Elevated homocysteine as a risk factor for the development of diabetes in women with a previous history of gestational diabetes mellitus: a 4-year prospective study

The Influence of Maternal Folate Status on Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

Maternal folate has been shown to relate to the risk of gestational diabetes mellitus (GDM). However, the existing studies have yielded inconsistent conclusions. The purpose of this study was to systematically review the association between maternal folate status and the risk of GDM. Observational studies up to 31 October 2022 were included. Study characteristics, the means and standard deviations (SDs) of folate levels (serum/red blood cell (RBC)), the odds ratios (ORs) with 95% confidence intervals (CIs) and the time for folate measurement were extracted. Compared with the non-GDM group, serum and RBC folate levels in women with GDM were significantly higher. Our subgroup analysis demonstrated that serum folate levels in the GDM group were significantly higher than in the non-GDM group only in the second trimester. RBC folate levels in the GDM group were significantly higher than in the non-GDM group in the first and second trimesters. Taking serum/RBC folate levels as continuous variables, the adjusted odds ratios of GDM risk showed that increased serum folate concentration rather than RBC folate elevated the risk of GDM. In the descriptive analysis, five studies reported high serum folate levels increased GDM risk, whereas the other five showed no association between serum folate levels and GDM risk. Moreover, the rest three studies pointed out high RBC folate levels increased GDM risk. Altogether we found that the risk of GDM is associated with high serum/plasma and RBC folate levels. Future studies should determine the recommended folic acid cutoff balancing the risk for GDM and fetal malformations.

Plasma metal concentrations and their interactions with genetic susceptibility on homocysteine levels

Limited studies have evaluated the associations of multiple metal exposures with homocysteine (Hcy) levels, which were independent risk factor for cardiovascular disease (CVD). Furthermore, the interactions between genetic variants and plasma metals in relation to Hcy levels were largely unknown. We aimed to explore the associations of multiple plasma metals (including metalloids arsenic [As] and selenium [Se]) with Hcy levels and whether their associations were modified by genetic susceptibility. We included 2989 participants from the baseline of the Dongfeng-Tongji cohort (DFTJ cohort) and conducted a cross-sectional study to explore the associations of 17 plasma metals with serum Hcy levels. Both multi-variable linear regression model (single-metal model) and LASSO penalized regression model (multiple-metal model) were used to identify the Hcy-associated metals. The weighted genetic risk score (GRS) was calculated based on 18 established Hcy-associated genetic variants. For metals that were associated with Hcy, we further assessed the gene-metal interactions on Hcy levels. Among 17 metals, plasma molybdenum (Mo), strontium (Sr), and Zinc (Zn) were positively associated with Hcy levels, whereas Se was inversely associated with Hcy levels in both single- and multiple-metal models. We also observed that the genetic predisposition to Hcy significantly modified the association between plasma Se and serum Hcy levels (P for interaction = 0.003), while no significant gene-metal interactions were found for Mo, Sr, and Zn (all P for interactions > 0.05). These findings provide novel insight into the associations of the plasma concentrations of Mo, Se, Sr and Zn with Hcy levels and address the importance of Se as a potential upstream modifiable factor for the personalized prevention of elevated Hcy levels and CVD.

The Relationship Between Folate, Vitamin B12 and Gestational Diabetes Mellitus With Proposed Mechanisms and Foetal Implications

The incidence of gestational diabetes mellitus (GDM) is rising, which warrants attention due to the associated complications during pregnancy and in the long term for both mother and offspring. Studies have suggested a relationship between maternal folate (vitamin B9) and vitamin B12 status and GDM risk. Seemingly the most problematic scenario occurs when there is B-vitamin imbalance, with high folate and low vitamin B12. This nutritional state can occur in vitamin B12 deficient women who exceed the recommended folic acid supplementation. However, the pathological mechanisms behind this relationship are currently unclear and are explored in this review article. A high folate/low B12 can lead to a functional folate deficiency through the methyl-trap phenomenon, impairing re-methylation of homocysteine and regeneration of folates for DNA synthesis and repair. Consequently elevated homocysteine concentration leads to endothelial dysfunction and oxidative stress. Vitamin B12 deficiency also leads to an impairment of the conversion of methylmalonyl-CoA to succinyl-CoA, which has been associated with insulin resistance. Insulin resistance is thought to contribute to the etiology of GDM. More studies are needed to confirm the impact of these and other mechanisms on disease development. However, it highlights a potential avenue for GDM risk modification through a vitamin B12 supplement and improvement of maternal metabolic health.

Folic Acid Supplementation Improves Glycemic Control for Diabetes Prevention and Management: A Systematic Review and Dose-Response Meta-Analysis of Randomized Controlled Trials

Background: There is a growing interest in the considerable benefits of dietary supplementations, such as folic acid, on the glycemic profile. We aimed to investigate the effects of folic acid supplementation on glycemic control markers in adults. Methods: Randomized controlled trials examining the effects of folic acid supplementation on glycemic control markers published up to March 2021 were detected by searching online databases, including Scopus, PubMed, Embase, and ISI web of science, using a combination of related keywords. Mean change and standard deviation (SD) of the outcome measures were used to estimate the mean difference between the intervention and control groups at follow-up. Meta-regression and non-linear dose-response analysis were conducted to evaluate the association between pooled effect size and folic acid dosage (mg/day) and duration of the intervention (week). From 1814 detected studies, twenty-four studies reported fasting blood glucose (FBG), fasting insulin, hemoglobin A1C (HbA1C), and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) as an outcome measure. Results: Results revealed significant reductions in FBG (weighted mean difference (WMD): −2.17 mg/dL, 95% CI: −3.69, −0.65, p = 0.005), fasting insulin (WMD: −1.63 pmol/L, 95% CI: −2.53, −0.73, p < 0.001), and HOMA-IR (WMD: −0.40, 95% CI: −0.70, −0.09, p = 0.011) following folic acid supplementation. No significant effect was detected for HbA1C (WMD: −0.27%, 95% CI: −0.73, 0.18, p = 0.246). The dose-response analysis showed that folic acid supplementation significantly changed HOMA-IR (r = −1.30, p-nonlinearity = 0.045) in non-linear fashion. However, meta-regression analysis did not indicate a linear relationship between dose, duration, and absolute changes in FBG, HOMA-IR, and fasting insulin concentrations. Conclusions: Folic acid supplementation significantly reduces some markers of glycemic control in adults. These reductions were small, which may limit clinical applications for adults with type II diabetes. Further research is necessary to confirm our findings.

Type 2 diabetes and the risk of colorectal polyps: A retrospective nationwide population-based study

The incidence rates of type 2 diabetes mellitus (T2DM) and colorectal polyps have been increasing over the last decades. However, direct associations between T2DM and colorectal polyps have not been extensively reported. We will explore the relationship between T2DM and colorectal polyps.In the retrospective study, we classified DM and NonDM groups (control) from 993,516 people in Taiwan nationwide population insurance database from the period of 2000 to 2013. We collected data on income and comorbidities through the international classification of diseases, ninth revision-clinical modification (ICD-9-CM) codes.The T2DM group had a higher incidence rate of colorectal polyps (31.97%, 95% confidence interval [CI] = 30.97-33.28) than the control group (25.9%, 95% CI = 25.1-26.72), and the crude incidence ratio was 1.235 (95% CI = 1.174-1.300). In 13 years of follow-up (2000-2013), T2DM was linked to a significantly higher cumulative probability of colorectal polyps (log-rank test: P = .0001).Patients with T2DM had a 1.23-fold higher risk of new colorectal polyps than control patients in 13 years of follow-up. We explain the T2DM increases incidence for colorectal polyps in long term follow-up.

Association between maternal folate status and gestational diabetes mellitus

Studies on the association between maternal folate status and gestational diabetes mellitus (GDM) have yielded inconsistent results. This meta-analysis was performed to determine whether there may exist some association between maternal folate status and GDM. Unrestricted searches of PubMed, Web of Science, Cochrane, and Embase were conducted. All relevant studies on the association between maternal folat status and GDM risk were screened. The standardized mean difference (SMD) with 95% CIs was used to determine the association between maternal folate and GDM. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models to assess the impact of maternal folate status on GDM risk. 12 studies were included. The overall data revealed that compared with the non-GDM group, women with GDM had higher level of folate (SMD 0.41, 95% CI 0.07 to 0.21, I2  = 17.2%) in second or third trimester. We also found that maternal high folate status may be associated with increased risk of GDM (OR 2.16, 95% CI 1.70 to 2.74, I2  = 0.0%). Compared with non-GDM group, women with GDM are prone to higher folate level. Moreover, high maternal folate status may predict a higher risk of GDM. As the number of included studies was limited, further large population studies are needed in the future.

Risk Factors for Progression From Gestational Diabetes to Postpartum Type 2 Diabetes: A Review

Gestational diabetes mellitus (GDM) complicates 6% to 8% of pregnancies and up to 50% of women with GDM progress to type 2 diabetes mellitus (DM) within 5 years postpartum. Clinicians have little guidance on which women are most at risk for DM progression or when evidence-based prevention strategies should be implemented in a woman's lifecycle. To help address this gap, the authors review identifiable determinants of progression from GDM to DM across the perinatal period, considering prepregnancy, pregnancy, and postpartum periods. The authors categorize evidence by pathways of risk including genetic, metabolic, and behavioral factors that influence progression to DM among women with GDM.

Homocysteine and diabetes: Role in macrovascular and microvascular complications

Diabetes mellitus (DM) can lead to the development of macro- and microvascular complications. Homocysteine (Hcy) may play a role in the development of cardiovascular (CV) diseases (CVDs). The role of Hcy in the development of the vascular complications associated with DM is not clearly defined. Despite a strong initial assumption regarding the importance of Hcy in DM and its complications, over time "enthusiasm has waned" because several studies showed unconvincing and occasionally contradictory results. A universal conclusion is not easy to draw given the diversity of studies (e.g. number of patients, design, folic acid and vitamin B status, ethnic differences, genetic background). For some complications, most results encourages further investigation. Impaired renal function is a major independent determinant of high total Hcy (tHcy) levels. However, the role of hyperhomocysteinaemia (HHcy) in the development of diabetic kidney disease (DKD) has yet to be determined. Hcy-lowering therapies can significantly decrease Hcy levels but their effects on CVD risk reduction are conflicting. Further studies are needed to determine the influence of Hcy-lowering therapy on CVD risk reduction, especially in patients with DM.

Cystathionine γ-lyase promotes estrogen-stimulated uterine artery blood flow via glutathione homeostasis

During pregnancy, estrogen (E₂) stimulates uterine artery blood flow (UBF) by enhancing nitric oxide (NO)-dependent vasodilation. Cystathionine γ-lyase (CSE) promotes vascular NO signaling by producing hydrogen sulfide (H₂S) and by maintaining the ratio of reduced-to-oxidized intracellular glutathione (GSH/GSSG) through l-cysteine production. Because redox homeostasis can influence NO signaling, we hypothesized that CSE mediates E₂ stimulation of UBF by modulating local intracellular cysteine metabolism and GSH/GSSG levels to promote redox homeostasis. Using non-pregnant ovariectomized WT and CSE-null (CSE KO) mice, we performed micro-ultrasound of mouse uterine and renal arteries to assess changes in blood flow upon exogenous E₂ stimulation. We quantified serum and uterine artery NO metabolites (NO_x), serum amino acids, and uterine and renal artery GSH/GSSG. WT and CSE KO mice exhibited similar baseline uterine and renal blood flow. Unlike WT, CSE KO mice did not exhibit expected E₂ stimulation of UBF. Renal blood flow was E₂-insensitive for both genotypes. While serum and uterine artery NO_x were similar between genotypes at baseline, E₂ decreased NO_x in CSE KO serum. Cysteine was also lower in CSE KO serum, while citrulline and homocysteine levels were elevated. E₂ and CSE deletion additively decreased GSH/GSSG in uterine arteries. In contrast, renal artery GSH/GSSG was insensitive to E₂ or CSE deletion. Together, these findings suggest that CSE maintenance of uterine artery GSH/GSSG facilitates nitrergic signaling in uterine arteries and is required for normal E₂ stimulation of UBF. These data have implications for pregnancy pathophysiology and the selective hormone responses of specific vascular beds.

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CSE-null mice exhibit abnormal estrogen augmentation of uterine artery blood flow.

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Estrogen lowers uterine artery nitric oxide metabolites in CSE null mice.

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CSE loss and estrogen additively impair uterine artery glutathione homeostasis.

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Neither CSE loss nor estrogen influences renal artery blood flow or glutathione.

Effect of folate supplementation on insulin sensitivity and type 2 diabetes: a meta-analysis of randomized controlled trials

Background

Various mechanisms link higher total homocysteine to higher insulin resistance (IR) and risk of type 2 diabetes (T2D). Folate supplementation is recognized as a way to lower homocysteine. However, randomized controlled trials (RCTs) show inconsistent results on IR and T2D outcomes.

Objective

The aim of this study was to examine the effect of folate supplementation on IR and T2D outcomes.

Design

We conducted a systematic literature search in PubMed, Web of Science, and EMBASE and prior systematic reviews and meta-analyses and identified 29 RCTs (22,250 participants) that assessed the effect of placebo-controlled folate supplementation alone or in combination with other B vitamins on fasting glucose, insulin, homeostasis model assessment for insulin resistance (HOMA-IR), glycated hemoglobin (HbA1c), or risk of T2D. The meta-analysis was conducted using both random- and fixed-effects models to calculate weighted mean differences (WMDs) or risk ratios with 95% CIs. Subgroup analyses were conducted based on intervention type (folate alone or in combination with other B vitamins), as well as analysis based on population characteristics, duration, dose, and change in homocysteine.

Results

When compared with placebo, folate supplementation lowered fasting insulin (WMD: -13.47 pmol/L; 95% CI: -21.41, -5.53 pmol/L; P < 0.001) and HOMA-IR (WMD: -0.57 units; 95% CI: -0.76, -0.37 units; P < 0.0001), but no overall effects were observed for fasting glucose or HbA1c. Heterogeneity was low in all meta-analyses, and subgroup analysis showed no signs of effect modification except for change in homocysteine, with the most pronounced effects in trials with a change of >2.5 µmol/L. Changes in homocysteine after folate supplementation correlated with changes in fasting glucose (β = 0.07; 95% CI: 0.01, 0.14; P = 0.025) and HbA1c (β = 0.46; 95% CI: 0.06, 0.85; P = 0.02). Only 2 studies examined folate supplementation on risk of T2D, and they found no change in RR (pooled RR: 0.91; 95% CI: 0.80, 1.04; P = 0.16).

Conclusion

Folate supplementation might be beneficial for glucose homeostasis and lowering IR, but at present there are insufficient data to conclusively determine the effect on development of T2D. This trial was registered on the Prospero database as CRD42016048254.

Mothers with HIP - The short term and long-term impact, what is new?

Hyperglycemia is one of the most common medical conditions that women encounter during pregnancy and it is due to gestational diabetes (GDM) in the majority of cases (International Diabetes Federation, 2015) [1]. GDM is associated with a higher incidence of maternal morbidity in pregnancy in term of hypertensive disorders/preclampsia and higher rate of cesarean delivery but also with long-term risk of type 2 diabetes and cardiovascular disease. Pregnancy can therefore be considered a stress test; diagnosis of HIP can unmask a preexisting susceptibility and consequently a future risk for type 2 diabetes and can be a useful marker of future cardiovascular risk. Postpartum follow up provides an excellent opportunity to implement healthy lifestyle behaviors to prevent or delay the development of diabetes or cardiovascular disease. The aim of the current review is to focus on short and long term maternal morbidity of HIP.

Reduced plasma level of irisin in first trimester as a risk factor for the development of gestational diabetes mellitus

BACKGROUND

The aim of this prospective cohort study was to investigate the association of first trimester irisin concentrations and the subsequent development of gestational diabetes mellitus (GDM).

METHODS

This cohort study was conducted at three maternity centers in China from July 2015 to June 2016. Data for fasting plasma glucose (FPG) and irisin concentrations in the first trimester and one-step GDM screening with 75-g oral glucose tolerance test (OGTT) performed between 24 and 28 weeks of gestation were collected and analyzed.

RESULTS

Plasma from women was available for 1150 women, of whom 135 (11.7%) developed GDM. The median value of irisin in those included women was 141.2 (IQR, 99.4-192.9) ng/ml. In multivariate models comparing the first (Q1), second (Q2) and third (Q3) quartiles against the fourth (Q4) quartile of irisin, levels of irisin in Q1 and Q2 were associated with GDM, and increased risk of GDM by 440% (odds ratios [OR] = 5.40; 95% confidence intervals [CI]: 2.35-11.40) and 283% (OR: 3.83; 95%CI: 1.63-8.01). A model containing known risk factors plus irisin compared with a model containing known risk factors without irisin showed a greater discriminatory ability to predict GDM, the area under the curve (AUC) increased from 0.776 to 0.809. A significant difference in the AUC between the clinical variables alone and the addition of irisin level was observed (difference, 0.034; P = 0.03).

CONCLUSIONS

Reduced plasma levels of irisin in first trimester was associated with the increased risk of GDM and might be useful in identifying women at risk for GDM for early prevention strategies.

Plasma trimethylamine-N-oxide and related metabolites are associated with type 2 diabetes risk in the Prevención con Dieta Mediterránea (PREDIMED) trial

Background

The role of trimethylamine-N-oxide (TMAO) in type 2 diabetes (T2D) is currently partially understood and controversial.

Objective

The aim of this study was to investigate associations between TMAO and related metabolites with T2D risk in subjects at high risk of cardiovascular disease.

Design

This is a case-cohort design study within the Prevención con Dieta Mediterránea (PREDIMED) study, with 251 incident T2D cases and a random sample of 694 participants (641 noncases and 53 overlapping cases) without T2D at baseline (median follow-up: 3.8 y). We used liquid chromatography-tandem mass spectrometry to measure plasma TMAO, l-carnitine, betaine, lyso-phosphatidylcholine (LPC) and lyso-phosphatidylethanolamine (LPE) species, phosphocholine, α-glycerophosphocholine, and choline at baseline and after 1 y. We examined associations with the use of weighted Cox proportional hazard models, accounting for the weighted case-cohort design by the Barlow method.

Results

After adjustment for recognized T2D risk factors and multiple testing, individuals in the highest quartile of baseline TMAO and α-glycerophosphocholine had a lower risk of T2D [HR (95% CI): 0.52 (0.29, 0.89) and 0.46 (0.24, 0.89), respectively]. The HR (95% CI) comparing the extreme quartiles of betaine was 0.41 (0.23, 0.74). Similar trends were observed for C16:0 LPC, C18:1 LPC, C18:0 LPC, C20:4 LPC, C22:6 LPC, C18:1 LPC plasmalogen, and C16:0 LPE. After correcting for multiple comparisons, participants in the highest quartile of 1-y changes in oleic acid LPC plasmalogen concentrations had a lower T2D risk than the reference quartile.

Conclusion

Whether the associations between plasma TMAO and certain metabolite concentrations with T2D risk reflect its pathophysiology or represent an epiphenomenon needs to be elucidated. This trial is registered at http://www.controlled-trials.com as ISRCTN35739639.

Hyperhomocysteinemia as a Metabolic Risk Factor for Glucose Intolerance Among High-Risk Groups of Chinese Adults

BACKGROUND Impaired glucose tolerance (IGT) is characterized by insulin resistance and causes atherosclerosis. Hyperhomocysteinemia is associated with insulin resistance and predicts cardiovascular diseases. In this study, we assessed the possible association between homocysteine and IGT. MATERIAL AND METHODS This was a cross-sectional study of 118 consecutive subjects with IGT (IGT group) and 128 consecutive subjects with normal glucose tolerance (NGT group). Homocysteine and clinical characteristics were measured. RESULTS The IGT group had higher homocysteine than the NGT group [18.00 (14.00, 22.25) vs. 12.50 (9.00, 15.00) μmol/L, p<0.001]. Homocysteine was positively associated with body mass index (BMI) (r=0.178, p=0.005), triglycerides (r=0.306, p<0.001), fasting blood glucose (FBG) (r=0.312, p<0.001), 2-hour postchallenge glucose (2hPG) (r=0.363, p<0.001), fasting insulin (FINS) (r=0.655, p<0.001), and homeostasis model assessment for insulin resistance (HOMA-IR) (r=0.643, p<0.001), and was negatively correlated with high-density lipoprotein cholesterol (HDL-C) (r=-0.250, p<0.001). After controlling for confounders, hyperinsulinemia (β=7.430, p<0.001) was independently related to hyperhomocysteinemia. In a logistic regression analysis, high triglycerides (OR=1.177, p<0.001) and homocysteine (OR=1.508, p=0.007), and low HDL-C (OR=0.315, p=0.026) were associated with IGT. CONCLUSIONS Patients with IGT have higher homocysteine levels compared with subjects with normal glucose tolerance, and hyperhomocysteinemia might be correlated with IGT.

High folate and low vitamin B12 status during pregnancy is associated with gestational diabetes mellitus

BACKGROUND & AIMS

B-vitamins and homocysteine may contribute to the development of gestational diabetes mellitus (GDM), but existing studies are inconsistent. We examined the cross-sectional associations of plasma folate, vitamins B6, B12, and homocysteine concentrations with GDM and glycemia in a sample of multi-ethnic Asian pregnant women.

METHODS

Plasma concentrations of folate, vitamins B6, B12, homocysteine and glucose were measured at 26-weeks' gestation in 913 pregnant women. GDM was diagnosed using the 1999 World Health Organization criteria. Associations were examined with linear or logistic regression, adjusted for confounders and stratified by ethnicity.

RESULTS

Higher plasma folate was associated with higher 2-h glucose and higher odds of GDM [0.15 (0.02, 0.23) per 1-SD increment in folate, OR 1.29 (1.00, 1.60)], mainly among Indian mothers. Higher plasma vitamin B12 and homocysteine were associated with lower fasting and 2-h glucose, and lower odds of GDM [-0.04 (-0.07, -0.01) per 1-SD increment in B12 and -0.09 (-0.18, -0.003) respectively, OR: 0.81 (0.68, 0.97); -0.05 (-0.08, -0.02) per 1-SD increment in homocysteine and -0.12 (-0.21, -0.02) respectively, OR: 0.76 (0.62, 0.92)]. The highest odds of GDM were observed among women with combined vitamin B12 insufficiency and high folate concentration [OR: 1.97 (1.05, 3.68)]. An association between higher vitamin B6 and higher 2-h glucose shifted towards null adjusting for other B-vitamins.

CONCLUSIONS

Higher maternal folate coupled with vitamin B12 insufficiency was associated with higher GDM risk. This finding has potential implications for antenatal supplement recommendations but will require confirmation in future studies.

Prevention of type 2 diabetes mellitus in women with previous gestational diabetes mellitus

Gestational diabetes mellitus (GDM), defined as any degree of glucose intolerance with onset or first recognition during pregnancy, is characterized by underlying maternal defects in the β-cell response to insulin during pregnancy. Women with a previous history of GDM have a greater than 7-fold higher risk of developing postpartum diabetes compared with women without GDM. Various risk factors for postpartum diabetes have been identified, including maternal age, glucose levels in pregnancy, family history of diabetes, pre-pregnancy and postpartum body mass index, dietary patterns, physical activity, and breastfeeding. Genetic studies revealed that GDM shares common genetic variants with type 2 diabetes. A number of lifestyle interventional trials that aimed to ameliorate modifiable risk factors, including diet, exercise, and breastfeeding, succeeded in reducing the incidence of postpartum diabetes, weight retention, and other obesity-related morbidities. The present review summarizes the findings of previous studies on the incidence and risk factors of postpartum diabetes and discusses recent lifestyle interventional trials that attempted to prevent postpartum diabetes.

Relationship between High Serum Cystatin C Levels and the Risk of Gestational Diabetes Mellitus

Aims

Serum cystatin C (CysC) has recently been shown to be associated with the incidence of type 2 diabetes mellitus (T2DM) and progression to the pre-diabetic state. The aim of this study was to explore the relationship between serum CysC and the risk of gestational diabetes mellitus (GDM) in Chinese pregnant women.

Methods

This cross-sectional study consisted of 400 pregnant women including111 with GDM and 289 with normal glucose tolerance at 24–28 weeks of gestation. The subjects were further divided into four groups according to the CysC quartiles, and their clinical characteristics were compared. The serum CysC concentration was measured using immunoturbidimetry and the degree of insulin resistance was assessed by the homeostasis model assessment of insulin resistance (HOMA-IR).

Results

Serum CysC levels were significantly higher in pregnant women with GDM than in the healthy pregnant women[1.0(0.8–1.8) vs 0.7(0.6–1.0), P<0.01). The Spearman’s correlation analysis showed that serum CysC was positively associated with HOMA-IR(r = 0.118, P<0.05) and the occurrence of GDM(r = 0.348, P<0.01). The pregnant women were divided into quartiles according to their serum CysC concentrations. Compared to the first quartile, pregnant women in Q2 (OR, 2.441; P = 0.025), Q3 (OR, 3.383; P = 0.001) and Q4 (OR, 5.516; P<0.001) had higher risk of GDM after adjusted for age, BMI, HbA1c and HOMA-IR. Further, with a rise in the serum CysC, there was an increasing trend in the HOMA-IR levels (P<0.05). A binary logistic regression analysis after adjusting for other confounding variables revealed a significant and independent association between serum CysC and GDM [OR = 14.269; 95% confidence interval, 4.977–40.908, P<0.01].The receiver operating characteristic curve analysis revealed that the optimal cutoff point for serum CysC to indicate GDM was 0.95mg/L.

Conclusions

Serum CysC is significantly and independently associated with insulin resistance and GDM. It may be a helpful biomarker to identify the risk of GDM in Chinese pregnant women.

Predictors of type 2 diabetes among Taiwanese women with prior gestational diabetes mellitus

AIM

The aims of this study were to determine the blood glucose screening rate of Taiwanese post-partum women with gestational diabetes (GDM) and to identify the predictors of type 2 diabetes among Taiwanese women with GDM.

METHODS

The medical records of 130 women with GDM, who were delivered at a hospital in southern Taiwan between 1997 and 2010, were retrospectively reviewed. The GDM diagnosis was performed according to the National Diabetes Data Group and Expert Committee Criteria. The 2010 American Diabetes Association diabetes diagnosis criteria were used to determine whether post-partum women subsequently developed type 2 diabetes.

RESULTS

In total, 71 records (54.6%) included blood glucose testing after childbirth between the first month and the ninth year, and 29 records (22.3%) documented subsequent type 2 diabetes. In a multiple logistic regression analysis, the patients' pre-pregnancy body mass indices and insulin use during pregnancy were independently associated with subsequent type 2 diabetes.

CONCLUSION

In this study, documentation during pregnancy, which could have provided beneficial insights, was limited. Healthcare professionals should develop a program to improve the post-partum follow-up of women diagnosed with GDM.

Homocysteine levels in women with a history of gestational diabetes mellitus

BACKGROUND

Previous gestational diabetes (pGDM) is a risk factor of type 2 diabetes, hypertension and cardiovascular diseases. Homocysteine is one of markers of cardiovascular risk. The aim of this study was to assess the homocysteine levels in women with pGDM and to evaluate its relationship with current carbohydrate metabolism and nourishment status.

METHODS

The study group comprised 199 women at 7.8 ± 1.0 years after pGDM and 50 control women in whom pGDM was excluded. The analyzed parameters: BMI, WHR, body composition (Tanita SC-330S analyzer), glucose and insulin levels in oral glucose tolerance test (OGTT), insulin resistance index (HOMA-IR), HbA1c, lipid profile, homocysteine, creatinine and creatinine clearance. The Mann-Whitney test and Chi-squared test were used for comparison of continuous and nominal variables, respectively. Correlations between continuous variables in each group were analyzed using Spearman's rank correlation coefficient (Rs). A logarithmic transformation was applied for variables with non-normal distribution.

RESULTS

There were no differences between the pGDM women and controls in terms of age, number of childbirths, time from indexed pregnancy, pre-pregnancy BMI, or current anthropometric parameters. In pGDM women HbA1c and all glucose levels in OGTT were significantly higher, but still within the normal range. No significant differences were found in homocysteine levels, HOMA-IR, blood lipids, creatinine and creatinine clearance. Homocysteine levels did not differ significantly in subgroups categorized according to the current OGTT results or BMI. Carbohydrate metabolism disorders, overweight and obesity were associated with higher creatinine clearance. Positive correlation between homocysteine and creatinine (r = 0.21, p < 0.004), and a negative correlation with creatinine clearance (r = -0.16, p < 0.03) were found.

CONCLUSIONS

In women with pGDM, homocysteine is not a marker of glucose tolerance disturbances and cardiovascular risk. Increased glomerular filtration rate, observed in more severe disorders of carbohydrate metabolism and greater BMI, may temporarily protect against an increase of proatherogenic homocysteine.

Distribution and determinants of plasma homocysteine levels in rural Chinese twins across the lifespan

Plasma homocysteine (Hcy) is a modifiable, independent risk factor for cardiovascular disease (CVD) and is affected by both environmental and genetic factors. This study aimed to describe the gender- and age-specific distribution of Hcy concentration for 1117 subjects aged 10–66 years, a subset of a community-based rural Chinese twin cohort. In addition, we examined environmental and genetic contributions to variances in Hcy concentration by gender and age groups. We found that the distribution pattern for Hcy varied by both age and gender. Males had higher Hcy than females across all ages. Elevated Hcy was found in 43% of male adults and 13% of female adults. Moreover, nearly one fifth of children had elevated Hcy. Genetic factors could explain 52%, 36% and 69% of the variation in Hcy concentration among children, male adults and female adults, respectively. The MTHFR C677T variant was significantly associated with Hcy concentrations. Smokers with the TT genotype had the highest Hcy levels. Overall, our results indicate that elevated Hcy is prevalent in the children and adults in this rural Chinese population. The early identification of elevated Hcy will offer a window of opportunity for the primary prevention of CVD and metabolic syndrome.

The mother--the long-term implications on metabolic and cardiovascular complications

There is cumulating evidence linking the occurrence of pregnancy complications, including miscarriage, stillbirth, hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm birth, and fetal growth restriction, with increased future risk of type 2 diabetes mellitus, and hospitalization and death due to cardiovascular and cerebrovascular diseases. Such association is largely related to genetic predisposition and shared pathophysiological mechanisms and changes, which may precede the index pregnancy. Awareness of this association would allow identification of the at-risk women for implementation of preventive measures to reduce the recurrence risk of these complications and mitigate the future development of metabolic and cardiovascular diseases worldwide.

Maternal outcomes and follow-up after gestational diabetes mellitus

Gestational diabetes mellitus reflects impaired maternal insulin secretion relative to demand prior to pregnancy, as well as temporary metabolic stressors imposed by the placenta and fetus. Thus, after delivery, women with gestational diabetes have increased risk of diabetes and recurrent gestational diabetes because of their underlying impairment, which may be further exacerbated by fat accretion during pregnancy and post-partum deterioration in lifestyle behaviours. This hypothetical model is discussed in greater detail, particularly the uncertainty regarding pregnancy as an accelerator of β-cell decline and the role of gestational weight gain. This report also presents risk estimates for future glucose intolerance and diabetes and reviews modifiable risk factors, particularly body mass and lifestyle alterations, including weight loss and breastfeeding. Non-modifiable risk factors such as race/ethnicity and insulin use during pregnancy are also discussed. The review concludes with current literature on lifestyle modification, recommendations for post-partum glucose screening, and future directions for research to prevent maternal disease.

Gestational diabetes mellitus in korean women: similarities and differences from other racial/ethnic groups

Gestational diabetes mellitus (GDM) reflects defects in insulin secretion in response to the metabolic demands of pregnancy. While GDM is increasingly common worldwide due in large part to the obesity epidemic, its frequency is relatively low in Korean women. In this report, the prevalence and risk factors for GDM, perinatal outcomes, and postpartum course are compared in non-Korean and Korean women. While Koreans and non-Koreans with GDM share pathophysiology and complications, there may be differences in the role of obesity and thus the effectiveness of interventions targeting obesity in GDM women. Further investigations of the effectiveness of weight loss interventions and pharmacotherapy specifically among Korean women are needed. Dietary and other lifestyle data from Korean populations could inform prevention and treatment strategies in other countries which suffer from significantly higher prevalences of GDM.

Interventions to Increase Access to Care and Quality of Care for Women With Gestational Diabetes

In Brief

Women with a history of gestational diabetes mellitus (GDM) and their offspring have a lifelong risk of developing type 2 diabetes. Appropriate diagnosis and documentation are needed to ensure that these women receive interventions to reduce that risk. This article describes efforts of the multistate GDM Collaborative program to better understand GDM prevalence data, identify gaps in data quality and documented care, and develop interventions to improve access and postpartum follow-up care. It highlights the documentation and intervention efforts of two GDM Collaborative states and emphasizes the need for other states to replicate these efforts.

Hypothesis: hyperhomocysteinemia is an indicator of oxidant stress

Elevated plasma homocysteine levels are associated with an increased risk of atherosclerosis and thrombosis, as well as a variety of other pathologies such as birth defects, Alzheimer's disease and other dementias, osteoporosis, diabetes and renal disease. Homocysteine metabolism is catalyzed by a number of enzymes that require B-vitamins as cofactors, and homocysteine levels are particularly responsive to folate status. The predictive power of plasma homocysteine level as a risk factor for atherothrombotic orders raised the appealing hypothesis that reduction of homocysteine levels by vitamin supplementation might result in a commensurate reduction is the risk of atherothrombotic events. Unfortunately, most clinical trials failed to show a significant benefit of vitamin supplementation on cardiovascular events, in spite of significant lowering of plasma homocysteine levels. Thus, it is not clear whether homocysteine actually plays a causal role in many pathologies with which it is associated, or whether it is instead a marker for some other underlying mechanism. A large body of data links hyperhomocysteinemia and folate status with oxidant stress. In this article I review data that suggests that homocysteine not only promotes cellular and protein injury via oxidant mechanisms, but is also a marker for the presence of pathological oxidant stress. Thus, it is possible that hyperhomocysteinemia is not a common primary cause of atherothrombotic disorders in the general population, but rather a marker of systemic or endothelial oxidant stress that is a major mediator of these disorders.

The risk of overt diabetes mellitus among women with gestational diabetes: a population-based study

AIMS

To determine the incidence of postpartum diabetes mellitus in the years following a diagnosis of gestational diabetes mellitus (GDM) and to determine whether the severity of GDM, represented by the magnitude of the deviation of diagnostic tests from the normal values or requirement for medications, is associated with the development of diabetes.

METHODS

A retrospective cohort study was performed among 185 416 pregnant women who had glucose challenge test or 3 h oral glucose tolerance test (OGTT) in a large health maintenance organization in Israel. Subsequent diagnosis of diabetes was ascertained by using an automated patient registry.

RESULTS

A total of 11 270 subjects were diagnosed with GDM, comprising 6.07% of the cohort. During a total follow-up period of 1 049 334 person-years there were 1067 (16.9 per 1000 person-years) and 1125 (1.1 per 1000 person-years) diagnoses of postpartum diabetes among GDM and non-GDM women, respectively. The cumulative risk of incident diabetes in GDM patients with up to 10 years of follow-up was 15.7%, compared with 1% among the non-GDM population. Gestational diabetes mellitus was associated with nearly an eightfold higher risk of postpartum diabetes after adjusting for important confounders, such as socioeconomic status and body mass index. Among women with a history of GDM, the number of abnormal OGTT values and use of insulin were associated with a substantially higher risk for developing diabetes.

CONCLUSIONS

Three or four abnormal OGTT values and GDM requiring insulin or oral hypoglycaemic medications are important predictors of postpartum diabetes risk in women with a history of GDM.

Low plasma vitamin B12 in pregnancy is associated with gestational 'diabesity' and later diabetes

AIMS/HYPOTHESIS

This study was designed to test the hypothesis that low plasma vitamin B(12) concentrations combined with high folate concentrations in pregnancy are associated with a higher incidence of gestational diabetes (GDM) and later diabetes.

METHODS

Women (N = 785) attending the antenatal clinics of one hospital in Mysore, India, had their anthropometry, insulin resistance (homeostasis model assessment-2) and glucose tolerance assessed at 30 weeks' gestation (100 g oral glucose tolerance test; Carpenter-Coustan criteria) and at 5 years after delivery (75 g OGTT; WHO, 1999). Gestational vitamin B(12) and folate concentrations were measured in stored plasma samples.

RESULTS

Low vitamin B(12) concentrations (<150 pmol/l, B(12) deficiency) were observed in 43% of women and low folate concentrations (<7 nmol/l) in 4%. B(12)-deficient women had higher body mass index (p < 0.001), sum of skinfold thickness (p < 0.001), insulin resistance (p = 0.02) and a higher incidence of GDM (8.7% vs 4.6%; OR 2.1, p = 0.02; p = 0.1 after adjusting for BMI) than non-deficient women. Among B(12)-deficient women, the incidence of GDM increased with folate concentration (5.4%, 10.5%, 10.9% from lowest to highest tertile, p = 0.04; p for interaction = 0.2). Vitamin B(12) deficiency during pregnancy was positively associated with skinfold thickness, insulin resistance (p < 0.05) and diabetes prevalence at 5 year follow-up (p = 0.009; p = 0.008 after adjusting for BMI). The association with diabetes became non-significant after excluding women with previous GDM (p = 0.06).

CONCLUSIONS/INTERPRETATION

Maternal vitamin B(12) deficiency is associated with increased adiposity and, in turn, with insulin resistance and GDM. Vitamin B(12) deficiency may be an important factor underlying the high risk of 'diabesity' in south Asian Indians.

An application of artificial immune recognition system for prediction of diabetes following gestational diabetes

Diabetes mellitus (DM) is a disease prevalent in population and is not easily perceived in its initial stage but may sway a patient very seriously in later stage. In accordance with the estimation of World Health Organization (WHO), there will be 370 million diabetics which are 5.4% of the global people in 2030, so it becomes more and more important to predict whether a pregnant woman has or is likely to acquire diabetes. This study is conducted with the use of the machine learning-Artificial Immune Recognition System (AIRS)-to assist doctors in predicting pregnant women who have premonition of type 2 diabetes. AIRS is proposed by Andrew Watkins in 2001 and it makes use of the metaphor of the vertebrate immune system to recognize antigens, select clone, and memorize cells. Additionally, AIRS includes a mechanism, limited resource, to restrain the number of memory cells from increasing uncontrollably. It has also showed positive results on problems in which it was applied. The objective of this study is to investigate the feasibility in using AIRS to predict gestational diabetes mellitus (GDM) subsequent DM. The dataset of diabetes has imbalanced data, but the overall classification recall could still reach 62.8%, which is better than the traditional method, logistic regression, and the technique which is thought as one of the powerful classification approaches, support vector machines (SVM).

Effect of homocysteine-lowering treatment with folic Acid and B vitamins on risk of type 2 diabetes in women: a randomized, controlled trial

OBJECTIVE

Homocysteinemia may play an etiologic role in the pathogenesis of type 2 diabetes by promoting oxidative stress, systemic inflammation, and endothelial dysfunction. We investigated whether homocysteine-lowering treatment by B vitamin supplementation prevents the risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS

The Women's Antioxidant and Folic Acid Cardiovascular Study (WAFACS), a randomized, double-blind, placebo-controlled trial of 5,442 female health professionals aged > or = 40 years with a history of cardiovascular disease (CVD) or three or more CVD risk factors, included 4,252 women free of diabetes at baseline. Participants were randomly assigned to either an active treatment group (daily intake of a combination pill of 2.5 mg folic acid, 50 mg vitamin B6, and 1 mg vitamin B12) or to the placebo group.

RESULTS

During a median follow-up of 7.3 years, 504 women had an incident diagnosis of type 2 diabetes. Overall, there was no significant difference between the active treatment group and the placebo group in diabetes risk (relative risk 0.94 [95% CI 0.79-1.11]; P = 0.46), despite significant lowering of homocysteine levels. Also, there was no evidence for effect modifications by baseline intakes of dietary folate, vitamin B6, and vitamin B12. In a sensitivity analysis, the null result remained for women compliant with their study pills (0.92 [0.76-1.10]; P = 0.36).

CONCLUSIONS

Lowering homocysteine levels by daily supplementation with folic acid and vitamins B6 and B12 did not reduce the risk of developing type 2 diabetes among women at high risk for CVD.

Antepartum glucose tolerance test results as predictors of type 2 diabetes mellitus in women with a history of gestational diabetes mellitus: a systematic review

BACKGROUND

Women with a history of gestational diabetes mellitus (GDM) are at high risk for type 2 diabetes mellitus (T2DM).

OBJECTIVE

We reviewed prospective studies of antepartum glucose tolerance test results as risk factors for development of T2DM among women with a history of GDM.

METHODS

We searched 4 electronic databases and hand-searched 13 journals for literature published through January 2007. The search strategy consisted of medical subject headings and text words for GDM, T2DM, and other relevant terms. Articles were excluded for the following reasons: (1) not written in English; (2) no human data; (3) no original data; (4) <90% of sample was diagnosed with GDM without a separate analysis for women with GDM; (5) case report or series; (6) diagnosis of GDM not based on 3-hour 100-g oral glucose tolerance test (OGTT) or 2-hour 75-g OGTT; (7) T2DM not evaluated as outcome; (8) no relative measure of association or incidence reported; or (9) design did not address antepartum OGTT as a predictor of T2DM. Two investigators independently reviewed citations, performed serial data abstraction on full articles, and assessed the quality of each article. Data were abstracted for study participants and characteristics, T2DM diagnosis, length of follow-up, regression model covariates, and measures of association and variability.

RESULTS

Of 11,400 unique citations, we identified 11 articles that evaluated antepartum glucose testing and risk of T2DM in women with a history of GDM. Five studies found that the fasting blood glucose (FBG) on the antepartum diagnostic OGTT was a significant predictor of T2DM (odds ratio [OR] range: 11.1-21.0; relative risk [RR] range: 1.37-1.5; relative hazard [RH] = 2.47). Risk of incident T2DM was predicted by the antepartum 2-hour OGTT plasma glucose in 3 studies (OR range: 1.02-1.03; RR = 1.3) and by the antepartum OGTT glucose AUC in 3 other studies (OR range: 3.64-15; RH = 2.13). Overall, study quality was limited by high losses to follow-up (>20% in 6 studies) and short duration. Few studies adjusted for adiposity, an established diabetes risk factor.

CONCLUSION

FBG, OGTT 2-hour blood glucose, and OGTT glucose AUC appeared to be strong and consistent predictors of subsequent T2DM among women who met diagnostic criteria for GDM using the OGTT.

Risk factors for type 2 diabetes among women with gestational diabetes: a systematic review

We conducted a systematic review of studies examining risk factors for the development of type 2 diabetes among women with previous gestational diabetes. Our search strategy yielded 14 articles that evaluated 9 categories of risk factors of type 2 diabetes in women with gestational diabetes: anthropometry, pregnancy-related factors, postpartum factors, parity, family history of type 2 diabetes, maternal lifestyle factors, sociodemographics, oral contraceptive use, and physiologic factors. The studies provided evidence that the risk of type 2 diabetes was significantly higher in women having increased anthropometric characteristics with relative measures of association ranging from 0.8 to 8.7 and women who used insulin during pregnancy with relative measures of association ranging between 2.8 and 4.7. A later gestational age at diagnosis of gestational diabetes, >24 weeks gestation on average, was associated with a reduction in risk of development of type 2 diabetes with relative measures of association ranging between 0.35 and 0.99. We concluded that there is substantial evidence for 3 risk factors associated with the risk of type 2 diabetes in women having gestational diabetes.

High plasma retinol binding protein-4 and low plasma adiponectin concentrations are associated with severity of glucose intolerance in women with previous gestational diabetes mellitus

CONTEXT

Women with previous gestational diabetes mellitus (pGDM) are at high risk of developing type 2 diabetes mellitus in the future. The role of adipokines in women with pGDM has not been established.

OBJECTIVE

We investigated whether circulating adipokine concentration is associated with abnormal glucose homeostasis in women with pGDM. DESIGN, SETTING, PATIENTS, AND MAIN OUTCOME MEASURES: We measured the plasma concentrations of retinol-binding protein-4 (RBP4), transthyretin (TTR), and adiponectin and metabolic parameters in four groups of women who exhibited normal glucose tolerance (NGT) during a previous pregnancy (NP, n = 17), NGT after GDM (GDM-NGT, n = 72), impaired glucose tolerance after GDM (GDM-IGT, n = 60), and type 2 diabetes after GDM (GDM-DM, n = 8).

RESULTS

Plasma RBP4 concentration was significantly higher in women with GDM-DM, GDM-IGT, and GDM-NGT than in those with NP. RBP4 concentration correlated positively with TTR concentration; fasting plasma glucose, insulin, and triglyceride concentrations; blood pressure; abdominal fat area; and homeostasis model assessment of insulin resistance. Plasma TTR concentration was elevated in women with GDM-DM compared with other groups. In contrast, adiponectin concentration was lowest in the GDM-DM group and correlated inversely with parameters of insulin resistance. Resistin concentration was higher only in the GDM-NGT and GDM-IGT groups, whereas leptin did not differ between groups. Plasma RBP4 and adiponectin concentrations were inversely correlated.

CONCLUSIONS

The severity of glucose intolerance in women with pGDM is associated with high RBP4 and low adiponectin concentrations.

Coffee consumption and type 2 diabetes — An extensive review

Coffee is a complex mixture of potentially active chemicals. It contains significant amounts of phenolic polymers, chlorogenic acid and also caffeine. Agricultural factors, roasting, blending, and brewing determine coffee’s chemical composition. Recent epidemiological studies suggest that habitual coffee consumption may help to prevent some chronic diseases including type 2 diabetes. Despite reports from the clinical trials of the effect of caffeine on decreasing insulin sensitivity, long-term prospective studies revealed that coffee may improve fasting glucose, glucose tolerance and insulin sensitivity as well. In the most recent publication habitual coffee drinkers have a lower total and cardiovascular mortality rate among diabetic subjects.

Long-term outcomes in mothers diagnosed with gestational diabetes mellitus and their offspring

Mothers with gestational diabetes mellitus (GDM) are at high lifetime risk of developing type 2 diabetes mellitus. The magnitude of risk for cardiovascular disease after GDM is less well established. Recently, intervention trials using lifestyle modification or medications used to treat type 2 DM have successfully prevented/delayed development of DM in women after GDM. Offspring of mothers with GDM are at risk for development of obesity and abnormal glucose metabolism during childhood, adolescence, and adulthood. Factors responsible for these risks are not fully understood. Having fetal hyperinsulinism is a risk factor for development of both obesity and abnormal glucose metabolism, and might be implicated in pathophysiology. It remains to be established whether the long-term effects of exposure to diabetes mellitus during intrauterine development can be prevented.

Total plasma homocysteine correlates in women with gestational diabetes

AIM

We aim to assess serum total homocysteine (tHcy) associations with metabolic syndrome components and B-vitamins in women with gestational diabetes mellitus (GDM).

METHODS

We studied 61 consecutive pregnant women, 44 with GDM and 17 with normal glucose tolerance (CG). Serum homocysteine levels were analyzed by ELISA, using Bio-Rad reagents. Serum folates and vitamin B(12) concentrations were determined by chemiluminescent immunoassay, free fatty acids (FFA) and lipids enzymatically.

RESULTS

Serum homocysteine levels were similar in both the GDM and the CG groups (8+/-2.0 vs 7.4+/-1.1 micromol/l, respectively). Women with GDM in comparison to CG women were characterized by higher values of homeostasis model of insulin resistance (HOMA-IR) (2.8+/-1.7 vs 1.6+/-0.9, P<0.01), serum triglycerides (2.7+/-0.9 vs 1.9+/-0.5 mmol/l, P<0.01) and FFA (0.6+/-0.2 vs 0.46+/-0.2 mmol/l, P<0.05). In GDM women serum tHcy correlated with vitamin B(12) (r= -0.47, P<0.01) and folates (r= -0.51, P<0.001); in CG women with HOMA-IR, a marker of insulin resistance (r= -0.49, P<0.05). In multiple regression analysis with serum tHcy as a dependent variable, folate and vitamin B(12) entered the analysis in GDM women (beta= -0.42 and -0.34, respectively, P<0.05), whereas in CG cystatin C and HOMA-IR entered the analysis (P<0.05).

CONCLUSIONS

In women with GDM, serum homocysteine is significantly associated with vitamin B(12) and folate levels, while in healthy pregnant women with HOMA-IR and with kidney function. The results suggest the importance of the B-group vitamins in regulation of serum tHcy levels in women with insulin resistance/gestational diabetes, what might be relevant in protection against pregnancy complications associated with elevated tHcy in GDM women.

[Steatosis, chronic hepatitis virus C infection and homocysteine]

Homocysteine, a sulfuric amino acid involved in methionine metabolism, belongs to the group of intracellular thiols. Hyperhomocysteinemia is frequent in the Caucasian population (more than 15%) and its role in vascular pathology has been clearly established. In hepatology, experimental data in transgenic mice deficient in homocysteine metabolism enzymes have shown the presence of severe liver steatosis with occasional steatohepatitis. In human beings, many studies have found a correlation between homocysteine and steatosis or even NASH. Some authors have suggested a discriminating threshold to differentiate simple steatosis from NASH. In chronic hepatitis C, preliminary data have shown that hyperhomocysteinemia is an independent risk factor for steatosis or even fibrosis. The physiopathological mechanism has now begun to be better understood. On one hand, there is a strong correlation between homocysteine and insulin resistance whatever its etiology. On the other hand, homocysteine has a direct effect on the liver, resulting in over expression of SREBP-1 and favouring steatosis. It stimulates proinflammatory cytokine secretion such as NF kappa B increasing the risk of NASH. Finally, homocysteine could increase the risk of fibrosis by stimulating TIMP 1. Moreover hepatitis C virus induces hypomethylation of STAT 1 and could decrease the antiviral activity of interferon. Results from in vitro studies have shown that the normalisation of STAT 1 methylation by bringing betaine and S Adenosyl Methionine (which belongs to homocysteine cycle) restores the antiviral activity of interferon. These data should be confirmed to evaluate the importance of homocysteine dosage in the diagnosis of NASH. Finally, treatment of hyperhomocysteinemia could have favourable consequences in steatopathies and HCV infection.