A Prospective, Randomized, Open Label Trial of Two Doses of Oral Betaine

This is a prospective, unblinded, randomized study of oral betaine in diabetic and
non-diabetic patients who have a clinical diagnosis of NAFLD and an ALT≥ 50 IU/mL. A clinical
diagnosis of NAFLD is based on the presence of risk factors for NAFLD (such as overweight and
insulin resistance) and the exclusion of other causes of liver disease, such as alcohol or
viral hepatitis.

Two cohorts of patients will be studied: Cohort 1 (diabetic) will consist of patients with a
clinical diagnosis of non-insulin dependent type II diabetes mellitus; Cohort 2
(non-diabetics) will consist of patients without a clinical diagnosis of type 2 diabetes
mellitus. 24 patients will be enrolled in each cohort (total of 48 patients enrolled in the
study) with an anticipated drop out of 4 subjects per cohort.

Patients will be given dietary instructions and advice on exercise appropriate for the
management of NAFLD (NIDDK and liverfoundation.org handouts). Patients will be prescribed 4
grams of betaine/day (2 grams PO BID) for the first 4 weeks of the study. After 4 weeks,
patients in each cohort (NIDDM and non-diabetic) will be randomized (1:1) to continue
receiving betaine 4 grams per day or increase to 8 grams per day for an additional 8 weeks.
All patients will be seen in clinic on a monthly basis during treatment, and again 4 and 12
weeks after completion of betaine treatment. The total duration of the study is 24 weeks (12
weeks of betaine treatment and 12 weeks of follow-up).

The primary outcome is change in ALT during 12 weeks of betaine treatment (i.e., ALT at week
12 compared with ALT at baseline (entry). Secondary outcomes include safety, efficacy of
betaine in each cohort, and are changes in laboratory tests related to NAFLD.

Inclusion Criteria:

Inclusion Criteria for all patients:

1. Age 18-75 years

2. A clinical diagnosis of non-alcoholic fatty liver disease.

3. Alanine aminotransferase (ALT) levels ≥60 IU/mL

4. Laboratory tests as defined below:

- Platelets > 100,000/dL

- Total bilirubin < 2 mg/dL

- Creatinine < 1.6 mg/dL

- Inclusion Criteria for Group 1: diabetic patients

1. At least one of the following:

- Fasting blood sugar ≥ 126mg/dL

- Hemoglobin A1c (HgA1c) of > 6.5%

- 2-hour plasma glucose level of > 200mg/dL during a glucose tolerance test

- Receiving treatment with insulin sensitizing drugs (metformin) or sulfonylureas
(glipizide, etc.) 3. Inclusion Criteria for Group 2: Non-diabetic patients with
insulin resistance (must have both)

- Fasting blood glucose of 100-125 mg/dL and

- Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) score >3.0

Exclusion Criteria:

1. Evidence of liver disease other than non-alcoholic fatty liver disease or
non-alcoholic steatohepatitis

2. Alcohol consumption of more than 12g/d (1 drink) for females or more than 24g/day (2
drinks) for males, for 3 months during the past year

3. Active substance abuse within the past year

4. Prior or ongoing use of injectable insulin

5. Use of oral corticosteroids within the prior 30 days

6. Hospitalization within the past 14 days

7. Known HIV infection

8. HgA1c >10%

9. Known heart failure of New York Heart Association class 2, 3, or 4

10. Any condition, which in the opinion of the investigator, would impede compliance or
hinder the completion of the study

11. History of allergic reactions attributed to compounds of similar chemical or biologic
composition to betaine

12. Current use of betaine or S-adenosylmethionine supplements, or refusal to abstain from
their use during the study

13. Known cystathionine beta-synthase (CBS) deficiency.

14. Pregnancy or refusal to use birth control measures or breast feeding