetables and other vegetables) were consumed by all the
respondents was examined in the investigation. Whole as well as washed pulses were
consumed by all the subjects & were consumed daily or alternate days by majority of the
subjects. Bean Shaped Dal such as Rajma, Rongi, Lobia and Soyabeen were consumed by
most of the subjects. Cereals were mostly consumed in form of chapatti. Dalia & Khichri
were mostly consumed by majority of the respondents.
Three main meals were consumed by most of the subjects. Consumption of food items by
subjects is as follows: cereals (229.327g by males, 22121g by females), pulses &
legumes (36.612.5g by males, 32.67.7g by females), Fruits & vegetables (25654.3g
by males, 282.861.3g by females), fats & oils(25.84.3g by males and 22.13.6g by
females), meat& poultry (81.512.3g by males, 113.628.6g by females) and Sugar &
Jaggery (22.33.8g by males & 20.93.8g by females) .
The intake of energy (2960532.22 Kcal by males, 2618404.40 Kcal by females) and
Protein (502.6 g by males and 358.8g by females) was higher than the recommended
value whereas intake of carbohydrate (33145.9g by males, 311.441.99g by females)
and fats (33.66.5g by males and 30.96.9g by females) was higher than the RDAs.
The intake of dietary fiber (29.35.1g by males and 28.85.20g by females) was lower
than the suggested values. The intake of ascorbic acid (22.925.16mg by males &
22.85.54 mg by females) was lower than the suggested intake.
Thus, it can be concluded that diet of gout patients were high in Energy, carbohydrates,
protein,but inadequate in fiber & ascorbic acid but were high in fats which predisposed
them to incidence of gout. The higher consumption of fried foods, snacks, refined foods,

low intake of dietary fiber and more amounts of sugar products were responsible cause of
overweight and obesity. Overweight and obesity were also leading cause of gout but were
high in fats which predisposed them to incidence of gout. Gout prevalence was more due
to less physical activity.
Therefore, nutrition education was imparted and were encouraged for the physical
exercise, yoga or to go for a walk regularly.
Two studies in theUnited Kingdom, one in the 1970s and the other in 1993, showed that
overall gout prevalence increased from 0.26% to 0.95%. In a US managed care
population, the prevalenceof gout in a population aged older than 75 years (ascertained by
pharmacy claims for gout medications) doubled from2.1% to 4.1% between 1990 and
1999.In the National Health Interview Survey, the overall prevalence of self-reported gout
rose from 0.5% in 1969 to 0.9% in 1996.In New Zealand, the gout prevalence in Maori
men rose from 4.5% in 1956 to 13.9% in1992, and from 0.7% to 5.8% in European
men.The prevalence may also be increasing in developing countries in the Far East.
Consume vegetable protein, nuts, legumes, and purine-rich vegetables, as they do not
increase the risk of gout and these food items (especially, nuts and legumes) are excellent
sources of protein, fiber, vitamins, and minerals. In fact, individuals who consumed
vegetable protein in the highest quintile of intake actually had a 27% lower risk of gout
compared with the lowest quintile. Furthermore, nut consumptions associated with several
important health benefits including a lower incidence of CHD, sudden cardiac deaths,
gallstones, and type 2 diabetes. Legumes or dietary patterns with increased legume
consumption have been linked to a lower incidence of coronary heart disease, stroke,
certain types of cancer, and type2 diabetes.The recent healthy eating pyramid
recommends 13 times daily consumption of nuts and legumes, which appears readily
applicable among patients with gout or hyperuricemia.

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APPENDIX-I
QUESTIONNAIRE
A.
1.
2.
3.
4.
5.
6.
7.
8.
9.

GENERAL INFORMATION
Name of Subject
:
Age
:
Sex
:
Address
:
Education Level
:
Occupation
:
Habitation
:
Marital Status
:
Caste/Religion
:

____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________

B. INFORMATION ABOUT THE FAMILY


1. Type of Family
:
Nuclear/Joint
2. Food Habits
:
Lacto-Veg / Ova-Veg /
Non-Veg / Vegetarian
Due
reasons

to

Economic/Religious/Health

3. Composition of Family :
S. No.

Name

Age

Sex

1.
2.
3.
4.
4. Total Family Income

Group I

Up to Rs. 10,000

Group II

Rs. 10,000- 20,000

Group III

Above Rs. 20,000

Relation to Subject

Occupation

C.
1.
2.
3.
4.
5.
6.

INFORMATION ABOUT THE DISEASE


Type of Gout?
When it was first diagnosed?
When was treatment started?
Type of treatment? Drugs/Diet
Any Family member suffering from Gout? Yes/No
How do you update your Books/Magazines/Knowledge about diseases?

Newspaper/ TV/ Internet


7. Do you think disease can be cured by changing dietary habits? Yes / No
D.
1.
2.
3.
4.

ACTIVITY PATTERN
Type of activity at work place?
Sedentary / Moderate/Heavy
Time spent at work place?
<8hr./8-10 hr./>10 hr.
Any activity undertaken at home?
Gardening/Sports/Other
Do you go for walk / exercise / Yoga?
Yes / No
If yes, specify:
Time spent :
_______________
Distance
:
_______________
5. Regularity in doing exercise? Daily/Alternate day/Weekly/Irregular
6. Means of going to work place? Car/Scooter /Cycle/Walk
E.
1.
2.
F.
1.

PSYCHOLOGICAL STRESS
At work place?
Less / More
At Home?
Less / More
DIETARY INFORMATION
Food Habits?
Lacto-Veg/Ova-Veg/Non-Veg/Veg
If Lacto-Veg:
a. Consumption of Milk/ :
Milk products:
Name
Amount
Milk
Curd
Paneer
Buttermilk
Ice Cream
Khoa
Any other
b. Type of Milk used :
If Non-Veg:

Whole / Toned / Double toned / Skimmed

a. Frequency of egg :

Daily / Twice weekly / Once consumption

a week / Occasionally
b. Form in which egg is:
Boiled/Poached/Fried/Omelet/Scramble/Other
consumed most frequently
c. Type of meat consumed: Fish/Chicken/Mutton/Other
2. Fat / Cooking oil used:
a. Type & quantity of oil/fat used daily :
Type

Amount

Mustard oil
______________________
Cottonseed oil
______________________
Sunflower oil
______________________
Groundnut oil
______________________
Soya oil
______________________
Rice oil
______________________
Desi Ghee
______________________
Butter
______________________
Vanaspati
______________________
Any Other
______________________
b. Amount purchased per month: ______________________
c. Type used for deep frying:
______________________
d. Type use for shallow frying:
______________________
e. Type used for paranthas:
______________________
f. Type used for chapattis :
______________________
g. Type used in Veg./Dals etc:
______________________
3. Consumption of Fruits:
a. Frequency of Fruit Consumption:

Twice daily/Once daily/


Alternate day/Twice a week / Irregular

b. Amount consumed at a time:


c. Fruits consumed commonly:

______________________
______________________

4. Consumption of Vegetables:
a. Type of vegetables consumed: Roots/Tubers/Green leafy/other vegetables
b. Quantity consumed at one meal:
1 katori / 2 katori
c. Frequency of consumption:
______________________
5. Consumption of Pulses & Legumes:
a. Type of Dal consumed :
Whole / Washed
b. Quantity consumed at one meal:
1 katori / 2 katori

c. Frequency of consumption:
d. Preferences:

Daily/Alternate days /Twice a week


______________________

6. Protein sources consumed:


a. Type & quantity of protein used :
Type
Paneer
Soya bean
Peas
Dry peas
Tofu
Milk
Mutton
Liver
Any other
b. Amount purchased per month:
c. Type used for cooking:
d. Protein source used in Prantha:
e. Special source used in Chapatti:

Amount
_________
_________
________
________
________
________
________
_________
_________
_______________________
_______________________
_______________________
_______________________

7. Consumption of Cereals:
a. Form in which cereal is mostly consumed:
Chapati/Parantha/Puri/Rice/Other
b. Number of chapattis in one meal:
c. Size of chapatti:
d. Frequency & amount of rice consumed:
e. Any other cereal preparation:
f. Amount of oil/ghee used:
G. MISCELLANEOUS
1. Do you Smoke?:
If yes, how frequently?:
2. Do you consume alcohol?:
If yes:
a. How frequently?:
b. How many pegs?:
c. How do you take it?:
d. When do you take it?:

2 / 3 / 4 or more
Small / Medium / Large
______________________
______________________
______________________

Yes / No
______________________
Yes / No
______________________
______________________
Neat / Diluted
Alone/ With friends

H. ANTHROPOMETRIC DATA
1. Weight:
___________________ Kg
2. Height:
___________________cms
3. BMI:
______________________

(Normal/Over wt./Obese)
4. What precautions are taking to maintain normal weight?
______________________
I.
1.
2.
3.
4.
5.
6.
7.
8.

BIOCHEMICAL TESTS
Serum Urea:
Serum Creatinine:
Uric acid:
TLC:
DLC:
FBS:
RBS:
Hb:

______________________
______________________
______________________
______________________
______________________
______________________
______________________
_____________________

J. 3-DAY DAILY DIET


First day
Meal

Menu

Ingredients

Amount

Ingredients

Amount

Early Morning
Breakfast
Mid Morning
Lunch
Evening Tea
Dinner
After Dinner
Second day
Meal

Menu

Early Morning
Breakfast
Mid Morning
Lunch
Evening Tea
Dinner
After Dinner

Third day
Meal
Early Morning
Breakfast
Mid Morning
Lunch
Evening Tea
Dinner
After Dinner

Menu

Ingredients

Amount