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Wang Q, Zhao J, Chang H, Liu X, Zhu R. Homocysteine and Folic Acid: Risk Factors for Alzheimer's Disease-An Updated Meta-Analysis. Front Aging Neurosci 2021; 13:665114. [PMID: 34122042 PMCID: PMC8188894 DOI: 10.3389/fnagi.2021.665114] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/09/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Recent studies have reported that homocysteine (Hcy) may play a vital role in the pathogenesis of vascular dementia (VaD) and Alzheimer's disease (AD). Our study explored the relationship between the plasma Hcy and folate levels and the risk of dementia. Methods: We searched Embase, PubMed, and Web of Science for published literature, including case-control studies and prospective cohort studies, and performed a systematic analysis. Results: The results of our meta-analysis, consisting of case-control studies, showed higher levels of Hcy and lower levels of folate in dementia, AD, and VaD patients than those in non-demented controls (for dementia: SMD = 0.812, 95% CI [0.689, 0.936], p = 0.000 for Hcy; SMD = −0.677, 95% CI [−0.828, −0.525], p = 0.000 for folate). AD patients showed significantly lower plasma Hcy levels compared to VaD patients (SMD = −0.278, 95% CI [−0.466, −0.09], p = 0.000). Subgroup analysis revealed that ethnicity, average age, and dementia type had no significant effect on this association. Furthermore, from the analysis of prospective cohort studies, we identified that elevated plasma Hcy levels were associated with an increased risk of dementia, AD, and VaD (RRdementia = 1.22, 95% CI [1.08, 1.36]; RRAD = 1.07, 95% CI [1.04, 1.11]; RRVaD = 1.13, 95% CI [1.04, 1.23]). In addition, every 5 μmol/L increase in the plasma Hcy level was associated with a 9% increased risk of dementia and a 12% increased risk of AD. Conclusion: Hcy and folic acid are potential predictors of the occurrence and development of AD. A better understanding of their function in dementia could provide evidence for clinicians to rationalize clinical intervention strategies.
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Affiliation(s)
- Qianwen Wang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Jingjing Zhao
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hongtao Chang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xu Liu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ruixia Zhu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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Zhang X, Bao G, Liu D, Yang Y, Li X, Cai G, Liu Y, Wu Y. The Association Between Folate and Alzheimer's Disease: A Systematic Review and Meta-Analysis. Front Neurosci 2021; 15:661198. [PMID: 33935641 PMCID: PMC8079632 DOI: 10.3389/fnins.2021.661198] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/17/2021] [Indexed: 12/20/2022] Open
Abstract
Alzheimer's disease (AD) is the most common type of neurodegenerative disease leading to dementia in the elderly. Increasing evidence indicates that folate plays an important role in the pathogenesis of AD. To investigate the role of folate deficiency/possible deficiency in the risk of AD and the benefical effect of sufficient folate intake on the prevention of AD, a systematic review and meta-analysis were performed. The Web of Science, PubMed, CENTRAL, EBSCO, CNKI, CQVIP, and Wanfang databases were searched. The analysis of cross-sectional studies showed that the standardized mean difference (SMD) was −0.60 (95% confidence interval (CI): −0.65, −0.55), indicating that plasma/serum folate level is lower in AD patients than that in controls. Moreover, the combined odds ratio (OR) of case-control studies was 0.96 (95% CI: 0.93, 0.99), while the combined ORs were 0.86 (95% CI: 0.46, 1.26) and 1.94 (95% CI: 1.02, 2.86) in populations with normal levels of folate (≥13.5 nmol/L) and folate deficiency/possible deficiency (<13.5 nmol/L), respectively. In addition, the risk ratio (RR) of the cohort studies was 1.88 (95% CI: 1.20, 2.57) in populations with folate deficiency/possible deficiency. Furthermore, when the intake of folate was equal to or higher than the recommended daily allowance, the combined RR and hazard ratio (HR) were 0.44 (95% CI: 0.18, 0.71) and 0.76 (95% CI: 0.52, 0.99), respectively. These results indicate that folate deficiency/possible deficiency increases the risk for AD, while sufficient intake of folate is a protective factor against AD.
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Affiliation(s)
- Xiaohong Zhang
- College of Marine Life Sciences, Ocean University of China, Qingdao, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China.,Shandong Collaborative Innovation Center for Diagnosis, Treatment & Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China
| | - Guangyi Bao
- Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China.,Shandong Collaborative Innovation Center for Diagnosis, Treatment & Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China
| | - Debiao Liu
- Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China.,Shandong Collaborative Innovation Center for Diagnosis, Treatment & Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China
| | - Yu Yang
- Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China.,Shandong Collaborative Innovation Center for Diagnosis, Treatment & Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China.,Center of Evidence-Based Medicine, Jining Medical University, Jining, China
| | - Xuezhi Li
- Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China.,Shandong Collaborative Innovation Center for Diagnosis, Treatment & Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China.,Center of Evidence-Based Medicine, Jining Medical University, Jining, China
| | - Gaomei Cai
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, China
| | - Yan Liu
- Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China.,Shandong Collaborative Innovation Center for Diagnosis, Treatment & Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China.,Center of Evidence-Based Medicine, Jining Medical University, Jining, China
| | - Yili Wu
- Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China.,Shandong Collaborative Innovation Center for Diagnosis, Treatment & Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China.,Center of Evidence-Based Medicine, Jining Medical University, Jining, China
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3
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Shen L, Ji HF. Associations between Homocysteine, Folic Acid, Vitamin B12 and Alzheimer's Disease: Insights from Meta-Analyses. J Alzheimers Dis 2016; 46:777-90. [PMID: 25854931 DOI: 10.3233/jad-150140] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The associations between homocysteine (Hcy), folic acid, and vitamin B12 and Alzheimer's disease (AD) have gained much interest, while remaining controversial. We aim to perform meta-analyses to evaluate comprehensively: i) Hcy, folic acid, and vitamin B12 levels in AD patients in comparison with controls; and ii) the association between Hcy, folic acid, and vitamin B12 levels and risk of AD. A literature search was performed using Medline and Scopus databases. A total of 68 studies were identified and included in the meta-analyses. Stata 12.0 statistical software was used to perform the meta-analyses. First, AD patients may have higher level of Hcy, and lower levels of folate and vitamin B12 in plasma than controls. Further age-subgroup analysis showed no age effect for Hcy levels in plasma between AD patients and matched controls, while the differences in folate and vitamin B12 levels further enlarged with increased age. Second, data suggests that high Hcy and low folate levels may correlate with increased risk of AD occurrence. The comprehensive meta-analyses not only confirmed higher Hcy, lower folic acid, and vitamin B12 levels in AD patients than controls, but also implicated that high Hcy and low folic acid levels may be risk factors of AD. Further studies are encouraged to elucidate mechanisms linking these conditions.
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Williams SR, Yang Q, Chen F, Liu X, Keene KL, Jacques P, Chen WM, Weinstein G, Hsu FC, Beiser A, Wang L, Bookman E, Doheny KF, Wolf PA, Zilka M, Selhub J, Nelson S, Gogarten SM, Worrall BB, Seshadri S, Sale MM. Genome-wide meta-analysis of homocysteine and methionine metabolism identifies five one carbon metabolism loci and a novel association of ALDH1L1 with ischemic stroke. PLoS Genet 2014; 10:e1004214. [PMID: 24651765 PMCID: PMC3961178 DOI: 10.1371/journal.pgen.1004214] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 01/14/2014] [Indexed: 12/31/2022] Open
Abstract
Circulating homocysteine levels (tHcy), a product of the folate one carbon metabolism pathway (FOCM) through the demethylation of methionine, are heritable and are associated with an increased risk of common diseases such as stroke, cardiovascular disease (CVD), cancer and dementia. The FOCM is the sole source of de novo methyl group synthesis, impacting many biological and epigenetic pathways. However, the genetic determinants of elevated tHcy (hyperhomocysteinemia), dysregulation of methionine metabolism and the underlying biological processes remain unclear. We conducted independent genome-wide association studies and a meta-analysis of methionine metabolism, characterized by post-methionine load test tHcy, in 2,710 participants from the Framingham Heart Study (FHS) and 2,100 participants from the Vitamin Intervention for Stroke Prevention (VISP) clinical trial, and then examined the association of the identified loci with incident stroke in FHS. Five genes in the FOCM pathway (GNMT [p = 1.60 × 10(-63)], CBS [p = 3.15 × 10(-26)], CPS1 [p = 9.10 × 10(-13)], ALDH1L1 [p = 7.3 × 10(-13)] and PSPH [p = 1.17 × 10(-16)]) were strongly associated with the difference between pre- and post-methionine load test tHcy levels (ΔPOST). Of these, one variant in the ALDH1L1 locus, rs2364368, was associated with incident ischemic stroke. Promoter analyses reveal genetic and epigenetic differences that may explain a direct effect on GNMT transcription and a downstream affect on methionine metabolism. Additionally, a genetic-score consisting of the five significant loci explains 13% of the variance of ΔPOST in FHS and 6% of the variance in VISP. Association between variants in FOCM genes with ΔPOST suggest novel mechanisms that lead to differences in methionine metabolism, and possibly the epigenome, impacting disease risk. These data emphasize the importance of a concerted effort to understand regulators of one carbon metabolism as potential therapeutic targets.
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Affiliation(s)
- Stephen R. Williams
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, United States of America
- Cardiovascular Research Center, University of Virginia, Charlottesville, Virginia, United States of America
| | - Qiong Yang
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- The Framingham Heart Study, Framingham, Massachusetts, United States of America
| | - Fang Chen
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, United States of America
| | - Xuan Liu
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Keith L. Keene
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Biology, East Carolina University, Greenville, North Carolina, United States of America
- Center for Health Disparities Research, East Carolina University, Greenville, North Carolina, United States of America
| | - Paul Jacques
- Jean Mayer USDA Human Nutrition Research Center on Aging and Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America
| | - Wei-Min Chen
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, United States of America
| | - Galit Weinstein
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Fang-Chi Hsu
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Alexa Beiser
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
| | - Ebony Bookman
- National Human Genome Research Institute, Bethesda, Maryland, United States of America
| | - Kimberly F. Doheny
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Philip A. Wolf
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Michelle Zilka
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Jacob Selhub
- Jean Mayer USDA Human Nutrition Research Center on Aging and Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America
| | - Sarah Nelson
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Stephanie M. Gogarten
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Bradford B. Worrall
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurology University of Virginia, Charlottesville, Virginia, United States of America
| | - Sudha Seshadri
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Michèle M. Sale
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Biochemistry and Molecular Genetics, University of Virginia, Charlottesville, Virginia, United States of America
- * E-mail:
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Maldonado-Hernández J, Prina-Ojeda LV, Montalvo-Velarde I, Del Prado-Manríquez M, de Lourdes Barbosa-Cortés M, Repetto-Madrid M. Validity and reliability of the 13C-methionine breath test for the detection of moderate hyperhomocysteinemia in Mexican adults. Clin Chem Lab Med 2014; 52:687-92. [PMID: 24607920 DOI: 10.1515/cclm-2013-0834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/24/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hyperhomocysteinemia (Hhcy) is considered an independent risk factor for vascular diseases and, more recently, for dementia. The methionine loading test (MLT) is useful for diagnosing additional subjects with moderate Hhcy. However, it is a complex and time-consuming procedure. A noninvasive test for the diagnosis of moderate Hhcy is desirable. METHODS The study protocol consisted of three consecutive visits. During the first visit, we performed an MLT to characterize the Hhcy status of 75 healthy adult subjects. For the breath test protocol, we selected a subsample and assigned to the control group 17 subjects with fasting and post-loading homocysteine (Hcy) ≤12 and <42.3 μmol/L, respectively, and to the Hhcy group 16 subjects with fasting Hcy ≤12 and >42.3 μmol/L after loading. Selected subjects were requested to have a second visit to perform a breath test within 1-4 weeks following the MLT test and received an oral dose of 2.5 mg/kg of 1-13C-methionine dissolved in water. Breath samples were collected at basal, 20, 40, 60, 80, 100 and 120 min (test 1). The same procedure was repeated within 1 week (test 2). RESULTS MLT was useful for diagnosing almost twice the number of individuals with Hhcy (24%) in comparison with the fasting determination alone (13.3%). The 13C-methionine breath test reported a sensitivity of 81.3% and a specificity of 64.7% against the MLT. The coefficient of variation between breath test 1 and breath test 2 was 9.0±5.4%. CONCLUSIONS The 13C-methionine breath test is a valid and reliable method for identifying subjects with moderate Hhcy.
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6
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The control of hyperhomocysteinemia through thiol exchange mechanisms by mesna. Amino Acids 2013; 46:429-39. [DOI: 10.1007/s00726-013-1636-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
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7
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Lopes da Silva S, Vellas B, Elemans S, Luchsinger J, Kamphuis P, Yaffe K, Sijben J, Groenendijk M, Stijnen T. Plasma nutrient status of patients with Alzheimer's disease: Systematic review and meta-analysis. Alzheimers Dement 2013; 10:485-502. [PMID: 24144963 DOI: 10.1016/j.jalz.2013.05.1771] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 05/02/2013] [Accepted: 05/21/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Alzheimer disease (AD) patients are at risk of nutritional insufficiencies because of physiological and psychological factors. Nutritional compounds are postulated to play a role in the pathophysiological processes that are affected in AD. We here provide the first systematic review and meta-analysis that compares plasma levels of micronutrients and fatty acids in AD patients to those in cognitively intact elderly controls. A secondary objective was to explore the presence of different plasma nutrient levels between AD and control populations that did not differ in measures of protein/energy nourishment. METHODS We screened literature published after 1990 in the Cochrane Central Register of Controlled Trials, Medline, and Embase electronic databases using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for AD patients, controls, micronutrient, vitamins, and fatty acids, resulting in 3397 publications, of which 80 met all inclusion criteria. Status of protein/energy malnutrition was assessed by body mass index, mini nutritional assessment score, or plasma albumin. Meta-analysis, with correction for differences in mean age between AD patients and controls, was performed when more than five publications were retrieved for a specific nutrient. RESULTS We identified five or more studies for folate, vitamin A, vitamin B12, vitamin C, vitamin D, vitamin E, copper, iron, and zinc but fewer than five studies for vitamins B1 and B6, long-chain omega-3 fatty acids, calcium, magnesium, manganese, and selenium (the results of the individual publications are discussed). Meta-analysis showed significantly lower plasma levels of folate and vitamin A, vitamin B12, vitamin C, and vitamin E (P < .001), whereas nonsignificantly lower levels of zinc (P = .050) and vitamin D (P = .075) were found in AD patients. No significant differences were observed for plasma levels of copper and iron. A meta-analysis that was limited to studies reporting no differences in protein/energy malnourishment between AD and control populations yielded similar significantly lower plasma levels of folate and vitamin B12, vitamin C, and vitamin E in AD. CONCLUSIONS The lower plasma nutrient levels indicate that patients with AD have impaired systemic availability of several nutrients. This difference appears to be unrelated to the classic malnourishment that is well known to be common in AD, suggesting that compromised micronutrient status may precede protein and energy malnutrition. Contributing factors might be AD-related alterations in feeding behavior and intake, nutrient absorption, alterations in metabolism, and increased utilization of nutrients for AD pathology-related processes. Given the potential role of nutrients in the pathophysiological processes of AD, the utility of nutrition may currently be underappreciated and offer potential in AD management.
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Affiliation(s)
- Sofia Lopes da Silva
- Nutricia Advanced Medical Nutrition, Nutricia Research, Utrecht, The Netherlands; Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Bruno Vellas
- Gerontopole and UMR INSERM 1027 University Paul Sabatier, Toulouse University Hospital, Toulouse, France
| | - Saskia Elemans
- Nutricia Advanced Medical Nutrition, Nutricia Research, Utrecht, The Netherlands
| | - José Luchsinger
- Department of Medicine, Columbia University, New York, NY, USA
| | - Patrick Kamphuis
- Nutricia Advanced Medical Nutrition, Nutricia Research, Utrecht, The Netherlands; Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Kristine Yaffe
- Department of Psychiatry, Neurology, and Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA, USA
| | - John Sijben
- Nutricia Advanced Medical Nutrition, Nutricia Research, Utrecht, The Netherlands.
| | - Martine Groenendijk
- Nutricia Advanced Medical Nutrition, Nutricia Research, Utrecht, The Netherlands
| | - Theo Stijnen
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
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Coppedè F. One-carbon metabolism and Alzheimer's disease: focus on epigenetics. Curr Genomics 2011; 11:246-60. [PMID: 21119889 PMCID: PMC2930664 DOI: 10.2174/138920210791233090] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 03/04/2010] [Accepted: 03/12/2010] [Indexed: 12/31/2022] Open
Abstract
Alzheimer’s disease (AD) represents the most common form of dementia in the elderly, characterized by progressive loss of memory and cognitive capacity severe enough to interfere with daily functioning and the quality of life. Rare, fully penetrant mutations in three genes (APP, PSEN1 and PSEN2) are responsible for familial forms of the disease. However, more than 90% of AD is sporadic, likely resulting from complex interactions between genetic and environmental factors. Increasing evidence supports a role for epigenetic modifications in AD pathogenesis. Folate metabolism, also known as one-carbon metabolism, is required for the production of S-adenosylmethionine (SAM), which is the major DNA methylating agent. AD individuals are characterized by decreased plasma folate values, as well as increased plasma homocysteine (Hcy) levels, and there is indication of impaired SAM levels in AD brains. Polymorphisms of genes participating in one-carbon metabolism have been associated with AD risk and/or with increased Hcy levels in AD individuals. Studies in rodents suggest that early life exposure to neurotoxicants or dietary restriction of folate and other B vitamins result in epigenetic modifications of AD related genes in the animal brains. Similarly, studies performed on human neuronal cell cultures revealed that folate and other B vitamins deprivation from the media resulted in epigenetic modification of the PSEN1 gene. There is also evidence of epigenetic modifications in the DNA extracted from blood and brains of AD subjects. Here I review one-carbon metabolism in AD, with emphasis on possible epigenetic consequences.
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Affiliation(s)
- Fabio Coppedè
- Department of Neuroscience, University of Pisa, Via Roma 67, 56126 Pisa, Italy
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