JMRI, 2009; 30 (2): (91-7)

91
Journal of the Medical Research Institute
JMRI, 2009; Vol. 30 No.2: (91-7)

Journal of the Medical Research Institute

Relation between Hyperuricemia and Metabolic Syndrome

Among Obese Women
Saneya A. Saleh, May N. Al -Muammar
Department of Community Health Sciences,College of Applied Medical Sciences, King Saud
University, Kingdom of Saudi Arabia

investigations

Abstract:

Bakgraound: Many studies found an association between hyperuricemia

& blood pressure elevation, obesity & metabolic syndrome.
Methods & Subjects: The present study was conducted on 108 obese
women to investigate the relationship between hyperuricemia and
traditional cardiovascular risk factors including metabolic syndrome.
Women enrolled in the study did not have heart, liver or kidney disease,
and were not on oral contraceptives, thiazides, loop diuretics, or low-dose
aspirin.
After explaining the aim of the research and obtaining consent of the
patients, personal and medical history were taken, blood pressure was
measured, anthropometric measurements to calculate body mass index
(BMI) and waist hip ratio (WHR) were done. After an overnight fast, a
venous blood sample was taken to assess serum uric acid, fasting blood
glucose and serum lipid profile.
Hyperuricemia is defined as serum uric acid level 7 mg/dl (in men) or
6.0 mg/dl (in women). Metabolic syndrome was defined using
AHA/NHLBI (American Heart Association/National Heart, Lung, and
Blood Institute) criteria.
Results: The present study showed that hyperuricemia was positively
associated with systolic and diastolic blood pressure elevation, BMI, age,
and serum triglycerides levels (TG), but negatively correlated to high
density lipoprotein. Hyperuricemia was an independent predictor to blood
pressure elevation. The diastolic and systolic blood pressure, HDL-C, age,
and waist circumference were responsible for 59.1% of the serum uric acid
variance. It seemed that there is a mutual relationship between
hyperuricemia and metabolic syndrome; each contributes to aggravation of
the other. Hyperuricemia which is an independent risk for cardiovascular
disease may also be induced by medications for metabolic syndrome.
Conclusion: Serum uric acid level should be monitored in patients with
metabolic syndrome and those at risk for coronary artery disease. Since
hyperuricemia is potentially modifiable, exclusion of hyperuricemic agents
and inclusion of anti-uricemic measures in the dietary and therapeutic
prophylactic regimens seems to carry better prognosis for patients at risk
for developing cardiovascular disease.
Key words: Hyperuricemia-Metabolic syndrome Hypertension -Obesity

Introduction

Cardiovascular disease is the leading

cause of death throughout the world.

It accounts for about 30% of death
worldwide, including 40% in high
income countries, and about 28% in
low and middle income countries.1
Many conditions including hypertension, glucose intolerance, dys-

proved

that

other

factors such as Chlamydia pneumoniae

infection, Cytomegaloviruses and

other microorganisms contribute to

the risk for cardiovascular problems.(4,5)

Recently, the association between

gout/hyperuricemia and metabolic
syndrome has pointed to increasing
cardiovascular risk6, and there is
increasing evidence that hyperuricemia

itself may be an independent risk

factor for cardiovascular disease.7,8
Gout, another lifestyle associated
disease, is the most common
inflammatory joint disease in affluent
men older than 40 years of age. It
affects at least 1% of the population
in Western countries.9 Recent studies
from Western countries suggest that
both the prevalence and incidence of
gout have been increasing over the
past 4 decades allover the world
affecting more women and a wider
range of socioeconomic groups for a
variety of reasons. Association
between gout and cardiovascular
disease has been recently reported.10
The risk of developing gout is
directly related to the degree of
hyperuricemia. Hyperuricemia can be
caused by overproduction of urate,
defective urinary excretion or a combination of these two mechanisms.
New dietary studies show an association of gout with high meat,

lipidemia, and others were proved to

predispose to the pathogenesis of
ischemic cardiac problems. Overindulgent lifestyle and metabolic
syndrome are identified as eminent
risks for cardiovascular insults.2,3

high-purine vegetables.10,11 Although

fructose is not a purine, it causes
hyperuricemia by accelerating the

Conventional predisposing factors

for cardiovascular disease are only
evident in almost 50% of the cases;

Several studies demonstrated that

hyperuricemia is linked with the

Relation
Relationbetween
betweenHyperuricemia
Hyperuricemiaand
andMetabolic
MetabolicSyndrome
SyndromeAmong
AmongObese
ObeseWomen
Women

seafood or alcohol intake, but not with

catabolism of adenine nucleotides.12,13

92

Saleh and Al Muammar

metabolic syndrome (hypertension, glucose intolerance,

dyslipidemia, truncal obesity, increased risk of cardiovascular disease), and there is increasing evidence that
hyperuricemia itself may be an independent risk factor for
cardiovascular disease.7,8
Hyperuricemia may be present in up to 18% of some
populations. Two thirds of patients with hyperuricemia
can remain asymptomatic with no joint affection.10,14
Since hyperuricemia can be controlled, its linkage to
cardiovascular risks needs more investigation.

Aim of the Study

The aim of the present work was to study the relation of
serum uric acid level to the metabolic syndrome as a
cardiovascular risk factor among obese women.

Subjects and Methods

In this cross sectional study, data were collected from 108
adult women, aged 21-56 years, attending two medical
nutrition therapy outpatient clinics in Alexandria, Egypt,
seeking medical advice for weight reduction, through the
period from June to July 2008.
All women included in the study were not pregnant or on
oral contraceptives, and neither of them has experienced
ischemic heart disease or complained of joint pain due to
gout. Women who had liver or kidney diseases or whose
investigations proved renal or hepatic insufficiency, those
receiving thiazides, loop diuretics, low-dose aspirin,
cyclosporine A, antituberculous antibiotics, niacin,
anticancer chemotherapy and didanosine11 or those who
refused to share in the study were excluded.
All patients under the study were subjected to an initial
assessment of their nutrition and health status using the
following tools:
Predesigned interview questionnaire to collect data
about personal and family characteristics, medical
history for the presence of associated disorders, and
intake of medication.
Complete physical and clinical examination comprised
pulse, blood pressure measurement, chest, heart and
abdominal examination. Blood pressure was measured
twice for accuracy and the mean value was then
calculated and compared to the recent guidelines to
classify hypertension.15 Patients with a systolic blood
pressure exceeding 140 mmHg, and a diastolic BP more
than 90 mmHg were considered hypertensive.
Anthropometric measurements comprised measurement
of weight, height, waist (wst) and hip measurements.
The body mass index (BMI) and waist hip ratio (WHR)
were calculated and then compared to the WHO
classification. Patients with a BMI 30 Kg/m2 were
considered obese, and those with a WHR > 0.85 were
considered to have abdominal central obesity.16
Venous blood samples were collected between 8-10 am after
an overnight fast for biochemical laboratory assay which
included serum uric acid, fasting serum glucose (FSG),

JMRI, 2009, Vol.30 No 2: (91-7)

serum lipid profile: total cholesterol (TC), triglycerides

(TG), high density lipoproteins cholesterol (HDL-C) and
low density lipoproteins cholesterol (LDL-C) levels.
- Uric acid was measured using a modification of the
uricase method.17
- Fasting serum glucose (FSG) level was determined
using enzymatic colorimetric method.18
- Total serum cholesterol (TC), serum triglycerides
level, LDL-C and HDL-C were determined using
enzymatic colorimetric method.19-22
Diagnosis criteria
Hyperuricemia was defined as serum uric acid level
6.0 mg/dl in women.23
The presence of metabolic syndrome24 among the
studied women was defined as those patients having
3 of the following 5 items:
1. waist circumference 80 cm;
2. serum triglyceride levels 150 mg/dl;
3. serum HDL-C levels <50 mg/dl;
4. systolic blood pressure 130 mmHg or diastolic
blood pressure 85 mmHg;
5. fasting serum glucose 110 mg/dl.
After completion of the initial assessment, patients were
divided into two groups based on their uric acid levels:
group 1 is the hyperuricemic group (uric acid 6mg/dl)
and group 2 is the normo-uricemic group (with a serum
uric acid less than 6 mg/dl).

Statistical Methods
Statistical analysis was performed using the SPSS
packages version 15. The data obtained were coded
tabulated and presented with arithmetic mean and
standard deviation. Student t-test was used to test for
mean differences between groups, and Pearsons
correlation coefficient was used to detect any relation
between hyperuricemia and certain studied variables
(BMI, waist hip ratio (WHR), blood pressure, fasting
serum glucose and lipid profile). Stepwise multiple
regression analysis was also adopted to select the most
significant predictors of elevated serum uric acid and
cardiovascular risk factors among the studied sample.25\

Results
In the present study 84.3% of patients were hypertensive,
two thirds (66.7%) were morbidly obese, and 72.2% had
central abdominal obesity. Biochemical assay showed that
more than one half of the studied sample had
hyperuricemia, (51.9%), while hypercholesterolemia and
hypertriglyceridemia, were prevalent in 55.6% and 66.7%
of the studied women respectively, (table 1).
The mean age of the studied patients was significantly
higher than that of non-hyperuricemic. Hyperuricemic
women had significantly higher anthropometric
measurements and indices, systolic and diastolic blood
pressure, fasting blood sugar level and lipid profile than
non-hyperuricemic ones at p<0.05, (table 2).

JMRI, 2009; 30 (2): (91-7)

93

Table (1): Distribution of the Studied Sample according to Anthropometric Indices, Blood Pressure, and Serum Biochemical
Parameters Levels.
Variable

Number (n=108)

6
18
12
72

5.6
16.6
11.1
66.7

30
78

27.8
72.2

17
91

15.7
84.3

52
56

48.1
51.9

48
60

44.4
55.6

36
72

33.3
66.7

47
61

43.5
56.5

29
79

26.9
73.1

BMI level (kg/m )

Overweight (25-<30)
Grade 1 Obese (30-<35)
Grade 2 Obese (35-<39)
Morbid Obesity ( 40)
Abdominal Obesity
WHR <0.85
WHR 0.85
Blood pressure level
Normotensive
Hypertensive
Serum Uric acid level (mg/dl)
Non-hyperuricemic (< 6 mg/dl)
Hyperuricemic ( 6 mg/dl)
Serum Lipid profile (mg/dl)
Total Cholesterol level
Desirable TC level
Hypercholesterolemia
Triglycerides level
Desirable TG level
Hyper-triglyceridemia
Low Density Lipoproteins Cholesterol (LDL-C)
Desirable LDL-C level
High LDL-c level
High Density Lipoproteins Cholesterol (HDL-C)
Desirable HDL-C level
Low HDL-C level

Table (2): Mean and SD of Age, Anthropometric Measurements and Indices, Blood Pressure, Serum Biochemical Parameters
among the Studied Sample according to Serum Uric Acid levels.

Variable

Age (years)
Anthropometric Measurements & Indices
- Weight (kg)
- BMI (kg/m2)
- Waist circumference (cm)
- Hip circumference (cm)
- WHR
Blood Pressure (mmHg)
- Systolic BP
- Diastolic BP
FSG (mg/dl)
Lipid profile (mg/dl)
- Serum TC
- Serum TG
- Serum LDL-C
- Serum HDL-C
* * Significant at p< 0.05 level

Serum Uric Acid level

Hyperuricemic
Normo-uricemic
n=56
n= 52
Mean
SD
Mean
SD
41.79
9.27
34.61
9.19

Test of
Significance

4.04**

0.000

118.41
43.41
121.50
142.21
0.86

16.63
6.43
11.24
13.33
0.08

99.67
38.30
107.14
133.45
0.81

15.85
6.06
12.60
13.69
0.09

5.98**
4.25**
6.23**
3.37**
3.34**

0.000
0.000
0.000
0.001
0.001

153.08
103.17
98.68

16.45
6.72
8.60

135.00
92.77
92.65

10.83
8.36
11.86

6.79**
7.09**
3.31**

0.000
0.000
0.003

267.29
159.69
202.13
33.21

45.64
70.27
43.51
1.93

203.86
113.25
141.45
39.75

24.54
43.12
22.12
2.01

8.89**
4.17**
9.03**
7.22**

0.001
0.000
0.003
0.000

Relation between Hyperuricemia and Metabolic Syndrome Among Obese Women

94

Saleh and Al Muammar

Table (3): Correlation between Serum Uric Acid and Age, Anthropometric Measurements and Indices, Blood Pressure, Lipid
Profile and Fasting Glucose Levels among the Studied Sample.
Variables

Test of Significance

Age

0.464*

0.000

Body mass index

0.254*

0.008

Waist circumference

0.480*

0.000

Systolic blood pressure

0.497*

0.000

Diastolic blood pressure

0.509*

0.000

Serum TC

0.041

0.891

Serum HDL-C

- 0.504*

0.030

Serum triglycerides

0.335*

0.000

Serum LDL-C

0.061

0.523

Fasting serum glucose

0.334*

0.000

* Significant at p< 0.05 level

Table (4): Stepwise Multiple Regression Analysis of Factors Affecting Serum Uric acid Levels among the Studied Sample.
Independent Variables

DBP
HDL-C
Age
SBP
Waist Circumference
Constant

SE(B)

Beta

0.057
0.011
0.063
0.033
0.027
1.768

0.023
0.002
0.015
0.014
0.012
1.856

0.302
0.413
0.359
0.317
0.217

2.535*
5.124*
4.160*
2.471*
2.258*
0.952

0.013
0.000
0.000
0.015
0.026

* Significant at p<0.05
R2 = 0.591

Table (5): Stepwise Multiple Regression Analysis of Factors Affecting Blood Pressure Level among the Studied Sample.
Variable

SE(B)

Beta

0.011
0.011
0.066
0.009
0.001
0.001
3.141

0.002
0.002
0.016
0.003
0.002
0.003
0.338

0.486
0.397
0.377
0.203
0.173
0.174

5.729*
5.023*
4.243*
2.799*
2.419*
2.061*
9.304

0.000
0.000
0.000
0.006
0.017
0.042

Hypertension

Waist circumference
FSG
Serum uric acid
HDL-C
LDL-C
S. Triglycerides
Constant

* Significant at p< 0.05 level

R2 = 0.508
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh

There was a positive significant intermediate association

between serum uric acid level and age, BMI, waist
circumference, systolic and diastolic BP, serum
triglycerides level and fasting serum glucose. Serum uric
acid level also had a significant negative association with
serum HDL cholesterol level, but no association with
serum TC nor with LDL-C (table 3).
JMRI, 2009, Vol.30 No 2: (91-7)

Table 4 showed that the blood pressure, serum HDL-C,

age and waist circumference were significant independent
predictors of 59.1% of serum hyperuricemia that occurred
in the studied patients.
Multiple regression analysis showed that the serum lipids
(HDL-C, LDL-C and TG), waist circumference, FSG and

JMRI, 2009; 30 (2): (91-7)

serum uric acid level caused a statistical elevation of

blood pressure level among the studied sample, (table 5).

Discussion
Despite the availability of effective therapies, gout and its
underling condition, hyperuricemia continue to be a
health problem around the world.26 Hyperuricemia can be
caused by overproduction of urates, defective urinary
excretion or a combination of both mechanisms.11
Obesity and weight gain are strong risk factors for gout,
whereas weight loss is protective.8,11 The present work
was conducted among overweight (5.6%), obese (27.7%)
and morbidly obese (66.7%) women to investigate the
prevalence of hyperuricemia among the obese women and
the association between uric acid levels and the
cardiovascular risk factors.
It was found that BMI was positively associated with
serum uric acid elevation. These findings match the
previous studies showing that increased BMI is directly
correlated with hyperuricemia.8,11,27 In the same line,
another study concluded that abdominal obesity is the
main determinant of uric acid variance.28 The majority of
the sample of the present study (72.2%) had abdominal
adiposity; stepwise regression analysis revealed that waist
circumference was an independent predictor ( = 0.217,
p=0.026) for hyperuricemia.
Elevation of serum uric acid among obese patients may
be attributed to several factors including accelerated
generation of uric acid through purine metabolism and
impaired excretion in the kidney.9,12,14 Leptin, a hormone
related to obesity, was also described to be a pathogenic
factor responsible for hyperuricemia among obese
patients.29
Previous studies showed that obese patients consuming
large amounts of red meat, sea food, alcoholic beverages
suffer from hyperuricemia. The same also applies to
obese subjects consuming soft drinks, sweets and
preserved fruits probably due to the presence of fructose
and high-fructose corn syrup.12-14
Hyperuricemia is a heritable condition, researchers in the
Framingham Heart Study identified several novel loci
linked to uric acid, and found possible pleiotropic effects
between uric acid, BMI and glucose.30 In our study
hyperuricemic women had a significantly higher level of
FSG than non hyperuricemic (p=0.003.), however, both
are still in the normal range.
Hyperuricemia seems to be linked to insulin resistance
and hyperinsulinemia through inducing the low excretion
type hyperuricemia. This might be expected from the fact
that uric acid production is linked to glycolysis which is
controlled by insulin. 8,27,31 In our study, hyperuricemic
women showed significant higher levels of serum
triglycerides. This finding might be explained by

95
accumulation of glycerol-3-phosphate caused by a
reduced responsiveness to insulin among the obese
women. The accumulation of glycolytic intermediates
may explain the association between insulin resistance,
hyperuricemia, and hypertriglyceridemia.8,23,31
In the present study, the negative correlation of serum
HDL-C to serum uric acid (p< 0.05) shown among the
studied obese women is not unique. A study conducted on
the relationship of uric acid to mortality in chronic kidney
diseases concluded that uric acid correlates positively
with triglycerides, phosphates, C-reactive protein and
intracellular adhesion molecule 1, but negatively with
calcium, HDL-C and apolipoproteins.32
In the present study, hyperuricemic women had
significantly higher mean age than those with normal
serum uric acid level. Age was also found to be positively
associated with increased uric acid level (r=0.464,
p=0.00), and regression analysis showed that age may
moderately predict serum uric acid elevation. Increase of
serum uric acid levels with age has been repeatedly
reported9,11; after menopause womens serum uric acid
values rise to levels comparable with those of men of the
same age especially those receiving diuretics.33,34
Furthermore, 50% of patients older than 60 years with
newly diagnosed gout are women, and the proportion may
exceed 50% in those older than 80 years.11 In the United
States, the increasing prevalence of gout was attributed to
increased longevity, because prevalence is a function of
both disease incidence and disease duration. 9,11
Hypertension may have contributed to the hyperuricemia
in the studied sample as the majority of women (84.3%)
in the present study were hypertensive. Paerson's
correlation coefficient revealed a significant positive
association between serum uric acid and systolic blood
pressure (r=0.497) and diastolic blood pressure (r=0.509)
among studied women (p<0.05).
Previous studies concluded that hypertension appears to
be partially responsible for the increased prevalence of
gout and was independent predictive of uric acid
elevation.35-37 Hyperuricemia is more pronounced in
hypertensive patients complicated by peripheral arterial
diseases and is associated with worse functional status of
the peripheral circulation. These adverse effects have
been linked to increased chemokine and cytokine
expression, induction of the rennin-angiotensin system,
and to increased vascular C-reactive protein
expression.28,38,39 In the present study, regression analysis
demonstrated that systolic and diastolic blood pressure are
independent predictors of serum uric acid elevation
among the studied women (p=0.013 and p=0.015
respectively).
Although uric acid has beneficial antioxidant functions, it
stimulates vascular smooth muscle cell proliferation
aggravating hypertension. It also contributes to
endothelial dysfunction by inducing antiproliferative
effects on endothelium and impairing nitrous oxide

Relation between Hyperuricemia and Metabolic Syndrome Among Obese Women

96

Saleh and Al Muammar

production. Thus uric acid may play a pathogenetic role

in hypertension, vascular disease and renal disease.40 In
the present study, patients with hyperuricemia had higher
SBP and DBP when compared to non-hyperuricemic
patients (153.0816.45 mmHg and 103.176.72 mmHg
versus 135.00 10.83 mmHg and 92.77 8.36 mmHg)
respectively (p<0.05).

2.

Stroke Statistics Subcommittee. Circulation 2008; 117: 25.

3.
4.

A great majority of studied women in the present work

seems to be at high risk for developing cardiovascular
disease as they suffer from obesity, hypertension,
dyslipidemia, and truncal adiposity. These conditions
were associated with higher levels of serum uric acid
levels. Previous studies revealed that men with
hyperuricemia had a 1.634-fold increased risk of
metabolic syndrome as compared with those without
hyperuricemia [odds ratio (OR)=1.634, p=0.000]. Women
with hyperuricemia had a 1.626-fold increased risk of
metabolic syndrome.41
The association of hyperuricemia with the conventional
cardiovascular risks should be seriously considered.
Truncal adiposity and hypertension may aggravate the
hyperuricemia, which in turn would contribute to the
pathogenesis of hypertension and endothelial injury
raising the risk for developing cardiovascular disease
especially in presence of dyslipidemia.32, 36 Recently,
there is a resurgence of interest in hyperuricemia as an
independent cardiovascular risk factor.10, 42
It seems that patients with cardiovascular risk factors are
also at risk for hyperuricemia. Potential risk of
hyperuricemia is associated with renal insufficiency of
any cause and hyperuricemia is also common in renal
transplant recipients and is associated with a need for
antihypertensive therapy to improve cardiovascular
outcomes.33-34, 36-37
Medications used by patients with traditional
cardiovascular risks factors may also carry the risk for
elevating serum uric acid level; thiazides, loop diuretics,
low-dose aspirin, cyclosporine A, and niacin are
especially incriminated.11 Recent reviewers concluded
that serum uric acid appears to be a stronger risk factor
for cardiovascular disease in individuals already at high
risk for cardiovascular disease than in healthy
individuals.26,38 Monitoring of serum uric acid level may
be mandatory in these conditions. Hyperuricemia is
potentially modifiable; exclusion of hyperuricemic agents
and inclusion of anti-uricemic measures in the dietary and
therapeutic prophylactic regimens for patients at risk for
developing cardiovascular disease seem to be beneficial.

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Relation between Hyperuricemia and Metabolic Syndrome Among Obese Women

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