In the liver, betaine can transfer its methyl group to homocysteine in order to form methionine. This can result in decreased concentrations of homocysteine and increased concentrations of methionine in the liver, resulting in decreased hepatic concentrations of SAH, whereas the latter can increase hepatic SAM concentrations, which leads to an increased SAM : SAH. An elevated SAM : SAH can trigger a cascade of events leading to formation of proper VLDL, to export of triacylglycerol and attenuation of fatty liver. Increased hepatic concentrations of SAM can activate cystathionine-synthase and lead to upregulation of the transsulfuration pathway, to increase synthesis of glutathione and attenuate oxidative stress. Thus, betaine can ameliorate ALD by attenuating fatty liver, inflammation, and fibrosis [66] .