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1Division of Nephrology, Hypertension, and Transplantation, University of Florida, Gainesville, Florida; 2Department of Research, The Heart Institute of Spokane, and 3Biostatistics, Washington State University, Spokane, Washington; 4Division of Nephrology-Medicine, Baylor College of Medicine, Houston, Texas; and 5Departamento de Nefrologia, Instituto Nacional de Cardiologia Ignacio Chavez, Tlalpan, Mexico
Submitted 6 April 2005 ; accepted in final form 26 September 2005
| ABSTRACT |
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obesity; insulin resistance
As obesity and type 2 diabetes have escalated to epidemic proportions (28), the causal role of dietary components must be considered. The last 25 years have witnessed a marked increase in total per capita fructose intake, primarily in the form of sucrose (a disaccharide consisting of 50% fructose) and high-fructose corn syrup (HFCS; 55% fructose content) (3). Fructose intake is linked to the epidemic of obesity and diabetes (22, 35). Soft drink intake (high in HFCS) is associated with an increased risk for obesity in adolescents (22) and for type 2 diabetes in young and middle-aged women (35). Excess fruit juice (also rich in fructose) is associated with the development of obesity in children (8). Fructose-fed rats also develop features of metabolic syndrome (15).
One distinction between fructose and glucose is that fructose raises serum uric acid (38). Elevated serum uric acid predicts the development of obesity and hypertension (23). This raised the possibility that uric acid may have a pathogenetic role in metabolic syndrome. In the current study, we show that fructose-induced metabolic syndrome is partially prevented by lowering serum uric acid in the rat. The reduction of endothelial nitric oxide (NO) bioavailability by uric acid may be a mechanism for insulin resistance and hypertension.
| METHODS |
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Experiment I: treatment of fructose-induced hyperuricemia with allopurinol. Male Sprague-Dawley rats (150200 g) were housed in standard conditions and fed a control (n = 7) or 60% fructose diet (Harlan, Madison, WI, n = 14) for 10 wk. The control diet contained 46% carbohydrate, which is mainly composed of starch, whereas the fructose diet contained 60% fructose as the carbohydrate. The caloric content of these diets are 3.1 and 3.6 kcal/g, respectively. At 4 wk, blood samples were obtained at 11 AM after 4 h of fasting. One-half of the fructose-fed rats were administered allopurinol (150 mg/l in the drinking water, Sigma, St. Louis, MO) for an additional 6 wk to lower serum uric acid. Fresh drinking water containing allopurinol was replaced every 2 days. Rats were divided into three groups: control, fructose, and fructose+allopurinol. At 10 wk, an oral glucose tolerance test (OGTT) was performed, in which rats were fasted overnight (16 h) and then administered 1.5 g/kg of a 50% glucose solution by gavage. Blood was sampled at 0, 30, 60, and 120 min for blood glucose and serum insulin measurement. The rats were then killed.
Experiment II: prevention of fructose-induced hyperuricemia with allopurinol. To assess the effect of preventing hyperuricemia during the period of the study, allopurinol was initiated on the day when the fructose diet was given (from week 0 to week 8). Three groups (control, fructose, and fructose+allopurinol; n = 8 each) were designed for this prevention study. Body weight was measured every 2 wk. Food consumption was measured for 3 days at 8 wk.
Experiment III: effect of lowering of uric acid by either allopurinol or benzbromarone on body weight and food consumption. In this experiment, the effect of benzbromarone, a uricosuric agent (150 mg/l in the drinking water, Sigma), was also examined to confirm the effect of lowering of uric acid on body weight and food intake. Fresh drinking water containing benzbromarone was replaced every 2 days. Three groups (control, allopurinol, and benzbromarone; n = 8 each) were studied. All groups were fed with the control diet for 8 wk. Body weight and the consumption of food were measured weekly for 8 wk.
Experiment IV: comparison between 60% dextrose and 60% fructose in development of metabolic syndrome and effect of lowering uric acid with benzbromarone. Rats were pair-fed with a 60% dextrose diet or a 60% fructose diet for 4 wk, both of which are isocaloric. Because experiment II showed that each rat normally eats 2530 g/day, we administered 25 g of the diet to each rat every day. At 4 wk, total food intake per animal was calculated from the food left over. Total food intake is the subtraction of the leftover food from the total food administered (1,425 g·rat1·28 days1). In addition to the above two groups, a third group of fructose-fed rats was administered benzbromarone. Their body weight was measured weekly. At 4 wk, after 5 h of fasting, insulin, triglyceride, and uric acid were measured.
All protocols were approved by the Animal Care Committee of the University of Florida.
Measurements. Systolic blood pressure was assessed as the mean value of three consecutive measurements obtained in the morning using a tail-cuff sphygmomanometer (Visitech BP2000, Visitech Systems, Apex, NC). All animals were preconditioned for blood pressure measurements 1 wk before each experiment. Serum uric acid was measured by the uricase method. Blood glucose was measured with the ONE TOUCH system (Johnson&Johnson, Milpitas, CA). Rat insulin was measured by ELISA (Crystal Chem, Chicago, IL). The insulin sensitivity index was calculated using the formula of Matsuda and DeFronzo [10,000/square root of (fasting glucose x fasting insulin) x (mean glucose x mean insulin during OGTT)], which is highly correlated (r = 0.73, P < 0.0001) with the rate of whole body glucose disposal during the euglycemic insulin clamp (24). Serum lipids were measured with an autoanalyzer (VETAce, Alfa Wassermann, West Caldwell, NJ) or a Triglyceride-SL assay kit (Diagnostic Chemicals, Charlottetown, PE, Canada).
Vasorelaxation of Rat Aortic Artery Segments
Rat aortic artery (AA) segments (1- to 0.5-mm diameter x 3- to 4-mm length) were isolated from 2- to 3-mo-old rats and suspended in individual organ chambers (Radnoti Four-Unit Tissue Bath System) with 5 ml in Earl's solution, oxygenated with 95% O2-5% CO2 at 37°C. After 1-h equilibration of resting force of 1.5 g, the vascular smooth muscle cell or endothelium integrity of this AA segment was confirmed by monitoring 0.5 µM U-46619 (a thromboxane A2 mimetic, Sigma)-mediated AA contraction or acetylcholine (5 µM)-mediated vasodilation, respectively. After being washed several times, the segments were incubated with various concentrations of uric acid (015 mg/dl) in an organ bath chamber for 30 min. Stable construction was induced by 0.5 µM U-46619 for 10 min before acetylcholine-induced vasorelaxation. The vascular tensions were continuously monitored with an isometric force transducer (Harvard Apparatus, Holliston, MA). To standardize the data, the U-46619-induced stable increase in vascular tone was set as 100%.
Statistical Analysis
All values presented are expressed as means ± SD and analyzed by one-way ANOVA or by unpaired Student's t-test. Significance was defined as P < 0.05.
| RESULTS |
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Serum uric acid levels, systolic blood pressure, and fasting insulin levels were elevated in fructose-fed rats compared with rats fed a control diet at 4 wk (Table 1). In addition, the body weight of fructose-fed rats tended to increase compared with rats fed a normal diet (Table 1). These data demonstrate that fructose feeding induces early features of metabolic syndrome in rats.
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While no groups developed fasting or postprandial hyperglycemia (Fig. 2A), fructose-fed rats developed fasting hyperinsulinemia that was reversed with allopurinol (Fig. 2B). Postprandial hyperinsulinemia also occurred in fructose-fed rats administered an OGTT, and this was partially but significantly lower in allopurinol-treated rats (Fig. 2B), resulting in improved insulin sensitivity (Fig. 2C).
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Endothelial dysfunction is common in metabolic syndrome. It is known that impaired NO response to insulin may be a mechanism for the development of insulin resistance (36). Previously, uric acid has been shown to potently reduce NO levels in cultured bovine endothelial cells (18). To further examine this relationship, we examined the acute effect of uric acid on acetylcholine-induced vasodilation of rat AA rings. As shown in Fig. 4, uric acid dose dependently blocked the vasorelaxation of AA rings in response to acetylcholine.
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| DISCUSSION |
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There is supporting evidence that uric acid may have a pathogenic role in metabolic syndrome. Hyperuricemia has been found to predict the development of both obesity and type 2 diabetes (29). Hyperuricemia is also commonly observed in metabolic syndrome (41), as well as in secondary insulin resistance syndromes such as that associated with gout (2), diuretic usage (21, 31), or preeclampsia (39). There are also older studies that showed that rats made chronically hyperuricemic with uricase inhibitors develop features of metabolic syndrome (42). These data introduce the novel concept that uric acid may have a causal role in metabolic syndrome.
Most authorities consider hyperuricemia in metabolic syndrome to be the consequence of elevated serum insulin levels, which have been shown to stimulate renal reabsorption of uric acid (9). Consistent with this observation is the finding that thiazolidinediones, which improve insulin sensitivity and lower insulin levels, also reduce the level of serum uric acid in diabetic patients (16, 40). On the other hand, our study demonstrated that lowering uric acid with either a xanthine oxidase inhibitor or a uricosuric agent also improves insulin sensitivity as well as other features of metabolic syndrome, including hypertension, obesity, and hypertriglyceridemia. While multiple factors are known to drive metabolic syndrome (6), these studies suggest that uric acid may also have a contributory role in the development of insulin resistance.
Hypertriglyceridemia was completely blocked by lowering of uric acid with allopurinol in this study. Compatible with our findings, it has been shown that the association of elevated serum uric acid with hypertriglyceridemia is stronger than with insulin sensitivity (41). Interestingly, treatment of hypertriglyceridemia with finofibrate or atorvastatin also reduces serum uric acid (1, 12, 27). Uricosuric agents such as benziodarone also lower serum triglycerides (12). Although the role of uric acid in the metabolism of triglycerides remains unknown, uric acid might be involved in either the overproduction or the reduction of clearance of triglycerides. A decrease in the clearance of triglycerides in fructose-fed rats has been attributed to a reduction in lipoprotein lipase activity in endothelial cells (19, 30); whether this is mediated by uric acid remains to be determined. An alternative explanation is the possibility that the de novo increase in purine synthesis observed in fructose-fed rats may be pathogenetically linked to hepatic fatty acid synthesis, resulting in overproduction of triglycerides (25, 41).
Endothelial dysfunction is a hallmark of metabolic syndrome (7). Therefore, we investigated the role of uric acid in endothelial dysfunction as a mechanism for insulin resistance. We showed that uric acid dose dependently blocked acetylcholine-mediated arterial dilation (Fig. 4), suggesting that uric acid can impair endothelial function. In addition, we have found that uric acid potently reduces endothelial NO bioavailability in both cell culture and in experimental animal models (18). In turn, reducing endothelial NO levels is a known mechanism for inducing insulin resistance (33). Thus endothelial NOS-deficient mice exhibit the features of metabolic syndrome (5). The mechanism is due to a blockade of insulin action, as insulin stimulates glucose uptake in skeletal muscle by increasing blood flow to these tissues through a NO-dependent pathway (33). In this scenario, allopurinol or benzbromarone may be acting to prevent metabolic syndrome by blocking hyperuricemia-induced endothelial dysfunction.
Unlike glucose, the oral ingestion of fructose results in a rapid increase in serum uric acid within 3060 min in humans (38). The mechanism by which fructose raises serum uric acid has been previously studied. Fructose enters hepatocytes, where it is rapidly phosphorylated by fructokinase to fructose-1-phosphate (13). During this reaction, ATP donates the phosphate, resulting in the generation of ADP, which is further metabolized to uric acid (13). This is aided by a fructose-mediated increase in AMP deaminase (37).
In addition to an effect of fructose to increase hepatic production of uric acid, we found that urinary excretion of uric acid was decreased in fructose-fed rats. There are multiple potential explanations for this observation. First, we have found that experimental hyperuricemia causes endothelial dysfunction and renal vasoconstriction (18, 26, 34), which is known to impair urate excretion (10). Second, fructose results in lactate production, which is a competitive inhibitor for urate excretion (14). Finally, hyperinsulinemia itself can lead to an impairment in urate excretion (9). The observation that impaired urate excretion was due, in part, to hyperuricemia was shown by the observation that allopurinol could reverse this effect. This would support uric acid-induced endothelial dysfunction and/or hyperinsulinemia as the central mechanism for this effect.
While the above studies provide evidence supporting a role for uric acid in the development of metabolic syndrome induced by fructose, allopurinol also blocks oxidants generated by the xanthine oxidase pathway. Oxidants are involved in the pathogenesis of diabetes and its complications (4). It is therefore possible that the beneficial effects of allopurinol may be attributed, in part, to the lowering of oxidants rather than an effect on uric acid per se. However, most studies suggest that the oxidants driving diabetic complications are generated as a consequence of mitochondrial dysfunction or activation of NADPH oxidase, neither of which would be blocked by a xanthine oxidase inhibitor. The observation that the uricosuric agent benzbromarone also prevented features of metabolic syndrome further suggests that the mechanism by which allopurinol works likely includes lowering uric acid. While future studies will need to dissect the mechanism by which allopurinol provides benefit, the observation that uric acid also impairs endothelial function provides a potential mechanism by which uric acid could have a pathogenic role in fructose-mediated metabolic syndrome. While speculative, we suggest that the worldwide epidemic in hypertension, obesity, and metabolic syndrome may have its roots in the marked increase in fructose intake and in the progressive rise in mean serum uric acid that has been observed in both developing and industrialized nations in the last century (17).
| GRANTS |
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| DISCLOSURES |
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| FOOTNOTES |
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The costs of publication of this article were defrayed in part by the payment of page charges. The article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
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