Gout — The ancient disease that is making a comeback

Have you ever associated having a disease with being high-class, noble, or even royal? While this notion seems very foreign to us in modern times, historically, this idea was much more common.

For hundreds of years, gout has been considered a disease of the wealthy and high-status. Having symptoms of gout was linked to high social and financial status — something that seems very strange with our modern-day understanding of health and wealth. While authors of the past used to write about gout in a positive light and as something to be desired, the current understanding of the disease has led many people to hide their condition, instead of flaunting it for the world to see.

Because gout has been around for centuries, the “disease of the wealthy and noble” has had plenty of time to adapt and adjust to become increasingly common. With cases of gout skyrocketing in America and around the world over the past few decades, it appears that our modern luxurious lifestyles may be partially to blame. Overindulgence in rich foods and alcohol is leading to an explosion of gout cases, as the disease is exacerbated by obesity, high blood pressure, high cholesterol, and other conditions associated with poor general health.

As an inflammatory disease, gout causes pain and limits the range of motion in a variety of joints in the body. Some of the most common joints impacted by a gout attack include the big toe, knees, ankles, feet, and elbows.¹

In the past half-century, the prevalence of gout in the American population has more than doubled. In 2017, it was reported that there were roughly 41.2 million cases of gout worldwide, with over more cases being diagnosed every year.²

But, despite the upward trend that seems to have no intent on slowing down, researchers say that gout is a largely preventable disease. With advancements in modern medicine and a shift in our cultural and societal concepts of healthy living practices, it is feasible that the prevalence of gout could be massively reduced throughout our global population.

What is gout and what causes it?

So, what exactly is the disease that kings and nobility used to associate with knowledge and privilege? Turns out, it is generally an unpleasant and painful condition that even with charitable interpretations, should be something that someone would not want to have.

Nowadays, we know that a gout is actually a form of inflammatory arthritis that primarily affects the function of joints throughout the body. Characterized by sudden attacks of symptoms seemingly from nowhere, gout is caused by the collection of urate crystals throughout the body. Uric acid, which is a normal component of human urine, is typically excreted from the body by the filtration system in the kidneys. When too much uric acid is left unfiltered, it can collect and crystallize in our joints, which results in a sudden attack of gout symptoms. The higher a person’s urate levels, the higher risk they have of developing chronic gout.³

Like many other types of arthritis, gout is a progressive disease that worsens over time if not properly managed. Gout currently has no cure. It is generally considered to have four stages:¹

1. High Uric Acid — As uric acid begins to build up in the body (associated with kidney function, diet, and genetics), the risk of developing gout increases. People in this stage are likely to have no symptoms and are likely to not be receiving treatment for gout.

2. Acute Flare-ups — Having reached a breaking point, the collected urate crystals will start to impact the function of one or more joints in the body. Swelling and pain in the affected joints are common. The severity of these flare-ups can greatly differ from person to person.

3. Intercritical Periods — After a gout attack, there is often a period of minimal to no symptoms. It is common for a person to think that their gout has miraculously healed, but this is not the case. They are still at high risk for developing another gout attack if they do not receive treatment for the condition.

4. Advanced Gout — After years of poor disease management, gout can develop into gouty arthritis. People with this condition still have gout attacks, but during the intercritical period, they will still have pain and low functionality of the impacted joints.

Symptoms of an acute gout attack

Because gout is a slowly progressive disease, many people living with elevated risk factors for developing the disease are completely unaware until they experience their first flare-up. While every person can present with different variations of gout symptoms, over 90% of gout attacks result in a flare-up that impacts their big toe on either foot.¹

Other common symptoms of a gout attack include pain, redness, and swelling to the elbows, ankles, wrists, or knees, kidney stones, extreme tenderness to the affected areas, and a feeling of heat or warmth radiating from the impacted joints.⁴

Wealthy nations are at a higher risk

As more people around the world are diagnosed with gout every year, trends are indicating that wealthy and developed nations are making up a large majority of the newest cases. Countries in North America and Western Europe have a high prevalence of gout, with about 1-4% of the population of countries in these regions being diagnosed with the condition.⁵ This prevalence rate is significantly higher than the average diagnosis rate in other nations of the world like Guatemala, Malaysia, the Philippines, and Saudi Arabia.⁵

According to the National Health and Nutrition Examination Survey (NHANES) in the United States, the increased prevalence of gout is likely due to the increase in hyperuricemia (high levels of uric acid in the blood) in the American population.⁶ This trend, as seen in other developed nations, is believed to have some connection to the modern diet, which relies heavily on convenience and fast-serve foods.

The modern diet is partially to blame

During ancient history, gout was common amongst the rich upper class because they were commonly the only group of people who would have access to plentiful amounts of rich foods. Now, in the modern era where gout has exploded in number in developed countries, we can turn to our diets yet again to understand why this might be the case.

With convenience and affordability becoming major driving factors for what foods people choose to eat, rates of obesity are rising across the globe. The average modern diet is made up of processed foods high in saturated fats, refined sugars, and high alcohol consumption. These rich and calorie-dense foods lead to a variety of health conditions, including obesity, high blood pressure, diabetes, and hyperuricemia.

Research has shown that people living with multiple medical comorbidities related to obesity and poor diet are significantly more likely to also be diagnosed with gout — thus beginning a never-ending spiral of worsening health and enhanced need for medical care.⁷

On top of the increased rates of obesity in developed countries, it is very common for the diets of these countries to be high in purines. Commonly found in animal-based proteins, purine compounds can raise the uric acid levels in the human body as they are broken down.⁸

Genetics, age, and gender also play a role

While diet and weight play a major role in the development of gout, not all people living with the condition meet this description. In a study conducted in 2018, it was found that genetic factors are more likely to be responsible for developing gout when compared to diet.⁹ So what was previously thought to be a “disease of the rich” due to lifestyle factors may have also been a disease of the privileged family lines — as wealthy and noble families kept their family trees small, passing their genetic information (and gout) on to future generations.

To this end, your gender also seems to play a role in your likelihood of developing gout. Men are statistically at a disadvantage when it comes to gout, typically making up over half of the newly diagnosed cases of gout every single year.¹⁰

Estrogen, the female sex hormone that is present in high levels throughout the female body until menopause, is largely believed to be responsible for offering women extra protection against developing gout at a younger age.

Despite your gender, age seems to be another factor that increases anyone’s risk for developing gout. As the human body ages, our organs slowly become less efficient at their job — and that includes the kidneys. With poorer filtration ability, uric acid levels can build up much quicker, resulting in a gout flare-up later in life. Research has shown that the average age of diagnosis for gout in men is 57, while the average age of diagnosis for women is over 60.¹¹

We need to manage gout more effectively

So, if we know all of this information about gout, why are so many people still getting diagnosed with it every year?

With advances in modern medical technology making the diagnosis of medical conditions easier and faster than ever before, you would think that gout would have been left in the history books. But, as it turns out, social stigma, limited access to adequate medical care, and poor education about the common symptoms of gout are preventing people from getting the treatment they need.

Because gout is a condition that comes and goes (at least until the advanced disease stage), many people do not seek medical attention for their symptoms during flare-ups. Depending on the amount of time in-between your flare-ups, it is very common for people to think that they are cured, or that the attack was a one-off episode. Unfortunately, as the amount of uric acid continues to accumulate in the body, gout attacks will only become more common and will become more severe as time goes on without adequate treatment.

Additionally, gout is, unfortunately, being misdiagnosed in older adults. Commonly blown-off as age-related joint pain, many people living with gout are not correctly diagnosed even when they start to show symptoms.¹²

And let’s face it - gout is no longer a sexy disease associated with wealth, power, and knowledge. Social stigma against gout and a general desire to avoid the doctor at all costs is another reason why many people live with gout for years before they are correctly diagnosed and treated. Rectifying these common pitfalls in gout diagnosis is an essential battle that our modern healthcare systems need to fight in order to reduce the number of future cases of gout.

Prevention is still rooted in lifestyle changes

Like every other disease, one of the best ways to manage its symptoms is to prevent exposures to common risk factors and triggers. While things like age, gender at birth, and genetics are not things you are capable of altering to reduce your risk of getting gout, lifestyle habits and diet are within our control.

As we have discussed, obesity plays a role in increasing a person’s risk factors for developing gout. While the average lifestyle of a person in the modern world is likely more sedentary than we would like, improving your daily exercise level is a great way to manage excess weight and the risk of developing gout. Low impact exercises like yoga, walking, and tai chi are great examples of ways to increase your daily exercise without having to overextend and exhaust yourself. These healthy habits are a great way to improve your overall health and wellness as well — which is truly a win-win!

Making dietary changes is also a great way to reduce the risk of having worsening gout attacks. Eating a diet that is low in purines (aka avoiding red meat, alcohol, seafood, and liver) is a great way to support the body and reduce the amount of uric acid being produced after each meal.¹³

While gout may not seem like a high-level threat to the health of our global community, the increased number of people diagnosed each year takes a toll on the capacity of our healthcare system. On top of that, chronically poorly controlled gout can lead to the extreme pain, limited range of motion, and poor quality of life — all of which have a huge impact on the individual living with the condition.

Despite the increased cases of gout being found every year, researchers are hopeful that they will be able to find a cure for this unpleasant chronic disease. With continued advancements in medical technology and more people accessing better quality healthcare, there is hope that gout will be able to be remembered as a disease of the distant past, after all.

Sources:

1. Gout: Risk Factors, Diagnosis, and Treatment | Hospital for Special Surgery

2. Prevalence, Incidence, and Years Lived With Disability Due to Gout and Its Attributable Risk Factors for 195 Countries and Territories 1990–2017: A Systematic Analysis of the Global Burden of Disease Study 2017 (2020)

3. Epidemiology of Gout (2015)

4. Gout | Cleveland Clinic

5. How common is gout in the United States, Really? | Rheumatology Network

6. Gout Emergency Department Visits Up | The Rheumatologist

7. Percentage of adults in the U.S. with gout who also had select health conditions from 2012 to 2014, by gender | Statista

8. Gout | CDC

9. Evaluation of the diet wide contribution to serum urate levels: meta-analysis of population based cohorts | The BMJ

10. Percentage of the U.S. population with gout from 2000 to 2015, by gender | Statista

11. Younger age at gout onset is related to obesity in a community-based cohort (2012)

12. Gout on the Rise as Americans Gain Weight | Scientific American

13. Facts about Gout | Hospital for Special Surgery

The author, Claire Bonneau, is a medical writer and certified trauma operating room nurse.