Increased Uric Acid and Life Style… Klongthalay S. et al.

199

ORIGINAL ARTICLE
Increased Uric Acid and Life Style Factors Associated with Metabolic
Syndrome in Thais
Suwit Klongthalay1, Kanjana Suriyaprom1*

ABSTRACT
OPEN ACCESS
Citation: Suwit Klongthalay, Kanjana BACKGROUND: The prevalence of metabolic syndrome (MS) has
Suriyaprom. Increased uric acid and life been continually increasing in developing countries especially in
style factors associated with metabolic
syndrome in Thais. Ethiop J Health Thailand. Although insulin resistance and central obesity are
Sci.2020;30(2):199. initially considered as significant risk factors, the other causal
doi:http://dx.doi.org/10.4314/ejhs.v30 i2.7
Received: October 3, 2019
factors leading to the development of MS continue to challenge the
Accepted: November 1, 2019 investigators. The aims of this study were to evaluate the
Published: March 1, 2020 prevalence of MS in Pathum Thani province, Thailand and to
Copyright: ©2020 Klongthalay S., et al.
This is an open access article distributed investigate the relationship between MS and risk factors.
under the terms of the Creative Commons METHODS: This cross-sectional study was performed with 202
Attribution License, which permits Thai volunteers. Anthropometric-biochemical variables and blood
unrestricted use, distribution, and
reproduction in any medium, provided the pressures in each subject were measured.
original author and source are credited. RESULTS: Almost one-third (32.7%) of the participants were
Funding: Faculty of Medical
Technology, Rangsit University
diagnosed with MS based on the harmonized criteria, and one of
Competing Interests: The authors the most significant risk factors is the elevated blood pressure.
declare that this manuscript was approved Weight, BMI, waist and hip circumferences, waist-hip ratio, blood
by all authors in its form and that no
competing interest exists. pressure, glucose, triglycerides and uric acid were significantly
Affiliation and Correspondence: higher in subjects with MS subjects. However, HDL-C levels were
1
Faculty of Medical Technology, significantly lower in subjects with MS, compared to subjects
Rangsit University, Phaholyothin Road,
Pathumthani 12000, Thailand without MS (p<0.001). The results of regression model after
*Email: kanjana.su@rsu.ac.th adjustment for age and gender showed that the increased serum
uric acid level (OR=1.31, 95%CI: =1.04-1.66), cigarette smoking
(OR=3.72, 95%CI: =1.51-9.15) and physical activity (OR=0.36,
95%CI: =0.19-0.67) were significantly related to MS.
CONCLUSIONS: These findings suggest that the decrease of uric
acid level, the promotion of physical activity and smoking cessation
may decrease the risk of developing MS among Thais.
KEYWORDS: Metabolic Syndrome, Life Style, Uric Acid

INTRODUCTION
Metabolic syndrome (MS) is a public health problem that has
reached epidemic proportions with a rapidly increasing worldwide
prevalence and for the adult population is estimated to be about 20 to
25% (1). There were evidences showing that MS is a clinical
constellation comprising risk factors associated with increased risk of
cardiovascular diseases (CVDs) by 2-fold and the risk of developing
Type 2 diabetes by 5-fold (2, 3). Thus, the clustering symptoms

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200 Ethiop J Health Sci. Vol. 30, No. 2 March 2020

leading to Type 2 diabetes and CVDs are typified participants were asked whether they had engaged
as the MS that is now considered to impact on in regular exercise or sports (at least once a week
global healthcare systems and financial plans. for 3 months continuously). The exclusion criteria
Thailand has gone through a period of epidemic of this study included pregnancy, severe
transition, and many metabolic risk factors: degenerative diseases, mental deficiency, stroke,
obesity, dyslipidemia, insulin resistance, and cancer, kidney diseases, gout, and bedridden
hypertension, are now common among the Thai patients. MS was defined using the harmonized
population (4). Obesity, especially visceral fat, definition (6) and required at least three of the
remains an important link among the components following:
of MS and the prevalence of obesity is rapidly • Raised waist circumference: >90 cm in
growing in low- and middle-income countries Asian men and >80 cm in Asian women
including Thailand. The central region of Thailand • Raised blood pressure: systolic blood
has the highest prevalence of obesity for both pressure >130 mmHg or diastolic blood
males (38.8%) and females (49.4%), compared pressure >85 mmHg, or current
with other regions: the southern region (27.4% and antihypertensive medication
44.7%), the northern region (27.5% and 36.3%) • Raised fasting plasma glucose: >100
and the north-eastern region (22.5% and 39.1%) mg/dl
(5). Despite of the importance of MS in the context • Raised triglycerides (TG) levels: >150
of noncommunicable diseases in Thailand, mg/dl
especially in the central region, information • Reduced high-density lipoprotein
regarding the importance of the prevalence of MS cholesterol (HDL-C): <40 mg/dl in men
and its determinants is scarce. The causal factors and <50 mg/dl in women
leading to the development MS continue to This study was conducted under the principles of
challenge the researchers. Therefore, this study the Declaration of Helsinki and the protocol was
aimed to evaluate the prevalence of MS in the approved by the Ethics Committee of Rangsit
population of Pathum Thani Province, the central University (RSEC 11/2560). All participants
region of Thailand and to investigate the agreeing to participate signed a consent form.
relationship between MS and risk factors. Measurement of biochemical markers: Five
MATERIALS AND METHODS milliliters of overnight fasting venous blood was
taken from each subject. Serum was used to assay
Study subjects: The study was performed with 202 biochemical variables. For example, total
Thai volunteers from the population in a suburban cholesterol, triglycerides, HDL-cholesterol, LDL-
community located at the Lak-Hok in Pathum cholesterol, uric acid, total protein, and albumin.
Thani Province, Thailand, aged between 20 to 80 NaF blood was used to assay glucose, and these
years old. This was a cross-sectional, population- biochemical markers were measured by using
based study with simple random sampling between COBAS INTEGRA® 400 plus analyzer, Roche
November 2017 and January 2019 with the Diagnostics Ltd., Switzerland.
objective to estimate the prevalence of MS and Anthropometric and blood pressure
associated factors in the adult population. The measurements: Anthropometric measurements
subjects were invited to the Medical Technology comprising weight, height, waist circumferences,
Clinic of Rangsit University for laboratory and hip circumference, were recorded. The body
examinations. All volunteers were interviewed by weight of each individual dressed in light clothing
using a questionnaire, regarding lifestyle pattern, was measured using a carefully calibrated beam
and medical health history. Participants who balance (Detecto®). The height of each individual
reported consuming alcohol at least once per week was measured using a vertical-measuring rod.
for more than 6 months were defined as drinkers. Waist circumference (WC) and hip circumference
Participants who had smoked at least one cigarette (HC) were calculated for waist-hip ratio (W/H
per day for more than 6 months were defined as ratio). The body mass index (BMI) was expressed
smokers. For Leisure-time physical activity, as weight (kg) / height (m2). The participants were

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 Increased Uric Acid and Life Style… Klongthalay S. et al. 201

classified according to their BMI as followings: calculate the odds ratio (OR). A p-value <0.05 was
normal weight (BMI<23.00 kg/m2), overweight considered statistically significant.
(BMI≥23.00–24.99 kg/m2) and obese (BMI≥25.00
kg/m2) (7). Blood pressure (BP) and pulse rate RESULTS
were measured by a nurse after 5 to 10 minutes’ This cross-sectional study enrolled 202 participants
rest in the sitting position. with mean age 53.2 ± 3.2 years; 37.1% and 62.9%
Statistical analysis: Statistics analyses were of all participants were males and females,
performed using SPSS for Windows version 17.0 respectively. Obesity and overweight rates in our
(SPSS, Chicago, IL). The median and 95% study were 43.1% and 17.3%, respectively.
confidence interval (C.I.) were calculated. The Demographic and lifestyle characteristics of the
difference between the two groups was compared studied population are shown in Table 1. More than
by using the Mann-Whitney U-Wilcoxon Rank thirty percent (32.7%) of the participants were
Sum W test. Relationship between MS and various diagnosed with MS based on the harmonized
parameters was tested using Chi-square test. The criteria, and the common risk factor was elevated
Minitab statistical computer program was used to blood pressure (Table 2).
Table 1: Demographic, anthropometric and lifestyle characteristics of the studied population

Characteristics N (%)
Gender Male 75(37.1)
Female 127(62.9)
Education (schooling <12 years 119(58.9)
years) > 12 years 83(41.1)
BMI Normal-weight 80(39.6)
Overweight 35(17.3)
Obese 87(43.1)
Physical activity Inactive 75(37.1)
Active 127(62.9)
Cigarette smoking No 165(81.7)
Yes 37(18.3)
Alcohol consumption No 154(76.2)
Yes 48(23.8)

Table 2: Prevalence of MS and its components

Total subjects
Metabolic syndrome components (N=202)
N (%)
Central obesity 111(55.0%)
Elevated glucose 64(31.7%)
Elevated TG 59(29.2%)
Reduced HDL-C 52(25.7%)
High blood pressure 120(59.4%)
Metabolic syndrome 66(32.7%)
HDL-C, high-density lipoprotein cholesterol

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202 Ethiop J Health Sci. Vol. 30, No. 2 March 2020

Anthropometric and biochemical data of the groups 27/59). Table 4 shows the risk factors are related to
with MS (66 subjects) and without MS (136 MS. Our results showed that lower secondary
subjects) are shown in Table 3. Age, weight, BMI, education (OR=1.99, p<0.05), cigarette smoking
WC, HC, waist-hip ratio, blood pressure, glucose, (OR=2.65, p<0.01), and physical activity
TG and uric acid were significantly higher in (OR=0.37, p<0.01) were associated with MS. The
subjects with MS subjects than in that without MS proportions of cigarette smoking and physical
(p<0.01). Meanwhile, HDL-C levels of subjects activity between the MS group and the non-MS
with MS were significantly lower than subjects group were 28.8% vs 13.2%, 47.0% vs 70.6%,
without MS (p<0.01). The prevalence of MS respectively. About 30.3% in the MS group and
according to age was showed that there was 46.3% in the non-MS group had completed
significantly different among age groups (p<0.05) secondary level education or higher. The
and rising with aging years. The percentage of correlation of uric acid with components associated
subjects with MS in each age group was: 20-39 with metabolic syndrome is shown in Table 5.
years (17.2%; 5/29), 40-49 years (25.0%; 8/32),
50-59 years (31.7%; 26/82) and > 60 years (45.8%;

Table 3: Comparison of anthropometric, biochemical variables and age between subjects with and without
MS
Subjects without MS Subjects with MS
Variables (n=136) (n=66) p-value
Mean (SD) Mean (SD)
Age (years) 51.7(14.2) 56.2(10.4) 0.011*
Weight (kg) 59.4(10.5) 68.2(11.4) <0.001**
Height (cm) 159.4(8.2) 158.9(8.9) 0.669
BMI (kg/m2) 23.3(3.4) 26.9(3.4) <0.001**
WC (cm) 82.0(10.0) 93.2(7.3) <0.001**
HC (cm) 95.4(7.1) 100.8(8.4) <0.001**
Waist-hip ratio 0.86(0.07) 0.93(0.05) <0.001**
Systolic BP (mmHg) 132.0(17.0) 142.0(18.0) <0.001**
Diastolic BP (mmHg) 78.0(9.0) 82.0(11.0) 0.002**
Pulse rate (beats/min) 78.0(10.0) 80.0(10.0) 0.147
Glucose (mg/dl) 88.8(10.6) 116.8(17.2) <0.001**
TC (mg/dl) 212.9(45.3) 208.8(44.9) 0.544
TG (mg/dl) 110.3(39.0) 171.9 (30.0) <0.001**
HDL-C (mg/dl) 63.4(15.1) 46.7(13.7) <0.001**
LDL-C (mg/dl) 141.7(43.0) 137.7(41.9) 0.521
Total protein (g/dl) 7.6(0.4) 7.7(0.4) 0.224
Albumin (g/dl) 4.0(0.3) 4.0(0.2) 0.915
Uric acid (mg/dl) 4.8(1.4) 5.4(1.4) 0.009**
BMI, body mass index: WC, waist circumference: HC, hip circumference: BP, blood pressure: HDL-C, high-density
lipoprotein cholesterol: LDL-C, low-density lipoprotein cholesterol: TG, triglyceride: TC, total cholesterol.
*=p<0.05, **=p<0.01 by using Student’s t-test

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 Increased Uric Acid and Life Style… Klongthalay S. et al. 203

Table 4: Risk factors related to MS

Parameters Subjects with Subjects Odds ratio p-value
MS without MS (95% CI)
N=66 N=136
Gender Female 39(59.1%) 88(64.7%) 1.27 0.439
Male 27(40.9%) 48(35.3%) (0.69-2.32)
Education (schooling <12 years 46(69.7%) 73(53.7%) 1.99 0.030*
years) > 12 years 20(30.3%) 63(46.3%) (1.06-3.70)
Physical activity Yes 31(47.0%) 96(70.6%) 0.37 0.001**
No 35(53.0%) 40(29.4%) (0.20-0.68)
Cigarette smoking Yes 19(28.8%) 18(13.2%) 2.65 0.007**
No 47(71.2%) 118(86.8%) (1.28-5.49)
Alcohol consumption Yes 14(21.2%) 34(25.0%) 0.81 0.553
No 52(78.8%) 102(75.0%) (0.40-1.64)
*=p<0.05, **=p<0.01 by using Pearson chi-square, OR- Odds ratio: 95%CI, 95% confidence interval

Serum uric acid level was positively correlated and gender showed that for every 1 mg/dl elevation
with BMI, WC, Waist-hip ratio, glucose and TG in the serum uric acid level, the OR for developing
levels, but correlated negatively with HDL-C. The MS had increased approximately 1.31-fold (95
possible associations between MS and education, %CI: 1.04-1.66), and cigarette smoking was 3.72
alcohol drinking, cigarette smoking, physical (95%CI: 1.51-9.15) times more likely to have MS.
activity and uric acid, are shown in Table 6. The Meanwhile, physical activity was related to lower
results of regression model after adjustment for age OR of the MS (OR= 0.36, 95% CI= 0.19-0.67).

Table 5: Correlation of uric acid with components associated with MS. (n=202)

Parameters Correlation Coefficient p-value

Glucose 0.161 0.020*
TG 0.358 <0.001**
HDL-C -0.397 <0.001**
Systolic BP 0.028 0.749
Diastolic BP 0.079 0.265
BMI 0.316 <0.001**
WC 0.357 <0.001**
Waist-hip ratio 0.344 <0.001**
*=p<0.05 by Spearman’s rank correlation (2-tailed)
**=p<0.01 by Spearman’s rank correlation (2-tailed)

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204 Ethiop J Health Sci. Vol. 30, No. 2 March 2020

Table 6: OR (95% CI) for predictors of MS, derived from logistic regression models with and without
control for other factors (n=202)
Predictors Unadjusted OR Adjusted ORa
(95%CI) (95%CI)
Education
1.99* (1.06-3.70) 1.77(0.93-3.39)
(<12 schooling years)
Alcohol consumption 0.81(0.40-1.64) 0.79 (0.37-1.67)
Cigarette smoking 2.65**(1.28-5.49) 3.72**(1.51-9.15)
Exercise activity 0.37** (0.20-0.68) 0.36** (0.19-0.67)
Uric acid (mg/dl) 1.29*(1.06-1.59) 1.31* (1.04-1.66)
OR-Odds ratio: 95%CI, 95% confidence interval, *=p<0.05, **=p<0.01 by using logistic regression.
a
adjusted for age and sex
DISCUSSION and hypertension (15). Hypertension was the major
component of MS in our study followed by central
MS is the major health problem which is increasing
obesity, and this finding was similar to a
worldwide. In the present study, the overall
comprehensive review of Katsimardou et al. that
prevalence of MS among participants in a suburban
hypertension was present in almost 80% of patients
community in Patumthani province was 32.7%
with MS (16). Regarding hypertension in MS, the
based on the harmonized criteria. Our finding was
pathophysiologic mechanism had been proposed
concordant with the prevalence of MS in the
that insulin resistance can stimulate the
InterASIA study among Thai adults from four
sympathetic nervous system and decrease nitric
regions of Thailand including the capital Bangkok
oxide production, contributing to increases in blood
(32.6%) (8) and Thai participants in Klong Luang,
Pathum Thani Province (36.5%) (9). Its prevalence pressure (17,18). Hypertension is the most common
modifiable risk factor for cardiovascular disease
in Khon Kaen (15.0%), a northeast province of
(CVD) including coronary heart disease,
Thailand, was lower than the our study (10).
myocardial infarction, heart failure, and stroke
Moreover, the prevalence of MS in this finding is
(19). Therefore, MS patients have a higher
in line with the countries of the Asia-Pacific region
susceptibility for cardiovascular problems.
ranged from 11% to 40% (11), such as 27.9% in
The underlying cause of MS is visceral
Malaysia (12) and 33% in India (13). However, the
obesity, and adipose tissue is a major organ that has
difference in the prevalence may be due to the
plentiful activity of xanthine oxidoreductase
differences in the race and MS definition,
(XOR) and the role of adipose tissue per se in the
especially in the cut-off points of waist
production of uric acid with a special focus on
circumference and fasting glucose level.
XOR, an enzyme known to catalyze purines, such
Additionally, the difference in participants’
as xanthine and hypoxanthine, to uric acid (20,21).
lifestyle may contribute to distinct prevalence
The explanation of this relation may be associated
levels; Pathum Thani Province, a neighboring
with hypoxia of obese adipose tissue that hypoxic-
province of the capital city of Thailand, has gone
induced increase in XOR activity has been revealed
through a period of epidemic transition, and risk
in several studies (20,22,23), and hypoxia also
factors associated with MS such as obesity plus a
induces dysfunction of adipose tissue, such as
sedentary lifestyle are commonly found in this
dysregulation of adipocytokines. In agreement with
population (9). Furthermore, this study found that
Tsushima et al. (20), our data found positive
the prevalence of MS was age-dependent with the
correlation of uric acid levels with obesity indices
highest prevalence in participants with age of >60
including WC and BMI. A study in identical twins
years old. This finding was in accordance with
also reported that serum uric acid was found to be
other studies (14,15) because many predisposing
significantly correlated with BMI even after
conditions which rising in the MS prevalence
adjusting for genetic and family environment
during aging, such as insulin resistance, obesity

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 Increased Uric Acid and Life Style… Klongthalay S. et al. 205

factors (24). Moreover, the present study revealed hypertension (36). The mechanism for uric acid
the association between serum uric acid and TG; mediated hypertension could be described by the
this relation is in line with previous studies (25,27). induction of endothelial dysfunction (37) and
There are some potential mechanisms for this activation of the renin-angiotensin system (38).
relationship that TG synthesis accelerates the de Therefore, it has been suggested that serum uric
novo synthesis of ribose-5-phosphate to acid might be an additional component of MS.
phosphoribosyl pyrophosphate (PPRP) through the Our study has shown that low education level
common metabolic pathway of NADP-NADPH, was prone to MS occurrence; similar data were
and as a result of increasing uric acid production reported by Kim et al. (39). A study done by
(28). Our results also showed that serum uric is Silventoinen et al. (40) also found that the
correlated with glucose, and this finding has been prevalence of MS was less in university education
reported in some previous studies (27,29). The level. These data may partly explain by the impact
potential mechanism is that increased uric acid of education that has the potential to improve the
levels can block the activation of AMPK, leading dietary habits and lifestyle while reducing
to the translocation of the transducer of regulated incidences of MS (39,41). Moreover, the result of
CREB activity 2 (TORC2) to the nucleus and the the present study is consistent with results from a
transcription of phosphoenolpyruvate meta-analysis of Sun et al. that cigarette smoking is
carboxykinase (PEPCK) and glucose-6- associated with developing MS (42). Bergman et
phosphatase (G6Pc) that stimulate de novo al. indicated that nicotine exposure had
production of glucose (30). Therefore, our data significantly increased IRS-1ser636 phosphorylation
provided confirmation of findings on association and decreased insulin sensitivity (43). Serine
between serum uric acid and components of MS. phosphorylation of many sites on (IRS-1),
The result of logistic regression analyses including ser636 decreases IRS-1 tyrosine
showed that after adjusted with age and sex, phosphorylation and insulin-stimulated glucose
cigarette smoking and hyperuricemia were risk uptake (44). These data suggest that inhibition of
factor whereas physical activity was a protective insulin signaling may be an important mechanism
factor of MS. Our study revealed that the person responsible for cigarette smoking-induced insulin
with high serum uric acid had 1.31 times higher in resistance, and many features of the MS are related
the odd of MS development, and this was to insulin resistance. Furthermore, smoking can
consistent with the studies in Taiwan (31) and Iran increase blood pressure, waist circumference,
(32). However, the precise biological mechanisms triglycerides, and reduce HDL-C (42). In the
underlying the relationship between serum uric present study, we found that leisure-time physical
acid and developing MS remain unclear. Zhu et al. activity was a protective factor for reducing MS in
found that increased uric acid level may directly Thais. This result was consistent with a meta-
inhibit insulin receptor substrate-1 (IRS-1) and Akt analysis of Roomi et al. (41) and in Taiwanese
insulin signaling and induce insulin resistance, workers (45). Huang et al. revealed that a high
which is the key pathophysiology of MS (33). level of physical activity had lower risks of MS
Although TG synthesis stimulates the uric acid including abdominal adiposity and
production, Kuwabara et al. (34) found that hypertriglyceridemia (45). The underlying
hyperuricemia is the risk factor for developing mechanisms for the advantages of high-intensity
hypertriglyceridemia. Oxidative stress may be exercise may involve in improved lipid biogenesis
responsible for uric acid mediated- in the adipose tissues and liver (46) and in
hypertriglyceridemia via citrate accumulation and increased HDL-C by stimulating expression of
stimulation of ATP citrate lyase leading to post-heparin lipoprotein lipase (47). Hence, the MS
increased fat production (35). Additionally, our may be prevented by changing the lifestyle to
study revealed that hypertension is the major lower the risk factor including frequent exercise
component of MS, and the study of Loeffler et al. and smoking cessation. This information derived
found that hyperuricemia is the risk factor of from Thais should be more applicable to our

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206 Ethiop J Health Sci. Vol. 30, No. 2 March 2020

society and other countries to improve the quality et al. Urban and rural variation in clustering of
of life and reduce the risk of various metabolic syndrome components in the Thai
noncommunicable diseases related to MS. population: results from the fourth National
The limitations of our study are the small Health Examination Survey 2009. BMC
sample size of both groups and the lack of diabetes Public Health. 2011;11(1):854.
indices including insulin and HOMA-IR value for 5. Teerawattananon Y, Luz A. Obesity in
evaluation of insulin resistance. Therefore, further Thailand and Its Economic Cost Estimation.
studies are required on larger cohorts with different Asian Development Bank Institute; 2017.
ethnic groups. 6. Alberti KG, Eckel RH, Grundy SM, Zimmet
In summary, the overall prevalence of MS in a PZ, Cleeman JI, Donato KA, et al.
suburban community in Pathum Thani Province, Harmonizing the metabolic syndrome: a joint
Thailand, was 32.7%; hypertension was the major interim statement of the International Diabetes
component of MS. The increased serum uric acid Federation Task Force on Epidemiology and
level, cigarette smoking and lack of physical Prevention; National Heart, Lung, and Blood
activity were significantly associated with Institute; American Heart Association; World
developing MS in Thais. Heart Federation; International
Atherosclerosis Society; and International
ACKNOWLEDGMENTS Association for the Study of Obesity.
Circulation. 2009;120(16):1640-5.
The authors wish to express their sincere thanks to
7. The Western Pacific Region, World Health
all volunteers and staff of the Faculty of Medical
Organization, International Associates for the
Technology, Rangsit University, for their
Study of Obesity, International Obesity Task
cooperation in carrying out this research. We also
Force. The Asia-Pacific perspective :
thank the Center of Translation, Faculty of Liberal
redefining obesity and its treatment.
Arts, Rangsit University, for proofreading this
Melbourne: Health Communications Australia
manuscript. The project was supported by funds
Pty Ltd; 2000.
from the Faculty of Medical Technology, Rangsit
8. Aekplakorn W, Chongsuvivatwong V,
University, Thailand.
Tatsanavivat P, Suriyawongpaisal P.
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