Original Article

Hyperhomocysteinemia as a Cardiovascular Risk Factor

in Indian Women : Determinants and Directionality
SN Pandey, ADB Vaidya, RA Vaidya, S Talwalkar
Abstract
Objective : To assess Homocysteine (Hcy), vitamin B12 and folic acid (FA) concentrations in resident Indian
women and to study their correlation with traditional risk factors for coronary artery disease.
Material and Methods : The study included 137 consecutive women who attended a health care program
(HCP) for women at and above 40 years of age (MAITREYIs HCP). Fasting blood samples for Hcy, B12 and
folate were collected on ice, centrifuged within hour and stored at -70 0 C till assayed using a
chemiluminescence method. All women underwent a screening for their general health profile including
cardiovascular health.
Results : Of the 137 women screened 21 were excluded because of presence of factors known to affect Hcy
levels (history of existing CAD had hypothyroidism or were on multivitamin supplements). The median Hcy,
folic acid and vitamin B12 levels were 9 mol/L (range 4.2 38.6), 8.8 ng/ml (2.3 - 31.6 range) and 214 pg/ml
(100 - 2400 range) respectively. The prevalence of hyperhomocysteinemia (>15 mol/L) was 24.2%. Correlation
for continuous variables using spearmans test and for categorical variables with chi-square test showed a
highly significant negative correlation with vitamin B12 (p<0.001) and FA (p<0.002). Both systolic (p<0.05)
and diastolic (p <0.02) and diastolic blood pressure also showed a significant correlation. However, no
correlation was found between plasma Hcy and blood sugars, lipids, age, body mass index and menopausal
status. The CAD risk was assessed using Framingham risk scores and this too did not show a correlation
with plasma Hcy.
Conclusions : A large number of women from the present study had hyperhomocysteinemia and were deficient
in vitamin B12. A significant negative correlation between vitamin B12 and plasma Hcy levels was found in
these older women. Most Indian studies including the present one do not show a positive correlation between
elevated Hcy levels and CAD in spite of a large percentage of persons showing elevated homocysteine levels.
Since high Hcy levels are recognized as an independent risk factor for CAD, these findings of absence of
correlation between Hcy and CAD as reported in various Indian studies need to be explored and explained.

INTRODUCTION

he prevalence of coronary artery disease (CAD) is

known to be significantly higher in immigrant South
Asians1,2 abroad and in resident Indians.3,4 CAD in
Indians is often premature, more extensive and severe
than amongst Caucasians.1 Mortality from CAD is slowly
replacing infectious diseases as the leading cause of
deaths in Indians. With a projected 239/100,000 women
dying of CAD, by 2015, the Indian health care delivery
system is going to face a humongous problem.3
In addition to traditional risk factors for CAD viz.
elevated lipids, hypertension (HT), diabetes mellitus
Bhavans SPARC, 13th NS Road, JVPD Scheme,
Mumbai - 400 049. Received : 19.4.2005; Revised : 8.11.2005;
Re-Revised : 10.4.2006; Re-Re-Revised : 5.8.2006;
Accepted : 22.8.2006
JAPI VOL. 54 OCTOBER 2006

(DM), obesity and smoking, women at and above 40 years

of age face an additional risk factor with approaching
menopause in the form of loss of protective effect of
estrogen on the heart. In a comprehensive health study
of women at and above 40 years of age (Bhavans SPARC
MAITREYIs Health Care Program) the incidence of
traditional risk factors for CAD were as follows: obesity/
overweight 70%, HT-33%, glucose intolerance/DM 31%
and dyslipidaemia 53%. Electrocardiographic changes
suggestive of ischoemia were found in 18.7% of women.5
Similar alarming findings are reported by other Indian
studies.6,7
In recent years, newer risk factors have been proposed
which predispose an individual to CAD. Homocysteine
(HCY) a non-protein forming, thiol-containing amino
acid is generated during methionine metabolism.
Elevated levels of Hcy have been associated with an
increased risk of occlusive vascular disease in studies

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769

done in Caucasians whereas studies in Asian Indian

have shown variable results.10,11 Plasma Hcy levels have
been shown to increase with natural menopause, which
could be one of the contributory mechanisms of
increased cardiovascular risk in women.12 Vitamin B12
and FA, essential co-factors in Hcy metabolism are
known determinants of plasma Hcy concentrations.13
Against the background of widespread nutritional
vitamin deficiency in Indians,14 estimation of plasma
Hcy and its correlation with risk factors for CAD
assumes importance. In the current study data from the
Bhavans SPARC-MAITREYIs HCP was evaluated to
assess other determinants of fasting plasma Hcy
concentrations.

MATERIAL AND METHODS

One hundred and thirty seven consecutive women
(36-71 years of age) participating in MAITREYIs HCP
were screened. Of these, five women were between 36-39
years of age. The screening included a detailed history,
physical examination and investigations like complete
blood count (CBC), erythrocyte sedimentation rate (ESR),
blood sugars with oral glucose tolerance test (75 gm oral
glucose), lipid profile, serum creatinine, serum thyroid
stimulating hormone (TSH), and an electrocardiogram
(ECG). Blood for Hcy (EDTA tubes), vitamin B-12 and FA
(plain tubes) was collected after overnight fast (12 hours),
transported to the laboratory on ice, centrifuged within
an hour of collection and stored at -70 C till assayed.
Hcy, vitamin B-12 and FA concentrations were estimated
in a single assay by using a chemiluminescence method
(Diagnostic Products Corporation, USA).
Vitamin B12 It is a competitive immunoassay using
a chemiluminescence method. The serum sample is
initially denatured by digestion at 1000 C and then
assayed in Immulite System. The treated sample is
incubated in presence of vitamin B12 (VB12) analog
coated on a polystyrene bead and the hog intrinsic factor
for 30 minutes at 370 C during which the VB12 in sample
competes with VB12 analog for limited binding sites on
hog intrinsic factor. A second antibody antihog
intrinsic factor coupled to alkaline phosphatase is then
introduced in the system so as to bind to the complex of
VB12 (in sample and analog coupled to solid phase hog
intrinsic factor. Separation of the bound and free
conjugated enzyme is achieved by centrifugation and
the bound fraction is reacted with a substrate to generate
luminescence that is measured by the machine.
Folic Acid - Sample is first digested in presence of
ligand and labeled folate and then reacted with folic
acid binding protein and the antibody to this protein
coated on a solid phase. During the 30 minutes
incubation of the sample folic acid competes with ligand
labeled folic acid for binding to the protein and this in
turn is captured on the solid phase. Alkaline
phosphatase conjugated to antiligand is then introduced
770

and the bound/free fractions of the ligand are separated

by centrifugation. The luminescence is measured by
addition of substrate to the bound fraction.
Homocysteine - Procedure involves preliminary
sample pretreatment for hydrolysis and release of Hcy
from binding proteins. The treated sample and alkaline
phosphatase labeled antibody are incubated with the
solid phase coated with S-adenosyl homocysteine (SAH).
During incubation the sample Hcy competes with SAH
on solid phase for binding to monoclonal antibody (anti
SAH) conjugated to alkaline phosphatase. The unbound
fraction is removed by centrifugation and washed.
Substrate is added and the luminescence generated is
then measured on the machine.
The Immulite system is fully automated and the
supplier of the kits does the calibration of each test
parameter and on receipt of reagent kit a fresh 2-point
calibration is carried out in the lab again for adjustment
of instrument to the fresh reagent kits. As per the
specifications of the manufacturer the calibrator range
of the assay for Hcy, vitamin-B 12 and FA were 2-50 mol/
L, 100-1200 pg/ml and 0.524 ng/ml respectively.
Of the 137 women screened, 21 women who had
history of existing CAD, had hypothyroidism or were
on multivitamin supplements (factors known to affect
Hcy concentration) were excluded from the analysis. No
woman had history of existing renal disease and there
were no smokers/alcoholics. A score for predisposition
to CAD was calculated on the basis of Framingham risk
assessment criteria.15
Statistical analysis :
Since plasma Hcy concentrations were positively
skewed, we used Spearmans correlation test for analysis
of continuous variables. The correlation for categorical
variables was done using a chi-square test. A value of <
0.05 was considered significant and p < 0.001 as highly
significant.

RESULTS
The general/clinical/laboratory characteristics of the
116 women (after exclusion of 21 vide supra) are shown
in Table 1. As Hcy, Vitamin B-12 and FA concentrations
were positively skewed, their median values are
reported. Of the 116 women, 78 (67.2%) were obese/
overweight (BMI > 25 kg/m2), 20 (17.2%) had impaired
glucose tolerance/DM, 45 (38.8%) had hypertension, and
60 (51.7%) dyslipidaemia. Sixty-seven women were pre/
perimenopausal and 39 were postmenopausal. A
positive family history of CAD risk factors was found in
92 (79.3%) women. All women had creatinine values
within normal limits. Low levels of vitamin B-12 and FA
were found in 35 and 4 women respectively. Elevated
Hcy concentrations (> 12 u mol/L) were found in 28
(24.2%) women.
Table 2 shows the Spearmans correlation coefficients

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JAPI VOL. 54 OCTOBER 2006

between plasma Hcy and other variables investigated.

Hcy was negatively correlated with vitamin B 12 (p <
0.001) and FA (p < 0.002) and showed a positive
correlation with both systolic (p < 0.05) and diastolic (p
< 0.02) blood pressure. The correlation between plasma
Hcy and blood sugars, lipids, age, body mass index (BMI)
and the Framingham score for CAD risk assessment was
not significant In a multiple regression analysis with
Hcy as the dependent variable, only vitamin B-12 (p <
0.006) and systolic blood pressure (p < 0.03) maintained
a significant correlation with Hcy (Table 3).

DISCUSSION
Our results confirm the observed associations
between Hcy, vitamin B 12 and FA concentrations in
large population based studies from abroad.16,17 A
positive correlation between Hcy and blood pressure as
shown in the present study has also been reported, both
in hypertensive and normotensive subjects.18
Our results do not show a significant correlation with
age, which is in contrast to the findings from the
Framingham Offspring cohort and the Hordaland
Homocysteine Study.16,17 Increasing BMI,16 and impaired
glucose tolerance/insulin resistance have also been
shown to be significant variables associated with
elevated Hcy concentrations both in Caucasians and
Asian Indian.11,19 However, our study did not show such
an association. In a study by Deepa et al, from Chennai
no difference between mean Hcy levels was found
between subjects with or without CAD and in those who
were diabetics v/s non-diabetics.20
No correlation was found with total cholesterol,
triglycerides, low-density lipoprotein (LDL) or highdensity lipoprotein (HDL) and Hcy in our study.
Amongst the women who had elevated total cholesterol
(> 200 mg/dl) the mean Hcy values were 10.5 mol/L as
compared to 10.3 mol/L in those with normal
Table 1 : Characteristics of women screened (n = 116)
Characteristic

Age (years)
BMI (kg/m2 )
Blood pressure (mm Hg)
systolic
diastolic
Fasting Blood
glucose (mg/dl)
Blood glucose
(2 hr OGTT) (mg/dl)
S. cholesterol (mg/dl)
S. triglycerides (mg/dl)
Homocysteine (mol/L)
S. vitamin B-12 (pg/ml)
S. folic acid (ng/ml)
Framingham risk score

Median

Mean

Standard
deviation
(SD)

47
27.32

48.47
27.71

7.698
4.385

130
80
75.5

128.3
80.74
81.19

16.53
9.541
23.48

90

103.1

42.68

195
119.2
9
214
8.8
3

198.8
142.8
10.40
278.4
11.03

36.12
84.24
5.534
262.7
6.896

OGTT: oral glucose tolerance test

JAPI VOL. 54 OCTOBER 2006

cholesterol. In a study by Glueck et al, 3.7% of patients

with hyperlipidaemia had high plasma Hcy.21 Results
from in vitro studies suggest that Hcy may interact with
cholesterol by increasing LDL oxidation, thus
predisposing to atherosclerosis.22 However, in vivo
studies in patients with homocystinuria do not show
such an effect.23
In a prospective study of 28363 postmenopausal
Caucasian women with no history of CAD at baseline,
an increase in Hcy concentration of 5 mol/L was
associated with a 20% increase in risk of a cardiovascular
event.24 There are no large-scale prospective studies in
Asian Indians to find out the correlation of elevated
plasma Hcy with CAD. However, Chambers et al in a
case controlled study in Asian Indian men in United
Table 2 : Correlation of homocysteine with vitamin B12,
folic acid and conventional CVD risk factors (n=116)
Variable

Spearmanns
Correlation (rs)

Folic acid (ng/ml)

Vit B12 (pg/ml)
Age (years)
Body mass index (kg/m2)
Blood sugar Fasting (mg%)
Blood sugar - 2hr post glucose (mg%)
S. cholesterol (mg%)
S. triglycerides (mg%)
S. low density lipoprotein (mg%)
S. High density lipoprotein (mg%)
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Framingham risk score

Menopausal status (Pre/peri vs.

Post menopausal)
K/C/O HT, Dyslipidaemia
Family history of CVD risk factor
(HT, dyslipidaemia, CVD, DM)
HT (SBP > 140 mm Hg,
DBP > 90 mm Hg)

p value

-0.21
-0.52
0.05
-0.03
-0.03
-0.04
0.01
0.03
0.01
-0.09
0.17
0.19
0.14
Chi square
2 )
test (
0.39

0.002 *
<0.001 #
0.5926
0.7626
0.7093
0.6698
0.9601
0.7910
0.8972
0.2948
0.0965 *
0.0587 *
0.1263
p value

0.57
1.62

0.4683
0.3984

0.05

0.4292

0.5355

* : significant, # : highly significant, HT : hypertension,

SBP : systolic blood pressure, DBP : diastolic blood pressure,
CVD : cardiovascular disease, DM : diabetes mellitus

Table 3 : Multiple regression analysis of variables (n=116)

Folic acid (ng/ml)

Vit B12 (pg/ml)
Age (years)
Body mass index (kg/m2)
Blood sugar Fasting (mg%)
S. cholesterol (mg%)
S. triglycerides (mg%)
S. low density lipoprotein (mg%)
S. high density lipoprotein (mg%)
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)

t ratio

p value

0.21
2.78
0.01
0.34
1.31
0.12
0.22
0.20
0.32
2.37
0.38

0.83
0.006 #
0.99
0.73
0.19
0.91
0.82
0.84
0.75
0.03*
0.70

* : significant, # : highly significant

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771

Table 4 : Homocysteine levels in Indians

A : Case-control studies (Cases of CAD v/s controls)
Study

Sample

Chako et al , 1998
Gheye et al27, 1999
Chambers et al25, 2000
Sastry et al 28, 2001
Deepa et al 20, 2001
26

Refsum et al292001

Sample

M/F (Cochin)
M (Hyd)
M (UK)
M/F (Hyd)
M (Chennai)
Without DM
With DM
M/F (Pune)
Without DM
With DM

size

Mean homocysteine levels

(mol/L)
cases
controls
p value

Hyperhomocysteinemia
( % )
cases
controls

cases

controls

56
35
257
221

53
27
518
344

10.98
21.50
12.0
18.3

9.41
19.70
10.8
18.04

NS
NS
0.002
NS

10.7
54
36

5.7
54
29

18
18

21
20

12.6
10.4

12.4
10.1

NS
NS

1.9
5

5.6
5.6

58
42

63
41

20.0
20.2

19.7
18.1

NS
NS

74
79

81
74

M: Male, F: Female, Hyd: Hyderabad, UK: United Kingdom, DM: Diabetes mellitus

B : Community based studies in resident Indians

Study

Sample

Sastry et al 28, 2001

M/F (Hyd)

Misra et al30, 2002

M/F (Delhi)

Maitreyi, 2003

F (Mumbai)

Sample size
cases
78 (M)
12 (F)
46 (slum)
26 (non-slum)
116

Homocysteine
(mol/L)

Vitamin B12
(pg/ml)

Folic acid
(ng/ml)

18.65 11.23
14.90 6.34
20.8 5.9
23.2 5.9
10.4 5.5

278.4 262.7

11.03 6.9

M: Male, F : Female, Hyd: Hyderabad

C : Community based comparative studies in A Ind v/s Caucasians

Study

Sample

Sample size
Indians Caucasians

Carmel et al 31, 2003

M/F (US)

60

143

Chandalia et al 11, 2003

M/F (US)

227

155

Homocysteine
(mmol/L)

Vitamin B12
(pmol/L)

Folic acid
(nmol/L)

9.4 (Indians)
8.1(Caucasians)
14 6.5 (Indians)
8.7 3.6 (Caucasians)

192 (Indians)
306 (Caucasians)
258 200 (Indians)
342 133 (Caucasians)

25.4 (Indians)
24 (Caucasians)

Kingdom found plasma Hcy as an independent risk

factor for CAD.25 Most studies done in resident Indians
have been done in patients with CAD. These do not
support an association between Hcy and CAD in resident
Indians. The mean Hcy concentrations reported in
various Indian studies are shown in Table 4. The cut-off
values of hyperhomocysteinemia are different in various
studies. The prevalence of hyperhomocysteinemia in
cases and controls is shown in Table 4 (A).
In most studies, both cases and control subjects had
elevated mean Hcy concentration if a cut-off value of 12
is taken for defining hyperhomocysteinemia. In our
study 24.2% women had Hcy concentration of
>12 mol/L.
One of the suggested reasons for this discrepancy in
results from studies done abroad and those in resident
Indians may be due to differences in dietary habits25.
Reduced intake of vitamin B 12 and folic acid may result
from prolonged cooking of vegetables, which is a
common practice in Indian households. 32 Dietary
deficiencies of vitamins may also result from chronic
intestinal infections, again common in India.33 Chronic
vitamin deficiencies could lead to elevated Hcy levels
but a compensatory mechanism probably develops
772

whereby this does not lead to development of CAD in

resident Indians. Population screening studies in
resident Indians28,29 show high mean Hcy concentration
in both men and women. Similar results are seen in both
cases of CVD and controls20,26-28 further supporting this
hypothesis. In the study by Refsum et al cobalamin
deficiency was common even in subjects with regular
intake of poultry.29 Since marked ethnic differences in
cobalamin metabolism have been reported, adaptation
of Indian to low cobalamin and resultant high Hcy
concentrations through genetic mechanisms may be a
possibility.
Another possible variable that has not received
attention is the relationship of vitamin B6 and fasting
Hcy concentrations. Studies have shown varied results
with no association34 to a moderate association16 between
B6 deficiency and elevated fasting Hcy levels.
A possible explanation for this is that mild impairment
of Hcy remethylation is associated with elevated fasting
Hcy but partially impaired transsulfuration (Vitamin B6
dependent) in heterozygotes for cystathionine-synthase deficiency is not associated with elevated
fasting Hcy concentrations.35 With an L-methionine load
test, it is possible to unmask hyperhomocysteinemia in

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JAPI VOL. 54 OCTOBER 2006

these subjects.36 Ours as well as other studies in resident

Indians have not estimated Hcy after a methionine load,
in which case results may have been different. Some
investigators have proposed that Vit B6 deficiency
contributing to an abnormal methionine load test could
be an independent risk factor for CAD.37
In a recent study by Chandalia et al, plasma Hcy levels
were higher and vitamin B 12 levels lower amongst
Asian Indians in U.S. compared to Caucasians.11 This
study done after food fortification of cereals and grains
with folate showed similar folate levels in both groups.
Significantly, even for levels of vitamin B-12 within the
clinically normal range, Indians had higher Hcy than
Caucasians. The authors proposed that genetic factors
may directly affect Hcy metabolism and also vitamin B12 absorption.
In conclusion, the present study of 137 women from
Mumbai shows that 24.2% of women have elevated
fasting plasma Hcy levels and a large number are
deficient in vitamin B-12, which is the major variable
correlating with Hcy. Intervention with vitamin B-12 and
FA supplementation may be necessary to reduce Hcy
concentrations.
With growing recognition of Hcy as an independent
risk factor for CAD, prospective population-based
studies are needed to study the mechanisms of Hcymediated vascular injury, especially in resident Indians
against the background of chronic folate and vitamin B12 deficiency.
Acknowledgements
We thankfully acknowledge Mr. Darshan Parmar
(National Manager Logistics and Distribution, Trivitron
diagnostics Ltd.) for the generous gift of kits of
homocysteine, vitamin B12 and folic acid (Diagnostic
Products Corporation, USA).
Maitreyis multidisciplinary team members are
thankfully acknowledged for their dedicated and
sustained services for menopausal health at Bhavans
SPARC. We appreciate technical help from Ms. Shubada
Agashe, Ms. Surekha Shah and Ms. Suma Santosh for
laboratory studies. Shree Dhirubhai Mehta, Director
General and Executive Secretary of Bharatiya Vidya
Bhavan has been a source of constant encouragement.

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heterozygosity for homocystinuria due to cystathionine betasynthase deficiency. Metab Clin Exp 1998;37:175-8.
36. Ubbik JB, van der Merwe, Delport R et al. The effect of a
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J Clin Invest 1996;98:177-84.

Announcement

Election Results of API/ICP

The election results of the Office Bearers, Members of the Governing Body of the Association of Physicians of India
and the Members of the Faculty Council of Indian College of Physicians 2007-2008.
Results of the API elections
The following members were declared elected:
President Elect
Vice President
Hon. General Secretary

Dr. SK Bichile, Mumbai

Dr. Pritam Gupta, New Delhi (unopposed)
Dr. Sandhya Kamath, Mumbai

4 Governing Body Members

Dr. Rohini Handa, New Delhi
Dr. Amal Kumar Banerjee, Howrah
Dr. R Sajith Kumar, Kottayam
Dr. Abhay N Rai, Gaya
Results of the ICP elections
5 Faculty Council Members
Dr. S Chugh, New Delhi
Dr. Subhash Chandra, New Delhi
Dr. MP Shrivastava, New Delhi
Dr. HM Lal, Hyderabad
Dr. BN Jha, Muzaffarpur

Announcement
Third Madras Diabetes Research Foundation (MDRF) American Diabetes Association (ADA) Postgraduate
Course on Diabetes, at Chennai, India, 6 - 8th October 2006.
The Third MDRF-ADA Postgraduate Course on Diabetes will be held from 6th to 8th October 2006 at Chennai,
India. The meeting will be hosted by the Madras Diabetes Research Foundation, Chennai.
For further details, contact : Dr. V Mohan, Or Dr. Rema Mohan, Madras Diabetes Research Foundation and Dr.
Mohans Diabetes Specialities Centre, No.4 Conran Smith Road, Gopalapuram, Chennai - 600 086, India.
Phone : (91 44) 28359048, 28359051, 28353351; Fax : (91 44) 28350935; E-mail : mvdsc@vsnl.com
Also visit our website at www.mdrf-ada.com or www.drmohansdiabetes.com
for details regarding registration etc.

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www.japi.org

JAPI VOL. 54 OCTOBER 2006