Prudent dietary pattern influences homocysteine level more than folate, vitamin B12, and docosahexaenoic acid: a structural equation model approach

  • Juliana Araujo Teixeira
  • Josiane Steluti
  • Bartira Mendes Gorgulho
  • Antonio Augusto Ferreira Carioca
  • Gizelton Pereira Alencar
  • Regina Mara Fisberg
  • Dirce Maria MarchioniEmail author
Original Contribution



A structural equation model (SEM) was used to test multiple and simultaneous relationships between socio-demographic factors, dietary patterns, biochemical levels of folate, vitamin B12, docosahexaenoic acid (DHA), and its effects on homocysteine (Hcy) level.


Socio-demographic and lifestyle characteristics, blood sample, anthropometric measurements, and a food-frequency questionnaire (FFQ) were obtained from 281 individuals of ISA-Capital study (Sao Paulo, Brazil). The dietary patterns (DP) were estimated using factor analysis with principal component’s estimation based on the frequency of daily intake derived from the 38-item FFQ. The SEM considered a theoretical model where the DP were expected to be directly associated with Hcy level, and indirectly via biochemical levels of folate, vitamin B12, and DHA. The variables sex, age, ethnicity, and MTHFR C677T polymorphism were included in the model.


The Prudent DP (− 0.12, p = 0.04) had a negative effect, while MTHFR C677T polymorphism (0.16, p = 0.01), age (0.22, p < 0.01), and being man (0.16, p = 0.01) had a positive effect on Hcy level. There were no indirect effects of any dietary patterns on Hcy level, neither via folate, vitamin B12, nor DHA. DHA was negatively associated with the Modern DP (− 0.12, p = 0.04) and positively associated with the Prudent DP (0.19, p < 0.01).


The DP mainly composed of fruits and vegetables, natural juices, potato/cassava/cooked cornmeal, fish, and chicken, which was negatively associated with the Hcy level in this population. These findings support the role of a healthy dietary pattern in health outcomes, rather than promoting specific foods or nutrients, for policy-based health promotion strategies.


One-carbon metabolism Folate Homocysteine MTHFR Structural equation model 



We would like to acknowledge the participants and all the members of the ISA-Capital study. In addition, we acknowledge the Sao Paulo Research Foundation (FAPESP) for the doctoral scholarship granted to Juliana Araujo Teixeira (2014/12647-1).

Compliance with ethical standards

Ethical approval

This study was approved by the Ethical Committee of School of Public Health, University of São Paulo (nº 2001, 275/09 and nº 1.501.677/16) and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Participants provided written consent in each stage of the study to be involved.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Martí-Carvajal AJ, Solà I, Lathyris D (2015) Homocysteine-lowering interventions for preventing cardiovascular events. In: Martí-Carvajal AJ (ed) Cochrane database of systematic reviews. Wiley, Chichester, p CD006612Google Scholar
  2. 2.
    Refsum H, Smith AD, Ueland PM et al (2004) Facts and recommendations about total homocysteine determinations: an expert opinion. Clin Chem 50:3–32. CrossRefPubMedGoogle Scholar
  3. 3.
    Kim J-M, Park K-Y, Shin D-W et al (2016) Relation of serum homocysteine levels to cerebral artery calcification and atherosclerosis. Atherosclerosis 254:200–204. CrossRefPubMedGoogle Scholar
  4. 4.
    Selhub J (2008) Public health significance of elevated homocysteine. Food Nutr Bull 29:S116–S125. CrossRefPubMedGoogle Scholar
  5. 5.
    Refsum H, Ueland PM, Nygård O, Vollset SE (1998) Homocysteine and cardiovascular disease. Annu Rev Med 49:31–62. CrossRefPubMedGoogle Scholar
  6. 6.
    Selhub J, Jacques PF, Wilson PW et al (1993) Vitamin status and intake as primary determinants of homocysteinemia in an elderly population. JAMA 270:2693–2698CrossRefGoogle Scholar
  7. 7.
    Jacques PF, Bostom AG, Wilson PW et al (2001) Determinants of plasma total homocysteine concentration in the Framingham Offspring cohort. Am J Clin Nutr 73:613–621CrossRefGoogle Scholar
  8. 8.
    Selhub J (2006) The many facets of hyperhomocysteinemia: studies from the Framingham cohorts. J Nutr 136:1726S–1730SCrossRefGoogle Scholar
  9. 9.
    de Benoist B (2008) Conclusions of a WHO technical consultation on folate and vitamin B12 deficiencies. Food Nutr Bull 29:S238–S244. CrossRefPubMedGoogle Scholar
  10. 10.
    World Health Organization (2006) Guidelines on food fortification with micronutrients. World Health Organization, Geneva, SwitzerlandGoogle Scholar
  11. 11.
    Li D, Mann NJ, Sinclair AJ (2006) A significant inverse relationship between concentrations of plasma homocysteine and phospholipid docosahexaenoic acid in healthy male subjects. Lipids 41:85–89CrossRefGoogle Scholar
  12. 12.
    García-Alonso FJ, Jorge-Vidal V, Ros G, Periago MJ (2012) Effect of consumption of tomato juice enriched with n-3 polyunsaturated fatty acids on the lipid profile, antioxidant biomarker status, and cardiovascular disease risk in healthy women. Eur J Nutr 51:415–424. CrossRefPubMedGoogle Scholar
  13. 13.
    Huang T, Zheng J, Chen Y et al (2011) High consumption of Ω-3 polyunsaturated fatty acids decrease plasma homocysteine: a meta-analysis of randomized, placebo-controlled trials. Nutrition 27:863–867. CrossRefPubMedGoogle Scholar
  14. 14.
    Huang T, Wahlqvist ML, Li D (2010) Docosahexaenoic acid decreases plasma homocysteine via regulating enzyme activity and mRNA expression involved in methionine metabolism. Nutrition 26(1):112–119. CrossRefPubMedGoogle Scholar
  15. 15.
    Huang T, Wahlqvist ML, Li D (2012) Effect of n-3 polyunsaturated fatty acid on gene expression of the critical enzymes involved in homocysteine metabolism. Nutr J 11:6. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    USDA Evidence Analysis Library Division (2014) A series of systematic reviews on the relationship between dietary patterns and health outcomes. United States Department of Agriculture, VirginiaGoogle Scholar
  17. 17.
    Tucker KL, Selhub J, Wilson PW, Rosenberg IH (1996) Dietary intake pattern relates to plasma folate and homocysteine concentrations in the Framingham Heart Study. J Nutr 126:3025–3031CrossRefGoogle Scholar
  18. 18.
    Konstantinova SV, Vollset SE, Berstad P et al (2007) Dietary predictors of plasma total homocysteine in the Hordaland Homocysteine Study. Br J Nutr 98:201–210. CrossRefPubMedGoogle Scholar
  19. 19.
    Gao X, Yao M, McCrory MA et al (2003) Dietary pattern is associated with homocysteine and B vitamin status in an urban Chinese population. J Nutr 133:3636–3642CrossRefGoogle Scholar
  20. 20.
    Bigio RS, Verly E, de Castro MA et al (2013) Are plasma homocysteine concentrations in Brazilian adolescents influenced by the intake of the main food sources of natural folate? Ann Nutr Metab 62:331–338. CrossRefPubMedGoogle Scholar
  21. 21.
    Gorgulho BM, Fisberg RM, Marchioni DML (2014) Away-from-home meals: prevalence and characteristics in a metropolis. Rev Nutr 27:703–713. CrossRefGoogle Scholar
  22. 22.
    ISA (2011) Inquéritos de Saúde no Município de São Paulo. ISA, São Paulo. Accessed 20 Nov 2017
  23. 23.
    Selem SSADC, de Carvalho AM, Verly-Junior E et al (2014) Validity and reproducibility of a food frequency questionnaire for adults of São Paulo, Brazil. Rev Bras Epidemiol 17:852–859. CrossRefPubMedGoogle Scholar
  24. 24.
    StataCorp (2011) Stata statistical software: release 12Google Scholar
  25. 25.
    Bagley PJ, Selhub J (2000) Analysis of folate form distribution by affinity followed by reversed-phase chromatography with electrical detection. Clin Chem 46:404–411PubMedGoogle Scholar
  26. 26.
    Kalmbach R, Paul L, Selhub J (2011) Determination of unmetabolized folic acid in human plasma using affinity HPLC. Am J Clin Nutr 94:343S–347S. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Beckman Coulter, Inc. (2009) Vitamin B12—Access Immunoassay Systems®. California (Technical Lab Manual)Google Scholar
  28. 28.
    Huang Z, Wang B, Crenshaw A (2006) A simple method for the analysis of trans fatty acid with GC–MS and ATTM-Silar-90 capillary column. Food Chem 98:593–598. CrossRefGoogle Scholar
  29. 29.
    Oki E, Norde MM, Carioca AAF et al (2016) Interaction of SNP in the CRP gene and plasma fatty acid profile in inflammatory pattern: a cross-sectional population-based study. Nutrition 32:88–94. CrossRefPubMedGoogle Scholar
  30. 30.
    Abbott Diagnostics Division (2011) Homocysteine (technical lab manual)Google Scholar
  31. 31.
    WHO (2014) Obesity and overweight. Fact sheet no. 311. WHO, GenevaGoogle Scholar
  32. 32.
    Miller SA, Dykes DD, Polesky HF (1988) A simple salting out procedure for extracting DNA from human nucleated cells. Nucleic Acids Res 16:1215CrossRefGoogle Scholar
  33. 33.
    Myakishev MV, Khripin Y, Hu S, Hamer DH (2001) High-throughput SNP genotyping by allele-specific PCR with universal energy-transfer-labeled primers. Genome Res 11:163–169CrossRefGoogle Scholar
  34. 34.
    Kline R (2011) Principles and practice of structural equation modeling, 4th edn. The Guilford Press, New YorkGoogle Scholar
  35. 35.
    Huang T, Hu X, Khan N et al (2013) Effect of polyunsaturated fatty acids on homocysteine metabolism through regulating the gene expressions involved in methionine metabolism. Sci World J. CrossRefGoogle Scholar
  36. 36.
    Browne MW, Cudeck R (1993) Alternative ways of assessing model fit. In: Testing structural equation models. Sage, Newbury ParkGoogle Scholar
  37. 37.
    Chen F, Curran PJ, Bollen KA et al (2008) An empirical evaluation of the use of fixed cutoff points in RMSEA test statistic in structural equation models. Sociol Methods Res 36:462–494. CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    R Core Team (2016) R: a language and environment for statistical computing. R Foundation for Statistical Computing, ViennaGoogle Scholar
  39. 39.
    Rosseel Y (2012) lavaan: an R package for structural equation modeling. J Stat Softw 48:1–36CrossRefGoogle Scholar
  40. 40.
    Zhong F, Zhuang L, Wang Y, Ma Y (2017) Homocysteine levels and risk of essential hypertension: a meta-analysis of published epidemiological studies. Clin Exp Hypertens 39:160–167. CrossRefPubMedGoogle Scholar
  41. 41.
    Hu Q, Teng W, Li J et al (2016) Homocysteine and Alzheimer’s disease: evidence for a causal link from mendelian randomization. J Alzheimer’s Dis 52:747–756. CrossRefGoogle Scholar
  42. 42.
    Numata S, Kinoshita M, Tajima A et al (2015) Evaluation of an association between plasma total homocysteine and schizophrenia by a Mendelian randomization analysis. BMC Med Genet 16:54. CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Bhatia P, Singh N (2015) Homocysteine excess: delineating the possible mechanism of neurotoxicity and depression. Fundam Clin Pharmacol 29:522–528. CrossRefPubMedGoogle Scholar
  44. 44.
    Welch GN, Loscalzo J (1998) Homocysteine and atherothrombosis. N Engl J Med 338:1042–1050. CrossRefPubMedGoogle Scholar
  45. 45.
    Steluti J, Carvalho A, Carioca A et al (2017) Genetic variants involved in one-carbon metabolism: polymorphism frequencies and differences in homocysteine concentrations in the folic acid fortification era. Nutrients 9:539. CrossRefPubMedCentralGoogle Scholar
  46. 46.
    Födinger M, Buchmayer H, Heinz G et al (2001) Association of two MTHFR polymorphisms with total homocysteine plasma levels in dialysis patients. Am J Kidney Dis 38:77–84CrossRefGoogle Scholar
  47. 47.
    Iglesia I, Huybrechts I, González-Gross M et al (2017) Folate and vitamin B12 concentrations are associated with plasma DHA and EPA fatty acids in European adolescents: the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study. Br J Nutr 117:124–133. CrossRefPubMedGoogle Scholar
  48. 48.
    Baierle M, Vencato PH, Oldenburg L et al (2014) Fatty acid status and its relationship to cognitive decline and homocysteine levels in the elderly. Nutrients 6:3624–3640. CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    van Wijk N, Watkins CJ, Hageman RJJ et al (2012) Combined dietary folate, vitamin B-12, and vitamin B-6 intake influences plasma docosahexaenoic acid concentration in rats. Nutr Metab (Lond) 9:49. CrossRefGoogle Scholar
  50. 50.
    Kulkarni A, Dangat K, Kale A et al (2011) Effects of altered maternal folic acid, vitamin B12 and docosahexaenoic acid on placental global DNA methylation patterns in Wistar rats. PLoS One 6:e17706. CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Khaire A, Rathod R, Randhir K et al (2016) A combined supplementation of vitamin B12 and omega-3 fatty acids across two generations improves cardiometabolic variables in rats. Food Funct 7:3910–3919. CrossRefPubMedGoogle Scholar
  52. 52.
    Kemse NG, Kale AA, Joshi SR (2014) A combined supplementation of omega-3 fatty acids and micronutrients (folic acid, vitamin B12) reduces oxidative stress markers in a rat model of pregnancy induced hypertension. PLoS One 9:e111902. CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Li J, Li B, Qi J, Shen B (2015) Meta-analysis of clinical trials of folic acid, vitamin B12 and B6 supplementation on plasma homocysteine level and risk of cardiovascular disease. Zhonghua Xin Xue Guan Bing Za Zhi 43:554–561PubMedGoogle Scholar
  54. 54.
    Jacobs DR, Gross MD, Tapsell LC (2009) Food synergy: an operational concept for understanding nutrition. Am J Clin Nutr 89:1543S–1548S. CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Jacobs DR, Steffen LM (2003) Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy. Am J Clin Nutr 78:508–513. CrossRefGoogle Scholar
  56. 56.
    Maddock J, Ambrosini GL, Griffin JL et al (2018) A dietary pattern derived using B-vitamins and its relationship with vascular markers over the life course. Clin Nutr. CrossRefPubMedGoogle Scholar
  57. 57.
    Öhrvik V, Lemming EW, Nälsén C et al (2018) Dietary intake and biomarker status of folate in Swedish adults. Eur J Nutr 57:451–462. CrossRefPubMedGoogle Scholar
  58. 58.
    McCourt HJ, Draffin CR, Woodside JV et al (2014) Dietary patterns and cardiovascular risk factors in adolescents and young adults: the Northern Ireland Young Hearts Project. Br J Nutr 112:1685–1698. CrossRefPubMedGoogle Scholar
  59. 59.
    Castro MA, Baltar VT, Marchioni DM, Fisberg RM (2016) Examining associations between dietary patterns and metabolic CVD risk factors: a novel use of structural equation modelling. Br J Nutr 115:1586–1597. CrossRefPubMedGoogle Scholar
  60. 60.
    de Castro Selem SS, de Castro MA, César CL et al (2014) Associations between dietary patterns and self-reported hypertension among Brazilian adults: a cross-sectional population-based study. J Acad Nutr Diet 114:1216–1222. CrossRefGoogle Scholar
  61. 61.
    Olinto MTA, Willett WC, Gigante DP, Victora CG (2011) Sociodemographic and lifestyle characteristics in relation to dietary patterns among young Brazilian adults. Public Health Nutr 14:150–159. CrossRefPubMedGoogle Scholar
  62. 62.
    de Andrade LOM, Pellegrini Filho A, Solar O et al (2015) Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries. Lancet 385:1343–1351. CrossRefPubMedGoogle Scholar
  63. 63.
    Hill RJ, Davies PS (2001) The validity of self-reported energy intake as determined using the doubly labelled water technique. Br J Nutr 85:415–430CrossRefGoogle Scholar
  64. 64.
    Claro RM, Carmo HCE do, Machado FMS, Monteiro CA (2007) Income, food prices, and participation of fruit and vegetables in the diet. Rev Saúde Públ 41:557–564CrossRefGoogle Scholar
  65. 65.
    Levy RB, Claro RM, Mondini L et al (2012) Regional and socioeconomic distribution of household food availability in Brazil, in 2008–2009. Rev Saúde Públ 46:6–15CrossRefGoogle Scholar
  66. 66.
    CSDH (2008) Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health, GenevaGoogle Scholar
  67. 67.
    Hosmer D, Sturdivant SL R (2013) Applied logistic regression. Wiley, HobokenCrossRefGoogle Scholar
  68. 68.
    von Elm E, Altman DG, Egger M et al (2007) Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 335:806–808. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Juliana Araujo Teixeira
    • 1
  • Josiane Steluti
    • 1
  • Bartira Mendes Gorgulho
    • 1
  • Antonio Augusto Ferreira Carioca
    • 1
    • 2
  • Gizelton Pereira Alencar
    • 1
  • Regina Mara Fisberg
    • 1
  • Dirce Maria Marchioni
    • 1
    Email author
  1. 1.Department of Nutrition, School of Public HealthUniversity of Sao PauloSao PauloBrazil
  2. 2.Discipline of NutritionUniversity of FortalezaFortalezaBrazil

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