Gout: Why the stigma?

Nutrition
To some, gout sounds like a medieval condition consigned to the history books; the name has an almost comical ring to it. In reality, gout is incredibly painful and surprisingly common. Here, we ask why no one is talking about gout.

People rarely discuss it, but gout can significantly affect quality of life.

Gout is a common form of arthritis that hyperuricemia, or a buildup of uric acid in the blood, triggers.

The body creates uric acid during the metabolism of purines, which are present in high levels in certain foods, including beef and seafood.

If the level of uric acid in the blood becomes too high, uric acid crystals (monosodium urate) can form in the joints.

In people susceptible to gout, these needle-shaped crystals tend to build up in the joint of the big toe, causing inflammation and severe pain.

The pain can be so intense that it becomes impossible to walk, put socks on, or even lay a sheet over the affected joint.

How common is gout?

An estimated 8.3 million people in the United States have gout, which equates to almost 1 in 25 adults. It affects men around three times more often than women.

This means that in the U.S., gout is more common than many better known conditions, such as psoriasis and rheumatoid arthritis.

In fact, the condition affects more people than celiac disease, multiple sclerosis, and peanut allergies combined. So why is no one talking about gout?

Gout appears to be becoming more common; from the late 1970s to the mid-1990s, prevalence has doubled in the U.S.

One factor behind this is likely to be rising obesity rates. This might be because obesity increases the risk of high blood pressure, and some drugs that people take to manage hypertension (diuretics) increase the risk of gout.

Also, obesity increases the risk of cardiovascular diseases, which also increase the risk of gout.

Because gout is more common among older adults, the aging population is likely to push the number of cases up.

A sense of embarrassment

Despite rising numbers, many people know nothing about gout, and those who experience it can feel embarrassed about discussing it.

For instance, an Alliance of Gout Awareness poll concluded that “[s]hame, confusion, and lack of awareness may keep people with gout from receiving the treatment they need.”

This is concerning because if left untreated, gout increases the risk of other conditions, including cardiovascular disease and kidney stones. It is also incredibly painful, and people should not feel that they need to experience it alone when medications and advice are available.

A study that examined the impact of gout on 11 men’s lives concluded that “shame, embarrassment, and stigma lead to trivialization of the impact of [gout] despite its severity.”

As someone who has gout, I can attest to the surprisingly intense pain it can cause. I can also confirm the associated embarrassment; I decided to write this Spotlight following a recent flare-up that occurred while I was attending a conference.

Explaining to my manager and team why I needed to limp home early reminded me of the misplaced shame that people with gout can experience.

Why the stigma?

Many people still associate gout with King Henry VIII and his overly luxurious lifestyle. In the past, and still today, people have considered gout a disease of wealth and royalty; indeed, some call it “the disease of kings.”

The Gout by James Gillray
‘The Gout’ by James Gillray. Published May 14, 1799.

Gout has a long history; scientists found evidence of uric acid in the joints of 4,000-year-old mummified Egyptians, and the first accurate description of gout seems to have come from Hippocrates around 400 BCE.

A paper discussing gout in 16–18th century literature explains that “gout was regarded as a badge of nobility, a talisman against other afflictions, and an aphrodisiac.”

According to this paper, some referred to gout as morbus dominorum et dominus morborum, or “lord of disease and disease of lords.”

Earlier still, the Ancient Greeks personified gout as Podagra, a child of Dionysus (god of wine) and Aphrodite (goddess of love). Consequently, in the Roman era, authors considered an excess of sex, food, and wine to cause gout.

Strangely, in 16–18th century Europe, many people considered gout a cure rather than a disease. They believed that people could only experience one condition at a time; confining the pain to a joint of one toe protected the rest of the body from disease.

It prevents other illness and prolongs life. Could I cure the gout, should not I have a fever, a palsy, or an apoplexy? […] I believe the gout a remedy and not a disease, and being so no wonder there is no medicine for it, nor do I desire to be fully cured of a remedy.”

English writer Horace Walpole, 1717–1797

So, as we see, gout was associated with being well heeled, making it almost desirable in times gone by.

Today, however, the perceived link with the upper class has subsided, and all that remains is the insinuation that someone with gout has an opulent lifestyle.

These fictional associations have left an indelible mark in the subconscious of society: Those who experience gout tend to blame themselves and, therefore, feel ashamed, while those who don’t have the condition make assumptions (subconsciously or otherwise) about the life choices of anyone with gout.

The truth of the matter

It is true that particular types of food and drink — such as alcohol, sugary drinks, shellfish, and meat — can increase the risk of a gout flare-up, but there is more to gout than a hedonistic lifestyle. Some people simply have a predisposition for gout, regardless of their lifestyle.

Meat selection
Certain foods, including meats, are high in purines.

A 2018 meta-analysis in the BMJ called into question the widely held belief that food choices are the primary driver of gout.

The scientists analyzed dietary information for 8,414 men and 8,346 women, none of whom had gout or kidney disease.

They measured levels of urate in the blood, which is the main risk factor for gout, and recorded their genetic profiles.

Before analysis, they also controlled for a range of variables that could influence the results, including body mass index (BMI), age, sex, and caloric intake.

They found that seven foods were associated with higher urate levels: liquor, beer, potato, wine, poultry, soft drinks, and meat.

Conversely, they pinned down eight foods associated with lower urate levels: peanuts, eggs, cheese, cold cereal, skimmed milk, brown bread, noncitrus fruits, and margarine.

However, they also showed that these foods accounted for less than 1% of the variation in blood levels of urate. Genetic factors, in comparison, were responsible for 23.9% of the variation. The authors conclude, “In contrast with genetic contributions, diet explains very little variation in serum urate levels in the general population.”

In a separate article by study co-author Tanya Major, she writes:

It came as no surprise to us that genetic factors have a larger influence on serum urate than dietary factors, what did surprise us was the magnitude of this difference, an almost 100-fold increase.”

She concludes that “[g]out is genetic, and drinking too much beer has very little influence on serum urate.”

In the past, this strong genetic influence has worked to strengthen gout’s mythical association with wealth and the high life; aristocrats and royalty tended not to mix their genes with those of the lower classes, thereby keeping gout in the family.

For instance, according to some scholars, “20 of the 34 kings of France were said to have been afflicted.”

It is worth reminding ourselves that around 1 in 25 people in the U.S. have gout. If you are reading this and have never experienced it, it is highly likely that someone in your group of friends has.

If you are reading this and have gout, remember that you are not alone. It is only by talking about gout publicly that we can slowly chip away at the stigma.

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