It was a typical office visit: a man with joint pain, a swollen toe, and, by the end of his appointment, a new diagnosis of gout. At that point, he mentioned a medical myth that dates back to antiquity: “But doc, I can’t have gout — I’m not rich!” And while I wished him good health as well as wealth, I had to explain that being wealthy had little to do with gout and that while there were a number of things he could do to treat or even prevent gout, having a modest income was no protection.
What Is Gout?
Gout is a form of arthritis that develops when crystals of uric acid (a normal waste product ordinarily removed by the kidneys) deposits in the joint. The blood levels of uric acid are usually high in people with gout because they produce excessive amounts, their kidneys cannot get rid of it fast enough, or they have a combination of both problems. Initial attacks usually last only a few days and most often affect the big toe, but over time attacks may last longer, affect other joints, or even several joints at once rather than one at a time. It also can be associated with kidney stones. Among the many factors that can increase the risk of gout or trigger an attack, alcohol is among the most powerful. Certain foods also can trigger gout, though this seems to be a less common observation in modern times.
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Why the Myth?
Descriptions of gout date back as far as the fifth century B.C., and throughout the ages gout was called the "King of Diseases and Disease of Kings." The reason: Attacks of gout seemed to follow banquets (apparently common among the royalty) during which participants drank excessive amounts of alcohol. In addition, eating large amounts of caviar and organ meats (such as pancreas or liver) also may have played a role in triggering gout at these feasts, because these foods are rich in the proteins that are broken down into uric acid. For those less able to afford large quantities of this food and drink, gout may have been less common.
The mistaken notion that gout only occurs in the wealthy developed in the same way that medical myths often develop: When two things occur together (gout and wealth), one is assumed to cause the other. The logic is as faulty as assuming that dieting causes obesity just because the overweight people you know always seem to be on a diet. In the case of gout, medical researchers would call the wealth of gout sufferers in ancient times a "confounder," a factor that is more often present in one group (people with gout) than in the other group (people without gout). Faulty conclusions are common unless confounders are taken into account.
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Alcohol and Gout: No Myth
The connection between drinking alcoholic beverages and attacks of gout is a strong one for many with the disease. Alcohol can lead to increased production of uric acid (and therefore, a higher risk of gout) for several reasons:
- Alcohol contains purines, proteins that are broken down into uric acid. The more alcohol you drink, the more uric acid is produced by degradation of purines.
- Alcohol inhibits anti-diuretic hormone, and that promotes water loss from the body. As a result, mild (or even severe) dehydration may follow, a situation that raises the uric-acid level in the blood.
- When alcohol is digested, a form of acid (called lactic acid) is produced. Heavy alcohol intake leads to enough lactic acid in the blood that it competes with uric acid for excretion by the kidney. If levels of lactic acid are high enough, the blood level of uric acid rises.
- Alcohol stimulates enzymes in the liver to become more active than usual, and these enzymes break down proteins to produce more uric acid.
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Gout Remains Mysterious
Myth flourishes when “truth” is elusive. Perhaps that is why so much myth has followed gout through the centuries — it’s as if myth fills in the blanks when medical science has no answers. Indeed, there are many things about gout that are poorly understood. For example:
- Why do attacks last only a few days in most cases?
- Why do some people get the disease while others do not, even when they have the same risk factors for the condition? And why does gout develop even in people without risk factors?
- Why do some people have a mild form of gouty arthritis, readily relieved with anti-inflammatory medications (such as ibuprofen) while others have frequent episodes of severe joint pain and swelling that are difficult to control?
- Why does alcohol seem to trigger gout in some people but not in others?
- Why does having a significant medical illness or surgery trigger gout?
It is remarkable that despite a detailed understanding of how uric acid is produced, handled by the body and deposited in the joints of gout patients, these basic questions have remained unanswered for many years. Future research may solve these mysteries. But for now, when patients ask “why me?” it is usually hard to provide a satisfactory answer.
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The Bottom Line
Gout is not limited to the wealthy, the royal or the otherwise well-connected. Having a modest income will not protect you from gout and, of course, having gout won’t make you rich. Observations linking gout to wealth has led to an association of cause and effect when, in fact, it was never the wealth that caused gout — it was the behavior of the wealthy that was the real link. Fact and fiction can sometimes change over time; what is believed to be myth now may someday be discovered to be true. Similarly, gout may have been highly associated with wealth in the past, even though it is not now.
My patient is living proof that you need not be a king to have the Disease of Kings. His beliefs about gout also prove how long a medical myth can last.
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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.