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Doctor's Consultation  by Dr. Iain Corness


Gout - and the middle way

When you mention the condition “gout”, a picture seems to flash up of a crusty old man with a glass of port and his foot on a stool, as he nurses an extremely painful big toe.  That’s not a bad description, but unfortunately a little limited.  You don’t have to drink port and you can get it in other joints.

However, if you are a sufferer, then you join some famous people such as Henry VIII, Benjamin Franklin and Thomas Jefferson.  They were not as lucky as you, as there was no real treatment in their day.

Gout is indicated in around five percent of all cases of arthritis and is present in around three to five percent of the population, with males outnumbering women around nine to one.  Afro-Americans and many Asian races also have higher incidence than Caucasians.

Gout is in its simplest fashion, a recurrent form of arthritis, and which generally affects just one joint.  This arthritis, or inflammation, occurs in association with high uric acid levels in the blood, and is described by patients as ‘exquisitely painful’.

The higher your concentration of serum uric acid (SUA), the more likely you are to get an acute attack.  The ‘normal’ range for SUA is taken as being between 3.5-7 mg/dl.  And if you are at the high end of the scale you are five times more likely to get gout.

What happens is that with high concentrations of uric acid it crystallizes out into the joint, leaving very sharp, needle-like crystals crunching inside the articular surface of the joint.  Very painful!

So who does get gout?  The typical gout sufferer is male in his 50’s, overweight, with high blood pressure, carnivorous and consumes large quantities of alcohol.  Is that you?

Gout affects almost four million men in the USA.  It has long been thought that purine-rich foods and a high protein intake are risk factors, and sufferers were advised to avoid meats, seafood, purine-rich vegetables, and animal protein.  One of the newer studies began on over 50,000 men from health professions in 1986.  Food-frequency questionnaires were sent out at baseline, and in 1990 and 1994.  Weight, medications, and medical conditions were recorded every two years.

The participants were assigned to groups according to the total intake of meat, their consumption of seafood, purine-rich vegetables, dairy products, low-fat dairy products, total protein, and animal protein.

During the study, there were 730 new cases of gout during the 12 years of follow-up.  Most of them were aged 55 to 64.

When total meat consumption was analyzed, the risk of acquiring gout was 1.41 times greater in the high meat eaters; in other words, eating more meat was a risk factor for gout.  Similarly, high seafood eaters were 1.51 times as likely to develop gout.  (Grass should be fairly safe to eat!)

In contrast, gout was less common in those taking more dairy products.  Men who drank two glasses a day of skim milk, or ate a serving of low-fat yogurt more than twice a week, halved their risk of developing gout.

In this study at least, purine-rich vegetables, and total protein had no influence on the chances of getting gout.

This large study confirmed that a diet high in meat and seafood increases the likelihood that a susceptible person will develop gout.  It also showed that milk proteins increase the excretion of uric acid in the urine.

So, to avoid developing gout, try to limit your intake of meat (beef, pork, lamb, and offal) and seafood, while increasing your intake of low-fat dairy produce (skim milk, yogurt).

This is all very important, as the long term outlook is not good for the unrepentant gout sufferer.  Constant high levels can lead to diabetes and even uric acid ‘stones’ being deposited in the kidneys (producing renal problems) and discharging lumps (called ‘tophi’) around joints, on the forearms and even on the outer ears.  Really a most bleak and depressing future, and not one I’d like to have.

Note too, that it is low-fat milk that is being proposed, as high fat milk introduces the cholesterol problems again!  It really is a fine line that we must all tread!  The Buddhist “middle way”.

Will 2012 be another year of abuse?

I think most of us, when pressed, will admit to abusing our bodies.  We punish our livers (New Year being a fine example), we also punish our brains with alcohol and we punish our joints and cardiovascular systems by being overweight.  We also regularly make New Year resolutions to stop doing all of the above, which lasts until February 1!

However, most patients self-select into two very different groups.  There are those who worry about every symptom they ever get, and then there are those who ignore their body’s telling them of things that are amiss.

It is between these two sides that the field of self-monitoring lies.  Some patients will slavishly carry out examination and recording far more than their disease process would require, but others will just not do these simple procedures, as they refuse to admit to sickness or ill-health in any way.

I am discussing here long term monitoring of chronic ailments, such as hypertension, diabetes or asthma.  I am not asking patients to become doctors and make their own diagnoses.  Sometimes it is hard enough for experienced doctors to do that!

This whole business of self monitoring is something that actually gets much space in the medical literature, and the medical profession itself is also divided over this issue.  Here I will try to provide the ‘middle ground’, which itself is not without certain problems.

Let’s take Blood Pressure problems first.  In actual fact it is quite difficult to get accurate blood pressure readings.  Blood pressure is a dynamic factor in the body.  Step off the kerb and be narrowly missed by a motorcycle and your blood pressure will rise immediately.  If it doesn’t, it probably means that he hit you and you are already dead.  There is also a well documented type of high blood pressure reading called ‘White Coat Hypertension’, where the BP goes up as the white coated doctor gets closer.

So what is your ‘real’ blood pressure reading?  For me, one isolated raised reading does not mean you have hypertension.  All that the one reading means is at that particular time, for any number of reasons, your BP was elevated.  It could be down again tomorrow.  Only by taking serial readings will you (and your doctor) really know.  Do not let anybody tell you that you have hypertension on one isolated reading!

However, if a definitive diagnosis of hypertension has been made, this is where self monitoring can be very good.  You can return to your doctor and give him serial readings, taken at home, and these will probably be closer to the ‘real’ numbers than ones taken in the sterile and sometimes frightening doctor’s office.  Mind you, this does depend upon accurate home measurement, using accurate equipment.

However, the physicians with the care of diabetic patients are not so enamored of glucose self monitoring as the cardiologists are with BP readings.  There is little evidence that home blood glucose monitoring improves outcomes in Type 2 diabetic patients.  There may even be negative effects associated with it, including increased distress and worry.  Regular hemoglobin A1c levels are more appropriate than daily finger pricks.  Since the Hb A1c levels show the overall diabetic control over the previous three months, it is actually a more consistent monitor, but there is no easy home testing kit.  It’s back to lining up to see your diabetic specialist on a regular basis, I’m afraid.

And so to asthma.  The respiratory physicians seem to be more in agreement with home monitoring for this chronic condition.  Serial lung function testing with simple hand-held devices can show the asthma sufferer the trends of decreasing or increasing respiratory function.  At predetermined levels, the patient can be instructed to initiate different therapies to stop them going into a full-blown asthma attack.  This is self monitoring towards a preventive end.  The main aim in asthma treatment.

The message is simple.  If you have a long-term condition, don’t ignore it, but monitor it!  And report to your doctor regularly.