18-19 IFMNT COT Cardiometabolic Genomics with Application Susan Allen-Evenson RDN, CCN, FMNS

18-19 IFMNT COT CardioMetabolic Genomics with Application Susan Allen-Evenson RDN, CCN, FMNS

• DIO1 and DIO2 • CBS • FUT2 • MTHFR • MTR and MTRR • SLC19A1 • TCN2 • APOC3 • CETP • LPL DIO1 and DIO2 Deiodinase, iodothyronine Type I (DIO1) and Type II (DIO2) Deiodinases regulate thyroid hormone activity DIO1 and DIO2: • Both catalyze conversion of thyroxine (T4), secreted from the thyroid gland, into the bioactive thyroid hormone T3 through deiodination of T4 • They require selenium and cysteine (selenocysteine) for optimal function

1. DIO1 Gene (Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=DIO1. Accessed December 24, 2019. 2. DIO2 Gene (Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=DIO2. Accessed December 24, 2019 3. Ristic A. A Gene That Activates Thyroid Hormones (DIO1). SelfDecode. https://selfdecode.com/blog/article/low-thyroid-dio1-18. Accessed December 25, 2019.. ©2019 COPYRIGHT. ALL RIGHTS RESERVED DIO1 and DIO2

• DIO1 activity mainly localized in thyroid, liver and kidneys • DIO2 activity expresses at high levels in brain, pituitary, central nervous system, thyroid, heart and peripheral tissues (skeletal muscle) • DIO2 significance: Accounts for up to 60% of T3 production

1. Watson R, Watson, Ronald Ross (university Of Arizona, Mel And Enid Zu. Selenium and Senescence (Ch.21). In: Foods and Dietary Supplements in the Prevention and Treatment of Disease In. Elsevier Science Publishing Co; 2015:211-229. 2. Ristic A. The Gene Associated with "Hidden Hypothyroidism" (DIO2). SelfDecode. https://selfdecode.com/blog/article/hidden-hypothyroidism-dio2-36. Accessed January 4, 2020.

• Thyroid hormones affect almost every aspect of the cardiovascular system • T3 increases force/speed of systolic contraction and speed of diastolic relaxation • T3 decreases vascular resistance, including coronary vascular tone, and increases coronary arteriolar angiogenesis

1. Kannan L, Shaw PA, Morley MP, et al. Thyroid Dysfunction in Heart Failure and Cardiovascular Outcomes. Circulation: Heart Failure. 2018;11(12). doi:10.1161/circheartfailure.118.005266. 2. Maino F, Cantara S, Forleo R, Pilli T, Castagna MG. Clinical significance of type 2 iodothyronine deiodinase polymorphism. Expert Review of Endocrinology & Metabolism. 2018;13(5):273-277. doi:10.1080/17446651.2018.1523714. ©2019 COPYRIGHT. ALL RIGHTS RESERVED Schematic Drawing of the Thyroid Hormone Network

Pörings A-S, Lowin T, Dufner B, Grifka J, Straub RH. A thyroid hormone network exists in synovial fibroblasts of rheumatoid arthritis and osteoarthritis patients. Scientific Reports. 2019;9(1). doi:10.1038/s41598-019-49743-4. ©2019 COPYRIGHT. ALL RIGHTS RESERVED DIO1 and DIO2

Implication of expressed SNPs: • Decreased enzyme activity and a decreased conversion of T4 to T3 • Increases risk of dyslipidemia and heart disease

Implication of expressed SNPs: "Hidden Hypothyroidism“ • Have symptoms of low thyroid hormones despite their lab results being in the normal range • DIO2 variant may be involved in this: • “C" allele on rs225014 (Thr92Ala) is associated with: • Poor response to thyroid meds • Obesity and insulin resistance • Inadequate blood sugar control • Impaired cognitive development (lower IQ) All of the above may indicate low thyroid hormones in DIO2 target tissues such as the brain, fat tissue, and muscles Ristic A. The Gene Associated with "Hidden Hypothyroidism" (DIO2). SelfDecode. https://selfdecode.com/blog/article/hidden-hypothyroidism-dio2-36. Accessed January 4, 2020. ©2019 COPYRIGHT. ALL RIGHTS RESERVED DIO1 and DIO2 Application

Analytes: • (High/Low) Thyroid Hormones (T3 - total and free), T4, TSH) Recommended Supplementation (as indicated): • Iodine/Iodide (food sources as well) • Levothyroxine (ex: Synthroid – T4) • Selenium/selenomethionine/selenocysteine • Liothyronine (Ex: Cytomel – T3)

1. Database G. DIO1 Gene(Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=DIO1. Accessed October 20, 2019. 2. Database G. DIO2 Gene(Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=DIO2. Accessed October 20, 2019. 3. Welsh KJ, Soldin SJ. DIAGNOSIS OF ENDOCRINE DISEASE: How reliable are free thyroid and total T3 hormone assays? European Journal of Endocrinology. 2016;175(6). doi:10.1530/eje-16-0193. ©2019 COPYRIGHT. ALL RIGHTS RESERVED CBS Cystathionine β-synthase

• The CBS enzyme catalyzes the first step of homocysteine transsulfuration as a rate-limiting enzyme – CBS uses vitamin B6 to convert amino acids (homocysteine and serine) to a molecule called cytathionine

1. Zhao J-Y, Yang X-Y, Shi K-H, et al. A functional variant in the cystathionine β-synthase gene promoter significantly reduces congenital heart disease susceptibility in a Han Chinese population. Cell Research. 2012;23(2):242-253. doi:10.1038/cr.2012.135. 2. CBS gene - Genetics Home Reference - NIH. U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/CBS. Accessed January 4, 2020.

Modified image: Kruger WD. Cystathionine β-synthase deficiency: Of mice and men. Molecular Genetics and Metabolism. 2017;121(3):199-205. doi:10.1016/j.ymgme.2017.05.011. ©2019 COPYRIGHT. ALL RIGHTS RESERVED CBS Mutations: Upregulation/Downregulation Upregulation • Upregulation of CBS genes = rapid sulfur metabolism = low homocysteine • When CBS gene is highly active, the body cycles through homocysteine quickly • Ammonia is a byproduct of metabolizing sulfur, thus increased CBS activity = higher levels of ammonia Downregulation • Downregulation/diminished CBS activity = poor sulfur metabolism, the pooling of sulfur groups, and potentially high homocysteine • Low CBS activity is associated with diseases like homocystinuria

1. A CBS Mutation Could Be Causing Your Health Problems. Dr. Lam Coaching - World Renowned Authority on Adrenal Fatigue Recovery. https://www.drlamcoaching.com/adrenal- fatigue/complications/cbs-mutation/. Accessed January 5, 2020. 2. CBS gene - Mutations and Nutrition Information by Dr. Aaron Gardner. Gene Food. https://www.mygenefood.com/genes/gastrointestinal-genes/cbs/. Accessed January 5, 2020. ©2019 COPYRIGHT. ALL RIGHTS RESERVED CBS Mutations Implication of expressed SNPs: – Upregulation: • Potential for sulfur intolerance, if other sulfur metabolism SNP mutations • Higher ammonia levels • Note: While it's true that CBS upregulation can cause increased taurine and ammonia production, their increase may not always be detected by measuring urinary levels • Urinary taurine is an unreliable test for CBS upregulation – It may be high however, levels are dependent on many factors, including age, genetics, gender, renal function, clinical conditions, and especially dietary intake

1. MTHFRsupport. CBS gene mutation. MthfrGeneHealth. https://mthfrgenehealth.com/cbs-gene-mutation/. Accessed January 4, 2020. 2. CBS Upregulation, Myth or Reality? CBS Upregulation, Myth or Reality. http://web.mit.edu/london/www/cbs.html. Accessed January 4, 2020. ©2019 COPYRIGHT. ALL RIGHTS RESERVED Addressing Upregulated CBS:

• Detoxifying ammonia – liver support, ensure adequate SCFA status (fiber/probiotics) • In the presence of ammonia, lowering excessive taurine levels (reduce protein intake to .5 gm/kg of body weight • Limiting foods and nutrients that contribute to ammonia (excess protein, especially processed beef) or sulfites • Supplying the body with depleted nutrients

• Unless addressed first, adding in other methylation cycle supports can lead to increased levels of ammonia, highly elevated taurine, hydrogen sulfide, and other toxic sulfur byproducts – Manganese is also important in ammonia detoxification; L-Ornithine may be effective, as well • Support the CBS enzyme for at least 6 weeks before starting methylation supplements • Consider doing a Urine Amino Acids (UAA) test – taurine should be 50% or less

McEvoy M. Metabolic Gateways: CBS Gene Mutations & Glutathione. Metabolic Healing. https://metabolichealing.com/metabolic-gateways-cbs-gene-mutations-glutathione/. Published March 27, 2013. Accessed December 5, 2018 ©2019 COPYRIGHT. ALL RIGHTS RESERVED CBS Mutations – Downregulation (CVD risk): • Elevated homocysteine = potential CVD risk • There is some debate as to why, but there is a relationship between high levels of homocysteine and artery damage (endothelial dysfunction) - leading to atherosclerosis (hardening of the arteries) and blood clots • Vit B6 deficiency makes it worse and decreases enzyme function independent of SNP expression

1. Beckerman J. Homocysteine Levels: How They Effect Your Risk for Heart Disease. WebMD. https://www.webmd.com/heart-disease/guide/homocysteine-risk. Published September 5, 2018. Accessed January 5, 2020. 2. CBS gene - Mutations and Nutrition Information by Dr. Aaron Gardner. Gene Food. https://www.mygenefood.com/genes/gastrointestinal-genes/cbs/. Accessed January 5, 2020. 3. Liang S, Zhou Y, Wang H, et al. The effect of multiple single nucleotide polymorphisms in the folic acid pathway genes on homocysteine metabolism. BioMed Research International. 2014. doi:10.1155/2014/560183. 4. Shi H, Yang S, Liu Y, et al. Study on Environmental Causes and SNPs of MTHFR, MS and CBS Genes Related to Congenital Heart Disease. PLoS ONE. 2015;10(6):1. doi:10.1371/journal.pone.0128646 ©2019 COPYRIGHT. ALL RIGHTS RESERVED CBS Mutations – Downregulation (CVD risk): • The rare "A" allele of rs289934891 (G/A) (associated with decreased CBS activity and high homocysteine levels) = potential for increased cardiovascular risk • The “C” allele of rs5742905 (T/C) (associated with increased levels of homocysteine in the blood/increased risk of cardiovascular disease

CBS gene - Mutations and Nutrition Information by Dr. Aaron Gardner. Gene Food. https://www.mygenefood.com/genes/gastrointestinal-genes/cbs/. Accessed January 5, 2020.

©2019 COPYRIGHT. ALL RIGHTS RESERVED CBS Mutations With CBS mutations (up or downregulation), may need to watch response to … Sulfur containing foods • Epsom salt baths • Garlic • Alpha lipoic acid, • Broccoli • Glutathione Chelating agents such • Eggs • as DMPS • Onions • NAC • Legumes • Milk Thistle • Meat • MSM

Lam M. A Little-Known CBS Mutation Could Be Causing Your Health Problems. DrLam.com. https://www.drlamcoaching.com/adrenal-fatigue/complications/cbs-mutation/. Published August 22, 2017. Accessed January 4, 2020. ©2019 COPYRIGHT. ALL RIGHTS RESERVED Identifying CBS Expression Analytes: Downregulation • High homocysteine Analytes: Upregulation • Low levels of homocysteine, typically less than 6. – Could be a strong indicator of CBS upregulations caused by the homocysteine being drawn excessively into transsulfuration via the CBS gene. • BUN (blood, urea, nitrogen) ranging greater than 20. – BUN may be elevated for other reasons, such as renal dysfunction or dehydration – However, with CBS mutations, elevated BUN levels may be the result of excess ammonia feeding into the urea cycle • ALT (alanine lactate transferase), greater than 30. – ALT is a metabolic enzyme that is found in several organs and tissues. – ALT may be elevated for a number of reasons, it can also be elevated from excess ammonia, from the mutation. 1. Database G. CBS Gene (Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=CBS&keywords=cbs. Accessed October 29, 2019. 2. A CBS Mutation Could Be Causing Your Health Problems. Dr. Lam Coaching - World Renowned Authority on Adrenal Fatigue Recovery. https://www.drlamcoaching.com/adrenal- fatigue/complications/cbs-mutation/. Accessed December 28, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED Recommendations Supplementation and diet – • Folate • Downregulation: B vitamins, esp. B6 – Caveats in upregulation: Several large-scale randomized clinical trials show that vitamin supplementation lowers plasma homocysteine levels, but may fail to prevent negative cardiovascular outcomes – Also, Vit B6 in P5P form may interfere with people with CBS SNPs (lower doses may be required) – More research into CBS function/mutations must be done, independent of high homocysteine levels

1. Cystathionine beta synthase (CBS) and angiogenesis. Mayo Clinic. https://mayoclinic.pure.elsevier.com/en/projects/cystathionine-beta-synthase-cbs-and-angiogenesis. Accessed January 5, 2020. 2. Erdei H, Chris, Caws, et al. Gene Mutations That Need To Be Addressed Before Starting with MTHFR. MTHFR Support. https://mthfrsupport.com/2013/05/other-gene- mutations-that-must-be-addressed-before-starting-an-mthfr-protocol/. Published August 3, 2017. Accessed January 5, 2020. ©2019 COPYRIGHT. ALL RIGHTS RESERVED FUT2 Fucosyl transferase 2 • This gene is one of two encoding the galactoside 2-L-fucosyltransferase enzyme • It is an enzyme responsible for the synthesis of the H-antigen in body fluids and on the intestinal mucosa • Determines secretor vs. non-secretor status • Strong connection to B12 levels

SelfDecode: Genome Analysis. SelfDecode.com. https://selfdecode.com/gene/fut2/. Accessed January 5, 2020.

©2019 COPYRIGHT. ALL RIGHTS RESERVED Secretor vs. Non-Secretor • Functional FUT2 gene: a person becomes a “secretor” – H-antigen (blood type antigens) are secreted into body fluids – i.e. saliva, mucus (in the digestive tract and the respiratory cavities), tears, sweat, etc. – Non-secretors (about 20%) – Secretor factor may determine risk for disease

• FUT2 variants have a strong association with levels of B12 (cobalamin) – Especially associated with SNP (rs602662)

GENOTYPE (RS602662) PHENOTYPE

AA [Advantage] More likely to have higher plasma vitamin B12 levels

AG Moderate plasma Vitamin B12 levels

GG [Limitation] More likely to lower plasma Vitamin B12 levels

• Associated with increased risk of vitamin deficiency B12 (esp. w/vegetarians and vegans) and elevated homocysteine – B12 deficiency is a risk factor for CVD (and more) • Coronary Artery Disease (CAD), hyperhomocysteinemia, megaloblastic anemia, Impaired immune defense, gastrointestinal disorders • Associated with low intestinal microbial diversity

1. Tanwar VS, Chand MP, Kumar J, et al. Short Communication: Common variant in FUT2 gene is associated with levels of vitamin B12 in Indian population. Gene. 2013;515:224- 228. doi:10.1016/j.gene.2012.11.021 2. Piazzolla G, Candigliota M, Fanelli M, et al. Hyperhomocysteinemia is an independent risk factor of atherosclerosis in patients with metabolic syndrome. Diabetology & Metabolic Syndrome. 2019;11(1). doi:10.1186/s13098-019-0484-0. 3. Know Your Genes: FUT2 "Vitamin B12 Gene". Xcode Life. https://www.xcode.life/dna-and-health/know-genes-fut2-vitamin-b12-gene/. Accessed January 6, 2020. ©2019 COPYRIGHT. ALL RIGHTS RESERVED H. pylori Connection • Research shows a correlation between FUT2 expression and the ability of H. pylori to bind to gastric mucosa • H. pylori in the lining of the stomach may hinder B12 absorption • FUT2 secretor variant worsens B12 status in cases with heterozygous GIF (Gastric Intrinsic Factor) mutations by impairing GIF secretion, independently from H. pylori-related gastritis

1. Magalhães A, Rossez Y, Robbe-Masselot C, et al. Muc5ac gastric mucin glycosylation is shaped by FUT2 activity and functionally impacts Helicobacter pylori binding. Scientific Reports. 2016;6(1). doi:10.1038/srep25575. 2. Chery C, Hehn A, Mrabet N, et al. Gastric intrinsic factor deficiency with combined GIF heterozygous mutations and FUT2 secretor variant. Biochimie. 2013;95(5):995- 1001. doi:10.1016/j.biochi.2013.01.022. ©2019 COPYRIGHT. ALL RIGHTS RESERVED FUT2 Pathway

Analytes: • Low B12 • High Homocysteine Recommended Supplementation (as indicated): Supplementation and diet - • B12 (especially for vegans/vegetarians – Methylated version depending on related factors • Address Microbiome: Probiotic food sources/supplements

Database G. FUT2 Gene (Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=FUT2&keywords=fut2. Accessed November 2, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED MTHFR Methylenetetrahydrofolate reductase

• MTHFR (gene) provides instructions for making the enzyme methylenetetrahydrofolate reductase, which is essential for folate and homocysteine metabolism • Methylenetetrahydrofolate reductase catalyzes the conversion of 5,10-methylenetetrahydrofolate to 5- methyltetrahydrofolate (active/usable) – 5-methyltetrahydrofolate is the primary circulatory form of folate utilized in homocysteine remethylation to methionine

1. Ueland PM, Rozen R. MTHFR Polymorphisms and Disease. Georgetown, TX: Landes Bioscience; 2005. 2. THFR gene - Genetics Home Reference - NIH. U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MTHFR#conditions. Accessed October 05, 2019.

MTHFR: HOMOZYGOUS MUTATION AND CORRELATED CARDIOVASCULAR RISK

• MTHFR: methylenetetrahydrofolate reductase gene • Associated with decreased enzymatic function, which may lead to decreased levels of 5MTHF (active form of folate, methylenetetrahydrofolate) and elevated homocysteine. – Exacerbated by low folate intake and Riboflavin insufficiency ©2019 COPYRIGHT. ALL RIGHTS RESERVED MTHFR

Implication of expressed SNPs: • Can lead to decreased levels of 5,10 methylfolate and elevated homocysteine • Increased risk for cardiovascular disease and stroke – Strong consistent relationship with CVD in the presence of homocysteinemia • Impact greater with additional SNP in MTHFR-2

1. Masud R, Baqai HZ. The communal relation of MTHFR, MTR, ACE gene polymorphisms and hyperhomocysteinemia as conceivable risk of coronary artery disease. Applied Physiology, Nutrition & Metabolism. 2017;42(10):1009-1014. doi: 10.1139/apnm-2017-0030 2. MTHFR gene - Genetics Home Reference - NIH. U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MTHFR#conditions. Accessed October 05, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED MTHFR Application

Analytes: • High Homocysteine • Low/high folate - as an indication of lack of conversion RBC Folate: Folate more concentrated than serum and reflects tissue stores , less sensitive to short term dietary effects Recommended Supplementation (as indicated): Supplementation and diet - • Methylfolate • Folate containing foods

1. Database G. GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=MTHFR&keywords=mthfr. Accessed November 6, 2019. 2. Masud R, Baqai HZ. The communal relation of MTHFR, MTR, ACE gene polymorphisms and hyperhomocysteinemia as conceivable risk of coronary artery disease. Applied Physiology, Nutrition & Metabolism. 2017;42(10):1009-1014. doi: 10.1139/apnm-2017-0030 3. MTHFR gene - Genetics Home Reference - NIH. U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MTHFR#conditions. Accessed October 05, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED MTR and MTRR MTR: Methionine Synthase (aka: 5-methyltetrahydrofolate-homocysteine methyltransferase) • Enzyme converts homocysteine to methionine MTRR: Methionine Synthase Reductase • Enzyme required for proper function of methionine synthase • After a period of being turned on (active), MTR turns off (becomes inactive) • MTRR reactivates MTR, so it can continue to produce methionine

1. MTR gene - Genetics Home Reference - NIH. U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MTR. Accessed October 5, 2019. 2. MTRR gene - Genetics Home Reference - NIH. U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MTRR#conditions. Accessed October 5, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED MTR and MTRR Homocysteine Metabolism Pathway

The Methylation Myths: MTR & MTRR. MTHFRSupport Australia. https://mthfrsupport.com.au/2014/09/mtr-mtrr/. Published March 20, 2019. Accessed December 13, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED MTR and MTRR

• Both MTR and MTRR require methylcobalamin (B12) to function properly

• Implication of expressed SNPs: – Reduced enzymatic activity leads to elevated homocysteine

• Gene encodes for the methionine synthase enzyme – which converts homocysteine into methionine through methylation, using methyl-tetrahydrofolate as the methyl donor • Along with MTHFR and MTRR, involved in the folate methylation-transsulfuration pathway • SNP expression: Higher homocysteine and lower B12. Risk is worse with smoking.

1. MTHFR gene - Genetics Home Reference - NIH. NIH U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MTHFR. Published December 4, 2018. Accessed December 5, 2018. 2. MTR gene - Genetics Home Reference - NIH. NIH U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MTR. Published December 4, 2018. Accessed December 5, 2018. 3. MTRR gene - Genetics Home Reference - NIH. NIH U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/MTRR. Published December 4, 2018. Accessed December 5, 2018. ©2019 COPYRIGHT. ALL RIGHTS RESERVED MTR and MTRR Application Analytes: • High Homocysteine • Low RBC Folate (high?) • Low Serum B12 (high?) Recommended Supplementation (as indicated): • Methylcobalamin (B12) supplementation • Note: If MTR/MTRR are malfunctioning, do not supplement with methylfolate • Inability to create methionine will cause risk of over- methylation • Over-methylation symptoms: drop in mood, aches and pains, a rash, headaches, and fatigue

1. The Methylation Myths: MTR & MTRR. MTHFRSupport Australia. https://mthfrsupport.com.au/2014/09/mtr-mtrr/. Published March 20, 2019. Accessed December 13, 2019. 2. Database G. MTR Gene (Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=MTR&keywords=mtr. Accessed November 9, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED SLC19A1 Human solute carrier gene (SLC) – Encompasses 55 gene families • Implication of expressed SNPs: – Folates are transported from blood into cells via SLC19A1 – Involved in the regulation of intracellular folate levels – Decreased enzymatic function can lead to elevated levels of homocysteine

1. Lin L, Yee SW, Kim RB, Giacomini KM. SLC transporters as therapeutic targets: emerging opportunities. Nature Reviews Drug Discovery. 2015;14(8):543-560. doi:10.1038/nrd4626. 2. SLC19A1 Gene. GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=SLC19A1. Accessed October 6, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED SLC19A1 SNP

• The membrane protein, RFC1 (reduced folate carrier)encoded by this gene is a transporter of folate and is involved in the regulation of intracellular concentrations of folate – Women who are homozygous for the c80G allele may be at increased risk for lower RBC Folate and of having a child affected with a neural tube defect and of developing pathologies that have been associated with folate insufficiency, such as cardiovascular disease. – Those with SLC19A1 c80A allele may have reduced serum RBC – Homozygous MTHFR c677TT and SLC19A1 c80GG increases risk for elevated homocysteine

A. Stanisławska-Sachadyn, et al. The reduced folate carrier (SLC19A1) c.80G>A polymorphism is associated with red cell folate concentrations among women. Ann Hum Genet. 2009 Sep; 73(Pt 5): 484–491. DOI: 10.1111/j.1469-1809.2009.00529.x ©2019 COPYRIGHT. ALL RIGHTS RESERVED SLC19A1 Pathway

Folate Transport into the Cell

Modified Image: Vidmar M, Grželj J, Mlinarič-Raščan I, Geršak K, Dolenc MS. Medicines associated with folate–homocysteine–methionine pathway disruption. Archives of Toxicology. 2018;93(2):227-251. doi:10.1007/s00204-018-2364-z. ©2019 COPYRIGHT. ALL RIGHTS RESERVED SLC19A1 Application

Analytes: • RBC folate • Homocysteine Recommended Supplementation (as indicated): Supplementation and diet - • Folate • B vitamins (B12, B6)

Database G. SLC19A1 Gene (Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=SLC19A1. Accessed November 20, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED TCN2 Transcobalamin II Transcobalamin II • Implication of expressed SNPs: – Responsible for making the protein transcobalamin and transporting it throughout the body – Associated with decreased enzyme function and decreased affinity to cobalamin • Increased risk for vitamin B12 deficiency • Increased risk of elevated homocysteine levels

1. Stanisławska-Sachadyn A, Woodside JV, Sayers CM, et al. The transcobalamin (TCN2) 776C>G polymorphism affects homocysteine concentrations among subjects with low vitamin B(12) status. European Journal Of Clinical Nutrition. 2010;64(11):1338-1343. doi:10.1038/ejcn.2010.157. 2. TCN2 gene - Genetics Home Reference - NIH. U.S. National Library of Medicine. https://ghr.nlm.nih.gov/gene/TCN2#. Accessed October 6, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED TCN2 SNP

• Associated with decreased enzyme function, with decreased affinity for cobalamin and increased risk for vitamin B12 deficiency, elevated homocysteine. • Result if expressed: Delivery of B12 to cells may be limited • If also COMT snp, use hydroxy or adenosylcobalamin

Analytes: • B12 • Methylmalonic acid • Homocysteine Recommended Supplementation (as indicated): Supplementation and diet - • Regulate B12

Database G. TCN2 Gene (Protein Coding). GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=TCN2&keywords=tcn. Accessed November 21, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED TCN2 Application

Analytes: • B12 • Methylmalonic acid, Serum >260-350 nmol/L – May reflect renal dysfunction instead • Homocysteine Recommended Supplementation (as indicated): Supplementation and diet - • Regulate B12

• Encodes a lipid-binding protein • Activates the enzyme lipoprotein lipase, which hydrolyzes triglycerides and thus provides free fatty acids for cells • Implication of expressed SNPs: – Associated with hyperlipoproteinemia type IB, characterized by hypertriglyceridemia, xanthomas, and increased risk of pancreatitis and early atherosclerosis – May be associated with lower HDL with higher cholesterol diet

1. APOC2 Gene. GeneCards. https://www.genecards.org/cgi-bin/carddisp.pl?gene=APOC2&keywords=APOC2. Accessed October 6, 2019. 2. APOC2 gene. Genetics Home Reference - NIH. https://ghr.nlm.nih.gov/gene/APOC2. Published January 2019. Accessed October 6, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED APOC3 Application Analytes: • Fractionated lipid panel Recommended Supplementation (as indicated): Supplementation and diet – • Antioxidants • Decrease fats/saturated fats, simple carbohydrates and sugars • Fruits/vegetables (high-fiber), lean proteins, and foods rich in monounsaturated fatty acids

Kanter JE, Shao B, Kramer F, et al. Increased apolipoprotein C3 drives cardiovascular risk in type 1 diabetes. Journal of Clinical Investigation. 2019;129(10):4165-4179. doi:10.1172/jci127308. ©2019 COPYRIGHT. ALL RIGHTS RESERVED APOC3 Pathway

Precision Nutrition to Target Pathways that Lower Blood Triglycerides. Precision Nutrition to Target Pathways that Lower Blood Triglycerides. https://www.gbhealthwatch.com/HotTopic-Multiple-pathways-elevated-triglycerides.php. Accessed December 10, 2019. ©2019 COPYRIGHT. ALL RIGHTS RESERVED CETP Cholesteryl ester transfer protein

• Protein encoded by this gene is involved in the transfer of cholesteryl ester from high density lipoprotein (HDL) to other lipoproteins • Implication of expressed SNPs: – Defects in this gene are a cause of hyperalphalipoproteinemia 1 (high HDL-C) – Associated with increased formation of sdLDL, TG, lipoproteins, VLDL, and lower HDL levels

1. CETP gene. Genetics Home Reference - NIH. https://ghr.nlm.nih.gov/gene/CETP. Published January 2019. Accessed October 6, 2019. 2. de Gonzalo-Calvo D, Llorente-Cortés V, Orbe J, Páramo JA, Badimon L. High triglyceride-low HDL cholesterol lipid profile is associated with a dysregulated gene expression in mononuclear leukocyte from hypercholesterolemic patients. International Journal Of Cardiology. 2015;178:102-104. doi:10.1016/j.ijcard.2014.10.126. ©2019 COPYRIGHT. ALL RIGHTS RESERVED CETP Application

Analytes: • Fractionated lipid panel Recommended Supplementation (as indicated): Supplementation and diet – • Antioxidants • Decrease saturated fats • Increase fruits/vegetables • Increase plant sterols

Shinkai H. Cholesteryl ester transfer-protein modulator and inhibitors and their potential for the treatment of cardiovascular diseases. Vascular Health and Risk Management. 2012:323. doi:10.2147/vhrm.s25238. ©2019 COPYRIGHT. ALL RIGHTS RESERVED LPL Lipoprotein lipase • Involved in production of lipoprotein lipase • Expressed in heart, muscle, and adipose tissue • Plays critical role in breaking down fat in the form of triglycerides • Implication of expressed SNPs: – Severe mutations that cause LPL deficiency result in type I hyperlipoproteinemia – Associated with lower binding affinity for lipoprotein lipase and reduced LPL activity • Leading to decreased hydrolysis of VLDL and chylomicrons to free fatty acids, with increased VLDL and TG levels

Analytes: • Fractionated lipid panel Recommended Supplementation (as indicated): Supplementation and diet – • EPA/DHA • Red rice yeast (in some circumstances) • Decrease fats/saturated fats