T.S. Elliott said, "Decide what you think is right, and stick to it."
Although that is a moral imperative, rather than medical advice, it applies to gout. Some people get gout attacks when they eat red meat, others when they consume beer or excessive quantities of meat. Around the holidays, flares of this painful form of arthritis are common. Find out what works for you, as a mechanism of avoiding gout, and stick to that. If gout attacks continue to plague you, consult your physician. We have great treatments available to lower the blood level of uric acid, the causative agent.
Somewhere in recent mammalian evolution, human beings lost the capacity to convert uric acid to less toxic compounds. Specifically, we lack the compound uricase in our bodies. Consequently, the "normal" level of uric acid is close to the saturation point, especially in middle-aged persons. We tend to under-diagnose gout in women. Historically, gout is a disease of men with large body girth. Today, we call that obesity. Along with obesity, we see the so-called "metabolic syndrome," characterized by hypertension, diabetes, high cholesterol and gout.
Classically, gout strikes unexpectedly with an incapacitating pain in the great toe. So severe is this discomfort that even the weight of a sheet may be too much to bear. This may last days to weeks. Indeed, we sometimes mis-diagnose gout as rheumatoid arthritis, as a smoldering variation of gout can persist for weeks or months. Gout also causes subcutaneous deposits of uric acid, which we call "tophi." Rheumatologists love to stick a needle in a tophus, or in a joint, in order to identify the needle-like "crystals" or monosodium urate, the calling card of gout. Advanced gout can destroy joints and can also lead to kidney stones.
Some have referred to gout as the "disease of kings," as historical figures often enjoyed fine wine and tasty food, predisposing to this painful condition. I always imagine someone like Henry the Eighth, with his imposing girth and exceptional access to beef, secured by Beefeaters (allowed to enjoy this delicacy by royal dispensation). Starving common folks probably suffered gout less frequently. I don't know if old Henry was afflicted, especially since doctors lacked sophisticated laboratory facilities half a millennium ago. Today, we enjoy a relative wealth of food and alcohol, if we are inclined to indulge, readily available at prices most of us can afford. So we see an obesity epidemic and gout.
With respect to alcohol, three mechanisms may underlie its propensity to cause gout. First, alcohol stimulates the production of uric acid. Second, alcohol contains the "purine" precursors that lead to elevated serum urate levels. An example would be guanosine, which beer contains in prominent levels. Third, alcohol consumption can lead to dehydration and so-called "acidosis," or a minute increase in blood acidity, impairing uric acid secretion. Celebrating the Yuletide season with a football game and a couple beers can combine the gout-producing effects of alcohol with the purine load of red meats (think steaks or hamburgers), giving rise to a gout attack. Some of my patients can tolerate white wine, but not red wine. Red wine contains higher levels of purines, the uric acid precursor compounds.
Obviously, the best way to avoid gout is to not indulge in alcohol or excessive consumption of red meats, organ meats and other gout-inducing compounds. On the other hand, it is hard to enjoy the season in a completely abstemious person for many of us. Therefore, another option is to consume in moderation. More importantly, your friendly local rheumatologist can help you. In addition to diagnosing gout, we can suggest pharmacological and dietary, interventions. Have a healthy 2025!
Dr. Scott Anderson ([email protected]), is a clinical professor at UC Davis Medical School. This column is informational and does not constitute medical advice.