About five years ago in Kathmandu, Nepal, we met an American guy sitting in our hotel restaurant with his foot on a chair.  Aged maybe 35, he was barely able to hobble. He said sadly: “I came here to do a trek. But now I have gout – it’s so painful I can’t even walk. My whole trip is wasted”.  Both he and his doctor were mystified about the cause. Gout is usually associated with too much meat and alcohol in older age men - not the case here.

According to a local journalist, gout is common in Nepal, and attacks "seem to start at a younger age group (less than 40 years) in Nepal than what is usually noted in Western medical textbooks (over 60 years)", for unknown reasons. https://www.spotlightnepal.com/2011/08/09/gout-in-nepal/ - Sue Dengate

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A ribonucleotide-containing noodle soup advertising blimp being towed through minor towns in Nepal

Sue's comment: I guess the culprit in both cases would be ribonucleotide flavour enhancer additives. These additives are heavily used in Nepalese food such as instant noodles, soups, sauces, fast food and snacks. These high purine additives are as strongly associated with increased uric acid and risk of gout attacks as high purine foods although, oddly, they are never mentioned in any medical gout diets or lists of high purine foods.

These additives can be called inosinates, guanylates and ribonucleotides (E627, E631 and E635) or  in America flavor enhancers Disodium Inosinate (DSI or IMP), Disodium Guanylate (DSG or GMP), and the combination of IMP and GMP (I&G).

"Ingestion of large amounts of these compounds by man can increase the serum uric acid level and urinary uric acid excretion and this needs to be considered in relation to people with gouty diathesis and those taking uric-acid retaining diuretics. Hence, specific mention of the addition of these substances on the label may be indicated (but this didn't happen - ed). The changes in dietary purine intake from the use of flavour enhancers are no greater than those likely to be occasioned by changes in consumption of those dietary items which are the main contributors of purine." - JECFA (the Joint FAO/WHO Expert Committee on Food Additives who assessed these additives in 1974) http://www.inchem.org/documents/jecfa/jecmono/v06je01.htm

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