The Straits Times (11 August 2019)
More men in their teens, 20s and 30s are plagued by the disease, on the back of less active lifestyles and diets packed with fructose-laden drinks and high-purine food like red meat
It started the morning after a night of heavy drinking. Mr Kevin Heng, who was 22 at the time, woke up to horrendous pain in his right ankle. He could barely walk. But he thought the ankle, which he had broken in secondary school playing touch rugby, was just acting up.
He was studying in Australia then and decided to tough it out. Finally, after 21/2 weeks of agony, he saw a doctor and was diagnosed with gout.
“I didn’t know what it was and thought I would wait it out,” the undergraduate, now 26 and studying in Singapore, said. “It was a constant, throbbing pain. The worst part about gout is that even when you are not moving, it actively hurts.”
Gout, a form of arthritis caused by high uric acid levels in the blood, used to be thought of as a rich, old man’s disease, striking people in their 50s who live it up with rich food and drink.
For decades, however, gout sufferers have gotten younger, with some getting it in their 30s.
There is no national-level tracking for gout, but from interviews with doctors, the disease has started striking teens and young men in their 20s too.
Dr Faith Chia Li-ann, senior consultant at Tan Tock Seng Hospital’s Department of Rheumatology, Allergy and Immunology, said the hospital has a patient who started having attacks at the age of nine. He has a strong family history of gout.
A general practitioner in private practice said that while most of his gout patients are in their 30s to 60s, he has six in their teens and 20s.
The youngest is a teenager who, like Mr Heng, started having pain in his ankle.
Dr Tan Teck Choon, senior consultant at Khoo Teck Puat Hospital’s Rheumatology, Clinical Immunology and Allergy Division, Department of General Medicine, said the hospital sees six to seven of these young patients a year. Many of them are serving national service and were referred to the hospital by the Singapore Armed Forces.
He said: “They might get gout flares and can’t train. We are beginning to see this group. They come in with various joint complaints, but gout sufferers make up a big percentage of these patients. Those with gout might also have other medical ailments such as high cholesterol levels and fatty liver.” The youngest patient the hospital has seen was 17 when he sought treatment. He had suffered gout attacks since he was 15.
Rich diets, lack of exercise
Why is this happening? Dr Tan said: “It’s the rich diets, the less active lifestyle – more video games and time spent indoors, and less exercise. Also, we all eat out quite regularly. Currently, kids’ diets are more Western than Asian. Desserts, sugary drinks and drinks sweetened with high fructose corn syrup can drive up blood uric acid levels.
“One patient had two cans of Coke a day and his uric acid levels were through the roof.”
Food and drink that are high in purines, which the body converts to uric acid, can trigger gout attacks. Examples include alcoholic drinks, shellfish, crustaceans, anchovies, sardines, red meat and organ meats. Drinks and food sweetened with high fructose corn syrup, and fructose-heavy fruit juices, are also culprits.
Dr Chia said fructose metabolises differently from other sugars. When the body breaks it down, chemical compounds that are the precursors to uric acid are released. “Fructose is also linked to weight gain and obesity, which is also correlated with high uric acid levels.”
A study in the United States in 2008 showed that men who drink two or more sugary sodas a day have an 85 per cent higher risk of gout than men who drink fewer than one soda a month.
Another study published in the Journal of the American Medical Association in 2010 showed that the risk of gout for women drinking orange juice every day was 41 per cent higher than women who rarely drank orange juice. Gout usually affects women in their 50s, when they lose oestrogen after menopause. The female hormone protects women from the disease.
Dr Tan advocates cutting down on sugar and desserts, and drinking more water. “The easiest thing to do would be to restrict soft drinks.”
Lasting consequences
Getting gout at a young age can have multiple effects, said Dr Chia. “Gout attacks are extremely painful and inhibit activity, which may disrupt time in school or the ability to participate in physical activities.”
Longer exposure to high uric acid levels can also lead to complications. One is the formation of tophi, which are deposits of uric acid crystals in the joints and surrounding tissue. These can erode bone.
Dr Tan sometimes shows patients a stark reminder of this. It is the X-ray of a patient’s foot, with bone in the big and little toes eroded by tophi.
Another complication, added Dr Chia, is kidney stones, which may affect kidney function. She added: “Children should maintain a healthy lifestyle and weight, with moderate consumption of foods that are high in purine and fructose.”
It’s the rich diets, the less active lifestyle – more video games and time spent indoors, and less exercise. Also, we all eat out quite regularly... Desserts, sugary drinks and drinks sweetened with high fructose corn syrup can drive up blood uric acid levels. ’’
DR TAN TECK CHOON, on more young people getting gout
It's like being stabbed
Patients with gout, no matter their age, are put on medication such as allopurinol to lower blood uric acid levels.
During a gout attack, resting the affected joint and placing ice packs on it help to ease the pain. Medications such as Arcoxia, used to treat osteoarthritis, may also be prescribed.
While a moderate diet, regular exercise and medication can keep gout at bay, this can be difficult for some, especially young people bogged down by school and who chafe at taking medication for the long term.
“Somehow, life gets in the way,” said Dr Tan. “We are also seeing patients who finish national service and go to university. And they put on more weight as a result of having less time for exercise.”
Mr Shawn Lee, 21, an undergraduate, was 19 years old when he was referred to Khoo Teck Puat Hospital by a general practitioner for pain in his right ankle.
A blood test confirmed that he had gout. He had felt pain in the ankle several times before, but never thought it might be gout, despite his father having it.
“I never linked soreness in my ankle to gout, until I couldn’t walk,” he said. “When you have a really bad attack, you don’t want to put any pressure on the joint. It’s like glass stabbing the joint.”
He manages the condition with medication and by watching what he eats and drinks, cutting down on red meat, bone broths, nuts and alcohol. He eats out less and prepares his own lunch to take to campus – usually rice and baked salmon or noodles in soup packed in a flask.
He has the occasional attack. He had one earlier this year, when he drank more soft drinks than usual during Chinese New Year and his purine level went up.
Mr Heng’s doctor had told him the strain on the previously broken ankle triggers the gout attacks and, going forward, he hopes to have it fixed.
“I thought my ankle was fine, but broken bones become problematic when you get older,” Mr Heng said. Until he sought proper treatment about a year ago, he would have three or four gout flares a year. The triggers, he said, were not consistent. The only time there was a correlation between what he ate and a gout attack was when he was heavily into whey protein.
He is now on medication for gout and fatty liver and has not had a gout attack in about a year. He has also stopped drinking alcohol and has cut down on red meat.
“It is easier to do that in Singapore because chicken is the main protein, compared with in Australia, where they eat lamb and beef a lot.”