Background-An elevated level of homocysteine (hyperhomocysteinemia) has been implicated as an independent risk factor for cardiovascular diseases. Deficiency of dietary factors like vitamin B 12 , folate, and genetic variations can cause hyperhomocysteinemia. The prevalence of hyperhomocysteinemia in the Indian population is likely to be high because most Indians adhere to a vegetarian diet, deficient in vitamin B 12 . In the background of vitamin B 12 deficiency, variations in genes involved in homocysteine metabolism might have a greater impact on homocysteine levels. Methods and Results-We genotyped 44 nonsynonymous single-nucleotide polymorphisms (nsSNPs) from 11 genes involved in homocysteine metabolism and found only 14 to be polymorphic. These 14 nsSNPs were genotyped in 546 individuals recruited from a tertiary care center in New Delhi, India, and it was found that choline dehydrogenase (CHDH A119C) and methylenetetrahydrofolate reductase (MTHFR C677T) were significantly associated with plasma total homocysteine levels (Pϭ0.009 and Pϭ0.001, respectively). These 2 SNPs were further genotyped in 330 individuals recruited from the same center, and the association remained significant even after increasing the sample size. Furthermore, we found the possibility of a significant interaction between vegetarian diet and the 2 polymorphisms that could explain the variation of homocysteine levels. We also genotyped all the polymorphic nsSNPs in apparently healthy individuals recruited from 24 different subpopulations (based on their linguistic lineage) spread across the country to determine their basal frequencies. The frequencies of these SNPs varied significantly between linguistic groups. Conclusion-Vegetarian diet along with CHDH A119C and MTHFR C677T play an important role in modulating the homocysteine levels in Indian population. (Circ Cardiovasc Genet. 2009;2:599-606.)Key Words: genetics Ⅲ homocysteine Ⅲ polymorphisms Ⅲ CHDH, MTHFR, Indian population A n elevated level of homocysteine, a thiol amino acid, has been associated with several diseases and/or clinical conditions including neural tube defects, 1 Alzheimer disease, 2 end-stage renal disease, 3 schizophrenia, 4 non-insulindependent diabetes, 5 etc. It has also been implicated as an independent and graded risk factor for cardiovascular disease. 6 In patients with coronary artery disease (CAD), homocysteine level is a significant predictor of mortality, independent of traditional risk factors. 7 Intracellular homocysteine metabolism is well regulated, and its concentration in circulation is Ͻ12 mol/L. However, deficiencies in the micronutrients like folate, vitamin B 12 , and vitamin B 6 impair homocysteine metabolism leading to elevated intracellular and extracellular levels of homocysteine. 8 -10 Apart from these micronutrients, polymorphisms in some of the genes involved in homocysteine metabolism also modulate homocysteine levels. 11,12 Clinical Perspective on p 606Several studies have found the association of certain nonsynonymous single-nucleo...