Understanding gout: The silent pain of an ancient disease

Gout is often associated with indulgence—visions of rich feasts and excessive drinking. But for those who live with it, the reality is far less glamorous. This ancient condition, once known as the “disease of kings,” continues to affect millions worldwide. In Southeast Asia alone, there are an estimated 2.8 million cases.¹ It’s a painful reminder of how our lifestyle choices can impact our health. But what exactly is gout, and how does it work?

At its core, gout is a type of arthritis, but it’s distinct in how it strikes and the intensity of its attacks. Gout occurs when there’s an excess of uric acid in the body. Uric acid is a byproduct of purine breakdown, substances found in many foods and drinks, particularly red meat, seafood, and alcohol. When the kidneys can’t process uric acid quickly enough, it builds up in the blood and forms sharp crystals in the joints. The body reacts, causing sudden, severe pain, redness, and swelling. The big toe is most commonly affected, but gout can also strike other joints, including the knees, ankles, and elbows.

The onset of a gout attack is sudden and intense, often waking people from their sleep. The affected joint can become hot to the touch, and even the slightest movement can bring excruciating pain. It is a reminder of how an imbalance in our bodily processes can manifest in ways that are both mysterious and painfully clear.

The science behind gout²

While the symptoms are dramatic, the science behind gout is fascinating. Here’s how it works:

	Uric acid production Uric acid is typically removed from the body through urine. However, when the body produces too much or the kidneys fail to excrete enough, the surplus uric acid crystallises.
	Crystal formation These crystals are needle-like and accumulate in the joints, usually in cooler areas like the big toe.
	Inflammation The body’s immune system sees these crystals as foreign invaders, triggering an inflammatory response that causes the pain, swelling, and redness.

Several factors lead to this imbalance:

	Genetics Some people are genetically predisposed to having higher levels of uric acid in their blood.
	Diet Foods high in purines (e.g., red meats such as beef or lamb), shellfish (e.g., lobster, crab, and oyster), certain fish (e.g., anchovies, sardines and mackerel), and high-fructose foods (e.g., soda, energy drinks, sports drinks) can raise uric acid levels.
	Obesity Extra weight puts more stress on the kidneys and can make it harder to excrete uric acid.
	Alcohol Excessive consumption, especially of beer and spirits, interferes with the kidneys' ability to process uric acid.

While gout was once considered a condition for the wealthy, who could afford to overindulge in food and drink, it has become more common in recent years, affecting both men and women, especially as obesity rates and related health problems rise.

The human experience

Li Wei (not his real name), a 45-year-old from Kuala Lumpur, had always lived an active life. But for several months, he had been noticing increasing pain in his feet, especially after a long day at work or a heavy meal. He attributed it to just “getting older” but was taken aback when the pain became unbearable one evening.

“I woke up in the middle of the night with intense pain in my big toe. It felt like my foot was on fire, and I couldn’t even touch it. I had to hobble to the clinic the next morning,” he says. At the clinic, Li Wei was diagnosed with gout. The doctor explained that uric acid, a natural waste product from food like meats, seafood, and alcohol, had built up in his blood, forming crystals in the joint. Li Wei, who regularly enjoyed spicy stir-fries, fried foods, and the occasional beer, was advised to make dietary changes to reduce purine-rich foods, especially meats like beef and pork, which were abundant in his diet.

The treatment for Li Wei included medications to reduce inflammation and lower his uric acid levels. The doctor also recommended that he avoid alcohol and cut back on foods like fried fish and shellfish, which he had enjoyed regularly. But the most challenging change was adopting a healthier lifestyle, including regular exercise and eating more vegetables and fruits—foods he hadn’t been fond of before.

“It wasn’t easy at first. I loved my weekend gatherings with friends, where we would have our favourite fried fish and beer. But after the first attack, I was determined to avoid it. It’s scary to think that the pain could come back at any time,” Li Wei says, his tone reflecting the concern that accompanies living with gout.

Since his diagnosis, Li Wei has made an effort to stay active and monitor his food intake. He still enjoys his local delicacies but in moderation, making sure his meals are balanced with more plant-based options. “Now, I pay more attention to what I eat. My gout doesn’t control me anymore, but I need to respect my body.”

Li Wei’s experience reflects the journey of many people living with gout: a sudden, painful awakening followed by adjustments in lifestyle and diet, as well as an ongoing commitment to managing the condition to avoid future flare-ups.

DID YOU KNOW?

Gout was known to the ancient Egyptians and was described in medical texts more than 4,000 years ago.
Beer is one of the biggest culprits in raising uric acid levels, as it contains both alcohol and purines.
A diet rich in fruits, vegetables, and whole grains can help lower uric acid levels and reduce gout flare-ups.

Symptoms of gout

Gout is a painful form of arthritis that can cause sudden, severe attacks. These attacks occur when uric acid builds up in the body and forms sharp crystals in the joints, leading to inflammation. Below are the key symptoms of gout:

Sudden intense joint pain: Often begins at night, usually in the big toe, but it can affect other joints like the knees, ankles, and elbows.
Swelling and redness: The affected joint becomes swollen, red, and shiny.
Heat in the joint: The joint feels hot to the touch due to inflammation.
Limited range of motion: The joint becomes stiff and difficult to move.
Tenderness: Even light touch or pressure can cause severe pain.
Fever (in some cases): A mild fever may accompany the flare-up.
Tophi (in chronic cases): Lumps of uric acid crystals that form under the skin, usually around joints.
Fatigue: General tiredness from pain and ongoing inflammation.

Treatment and management³

The good news is that gout is treatable, and with the right management, flare-ups can be prevented or at least minimised. Here are some common treatments and lifestyle tips for managing gout:

Medications

Non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are commonly used to reduce pain during an acute attack.
Medications like allopurinol and febuxostat lower uric acid levels over time, helping prevent future attacks.

Lifestyle changes

Weight management: Maintaining a healthy weight can reduce stress on your kidneys and help keep uric acid levels in check.
Hydration: Drinking plenty of water (at least 8 glasses a day) helps the kidneys process and eliminate uric acid more effectively.
Diet adjustments: Focus on a diet rich in vegetables (e.g., carrots, spinach), whole grains (e.g., barley, brown rice), and low-fat dairy, while limiting high-purine foods like red meats, organ meats, and shellfish.
Alcohol: Reducing alcohol consumption, especially beer, is crucial for managing gout.
Coffee: Some studies suggest that moderate coffee consumption may help lower uric acid levels. However, it’s important to avoid excessive amounts, as caffeine can be a diuretic and may lead to dehydration, which could worsen gout symptoms.

Health implications of gout

If gout is left untreated or poorly managed, it can lead to a range of serious health complications:

	Increased risk of cardiovascular diseases Elevated uric acid levels have been linked to an increased risk of heart attack, stroke, and high blood pressure. Chronic gout and high uric acid can contribute to the development of atherosclerosis (hardening of the arteries), which can lead to heart disease.
	Joint damage Repeated gout attacks can cause long-term damage to the affected joints. Over time, uric acid crystals can lead to permanent joint damage, resulting in deformities and chronic pain. In severe cases, this can impair mobility and function.
	Kidney damage Chronic high levels of uric acid can also lead to kidney stones or even kidney disease. The accumulation of uric acid crystals in the kidneys can cause significant damage, potentially leading to kidney failure if left untreated.
	Tophi formation In long-term, uncontrolled gout, tophi (lumps of uric acid crystals) can form around joints and other tissues. These deposits can cause joint deformity, chronic pain, and even infection if they rupture.

Proper management of gout, including medications and lifestyle changes, is essential to prevent these complications and maintain a good quality of life. For Li Wei, the key to managing gout has been moderation. “I can still eat my favourite foods, but now I balance them with healthier choices. I’ve learned that lifestyle is everything when it comes to gout management,” he says.

The road ahead

While gout is manageable, it remains a lifelong condition for many. As research continues, better therapies and prevention strategies may emerge, offering more hope for those affected. But for now, the onus lies on those with gout to adapt their lifestyles, focusing on maintaining balance and taking proactive steps to manage their condition.

Gout serves as a reminder of how small imbalances in our body can lead to big consequences. And for those like Li Wei, it’s a constant learning process of understanding the triggers and taking control—one mindful choice at a time.

DID YOU KNOW?

Gout attacks can be triggered by sudden changes in diet or dehydration, which is why staying hydrated and avoiding rich, fatty foods is essential.
Gout attacks can strike without warning, although they often occur at night.
Consuming cherries has been associated with a reduced risk of gout attacks.⁴

We hope you found this article informative. Healthful welcomes contributions from healthcare professionals, patients, and community members. If you have a story, research, or a perspective that can enrich our dialogue, please get in touch with us at [email protected].

References

Jatuworapruk K, De Vera R, Estrella AM, et al. The APLAR Gout Registry: A multinational collaboration to better understand people with gout in the Asia-Pacific. Int J Rheum Dis. 2023;26(8):1432-1434.
All about gout. Harvard Medical School. Available at: https://www.health.harvard.edu/diseases-and-conditions/all-about-gout.
Gout – Achieving the management goal (2023). ACE. Available at: https://www.ace-hta.gov.sg/docs/default-source/acgs/gout-achieving-the-management-goal-dec2023.pdf.
Chen PE, Liu CY, Chien WH, Chien CW, Tung TH. Effectiveness of Cherries in Reducing Uric Acid and Gout: A Systematic Review. Evid Based Complement Alternat Med. 2019;2019:9896757.

The science behind gout²

The human experience

Symptoms of gout

Treatment and management³

Health implications of gout

The road ahead

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The science behind gout2

The human experience

Symptoms of gout

Treatment and management3

Health implications of gout

The road ahead

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The science behind gout²

Treatment and management³