Journal of Human Nutrition and Dietetics

The Official Journal of The British Dietetic Association

Journal of Human Nutrition and Dietetics

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

Keywords aged, diet, disease management, evidencebased medicine, gout. Correspondence Michelle Miller, Department of Nutrition and Dietetics, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia. Tel.: +61 08 8204 4715 Fax: +61 08 8204 6406 E-mail: michelle.miller@inders.edu.au doi:10.1111/j.1365-277X.2008.00928.x

Abstract Background: Evidence supports dietary modications in the management of gout. Despite this, the degree of implementation of this evidence by nutrition professionals and rheumatologists and those affected by gout is unknown. The present study aimed to compare usual dietary practices of patients with gout to evidence for dietary management of gout and to investigate whether the knowledge and attitudes of nutrition professionals and rheumatologists reects current evidence. Methods: A food frequency questionnaire was used to determine usual dietary intake of patients with gout, a separate questionnaire examined gout-related dietary modications (n = 29). Online questionnaires to examine attitudes towards dietary management of gout were completed by nutrition professionals and rheumatologists. Results: Proportions of participants whose reported intakes were inconsistent with current evidence for the dietary management of gout were: alcohol, n = 14 (48%); beer, n = 18 (62%); seafood, n = 29 (100%); meat, n = 7 (24%); beef/pork/lamb, n = 24 (83%); dairy products, n = 12 (41%); vitamin C supplementation, n = 29 (100%). Of the 61 rheumatologists and 231 nutrition professionals who completed the online survey, the majority considered that weight loss and decreased alcohol intake were important or very important outcomes. Proportions were lower for decreased purine intake. Thirty-four (56%) rheumatologists do not refer patients with gout to dietetic services and, of those who do, the majority refer less than half. Conclusions: Overall, patients with gout in the present study were not implementing evidence for dietary management of their condition and complex dietary issues were evident.

Introduction The therapeutic goal of serum uric acid (SUA) lowering therapy in individuals with gout is to promote crystal dissolution and prevent crystal formation by achieving a SUA level of 6 mg dL)1 or 360 lmol L)1 (Zhang et al., 2006). Among other factors, obesity and increased age have been associated with an increased risk of gout and hyperuricemia (Choi et al., 2005a; Peronato, 2005; Saag & Choi, 2006). Gender differences are also evident, with
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more men than women suffering from gout (Kramer & Curhan, 2002; Wallace et al., 2004). Recent evidence-based recommendations for the management of gout state, Patient education and appropriate lifestyle advice regarding weight loss if obese, diet and reduced alcohol (especially beer) are core aspects of management (Zhang et al., 2006). There is evidence to support that dietary factors, including consumption of alcohol and purine-rich foods such as seafood and meat, increase the risk of gout. This evidence does not extend to purine-rich
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vegetables (Choi et al., 2005b). In contrast, low-fat dairy products and vitamin C have been shown to be potentially protective (Choi et al., 2005b). Table 1 highlights the magnitude of the effect for the range of dietary factors. In summary, it has been found that an increased intake of meat (particularly beef, pork, lamb) increases the risk of gout by 4050%, seafood increases the risk of gout by 3545% and that alcohol (particularly beer and spirits) increases the risk of gout by 30250% (Choi et al., 2004a,b). Low-fat dairy products, although not as extensively studied as other dietary factors, have been found to potentially decrease the risk of gout by 3342% (Choi et al., 2004a) Correspondingly, studies have found that increased intakes of meat, seafood and alcohol were associated with higher SUA levels (Choi & Curhan, 2004; Choi et al., 2005b) and one study showed that adherence to a low-purine diet resulted in a decrease in SUA level that was comparable to that of Allopurinol administration of 150300 mg daily (Peixoto et al., 2001). In addition, there is evidence demonstrating that increased dairy product intake (regardless of fat content) and supplementation of 500 mg per day of vitamin C result in a decreased SUA level (Choi et al., 2005b; Huang et al., 2005). Studies examining the medical but not dietetic management of gout have been conducted amongst rheumatologists and physicians (Fang et al., 2006; Schlesinger et al.,

2006). Despite the evidence for dietary management of gout, the implementation of this evidence by nutrition professionals and rheumatologists and those affected by gout is unknown. The present study comprised an investigation of the usual dietary practices of patients with gout, how these are inuenced by their condition and how their intake compares to evidence for dietary management of gout. Furthermore, whether the knowledge and attitudes of nutrition professionals and rheumatologists who are regularly involved in the dietary management of patients with gout reects current available evidence, and any perceived barriers to implementation of the evidence, were investigated. Materials and methods This study was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on July 5, 2006 [ANZCTRN012606000282583]. Usual dietary practices of patients with gout The investigation was a cross-sectional study, with ethics approval from and conducted in accordance with the ethical standards of the Repatriation General Hospital (RGH) Research and Ethics Committee, was implemented

Table 1 Magnitude of effect for the range of dietary factors found to be associated with gout Author (year) Choi et al. (2004a) Study design (sample) Cohort (47 150 men)

Exposure (serves) Meat <0.81; 0.811.12, 1.131.46, 1.471.9, >1.92 day)1 Beef, Pork, Lamb (main dish), <1 month)1, 13 month)1, 1 week)1, 2 week)1 Seafood <0.15, 0.150.28, 0.290.36, 0.370.56, >0.56 day)1

RR (95% CI) Q1 versus Q5: 1.41 (1.071.86) Q1 versus Q4: 1.50 (1.042.17) Q1 versus Q2: 1.35 (1.051.74) Q1 versus Q3: 1.45 (1.131.87) Q1 versus Q4: 1.38 (1.061.79) Q1 versus Q5: 1.51 (1.171.95) 1.28 (1.031.60) 1.32 (1.061.64) 1.52 (1.171.97) 1.55 (1.182.02) Q1 versus Q4: 0.67 (0.530.85) Q1 versus Q5: 0.58 (0.450.76) S1 versus S5: 1.49 (1.141.94) S1 versus S6: 1.96 (1.482.93) S1 versus S7: 2.53 (1.733.70) Q1 versus Q3: 1.27 (1.001.62) Q1 versus Q4: 1.75 (1.322.32) Q1 versus Q5: 2.51 (1.773.55) Q1 versus Q5: 1.60 (1.192.16)

Canned tuna sh 1 week)1 versus <1 month)1 Dark meat sh 1 serve per week versus <1 month)1 Other sh 13 serves per month versus <1 month)1 Other sh 1 serve per week of versus <1 month)1 Low-fat dairy <0.2, 0.20.56, 0.570.99, 1.001.67, >1.67 day)1 Choi et al. (2004b) Cohort (47,150 men) Alcohol 0, 0.14.9, 5.09.9, 10.014.9, 15.029.9, 30.049.9, >50.0 g day)1 Beer <1 month)1, 1 month)1 to 1 week)1, 24 week)1, 5 week)1 to 1 day)1, >2 day)1 Spirits <1 month)1, 1 month)1 to 1 week)1, 24 week)1, 5 week)1 to 1 day)1, >2 day)1 Refers to sh other than canned tuna sh and dark-meat sh. CI, condence interval.

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using patients registered over the previous 2 years in the department of rheumatology database. Individuals, who had a conrmed diagnosis of gout (Wallace et al., 1977) recorded in medical records and whose primary language was English were invited to participate in the study. They were contacted via telephone and a time was arranged in which one of the investigators (PS) visited those interested. Informed written consent was obtained. A face-toface interview with duration of approximately 1 h was then undertaken. Demographic information, medical history, anthropometric measurements, dietary intake, and information regarding awareness of diet and gout associations were collected. Gender and age were obtained from medical records. Participants were weighed using calibrated portable digital scales (BF-681; Tanita, IL, USA). Knee height, measured using a sliding broad-blade calliper (Ross Laboratories, Columbus, OH, USA), was used to estimate height in accordance with standard protocol (Chumlea et al., 1998). Where knee height was unable to be obtained, demi-span, measured using a exible steel tape (KDS Corporation, Chicago, NJ, USA), was used to estimate height in accordance with standard protocol (Bassey, 1986). Weight and estimated height were used to determine body mass index (BMI) (Garrow & Webster, 1985). Dietary intake data was collected using a 74-item semi-quantitative food frequency questionnaire (FFQ) developed specically for Australian adults by the AntiCancer Council of Victoria, and previously validated in Australian adult populations (Giles & Ireland, 1996; Hodge et al., 2000; Xinying Xie et al., 2004). This instrument was selected because it was likely to be culturally appropriate with regard to food preferences, provides a large range of food items and allows respondents to select from seven portion sizes, which were used to calculate an individualized portion size factor for adjustment of the standard portion sizes used in the FFQ. Questions regarding frequency of seafood intake and total daily uid consumption were asked in addition to those on the FFQ. Two additional open-ended questions about dietary modications and a series of open-ended questions regarding food avoidances were asked. The same investigator (PS) conducted all dietary interviews and obtained all anthropometric measurements. Frequency and amount of alcohol consumed (standard drinks per day) were compared with national guidelines and the current evidence regarding alcohol intake for patients with gout (Australian Government Department of Health and Ageing, 2006). Intakes of seafood, meat and dairy products were calculated from frequencies of consumption and portion size factors from the FFQ, intakes were compared with evidence for consumption of these foods by individuals with gout.
2009 The Authors. Journal compilation. 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 311

Attitudes of nutrition professionals and rheumatologists regarding the dietary management of gout compared to current evidence A cross-sectional study of nutrition professionals and rheumatologists in Australia, approved by and conducted in accordance with ethical standards of the Flinders University Social and Behavioural Research Ethics Committee, involved administration of two online profession specic questionnaires, which sought demographic information and information regarding the attitudes surrounding the dietary management of patients with gout by these health professionals. Nutrition professionals and rheumatologists were invited to complete the corresponding online questionnaires via their respective national association e-mail distribution service (Australian Rheumatology Association and Dietitians Association of Australia). A total of three e-mails were distributed to the membership group of each profession. All members of these associations were eligible to participate. The questionnaires were developed following review of other questionnaires directed towards general practitioners and nutrition professionals (Collins, 2003; Nicholas et al., 2003). Demographic information collected included age, gender, years of practice, geographic area and setting of practice. To investigate whether nutrition professionals and rheumatologists were translating evidence into practice, using a ve-point Likert scale, both groups were questioned, in relation to perceived effectiveness of dietary treatment in gout and perceived importance of specic diet-related outcomes. The diet-related outcomes were weight loss, improved food and exercise habits regardless of weight loss, decreased purine intake and decreased alcohol intake. Response options for perceived importance of diet-related outcomes were: very important, important, undecided, not important, not important at all. Responses were collapsed into three categories for statistical analysis (very importantimportant, undecided, not importantnot important at all). For perceived effectiveness of dietary treatment the response options were: strongly disagree, disagree, undecided, agree and strongly agree, collapsed into these three response categories for statistical analysis (strongly disagreedisagree, undecided, agreestrongly agree). Rheumatologists were questioned about the proportion of patients that they refer to dietetic services with ve response categories: none, one quarter, half, three quarters, all, and collapsed into three categories for statistical analysis (none-one quarter, half, three quarters-all). An open-ended question regarding barriers in referring to dietetic services was also asked. Nutrition professionals were independently asked from which source gout patients were predominantly referred (closed-ended),
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what the referrals request (open-ended) and their level of satisfaction with the current available information (closed-ended) and, where relevant, how this could be improved (open-ended). Questionnaires were reviewed by two clinical dietitians and a rheumatologist prior to questionnaire distribution. Statistical analysis All de-identied data was entered into SPSS, version 12.0.1 (Chicago, IL, USA). Continuous data were checked for normality and presented accordingly as mean with 95% condence intervals or median with interquartile range (IQR). Chi-square analysis was used to determine whether there were any signicant differences between nutrition professionals and rheumatologists regarding the perceived effectiveness of dietary strategies and the perceived importance of diet-related outcomes for patients with gout. Results Recruitment and demographics of study participants with gout Of 78 eligible persons, 29 (37%) provided their informed written consent and complete data for analysis. The age range of the participants was 5091 years, with a median (IQR) age of 74 (5981) years, 25 (86%) were male and the median (IQR) BMI was 28.0 (25.732.1) kg m)2. Twenty (69%) participants were classed as overweight or obese based on denitions by the World Health Organization (1998). Dietary intake of study participants with gout Twenty four (83%) participants reported having received dietary advice regarding management of gout. Most frequently reported sources of dietary advice included rheumatologists (n = 11, 28%), dietitians (n = 9, 23%), general practitioners (n = 6, 15%) and the Internet (n = 4, 10%). Of the 27 (93%) participants who consumed alcohol, the total average intake was in the range 0.210.6 standard drinks per day, with a median (IQR) intake of 0.9 (0.33.9) standard drinks per day. Results regarding patterns of alcohol consumption are displayed in Table 2. No participants reported complete avoidance of seafood. More than half of participants (n = 16, 55%) reported consuming shellsh never to less than once per month, 10 (35%) and one (3%) reported consuming shellsh one to three times per month and once per week respectively. Eight (28%), 15 (52%) and six (17%) reported consuming sh (other than shellsh) one to
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three times per month, one to two times per week and three or more times per week respectively. Twelve (41%) participants avoided shellsh and four (14%) reported avoiding sh as a result of having gout. Average daily consumption of meat products was greater than 1.9 serves per day for seven (24%) and consumption of beef/pork/lamb was 2 serves per week for 24 (83%). Five (17%) participants reported having decreased their portion size of meat as a result of having gout. Average daily consumption of dairy products was less than 1.7 serves for 12 (41%). Eight (28%) reported consumption of solely reduced fat or skim milk and four (14%) reported consumption of low-fat cheese as opposed to full fat varieties. Two (7%) participants reported consuming both low-fat or skim milk and lowfat cheese. Four (14%) reported daily consumption of multivitamin supplements; however, none reported consumption of vitamin C supplements. Additional foods reported to be avoided secondary to gout included offal, Vegemite/Promite, citrus fruit, tomatoes and tomato products, wholemeal bread, cauliower and lentils. Eighteen (62%) reported avoiding one or more foods as a result of gout. Recruitment and demographics of nutrition professionals and rheumatologists Nutrition professionals Two hundred and thirty-one out of 2995 nutrition professionals responded to the survey, giving a response rate of 8%. Of these, 132 (57%) worked in a metropolitan/
Table 2 Alcohol consumption behaviours among participants (n = 29) Alcohol behaviour Met gender specic national recommendations for daily alcohol intake Complete avoidance of all alcohol Alcohol consumption of <1.5 standard drinks per day Beer consumption <2 standard drinks per week Spirit/liqour consumption 1 standard drinks per day Wine consumption 2 standard drinks per day Met gout-related recommendations for beer, spirits/liqours, wine Alcohol consumption on 6 days per week

n 12 2 12 8 24 24 7 14

% 41 7 46 31 92 92 27 54

Recommended that males consume no more than an average of no more than four standard drinks per day and that females consume a average of no more than two standard drinks per day (Australian Government Department of Health and Ageing, 2006). Results do not include those who abstained from alcohol consumption. Two alcohol free days per week recommended for both men and women (Australian Government Department of Health and Ageing, 2006).
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Nutrition and gout Table 3 Perceived importance of diet-related outcomes for individuals with gout by nutrition professionals (n = 154) and rheumatologists (n = 61) who participated in the online survey Perceived importance of advice provision Rheumatologists n (%) Nutrition professionals n (%)

urban location, 78 (34%) worked in a regional/rural or remote location and 14 (6%) worked across all locations listed. Of those who responded, 175 (76%) were involved in the dietary management of patients with gout. Of these, 154 (88%) provided complete data and were therefore included in subsequent analysis. Rheumatologist Sixty-one of 266 eligible rheumatologists, responded to the online survey, giving a response rate of 24%. Of the rheumatology respondents, the majority (n = 45, 74%) worked in the metropolitan/urban location. All rheumatologist respondents were involved in the management of gout patients. Perceived effectiveness of dietary strategies and importance of diet-related outcomes for patients with gout by nutrition professionals and rheumatologists For the question regarding the degree to which rheumatologists and nutrition professionals agreed with the statement dietary strategies are effective in the management of gout, a signicant difference was observed in perceived effectiveness between nutrition professionals and rheumatologists (P < 0.0001). Subsequent analysis revealed that the signicant difference was between those nutrition professionals and rheumatologists who disagree/strongly disagreed that dietary strategies are effective (P < 0.0001) with no signicant difference between those who agreed/ strongly agreed or were undecided. Fifty-nine (97%) rheumatologist respondents reported that they consider diet in the management of their patients with gout. Table 3 reports the perceived importance of diet-related outcomes for individuals with gout reported by nutrition professionals and rheumatologists. Chi-square analysis indicated a signicant difference in perceived importance of decreased purine intake for patients with gout (P = 0.007), and that the difference lay between nutrition professionals and rheumatologists who were undecided regarding the importance of this dietary outcome, with a greater proportion of nutrition professionals being undecided. There was no signicant difference in perceived importance for the other outcomes. Sixteen (10%) nutrition professionals added that they thought adequate uid intake was an important outcome for patients with gout. Referral of patients with gout to dietetic services Thirty-four (56%) rheumatologists reported not referring any patients with gout to dietetic services. Twenty-four (39%) reported referring either a quarter or half and three (5%) reported referring three quarters to all of their patients with gout. Thirty-six (59%) rheumatologist
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P value

Weight loss Not important at all/not 4 (7) 2 (1) important Undecided 7 (11) 21 (14) Important/very important 49 (82) 129 (85) Improved diet and exercise habits regardless of weight loss Not important at all/not 4 (7) 2 (1) important Undecided 5 (8) 7 (5) Important/very important 51 Decreased alcohol consumption Not important at 0 all/not important Undecided 3 Important/very important 58 Decreased purine intake Not important at all/not 11 important Undecided 6 Important/very important 43 (85) (0) (5) (95) (18) (10) (72) 144 (94) 0 (0) 5 (3) 148 (97) 21 (14) 47 (31) 85 (55)

0.103

0.053

0.518

0.007

respondents reported perceived barriers in referring to dietetic services. The main barriers detailed by these respondents were: expense of private dietetic services (n = 23, 64%), inadequate availability and access (n = 21, 58%), long waiting times (n = 12, 33%) and poor compliance or motivation of patients with gout (n = 11, 31%). The sources of referral of gout patients as reported by nutrition professionals were: general practitioners (n = 84, 55%), medical ofcers (n = 11, 7%), nurses (n = 7, 5%), nephrologists (n = 6, 4%), rheumatologists (n = 3, 2%) and self-referral by gout patients (n = 41, 27%). Discussion Results from this cross-sectional study indicate that patients with gout are not following evidence-based dietary strategies to manage gout. The attitudes of nutrition professionals and rheumatologists appear to be consistent with the evidence for managing patients with gout; however, improvements could be made to optimize attitudes and thus potentially improve dietary management within this patient group. Barriers to optimizing services were identied by nutrition professionals and rheumatologists, highlighting that further investigation is necessary to explore the barriers and formulate strategies to overcome or manage them.
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The higher proportion of male than female participants in this study is expected given that gout occurs more frequently in men than women (Kramer & Curhan, 2002; Wallace et al., 2004). The likely explanation offered for the increased prevalence in men is that of the uricosuric effect of oestrogen in women (Saag & Choi, 2006). The evidence base for dietary management of gout is based on male subjects and, although no literature was located identifying differences in efcacy of treatment between men and women, caution should be taken when extrapolating the evidence to the female population. In this sample, beer consumption was particularly concerning because the majority of participants consumed more than two standard drinks of beer per week. Evidence for restriction of specic types of alcoholic beverages is reasonably recent, possibly explaining a lack of awareness amongst patients with gout and inconsistency with the evidence. Other factors that may contribute to the inconsistency include the relaxation and social effects that can accompany consumption of alcohol (Commonwealth of Australia, 2006) and the potential awareness of evidence suggesting an inverse relationship between moderate intakes of alcohol and the risk of cardiovascular diseases (Goldberg et al., 2001). All participants consumed seafood; however, the intake was infrequent. Frequency of sh intake was higher with consumption as high as ve to six times per week for some participants. Persistent high intakes of sh may be explained by knowledge of potential cardiovascular health benets of the consumption of the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid found in sh (Hooper et al., 2004). Evidence based dietary practices for total daily meat intake were met by the majority of participants; however, it is unlikely that adherence to this guideline was intentional by all of these participants because less than one quarter of participants reported that they had intentionally decreased their portion size of meat due to presence of gout. In addition, the majority reported an intake of beef/lamb/pork that was greater than that recommended (Choi et al., 2005b). Evidence for low-fat dairy product intake was not followed by the majority of participants. Only two (7%) participants reported the consumption of both low-fat or skim milk and low-fat cheese consistent with guidelines for low-fat dairy consumption in gout. Figures for compliance with this guideline may alter depending on the type of yoghurt consumed because data were not collected regarding low-fat versus full-fat for yoghurt; however, yoghurt consumption was less than once per week for the majority (75%) of participants. Evidence for the protective effect of low-fat dairy products is very recent and thus it is possible that the participants surveyed in the present study have not received any guidance regard8

ing dairy product consumption for prevention of gout. A similar explanation could be used for vitamin C because all participants were inconsistent with evidence regarding daily supplementation. Some food avoidances reported by participants are not supported by the current evidence: tomatoes and tomato products, citrus fruits, lentils, wholemeal bread and vegetables. Unsubstantiated modications to the diet without appropriate monitoring may result in suboptimal nutrient intake and adverse consequences. Additional reasons why patients may not comply with the evidence include: high efcacy of anti-gout preparations, lack of up to date knowledge of appropriate dietary behaviours, disbelief of effectiveness of dietary alterations, patients being unaffected by gout for a substantial period of time and food preferences, such as the traditional meat and vegetable style diet that is common in the elderly Australian population. In addition, there is evidence to support poor recall and incomplete adherence to nonpharmacological advice in elderly patients (Lainscak et al., 2007). Although both nutrition professionals and rheumatologists reported that specic diet-related outcomes (weight loss, alcohol, purines) were important, nutrition professionals were more likely than rheumatologists to suggest that dietary strategies could be effective. The availability of potent, more effective uric acid-lowering medications or perceived poor compliance with dietary therapy (Fam, 2002, 2005) may be a potential explanation. Secondary to strong evidence for moderation of dietary purine consumption, the proportions of nutrition professionals and rheumatologists who reported that decreased purine intake was an important outcome for patients with gout was lower than expected. Possible explanations for this may again be that the effect of dietary alterations in lowering serum uric acid levels is smaller compared to the effect of uric-acid lowering medications and the traditional rigid low-purine diet can rarely be sustained longterm, secondary to it being unpalatable and impractical (Fam, 2002, 2005). Moderation in dietary purine consumption rather than the traditional strict low-purine diet is more feasible (Fam, 2002). Despite existing evidence-based guidelines that reinforce the importance of dietary education and appropriate dietary advice and evidence that hyperuricemia is associated with other diet-related conditions including hyperlipidaemia, hypertension, diabetes and insulin resistance and obesity, approximately half of rheumatologists reported not referring any of their patients with gout to dietetic services (Zhang et al., 2006). Poor referral rates may be related to the nding that approximately half of rheumatologists who responded reported being undecided or disagreeing with the overall concept that dietary strategies are effective in the management of this patient group. How 2009 The Authors. Journal compilation. 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 311

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ever, an additional explanation for low referral rates could be that rheumatologists themselves may be providing dietary advice to patients with gout. Reported barriers to referring to dietetic services may be another explanation for the low referrals rates observed. Diet-related pamphlets or group education sessions for patients with gout may help to overcome barriers reported by nutrition professionals and rheumatologist in the present study. Interestingly, over half of the nutrition professionals who responded reported that general practitioners were their main source of referral of patients with gout, with only a very small number reporting that rheumatologists were the main source of referral. This is consistent with general practitioners being the primary medical contact for most patients with gout, indicating the need for similar research involving general practitioners (Wortmann, 2006). The limitations of this study are: (i) a small sample of participants with gout (n = 29), which limits the extent to which the results may be generalized and made subgroup analyses difcult; (ii) the response rate of 37% for patients with gout was less than desired; however, this may be expected given the age group used and that the database used for recruitment was 2 years old and thus contact details may not have been current; (iii) patients with gout in the present study may represent a biased sample because they were recruited from a rheumatology database and the management of these patients is likely to be more complex than for those attending their general practitioner; and (iv) the response rates of nutrition professionals and rheumatologists 8% and 24%, respectively, are less than desirable, but remarkably similar to that seen in previous studies of nutrition professionals and rheumatologists (Barnard & Kerruish, 2006; Schlesinger et al., 2006). It should also be noted that one participant provided self-reported data for height and weight because they were from a regional area. Although errors may have been introduced as a result of this, it is unlikely that the data from one participant would greatly inuence the ndings of the study. Further research should ensure that dose of vitamin C from multivitamin supplements is collected to ensure accurate determination of consistency with guidelines. In summary, it is evident that patients with gout within this sample are not following evidence-based practices, particularly for alcohol, purine intake (including seafood and certain meats), vitamin C supplementation and low-fat dairy product intake. Inappropriate food-avoidances also need to be addressed. Although the evidence for medications is stronger than that for diet, the present study has indicated that this patient group have complex, often unaddressed dietary issues, indicating the need for dietetic input. Appropriate current promotional materials located in rheumatology clinics may
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help to raise awareness and access to information regarding diet and gout. In general, nutrition professionals and rheumatologists reported attitudes in line with the current evidence for the dietary management of patients with gout. Although it is likely that attitudes would be reected in the practice of nutrition professionals and rheumatologists, it is our belief that increased research regarding actual practices in provision of diet-related education and specic strategies used in the dietary management are required to form sound, specic evidence-based recommendations that result in an improved service provision to this patient group. Despite this, barriers will need to be addressed to further improve dietetic services to patients with gout. These results also suggest that general practitioners are an appropriate target for similar future research. Acknowledgments The authors would like to thank the patients with gout, nutrition professionals and rheumatologists who took time to participate in this study. The authors also wish to acknowledge the group of Flinders Nutrition and Dietetic students who were involved in some preliminary planning of the study. Conict of interest, source of funding and authorship The authors declare that they have no conicts of interest. We did not receive any funding for the project, which was conducted as part of a honours project for a Bachelor of Nutrition and Dietetics student (PS). PS contributed to the planning of the project, conducted all data collection and analysis and prepared the rst draft of the manuscript. JT contributed to the planning of the project, supervised data collection and provided intellectual input into the preparation of the manuscript. MM contributed to the planning of the project, supervised implementation of the project, provided support for data analyses and intellectual input into the preparation of the manuscript. MS provided infrastructure and access to project participants and provided intellectual input into the preparation of the manuscript. MA contributed to the planning of the project, supervised implementation, provided infrastructure and access to project participants and provided intellectual input into the preparation of the manuscript. Work should be attributed to Flinders University Department of Nutrition and Dietetics and Flinders University Department of Rheumatology and Clinical Immunology. All authors critically reviewed the manuscript and approved the nal version submitted for publication.

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