Possible Risk Factors 1 Homocysteine

Patients with CHD have higher plasma concentrations of homocysteine than controls, and these differences have been observed in both case-control and prospective studies.54-56 Plasma concentrations of homocys-teine are inversely related to the dietary intake of folic acid, vitamin B6, and vitamin B12.57

Typically, vegetarians have relatively high intakes of folate and similar intakes of vitamin B6, as compared with the general population.58 However, vegetarians (and particularly vegans) typically have relatively low intakes of vitamin B12.59 Vitamin B12 is essentially absent from plant foods and is present in small amounts in dairy products (but in somewhat higher amounts in eggs). Therefore, dietary intake of vitamin B12 in vegetarians is low unless they consume large amounts of dairy products and eggs, or regularly consume fortified foods or vitamin supplements. For example, Hokin and Butler60 reported that 73% of vegetarian Seventh-Day Adventist ministers in Australia had low serum vitamin B12 (<221 pmol/L), probably because of the limitation in food fortification with vitamin B12 in Australia. Similarly, Woo et al.16 reported that 54% of elderly Chinese vegetarians had serum vitamin B12 below the reference range. In the general population (largely non-vegetarian), folate is an important determinant of homocysteine, whereas vitamin B12 is not, but vitamin B12 intakes are relatively high and vitamin B12 deficiency is rare. Vegetarians are at increased risk of vitamin B12 deficiency and this might cause elevated homocysteine. Indeed, a recent small study in Chile reported that 21 out of 26 vegetarians had serum vitamin B12 concentrations below 200 pg/ml and that mean plasma homocysteine was 41% higher in the vegetarians than in age-matched meat-eaters.39

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