_ _ _ _ _ handout 1 _ _ _ _ _
/ADA nutrition book/

/Low fat/       /1800 calories/
/Low oxalate/
/Low sugar/

    |
527 |
Purine-restricted Diet
(Approximately 150 mg)

PURPOSE
The purine-restricted diet is designed to decrease elevated blood
and urinary acid levels.

USE
For patients with gout and/or uric acid stones
in conjunction with drug therapy.

MODIFICATIONS
The following modifications are recommended.
1. Eliminate foods that contain 150 mg purines
   or more per serving.
2. Daily protein intake should not exceed 1 gm/kg of ideal body
   weight.^9  Do not exceed 3-4 oz meat per meal.
3. Maintenance of adequate carbohydrate intake to prevent tissue
   catabolism and/or ketosis. Avoid excess loads of dietary
   fructose.^7
4. Avoid excessive fat intake.
5. Maintain ideal weight.

   If patient is overweight, weight loss should be gradual.

   Rapid weight loss could induce ketonemia,
   which could trigger an attack of gout.

   The calorie level should be adjusted to 500 Kcal below that
   required for maintenance to effect a weight loss of
   1 to 2 pounds per week, or 6 pounds per month.

6. Alcohol consumption should be reduced or eliminated. Excessive
   amounts of alcohol may inhibit the renal excretion of urates
   due to lactic acid accumulation and this can lead to
   hyperuricemia.^1,^8
7. Fluid intake should be at least 2-3 quarts per day to
   eliminate the uric acid via the urine and prevent the
   formation of renal calculi.^10.^11
8. Liberal use of fruits and vegetables.

ADEQUACY
Due to the restriction of meat, the diet may be inadequate in
thiamin and iron according to the National Research Council's
Recommended Dietary Allowances, 1980.

RELATED PHYSIOLOGY
The end product of the metabolism of purines is uric acid. The
ingestion of preformed purines add to the burden of the uric acid
pool. In addition

|
| 528 SECTION X. MISCELLANEOUS & TEST DIETS

to drug therapy, a diet restricted in purine content will reduce
the excretion of uric acid by 200 to 400 mg per day and lower the
mean serum urate value by 1 mg/100 ml.

When the food intake is poor because of illness, it is essential
that high carbohydrate fluids be given so that adipose tissue is
not excessively catabolized, producing a ketotic state. Keto
acids promote urate retention by the kidney and hyperuricemia.

A diet high in fat should be avoided as (a) the body tends to
burn fat instead of carbohydrate, leading to ketosis and
acidosis, (b) abnormalities in lipid metabolism have often been
reported in patients with primary gout, or (c) it may hinder
weight control.

There is a strong positive correlation between body weight and
serum urate concentration.^1,^2  Rapid weight loss should be
avoided as ketonemia may increase serum urate by producing a
ketotic state.^5

Chronic ingestion of alcohol promotes (a) increased purine
production, resulting in increased hyperuricemia and
hyperaciduria,^1 (b) increased lactic acid, which favors urate
retention by the kidneys and hyperuricemia, (c) reduction of
urate clearance,^2 (d) acceleration of nucleotide catabolism with
a resultant increase in purine biosynthesis de novo.^2 The added
purine load resulting from regular ingestion of beer may also be
detrimental.^3

Dehydration contributes to uric acid nephrolithiasis.^1
Hydration and alkalinization of the urine are an important part
of the treatment for uric acid nephropathy along with drugs that
inhibit the enzyme xanthine oxidase.^1  A high fluid intake
minimizes the potential risk of uric acid nephropathy or stone
formation.^4

The protein is restricted because the rate of endogenous purine
production is greater on a high-protein diet and uric acid
synthesis from glycine is accelerated when the protein content
of the diet is increased.

To effect a neutral or slightly alkaline urine when allopurinol
is prescribed, the diet should be liberal in its content of
fruits and vegetables.

The Arthritis Foundation
1314 Sring Street N.W.
Atlanta GA 30309
has a pamphlet on gout as part of its Medical Information Series,
which would be of benefit to patients.

REFERENCES
 1. German, D.C., and Holmes, E.W.:
    Gout and hyperuricemia: Diagnosis and management.
    Hosp Pract 21:119, 1986
 
 2. German, D.C., and Holmes, E.W.:
    Hyperuricemia and Gout.
    Med Clin North Am 70(2):419, 1986
 
 3. Gibson T., Rodgers, A.V., Simmonds, H.A., and Toseland, P.:
    Beer drinking and its effect on uric acid.
    Br J Rheumatol 23:203, 1984
 
 4. Palella, T.D., and Kelly, W.N.:
    An approach to hyperuricemia and gout.
    Geriatrics 39(11):101, 1984
 
 5. Wisner, D.E., and Simkin, P.A.:
    Management of gout and hyperuricemia.
    Prim Care 11(2), 1984
 
 6. Clifford, A.J., and Story, D.L.:
    Levels of purines in foods and their metabolic effects in rats
    J Nutr 106:435, 1976
 
 7. Emerson, B.T.:
    Effects of oral fructose on urate production.
    Ann Rheum Dis 33:276, 1974.

 8. ?
 9. ?
10. ?
11. ?

    |
529 | Purine-Restricted Diet

Food Category           Foods Recommended           Foods Excluded
Milk and milk products  Skim or 1% low-fat milk     Whole milk
 (2 c/day)

Vegetables              All                         Dried legumes, lentils^6
4 or more servings/day  Limit the following to      Beet tops/greens
                         2 times a week:            celery, swiss chard
                        Mushrooms, peas, spinach,   chives, collard, eggplant
                         asparagus, cauliflower     escarole

Fruits
 4 serv/day             All except                  Blackberries, Blueberries
1/2 cup or 1 small                                  red currants, Raspberries
 fruit = 1 serving                                  Strawberries, Tangerines

Breads and cereals      All enriched bread          wheat germ
                         and cereal products
                        Limit the following to
                          2 servings per week:
                        Whole grain breads and
                         cereals, wheat-germ,
                         bran, oatmeal
                        Limit use of higher fat      <-Avoid
                         foods such as pancakes,
Combined 6 serving/dy     French toast, biscuits
 1 serving=3/4 c cereal,
 1 slice bread

Potato or substitute    Potatoes                     None
1/2 c rice, noodles,    Enriched rice, barley, noodles
potatoes                 spaghetti, macaroni, and
                         other pastas

Meats                   Limit meats on this list to 3    Sweetbreads
                         times weekly:                   Anchovies
Limit to                bluefish, crab, finnan hadie,    Sardines
3 oz portion            herring, oysters, salmon, shad,  Liver
                        tuna fish, white fish, lobster,  Beef kidneys
                        chicken, ham, mutton             Brains
                                                         Meat extracts
                                                         Gravies
                                                         Shrimp, mackeral^6
                        Limit to 2x/wk from this list:   Bacon
                        beef, chicken soup, meat
                        soups
                        turkey, veal, perch, codfish
                        Lean pork

Meat substitutes        Eggs, cheese                     peanuts/pecans

                        almond butter - 2Tbs = 1 serving

apple       pear            papaya
grapefruit  peaches         thomas seedless grapes 17 grapes/serving
plum        honeydew melon
            mango

|
| 530 Section X. Miscellaneous & Test Diets

Food Category           Foods Recommended      Foods Excluded

Fats                    All fats and oils      Meat gravies
 Limit to 4 tsp daily

Soups                   Cream soups made with  Meat bouillon, broth
                         low fat milk and       and consomme
                         allowed vegetables    Soups made with meat
                        Vegetable bouillon,     stock base
                         vegetable broth,
                         consomme

Sweets and desserts                            Avoid chocolate

Beverages                                      Non caloric beverages only allowed
Coffee 8 oz/day

Miscellaneous          Iodized salt, herbs,    Baker's and brewer's yeast
                         and spices

                              /Low oxalate, low fat, low sugar/
Sample Menu   Sample Menu for Purine-Restricted Diet   /1800 calories/

Breakfast              Lunch                              Dinner
Farina (3/4 c)         Vegetarian vegetable soup          Broiled chicken 3 oz
Poached egg (1)         (6 oz)                            Baked potato (1 large)
White toast (1 slice)  Cheese sandwich (consisting        Broccoli 1 cup
Low sugar Jelly (1 T)   of 2 oz cheddar cheese)(lowfat)   1 peach
Coffee (1 c)           White bread (2 slices)             Coffee (1 c)
1% Milk (8 oz)         Mayonnaise (1 t)                   Salad w/ oil + vinegar
                       Sliced tomato and lettuce leaf
                        (3 oz)
                       Apricot halves
                        (1/2 c)
                       1% Milk (8 oz)

Approximate Nutritional Analysis of Sample Purine-Restricted Diet
Protein  86 gm        Vitamin C 175 mg     Phosphorus 1500 mg
Fat      55 gm        Niacin     20 mg     Iron         14 mg
Carbohydrate 298 gm   Riboflavin  2.1 mg   Sodium     2765 mg
Calories 1800         Thiamin     1.4 mg   Potassium  3795 mg
Vitamin A 9435 I.U.   Calcium    1420 mg

Snack
1 cup watermelon


    |
531 | Purine-Restricted Diet

Food List 1
May be used as desired; foods that contain an insignificant amount of purine bodies
Beverages                     Eggs                            Cabbage
 Carbonated                                                   Carrots
 Chocolate                    Fats of all kinds (in           Celery
 Cocoa                         moderation)                    Corn
 Coffee                                                       Cucumber
 Fruit juices                 Fruits of all kinds             Eggplant
 Postum                                                       Endive
 Tea                          Plain or flavored gelatin       Kohlrabi
                                                              Lettuce
Butter                        Milk: buttermilk, evaporated,   Okra
                               malted, sweet                  Parsnips
Bread: white, crackers,                                       Potato, white and sweet
 cornbread                    Nuts of all kinds,* peanut      Pumpkin
                               butter*                        Rutabagas
Cereals and cereal products                                   Sauerkraut
 Corn                         Pies* (except mincemeat)        String beans
 Rice                                                         Summer squash
 Tapioca                      Sugar and sweets                Swiss chard
 Refined wheat                                                Tomato
 Macaroni                     Vegetables                      Turnips
 Noodles                        Artichokes
                                Beets
Cheeses of all kinds*           Beet greens
                                Broccoli
                                Brussels sprouts

FOOD LIST 2
One item 4 times a week;
foods that contain a moderate amount (up to 75 mg)
of purine bodies in 100 gm serving
Asparagus    Finnan haddie  Mushrooms   Salmon
Bluefish     Ham            Mutton      Shad
Bouillon     Herring        Navy beans  Spinach
Cauliflower  Kidney beans   Oatmeal     Tripe
Chicken      Lima beans     Oysters     Tuna fish
Crab         Lobster        Peas        Whitefish

|
| 532 Section X. Miscellaneous & Test Diets

FOOD LIST 3
One item once a week;
foods that contain a large amount (75-150 mg)
of purine bodies in 100 gm serving
Bacon         Goose          Pheasant  Shellfish
Beef          Halibut        Pigeon    Squab
Calf tongue   Lentils        Pike      Trout
Carp          Liver sausage  Pork      Turkey
Chicken soup  Meat soups     Quail     Veal
Codfish       Partridge      Rabbit    Venison
Duck          Perch          Sheep

FOOD LIST 4
Avoid entirely;
foods that contain very large amounts (150-1000 mg)
of purine bodies in 100 gm serving
Sweetbreads 825 mg        Liver(calf, beef) 233 mg   Meat extracts 160-400 mg
Anchovies   363 mg        Kidneys  200 mg            Gravies       Variable
Sardines(in oil) 295 mg   Brains   195 mg

*High in fat

Reprinted with permission.
Sue Rodwell Williams:
Nutrition and Diet Therapy, 5th ed.,
St. Louis MO:
The C.V. Mosby Company, 1985



_ _ _ _ _ handout 2 _ _ _ _ _
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Kidney stones: Low oxalate meal plan    Page 1 of 4
Published in The Orlando Sentinel, Tuesday, June 24, 1997   
Low-oxalate meal plan for kidney stones

   Doctors at the Florida Hospital Kidney Stone Center distribute
   this list of good and bad foods to patients with
   calcium-oxalate kidney stones, the most common kind of stone.

   Other centers and doctors may use lists that vary slightly
   from this one.

   Beverages | Milk | Meat (protein) | Fruits | Vegetables |
   Bread | Fats | Other



   Food

   Beverages/
   juices
   Eat as desired
   Little or no oxalates: less than 2 milligrams of oxalates per
   serving
     . Apple juice
     . Beer, bottled
     . Coca-Cola (12-ounce limit per day)
     . Distilled alcohol
     . Grapefruit juice
     . Lemonade or limeade, no peel
     . Wine, red, rose
     . Pepsi-Cola (12-ounce limit per day)
     . Pineapple juice
     . Tap water (preferred for extra calcium)

   Limit 2 half-cup servings per day from each of the 8 food
   groups
   Moderate oxalate content: 2-10 milligrams of oxalates per
   serving
     . Coffee, any kind (8-ounce serving)
     . Cranberry juice
     . Grape juice
     . Orange juice
     . Tomato juice
     . Nescafe powder (1 cup)

   Avoid completely
   High oxalate foods: more than 10 milligrams of oxalates per
   serving
     . Draft beer: Stout, Guinness Draft Lager, Tuborg Pilsner
     . Juices containing berries
     . Ovaltine and other beverage mixes
     . Tea
     . Cocoa



Kidney stones: Low oxalate meal plan    Page 2 of 4

   Milk (2 or more cups)
   Eat as desired
   Little or no oxalates: less than 2 milligrams of oxalates per
   serving
     . Buttermilk
     . Lowfat milk
     . Lowfat yogurt with allowed fruit
     . Skim milk

   . .


   Meat group (protein)
   Eat as desired
   Little or no oxalates: less than 2 milligrams of oxalates per
   serving
     . Eggs
     . Cheese, cheddar
     . Lean lamb
     . Lean beef
     . Lean pork
     . Poultry
     . Seafood

   Limit 2 half-cup servings per day from each of the 8 food
   groups
   Moderate oxalate content: 2-10 milligrams of oxalates per
   serving
     . Sardines

   Avoid completely
   High oxalate foods: more than 10 milligrams of oxalates per
   serving
     . Baked beans, canned in tomato sauce
     . Peanut butter
     . Soybean curd (tofu)



   Fruits
   Eat as desired
   Little or no oxalates: less than 2 milligrams of oxalates per
   serving
     . Avocados
     . Bananas
     . Cantaloupe
     . Casaba melon
     . Cherries, bing
     . Grapefruit
     . Grapes, Thompson seedless
     . Honeydew
     . Mangoes
     . Nectarines
     . Peaches
     . Plums, green or golden gage
     . Watermelon

   Limit 2 half-cup servings per day from each of the 8 food
   groups
   Moderate oxalate content: 2-10 milligrams of oxalates per
   serving
     . Apples
     . Apricots
     . Black currants
     . Cherries, red sour
     . Oranges, edible portion
     . Peaches, Alberta
     . Pears
     . Pineapple
     . Plums, Damson
     . Prunes, Italian

   Avoid completely
   High oxalate foods: more than 10 milligrams of oxalates per
   serving
     . Blackberries
     . Blueberries
     . Concord grapes
     . Red currants
     . Dewberries
     . Fruitcake
     . Fruit cocktail
     . Gooseberries
     . Lemon peel
     . Orange peel
     . Raspberries
     . Rhubarb
     . Strawberries
     . Tangerines



   Vegetables
   Eat as desired
   Little or no oxalates: less than 2 milligrams of oxalates per
   serving
     . Avocados
     . Brussels sprouts
     . Cauliflower
     . Cabbage
     . Mushrooms
     . Onions
     . Peas, green
     . Potatoes (Irish)
     . Radishes

   Limit 2 half-cup servings per day from each of the 8 food
   groups
   Moderate oxalate content: 2-10 milligrams of oxalates per
   serving
     . Asparagus
     . Broccoli
     . Carrots
     . Corn, sweet white, sweet yellow
     . Cucumber, peeled
     . Green peas, canned
     . Lettuce, iceberg
     . Lima beans
     . Parsnips
     . Tomato, 1 small
     . Turnips

   Avoid completely
   High oxalate foods: more than 10 milligrams of oxalates per
   serving
     . Beans, green
     . Beets, tops, roots, greens
     . Celery
     . Chard, Swiss
     . Chives
     . Collards
     . Dandelion greens
     . Eggplant
     . Escarole
     . Kale
     . Leeks
     . Mustard greens
     . Okra
     . Parsley
     . Peppers, green
     . Pokeweed
     . Potatoes, sweet
     . Rutabagas
     . Spinach
     . Summer squash
     . Watercress



   Bread and starches
   Eat as desired
   Little or no oxalates: less than 2 milligrams of oxalates per
   serving
     . Corn flakes
     . Macaroni
     . Noodles
     . Oatmeal
     . Rice
     . Spaghetti
     . White bread

   Limit 2 half-cup servings per day from each of the 8 food
   groups
   Moderate oxalate content: 2-10 milligrams of oxalates per
   serving
     . Corn bread
     . Sponge cake
     . Spaghetti, canned in tomato sauce

   Avoid completely
   High oxalate foods: more than 10 milligrams of oxalates per
   serving
     . Fruitcake
     . Grits, white corn
     . Soybean crackers
     . Wheat germ



   Fats and oils
   Eat as desired
   Little or no oxalates: less than 2 milligrams of oxalates per
   serving
     . Bacon
     . Mayonnaise
     . Salad dressing

   .
   Avoid completely
   High oxalate foods: more than 10 milligrams of oxalates per
   serving
     . Peanuts
     . Pecans



   Other
   Eat as desired
   Little or no oxalates: less than 2 milligrams of oxalates per
   serving
     . Jelly or preserves with allowed fruits
     . Lemon, lime juice
     . Salt
     . Pepper (up to 1 teaspoon a day)
     . Soups with allowed ingredients
     . Sugar

   .
   Avoid completely
   High oxalate foods: more than 10 milligrams of oxalates per
   serving
     . Chocolate, cocoa
     . Pepper, in excess of 1 teaspoon per day
     . Vegetable soup
     . Tomato soup

   Source:
   Nutritional Care in Diseases of the Kidney, K.G. Wilkens;
   Food Nutrition and Diet Therapy, M.Y. Kraus and L.K. Mahan, eds.

[Posted 06/23/97 6 p.m. EST]

1997 Orlando Sentinel Online
http://www.orlandosentinel.com/sfeature/ksdiet.htm    11/04/1999