title: Dietary diversity no longer offsets the mortality risk of hyperhomocysteinaemia in older adults with diabetes: a prospective cohort study.
abstract: OBJECTIVE
  The increased mortality risk of hyperhomocysteinaemia in diabetes may be mitigated by dietary quality.
  
  
  METHODS
  The Nutrition and Health Survey in Taiwan of 1999-2000 for elders formed this prospective cohort. Baseline health status, diet and anthropometry were documented and plasma homocysteine and biomarkers for B vitamins measured. Participants without diabetes (n=985) were referent for those who had diabetes or developed diabetes until 2006 (n=427). The effect of homocysteine on mortality risk during 1999-2008 was evaluated.
  
  
  RESULTS
  Men, smokers and those with poorer physical function had higher homocysteine, but less so with diabetes. Diabetes incidence was unrelated to homocysteine. In hyperhomocysteinaemia (>=15 vs <15 μmol/L), those with diabetes had an adjusted hazard ratio (HR) (95% CI) for mortality of 1.71 (1.18-2.46); p for interaction between homocysteine and diabetes was 0.005. Without diabetes, but with hyperhomocysteinaemia and a low dietary diversity score (DDS <=4 of 6), where the joint mortality hazard for the greater DDS, (>4) and lower homocysteine (<15) was referent, the HR was 1.80 (1.27-2.54) with significant interaction (p=0.008); by contrast, there was no joint effect with diabetes. The contribution of DDS to mortality mitigation in hyperhomocysteinaemia could not be explained by B group vitamins, even though plasma folate was low in hyperhomocysteinaemic participants. With hyperhomocysteinaemia, heart failure was a major cause of death.
  
  
  CONCLUSIONS
  In non-diabetic hyperhomocysteinaemia, a more diverse diet increases survival prospects independent of B group vitamins, but not in hyperhomocysteinaemic diabetes where the cardiomyopathy may be less responsive.
authors.affiliation: Division of Preventive Medicine and Health Services Research, Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan, ROC.|School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC.|Monash Asia Institute, Monash University, Melbourne, Australia.|Fuli Institute of Food Science and Nutrition, Zhejiang University, Hangzhou, Zhejiang, China.
authors.forename: Mark L
authors.initials: ML
authors.lastname: Wahlqvist
authors.affiliation: Department of Food Science and Nutrition, Zhejiang University, Hangzhou, Zhejiang, China.|School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China.
authors.forename: Lili
authors.initials: L
authors.lastname: Xiu
authors.affiliation: School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC. Email: mmsl@ndmctsgh.edu.tw.|Monash Asia Institute, Monash University, Melbourne, Australia.
authors.forename: Meei-Shyuan
authors.initials: MS
authors.lastname: Lee
authors.affiliation: Division of Preventive Medicine and Health Services Research, Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan, ROC.
authors.forename: Rosalind Chia-Yu
authors.initials: RC
authors.lastname: Chen
authors.affiliation: Department of Hospitality Management, Chung-Hwa University of Medical Technology, Tainan, Taiwan, ROC.|Department of Nutrition and Health Science, Fooyin University, Kaohsiung City, Taiwan, ROC.
authors.forename: Kuan-Ju
authors.initials: KJ
authors.lastname: Chen
authors.affiliation: Department of Food Science and Nutrition, Zhejiang University, Hangzhou, Zhejiang, China.
authors.forename: Duo
authors.initials: D
authors.lastname: Li
mesh_terms: D000368:Aged; D000886:Anthropometry; D015415:Biomarkers / Q000097:blood; D015331:Cohort Studies; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000097:blood / Q000401:mortality*; D004032:Diet / Q000401:mortality* / Q000706:statistics & numerical data; D005260:Female; D006304:Health Status; D006306:Health Surveys / Q000706:statistics & numerical data*; D006710:Homocysteine / Q000097:blood*; D006801:Humans; D020138:Hyperhomocysteinemia / Q000097:blood / Q000401:mortality*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D017678:Sex Distribution; D013624:Taiwan; D014803:Vitamin B Complex / Q000097:blood
chemical_list: D015415:Biomarkers; D006710:Homocysteine; D014803:Vitamin B Complex