Conditions: Obesity Dysglycemia
Keywords: Obesity Glucose Intolerance
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 28
Healthy volunteers: no

Brief summary:
Betaine is important in cellular metabolic pathways. Few epidemiologic studies link betaine levels to diabetes and cardiovascular disease. Small human studies suggest benefit for non-alcoholic liver disease. In this study we will determine if administration of betaine improves metabolic measures, liver fat and/or endothelial function in humans with glucose intolerance who are overweight.

Detailed description:
This study is a single site, prospective, randomized (1:1), double masked, placebo controlled trial to assess metabolic effects of betaine compared to placebo on glycemia and insulin sensitivity, liver fat and endothelial function.

Arms:
arm 1: None arm 2: None

Interventions: intervention 1: Betaine intervention 2: Placebo
Intervention descriptions: intervention 1: Betaine or placebo administered orally in divided doses over 12 weeks intervention 2: Placebo administered orally in divided doses over 3 months

Protocol document:
Prot_000.pdf: 
PARTNERS HUMAN RESEARCH COMMITTEE 
PROTOCOL SUMMARY 
Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
1 
 
Answer all questions accurately and completely in order to provide the PHRC with the relevant 
information to assess the risk-benefit ratio for the study.  Do not leave sections blank. 
 
PRINCIPAL/OVERALL INVESTIGATOR 
Allison B. Goldfine, MD 
 
PROTOCOL TITLE 
Metabolic Effects of Betaine Supplementation 
 
FUNDING 
American Diabetes Association  
 
VERSION DATE 
September 19, 2016 
 
SPECIFIC AIMS 
Concisely state the objectives of the study and the hypothesis being tested. 
 
In Specific Aim 1 we propose to study whether betaine supplementation will 
improve insulin sensitivity and/or glycemia in overweight insulin resistant 
persons with abnormal glucose tolerance.  In this proof-of-concept study that translates 
findings from bedside- to- bench, and now back- to- beside, we will administer betaine over 3 
months to persons with grade 1-3 obesity and dysglycemia in a single-site randomized, placebo 
controlled, double masked study.  We will assess glycemia during oral glucose tolerance test, 
insulin action by two- step euglycemic hyperinsulinemic clamp using deuterated glucose to 
assess hepatic and peripheral insulin sensitivity, and energy expenditure and oxidative and non-
oxidative metabolism using indirect calorimetry.  
In Specific Aim 2 will determine if betaine supplementation reduces hepatic fat in 
obese insulin resistant persons.  Hepatic steatosis will be quantified by MRI/MR 
spectroscopy at baseline and following 3 months of betaine supplementation.  As an exploratory 
aim, we will measure glutathione levels in the liver.   
In Specific Aim 3 we will evaluate whether betaine supplementation reduces 
oxidative stress and restores endothelium-dependent vasodilation in obese insulin 
resistant persons.  We will use brachial artery flow-mediated dilation and nitroglycerin-
mediated, endothelium-independent vasodilation to assess vascular function. 
 
BACKGROUND AND SIGNIFICANCE 
Provide a brief paragraph summarizing prior experience important for understanding the 
proposed study and procedures. 
 
Our group identified low circulating levels of betaine in the blood correlate with insulin 
resistance.  Betaine is important in cellular metabolic pathways.  Epidemiologic studies link 
betaine levels to diabetes and cardiovascular disease.  Small human studies suggest benefit for 
non-alcoholic liver disease.  We have shown in rodents that betaine levels fall with high fat 
feeding and there are metabolic improvements with replacement.  In this study we will 
determine if administration of betaine improves metabolic measures, liver fat and/or 
endothelial function in humans with glucose intolerance who are overweight.  


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
2 
 
RESEARCH DESIGN AND METHODS 
Briefly describe study design and anticipated enrollment, i.e., number of subjects to be enrolled 
by researchers study-wide and by Partners researchers.  Provide a brief summary of the 
eligibility criteria (for example, age range, gender, medical condition).  Include any local site 
restrictions, for example, “Enrollment at Partners will be limited to adults although the sponsor’s 
protocol is open to both children and adults.”
 
Patient identification: We will identify patients with prediabetes through a screening 75 
gram oral glucose tolerance test. Currently, we diagnose 30% prediabetes in screening persons 
with one or more risk factor for type 2 diabetes [88].  Thus, we anticipate screening 90-100 
persons to identify the 30 subjects for this study.  Many participants may come from those 
screened for other ongoing studies at the Joslin Diabetes Center who have expressed interest in 
participation in additional studies.  Persons screened for this study will meet trial 
inclusion/exclusion criteria including grade 1-3 obesity and one or more diabetes risk factors 
including: physical inactivity; high risk ethnic population; first degree relative with T2D; women 
who delivered an infant >9lbs or with gestational diabetes, or with polycystic ovarian syndrome; 
hypertension (controlled); low HDL or high triglyceride (but <500 mg/dL); age >45 years; or 
dysglycemia on prior testing. 
Inclusion Criteria: 1) Men and women aged 21-70 years old; 2) Dysglycemia/prediabetes is 
defined as impaired fasting glucose (≥100 mg/dl), impaired glucose tolerance (2 hour post 75 g 
oral glucose load 140-200 mg/dl) and/or HbA1c 5.7-6.5%); 3) Overweight to grade 3 obesity 
(BMI ≥ 25 to 45 kg/m2). 
Exclusion Criteria: 1) cystathionine beta-synthase (CBS deficiency) (based on medical history 
and reported family history); 2) Presence of liver disease other than NAFLD; 3) Use of 
medications causing steatosis 4) Known alcohol consumption ≥ 2 drink per day; 5) Use of 
medications known to cause insulin resistance; 6) Use of weight loss drugs (or program) within 
3 months of screening; 7) Treatment with any experimental drug within the past 6 months; 8) 
Subjects must be willing to abstain from use of phosphodiesterase type 5 (PDE-5) inhibitors; 9) 
Pregnancy or lactation, and women of child bearing potential must use adequate contraception; 
10) Surgery within 30 days of screening; 11) Heart disease defined as New York Heart 
Association Class III or IV cardiac status or hospitalization for congestive heart failure, unstable 
angina, myocardial infarction, cerebrovascular accident, transient ischemic attack or any 
revascularization within 6 months; 12) Uncontrolled hypertension; 13) eGFR <60; 14) History of 
acquired immune deficiency syndrome; 15) History of malignancy within 5 years; 16) 
Hemoglobin <12 g/dL (males), <10 g/dL (females); 17) Triglycerides (TG) >500 mg/dL; 18) 
Poor mental function or any other reason to expect patient difficulty in complying with study 
requirements; 19) Metal clips or implants that preclude magnetic resonance imaging. 
 
Briefly describe study procedures.  Include any local site restrictions, for example, “Subjects 
enrolled at Partners will not participate in the pharmacokinetic portion of the study.”  Describe 
study endpoints.
 
We propose a randomized (1:1) double-masked proof-of concept study of betaine administration 
over 3 months to 30 patients with prediabetes (defined below) and Overweight to grade 3 
obesity (BMI ≥ 25 to 45 kg/m2). Betaine will be dosed at 333/o mg/ml oral suspension, 2 
teaspoons (3300 mg: 10 ml) twice daily for 10 days, then 1 tablespoon (4950 mg: 15 ml per dose, 
10 g/d total) twice daily for the remainder of the 3 months, the dose used to treat patients with 
homocysteinuria and tolerated with evidence of benefit in pilot studies in humans with NASH.  
Participants will have oral glucose tolerance test, euglycemic hyperinsulinemic clamp, MRI of 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
3 
the liver, and brachial artery flow mediated dilation studies performed at baseline and after 12 
weeks of randomized assignment to betaine or placebo.  
 
For studies involving treatment or diagnosis, provide information about standard of care at 
Partners (e.g., BWH, MGH) and indicate how the study procedures differ from standard care.  
Provide information on available alternative treatments, procedures, or methods of diagnosis.
  
Patients with pre-diabetes may undergo lifestyle approaches to reduce risk of progression to 
overt diabetes.  Multiple pharmaceutical agents have been demonstrated to reduce risk of 
progression to overt diabetes, but are not FDA approved for this indication at this time.  
Consideration of use of metformin is recommended by the American Diabetes Association. 
 
Describe how risks to subjects are minimized, for example, by using procedures which are 
consistent with sound research design and which do not unnecessarily expose subjects to risk or 
by using procedures already being performed on the subject for diagnostic or treatment purposes.
 
Potential Risks and Protection from Potential Risks 
Betaine 
The 
most 
serious 
potential 
risk 
is 
cerebral 
edema 
in 
patients 
with 
hypermethioninemia. 
 
Patients 
with 
cystathionine 
beta-synthase 
(CBS 
deficiency): 
Homocystinuria due to CBS deficiency is inherited in an autosomal recessive pattern, and 
patients with family history of CBS deficiency will be excluded from participation.  The most 
common adverse reactions are nausea and gastrointestinal distress.  (See concise monograph for 
betaine anhydrous). 
Euglycemic hyperinsulinemic clamp   Insulin and glucose are substances which are 
normally found in the body.  The major potential adverse effect of insulin is hypoglycemia.  
During the insulin clamp study the plasma glucose concentration is measured at 5 minute 
intervals and as glucose will be infused to maintain the plasma glucose concentration constant, 
hypoglycemia should not occur. 
Isotope administration   6-6-D2 glucose is a glucose analogue containing two stable 
deuterium atoms at position 6 in the glucose ring.  There are no known adverse effects of its 
administration. 
 
Indirect Calorimetry It is possible that subjects may experience slight claustrophobia when 
the ventilated hood is placed over their head.  It is made of clear plastic to prevent this 
sensation. 
MRI/MRS Magnetic Resonance Imaging is considered non-invasive and is not associated with 
any known adverse effect except for people with metal or magnetic implants (such as metallic 
clips in the brain or cardiac pacemakers), or possibly to pregnant women.  Persons with metal 
clips or other devices will not be included.  Metal objects can heat up or possibly move in the 
patient’s body. Some types of (home-made) tattoos can also heat up and cause discomfort. Metal 
objects can also become projectile when placed near the magnetic field. This has been reported 
at a few sites, but it is a very rare occurrence. Protection from magnetic objects can be 
safeguarded by the usual safety techniques that are practiced in MRI/MRS sessions such has 
having subjects and researchers take all metal objects off of their person before entering the 
environment. 
The image procedure can be claustrophobic caused by being in the enclosed space of the 
MRI/MRS scanners. Any subjects who find that they are anxious or uncomfortable during any 
part of the procedure will be immediately taken out of the scanner and not tested. Noise levels in 
the magnet can be uncomfortable for subjects and they will be wearing earplugs through all 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
4 
MRI/MRS procedures. This will be reviewed with each subject as part of the consent process 
prior to study participation.   
The administration of contrast can be contraindicated by renal disease however gadolinium or 
other contrast agent will not be used so there is no increased risk of gadolinium induced fibrotic 
syndromes may be seen in patients with reduced renal function.  
Incidental findings from MRI imaging may need additional medical evaluation and lead to 
unexpected costs or new findings. 
Risk Management and Emergency Response: Each subject will complete a checklist that is the 
same as used by the Brigham and Women’s Hospital MRI department to screen for metal 
implants, pregnancy, and other MR contraindications.  Patients who are not able to understand 
the procedures and risks will not be tested. In addition to completing the MRI screening 
checklist, subjects will also be asked verbally by the experimenter about metal implants, and 
surgical procedures.  If the answers to these questions are not known, or if the subject is 
uncertain about any answers, then they will not be tested in the MRI/MRS experiments. All 
subjects are asked to empty pockets, remove any clothing with possible magnetic materials, and 
remove all jewelry before the experiments.   
A licensed technologist will review screenings in order to comply with MR safety regulations. If 
there is a possibility of metal in the head and neck area, such as a report of shrapnel in the body 
somewhere, an x-ray will be done. This x-ray is not routinely done, nor is it done to rule out a 
cardiac pacemaker. It is only done if there is a question of ferrous metal in the body from a 
source such as shrapnel or metal from working as a sheet metal worker, or if the subject reports 
having had metal in the head or neck area, including the eye. In these instances an X-ray is 
performed. This x-ray will be read immediately and if no metal is found, the MRI/MRS scan will 
continue. If metal is found, then the MR scan will be cancelled.  The x-ray report will become 
part of the subject’s medical record as detailed in the consent form so that it will not be 
unnecessarily repeated for MRI/MRS exams that the study subject may be required to do in the 
future. 
Noise levels in the MRI/MRS will be reduced, as subjects will be given earplugs. These are used 
routinely in hospital MRI clinical settings. There is also microphone in the bore of the magnet.  
Subjects are instructed to talk to the experimenter if they feel uncomfortable for any reason 
during the testing procedures.  If subjects feel uncomfortable they are immediately taken out of 
the scanner.   
Vascular Function Studies The only vasoactive drug used in this study to assess vascular 
function is nitroglycerin, which is administered sublingually This may cause a fall in blood 
pressure and symptoms of hypotension. To avoid the latter, nitroglycerin will not be 
administered to any participant whose systolic blood pressure is ≤100 mmHg. In addition, 
subjects must be willing to abstain for one week prior to endothelial measures from PDE-5 
inhibitors such as sildenafil citrate, (i.e., Viagra, Revatio), tadalafil (Cialis), and vardenafil 
(Levitra), as use of these drugs could significantly increase risk of hypotension.  Ultrasound 
imaging is non-invasive and has no radiation risk.  Blood pressure cuff inflation can cause 
discomfort and numbness of the hand. 
Phlebotomy blood loss and discomfort with required laboratory blood draws and intravenous 
catheters. Bleeding, bruising or phlebitis at the site of venipucture are also a possibilities. Blood 
loss:  The total amount of blood drawn during the protocol is approximately 650 ml.  This is 
approximately equal to 1 ½ units of blood.  One unit is the volume typically donated at a single 
visit to a blood bank, and can be donated every other month.  In this study phlebotomy will be 
distributed over each visit spanning three months.  Thus, phlebotomy does not exceed the rate 
of 1 unit per month and should not present a significant stress to any individual.  Volunteers will 
be requested not to donate blood within 2 months after the study.  Any subject who has just 
donated blood will be asked to postpone entry to the study until 2 months have elapsed. 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
5 
Screening tests and procedures It is possible that as a result of the screening process a 
subject may learn that they have a health disorder that they were unaware they had. Every effort 
will be made to help the participant obtain the care that they need. 
Breach of Confidentiality While every effort will be made to protect the confidentiality of 
participant identifiable information, there is the potential loss of confidentiality by participating 
in this study. 
Inconvenience and Unknown Risks Participants may be inconvenienced by the time 
commitment involved in participation in the study. There may be other risks from this study not 
yet identified. 
Participants can choose not to participate in the clinical research project and can withdraw 
consent at any time. 
Describe explicitly the methods for ensuring the safety of subjects.  Provide objective criteria for 
removing a subject from the study, for example, objective criteria for worsening disease/lack of 
improvement and/or unacceptable adverse events.  The inclusion of objective drop criteria is 
especially important in studies designed with placebo control groups.
 
Participants with be withdrawn from the study for the following reasons: 
a. Subject decision to withdraw consent for study participation 
b. Evidence of allergy to administered products 
c. Acute change in renal function (eGFR decline >50%, validated) or liver function 
(> 3-fold increase in ALT or AST) 
d. New diagnosis of exclusionary medical condition 
e. Intolerable adverse event as judged by investigator and participant 
 
FORESEEABLE RISKS AND DISCOMFORTS 
Provide a brief description of any foreseeable risks and discomforts to subjects.  Include those 
related to drugs/devices/procedures being studied and/or administered/performed solely for 
research purposes.  In addition, include psychosocial risks, and risks related to privacy and 
confidentiality.  When applicable, describe risks to a developing fetus or nursing infant.
 
Risks of Taking Betaine 
 
Betaine occurs naturally in the body. It is a metabolite of choline and is present in small 
amounts in foods such as beets, spinach, cereals, and seafood.  However, taking betaine may 
cause one or more of the side effects listed below.  
Common side effects: 
 
Nausea (2 out of 100 people reported this side effect) 
 
Gastrointestinal complaints (2 out of 100 people reported this side effect) 
 
Uncommon side effects: 
 
A few cases of cerebral edema (brain swelling) have been reported in patients 
with a rare inherited disorder called cystathionine beta synthase (CBS) 
deficiency. 
 
There may be other risks of betaine that are currently unknown. 
 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
6 
As with any drug, an allergic reaction can occur.  Allergic reactions can be mild or more serious, 
and can even result in death.  Common symptoms of an allergic reaction are rash, itching, skin 
problems, swelling of the face and throat, or trouble breathing. 
 
Betaine is pregnancy class C. 
 
Of note that Cystadene 20g/d (twice the amount proposed in this study) is the upper end of the 
recommended daily dose range for patients with hyperhomocysteinemia: from Cystadane 
Product Information (package insert).   
 
Betaine doses of 20 g/d for 12 months have been studied in about 30 patients with liver disease, 
with this number receiving the active betaine.  Safety assessment and findings of these 
published studies are summarized below. 
 
In the first study, Abdelmalek et al (Am J Gastroenterol. 2001 Sep;96(9):2711-70) surveyed 
safety with patients contacted by phone by the study coordinator at wk 1, 2, and 4 of treatment, 
and then monthly for the duration of treatment. At every contact point adverse events, 
concurrent illnesses, concomitant medications, and compliance with the study medication were 
assessed. Monitoring laboratory tests including liver biochemistries (ALT, AST, alkaline 
phosphatase,  serum bilirubin, albumin, and prothrombin time), hematology panel, serum 
creatinine, and glucose were performed at 1, 3, 6, 9, and 12 months during the study. A complete 
medical history and physical examination were repeated at the end of treatment in each patient. 
Seven of 10 patients completed 1 yr of treatment with betaine. Two patients moved and were lost 
to follow-up at 3 and 9 months; and one patient was on treatment for only 6 months as a result 
of inability to obtain study medication because of a transient shortage in supply by the 
manufacturer.  
 
Four of 10 patients experienced adverse events during treatment with betaine including nausea, 
abdominal cramps, loose stools, and body odor. None of these adverse events were dose 
limiting, and all four patients completed 1 yr of treatment. There were no adverse events noted 
in hematology or blood chemistry results. 
 
Please note that body odor is not in other reports or the package insert and has not been added 
to the consent document. 
 
In the second study, Abdelmalek et al (Hepatology. 2009 Dec;50(6):1818-26) followed safety 
with patients evaluated at the study center every 3 months and phone communication was made 
with each study participant on a monthly basis to assess compliance with study medication and 
development of any adverse events. Of those who completed 12 months of therapy (betaine 17, 
placebo 18), no changes in weight, BMI, or serum aminotransferases or lipid or laboratory safety 
monitoring parameters were noted.  There was no clinically apparent hepatotoxicity (defined as 
ALT or AST  3x  baseline value) rise in total bilirubin value of 2x normal, or severe adverse 
events reported in either treatment group. The overall incidence of gastrointestinal adverse 
events (i.e., nausea, vomiting, abdominal bloating, and/or diarrhea) in those treated with 
betaine was 33% versus 9%, in those treated with placebo, (P<0.05). A comparable number of 
patients in each treatment arm were either noncompliant with study drug and/or voluntarily 
withdrew their participation. Eighteen subjects (nine in each group) voluntarily withdrew 
consent for adverse effects, noncompliance, and the “inconvenience”of taking study drug, or 
inability to continue study participation. 
 
The studies in healthy persons at ≥6g/d note similar side gastrointestinal side effects. 
 
 
 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
7 
Risks of Phlebotomy and intravenous catheters: 
Participants may have a bruise (a black and blue mark) or pain where we take the blood 
samples.  There is also a small risk of infection, lightheadedness, and/or fainting.   
 
The total amount of blood drawn during the entire study is approximately 650 ml.  This is about 
1 ½ pints of blood. Adults can safely donate 1 pint (2 cups) of blood every two months.  In this 
study blood draws will be distributed over visits spanning three months, with most blood drawn 
at visits 3-4 and 7-8.  Participants should delay enrollment into the study if they have given 
blood (ie at a hospital or the Red Cross) within 2 months, and should not donate blood during 
the study or for two months after taking part in this study to minimize risk of anemia (low blood 
counts). 
  
Risks of Oral Glucose Tolerance Test 
Nausea or incidental findings  
 
Risks of Use of Insulin 
Hypoglycemia 
 
Risks of Use of Glucose 
Hyperglycemia 
 
Risks of Use of Nitroglycerin 
Headache, dizziness, hypotension, bradycardia 
 
If participants use Viagra (sildenafil), Levitra (vardenafil), or Cialis (tadalafil):  The use of these 
drugs may cause a harmful interaction with the nitroglycerin used in the ultrasound procedure, 
therefore participants will be advised not to take these medications for one week before 
participating in the ultrasound procedure.  On the day of the procedure, participants will be 
asked about taking any of these products; and informed an untruthful answer may place them at 
unnecessary risk. 
 
Risks of Ultrasound Procedure 
During the ultrasound a blood pressure cuff will be used to stop the blood in participants arm 
for short periods of time.  This may cause some numbness or discomfort in the arm.  This will 
disappear soon after the cuff is released.  Occasionally, bruising occurs in the area where the cuff 
was inflated.  This will disappear within a few days.   
 
Incidental Findings 
 
Risks of Indirect Calorimetry 
Slight claustrophobia  
 
Risks of MRI 
There is not radioactive exposure from MRI.  There are no known or foreseeable risks or side 
effects associated with conventional MRI procedures except to those people who have 
electrically, magnetically or mechanically activated implants (such as cardiac pacemakers) or to 
those who have clips on blood vessels in their brain.  If participants have any of the above 
implants, then they are not eligible for this study. The MRI systems will be operated in a manner 
accepted by the FDA. System safeguards and screening procedures have been designed and 
operating guidelines have been provided to minimize any possible risks.   Participants comfort 
will be verified periodically during the study. Participants will be provided with mandatory 
hearing protection (earplugs), which will prevent discomfort due to scanner noise.   
 
Incidental findings 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
8 
 
Loss of Confidentiality 
 
There is the potential loss of confidentiality by participating in this study, but every effort will be 
made to protect the confidentiality of participant’s identifiable information.  The study team 
members are trained in the ethical conduct of clinical research and current privacy protection 
practices. 
 
Unknown Risks 
 
There may be unforeseen risks associated with participation in this study. 
 
EXPECTED BENEFITS 
Describe both the expected benefits to individual subjects participating in the research and the 
importance of the knowledge that may reasonably be expected to result from the study.  Provide 
a brief, realistic summary of potential benefits to subjects, for example, “It is hoped that the 
treatment will result in a partial reduction in tumor size in at least 25% of the enrolled subjects.”  
Indicate how the results of the study will benefit future patients with the disease/condition being 
studied and/or society, e.g., through increased knowledge of human physiology or behavior, 
improved safety, or technological advances. 
 
The purpose of this study is to further elucidate the pathophysiology of insulin resistance and 
type 2 diabetes.  It is possible that new treatment options to treat or prevent the development of 
overt disease can be developed. This project is not designed to be of direct benefit to any 
individual subject, although it is hoped that through the knowledge gained from these studies 
there will be general benefit to persons with or at risk of development of type 2 diabetes 
mellitus.  Subjects randomized into the trial receive comprehensive medical evaluation and good 
medical care. As such, risks as such are appropriate in relation to the potential significant 
benefits for the large number of persons with diabetes and prediabetes.  Thus, we feel that the 
potential benefits to society outweigh the risks to the individual subject.  
T2D and prediabetes continues to increase in incidence throughout the USA and worldwide, and 
remains at epidemic proportions. The long term sequelae of these diseases are substantial and 
well documented, with substantial individual and public health care cost burden. Data from this 
grant may lay the groundwork for future studies that could substantially change the 
understanding of the pathophysiology of diabetes, and/or impact novel therapeutic strategies. 
This proof-of-concept study may also lays the groundwork for trials evaluating safety and 
efficacy of betaine supplementation.  Significant findings will need to be confirmed in future 
clinical trials. Despite this limitation, this study potentially could contribute to development of a 
novel therapeutic intervention to improve outcomes for the millions of Americans affected by 
type 2 diabetes and/or prediabetes. 
 
Individual participants will not benefit from taking part in this research study.  However, they 
may learn they have diabetes or prediabetes and benefit from improved medical education and 
care. 
 
Others with obesity, pre-diabetes or diabetes, heart disease or liver disease may benefit in the 
future from what we learn in this study. 
 
EQUITABLE SELECTION OF SUBJECTS 
The risks and benefits of the research must be fairly distributed among the populations that stand 
to benefit from it.  No group of persons, for example, men, women, pregnant women, children, 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
9 
and minorities, should be categorically excluded from the research without a good scientific or 
ethical reason to do so.  Please provide the basis for concluding that the study population is 
representative of the population that stands to potentially benefit from this research.
 
Participants will not benefit from taking part in this research study. 
 
If participants receive betaine, it is possible that their health will improve while taking it.   
 
Others with obesity, pre-diabetes or diabetes, heart disease or liver disease may benefit in the 
future from what we learn in this study. 
 
We have no reason to believe that risk or benefit will differ based on gender, race, or other 
categorical differences by group. 
 
When people who do not speak English are excluded from participation in the research, provide 
the scientific rationale for doing so.  Individuals who do not speak English should not be denied 
participation in research simply because it is inconvenient to translate the consent form in 
different languages and to have an interpreter present.
 
Individuals who do not speak English, will not be denied participation, if there is a hospital 
interpreter available to translate to the participant’s language, and there is an available form in 
the appropriate language, and there is a translator available to the patient during emergency 
hours to communicate any potential adverse events to the study team.  
 
 
The Principal Investigator (or other member of the study staff with PI-delegated 
responsibility for obtaining informed consent) will present the PHRC-approved 
English version of the consent form orally to the subject through a medical 
interpreter physically present and fluent in English and the language 
understandable to the subject;  
 
The subject will be given a written translation of the 'full version’ consent 
document in Spanish to him/her to read; for other languages the “Short Form” 
Consent will be used. 
 
The entire consent process will be witnessed by an individual who is fluent in 
both English and the language understandable to the subject. The interpreter 
may serve as the witness to the consent process (presentation of the information 
in the consent form in the language understandable to the subject and the 
opportunity to ask and receive answers to questions);  
 
The PHRC-approved English version of the consent form will be signed by the 
investigator obtaining informed consent and the witness to the consent process;  
 
The written translation of the ‘full version form’ will be signed by the subject and 
the witness to the consent process; and  
 
The subject will be given signed copies of both the PHRC-approved English 
version of the consent form and the written translation of the ‘full version’ 
consent document.  
 
The original signed English version of the consent form with the original signed 
written translation of the ‘full version’ document attached will be placed in the 
subject’s research record.  A copy of both forms will be placed in the subject’s 
medical record, if the information is relevant to their medical care.  
 
The interpreter will come from the pool of experienced medical interpreters 
available through Interpreter Services as the PHRC requires that the interpreter. 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
10 
The PHRC will consider approving an exception to the requirement to use an 
interpreter from Interpreter Services on a case-by-case basis. 
 
Participants who do not speak English and do not have ready access to an interpreter when the 
hospital service interpreter is not available will not be enrolled as the study team may not be 
able to understand emergency related complaints, putting these individuals at increased risk.   
 
For guidance, refer to the following Partners policy: 
          Obtaining and Documenting Informed Consent of Subjects who do not Speak English
          http://healthcare.partners.org/phsirb/nonengco.htm 
 
 
 
RECRUITMENT PROCEDURES 
Explain in detail the specific methodology that will be used to recruit subjects.  Specifically 
address how, when, where and by whom subjects will be identified and approached about 
participation.  Include any specific recruitment methods used to enhance recruitment of women 
and minorities.
 
Subjects will be recruited using web-based advertisement, newspaper and other printed 
advertisement, use of recruitment brochures, PCP outreach and patient mailings, and will also 
be identified and recruited through the Partners RPDR and through the identified health 
information and/or samples from the patients in the Partners HealthCare Biobank. No 
recruitment materials will be used without first receiving IRB approval. 
 
Provide details of remuneration, when applicable.  Even when subjects may derive medical 
benefit from participation, it is often the case that extra hospital visits, meals at the hospital, 
parking fees or other inconveniences will result in additional out-of-pocket expenses related to 
study participation.  Investigators may wish to consider providing reimbursement for such 
expenses when funding is available
 
Participants will not be compensated for time and effort of participation for screening oral 
glucose tolerance tests (OGTT).  We recognize these take time and cause inconvenience, 
such as travel, however, only persons with one or more risk factor for diabetes will be 
screened by OGTT.  We will be able to provide them information of personal value that they 
have normal glucose tolerance, dysglycemia or type 2 diabetes.  Persons with type 2 diabetes 
will be encouraged to share this information with their care provider and receive 
management for this chronic condition.  Persons with dysglycemia will be invited to 
participate further in the study. 
 
Participants who complete the assessments will receive $400 for their time, effort and 
inconvenience associated with participation. Participants who complete the baseline 
assessments and drop out of the study before initiation of study drug, will receive $75 for 
their time, effort and inconvenience associated with participation. 
 
All participants will receive a light meal or snack following fasted visits. 
 
Parking will be paid by voucher. 
 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
11 
For guidance, refer to the following Partners policies: 
          Recruitment of Research Subjects 
          http://healthcare.partners.org/phsirb/recruit.htm
 
          Guidelines for Advertisements for Recruiting Subjects
          http://healthcare.partners.org/phsirb/advert.htm
 
          Remuneration for Research Subjects
          http://healthcare.partners.org/phsirb/remun.htm
 
 
CONSENT PROCEDURES 
Explain in detail how, when, where, and by whom consent is obtained, and the timing of consent 
(i.e., how long subjects will be given to consider participation).  For most studies involving more 
than minimal risk and all studies involving investigational drugs/devices, a licensed physician 
investigator must obtain informed consent.  When subjects are to be enrolled from among the 
investigators’ own patients, describe how the potential for coercion will be avoided.
 
Persons who express interest in the trial will behave all procedures, risks and potential benefits 
described, and will be provided for review IRB-approved consent documents for participation in 
the trial.  All potential participants will have the opportunity to review the consents privately, 
and to have all of their questions answered prior to signing. Individual appointments for final 
questions and signing of the consent form with one of the licensed physicians investigators will be 
scheduled.  Subjects will then be scheduled for baseline visits which will be conducted prior to 
randomization to study drug or placebo.   
 
NOTE: When subjects are unable to give consent due to age (minors) or impaired decision-
making capacity, complete the forms for Research Involving Children as Subjects of Research 
and/or Research Involving Individuals with Impaired Decision-making Capacity, available on 
the New Submissions page on the PHRC website: 
http://healthcare.partners.org/phsirb/newapp.htm#Newapp
 
For guidance, refer to the following Partners policy: 
          Informed Consent of Research Subjects
          http://healthcare.partners.org/phsirb/infcons.htm
 
 
 
DATA AND SAFETY MONITORING 
Describe the plan for monitoring the data to ensure the safety of subjects.  The plan should 
include a brief description of (1) the safety and/or efficacy data that will be reviewed; (2) the 
planned frequency of review; and (3) who will be responsible for this review and for determining 
whether the research should be altered or stopped.  Include a brief description of any stopping 
rules for the study, when appropriate.  Depending upon the risk, size and complexity of the 
study, the investigator, an expert group, an independent Data and Safety Monitoring Board 
(DSMB) or others might be assigned primary responsibility for this monitoring activity.        
 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
12 
NOTE: Regardless of data and safety monitoring plans by the sponsor or others, the principal 
investigator is ultimately responsible for protecting the rights, safety, and welfare of subjects 
under his/her care. 
 
In brief, the Principal Investigator, Dr. Goldfine, will be responsible for ensuring that the study 
is conducted in accordance with the IRB approved protocol and will review all adverse events, 
serious adverse events. The study nurse coordinator will also perform a periodic review on all 
data. The members of the study team will conduct regularly scheduled meeting approximately 
weekly as well as on an add needed basis to review status of the trial inclusive of enrollment, 
oversight of informed consent, general conduct of the trial as well as reporting of any 
complications as needed to the NIH or IRB as stated below. 
All adverse events will be reported to the IRB. 
• Serious adverse events including death, life-threatening experience, event resulting in 
hospitalization, event resulting in an intervention, and event resulting in congenital 
anomaly/birth defect will be reported within 24 hours followed by a full written report 
within one week by the principal investigator. 
• Adverse events and unanticipated problems will be reported per PHRC reporting guidelines. 
• Mild to moderate adverse events that are unexpected but not related to the study will 
be reported to IRB in the periodic review. 
• Expected adverse events that are not serious will be reported to the IRB in the periodic 
review. 
• A written periodic review will be submitted to the IRB for continuing review annually. 
• All adverse events at all performance sites will be reviewed by the principal 
investigator. 
Safety reviews. The Principal Investigator (Dr. Allison Goldfine, MD) will review the safety 
and progress of this study on a bi-monthly basis. She will report to the Institutional Review 
Boards, Safety Officer and Patient Advocates, any adverse event of moderate or greater severity, 
and a Data Safety Monitor Board if appointed by the NIH, and FDA. She will review the study 
and potential new literature on an ongoing basis to ensure no new information is present to 
cause early study termination. 
In time safety– in addition all information including medical history, physical 
examination and laboratory assessment will be assessed by a study investigator as 
collected or completed by the laboratory. Summary data will be reviewed bi-monthly by 
the Principal Investigator (Dr. Goldfine). 
Annual reviews. The Principal Investigator (Dr. Allison Goldfine, MD) will review this 
protocol on a continuing basis for subject safety and provide written summary of results 
annually for review in the annual progress reports submitted to the IRB’s,and safety officer, FDA 
and American Diabetes Association (Sponsor). 
Annual reports. The annual report will include a list of adverse events. These will be provided 
to the institutional review boards. Annual reports will be generated both site specific and for the 
overall conduct of the trial. Content of annual reports: The annual report will address: (1) 
whether adverse event rates are consistent with pre-study assumptions; (2) reason for dropouts 
from the study; (3) whether all participants met entry criteria; (4) whether continuation of the 
study is justified on the basis that additional data are needed to accomplish the stated aims of 
the study; and (5) conditions whereby the study might be terminated prematurely. 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
13 
Laboratory review: Laboratory assessment will be performed at scheduled and 
predetermined intervals. The study investigators will review all laboratory reports within 24 
hours of completion by the laboratory for participant safety. 
Rules for stopping the trial in the event that expected or unexpected adverse events arise, 
particularly, but not exclusively, as explained in the Risks and Discomforts section of Protocol 
and its Informed Consent. 
Study therapy should be discontinued for any of the following reasons: 
a. Subject decision to withdraw consent for study participation 
b. New diagnosis of exclusionary medical condition  
c. Evidence of allergy to administered products 
d. Acute change in renal function (eGFR decline >50%, validated) or liver function (> 3-
fold increase in ALT or AST) 
e. Intolerable adverse event as judged by investigator and participant 
f. Pregnacy or unwillingness to use appropriate contraception. 
 
The trial may be stopped by the regulatory oversight committees including, but not limited to 
the IRB, American Diabetes Association, or FDA. 
 
Describe the plan to be followed by the Principal Investigator/study staff for review of adverse 
events experienced by subjects under his/her care, and when applicable, for review of sponsor 
safety reports and DSMB reports.  Describe the plan for reporting adverse events to the sponsor 
and the Partners’ IRB and, when applicable, for submitting sponsor safety reports and DSMB 
reports to the Partners’ IRBs.  When the investigator is also the sponsor of the IND/IDE, include 
the plan for reporting of adverse events to the FDA and, when applicable, to investigators at 
other sites.   
 
NOTE: In addition to the adverse event reporting requirements of the sponsor, the principal 
investigator must follow the Partners Human Research Committee guidelines for Adverse Event 
Reporting
See above 
 
 
MONITORING AND QUALITY ASSURANCE 
Describe the plan to be followed by the principal investigator/study staff to monitor and assure 
the validity and integrity of the data and adherence to the IRB-approved protocol.  Specify who 
will be responsible for monitoring, and the planned frequency of monitoring.  For example, 
specify who will review the accuracy and completeness of case report form entries, source 
documents, and informed consent.   
 
NOTE: Regardless of monitoring plans by the sponsor or others, the principal investigator is 
ultimately responsible for ensuring that the study is conducted at his/her investigative site in 
accordance with the IRB-approved protocol, and applicable regulations and requirements of the 
IRB.
See above 
 
 
For guidance, refer to the following Partners policies: 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
14 
          Data and Safety Monitoring Plans and Quality Assurance
          http://healthcare.partners.org/phsirb/guidance.htm#13
 
          Reporting Unanticipated Problems (including Adverse Events)
          http://healthcare.partners.org/phsirb/guidance.htm#7
 
 
 
PRIVACY AND CONFIDENTIALITY 
Describe methods used to protect the privacy of subjects and maintain confidentiality of data 
collected.  This typically includes such practices as substituting codes for names and/or medical 
record numbers; removing face sheets or other identifiers from completed 
surveys/questionnaires; proper disposal of printed computer data; limited access to study data; 
use of password-protected computer databases; training for research staff on the importance of 
confidentiality of data, and storing research records in a secure location.   
 
NOTE: Additional measures, such as obtaining a Certificate of Confidentiality, should be 
considered and are strongly encouraged when the research involves the collection of sensitive 
data, such as sexual, criminal or illegal behaviors.
Research data will be obtained in the form of medical history and review of selected medical 
record information including personal and family history including personal and family history, 
anthropometric measurements, laboratory tests, questionnaires. Data will be collected by study 
staff and stored in computerized databases. Only those involved directly with the study and 
patient care will have access to any data collected. Computer files with subject information will 
be kept locked with restricted access. No information about a subject will be shared with other 
parties unless the subject has given written or witnessed consent to do so. 
 
SENDING SPECIMENS/DATA TO RESEARCH COLLABORATORS OUTSIDE 
PARTNERS 
Specimens or data collected by Partners investigators will be sent to research collaborators 
outside Partners, indicate to whom specimens/data will be sent, what information will be sent, 
and whether the specimens/data will contain identifiers that could be used by the outside 
collaborators to link the specimens/data to individual subjects.
 
Specimens collected for this protocol will be procured and processed at laboratories including 
those at BWH, the Joslin and Quest Diagnostic, the Catalyst Core laboratory and LabCorp. 
Health data will be shared by the investigative teams at the Joslin Diabetes Center and Brigham 
and Women’s Hospital. All investigators and study staff will be trained in the ethical conduct of 
clinical research and privacy protection practices and credentialed by their institutions for the 
level of their staff positions. Biospecimens obtained at the time of the study visits will be stored 
at the Joslin Diabetes Center for batch analysis. Data may be analyzed at a later date for cost 
effectiveness as described in the protocol. Clinical research specimens and research level data 
will be labeled with a unique identifier. However, as clinical care is coordinated at two 
institutions and in a certified clinical laboratory (Quest and/or LabCorp.  A study nickname and 
numeric code will be used, but Date of Birth must be provided for age relevant normative 
interpretation.  It is hard to identify an individual in the New England Area based solely on 
DOB. 
 


Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
15 
Some specimens will be saved for batch analysis in core laboratories. Samples will be stored at 
the Joslin Diabetes Center. The Joslin Diabetes Center has ceded review to Partners.  Application 
ID: 1291 - Metabolic Effects of Betaine Supplementation, August 16th, 2013. 
 
Specifically address whether specimens/data will be stored at collaborating sites outside 
Partners for future use not described in the protocol.  Include whether subjects can withdraw 
their specimens/data, and how they would do so.  When appropriate, submit documentation of 
IRB approval from the recipient institution.
 
RECEIVING SPECIMENS/DATA FROM RESEARCH COLLABORATORS OUTSIDE 
PARTNERS 
When specimens or data collected by research collaborators outside Partners will be sent to 
Partners investigators, indicate from where the specimens/data will be obtained and whether the 
specimens/data will contain identifiers that could be used by Partners investigators to link the 
specimens/data to individual subjects.  When appropriate, submit documentation of IRB 
approval and a copy of the IRB-approved consent form from the institution where the 
specimens/data were collected.
Specimens obtained during the study of “Metabolic Effects of Betaine Supplementation” will be 
labeled with unique alpha numeric identifier. Samples may be assayed in clinical or core 
laboratories at Partner’s Healthcare, Joslin, or Quest or LabCorp laboratories.  Only CLIA 
certified labs will be used for safety measures. 
 
 

SAP_001.pdf: 
Metabolic Effects of Betadine Supplementation Statistical Plan:                                    1/9/14 
NCT 01950039; CHS 2017-31 
 
Statistical Plan 
Sample Size and Data Analysis: The study will use a single site randomized, double- 
mask design. Our primary analysis to examine the effect of betaine supplementation will 
be by change from baseline to 3-month values compared to placebo in completer analysis 
for all endpoints of Aims 1-3. Safety will be assessed by intention to treat. Prior to data 
analysis, the data will be examined for outliers. Continuous measures whose distributions 
are not symmetric will be transformed. In secondary analysis for all outcomes we will 
determine if baseline betaine determines response to supplementation. 
Insulin Sensitivity-Basis for power calculations: In an overweight prediabetes population 
of 14 persons similar to that proposed in this grant and using a similar clamp protocol, we 
demonstrated insulin sensitivity of 5.9±2.1 mg/kg/min, a value significantly lower than 
8.3±1.8 in our normoglycemic control group of 27 patients (P=0.0005). This 
demonstrates likelihood that the cohort proposed will be insulin resistant. We also 
recently assessed insulin sensitivity by clamp before and after placebo in a cohort of 29 
persons with impaired glucose tolerance in another 3-month randomized study.  Baseline 
values were 4.0±1.5 mg/kg/min and 3 months later 4.1±1.7, P=0.3. The placebo change 
over time was 0.16±0.81, or variance <4%. This demonstrates the high reproducibility of 
clamp measures. A total of 30 patients entering this two-treatment parallel-design study, 
provides 80% probability of detecting a treatment difference at a paired two-sided 
comparison with type 1 error 0.05 significance, if the standard deviation is 0.81 and the 
true difference between treatments is 0.85 mg/kg/min (a between-group difference of 
20% change from baseline). Given the short duration of the study, we anticipate ≥80% 
retention rate, but even 24 completers would detect difference between treatment groups 
of 0.96 mg/kg/min (25% change from baseline between groups). 
Glycemia is a secondary end-point of strong interest. In a recent study of patients with 
prediabetes mean/SD fasting glucose was 103±9.5 mg/dl, and did not change over 3- 
months (0.28±10.3 mg/dl, P=0.9). With 30 patients in a two-treatment parallel-design 
study, and standard deviation of 10, the probability is 80% that the study will detect a 
treatment difference at a two-sided 0.05 significance level, if the true difference between 
treatments is 7 mg/dl. This would be clinically significant, and 1/4-1/3 the magnitude of 
the placebo-corrected reduction in fasting glucose of 25% seen in HFD-fed mice with 
betaine supplementation. 
Change in liver fat. Previous studies suggest high reproducibility of liver fat assessed by 
MR over 28 weeks. The mean hepatic fat content, determined by magnetic resonance 
spectroscopy, was higher in subjects with NASH than healthy controls (19.5±3.1% vs. 
3.0±0.7%, respectively, P<0.001). Overweight, dysglycemic persons are anticipated to fall 
between this range. However, assuming variability between images equals the variability 
seen in patients with NASH (i.e. an assumption that the SD of the response variable change 
in hepatic fat over the treatment interval is 3.1, a likely overestimate), and with a total of 
30 patients entering this two-treatment parallel-design study, there is 80% probability 
that the study will detect a treatment difference at a two-sided 0.05 significance level, if 
the true difference in change from baseline between treatments is 3.3% of liver fat. 
Endothelial function. We will determine if betaine supplementation compared to placebo 
changes endothelial function. In a secondary analysis for this aim we will determine if 
either baseline betaine concentration determines endothelial responsiveness. The latter 
will test the hypotheisis that folate status may modulate the effect of betaine on 
homocysteine response to methionine load. 


Metabolic Effects of Betadine Supplementation Statistical Plan:                                    1/9/14 
NCT 01950039; CHS 2017-31 
 
To calculate sample size, we estimated mean and standard deviations of flow-mediated 
vasodilation from our previously reported findings for a placebo-treated group composed 
of patients with T2D. The reported change from baseline following placebo was -0.9 ± 1.2% 
(from a baseline value of 5.8 ± 1.1% to 4.9 ± 0.9% at six month follow up). It is anticipated 
that betaine will increase flow-mediated, endothelium-dependent vasodilation by 25% 
compared with placebo. Therefore, we expect the mean change in the betaine group to be 
1.45% (from a baseline value of 5.8% to a three month value of 7.25%). Although we will 
analyze the data using a mixed model, to estimate required sample sizes we used the 
methods of Cochran and Cox for a two-sample t-test with an alpha of 0.05 for a two-tailed 
test of significance and 80% power.. 
Secondary Outcomes. Secondary outcomes are considered exploratory. We recognize that 
this study will allow for detection of only relatively large effects.