Gout is a neglected non-communicable disease in the Pacific

In this issue of The Lancet Global Health, Pascart and colleagues1Pascart T Wasik KA Preda C et al.The gout epidemic in French Polynesia: a modelling study of data from the Ma'i u'u epidemiological survey.Lancet Glob Health. 2024; 12: e685-e696Google Scholar report a modelling study that evaluated the prevalence of gout and hyperuricaemia in French Polynesia. This comprehensive study addresses an important issue. Gout, considered to be the first cause of non-infectious arthritis worldwide, imposes a massive—yet overlooked—burden in French Polynesia. Clinically, a prominent feature of gout in the Pacific is that severe cases in people younger than 30 years are commonplace. Pascart and colleagues identified a 2·5% prevalence of gout in men aged 18–29, and their multivariate analysis substantiated the notion that male individuals are more likely than female individuals to be affected by gout (odds ratio 10·3, 95% CI 1·8–60·7); the risk of gout increased for every 10 years of age (1·5, 1·2–1·8).1Pascart T Wasik KA Preda C et al.The gout epidemic in French Polynesia: a modelling study of data from the Ma'i u'u epidemiological survey.Lancet Glob Health. 2024; 12: e685-e696Google Scholar Other well known risk factors were also shown to have an effect, with type 2 diabetes and high BMI increasing the risk. With data from the Ma'i u'u survey—an epidemiological, prospective, cross-sectional, gout-focused survey—and including a random sample of adults from the general adult population of French Polynesia, the information provided by this study indicates an estimated prevalence of gout in French Polynesia as high as 14·5% (95% CI 9·9–19·2), far more than the global range of 0·1–10%.1Pascart T Wasik KA Preda C et al.The gout epidemic in French Polynesia: a modelling study of data from the Ma'i u'u epidemiological survey.Lancet Glob Health. 2024; 12: e685-e696Google Scholar Comparison with drug-dispensing data showed consistency, providing further support for these prevalence findings. From an epidemiological perspective, Pacific island countries and territories (PICTs) are recognised as having the highest global burden of gout.2Kuo C-F Grainge MJ Zhang W Doherty M Global epidemiology of gout: prevalence, incidence and risk factors.Nat Rev Rheumatol. 2015; 11: 649-662Crossref PubMed Scopus (839) Google Scholar Although people of Melanesian ancestry might have a lower burden than people of Polynesian and Micronesian ancestry, as exemplified in a multi-ethnic cohort in New Caledonia,3Bardin T Magnat E Clerson P Richette P Rouchon B Epidemiology of gout and hyperuricemia in New Caledonia.Joint Bone Spine. 2022; 89105286Crossref PubMed Scopus (6) Google Scholar people of both Polynesian (including New Zealand Māori and Hawaiian native) and Micronesian (including Nauruan, Carolinian, and Chamorro) ancestry have been reported to have higher serum urate, and thus a higher risk of gout than in other populations worldwide, including India, the USA, and China.4Gosling AL Matisoo-Smith E Merriman TR Hyperuricaemia in the Pacific: why the elevated serum urate levels?.Rheumatol Int. 2014; 34: 743-757Crossref PubMed Scopus (14) Google Scholar A study comparing Tokelauan people who migrated to urban New Zealand with Tokelauan people living in their home Polynesian country showed a 9-fold increased risk of gout in the people who migrated, indicating a genetics–environment interaction in hyperuricaemia and gout.5Prior IA Welby TJ Ostbye T Salmond CE Stokes YM Migration and gout: the Tokelau Island migrant study.Br Med J (Clin Res Ed). 1987; 295: 457-461Crossref PubMed Google Scholar Dietary factors, particularly the intake of animal protein (especially red meat, fish, and seafood) and alcoholic beverages, are well established risk factors for gout. However, these risk factors were not observed in Pascart and colleagues' study, possibly due to reporting bias or successful risk communication in the French Polynesia population. Furthermore, the study by Pascart and colleagues1Pascart T Wasik KA Preda C et al.The gout epidemic in French Polynesia: a modelling study of data from the Ma'i u'u epidemiological survey.Lancet Glob Health. 2024; 12: e685-e696Google Scholar investigated the frequency of a specific HLA allele associated with severe side-effects of urate-lowering therapies and found a low prevalence of this allele in the study population. Although this result cannot be generalised to the entire region, it suggests that currently available treatment options could effectively reduce the burden of gout in the Pacific. Arnold and colleagues6Arnold J Harris R Masina LA Graham K Pacific Peoples health—gout data insights.https://pharmac.govt.nz/assets/2022-04-11-Pacific-Peoples-Health-Gout-Data-Insights.pdfDate: 2022Date accessed: February 12, 2024Google Scholar presented a comprehensive overview of the inequity associated with the gout burden and treatment in Pacific islanders. Compared with non-Māori and non-Pacific individuals, Pacific islanders were approximately 3 times more likely to receive gout medication, starting treatment a mean 13 years earlier. Pacific people who are prescribed gout medication take 3·5 times more non-steroidal anti-inflammatory drugs. The adherence to long-term treatment was also lower in Pacific people (64%) than in non-Māori, non-Pacific individuals (59%).6Arnold J Harris R Masina LA Graham K Pacific Peoples health—gout data insights.https://pharmac.govt.nz/assets/2022-04-11-Pacific-Peoples-Health-Gout-Data-Insights.pdfDate: 2022Date accessed: February 12, 2024Google Scholar The review also highlighted that Pacific islanders are more likely to live with multiple chronic conditions, such as type 2 diabetes, and are almost 14 times more likely to be treated in hospital with a primary diagnosis of gout. In 2018 and 2019, almost 50% of Pacific people treated in hospital for gout had not been taking preventive gout medication in the previous 6 months. To overcome this treatment gap, the review estimated that an additional 8700 Pacific islanders needed to receive gout medication annually to achieve treatment equity.6Arnold J Harris R Masina LA Graham K Pacific Peoples health—gout data insights.https://pharmac.govt.nz/assets/2022-04-11-Pacific-Peoples-Health-Gout-Data-Insights.pdfDate: 2022Date accessed: February 12, 2024Google Scholar PICTs also have substantial burdens of obesity, type 2 diabetes, and hypertension. Efforts are underway to improve prevention and treatment for these non-communicable diseases. Although improvements in physical activity and dietary habits targeted by non-communicable-disease prevention programmes might help alleviate the burden of gout, specific programmes for gout should focus on proper follow-up and the use of urate-lowering therapies in people with hyperuricaemia to prevent debilitating gout attacks. Gout is overlooked in national, regional, and global public health plans and agendas. Although it has been attracting increased research interest in the past decade,7Wen P Luo P Zhang B Zhang Y Mapping knowledge structure and global research trends in gout: a bibliometric analysis from 2001 to 2021.Front Public Health. 2022; 10924676Crossref Scopus (13) Google Scholar efforts are still needed, including in health literacy, to tackle the burden of this disease.8The Lancet RheumatologyBig Little Lies: challenging misperceptions of gout.Lancet Rheumatol. 2019; 1: e75Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar The Article by Pascart and colleagues1Pascart T Wasik KA Preda C et al.The gout epidemic in French Polynesia: a modelling study of data from the Ma'i u'u epidemiological survey.Lancet Glob Health. 2024; 12: e685-e696Google Scholar could provide an opportunity to emphasise the importance of gout in the global health agenda in the coming years. We declare no competing interests. The gout epidemic in French Polynesia: a modelling study of data from the Ma'i u'u epidemiological surveyFrench Polynesia has an estimated high prevalence of gout and hyperuricaemia, with gout affecting almost 15% of adults. Territorial measures that focus on increasing access to effective urate-lowering therapies are warranted to control this major public health problem. Full-Text PDF Open Access