Abstract

High levels of serum homocysteine levels is known as hyperhomocysteinemia and is associated with higher risk of cardiovascular, neurological and other diseases. The purpose of this study was to investigate the effectiveness of  iTHRIVE-in-3 intervention protocol on lowering the total homocysteine concentration of the study participants. A total of 35 study participants having a total homocysteine concentration greater than 6 μmol/L were enrolled in the twelve week program of Thrive tribe wellness solutions pvt. Ltd. (iThrive). The program comprised of dietary interventions such as elimination of inflammatory foods such as gluten containing foods, dairy products, soy and soy products, corn and vegetable/seed oils along with incorporation of certain micronutrients such as folic acid, vitamin B6, vitamin B12, betaine/Trimethylglycine in supplemental form with addition of practices such as meditation, physical activity and lymphatic massage. The homocysteine levels at the baseline and post-intervention were recorded. After the twelve week intervention program, a significant drop was observed in the homocysteine levels between pre and post intervention (p <0.001). The results point out that the iThrive interventional strategy can be effectively employed for achieving reduction in the homocysteine levels to a great extent among the Indian population.

Keywords: iTHRIVE protocol, hyperhomocysteinemia, nutrients, lifestyle

Introduction

Homocysteine, a sulfur containing amino acid, is derived from the essential amino acid methionine. This amino acid is absent from dietary sources and solely produced from methionine as part of the metabolic conversion of methionine to cysteine. Some metabolic aberrations could lead to an increased circulating levels of homocysteine and is generally termed as hyperhomocysteinemia. It can cause damage to the endothelial lining of the blood vessels and contributes to inflammation. Such a condition is associated with stroke, heart attacks, cardiovascular diseases, cognitive impairment and depression (Kumar & Palfrey, 2017).

Homocysteine metabolism

Homocysteine is formed in the methylation pathway as an intermediate in the S-adenosyl methionine (SAM) cycle (Fig.1).The first step is the reaction of methionine with ATP resulting in the formation of SAM; a universal methyl donor. SAM donates the methyl group to acceptor molecules like DNA, RNA, amino acids, proteins, phospholipids etc. and the resulting demethylated compound formed is S-Adenosyl homocysteine (SAH). This SAH then further undergoes deadenosylation resulting in the formation of homocysteine. The homocysteine formed as a result of methylation can be remethylated back to methionine and it requires methionine synthase, a vitamin B12 dependent enzyme. This pathway of homocysteine metabolism is called the remethylation pathway. Homocysteine can also combine with serine to form cystathionine which is catalyzed by cystathionine β synthase (CβS), a vitamin B6 dependent process. This route of the metabolism of homocysteine  is called the transsulfuration pathway.

Excess accumulation of homocysteine in the body also causes cell damage and leads to vascular and microvascular disease thereby promoting cerebrovascular dysfunction (Kamat & Vacek, 2015). This occurs because of an error in biochemical transformation in metabolic processes. Hyperhomocystinemia may serve as a possible indicator of a lack of necessary and essential vitamins (Folic acid, vitamin B6, vitamin B12) required for physiological processes within the body. The insufficiency of these vitamin cofactors in transformation pathways can produce elevated homocysteine levels that place patients at risk for vascular disease. Hyperhomocystinemia is associated with damage to the vascular system through oxidative stress, resulting in a build-up of damaging free radicals (Vazquez & Escobedo, 2010). Free radical oxygen species may trigger many brain diseases including stroke and vascular dementia. These reactive chemical, oxygen, or nitrogen species generate free radicals, which can damage the neuronal lipid bilayer by oxidizing lipids and proteins in the vascular endothelial wall. Homocysteine  itself can undergo auto-oxidation, thus causing the disruption of redox homeostasis and affecting the redox signaling pathways in vascular and neuronal cells (Vazquez & Escobedo, 2010).

Root causes of high homocysteine levels

Increased levels of homocysteine can be due to defective metabolism of methionine, resulting from either mutation in certain genes or enzymes (MTHFR) or deficiencies of certain vitamin cofactors such as vitamin B12, folic acid or vitamin B6. Methylenetetrahydrofolate reductase (MTHFR) is a crucial enzyme in the homocysteine metabolism that catalyzes the conversion of 5,10-methylenetetrahydrofolate into 5-methyltetrahydrofolate, the predominant circulating form of folate. In addition to genetic alterations and vitamin deficiencies, several other environmental factors are known to contribute to variations in homocysteine  levels. People with renal dysfunction often exhibit high homocysteine levels. The close relationship between plasma homocysteine and glomerular filtration rate (GFR) suggests that homocysteine is cleared from the body by urinary excretion after glomerular filtration, just like creatinine (Guldener, 2006,).

Homocysteine is elevated in patients with chronic alcoholism but decreases in alcohol withdrawal. Homocysteine is regulated through a series of pathways, which are dependent on B vitamins, particularly folate. Moderate alcohol intake is associated with reduced folate and vitamin B12 status in the body (Gibson & Woodside, 2008). Similarly, in smokers, increased homocysteine levels are strongly correlated with an increased tendency to develop low levels of folate and vitamin B12 (Dhouha & A, 2011). Moreover, stress has also been attributed to raise the homocysteine levels in the body (Sawai & Ohshige, 2008). It has also been found that plasma homocysteine level was increased by caffeine and coffee intake in randomized controlled trials (Lim & Chang, 2020).

Certain medical conditions like hypothyroidism are also indicators of increased levels of homocysteine. Thyroid hormones markedly affect riboflavin metabolism, mainly by stimulating flavokinase and thereby the synthesis of flavin mononucleotide (FMD) and flavin adenine dinucleotide (FAD). These compounds serve as a cofactor for enzymes involved in the metabolism of vitamin B6, vitamin B12 and folate (Lien & Hustad, 2001). Thus, thyroid status has profound secondary effects on homocysteine metabolism. 

The lymphatic system, which is known as the body's “waste disposal", also disposes of homocysteine. Excretion of homocysteine becomes difficult in the presence of lymphatic congestion (Medi, n.d.). Moreover, some medications are believed to alter total homocysteine concentrations by interfering with the metabolism of folate or vitamins B12 or B6 or by altering renal function. Several widely used drugs, such as lipid-lowering drugs (like fibrates and niacin), oral hypoglycemic drugs (like metformin), insulin, drugs used in rheumatoid arthritis, and anticonvulsants are also known to be causes of elevated homocysteine concentrations (Dierkes & Westphal, 2005).

Deleterious effects of elevated homocysteine levels

Hyperhomocysteinemia is the term to denote the increased circulating levels of homocysteine and is generally recognized as a causative factor for various pathologies. Hyperhomocysteinemia leads to endothelial cell damage, damage flexibility of vessels, and alters the process of hemostasis. All these mechanisms have been linked to cause cardiovascular problems (Ganguly & Alam, 2015).

Study Methodology

The study was conducted for a time period of 12 weeks as per the iTHRIVE-in-3 protocol. The inclusion criteria were as follows: people of 25-50 years with high homocysteine levels (>6 μmol/L). The exclusion criteria were as follows: pregnant women and lactating mothers and participants unable to follow the interventional strategies included in the  iTHRIVE-in-3 dietary protocol. A total of 35 participants were enrolled in the study and an informed consent was obtained from the entire study group.

The participants were tested for their total homocysteine levels at the baseline and post-intervention after a period of 3 weeks. A qualified functional nutritionist was assigned to each study participant to counsel them regarding the intervention. The iTHRIVE-in-3 protocol consisted of the following interventions:

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A. Dietary management

1. Total elimination of gluten containing foods, dairy products, soy and corn products to lower inflammation caused by high homocysteine
2. Total elimination of tea and coffee for better absorption of nutrients and reduction in homocysteine levels
3. Total elimination of  vegetable/ seed oils to lower inflammation and oxidative stress

B. Micronutrient supplementation

1. Micronutrient supplementation, especially vitamin B6, B12 and folate
2. Supplementation with trimethyglycine (TMG, also known as betaine)

C. Physical activity - strength training, cardio workouts, yoga, pilates

D. Stress management modalities such as meditation

E. Lymphatic massage to enable lymphatic drainage

Dietary habits along with other interventional guidelines recommended as part of iTHRIVE-in-3 dietary protocol were tracked and assessed daily through Google sheets containing pre-determined categories such as weight, daily food intake, supplementation, meditation, physical activity. The serum homocysteine levels were measured after 12 weeks and the statistical analysis was performed using a t-test.

Results

The baseline homocysteine levels were found to be an average of 15.49 μmol/L. The participants were counseled by individual nutritionists regarding the iThrive intervention protocol. Daily compliance with the protocol was tracked using Google sheets. All 35 participants followed the dietary changes, supplementation regimen, exercise, meditation and massage for 12 weeks. Post the intervention period, their homocysteine levels were analyzed using blood tests. The statistical analysis was performed using a t-test and it revealed significant reduction in the homocysteine levels pre and post intervention.