Gout, the disease of kings

By DR. PRADNYA KULKARNI

HONG KONG, China, One not-so-fine early morning, Harish woke up because of excruciating pain in his right ankle. "It hurt so much that I could not even stand on my feet," he says. "I did not recollect spraining or injuring my ankle the previous day."

An Indian in his mid-thirties who had moved to Hong Kong six months ago, Harish remembered he had suffered from a similar episode in the recent past. Being too stressed at his new office to care for his health, he had let it pass, since the pain had responded to pain killers. But this time he took the arthritic attack seriously and undertook an investigation. His blood uric acid level turned out to be more than 9mg/dl, as against a normal range of 3-7mg/dl. Harish was diagnosed with gout.

Harish's story is typical of the first episode of gout in most patients.

This is one of the oldest diseases known to mankind, first identified by the Egyptians in 2640 BC and later recognized by Hippocrates, the father of medicine, in the fifth century BC. For centuries people have known this painful arthritis to be precipitated by overindulgence in food and alcohol, and that is why it was called the disease of kings. Then it was known as a disease that disabled and hurt, but did not kill. But today, physicians believe otherwise.

Numerous studies worldwide show that the incidence of gout is rising. Patients also suffer from a mosaic of deranged health parameters and they all point toward increased risk of death due to all causes, especially heart diseases, according to a study by Dr. Hyon K. Choi from the Rheumatology Division at Vancouver General Hospital in Canada.

The primary culprit in this metabolic disorder is the chemical uric acid, a waste product normally present in blood, produced by the breakdown of dietary substances called purines. In health, uric acid dissolves in blood and is taken to the kidneys, from where it is discarded through urine

For some reasons, sometimes genetic but more often related to food and lifestyle, too much uric acid is produced or too little is expelled from the kidneys and its blood levels increase. These result in the formation of urate crystals called tophi which are deposited in the big toe, ankle, foot, wrist, fingers, cartilage, tendons or ear lobes, giving rise to severe throbbing and crushing pain

Sometimes patients suffer from painful kidney stones, if crystals deposit in kidneys. This was the case with Harish, who had suffered from a kidney stone attack too a few years ago, but it never occurred to him then that this was a result of high uric acid.

Tophi are not the only problems linked with increased uric acid levels or hyperuricemia. Scientists have noted that these people also have many other serious health problems.

Often these patients are overweight. Dr. F. Matsuura and team from the Second Department of Internal Medicine at Osaka University Medical School in Japan published a study in the journal Metabolism in February 1998 which suggests that central obesity* is linked with overproduction of uric acid. Perhaps a diet comprising of meat and alcoholic drinks, especially beer, contribute to obesity as well as high uric acid levels.

A study published in February last year in the journal Hypertension concluded that patients with hyperuricemia are at an increased risk of hypertension. Dr. Eswar Krishnan and team from the Division of Rheumatology and Clinical Immunology at the University of Pittsburgh in the United States studied for six years 3073 non-diabetic men. They noted that men with uric acid levels more than 7 mg/dl recorded higher blood pressure values in follow-up visits, as compared to those with normal uric acid levels

Dr. D. Conen and team from the Division of Hypertension and Vascular Medicine at CHUV in Lausanne, Switzerland studied 1,011 subjects and found that bad fats, or triglycerides, were high while the good fat HDL was low in the blood of patients with hyperuricemia. Such patients are at a high risk of coronary heart disease and stroke. The researchers fear this could be the result of a lifestyle of fatty food and no exercise.

Insulin resistance, a condition in which excess amounts of insulin are required to use blood glucose, is also associated with gout. This condition progresses to frank diabetes if not attended to in time. Dr. S. Takahashi, from the Third Department of Internal Medicine at Hyogo College of Medicine in Japan published a study in Metabolism in April 2001, which suggests that gout patients have some factors that cause insulin resistance and they become more prominent with abdominal obesity.*

All these dangerous health associations comprise the metabolic syndrome, a collection of various risk factors that increase the susceptibility for heart diseases, stroke and diabetes, which cause millions of deaths worldwide

Once thought to be a disease of kings, today gout is the disease of an average middle-class man who can afford to wine and dine every day like a king did in the past.

Changes in food habits, along with medication, are a must in the treatment and prevention of gout. Extensive research has been conducted in the past couple of decades and today most physicians agree that gout sufferers should stay away from foods like meat, sea food, alcohol and beer. Low-fat dairy products appear beneficial as the milk protein casein helps in excreting uric acid.

Vegetarians have no food restrictions but all must refrain from sugary soft drinks and fruit juices. Dr. Hyon K. Choi published a study last month in the British Medical Journal stating that these drinks are rich in fructose, which increases insulin resistance and uric acid and hence the risk of gout

The increasing prevalence of gout seems yet another testimony to the price that man is paying for giving up lifestyles of moderation and adopting lifestyles of vagary.

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