Gout is a chronic progressive systemic disease characterized by impaired metabolism of uric acid salts, their deposition in tissues. Translated from the ancient Greek language, the name of the disease translates as “trap for the foot.”
Since ancient times, gout was considered a noble disease, because only the rich could afford to drink plenty of wine and eat meat.
Clinically, pathology is manifested by gouty arthritis and nephropathy.
- Why does gouty arthritis occur?
- Symptoms of Gouty Arthropathy
- Diagnosis of the disease
- Gouty arthritis: stages of the disease and how to recognize on time
- Effect on the k >In addition, gout is often accompanied by the formation of urate in the kidneys, which leads to urolithiasis and, in some cases, to kidney inflammation. In women, the disease is slightly milder, showing chronic pain in the ankle or knee joints, which is typical for arthrosis, and to determine that this is not arthrosis is possible only by severe swelling of the affected joint. Note that gout and arthritis are not the same disease.
- Treating Gouty Arthritis
- Diet for treatment
- Gouty arthritis: forms of the course of the disease and its treatment
- About the Developer
- Acute gouty arthritis
- Chronic gouty arthritis
- Gouty arthritis: causes, symptoms and treatment
- Make an appointment is free
- How does gouty arthritis occur?
- Symptoms of Gouty Arthritis
- Causes of Gouty Arthritis
- What is the danger of gouty arthritis
- Feedback on treatment
- Treating Gouty Arthritis
Why does gouty arthritis occur?
The disease often develops in men over 50 years of age, and 20 times more often than in women. Why is this happening?
Just one of the reasons for the development of gouty arthritis is a genetic predisposition found only in males. A gene defect occurs that encodes the synthesis of enzymes involved in the metabolism of uric acid and its excretion by the kidneys.
In addition to congenital features, the development of gout also contributes to:
- binge eating;
- eating a lot of meat food;
- reception of alcoholic beverages (especially dry wine, beer);
- sedentary lifestyle.
In women, acute gouty arthritis occurs after menopause due to a decrease in the level of sex hormones (estrogens).
An increase in uric acid also causes a number of diseases:
- Wakez disease (true polycythemia);
- congenital heart defects, accompanied by an increase in the number of red blood cells;
- chronic lung diseases (emphysema, chronic bronchitis);
- some tumors (acute and chronic leukemia, myeloma, lymphomas, kidney carcinoma);
- hemolytic anemia;
- von Willebrand disease (congenital blood clotting defect);
- Gaucher disease
- Infectious mononucleosis;
- chronic renal failure;
- lead and beryllium poisoning;
- conditions accompanied by a lack of oxygen.
Classification of gouty arthritis according to ICD-10
- chronic with the formation of paraarticular tofus.
- metabolic type;
- hypoexcretory type;
Symptoms of Gouty Arthropathy
Acute gouty arthritis usually occurs at night after a hearty dinner with wine or beer. A man, without thinking about anything bad, goes to bed, and at night he suddenly wakes up from unbearable pain in the joints.
Most often, the first metatarsophalangeal, knee or ankle joint is affected. The joint increases in size, the skin above it becomes cyanotic-crimson and glossy, the temperature rises locally. The patient cannot move his leg, the joint cannot perform its function. Some patients compare the arising pain with pain during dislocation of the joint or rupture of ligaments.
An acute attack is usually accompanied by general weakness, fever with chills, nausea, vomiting and lack of appetite.
The first attack in most cases lasts up to a week, then all the symptoms of the lesion disappear: the leg decreases to its previous size, the skin restores normal color, and the body temperature decreases. Patients return to a full life until a new attack. Each new attack arises faster.
Provoke new attacks can:
- acute respiratory viral diseases;
- physical overwork;
- neuro-emotional stress, stress;
- injuries, bruises of the legs;
- taking certain medications (diuretics, anticoagulants).
The subacute form is accompanied by minor pain and tissue edema.
Symptoms of chronic gouty arthritis include the following:
- gradually the majority of joints of the lower and upper extremities are involved in the pathological process;
- stiffness of joints develops, their configuration, function can be completely lost;
- muscle atrophy occurs around the lesion;
- pain during seizures becomes less intense, is easier for patients, but does not disappear completely;
- the attack can last for several weeks;
- in places of deposition of uric acid (fingers and toes, knees, auricles, elbows, Achilles tendon), tofuses are formed – dense hypodermic tubercles, the skin over which can ulcerate, and a white-yellow, crystalline, crystalline substance consisting of salts uric acid. The opened tofus do not become infected, but heal slowly.
Gouty status is a very dangerous complication of pathology, characterized by a persistent attack of pain and swelling of the tissues caused by a massive release of uric acid into the blood.
Atypical forms of gout arthritis:
It is characterized by a primary lesion of the small joints of the hands of the type of mono- or oligoarthritis.
The manifestations of intoxication come to the fore: high fever, heavy sweats, shaking chills.
By type of infectious-allergic polyarthritis
The inflammatory process quickly subsides, can move from one joint to another.
The patient is only concerned with mild pain with mild flushing of the skin.
The pathological process is localized in the tissues surrounding the joint (tendons, bags), the calcaneal tendon is most often affected.
Diagnosis of the disease
There are many laboratory and instrumental methods for detecting arthropathy:
General blood analysis
Increased white blood cell count, especially neutrophils, increased ESR, anemia, decreased platelet count
PH shift to the acid side, detection of uric acid crystals
Biochemical analysis of blood
The appearance of large amounts of acute phase proteins in the blood (C-reactive protein, seromucoid, sialic acids, haptoglobin), an increase in the level of uric acid by more than 0,40 mmol / l, an increase in the concentration of nitrogenous slags (urea, creatinine)
Narrowing of the joint gap, marginal bone erosion, “punch symptom” – tofus penetrates deep into the bone, thereby destroying it
Synovial fluid examination
A large number of leukocytes, especially granulocytes, crystals of sodium urate
Tofus Puncture Biopsy
Detection of sodium urate crystals
A blood and urine test to detect urates should be done after a 3-day diet that excludes the use of purines (meat, fish, legumes, tea, coffee, beer, dry red wine).
Gouty arthritis should be distinguished from:
- attack of pseudogout;
- reactive arthritis;
- polysyndromic rheumatism;
- rheumato >
The treatment for acute gouty arthritis depends on how far the disease has gone. Therapy of the disease has two main objectives:
- relief of an acute pain attack;
- prevention of relapse and chronicity of the process.
How to treat gouty arthritis, know, first of all, rheumatologists who should be consulted in case of the first signs.
Therapy of gout, like many other diseases, begins with non-drug methods:
- diet No. 6 – an exception from the diet of meat and dairy products, fish, restriction of salt and fat intake. The patient is recommended to drink up to 2,5 liters of liquid (alkaline mineral water, teas, juices, cranberry juice), eat cereals, vegetables and fruits;
- decreased body weight;
- activation of the patient – dosed physical activity, race walking.
Relief of an acute attack:
- anti-inflammatory and painkillers: diclofenac sodium and potassium (Rapten rapid), nimesulide (Nise, Nimesil), ibuprofen (Nurofen) in the absence of contraindications;
- colchicine – the oldest drug for the treatment of gout, has many side effects, which is why its use is limited;
- glucocorticosteroids: prednisone, triamcinolone acetonide perfectly eliminate tissue edema, prevent cell proliferation. They can be prescribed in the form of tablets or injections in the joint.
Treatment of chronic forms is aimed at reducing the level of urate in the blood and urine by inhibiting the synthesis of uric acid or accelerating its excretion.
Drugs that inhibit the formation of urate:
Medicinal substances that increase the excretion of uric acid by the kidneys:
- sulfinpyrazone (anturan);
- probenecid (benemide);
- benzobromarone (desuric).
Physiotherapeutic methods of treatment:
- ultraviolet irradiation;
- phonophoresis, iontophoresis;
- heat therapy;
Gouty arthritis: stages of the disease and how to recognize on time
The disease – gouty arthritis, is directly related to metabolic disorders. This is a disease characterized by the deposition of uric acid salts in the joints. It is more common in men than in women, since the significant influence of male sex hormones on the concentration of uric acid affects. The tendency to the disease is inherited, but it does not always occur.
The main stimulant for the development of gouty arthritis is the ingestion of alcohol, meat, smoked meats, salted fish, chocolate, liver, and beans. If these products are abused, the uric acid content in the blood rises, which contributes to the formation of a poorly soluble salt of sodium urate.
Microcrystals of sodium urate are deposited in the joint cavity, irritating it and causing pain. When maintaining a healthy lifestyle with a properly organized diet, the disease can exist all his life in a latent (latent) form and does not bother a person.
The first attacks of gouty pain, as a rule, are short-lived, occur suddenly, most often at night. In the vast majority of cases, the joint of the big toe is inflamed, less often, there is a complex lesion of the joints of the big toes, ankle, knee, ulnar, in rare cases – wrist.
The affected joint begins to redden, swell, the skin on it becomes hot. Pain can be incredible. Often, even the slightest touch on an inflamed joint can cause unbearable pain.
Gouty attacks can continue for 3-5 days, after which they pass just as suddenly as they started. However, such a “lull” does not last forever, and bouts of pain are repeated again and again. Acute gouty arthritis is often taken by surprise due to the appearance of sharp pains and inflammation of the periarticular tissues.
At the initial stage of the disease, the intervals between seizures are quite long (one to eight months), and the seizures themselves are short-lived, but the picture is gradually changing: the duration of seizures is increasing, and the intervals of “lull” are getting shorter.
In this case, the destruction of the cartilage of the joint begins, and characteristic defects (“punches”) appear in the adjacent bones, which are a cavity that is filled with microcrystals of sodium urate. Moreover, salt crystals can accumulate even under the skin (tofuses are formed – solid whitish nodules with a porridge-like mass).
Most often, tofuses are located near the joints or on the auricles. Sometimes breakouts of nodules and excretion of uric acid crystals through the fistula occur. Symptoms of gouty arthritis are different from reactive arthritis.
Shishkevich Vladimir, orthopedic and traumatologist, project editor-in-chief ExpertNews.
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Effect on the k >In addition, gout is often accompanied by the formation of urate in the kidneys, which leads to urolithiasis and, in some cases, to kidney inflammation.
In women, the disease is slightly milder, showing chronic pain in the ankle or knee joints, which is typical for arthrosis, and to determine that this is not arthrosis is possible only by severe swelling of the affected joint. Note that gout and arthritis are not the same disease.
If gouty arthritis is suspected, the patient is prescribed a biochemical blood test, as well as an x-ray of the feet and hands.
Results showing elevated uric acid levels and the presence of “punctures” confirm the accuracy of the diagnosis.
However, a single blood test may not be enough, because during an attack (and the patient, as a rule, treats it at the time of exacerbation), uric acid is concentrated in the joint, so its level in the blood at this time may be normal. It is necessary to repeat the analysis between attacks.
Treatment is based on antigout medications and a compulsory diet.
Treating Gouty Arthritis
Gouty arthritis requires a comprehensive treatment.
With gout, the amount of uric acid in the blood and tissues increases, the body’s reaction to them leads to pain and inflammation of the joints. Uric acid is formed from products containing purines (nitrogenous substances found in proteins).
It turns out that the treatment of gouty arthritis can be carried out in several directions, further:
Diet for treatment
Be sure to know that without a diet, all other methods of treating gouty arthritis are ineffective.
A large number of purines is found in meat, especially in offal, when cooking a considerable part of them goes into the broth. That is, from meat products only non-fat beef without broth, lean pieces of poultry, rabbit meat are allowed, and, every other day and in the first half of the day. There are a lot of purines in legumes, mushrooms, fatty fish – it is worth all this to be significantly reduced in the diet.
Significantly reduce or remove from the diet:
We must try to reduce the amount of coffee, cocoa, chocolate. Alcohol makes it difficult for uric acid to be excreted by the kidneys, provokes an acute attack of gouty arthritis, and increases the likelihood of side effects of drugs. Since gout disrupts the exchange of not only urates, but also oxalates, it is necessary to reduce the consumption of greens, especially sorrel and spinach, cauliflower, radish, turnips, tomatoes. Salt consumption is reduced.
Without restrictions it is possible cereal (except for oatmeal), dairy and, especially, dairy products. Bread and flour products, sweets, vegetables and fruits (except the above), eggs, low-fat cheese, nuts, dried fruits. Lemon juice dissolves and removes urate well, but here you need to be careful with the stomach.
If you follow all the conditions, diet, take medications recommended by your doctor, gout responds well to treatment. So, it’s up to you to continue to lead your previous lifestyle and suffer from unbearable pain, or sacrifice your habits (at least temporarily), but become healthy.
Gouty arthritis: forms of the course of the disease and its treatment
About the Developer
Rheumatologist, candidate of medical sciences.
Research interests: cardiovascular pathology in systemic diseases of the connective tissue, modern methods in the diagnosis and treatment of rheumatoid, psoriatic, gouty and other arthritis, reactive arthritis.
Author of the methodology and computer program for the early diagnosis of heart failure in patients with systemic lupus erythematosus, organizer and presenter of schools for patients.
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Before we dwell directly on the features of damage to the osteoarticular system in gout – gouty arthritis proper – it is necessary to define the disease itself. Gout is a chronic disease in which urate crystals are deposited in different tissues of the body, which in their chemical structure are represented by crystals of sodium monourate and / or uric acid. According to the International Classification of Diseases of the X revision (ICD-10), gout and its associated gouty arthritis are diseases of the musculoskeletal system and connective tissue. The most common clinical manifestation of this disease is “classic” acute gouty arthritis. The first attack (attack) is most often observed at the age of 40-50 years, although it can remind of itself at any age. Men are most susceptible to this pathology.
Acute gouty arthritis
The most typically acute (sometimes even the most acute) onset of the disease, often at night or in the early morning hours. There is a very sudden, acute and severe soreness in the joints, usually the feet. The pain builds up quite quickly, sometimes reaching unbearable intensity, the outwardly affected joint is swollen, the skin over the projection of the joint is hot, red. Active and passive movements in the joint are impossible or very limited, the patient walks with difficulty. The pain in the affected area can be so intense that even in a calm state they cause unbearable suffering, even touching the clothes makes the symptoms worse. In severe cases, the joint changes its configuration so much that the specialist sometimes has the idea of a diffuse purulent lesion (phlegmon). As we indicated above, during the first attack of gouty arthritis, arthritis of the joints of the foot is observed, especially often there is damage to the joint of the big toe (monoarthritis – damage to only one joint) of the leg, which is an undoubted indication of possible gout. Lesions of the elbow, knee, wrist joints, joints of the hands, hips and other localizations are slightly less common. Sometimes during an attack of acute gouty arthritis, a marked general malaise is also observed: an increase in body temperature, sweating. Also, in blood tests, an increase in ESR and leukocytes (leukocytosis), which are non-specific markers of inflammation, may attract attention.
Among the factors that provoke an attack of arthritis (triggers), the following most common can be distinguished:
- increased physical activity
- violation of the diet (often an attack occurs after feasts),
- excessive drinking
- taking certain medications (for example, diuretics, antitumor drugs, vitamin B12, heparin, etc.) and some other reasons.
Despite such an acute and sudden onset, arthritis with gout is also characterized by a very rapid “extinction” of symptoms (even without treatment) within a few days. This feature should suggest the possibility of gouty arthritis. However, this feature of the disease is not a reason not to pay attention to such an insidious ailment, since untreated gout is very variable in its clinical expressions. So, in neglected cases there is a gradual increase in arthritis attacks and / or a tendency to a more prolonged course of them. In the most difficult cases, we see the most severe course of the disease with an almost complete absence of interictal (“light”) periods and the formation of the so-called tofus – deposits of urate crystals.
Chronic gouty arthritis
This is essentially an already developed picture of the disease, characterized by the presence of various manifestations of this disease: tofus, a chronic form of joint damage, kidney damage with an outcome in urolithiasis (ICD). The most typical localizations of tofus are as follows: joints of the hands, elbow and knee joints, joints of the feet, and also in soft tissues – in the projection of tendons, auricles. Tofus often do not cause pain, often located near the most persistently affected joints. Sometimes tofus can spontaneously open, and a thick, pasty, whitish or yellowish content is released from the opened tofus. In severe cases, suppuration and ulceration of tofus can be observed. Sometimes numerous joints are involved in the pathological process, and the course of the disease begins to resemble rheumatoid arthritis, which requires a thorough differential diagnosis. In severe cases of the disease and in advanced cases, severe, disabling damage to the joints with their persistence and severe deformation and impaired function is noted.
Diagnosis of gouty arthritis is based on an assessment of clinical and medical history (i.e., patient history and patient life), as well as test results and instrumental examinations. Thus, complaints or the presence in the anamnesis of a typical acute gouty attack (severe pain in the joint area, monoarthritis, sudden onset and subsidence of symptoms), the presence of gouty tofuses of characteristic localization will indicate the disease. Among other things, attention should be paid to the concentration of uric acid in the blood of patients: for a woman – more than 0,36 mmol / l, for men – more than 0,42 mmol / l. It is also important that during the attack and immediately after it, uric acid can be within normal limits, which should not confuse the doctor and patient! To make a diagnosis, the study of synovial (articular) fluid, in which urate crystals can be found, can help. X-ray (MRI, CT) for gouty arthritis, we observe intraosseous cystic formations, often cartilage damage (destruction) and marginal bone erosion. Polarization microscopy of synovial fluid and tissues (tofuses) with the detection of urate crystals having a specific needle-like shape and a special light-optical phenomenon – negative birefringence may be useful.
The methods of treatment for this disease can very roughly be divided into drug and non-drug. It should be remembered that only in a small number of patients with confirmed arthritis and a relatively small increase in the level of uric acid in the blood can a long-term remission be achieved only by dietary recommendations and lifestyle changes. Many patients often need medical treatment. However, the fact that the lifestyle and the nature of nutrition should be reviewed for each patient is also undeniable! Before we dwell on how to treat gouty arthritis medically, we indicate the basic principles of supervision of such patients.
Recommendations for a diet for gouty arthritis are to limit meat, fish, legumes, strong coffee and tea – all this leads to the accumulation of uric acid. Relatively speaking, the amount of protein consumed is reduced to 1 g per kg of body weight, fat – to 1 g / kg, and the need for calories is satisfied mainly by carbohydrates. It is necessary to control weight, reduce if necessary and whenever possible. It is better to refuse alcohol consumption altogether, drink liquids of at least 2-3 liters per day.
Now we dwell in more detail on the clinical forms of the disease and approaches to their treatment. In an acute attack of gout, the primary task is to eliminate severe pain (which, recall, is often unbearable intensity) and inflammation in the joints. For these purposes, nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine are traditionally used. In practice, NSAIDs are most often used nevertheless due to their mass prevalence (usually over-the-counter release from pharmacies) and the awareness of patients who deservedly serve as first-line drugs for the relief of pain. In the absence of the desired effect of taking NSAIDs, they sometimes resort to the appointment of glucocorticosteroid hormonal drugs – orally, orally or intraarticularly. Local therapy (ointments, creams, gels) is rarely used because of its low effectiveness, although sometimes compresses for the joints of the feet, ankles, knees and other joints are recommended for treatment, which is more of a “distracting” nature.
The selection and appointment of anti-gout therapy for continuous use never begin during an acute attack of arthritis! Usually, treatment begins no earlier than 3-4 weeks after the full leveling of symptoms of acute gouty arthritis. Most often in our country, the drug ALLOPURINOL is prescribed. The dose of the drug is selected purely individually. Often start with minimal doses and titrate (increase) as needed. Less commonly used are other drugs, such as BENZBROMARON, FEBUKSOSTAT, which are much more expensive than NSAIDs and allopurinol, which significantly limits the mass intake in our country. In recent years, new effective drugs have been actively developed for the treatment of gouty arthritis, which affect the subtle mechanisms of pathogenesis and symptoms of this insidious disease.
Gouty arthritis: causes, symptoms and treatment
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- Symptoms of Gouty Arthritis
- Causes of Gouty Arthritis
- What is the danger of gouty arthritis
- Treating Gouty Arthritis
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How does gouty arthritis occur?
The disease occurs due to elevated levels of uric acid in the blood. This occurs in two cases. In the first case, the body produces too much uric acid, and the kidneys do not have time to remove it. In the second case, the amount of uric acid is normal, but the kidneys can not cope with their function.
When the concentration of uric acid in the blood exceeds the permissible level, its salts in the form of crystals are deposited in the joints and organs. It destroys the joint. Gouty arthritis affects the joints of the fingers, hands, elbows, knees, feet. Most often, toes suffer from the disease.
Symptoms of Gouty Arthritis
Symptoms of the disease appear during an attack of gouty arthritis. It develops abruptly, usually at night, after overeating or drinking alcohol.
There is a sharp pain in the joint area of the big toe. The skin over the inflamed joint turns red, the joint swells, the temperature rises. A person’s appetite disappears, nausea, heartburn appears, and blood pressure rises. Touching the joint and movement cause acute pain. In the afternoon, pain in the joint decreases, but in the evening it intensifies again.
After 3-4 days, the symptoms of gouty arthritis disappear, but the attack may recur. The interval between attacks of the disease is from 1 to 8 months. Before a new attack, a person feels a tingling sensation in the affected joint.
Due to the disease, nodules of a yellowish color are formed – tofus. Nodules are deposits of uric acid salt. They appear on the legs, ears, elbows, feet, fingers, hips, legs. If the nodules burst, a person feels severe pain.
Causes of Gouty Arthritis
Gouty arthritis develops in people with hypertension, diabetes, kidney failure, and problems with the gastrointestinal tract. These diseases disrupt the metabolism and can lead to an increase in the concentration of uric acid in the blood.
Diseases are prone to people with a hereditary predisposition, overweight, who move a little, often drink alcoholic beverages, prefer protein foods: meat, fish, mushrooms, beans, peas, liver, beef tongue.
What is the danger of gouty arthritis
Without proper treatment, gouty arthritis becomes chronic. Chronic gout disrupts the kidneys and bladder, causes kidney stones and gouty nephritis. Attacks of the disease are repeated more often and take over new joints.
With the formation of tofus, the body perceives them as a foreign body, which must be fought. As a result, the number of leukocytes in the body increases and inflammation begins.
Gout without treatment leads to urolithiasis. Kidney stones are formed from crystallized uric acid. They can cause kidney failure and can be fatal.
Feedback on treatment
I would like to say a big thank you to Alexander Chukaev. Half a year has already passed after the treatment, but I still constantly think about how good it is that I got to him! I came to see him in despair. At that time, I was 25 years old and was severely limp due to pain in the inner thigh for 1,5 years. I could not only engage in some kind of active activities (running, any outdoor games in nature, etc.), but also just walk normally. I visited 5 doctors before him, including the clinic, 122 medical units, where I got to the head of the department of traumatology, and 3 paid clinics. I went through all the examinations (MRI, ultrasound, x-ray) and NOBODY could tell me what was the matter. Everyone agreed: “this is not a joint.” Everyone wrote some recommendations, but there was nothing concrete. I had a course of magnetotherapy, injected a blockade, prescribed ointments, but nothing gave even a short-term effect. Alexander immediately determined the diagnosis, explained everything in great detail and showed in the pictures, answered all my silly questions, prescribed a treatment that was constantly monitored, and after 2 months I was able to walk without limping! Now for all questions only to him
For pain and discomfort in the joints, consult a specialist. The doctor of our clinic in St. Petersburg will distinguish gouty arthritis from other diseases and make an accurate diagnosis using a comprehensive examination. We use the following diagnostic methods:
Treating Gouty Arthritis
The doctors of our clinic treat the disease with conservative methods. Conservative treatment relieves pain and inflammation in the joints and heals the body.
We treat the patient individually. The doctor prescribes a course of procedures taking into account the stage of the disease, the characteristics of the patient’s body. Treatment takes from 3 to 6 weeks, the procedure needs to be done 2-3 times a week. The course includes at least 5 different procedures from the list:
Treatment of gouty arthritis in our clinic in St. Petersburg relieves pain and inflammation, normalizes the concentration of uric acid in the blood and metabolism, restores the structure of the joint. Procedures activate blood circulation, nourish joint tissues, eliminate salt deposits. Attacks of an illness happen less often or in general pass.
After completing the course, the doctor will give recommendations on what lifestyle to lead so that the disease does not return.
When treating gouty arthritis, it is important to follow a diet. Eat 4-5 times a day, do not overeat and do not starve. Drink at least 1,5 liters of water per day.
Include boiled and steamed dishes, vegetable soups, dairy products, low-fat cheese and cottage cheese, cereals, pasta in the menu. Eat vegetables: cabbage, carrots, potatoes, cucumbers, zucchini, eggplant. Eat fresh fruits: apples, pears, plums, apricots, citrus fruits.
Avoid fatty meat, smoked foods, canned food, salted and fried fish, legumes: lentils, peas, beans, asparagus. Exclude from the menu broths, alcoholic beverages, spices, cakes, chocolate, figs, grapes, spicy and salty cheeses.