Skip to main content Accessibility help

Vitamin B12 and folate status in Spanish lacto-ovo vegetarians and vegans

  • Angélica Gallego-Narbón (a1), Belén Zapatera (a1), Laura Barrios (a2) and M. Pilar Vaquero (a1)


Studies on the nutritional status of vegetarians in Spain are lacking. Prevention of vitamin B12 deficiency is the main concern, as dietary sources are of animal origin. The present study aimed to evaluate vitamin B12 and folate status of Spanish vegetarians using classical markers and functional markers. Participants were adult and healthy lacto-ovo vegetarians (forty-nine subjects) and vegans (fifty-four subjects) who underwent blood analyses and completed a FFQ. Serum vitamin B12, homocysteine (Hcy), methylmalonic acid (MMA), erythrocyte folate and haematological parameters were determined. The effects of the type of plant-based diet, and the intake of supplements and foods were studied by a FFQ. Mean erythrocyte folate was 1704 (sd 609) nmol/l. Clinical or subclinical vitamin B12 deficiency was detected in 11 % of the subjects (MMA>271 nmol/l) and 33 % of the participants showed hyperhomocysteinaemia (Hcy>15 µmol/l). Regarding plant-based diet type, significantly higher Hcy was observed in lacto-ovo vegetarians compared with vegans (P = 0·019). Moreover, use of vitamin B12 supplements involved an improvement of vitamin B12 status but further increase in erythrocyte folate (P = 0·024). Consumption of yoghurts was weakly associated with serum vitamin B12 adequacy (P = 0·049) and that of eggs with lower Hcy (P = 0·030). In conclusion, Spanish vegetarians present high folate status but vitamin B12 subclinical deficiency was demonstrated using functional markers. The lack of influence of dietary sources on functional markers and the strong effect of vitamin B12 supplement intake emphasise the need of cobalamin supplementation in both lacto-ovo vegetarians and vegans.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Vitamin B12 and folate status in Spanish lacto-ovo vegetarians and vegans
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Vitamin B12 and folate status in Spanish lacto-ovo vegetarians and vegans
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Vitamin B12 and folate status in Spanish lacto-ovo vegetarians and vegans
      Available formats


This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

*Corresponding author: M. Pilar Vaquero, email


Hide All
1.Rizzo, G, Laganà, AS, Rapisarda, AM, et al. (2016) Vitamin B12 among vegetarians: status, assessment and supplementation. Nutrients 8, e767.
2.Key, TJ, Appleby, PN & Rosell, MS (2006) Health effects of vegetarian and vegan diets. Proc Nutr Soc 65, 3541.
3.Haider, LM, Schwingshackl, L, Hoffmann, G, et al. (2018) The effect of vegetarian diets on iron status in adults: a systematic review and meta-analysis. Crit Rev Food Sci Nutr 58, 13591374.
4.Pawlak, R, Lester, SE & Babatunde, T (2014) The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature. Eur J Clin Nutr 68, 541548.
5.Melina, V, Craig, W & Levin, S (2016) Position of the Academy of Nutrition and Dietetics: vegetarian diets. J Acad Nutr Diet 116, 19701980.
6.Herrmann, W, Schorr, H, Purschwitz, K, et al. (2001) Total homocysteine, vitamin B12, and total antioxidant status in vegetarians. Clin Chem 47, 10941101.
7.Krishnaswamy, K & Madhavan Nair, K (2001) Importance of folate in human nutrition. Br J Nutr 85, Suppl. 2, S115S124.
8.Kapoor, A, Baig, M, Tunio, SA, et al. (2017) Neuropsychiatric and neurological problems among vitamin B12 deficient young vegetarians. Neurosciences (Riyadh) 22, 228232.
9.Hunt, A, Harrington, D & Robinson, S (2014) Vitamin B12 deficiency. BMJ 349, g5226.
10.Pawlak, R (2015) Is vitamin B12 deficiency a risk factor for cardiovascular disease in vegetarians? Am J Prev Med 48, e11e26.
11.Yetley, EA, Pfeiffer, CM, Phinney, KW, et al. (2011) Biomarkers of vitamin B12 status in NHANES: a roundtable summary. Am J Clin Nutr 94, 313S321S.
12.Klee, GG (2000) Cobalamin and folate evaluation: measurement of methylmalonic acid and homocysteine vs vitamin B12 and folate. Clin Chem 46, 12771283.
13.Blom, HJ, van Rooij, A & Hogeveen, M (2007) A simple high-throughput method for the determination of plasma methylmalonic acid by liquid chromatography-tandem mass spectrometry. Clin Chem Lab Med 45, 645650.
14.Krajcovicova-Kudlackova, M, Blazicek, P, Kopcova, J, et al. (2000) Homocysteine levels in vegetarians versus omnivores. Ann Nutr Metab 44, 135138.
15.Herrmann, W, Schorr, H, Obeid, R, et al. (2003) Vitamin B12 status, particularly holotranscobalamin II and methylmalonic acid concentrations, and hyperhomocysteinemia in vegetarians. Am J Clin Nutr 78, 131136.
16.Kumar, A, Palfrey, HA, Pathak, R, et al. (2017) The metabolism and significance of homocysteine in nutrition and health. Nutr Metab (Lond) 14, 78.
17.Windelberg, A, Arseth, O, Kvalheim, G, et al. (2005) Automated assay for the determination of methylmalonic acid, total homocysteine, and related amino acids in human serum or plasma by means of methylchloroformate derivatization and gas chromatography-mass spectrometry. Clin Chem 51, 21032109.
18.Birch, CS, Brasch, NE, McCaddon, A, et al. (2009) A novel role for vitamin B12: cobalamins are intracellular antioxidants in vitro. Free Radic Biol Med 47, 184188.
19.Sobczynska-Malefora, A, Gorska, R, Pelisser, M, et al. (2014) An audit of holotranscobalamin (“active” B12) and methylmalonic acid assays for the assessment of vitamin B12 status: application in a mixed patient population. Clin Biochem 47, 8286.
20.Watanabe, F (2007) Vitamin B12 sources and bioavailability. Exp Biol Med 232, 12661274.
21.Watanabe, F, Yabuta, Y, Bito, T, et al. (2014) Vitamin B12-containing plant food sources for vegetarians. Nutrients 6, 18611873.
22.Watanabe, F, Katsura, H, Takenaka, S, et al. (1999) Pseudovitamin B12 is the predominant cobamide of an algal health food, spirulina tablets. J Agric Food Chem 47, 47364741.
23.Nakos, M, Pepelanova, I, Beutel, S, et al. (2017) Isolation and analysis of vitamin B12 from plant samples. Food Chem 216, 301308.
24.Pawlak, R, Parrott, SJ, Raj, S, et al. (2013) How prevalent is vitamin B12 deficiency among vegetarians? Nutr Rev 71, 110117.
25.Gallego-Narbón, A, Zapatera, B, Álvarez, I, et al. (2018) Methylmalonic acid levels and their relation with cobalamin supplementation in Spanish vegetarians. Plant Foods Hum Nutr 73, 166171.
26.AECOSAN (2011) National Survey of Dietary Intake (2009–2010). Results on Consumption Data. Madrid: Spanish Agency for Consumer Affairs, Food Safety and Nutrition Government of Spain.
27.Allen, L, de Benoist, B, Dary, O, et al. (2006) Guidelines on Food Fortification with Micronutrients. Geneva: World Health Organization/Food and Agriculture Organization.
28.Herklotz, R, Luthi, U, Ottiger, C, et al. (2006) Metaanalysis of reference values in hematology. Ther Umsch 63, 524.
29.Dyett, P, Rajaram, S, Haddad, EH, et al. (2014) Evaluation of a validated food frequency questionnaire for self-defined vegans in the United States. Nutrients 6, 25232539.
30.Obersby, D, Chappell, DC, Dunnett, A, et al. (2013) Plasma total homocysteine status of vegetarians compared with omnivores: a systematic review and meta-analysis. Br J Nutr 109, 785794.
31.Faul, F, Erdfelder, E, Buchner, A, et al. (2009) Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41, 11491160.
32.Molloy, AM, Pangilinan, F, Mills, JM, et al. (2016) A common polymorphism in HIBCH influences methylmalonic acid concentrations in blood independently of cobalamin. Am J Hum Genet 98, 869882.
33.Waldmann, A, Koschizke, JW, Leitzmann, C, et al. (2004) Homocysteine and cobalamin status in German vegans. Public Health Nutr 7, 467472.
34.Majchrzak, D, Singer, I, Manner, M, et al. (2006) B-vitamin status and concentrations of homocysteine in Austrian omnivores, vegetarians and vegans. Ann Nutr Metab 50, 485491.
35.Elmadfa, I & Singer, I (2009) Vitamin B12 and homocysteine status among vegetarians: a global perspective. Am J Clin Nutr 89, 1693S1698S.
36.Colapinto, CK, O'Connor, DL & Tremblay, MS (2011) Folate status of the population in the Canadian Health Measures Survey. CMAJ 183, E100E106.
37.Schüpbach, R, Wegmüller, R, Berguerand, C, et al. (2017) Micronutrient status and intake in omnivores, vegetarians and vegans in Switzerland. Eur J Nutr 56, 283293.
38.Herrmann, W & Geisel, J (2002) Vegetarian lifestyle and monitoring of vitamin B12 status. Clin Chim Acta 326, 4759.
39.Schmidt, JA, Rinaldi, S, Scalbert, A, et al. (2016) Plasma concentrations and intakes of amino acids in male meat-eaters, fish-eaters, vegetarians and vegans: a cross-sectional analysis in the EPIC-Oxford cohort. Eur J Clin Nutr 70, 306312.
40.Bissoli, L, Di Francesco, V, Ballarin, A, et al. (2002) Effect of vegetarian diet on homocysteine levels. Ann Nutr Metab 46, 7379.
41.Huang, T, Yang, B, Zheng, J, et al. (2012) Cardiovascular disease mortality and cancer incidence in vegetarians: a meta-analysis and systematic review. Ann Nutr Metab 60, 233240.
42.Mezzano, D, Kosiel, K, Martinez, C, et al. (2000) Cardiovascular risk factors in vegetarians. Normalization of hyperhomocysteinemia with vitamin B12 and reduction of platelet aggregation with n-3 fatty acids. Thromb Res 100, 153160.
43.Gilsing, AM, Crowe, FL, Lloyd-Wright, Z, et al. (2010) Serum concentrations of vitamin B12 and folate in British male omnivores, vegetarians and vegans: results from a cross-sectional analysis of the EPIC-Oxford cohort study. Eur J Clin Nutr 64, 933939.
44.Naik, S, Mahalle, N & Bhide, V (2018) Identification of vitamin B12 deficiency in vegetarian Indians. Br J Nutr 119, 629635.
45.Yajnik, CS, Deshpande, SS, Lubree, HG, et al. (2006) Vitamin B12 deficiency and hyperhomocysteinemia in rural and urban Indians. J Assoc Physicians India 54, 775782.
46.Menal-Puey, S & Marques-Lopes, I (2017) Development of a food guide for the vegetarians of Spain. J Acad Nutr Diet 117, 15091516.


Vitamin B12 and folate status in Spanish lacto-ovo vegetarians and vegans

  • Angélica Gallego-Narbón (a1), Belén Zapatera (a1), Laura Barrios (a2) and M. Pilar Vaquero (a1)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed