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Fructose-Rich Beverages and Risk of Gout in Women JAMA, November 24, 2010—Vol 304, No. 20

Fructose-Rich Beverages and Risk of Gout in Women JAMA, November 24, 2010—Vol 304, No. 20. 張秋密 0224. Gouts is a common and excruciatingly painful inflammatory arthritis.

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Fructose-Rich Beverages and Risk of Gout in Women JAMA, November 24, 2010—Vol 304, No. 20

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  1. Fructose-Rich Beverages and Risk of Goutin WomenJAMA, November 24, 2010—Vol 304, No. 20 張秋密0224

  2. Gouts is a common and excruciatingly painful inflammatory arthritis. Emerging evidence suggests that gout is strongly associated with metabolic syndrome and may lead to myocardial infarction,diabetes, and premature.

  3. The increasing disease burden of gout in the United States over the last few decades (eg, an annual incidence of 16/ 100 000 in 1977 vs 42/100 000 in 19966) coincided with a substantial increase in soft drink and fructose consumption A recent prospective study of men found that sugar-sweetened sodas, fruit juices, and fructose were associated with a substantially increased risk of gout among men.

  4. Objective To examine the relationship between intake of fructose-rich beverages and fructose and the risk of incident gout among women.

  5. METHODSStudy Population The Nurses’ Health Study was established in 1976 when 121 700 female registered nurses who were predominantly white (95%), aged 30 to 55 years, and living in 11 states completed a mailed questionnaire providing detailed information about their medical history, lifestyle, and other risk factors

  6. The information is updated every 2 years to identify newly diagnosed diseases and the follow-up rate exceeds 90%. In 1980, a food frequency questionnaire was added and in 1984, participants were asked about intake of sodas in detail. For our analysis, we excluded women with a previous diagnosis of gout before 1984 or participants who did not complete more than 10 items on the 1984 dietary questionnaire, leaving 78 906 eligible women who were followed up from 1984 to 2006.

  7. Assessment of Beverage, Fructose,and Other Dietary Intake The dietary questionnaires were completed in 1980, 1984, 1986, 1990, 1994, 1998, and 2002. Starting in 1984, participants were asked how often on average during the previous year they had consumed sugar sweetened soda (“Coke, Pepsi, or other cola with sugar,” “caffeine-free Coke, Pepsi, or other cola with sugar,” and “other carbonated beverages with sugar”) and diet sodas (“low-calorie cola with caffeine,” “low-calorie caffeine-free cola,” and“other low-calorie beverages”).

  8. 雙醣的形式：以蔗糖為例，蔗糖由一分子的葡萄糖及一分子的果雙醣的形式：以蔗糖為例，蔗糖由一分子的葡萄糖及一分子的果 糖脫去一分子的水而形成 Half of the disaccharide sucrose is fructose, which is split from sucrose in the small intestine. Therefore, total fructose intake is equal to the intake of free fructose plus half the intake of sucrose.

  9. Assessment of Nondietary Factors At baseline and every 2 years thereafter, participants provided information on weight, regular use of medications (including diuretics), and medical conditions (including hypertension). Body mass index was calculated

  10. Ascertainment of Incident Casesof Gout We ascertained incident cases of gout using the American College of Rheumatology gout survey criteria.

  11. Statistical Analysis We used Cox proportional hazards modeling (PROC PHREG) to estimate the relative risk (RR) of incident gout in all multivariate analyses (SAS software, version 9.1, SAS Institute Inc, Cary North Carolina). Multivariate models for soda and juice consumption were adjusted for the following variables in a time-varying manner: age (continuous), total energy intake For all RRs, we calculated 95% confidence intervals (CIs). All P values are 2-sided, with P ＜.05 considered statistically significant.

  12. RESULTS

  13. The corresponding absolute risk differences were 36 and 68 cases per 100 000 person-years. • Women who consumed 1 serving per day of sugar sweetened soda had a 74% higher risk of incident gout and women who consumed 2 servings or more per day had a 2.4-fold increased risk.

  14. The corresponding absolute risk differences were 14 and 47 cases per 100 000 person-years, respectively Orange juice was by far the highest contributor of free fructose intake (17%) among juices in this cohort, followed by apple juice at 2.9% and other juices at 2.6% at the midpoint of follow-up. women who consumed 2 servings or more of orange juice showed a 2.4-fold increased risk of incident gout.

  15. The corresponding absolute risk difference was 28 cases per 100 000 person-years Similar trends were observed with intake of total fructose (ie, free fructose plus half the intake of sucrose), although the magnitudes of associations tended to be smaller (Table 4). When we examined fructose intake as a continuous variable, the multivariate RR for a 5% increment in energy from free fructose, compared with equivalent energy intake from other types of carbohydrates, was 1.86 (95% CI,1.44-2.40) and the corresponding RR for total fructose was 1.47 (95% CI, 1.20-1.80)

  16. We also conducted stratified analyses to evaluate whether the association between sweetened soda and fructose consumption and risk of gout varied according to body mass index, alcohol use, and dairy intake. • Relative risks from these stratified analyses consistently suggested associations similar to those from main analyses, and there was no significant interaction with these variables (all P.14 for interaction)

  17. COMMENT In this large prospective study of women, we found that risk of incident gout increased with increasing intake of sugar-sweetened soda. In contrast, diet soda intake was not associated with risk of incident gout. Further more,risk of gout was significantly increased with increasing intake of fructose, the main ingredient thought to cause the increased risk

  18. These associations were independent of risk factors for gout such as body mass index, age, hypertension, menopause, diuretic use, alcohol, and intake of dairy, meat, seafood, coffee, and vitamin C. • These findings confirm the associations observed in the recent prospective study of men and provide the first prospective evidence among women • Fructose and fructose-rich beverages are important risk factors to be considered in the primary prevention of gout.

  19. This potential sex difference has been thought to be due to sex hormones because studies in rats have shown that female sex hormones protect against the development of hyperinsulinemia associated with high fructose intake. Hyperinsulinemia decreases renal excretion of urate and correlates with higher serum uric acid levels, the protective effect of estrogen may lead to an attenuated effect of fructose on serum uric acid levels.

  20. Nevertheless, as gout among women occurs predominantly after menopause, when the female hormonal influence substantially declines, the sex difference of the fructose effect on the risk of gout may be less apparent than that on serum uric acid levels observed in the general population that included premenopausal women.

  21. Fructose induces uric acid production by increasing adenosine triphosphate (ATP) degradation to adenosine monophosphate, a uric acid precursor Fructose phosphorylation in the liver uses ATP, and the accompanying phosphate depletion limits regeneration of ATP from adenosine diphosphate, which in turn serves as substrate for the catabolic pathway to uric acid formation.

  22. Our findings have practical implications for the prevention of gout in women. As conventional dietary recommendations for gout have focused on restriction of purine intake, low purine diets are often high in carbohydrates, including fructose-rich foods.

  23. Our data provide prospective evidence that fructose poses an increased risk of gout among women, thus supporting the importance of reducing fructose intake. Interestingly, this recommendation is consistent with Osler’s diet prescription as a means to prevent gout more than 100 years ago: “The sugar should be reduced to a minimum.” Furthermore, because fructose intake is associated with increased serum insulin levels, insulinresistance, and increased adiposity, the overall negative health effect of fructose is expected to be larger in women with a history of gout, 70% of whom have metabolic syndrome.

  24. In conclusion, our findings provide prospective evidence that consumption of sugar-sweetened sodas, orange juice, and fructose is associated with an increased risk of incident gout among women, although their contribution to the risk of gout in the population is likely modest given the low incidence rate among women. • In contrast, diet soda intake is not associated with the risk of gout. • Physicians should be aware of the potential effect of these beverageson the risk of gout, a common and excruciatingly painful arthritis.

  25. 感謝您的聆聽

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