A Country Doctor Writes:

I am seeing more gout cases than I ever used to. I am also learning more and more about the linkages between gout, uric acid and the cardiometabolic diseases – stroke, heart failure, angina, hypertension, dyslipidemia and diabetes.

I have reflected before on the lack of knowledge, even among physicians, about gout treatment. That doesn’t at all mean I am professing to be an expert on the subject, only that I have developed an interest in it.

A while back, while trying all the usual angina medications for my patient with Cardiac Syndrome X, I read about using the gout medication, allopurinol, for angina. Every time I return to this topic I find more interesting facts and theories about allopurinol, gout, and heart disease.

It turns out that this old, generic, gout medication can decrease angina symptoms and heart attacks, improve pump function in heart failure patients, and lower blood pressure. These effects can be seen even in heart disease patients with normal levels of uric acid. We know allopurinol can reduce so called “oxidative stress”, believed to be at the core of many disease processes from heart disease to dementia.

In people without heart disease, but with high levels of the gout chemical, uric acid, allopurinol can improve both cholesterol and blood sugar levels.

Less known, but perhaps even more interesting, is that diets that reduce blood levels of uric acid have effects similar to allopurinol. Traditionally, such diets were severely protein-restricted, since uric acid is a by-product of protein metabolism. Newer research has shown that a high-protein diet low in sugar, fructose and saturated fat is more effective in reducing gout attacks and has better effect on cardiovascular risk than traditional, low-protein, gout diets. Both the high-protein, low-fructose diet and allopurinol reduce insulin resistance, which helps improve blood pressure, blood sugars and lipid levels. They also both increase elimination of uric acid through the kidneys.

I have been aware of the increased heart attack risk among patients with inflammatory conditions, which received attention when Ridker published his papers on C-reactive protein (CRP). Many clinicians, and many laboratories, hold the belief that very high CRP levels are a marker only of autoimmune disease but not of cardiac risk. Somehow, only mildly elevated levels are thought to be dangerous. Unfortunately, very high CRP levels, except perhaps (?) in acute illnesses, regardless of cause, are associated with very high cardiac risk.

Gout may be the oldest disease we know. First described by the Egyptians more than 4,000 years ago, gout was called the Disease of Kings, although it is now seen in all socioeconomic groups, but varies in incidence among age, sex and ethnic groups. In most areas of the world, gout incidence is on the rise 

Hippocrates, writing 2,500 years ago, pointed out that eunuchs, prepubescent boys and premenopausal women don’t tend to get gout. These are also the groups of people who are least likely to develop heart disease. The new findings about uric acid, allopurinol and heart disease illustrate that, in medicine, very few ideas are entirely new.

I agree with those who say that men only think of one thing – at least only one thing at a time.

Every week I hear male patients tell me their wives say they don’t listen, especially when they are occupied with reading or watching the news.

Many women, on the other hand, seem to have no trouble doing two or three things at the same time.

Certainly, multitasking has been a necessity throughout history for women, who kept house, raised children, cared for animals and did all kinds of farm chores.

In many early cultures dating back thousands of years, men would go out to catch the tiger or some other dangerous beast. That sort of endeavor was more likely to be successful if the hunter put all other random thoughts and projects out of his mind right then until the tiger was successfully taken care of. 

Today’s men generally operate very much like prehistoric man. If we split wood, we only do that, and if we mow the lawn, we don’t stop in the middle to split some wood or balance our checkbooks, unless we have Attention Deficit Disorder, or ADD.

When I grew up, there was only one channel on Swedish TV (I was five when I first saw a TV program). We played games that followed the pace of our minds and bodies, and we played them one at a time.

The generations born after me have been subjected to far more simultaneous sensory inputs, and they have played games that set the pace for the players; computer games often don’t slow down for the player, who needs more time. Children also often play games while watching TV in the background.

I, who no longer have a TV at home, was reminded at the airport recently of the flood of sensory inputs we can subject ourselves to today. The TV monitors had a news anchor occupying most of the screen. To the right was a live feed from the latest disaster scene and along the bottom of the screen was a ticker-type text with completely unrelated headline stories. A young couple was standing near a monitor, busily talking while each was texting on a Blackberry.

Modern society seduces us into trying to do more than one thing at a time. I often wonder what that does to a developing nervous system.

Are some young brains better equipped to select which outside inputs to process and which ones to ignore? Are some just unable to prioritize, and do they therefore rarely find the level of engagement necessary to complete tasks? It is well known that boys with ADHD can hyperfocus and do extremely well in high-risk situations, where dopamine is released within the central nervous system. But are low dopamine levels at the root of this condition?

What about the simultaneous rise in rates of Asperger spectrum disorders? Are they Attention Excess Disorders? Asperger children are in many ways doing the opposite of ADD children; instead of “taking it all in” and doing everything at once, they “tune out” many inputs others think of as important and focus their attention on details others might think of as irrelevant. Instead of always checking how their peers are reacting (Is anybody laughing at me, the Class Clown?), they fail to read the reactions of others, and tend to be socially awkward.

Or is our society less tolerant of these different coping mechanisms to an increasingly unhealthy environment? Is it so, that as our society becomes more intense, more and more people will fall outside the norm for what we think is an acceptable way to deal with the barrage of sensory inputs?