Understanding Gouty Arthritis
Gouty arthritis, commonly known as gout, is a painful and debilitating form of inflammatory arthritis that affects millions of people worldwide. It is caused by the buildup of uric acid crystals in the joints, leading to inflammation, swelling, and intense pain. Gout typically affects the joint at the base of the big toe but can also occur in other joints such as the ankles, knees, wrists, and elbows.
Uric acid is a waste product that is naturally produced by the body as it breaks down purines, which are substances found in certain foods and drinks. Normally, uric acid dissolves in the blood and is eliminated through the kidneys. However, when the body produces too much uric acid or the kidneys do not excrete it efficiently, it can accumulate in the blood and form sharp, needle-like crystals in the joints. These crystals can cause sudden, severe episodes of pain, redness, and swelling, known as gout attacks.
Gout has been recognized as a medical condition for thousands of years and was once considered a disease of the wealthy due to its association with rich foods and alcohol consumption. Today, we know that gout can affect anyone, regardless of social status, and that various factors, including genetics, diet, and lifestyle, can contribute to the development of this condition.
While there is no cure for gout, it can be effectively managed through a combination of medications, lifestyle changes, and dietary modifications. Early diagnosis and treatment are crucial in reducing the frequency and severity of gout attacks, as well as minimizing the risk of long-term complications, such as joint damage and kidney problems.
In this article, we will explore the causes, symptoms, and treatment options for gouty arthritis, as well as discuss lifestyle factors, dietary recommendations, and strategies for managing and preventing gout attacks. Additionally, we will address common questions and concerns related to this painful and often misunderstood condition.
Table of contents
- Understanding Gouty Arthritis
- Causes of Gouty Arthritis
- Symptoms and Diagnosis of Gouty Arthritis
- Lifestyle Factors and Gouty Arthritis
- Medical Treatment Options for Gouty Arthritis
- Natural Remedies for Gouty Arthritis
- Dietary Recommendations for Gouty Arthritis
- Gouty Arthritis and Comorbidities
- Managing Gouty Arthritis Flare-Ups
- Preventing Gouty Arthritis
- Gouty Arthritis: Common Questions and Answers
Causes of Gouty Arthritis
Gouty arthritis, commonly referred to as gout, is a painful form of inflammatory arthritis caused by the buildup of uric acid crystals in the joints. Uric acid is a waste product that is usually eliminated from the body through urine. However, in some cases, the body may produce too much uric acid, or the kidneys may not be able to remove it efficiently, leading to a buildup of uric acid in the blood. This condition, known as hyperuricemia, can result in the formation of sharp, needle-like crystals in the joints, causing inflammation and pain.
Several factors can contribute to the development of gouty arthritis. Some of the most common causes include:
- Genetics: Family history plays a significant role in the development of gout. If one or both of your parents have gout, you are more likely to develop the condition yourself. Certain genetic factors can predispose individuals to produce too much uric acid or have reduced kidney function, increasing the risk of gout.
- Diet: Consuming foods and beverages high in purines can increase the risk of gout. Purines are naturally occurring compounds found in many foods, particularly organ meats, seafood, and some vegetables. When purines are broken down in the body, they produce uric acid. A high-purine diet can lead to an increase in uric acid levels and the development of gout.
- Obesity: Excess body weight can contribute to the development of gout, as it increases the production of uric acid and puts additional stress on the kidneys. Obesity can also lead to insulin resistance, which can impair the body’s ability to eliminate uric acid efficiently.
- Medications: Certain medications can increase the risk of gout by affecting the body’s ability to eliminate uric acid. Diuretics, commonly prescribed for high blood pressure, can reduce kidney function and increase uric acid levels. Other medications, such as aspirin and some immunosuppressants, can also contribute to hyperuricemia.
- Kidney disease: Reduced kidney function can impair the body’s ability to eliminate uric acid, leading to a buildup of uric acid in the blood and an increased risk of gout. Chronic kidney disease is a common comorbidity in individuals with gout.
- Alcohol consumption: Drinking alcohol, particularly beer, can increase the risk of gout. Alcohol interferes with the body’s ability to eliminate uric acid and can also increase the production of uric acid by promoting the breakdown of purines.
It is important to note that not everyone with high uric acid levels will develop gout. In some cases, individuals may have asymptomatic hyperuricemia, where they have elevated uric acid levels but do not experience gout symptoms. However, understanding the causes of gouty arthritis can help individuals make informed decisions about their lifestyle and treatment options to manage and prevent the condition.
Symptoms and Diagnosis of Gouty Arthritis
Identifying the signs and symptoms of gouty arthritis is crucial for early diagnosis and proper treatment. Gouty arthritis typically presents as sudden, severe pain in the affected joint, most commonly the big toe. The pain may be accompanied by redness, swelling, and warmth in the joint, making it difficult to move. These symptoms usually occur at night and can last for several days or even weeks if left untreated.
While the big toe is the most common site for gouty arthritis, other joints can also be affected, such as the ankles, knees, wrists, and fingers. In some cases, gout can cause more generalized symptoms, including fever, fatigue, and a general feeling of malaise.
To diagnose gouty arthritis, a healthcare professional will typically perform a physical examination and review the patient’s medical history, including any history of gout or kidney problems. Blood tests may be ordered to measure the levels of uric acid in the blood, as elevated levels can be an indicator of gout. However, it is important to note that not all individuals with high uric acid levels will develop gout, and some people with normal levels may still experience gouty arthritis.
In some cases, a joint fluid analysis may be necessary to confirm the diagnosis. This procedure involves extracting a small amount of fluid from the affected joint using a needle and syringe. The fluid is then examined under a microscope for the presence of urate crystals, which are the primary cause of gouty arthritis. Imaging studies, such as X-rays, may also be used to assess the extent of joint damage and rule out other potential causes of joint pain.
Early diagnosis and treatment of gouty arthritis are essential for preventing long-term complications, such as joint damage and loss of mobility. If you suspect that you may be experiencing symptoms of gout, it is important to consult with a healthcare professional for a thorough evaluation and appropriate treatment recommendations.
Lifestyle Factors and Gouty Arthritis
When it comes to managing gouty arthritis, lifestyle factors play a significant role in determining the frequency and severity of flare-ups. By making certain adjustments to daily habits, individuals can effectively reduce the risk of gout attacks and improve their overall quality of life. The following lifestyle factors can have a direct impact on gouty arthritis:
1. Weight management: Carrying excess weight puts more pressure on the joints and increases the risk of developing gout. Losing weight can help to reduce uric acid levels in the body, thereby decreasing the likelihood of gout attacks. It is essential to lose weight gradually and through a combination of healthy eating and regular physical activity, as rapid weight loss can temporarily increase uric acid levels.
2. Exercise: Engaging in regular physical activity can help to maintain a healthy weight and promote overall joint health. Low-impact exercises, such as swimming, walking, or cycling, are particularly beneficial for individuals with gouty arthritis, as they help to strengthen the muscles around the joints without causing excessive strain.
3. Alcohol consumption: Excessive alcohol intake, especially beer and liquor, can raise uric acid levels and trigger gout attacks. It is important to limit alcohol consumption or avoid it altogether if you have gouty arthritis. Moderate wine consumption may be less likely to cause gout flare-ups, but it is still essential to discuss this with your healthcare provider.
4. Hydration: Drinking plenty of water throughout the day can help to dilute uric acid levels in the body, reducing the risk of crystal formation in the joints. Aim for at least 8-10 glasses of water daily, and consider increasing your fluid intake during hot weather or when engaging in physical activity.
5. Stress management: High levels of stress can contribute to gout flare-ups, as stress can cause the body to produce more uric acid. Implementing stress-reduction techniques, such as deep breathing exercises, meditation, or engaging in hobbies that promote relaxation, can help to manage stress levels and reduce the risk of gout attacks.
6. Smoking: Smoking has been linked to an increased risk of gouty arthritis, as it can interfere with the body’s ability to eliminate uric acid. Quitting smoking is an essential step in managing gout and improving overall health.
By addressing these lifestyle factors, individuals with gouty arthritis can reduce the frequency and severity of their flare-ups, leading to a better quality of life. It is important to work closely with your healthcare provider to develop a personalized plan that addresses your specific needs and risk factors.
Medical Treatment Options for Gouty Arthritis
When it comes to managing gouty arthritis, medical treatment plays a crucial role in providing relief from pain, reducing inflammation, and preventing future flare-ups. A variety of medications are available to treat gout, and your healthcare provider will prescribe the most appropriate option based on your specific needs and medical history. Here are some of the most common medical treatment options for gouty arthritis:
1. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs are often the first line of treatment for gouty arthritis. They help to reduce pain and inflammation during a gout attack. Over-the-counter NSAIDs, such as ibuprofen and naproxen, may be effective for mild to moderate gout pain. However, stronger prescription NSAIDs, like indomethacin or celecoxib, may be necessary for more severe cases. It’s essential to follow your healthcare provider’s recommendations regarding the dosage and duration of NSAID use, as long-term use can lead to side effects such as gastrointestinal issues and increased risk of cardiovascular events.
2. Colchicine: Colchicine is another medication used to treat gout attacks. It works by decreasing the build-up of uric acid crystals in the joints, thereby reducing inflammation and pain. Colchicine is typically prescribed for patients who cannot tolerate NSAIDs or have contraindications for their use. It can be used as a short-term treatment during a gout flare-up or as a long-term preventive measure. However, colchicine can cause side effects such as nausea, vomiting, and diarrhea, so it’s essential to follow your healthcare provider’s instructions regarding its use.
3. Corticosteroids: Corticosteroids, such as prednisone, are powerful anti-inflammatory medications that can provide rapid relief from gout pain and inflammation. They can be taken orally or injected directly into the affected joint. Corticosteroids are typically reserved for patients who cannot take NSAIDs or colchicine, or for those who have not responded well to these medications. Long-term use of corticosteroids can lead to side effects such as weight gain, high blood pressure, and increased risk of infections, so they are typically used for short-term management of gout symptoms.
4. Urate-Lowering Therapy (ULT): ULT medications, such as allopurinol and febuxostat, work by reducing the production of uric acid in the body. These medications are used for long-term management of gouty arthritis and help to prevent future gout attacks by maintaining lower uric acid levels. It’s essential to monitor uric acid levels regularly while on ULT to ensure the medication is working effectively and to adjust the dosage as needed. Side effects of ULT medications can include rash, liver function abnormalities, and gastrointestinal issues.
5. Uricosuric Agents: Uricosuric agents, such as probenecid, work by increasing the excretion of uric acid through the kidneys. These medications can help lower uric acid levels and prevent gout attacks in patients with under-excretion of uric acid. However, uricosuric agents are not recommended for patients with kidney problems or a history of kidney stones. Side effects may include rash, gastrointestinal issues, and an increased risk of kidney stones.
It’s important to remember that medical treatment for gouty arthritis should be tailored to each individual’s needs and medical history. Your healthcare provider will work with you to determine the most appropriate treatment plan to manage your gout symptoms and prevent future flare-ups. In addition to medical treatment, lifestyle modifications and dietary changes can also play a significant role in managing gouty arthritis effectively.
Natural Remedies for Gouty Arthritis
While medical treatments are often necessary for managing gouty arthritis, many individuals also turn to natural remedies to help alleviate symptoms and prevent future flare-ups. These remedies can be used in conjunction with medical treatments, but it is essential to consult with your healthcare provider before trying any new therapies. Here are some popular natural remedies for gouty arthritis:
- Cherries: Cherries, particularly tart cherries, have been shown to have anti-inflammatory properties and may help reduce uric acid levels in the body. Consuming cherries or cherry juice regularly may help alleviate gout symptoms and prevent flare-ups.
- Apple Cider Vinegar: Apple cider vinegar is believed to help balance the body’s pH levels and reduce inflammation. Mixing a tablespoon of apple cider vinegar with a glass of water and drinking it daily may help reduce gout symptoms.
- Ginger: Ginger is known for its anti-inflammatory properties and may help reduce inflammation associated with gouty arthritis. You can consume ginger in various forms, such as adding it to your meals, drinking ginger tea, or taking ginger supplements.
- Hydration: Staying well-hydrated is essential for individuals with gout, as it helps the kidneys flush out excess uric acid from the body. Drinking plenty of water throughout the day can help prevent gout flare-ups and alleviate symptoms.
- Cold Compress: Applying a cold compress to the affected joint can help reduce inflammation and provide temporary pain relief during a gout flare-up. Wrap ice or a cold pack in a towel and apply it to the joint for 20-30 minutes at a time, several times a day.
- Epsom Salt Bath: Soaking in a warm bath with Epsom salts can help relax muscles and relieve joint pain associated with gout. Add 1-2 cups of Epsom salts to a warm bath and soak for at least 20 minutes.
- Essential Oils: Some essential oils, such as lavender, eucalyptus, and peppermint, may help reduce inflammation and provide pain relief. Dilute a few drops of essential oil in a carrier oil, such as coconut or almond oil, and gently massage it onto the affected joint.
It is important to remember that while these natural remedies may help alleviate gout symptoms, they should not replace medical treatments prescribed by your healthcare provider. Always consult with your doctor before trying any new therapies, and continue to follow their recommendations for managing your gouty arthritis.
Dietary Recommendations for Gouty Arthritis
When it comes to managing gouty arthritis, diet plays a crucial role in controlling the levels of uric acid in the body. Uric acid is a waste product that is produced when the body breaks down purines, which are found in certain foods. High levels of uric acid can lead to the formation of urate crystals, which cause inflammation and pain in the joints. By making some dietary adjustments, you can help reduce the frequency and severity of gouty arthritis flare-ups.
Here are some dietary recommendations for individuals with gouty arthritis:
- Limit high-purine foods: Foods that are high in purines can contribute to increased uric acid levels. These foods include red meat, organ meats (such as liver and kidneys), seafood (especially shellfish, anchovies, and sardines), and some types of fish (like mackerel and herring). It’s essential to limit your intake of these foods to prevent gouty arthritis flare-ups.
- Increase low-purine foods: Consuming a diet rich in low-purine foods can help reduce uric acid levels. These foods include fruits, vegetables, whole grains, and low-fat dairy products. Opt for plant-based protein sources like beans, lentils, and tofu, as they are lower in purines compared to animal-based proteins.
- Stay hydrated: Drinking plenty of water can help flush out excess uric acid from the body and reduce the risk of kidney stones, which can sometimes develop in people with gouty arthritis. Aim for at least 8-10 glasses of water per day, and consider drinking more during hot weather or when exercising.
- Limit or avoid alcohol: Alcohol, especially beer, can increase uric acid levels and trigger gouty arthritis flare-ups. It’s best to limit your alcohol intake or avoid it altogether if you have a history of gouty arthritis. If you do choose to drink alcohol, opt for wine over beer, and always drink in moderation.
- Maintain a healthy weight: Excess weight can put additional stress on the joints and increase the risk of gouty arthritis flare-ups. Losing weight, if necessary, through a balanced diet and regular exercise can help manage gouty arthritis symptoms and improve overall health.
- Avoid sugary drinks and foods: High fructose corn syrup, a common ingredient in many processed foods and sugary drinks, has been linked to an increased risk of gouty arthritis. Limit your intake of these products and opt for water, herbal teas, and natural fruit juices instead.
- Consider supplements: Some supplements, such as vitamin C, may help lower uric acid levels. However, it’s essential to consult with a healthcare professional before starting any new supplement regimen, as some supplements may interact with medications or have side effects.
Adopting these dietary recommendations can help manage gouty arthritis symptoms and reduce the frequency of flare-ups. It’s essential to work closely with a healthcare professional to develop a personalized dietary plan that meets your specific needs and takes into account any other health conditions or medications you may be taking.
Gouty Arthritis and Comorbidities
Gouty arthritis is a painful and debilitating condition that affects millions of people worldwide. While it is primarily known for its impact on the joints, it is also associated with several comorbidities, or co-occurring health conditions. Understanding these comorbidities can help individuals with gouty arthritis better manage their overall health and well-being.
One of the most common comorbidities associated with gouty arthritis is cardiovascular disease. Studies have shown that individuals with gout are at an increased risk of developing heart disease, heart attacks, and strokes. This may be due to the increased levels of uric acid in the blood, which can contribute to the formation of plaque in the arteries and lead to atherosclerosis.
Another common comorbidity is kidney disease. High levels of uric acid can lead to the formation of kidney stones and, in severe cases, kidney damage or failure. It is essential for individuals with gouty arthritis to monitor their kidney function and take steps to protect their kidney health, such as staying well-hydrated and avoiding medications that can be harmful to the kidneys.
Metabolic syndrome is also frequently associated with gouty arthritis. This cluster of conditions includes high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels. These factors can increase the risk of developing type 2 diabetes, heart disease, and stroke. Managing metabolic syndrome through lifestyle changes and, if necessary, medication can help reduce the risk of these serious health complications.
Obesity is another common comorbidity in individuals with gouty arthritis. Excess body weight can put additional strain on the joints, making gout symptoms more severe and increasing the risk of joint damage. Losing weight through a healthy diet and regular exercise can help alleviate gout symptoms and reduce the risk of other health issues related to obesity.
Finally, individuals with gouty arthritis are at an increased risk of developing depression and anxiety. The chronic pain and limited mobility associated with gout can negatively impact a person’s mental health and overall quality of life. It is important for individuals with gout to seek support from friends, family, and healthcare professionals to help manage their mental health and maintain a positive outlook on life.
In conclusion, gouty arthritis is not just a condition that affects the joints; it is also associated with several comorbidities that can have a significant impact on a person’s overall health. By understanding these comorbidities and taking steps to manage them, individuals with gouty arthritis can improve their quality of life and reduce their risk of developing further health complications.
Managing Gouty Arthritis Flare-Ups
Experiencing a gouty arthritis flare-up can be extremely painful and debilitating. However, there are several strategies that can help you manage these episodes and reduce their frequency. By implementing these approaches, you can take control of your condition and improve your overall quality of life.
1. Medication: During a flare-up, your doctor may prescribe medications to help manage your symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to reduce inflammation and alleviate pain. Colchicine is another medication that can help reduce the severity of a gout attack. In some cases, corticosteroids may be prescribed for short-term use to control severe inflammation. It’s crucial to follow your doctor’s recommendations and take medications as prescribed.
2. Rest and elevate the affected joint: During a gout flare-up, it’s essential to give your body the rest it needs. Avoid putting pressure on the affected joint and try to keep it elevated above the level of your heart. This can help reduce swelling and alleviate discomfort.
3. Apply ice: Applying ice to the affected joint can help reduce inflammation and numb the area, providing temporary pain relief. Wrap an ice pack or a bag of frozen vegetables in a thin towel and apply it to the joint for 15-20 minutes at a time, several times a day.
4. Stay hydrated: Drinking plenty of water can help flush excess uric acid from your body, reducing the likelihood of gout flare-ups. Aim for at least eight glasses of water per day, and avoid alcohol and sugary drinks, as they can contribute to increased uric acid levels.
5. Maintain a healthy weight: Carrying excess weight can put additional stress on your joints and increase your risk of gout flare-ups. Losing weight through a balanced diet and regular exercise can help reduce the frequency and severity of gout attacks.
6. Manage stress: Stress can be a trigger for gout flare-ups, so it’s essential to find healthy ways to cope with stress. Techniques such as deep breathing exercises, meditation, and progressive muscle relaxation can help you manage stress and reduce the likelihood of gout attacks.
7. Keep a symptom diary: Tracking your symptoms, as well as potential triggers, can help you identify patterns and manage your gout more effectively. Note the severity and duration of each flare-up, along with any potential triggers, such as specific foods, medications, or activities. This information can be useful for both you and your healthcare provider in managing your condition.
By implementing these strategies and working closely with your healthcare provider, you can effectively manage gouty arthritis flare-ups and reduce their impact on your daily life. Remember that every individual’s experience with gout is unique, so it’s essential to find the approaches that work best for you.
Preventing Gouty Arthritis
Preventing gouty arthritis is crucial for individuals who are at risk or have experienced gout attacks in the past. By implementing certain lifestyle changes and following specific dietary guidelines, one can significantly reduce the likelihood of gout flare-ups and improve overall health. The following are some key strategies to help prevent gouty arthritis:
Maintain a healthy weight: Obesity is a significant risk factor for gout. Losing excess weight can help lower uric acid levels in the body and reduce the risk of gout attacks. It is important to lose weight gradually, as rapid weight loss can temporarily increase uric acid levels.
Stay hydrated: Drinking plenty of water and other fluids can help dilute uric acid in the body, reducing the risk of crystal formation in the joints. Aim for at least eight glasses of water per day, and consider increasing fluid intake during hot weather or when exercising.
Limit alcohol consumption: Alcohol, particularly beer, can raise uric acid levels and trigger gout attacks. It is recommended to limit alcohol intake or avoid it altogether, especially during gout flare-ups.
Limit high-purine foods: Purines are natural substances found in many foods, and they are broken down into uric acid in the body. High-purine foods, such as red meat, organ meats, and some types of seafood, can increase uric acid levels and the risk of gout attacks. Opt for low-purine options like fruits, vegetables, and whole grains instead.
Consume low-fat dairy products: Studies have shown that low-fat dairy products, such as yogurt and skim milk, can help reduce the risk of gout. Incorporate these foods into your diet to help maintain healthy uric acid levels.
Exercise regularly: Regular physical activity can help maintain a healthy weight and reduce the risk of gout. Aim for at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity exercise per week, along with muscle-strengthening activities on two or more days per week.
Take medications as prescribed: If you have been prescribed medications to manage uric acid levels or prevent gout attacks, be sure to take them as directed by your healthcare provider. Do not stop taking the medication without consulting your doctor, as this can increase the risk of gout flare-ups.
Following these preventive measures can help you reduce the risk of developing gouty arthritis or manage the condition more effectively if you already have it. Remember to consult your healthcare provider for personalized advice and recommendations tailored to your specific needs and medical history.
Gouty Arthritis: Common Questions and Answers
In this section, we will address some common questions and answers related to Gouty Arthritis to provide a comprehensive understanding of this condition.
Q: What is the main cause of Gouty Arthritis?
A: The primary cause of Gouty Arthritis is the buildup of uric acid in the bloodstream, leading to the formation of urate crystals in the joints. This can be due to increased production of uric acid, decreased excretion of uric acid by the kidneys, or a combination of both.
Q: Can Gouty Arthritis be cured?
A: While there is no definitive cure for Gouty Arthritis, it can be effectively managed with lifestyle changes, medications, and other treatment options. Proper management can help prevent future flare-ups and minimize the risk of complications.
Q: How can I tell if my joint pain is due to Gouty Arthritis?
A: Gouty Arthritis typically presents with sudden, severe pain, redness, and swelling in the affected joint, commonly the big toe. However, it can also affect other joints such as the knees, ankles, and wrists. If you suspect you have Gouty Arthritis, it is essential to consult with a healthcare professional for a proper diagnosis and appropriate treatment.
Q: What foods should I avoid if I have Gouty Arthritis?
A: Foods high in purines, which can increase uric acid levels in the body, should be avoided or limited. These include red meat, organ meats, seafood, alcohol (especially beer), and sugary beverages. Instead, focus on consuming a balanced diet rich in fruits, vegetables, whole grains, and low-fat dairy products.
Q: Can Gouty Arthritis be prevented?
A: While there is no guaranteed way to prevent Gouty Arthritis, adopting a healthy lifestyle, maintaining a healthy weight, and managing other medical conditions can help reduce the risk of developing the condition. Regular check-ups with your healthcare provider can also help identify and address any potential issues early on.
Q: Are there any natural remedies for Gouty Arthritis?
A: Some natural remedies, such as cherry juice, ginger, and turmeric, may help reduce inflammation and alleviate symptoms of Gouty Arthritis. However, it is important to discuss these options with your healthcare provider before incorporating them into your treatment plan, as they may interact with medications or have side effects.
Q: How can I manage Gouty Arthritis flare-ups?
A: During a flare-up, it is essential to rest the affected joint, apply ice to reduce inflammation, and take over-the-counter anti-inflammatory medications as directed by your healthcare provider. It is also crucial to adhere to your prescribed treatment plan, including any medications and lifestyle modifications, to help prevent future flare-ups.
Q: Can Gouty Arthritis lead to other health complications?
A: If left untreated or poorly managed, Gouty Arthritis can lead to several complications, including joint damage, kidney stones, and an increased risk of cardiovascular disease. Proper management and regular follow-ups with your healthcare provider can help minimize the risk of these complications.
In conclusion, understanding and addressing the common questions related to Gouty Arthritis can help individuals better manage their condition and improve their overall quality of life. Remember, it is essential to consult with a healthcare professional for personalized advice and treatment options.