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The impact of vitamin A supplementation on thyroid function and insulin sensitivity: implication of deiodinases and phosphoenolpyruvate carboxykinase in male Wistar rats

Purpose Vitamin A is an essential nutrient with vital biological functions. The present study investigated the effect of different doses of vitamin A palmitate at different time intervals on thyroid hormones and glycemic markers. Methods Male rats were administrated vitamin A palmitate at different doses (0, 0.7, 1.5, 3, 6, and 12 mg/kg, oral) and samples were collected at different time intervals of 2, 4, and 6 weeks. The levels of vitamin A, thyroid hormones (T3, T4, and TSH), deiodinases (Dio1 and Dio3), glycemic markers (blood insulin and fasting glucose levels, HOMA IR and HOMA β), retinol-binding protein 4 (RBP4) and the gluconeogenic enzyme phosphoenolpyruvate carboxykinase (PEPCK) were measured. Results The findings demonstrated that long-term supplementation with high doses of vitamin A palmitate resulted in hypothyroidism (lower T3 and T4 levels and elevated TSH levels) as well as upregulation of Dio1 and Dio3 expression levels. This effect was associated with elevated glucose and insulin levels, enhanced HOMA IR, and decreased HOMA B index. In addition, prolonged vitamin A supplementation significantly increased RBP4 levels that upregulated the expression of PEPCK. Conclusion High doses of vitamin A supplementation increased the risk of hypothyroidism, modulated insulin sensitivity, and over a long period, increased the incidence of type 2 diabetes mellitus associated with oxidative stress and hepatitis.


Introduction
Vitamin A is a significant micronutrient for humans, and it must be obtained from dietary sources as it cannot be biosynthesized in the body [1]. Vitamin A found in animal food sources as preformed vitamin A exists in three primary forms: retinal, retinol, and retinoic acid [2]. Vitamin A is essential for the body to perform a variety of vital metabolic functions, including vision, regulation of immune function, growth, and development [3]. Vitamin A is not a well-known antioxidant, and only a few studies have indirectly reported its potential antioxidant role. Interestingly, all-trans retinoic acid has been proven to play a crucial role in inhibiting hepatic stellate cells activation via suppressing thioredoxin-interacting protein and reducing oxidative stress levels [4]. Furthermore, all-trans retinoic acid was found to induce superoxide dismutase (SOD) and glutathione S-transferase (GST) activities while decreasing malondialdehyde and reactive oxygen species in both healthy and varicocele sperm [5]. Therefore, there is growing evidence suggesting that vitamin A enhances the antioxidant enzymes activities and may play a role in protecting the body against oxidative stress damage.
The transport of vitamin A in plasma is a distinct process mediated by plasma retinol-binding protein 4 (RBP4), which is mainly produced by hepatocytes [6]. RBP4 forms a reversible complex with a carrier protein called transthyretin (TTR). RBP4 binding to TTR prevents the extensive loss of RBP4 through glomerular filtration [7]. Transthyretin functions as a transporter protein for RBP4 and thyroxine (T4) [8], the primary hormone released into the bloodstream by the thyroid gland. T4 and T3 (3,5,3′-triiodothyronine) are 1 3 thyroid hormones that significantly contribute to growth, differentiation, and metabolism. Thyroid hormones can act as insulin agonists and antagonists and maintain a proper glucose homeostasis balance [9]. Hypothyroidism can disrupt glucose metabolism and break this equilibrium leading to insulin resistance (IR) [10].
Moreover, thyroid disorders (hypo-and hyperthyroidism) were reported to be associated with IR due to the alteration of various mechanisms such as lipid levels and insulin secretion [11]. Few studies reported hyperinsulinemia in subclinical hypothyroidism [12]. Another study by Garduño-Garcia Jde, Camarillo Romero [13] detected a negative correlation between thyroid hormones, homeostasis model assessment for insulin resistance (HOMA IR), and basal insulin.
Interestingly, RBP4 might also alter the hepatic regulation of glucose homeostasis. RBP4 modulates insulin sensitivity in muscle and liver tissues and indicates a relation between RBP4 and insulin resistance [14,15]. Yang, Graham [16] demonstrated that RBP4 concentration increased in obesity and IR models, and depletion of the RBP4 gene in mice has been proven to improve insulin sensitivity. Moreover, vitamin A and RBP4 regulate the expression of gluconeogenic enzyme phosphoenolpyruvate carboxykinase (PEPCK), which catalyzes the first limited step in gluconeogenesis [17]. Wolf [18] reported that the increased level of RBP4 increased the production of glucose by stimulating the expression level of PEPCK. In addition, RBP4 was found to impair glucose uptake by decreasing the expression of glucose transporter 4 (GLUT4) in adipocytes and inducing IR [14,15].
The present study was aimed to investigate the effect of different doses of vitamin A palmitate at different time intervals on the antioxidant status, thyroid [T3, T4, thyroid-stimulating hormone (TSH), and deiodinases (Dio1 and Dio3)] and glycemic markers (blood insulin, glucose, HOMA IR, HOMA β and RBP4 levels) using a rat model.

Materials
Vitamin A palmitate was obtained from BDH Chemicals, Ltd., Poole, England. A rat insulin ELISA kit was purchased from Thermo Fisher (USA), and a mouse/rat T3 ELISA kit was obtained from Calbiotech Inc (USA). Rat T4 and TSH ELISA kits were obtained from Kamiya Biomedical Company (USA), vitamin A and RBP ELISA kits were obtained from NOVA Technology (China). Trichloroacetic acid (TCA), Thiobarbituric acid (TBA), sulfosalicylic acid, 5,5-dithio-bis-2-nitrobenzoic acid (DTNB), reduced glutathione (GSH), and P-nitrobenzyl chloride were purchased from Sigma-Aldrich (USA). Tris-HCl and pyrogallol were purchased from Win Lab (UK) and Fluka (Switzerland), respectively. Easy-red™ total RNA extraction kit, reverse transcriptase kit (Maxime RT Pre Mix kit) and 2X PCR master mix solution (i-Taq) were obtained from iNtRON Biotechnology (Korea).

Animals and experimental design
The current study was performed on 105 male Wistar rats weighing (100-110 g) purchased from the Institute of Graduate Studies and Research (Alexandria, Egypt). The animals were housed (5 rats/cage). The rats were housed under a 12-h light/dark cycle with free access to a standard balanced diet and drinking water ad libitum. Appropriate measures were taken to reduce the animals' stress, pain, or discomfort, and only the least number of animals was used, which was necessary to obtain reliable scientific data. All the animal handling procedures and care were conducted in accordance with the National Institutes of Health Guide for the Care and Use of Laboratory Animals (NIH 1996) and followed ARRIVE guidelines. The Ethics Committee of Animal Research in the City of Scientific Research and Technology Applications (SRTA-City), Institutional Animal Care and Use Committees (IACUC)/IACUC # 27-1V-0321 approved the experimental animal design.
The rats were randomly divided into seven groups (15 rats/group). Group 1 served as the negative control; Group 2 received olive oil (0.5 ml/day) orally via a stomach tube and served as the olive oil control; Group 3-7 received different doses of vitamin A palmitate (0.7, 1.5, 3, 6, 12 mg/kg/ day, orally), respectively. Vitamin A palmitate was dissolved in olive oil. Five rats from each group were fasted for 12 h before decapitation at time intervals of 2, 4, and 6 weeks. Indeed, the tested doses 0.7, 1.5, 3, 6, 12 mg/kg equivalent to 1272, 2727, 5454, 10,908 and 21,816 IU/ kg, respectively.

Sample preparation
Blood samples were collected from the heart by cardiac puncture. Sera and plasma were separated after centrifugation at 3000 rpm for 15 min. The plasma was used to estimate glucose level, and the sera were stored at -20 °C for biochemical analysis. Liver tissues were removed quickly and washed in ice-cold saline. For histopathological studies, one part of the liver was fixed in 10% buffered formalin. The remaining liver was stored at − 80 °C until further use. The liver homogenate was prepared (10%, W/V) in phosphate buffer saline (PBS, 0.1 M, pH 7.4), then centrifuged at 10,000×g at 4 °C, and the clear supernatant was collected for the measurement of the oxidative stress parameters.

Serum and plasma parameters
Serum levels of vitamin A, RBP, insulin, T3, T4, and TSH were measured using the commercial ELISA kits. Serum alanine aminotransferase and aspartate aminotransferase (ALT and AST) activities were estimated according to the manufacturer's protocols of Biosystems S.A., Spain. Fasting plasma glucose level was measured using a commercial kit. Insulin sensitivity was estimated by homeostasis model assessment for insulin resistance (HOMA IR), and β-cell function was evaluated by HOMA β according to the following equations: [19] Oxidative stress biomarkers Thiobarbituric acid reactive substances (TBARS) Thiobarbituric acid reactive substances (TBARS) is a bio-parameter utilized as an index for lipid peroxidation. Elevated TBARS levels can be interpreted as a marker of hepatic liver damage. It was measured as previously described by Tappel and Zalkin [20]. In brief, 500 µl of either liver homogenate or PBS (blank) were added to 1 ml TCA (15%) and then thoroughly mixed and centrifuged at 3000 rpm for 10 min. The supernatant (1 ml) and 0.5 ml of TBA (0.7%) were heated for 60 min at 90 °C, and the obtained color was measured spectrophotometrically at 532 nm against blank. The results were expressed as μmol/mg protein.

Glutathione-S-transferase (GST) activity
Glutathione-S-transferase activity was measured as previously described by Habig, Pabst [21]. 10 µl of p-nitrobenzyl chloride (1 mM) was added to 1.37 ml of phosphate buffer (0.1 M, pH 6.5) and thoroughly mixed. 25 µl of liver homogenate supernatant or PBS (blank) was added and incubated at 37 °C for 5 min, then 100 μl of GSH (5 mM) was added to start the reaction and incubated for 20 min at room temperature. The absorbance at 310 nm was measured using a UV spectrophotometer, and the enzyme activity was expressed as U/ mg protein (μmol/min/mg protein).
Superoxide dismutase (SOD) activity Superoxide dismutase activity was measured according to the method described by Marklund and Marklund [22]. In quartz cuvette, 20 µl of liver homogenate supernatant or standard SOD was added to 10 µl pyrogallol (20 mM in 10 mM HCl) and 1 ml of the assay mixture (20 mM Tris-HCl buffer, pH 8.2 containing 1 mM diethylene triamine Penta acetic acid). After 30 and 90 s, the absorbance was measured at 420 nm against air. The results were expressed as U/mg protein (μmol/min/mg protein).

RNA isolation and reverse transcriptase polymerase chain reaction (RT-PCR)
Total RNA was isolated from liver tissues (approximately 100 mg) using Easy-red™ total RNA extraction kit. The concentration and purity of RNA were estimated by measuring the absorbance at 260 and 280 nm. Samples with A260/280 ≥ 1.8 were used further. Isolated RNA was reverse transcribed into complementary DNA (cDNA) using reverse transcriptase enzyme (Maxime RT PreMix kit, iNtRON Biotechnology, Korea). PCR reaction was amplified using cDNA as a template and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) as a housekeeping gene. Primers sequences are depicted in Table 1. The PCR mixture was prepared as follows: 10 µl of master mix, 1 µl of forward primer, 1 µl of reverse primer, and 1 µl of template cDNA were dispensed in PCR tubes (0.2 ml), then completed to 20 µl with nuclease-free distilled water. PCR was performed using the following thermal cycling conditions; initial denaturation at 94 °C for 60 Sec, 30 cycles of denaturation at 94 °C for 20 Sec, annealing temperature as depicted in Table 1, extension at 72 °C for 30 Sec and finally, one cycle of final extension at 72 °C for 5 min. After the thermal cycling, 10 µl of PCR product was resolved on 1.5% agarose electrophoresis. Ultraviolet exposure was used to reveal DNA bands using the gel documentation system. An image analysis system was used to determine the intensity of each band (UVitec software). After normalization to the housekeeping gene, the relative gene expression was quantified.

Histopathological study
The liver tissue was fixed in 10% buffered formalin, dehydrated by immersing in serial alcohol concentrations, cleared using xylene as an organic solvent, and infiltrated with paraffin wax forming blocks. Sections of 5 μm thickness were cut using a rotary microtome. The sections were stained with hematoxylin and eosin (H and E) and then examined under the light microscope to detect any histopathological changes.

Statistical analysis
Results are expressed as means ± SD. The significance of differences between means was tested using the one-way analysis of variance (ANOVA) using the LSD test. The significance of the obtained results is determined at p ≤ 0.05. The Statistical Package for Social Sciences (SPSS), V 20, was used to analyze data (Chicago, IL, USA).

The effect of different doses and time intervals of vitamin A palmitate on serum vitamin A and RBP4 levels
Administration of olive oil for 2, 4, and 6 weeks demonstrated a non-significant change in the level of serum vitamin A and serum RBP4 compared to the negative control, Fig. 1. A levels in all treated groups compared to olive oil control. However, serum RBP4 level was significantly increased after administrating vitamin A palmitate at 1.5, 3, 6, and 12 mg/ kg for 2, 4, and 6 weeks in a dose and time-dependent manner compared to olive oil control, Fig. 1.

The effect of different doses and time intervals of vitamin A palmitate on serum thyroid parameters
Olive oil administration for 2, 4 and 6 weeks resulted in a significant decrease in serum T3 and T4 levels compared to the negative control (Fig. 2). The serum levels of T3 and T4 were significantly affected by different vitamin A doses. After 2 weeks, there was a significant decrease in serum T3, and T4 levels in the 6 and 12 mg/kg supplemented groups compared to the olive oil group. After 4 and 6 weeks, there was a significant decrease in T3 and T4 levels in all doses compared to olive oil, especially in the 3, 6, and 12 mg/kg supplemented groups. Rats supplemented with 12 mg/kg vitamin A palmitate for 6 weeks demonstrated the highest reduction in T3 and T4 levels by 66 and 69%, respectively, compared to the olive control group (Fig. 2). In contrast, serum TSH level was significantly increased after administration of olive oil for 4 and 6 weeks compared to the negative control (Fig. 2). Vitamin A supplementation resulted in a significantly higher serum TSH level in a dose-and time-dependent manner than olive oil (p ≤ 0.05). When 0.7 mg/kg was administered for 2 weeks, the difference was insignificant compared to olive oil. After 6 weeks, the serum TSH levels in the 1.5, 3, 6, and 12 mg/kg supplemented groups increased by 105, 188, 216, and 336%, respectively (Fig. 2).

The effect of different doses and time intervals of vitamin A palmitate on glycemic markers
Olive oil administration for 2, 4, and 6 weeks showed a non-significant change in plasma glucose, serum insulin levels, and HOMA IR and HOMA β were not affected by its administration compared to the negative control. Glucose level was significantly increased in a dose and time-dependent manner after vitamin A supplementation, especially at 6 and 12 mg/kg for 4 and 6 weeks compared to olive oil controls (Fig. 3). Furthermore, serum insulin level was altered after vitamin A supplementation and affected by the time interval. Low doses of vitamin A (0.7, 1.5 mg/kg) resulted in a significant increase in serum insulin level. Compared to the olive oil control group, high doses (6 and 12 mg/kg) resulted in a significant decrease in serum insulin levels (Fig. 3). In addition, the decrease in serum insulin level was dose and time-dependent.
Vitamin A supplementation at 1.5 and 3 mg/kg (for 2 weeks) and at 0.7, 1.5, 3 and 6 mg/kg (for 4 weeks) as well as at 0.7 and 1.5 mg/kg (for 6 weeks) significantly increased the HOMA IR level compared to the olive oil controls. However, vitamin A supplementation at 12 mg/ kg for 4 and 6 weeks decreased the HOMA IR level significantly compared to the olive oil control. On the contrary, the administration of different doses of vitamin A showed a significant decrease in HOMA β in a dose and timedependent manner than olive oil controls (Fig. 3).

The effect of different doses and time intervals of vitamin A palmitate on hepatic antioxidant parameters
TBARS level was significantly increased only after supplementation of the highest dose of vitamin A (12 mg/kg) for 2, 4, and 6 weeks compared to olive oil control (Fig. 4). In addition, there is no significant change in hepatic GST and SOD activities after the administration of either vitamin A or olive oil for 2, 4, or 6 weeks compared to olive oil or negative control (Fig. 4). Nevertheless, administration of 12 mg/kg of vitamin A for 4 and 6 weeks showed a significant decrease in SOD activity compared to olive oil control.

The effect of different doses and time intervals of vitamin A palmitate on serum ALT and AST activities
The serum ALT and AST activities were not significantly changed after administration of olive oil for 2, 4, and 6 weeks compared to the negative control. After 4 weeks of vitamin A administration, only 6 and 12 mg/kg significantly increased the serum ALT and AST activities compared to the olive oil control. After 6 weeks of vitamin A supplementation at 1.5, 3, 6, and 12 mg/kg, rats demonstrated a significant increase in ALT activity (Fig. 5). Furthermore, a significant increase in the AST activity was observed after 6 weeks of vitamin A supplementation at 3, 6, and 12 mg/ kg compared to the olive oil control (Fig. 5).

The effect of different doses and time intervals of vitamin A palmitate on hepatic Dio1 and Dio3 gene expression
Administration of olive oil for 2, 4, and 6 weeks showed a non-significant change in Dio1 and Dio3 expression levels compared to the negative control. Nonetheless, the supplementation of vitamin A for 2 and 4 weeks resulted in a significant increase in Dio1and Dio3 expression levels compared to the olive oil control. On the contrary, after 6 weeks, Dio1 and Dio3 expression levels were significantly increased at 0.7, 1.5, and 3 mg/kg supplemented rats, and a considerable decrease was observed at 6 and 12 mg/kg supplemented rats compared to the olive oil control (Fig. 6).

The effect of different doses and time intervals of vitamin A palmitate on hepatic RBP4 and PEPCK gene expression levels
The level of hepatic RBP4 and PEPCK gene expression did not significantly change after administration of olive oil for 2, 4, and 6 weeks compared to the negative control. After 2 weeks of vitamin A supplementation, only 6 and 12 mg/ kg demonstrated a significant increase in RBP4 and PEPCK gene expression levels compared to the olive oil control. After 4 and 6 weeks, a marked elevation in hepatic RBP4 and PEPCK gene expression levels was observed in 1.5, 3, 6, and 12 mg/kg treated rats compared to the olive oil control (Fig. 7).

The histopathological findings of liver tissue
Negative and olive oil control groups showed normal hepatocytes' architecture. Liver lobules have been proven to be composed of cords of hepatocytes separated by sinusoids.
On the contrary, 6 mg/kg retained normal architecture after 2 weeks of vitamin A supplementation. However, dilation of the central vein and portal vessels was detected.

Different doses and time intervals of vitamin A palmitate d)
Hepatocytes were eosinophilic with no degenerative changes. Furthermore, 12 mg/kg vitamin A supplementation showed focal micro-vesicular steatosis of hepatocytes (Fig. 8). After 4 weeks of vitamin A supplementation, 6 mg/kg vitamin A supplementation demonstrated diffuse microvesicular steatosis of hepatocytes, and 12 mg/kg vitamin A resulted in additional mild portal inflammation (Fig. 8).
After 6 weeks of supplementation, 0.7 mg/kg showed normal liver histology with no significant changes. 1.5 and 3 mg/kg supplemented rats showed moderately congested central vein, while mild portal inflammation was detected in 3.0 mg/kg treated rats (Fig. 8). In addition, the liver tissue started to show diffuse micro-vesicular steatosis in the hepatocytes at 6, and 12 mg/kg supplemented rats. In addition to moderate portal inflammation and focal lytic necrosis in 12 mg/kg supplemented rats (Fig. 8).

Discussion
It has been known that vitamin A deficiency affects thyroid hormones for many years, resulting in iodine deficiency disorders, while vitamin A supplementation alleviates the risk of subclinical hypothyroidism [23,24]. Recently, a study has been conducted to investigate the relationship between vitamin A and thyroid function in obese individuals. Vitamin A deficiency is more common in subjects with obesity and is significantly related to thyroid dysfunction. Adequate vitamin A levels improved thyroid function in obese subjects with subclinical hypothyroidism [25]. However, no study has focused on the association between vitamin A overload, thyroid dysfunction, and insulin resistance. Therefore, the current study aimed to investigate the Vitamin A supplementation at various doses (1.5-12 mg/ kg/day) has not affected the serum vitamin A level due to the storage of vitamin A in the liver [26]. In accordance, Cha, Yu [27] reported no significant change in the plasma retinol level after supplementation of 2.2, 4.4, and 11 mg/kg retinyl palmitate diet to rats for 4 weeks. The daily supplementation of high doses (6 and 12 mg/kg for 4 and 6 weeks) of vitamin A would be expected to fill up the liver store capacity and subsequently impact the liver function as indicated by the significant elevation of ALT and AST activities and the histopathological alterations that indicate micro-vesicular steatosis, moderate portal inflammation in addition to focal lytic necrosis in the hepatocytes. Tanumihardjo, Russell [28] reported the implications of vitamin A toxicity and deduced that daily supplementation of 7500 μg retinol equivalents for 6 years was associated with liver cirrhosis in humans. RBP4 was found to be not just a carrier protein. Nevertheless, it also regulates retinoids' metabolism, transport, and action [29]. The availability of vitamin A regulates the secretion of RBP4 from the liver, and it is reported to be inhibited during vitamin A deficiency. In contrast, high doses of vitamin A lead to a rapid secretion of RBP4 from the liver, increasing its plasma level [30], which explains the present findings, as serum RBP4 level was increased in a dose-dependent manner, especially in 1.5, 3, 6, and 12 mg/kg supplemented groups after 4 and 6 weeks of supplementation, and the RBP4 gene expression level confirmed these results.
Primary hypothyroidism is a common disorder characterized by a reduction in thyroid hormones production [31]. Our results revealed that vitamin A palmitate could lead to primary hypothyroidism with a significant reduction in T3 and T4 levels and a significant elevation in TSH levels. High doses of vitamin A can increase the membrane permeability, affect the biosynthesis of membrane compounds and alter the epithelial histological structure. These alterations elevated the distribution space of T3 and T4 and rapidly entered the cells, which explains the reduction of serum T3 and T4 levels [32]. Furthermore, Morley, Melmed [33] and Zimmermann, Wegmüller [23] reported that vitamin A could enhance the hepatic activation of T4 into T3 by increasing the activity of mono-deiodinases (Dio1 and Dio2) and finally decreasing the serum level of T4. The deiodinases-type 1 and 3 (Dio1 and Dio3) iodothyronine are kinetic enzymes that can activate or inactivate T4 on an equimolar basis [34,35]. Their function was inhibited through the decrease in T4 uptake or the reduction of T3 level [36]. It was reported that retinoids upregulate Dio1 and Dio3 levels through thyroid hormone receptor (THR) heterodimerized with retinoic acidand retinoid X-receptors [37,38]. The present study demonstrated an increase in Dio1 and Dio3 expression levels after supplementation of vitamin A palmitate for 2 and 4 weeks, resulting in the inactivation of T3 and preventing T4 activation, leading to hypothyroidism. However, after 6 weeks of vitamin A supplementation (12 mg/kg), Dio1 and Dio3 expression levels were started to decrease. It suggested that the lowest level of T3 observed after 6 weeks of supplementation leads to the inhibition of their expression.
Furthermore, the binding of T3 with THR acts as a ligand activating transcription factor that regulates TSH secretion and is involved in the negative feedback regulation of the hypothalamus-pituitary-thyroid axis. Therefore, T3-THR interaction inhibited the TSH expression and decreased serum TSH level [39]. Accordingly, in the current results, the suppressed T3 level could suppress T3-THR interaction and the activation of TSH production, leading to elevated levels of serum TSH.
Indeed, thyroid hormones were found to regulate hepatic glycogenolysis and gluconeogenesis as they upregulate the expression of phosphoglycerate kinase and GLUT4 genes involved in the glycolysis and glucose transport, respectively [40,41]. Disorders of carbohydrates metabolism are frequently reported in both hypothyroidism and hyperthyroidism [41]. Elevated fasting blood glucose, insulin, and HOMA IR were observed in subclinical hypothyroidism with elevated TSH levels [10]. A low level of intracellular T3 leads to increased TSH concentration and thus decreases GLUT4 transcription, in addition to disrupting its translocation in the plasma membrane, leading to carbohydrate metabolism disorders and elevated blood glucose levels [42]. Moreover, Yang et al. [16] reported that RBP4 could be considered an essential factor in diabetes pathogenesis. Elevated RBP4 levels impaired the glucose uptake through the downregulation of GLUT4 expression level and increased the production of glucose through stimulating the expression of the gluconeogenic enzyme (PEPCK) [15,18]. Consistent with the previous findings, the current results are consistent where prolonged supplementation of vitamin A resulted in elevated RBP4 protein and gene expression levels and primary hypothyroidism that resulted in elevated hepatic PEPCK gene expression and serum TSH level, respectively, in a dose and time-dependent manner. Elevated PEPCK and TSH levels enhance gluconeogenesis and inhibit cellular glucose uptake, resulting in elevated serum glucose levels. Furthermore, the supplementation of vitamin A caused variable changes (increasing or decreasing) in serum insulin level and HOMA IR index. Serum insulin level and HOMA IR index were markedly increased after administration of low doses of vitamin A (0.7 and 1.5 mg/kg) and decreased at high doses (6 and 12 mg/kg). The decrease in serum insulin levels at high doses might be due to the destruction of β-cells resulting in the deficiency of insulin production. These results were confirmed by the values of HOMA β that showed a significant decrease in the β-cell function. Therefore, the current results and multiple studies reported the positive influence of prolonged vitamin A supplementation on serum glucose and insulin levels and HOMA IR index [43,44] and the negative influence on HOMA β index [45,46]. These results confirmed the positive correlation between prolonged vitamin A supplementation and elevated RBP4 with hyperglycemia, insulin resistance, and T2DM.
Vitamin A is a well-known antioxidant fat-soluble vitamin. Several studies reported the antioxidant potential of vitamin A [47][48][49]. Low doses of vitamin A (7, 5, 15, or 60 μg of retinyl palmitate daily) can reduce oxidative stress in rats [48]. Moreover, several studies reported that vitamin A could work as either an antioxidant or prooxidant depending on its concentration [27,50,51]. Petiz, Girardi [51] illustrated that oral retinyl palmitate supplementation induces a prooxidant environment in several tissues, and despite its antioxidant status, vitamin A supplementation induces the release of stress markers, redox imbalance in serum, tissue damage, impaired antioxidant capacity, and inflammation. Therefore, high doses of vitamin A may cause several problems [52][53][54].
Moreover, RBP4 has a positive correlation with the induction of oxidative stress. The cross-talking between RBP4, oxidative stress, and inflammation were previously reported [26,[55][56][57]. In the present study, the supplementation of vitamin A at high doses showed an elevation in hepatic TBARS level and induced inflammation in liver tissues, indicating the prooxidant effect of vitamin A. The The histopathological findings of liver tissues after 2, 4, and 6 weeks of vitamin A palmitate supplementation. Negative control, Olive oil control, 0.7, 1.5, 3, 6, 12 mg/kg supplemented groups with different doses of vitamin A palmitate antioxidant enzymes, including GST activity, showed nonsignificant changes upon supplementation of different doses of vitamin A. However, SOD activity demonstrated a significant decrease after supplementation with a high dose of vitamin A (12 mg/kg) for 4 and 6 weeks. Our results align with Cha, Yu [27], who found that different doses of vitamin A (0, 2.2, 4.4, and 11 mg retinyl palmitate/kg) showed an insignificant effect on GST and SOD activities while significantly increasing hepatic TBARS level at high doses compared to the lower doses.
The thyroid gland and the liver share an essential and complex relationship between disease and health. It was confirmed that patients with liver cirrhosis showed increased thyroid volume by 17%, with low total and free T3 and high rT3. Moreover, acute hepatitis patients also showed elevated levels of T4 [58]. Furthermore, vitamin A can also affect liver function, as its metabolism takes place in the hepatocytes, and it can give rise to some polar metabolites that can lead to liver inflammation and induce liver cell necrosis [59]. Therefore, high doses of Vitamin A (6 and 12 mg/kg) after 4-and 6-weeks significantly elevated the liver enzymes (ALT & AST) and indicated the inflammatory process. Histopathological findings supported the present results, indicating micro-vesicular steatosis in the hepatocytes, moderate portal inflammation, and focal lytic necrosis in 12 mg/kg supplemented rats after 6 weeks due to the storage of vitamin A in the liver for a prolonged time. These findings also Fig. 9 The impact of Vitamin A administration on thyroid hormones, glucose metabolism, and the incidence of insulin resistance and T2DM confirm the thyroid results, which show the lowest values of T3 and T4 and the highest TSH levels.

Conclusion
Overall, supplementation of vitamin A palmitate for 2 weeks at low doses (0.7 mg/kg/day or less) maintained the redox balance and did not affect the thyroid function and carbohydrates metabolism. While long-term administration for 4 and 6 weeks, particularly at high doses (6 and 12 mg/kg/ day), resulted in primary hypothyroidism (reduced serum T3 and T4 levels and elevated serum TSH levels as well as altered Dio1 and Dio3 expression level). Subsequently, it resulted in changes in the glycemic biomarkers where it increased the gluconeogenic enzyme (PEPCK) gene expression level, increased the fasting glucose and insulin levels, which affect HOMA IR and HOMA β indexes. Furthermore, prolonged supplementation of vitamin A palmitate disrupted the redox balance (elevated TBARS level and reduced SOD activity). Finally, it resulted in hepatic inflammation and steatosis (increased ALT and AST activities as well as necrotic and leucocytic infiltrations with fatty changes) in a dose and time-dependent manner. Therefore, long-term supplementation of vitamin A is not recommended as it may induce hypothyroidism, insulin resistance and increase the incidence of T2DM (Fig. 9). However, studies concerning the detailed toxicity and pharmacokinetic profiles of Vitamin A are needed to investigate the biodistribution and accumulation of different forms of Vitamin A in different organs.
Funding Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

Conflict of interest The authors declare no conflict of interest.
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