Clinical Nutrition 31 (2012) 448e454

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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

Review

Meta-analysis of B vitamin supplementation on plasma homocysteine,

cardiovascular and all-cause mortality
Tao Huang a, b, e, Ying Chen a, b, Bin Yang a, b, Jing Yang a, b, Mark L. Wahlqvist a, b, c, d, Duo Li a, b, *
a
Department of Food Science and Nutrition, Zhejiang University, Hangzhou 310029, PR China
b
APCNS Centre of Nutrition and Food Safety, Hangzhou, PR China
c
National Health Research Institutes, Zhunan, Taiwan
d
Monash Asia Institute, Monash University, Melbourne, Australia

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Results from randomized controlled trials (RCT) of B vitamin supplementation on
Received 16 September 2010 risk of cardiovascular disease (CVD) were inconclusive. The aim of the present study was to systemati-
Accepted 4 January 2011 cally review the effects of B vitamin supplementation on plasma homocysteine (Hcy), cardiovascular and
all-cause mortality in RCT.
Keywords: Methods: RCT publications on the effect of B vitamin supplementation on plasma Hcy, cardiovascular and
B vitamin
all-cause mortality were searched from PubMed and web of science database. Data were independently
Plasma homocysteine
abstracted by 2 investigators using a standardized protocol. The results were pooled with a xed-effects
Cardiovascular disease
All-cause mortality
model using Stata software.
RCT Results: Data from 19 studies including 47921participants were analyzed using a xed-effects model. The
overall relative risks with 95% condence intervals of outcomes for patients treated with B vitamin
supplementation compared with placebo were 0.98 (0.94e1.03) for CVD, 0.98 (0.92e1.05) for coronary
heart disease (CHD), 0.97 (0.90e1.05) for myocardial infarction (MI), 0.88 (0.82e0.95) for stroke, and 0.97
(0.91e1.02) for cardiovascular death, 0.99 (0.95e1.04) for all-cause mortality. Blood Hcy levels were
decreased in all included RCTs.
Conclusions: B vitamin supplementation has a signicant protective effect on stroke, but none on the risk
of CVD, MI, CHD, cardiovascular death, or all-cause mortality.
2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

1. Introduction
The homocysteine (Hcy) level in blood is a sensitive indicator of
vitamin B12 and folate deciencies.1,2 It is related to pregnancy
complications, neural tube defects, cognitive impairment, and
mental disorders in the elderly.3 Clinical and epidemiological
studies report that Hcy is directly associated with cardiovascular
risk4; Evidence from studies involving so-called Mendelian
randomization,5 demonstrating an association between cardio-
vascular disease (CVD) and the C677T methylenetetrahydrofolate
reductase polymorphism, has provided additional support for
a causal relation between Hcy and CVD.6
Plasma Hcy can be lowered with B vitamin supplementation.7 In
1988, Brattstrm et al. showed that healthy subjects responded to
* Corresponding author. Department of Food Science and Nutrition, Zhejiang
University, 268 Kaixuan Road, Hangzhou 310029, PR China. Tel./fax: 86 571
86971024.
E-mail addresses: taohuang83@gmail.com (T. Huang), duoli@zju.edu.cn (D. Li).
e
Present address: Department of Food Science and Nutrition, Zhejiang Univer-
sity, 268 Kaixuan Road, Hangzhou 310029, PR China.
a high dose of folic acid with a marked reduction in their Hcy
levels.8 Since then, several studies have demonstrated that
0.65e10 mg/d of folic acid alone or together with vitamin B12 and/
or B6 reduce the fasting Hcy level by 25e50%, both in healthy and in
hyperhomocysteinemic subjects and in vascular patients.3 Daily
supplementation with folic acid, vitamin B6, vitamin B12, or
a combination has been shown to reduce Hcy levels to varying
degrees in intervention studies.9
The lowering of the mean level of Hcy in the United States by
fortifying food with folic acid is estimated to have prevented 17,000
deaths from coronary causes each year,10 and the inclusion of folic
acid in a combination pill has been suggested as a means to prevent
cardiovascular disease (CVD).11 Persons with high plasma levels or
dietary intake of folate and vitamin B6 have a decreased risk of
CHD.12
Based on these data, several randomized trials were designed to
test the hypothesis that supplementation with B vitamins or both
would prevent CVD. However, published trials on patients with
preexisting vascular disease have not demonstrated a benet of
folic acid or B vitamins on CVD risk.13

0261-5614/$ e see front matter 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2011.01.003
 T. Huang et al. / Clinical Nutrition 31 (2012) 448e454
In contrast to what was expected on the basis of epidemiologic
evidence, a randomized trial found that lowering the total Hcy
levels with B vitamin failed to prevent recurrent stroke, myocardial
infarction (MI), or death in patients who had a recent stroke.14 A
post hoc efcacy analysis indicated, however, that a large subgroup
of the participants in the trial might have beneted from B vitamin
treatment.15 Studies of the effects of B vitamin on the risk of
restenosis after percutaneous coronary intervention have also
yielded inconsistent results.16,17 In 2006, a meta-analysis, which
pooled all the randomized clinical trials (RCT), reported that folic
acid supplementation did not reduce risk of cardiovascular diseases
or all-cause mortality among participants with a prior history of
vascular disease. However, based on ve recently published
RCT,18e21 we wished to review these ndings.
We thus performed an updated meta-analysis of RCTs to
determine the relationship between B vitamin supplementation
and Hcy and risk of CVD and all-cause mortality among persons
with preexisting vascular disease.
2. Methods
2.1. Data sources and study selection
We searched the following electronic databases from inception
to November 2010: Medline, web of science for the terms
cardiovascular disease, coronary disease, coronary heart
disease, myocardial infarction, cardiovascular death, cere-
brovascular accident, all-cause mortality, randomized
controlled trial, clinical trials, folate, and folic acid, vitamin
B12, vitamin B6, and B vitamins. The search was restricted to
human studies and studies published in English-language journals.
Hand searching of the bibliographic sections of all relevant articles
and recent reviews was undertaken.22,23
A standard search lter was used to identify the studies. Addi-
tional studies were identied by searching references cited in
identied primary studies. No restrictions were placed on duration
of follow-up or sample size. Studies were excluded from the pooled
analysis if outcome or change data were not obtainable. Studies
were eligible for inclusion if (1) the study design was a randomized
controlled trial; (2) the relative risk (RR) or the number of events
for CVD, coronary heart disease (CHD), stroke, and/or all-cause
mortality that occurred during the study was reported by inter-
vention and control groups; (3) the intervention was B vitamins;
and (4) there was no limitation on the intervention duration. The
abstracts or full-text manuscripts identied through the literature
search were reviewed independently by 2 investigators (TH and JY)
in duplicate to determine whether they met eligibility criteria for
inclusion. Where discrepancies between investigators occurred for
inclusion or exclusion, a third investigator (YC) was involved to
conduct additional evaluation of the study, and discrepancies were
resolved in conference.
2.2. Data abstraction
Data extraction was undertaken independently by two investi-
gators with discrepancies resolved by consensus. When data were
not available in a published report, we did not contact authors to
request additional information. Study characteristics recorded were
as follows: rst authors name; year of publication; mean age of
participants; percentage of males; preexisting conditions among
the study participants; percentage with diabetes; mean levels of
Hcy prior to and after treatment or control periods; study design;
type of blinding; number of intervention groups; intervention
regimen; type of control; duration of intervention; and number of
449
CVD, CHD, stroke, and all-cause mortality events that occurred in
each group.
2.3. Data analysis and statistical methods
Extracted data was analyzed using the Stata, version 11 software
(StataCorp, College Station, TX, USA). Effect sizes are presented as
relative risk (RR) with 95% condence interval (CI). RR was used as
a measure of the association between B vitamins supplementation
and risk of CVD, CHD, MI, stroke, or all-cause mortality. Some of the
studies included in our meta-analysis differed in the units used for
reporting levels of Hcy (mg/L vs mmol/L). Therefore, we converted
the unit to mmol/L, using the conversion factors 1 mg/
L 7.397 mmol/L. Both xed-effects and random-effects models24
were used to calculate the pooled RR for B vitamins supplemen-
tation compared with control. Statistical testing for heterogeneity
between studies was performed.
2.4. Publication bias
To assess the potential for publication bias, we constructed
funnel plots for each outcome. In addition, the Begg rank correla-
tion test was used to examine the association between effect esti-
mates and their variances, and the Egger linear regression test was
used to detect publication bias.25,26 We also conducted a sensitivity
analysis in which each trial was excluded in turn to evaluate the
inuence of that trial on the pooled estimate.
3. Results
Our comprehensive search identied 19 RCT which contained
47,921 participants.10,14,17e21,27e37 The process is shown in a ow
diagram (Fig. 1). The characteristics of the included studies are
shown in Table 1. The number of participants ranged from 81 in
a study by Righetti et al.28 to 8164 in the trial reported by VITATOPS
(2010).36 Sixteen trials included both men and women. One study
did not include men.18 One study did not include women.36 Most of
the studies were conducted in a predominantly European country.
The age of the participants ranged from 10 to 90 years. The
percentage of subjects with diabetes mellitus ranged from 9 to 55.
The characteristics of the design of the RCTs are presented in
Table 2. The dosage of B vitamins in the intervention groups among
Fig. 1. Flow chart on selection of included studies.
450 T. Huang et al. / Clinical Nutrition 31 (2012) 448e454

trials is shown in Table 2. Trials were primarily parallel group in
design. Fourteen of the 19 trials were double blind design. Fourteen
of the 19 trials provided a placebo pill, while others used usual care
as control. The duration of intervention and follow-up ranged from
6 to 85 months.
Net change in blood Hcy levels and RR with 95% condence
intervals (CI) for CVD, CHD, stroke, MI, cardiovascular death, and
all-cause mortality are presented in Table 3. All trials showed
a reduction in Hcy levels, ranging from 1.5 to 26.0 mmol/L. There
was no statistically signicant relationship between net change in
Hcy level and RR for any of the clinical outcomes.
Fig. 2 depicts the results from xed-effects models pooling the
RR for CVD, CHD, MI, stroke, cardiovascular death, and all-cause
mortality. No signicant heterogeneity was present for trials
reporting CVD outcomes (I2 30.4%, p 0.126), or for CHD
outcomes (I2 40.5%, p 0.057), for MI (I2 12.0%, p 0.330), and
exclusion of any single trial from the analysis did not alter the
overall ndings of no effect of B vitamins supplementation on CVD,
CHD or MI. There was also no signicant heterogeneity for
cardiovascular death (I2 0.0%, p 0.724), for all-cause mortality
(I2 0.0%, p 0.644), and the exclusion of any single study from the
analysis did not alter the overall ndings of no effect of B vitamins
supplementation on cardiovascular death or all-cause mortality
(Table 4).
For trials reporting stroke outcomes, no signicant heteroge-
neity was present (I2 18.5%, p 0.247). A signicant protective
effect of B vitamins supplementation on stroke (RR, 0.88; 95% CI,
0.82e0.95) was observed.
There was no evidence of publication bias in funnel plots or by
rank correlation or regression testing. No statistically signicant
heterogeneity was detected on testing.
4. Discussion
In the present meta-analysis, we sought to combine the studies
of B vitamins supplementations to give reasonable power for
detecting associations with risk of CVD. The present study included
only RCTs with relatively large number of subjects. Therefore, the
present results represent the most recent information available on
the associations between B vitamins supplementations and risk of
CVD. We found that B vitamin supplementation was associated
with a decrease in blood Hcy levels and a signicant protective

Table 1
Baseline characteristics of participants in randomized controlled trials of B vitamins supplementation.

Source Participants Age, mean (SD), y Men, % Preexisting condition Diabetes Homocysteine,
mellitus, % mean (SD), mmol/L
Baker et al., 2002 1882 NR NR Coronary heart disease NR 11.2 (6.9)
Schnyder et al., 2002 553 62.6 (10.8) 80.5 Undergone angioplasty of 27.5 11.3 (4.6)
at least 1 signicant coronary
stenosis (>50%)
Righetti et al., 2003 81 64 (14) 55.7 End stage renal disease 12.9 50.3 (6.0)
Lange et al., 2004 636 61.4 (10.3) 77 Coronary heart disease, 14.7 12.6 (4.9)
undergone successful coronary
stenting
Liem et al., 2004 283 59 69.5 Hypercholesterolemia following NR NR
acute myocardial infarction
Toole et al., 2004 3680 66.3 62.5 Acute ischemic stroke, most participants 29.1 13.4
had routine diagnostic tests such as
carotid duplex ultrasonography and
transthoracic echocardiography
Wrone et al., 2004 510 60.2 (15.1) 50 End stage renal disease, adult patients 45.5 32.9 (20)
undergoing hemodialysis or peritoneal dialysis
Liem et al., 2005 593 65.2 (9.8) 78 Stable coronary artery disease 9 12.1 (4.3)
Bonaa et al., 2006 2815 63.0 (11.7) 73.7 Acute myocardial infarction 9.8 13.1 (5.2)
Lonn et al., 2006 5522 68.9 (6.9) 71.8 Coronary heart disease 40 11.8
Righetti et al., 2006 88 64.3 (11.7) 56 Patients on maintenance hemodialysis for 16.2 35.0 (13.1)
at least 4 months without treatment with
theophylline,estrogens, or anti-epileptic drugs
Zoungas et al., 2006 315 56 (13.5) 32.3 Chronic renal failure of any cause, a serum 23.2 27 (13.0)
creatinine of 0.40 mmol/l or greater, and either
awaiting dialysis or already treated with continuous
ambulatory peritoneal dialysis, intermittent
peritoneal dialysis, or hemodialysis
Jamison et al., 2007 2056 65.4 (12.0) 98 Advanced chronic kidney disease 55 21
(estimated creatinine clearance 30 mL/min)
(n 1305) or end-stage renal disease (n 751)
and high homocysteine levels.
Albert et al., 2008 5442 62.8 (8.8) 0 With either a history of CVD or 3 or more 21 >21
coronary risk factors
Ebbing et al., 2008 3096 61.7 79.5 59.3% had double- or triple-vessel disease, 10 11
83.7% had stable angina pectoris, and 14.9%
had acute coronary syndromes
Saposnik et al., 2009 5522 68.8 (7.1) 72 Coronary, cerebrovascular disease, or peripheral 40 11.5 (0.80)
arterial disease, or diabetes mellitus and at least 1
additional cardiovascular risk factor,
Heinz et al., 2010 650 61(13) 58 End stage renal disease treated for at least 1 month by 40 29
hemodialysis were enrolled, regardless of their
homocysteine levels
SEARCH 2010 6033 64.2 (8.9) 83 With myocardial infarction 11 13.5 (4.8)
VITATOPS 2010 8164 62$6 (12$5) 100 With recent transient ischaemic attack or stroke 24 14.3 (8.5)

NR: not reported.

 T. Huang et al. / Clinical Nutrition 31 (2012) 448e454 451

Table 2
Study design characteristics of 19 randomized controlled trials of B vitamins supplementation.

Source Blinding Control Duration, month Intervention group B vitamins dosage

Baker et al., 2002 Double Placebo 20 5 mg/d
Schnyder et al., 2002 Double Placebo 6 1 mg/d folic acid,
400 mg/d vitamin B12,and 10 mg/d vitamin B6
Righetti et al., 2003 Open Usual care 12 5 mg/d or 15 mg/d
Lange et al., 2004 Double Placebo 6 1.2 mg of folic acid, 48 mg of vitamin B6,
and 60 mg of vitamin B12
Liem et al., 2004 Open Usual care 12 5 mg/d folic acid
Toole et al., 2004 Double Placebo 24 25 mg of pyridoxine, 0.4 mg of cobalamin,
and 2.5 mg of folic acid; or the low-dose formulation,
containing 200 mg of pyridoxine, 6 mg of cobalamin,
and 20 mg of folic acid.
Wrone et al., 2004 Double Usual care 24 1, 5, or 15 mg of folic acid contained in a renal
multivitamin
Liem et al., 2005 Open Usual care 42 0.5 mg/d folic acid
Bonaa et al., 2006 Double Placebo 36 0.8 mg of folic acid, 0.4 mg of vitamin B12,
and 40 mg of vitamin B6;
Lonn et al., 2006 Double Placebo 60 2.5 mg/d
Righetti et al., 2006 Open Usual care 29 5 mg oral daily folic acid, or 5 mg every other
day and also added an every other day oral
vitamin B complex (thiamine 250 mg,
piridoxine 250 mg, cianocobalamine 500 mg).
Zoungas et al., 2006 Double Placebo 43 15 mg of folic acid daily
Jamison et al., 2007 Double Placebo 36 40 mg of folic acid, 100 mg of vitamin B6,
and 2 mg of vitamin B12
Albert et al., 2008 Double Placebo 85 2.5 mg of folic acid, 50 mg of vitamin B6,
and 1 mg of vitamin B12.
Ebbing et al., 2008 Double Placebo 48 0.8 mg of folic acid, plus 0.4 mg of vitamin B12,,
plus 40 mg of vitamin B6,
Saposnik et al., 2009 Open Placebo 60 2.5 mg of folic acid, 50 mg of vitamin B6,
and 1 mg of vitamin B12
Heinz et al., 2010 Double Placebo 24 5 mg of folic acid, 50 g of vitamin B12,
and 20 mg of vitamin B6
SEARCH 2010 Double Placebo 80 2 mg of folic acid, 1 mg vitamin B12
VITATOPS 2010 Double Placebo 40 2 mg of folic acid, 25 mg vitamin B6,
and 0.5 mg vitamin B12

SEARCH: Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine VITATOPS: VITAmins TO Prevent Stroke.

effect on stroke. However, we found no signicant benet or harm
of B vitamins supplementation on the risk of CVD, MI, CHD,
cardiovascular death, or all-cause mortality.
Epidemiological studies have reported that elevated blood Hcy
are associated with higher risks of CHD, stroke, and peripheral
vascular disease and have been identied as a potentially important
risk factor for CVD.38,39 It has also been suggested that a prolonged
blood Hcy level below 5 micmol/L might be associated with one-
third less vascular disease.39 A meta-analysis of 29 epidemiologic
studies indicated that elevated levels of Hcy are related to CHD and
stroke.38 In 2002, an updated meta-analysis focusing on prospec-
tive observational studies conrmed this association, with an

Table 3
Clinical outcomes in 19 randomized controlled trials of B vitamins supplementation.

Source Change Hcy Relative risk (95% CI)

from baseline

Net, mmol/L CVD MI CHD Stroke Cardiovascular death All-cause mortality

Baker et al., 2002 1.5 NR NR 1.91 (0.96e3.82) NR NR NR
Schnyder et al 2002 2.9 0.68 (0.48e0.96) 0.57 (0.27e1.42) 0.69 (0.51e0.98) NR 0.51 (0.15e2.00) 0.52 (0.21e1.56)
Righetti et al., 2003 26.0 0.70 (0.36e1.35) NR NR NR NR NR
Lange et al., 2004 3.6 NR NR 1.53 (1.03e2.28) NR NR 1.01 (0.06e16.12)
Liem et al., 2004 NR 0.98 (0.69e1.38) NR 0.95 (0.67e1.35) 3.06 (0.13e74.58) NR 1.02 (0.37e2.84)
Toole et al., 2004 2.1 0.98 (0.84e1.16) 0.90 (0.60e1.20) 0.94 (0.73e1.20) 1.04 (0.84e1.29) 0.90 (0.60e1.10) 0.86 (0.66e1.11)
Wrone et al., 2004 3.6 1.29 (0.75e2.22) NR 1.41 (0.65e3.09) 1.17 (0.52e2.61) NR 0.92 (0.71e1.20)
Liem et al., 2005 2.6 0.85 (0.60e1.21) NR 1.25 (0.69e2.26) 0.65 (0.27e1.57) NR 0.68 (0.38e1.21)
Bonaa et al., 2006 3.8 1.08 (0.92e1.27) 1.23 (0.99e1.52) 1.08 (0.91e1.29) 0.83 (0.47e1.47) NR 1.21 (0.91e1.61)
Lonn et al., 2006 3.2 0.95 (0.85e1.06) NR 0.98 (0.85e1.13) 0.76 (0.59e0.96) NR 0.99 (0.88e1.11)
Righetti et al., 2006 15.1 0.73 (0.49e1.10) NR 0.81 (0.47e1.40) 0.55 (0.19e1.62) NR 0.69 (0.28e1.67)
Zoungas et al., 2006 2.4 0.91 (0.74e1.13) 0.98 (0.66e1.47) 1.23 (0.70e2.17) 0.45 (0.20e1.01) 0.87 (0.58e1.32) 0.96 (0.75e1.24)
Jamison et al., 2007 6.2 NR 0.86 (0.67e1.08) NR 0.90 (0.58e1.40) 0.99 (0.88e1.12) 1.04 (0.91e1.18)
Albert et al., 2008 2.27 1.03 (0.90e1.19) 0.87 (0.63e1.22) 1.00 (0.85e1.18) 1.14 (0.82e1.57) 1.01 (0.76e1.35) 0.97 (0.81e1.15)
Ebbing et al., 2008 3.6 1.00 (0.78e1.27) 1.21 (0.95e1.56) NR 0.72 (0.44e1.17) 1.27 (0.90e1.79) 1.09 (0.90e1.32)
Ebbing et al., 2008 3.6 1.16 (0.91e1.48) 0.85 (0.66e1.09) NR 0.87 (0.54e1.40) 0.94 (0.66e1.32) 0.90 (0.74e1.09)
Saposnik et al., 2009 2.1 NR NR NR 0.75 (0.59e0.97) NR NR
Heinz et al., 2010 10.4 0.79 (0.59e1.07) 1.00 (0.53e1.88) 0.44 (0.19e1.03) 0.73 (0.33e1.60) 0.88(0.15e1.61) 1.14 (0.85e1.52)
SEARCH 2010 3.8 1.04 (0.97e1.12) 1.01(0.88e1.18) 1.09(0.97e1.28) 1.02(0.86e1.21) 1.04(0.92e1.16) 1.04(0.95e1.13)
VITATOPS 2010 1.09 NR 1.03(0.80e1.33) NR 0.92(0.81e1.01) 0.92(0.84e1.01) 0.97(0.87e1.07)
452 T. Huang et al. / Clinical Nutrition 31 (2012) 448e454

CVD CHD
Author (year) ES (95% CI) Author (year) ES (95% CI)

Schnyder e al (2002) 0.68 (0.48, 0.96) Baker et al (2002) 1.91 (0.96, 3.82)
Righetti et al (2003) 0.70 (0.36, 1.35) Schnyder e al (2002) 0.69 (0.51, 0.98)
Liem et al (2004) 0.98 (0.69, 1.38) Lange et al (2004) 1.53 (1.03, 2.28)
Toole et al (2004) 0.98 (0.84, 1.16) Liem et al (2004) 0.95 (0.67, 1.35)
Wrone et al (2004) 1.29 (0.75, 2.22) Toole et al (2004) 0.94 (0.73, 1.20)
Liem et al (2005) 0.85 (0.60, 1.21)
Wrone et al (2004) 1.41 (0.65, 3.09)
Bonaa et al (2006) 1.08 (0.92, 1.27)
Liem et al (2005) 1.25 (0.69, 2.26)
Lonn et al (2006) 0.95 (0.85, 1.06)
Bonaa et al (2006) 1.08 (0.91, 1.29)
Righetti et al (2006) 0.73 (0.49, 1.10)
Zoungas et al (2006) 0.91 (0.74, 1.13) Lonn et al (2006) 0.98 (0.85, 1.13)
Albert et al (2008) 1.03 (0.90, 1.19) Righetti et al (2006) 0.81 (0.47, 1.40)
Ebbing et al (2008) 1.00 (0.78, 1.27) Zoungas et al (2006) 1.23 (0.70, 2.17)
Ebbing et al (2008) 1.16 (0.91, 1.48) Albert et al (2008) 1.00 (0.85, 1.18)
Heinz et al (2010) 0.79 (0.59, 1.07) Heinz et al (2010) 0.44 (0.19, 1.03)
SEARCH (2010) 1.04 (0.97, 1.12) SEARCH (2010) 1.09 (0.97, 1.28)
Overall (I-squared = 30.4%, p = 0.126) 0.98 (0.94, 1.03) Overall (I-squared = 40.5%, p = 0.057) 0.98 (0.92, 1.05)

0 1 0 1

MI Stroke
Author (year) ES (95% CI)
Author (year) ES (95% CI)
Toole et al (2004) 1.04 (0.84, 1.29)
Schnyder e al (2002) 0.57 (0.27, 1.42) Wrone et al (2004) 1.17 (0.52, 2.61)
Toole et al (2004) 0.90 (0.60, 1.20) Liem et al (2005) 0.65 (0.27, 1.57)
Bonaa et al (2006) 0.83 (0.47, 1.47)
Bonaa et al (2006) 1.23 (0.99, 1.52)
Lonn et al (2006) 0.76 (0.59, 0.96)
Zoungas et al (2006) 0.98 (0.66, 1.47) Righetti et al (2006) 0.55 (0.19, 1.62)
Jamison et al (2007) 0.86 (0.67, 1.08) Zoungas et al (2006) 0.45 (0.20, 1.01)
Albert et al (2008) 0.87 (0.63, 1.22) Jamison et al (2007) 0.90 (0.58, 1.40)
Ebbing et al (2008) 1.21 (0.95, 1.56) Albert et al (2008) 1.14 (0.82, 1.57)
Ebbing et al (2008) 0.72 (0.44, 1.17)
Ebbing et al (2008) 0.85 (0.66, 1.09) Ebbing et al (2008) 0.87 (0.54, 1.40)
Heinz et al (2010) 1.00 (0.53, 1.88) Saposnik et al (2009) 0.75 (0.59, 0.97)
SEARCH (2010) 1.01 (0.88, 1.18) Heinz et al (2010) 0.73 (0.33, 1.60)
VITATOPS (2010) 1.03 (0.80, 1.33) SEARCH (2010) 1.02 (0.86, 1.21)
VITATOPS (2010) 0.92 (0.81, 1.01)
Overall (I-squared = 12.0%, p = 0.330) 0.97 (0.90, 1.05)
Overall (I-squared = 18.5%, p = 0.247) 0.88 (0.82, 0.95)

0 1 0 1

Cardiovascular death All cause mortality

Author (year) ES (95% CI)
Author (year) ES (95% CI)
Schnyder e al (2002) 0.52 (0.21, 1.56)
Liem et al (2004) 1.02 (0.37, 2.84)
Schnyder e al (2002) 0.51 (0.15, 2.00)
Toole et al (2004) 0.86 (0.66, 1.11)
Toole et al (2004) 0.90 (0.60, 1.10) Wrone et al (2004) 0.92 (0.71, 1.20)
Zoungas et al (2006) 0.87 (0.58, 1.32) Liem et al (2005) 0.68 (0.38, 1.21)
Bonaa et al (2006) 1.21 (0.91, 1.61)
Jamison et al (2007) 0.99 (0.88, 1.12) Lonn et al (2006) 0.99 (0.88, 1.11)
Albert et al (2008) 1.01 (0.76, 1.35) Righetti et al (2006) 0.69 (0.28, 1.67)
Ebbing et al (2008) 1.27 (0.90, 1.79) Zoungas et al (2006) 0.96 (0.75, 1.24)
Jamison et al (2007) 1.04 (0.91, 1.18)
Ebbing et al (2008) 0.94 (0.66, 1.32) Albert et al (2008) 0.97 (0.81, 1.15)
Heinz et al (2010) 0.88 (0.14, 1.61) Ebbing et al (2008) 1.09 (0.90, 1.32)
Ebbing et al (2008) 0.90 (0.74, 1.09)
SEARCH (2010) 1.04 (0.92, 1.16)
Heinz et al (2010) 1.14 (0.85, 1.52)
VITATOPS (2010) 0.92 (0.84, 1.01) SEARCH (2010) 1.04 (0.95, 1.13)
Overall (I-squared = 0.0%, p = 0.724) 0.97 (0.91, 1.02) VITATOPS (2010) 0.97 (0.87, 1.07)
Overall (I-squared = 0.0%, p = 0.644) 0.99 (0.95, 1.04)

0 1 0 1

Fig. 2. Relative risk estimates for cardiovascular disease, coronary heart disease, stroke, myocardial infarction, cardiovascular death, and all-cause mortality (B vitamins supple-
mentation vs placebo), by trial and pooled. ES: Effect size.

estimated 25% reduction in Hcy levels associated with 11% lower
risk of CHD and 19% lower risk of stroke.40
Even though dietary fatty acids have been demonstrated
recently to be associated with plasma Hcy concentration,41,42 B
vitamins appear to be the more effective Hcy-lowering nutrients.15
The large-scale clinical trials of sufcient dose and duration were
conducted to determine whether lowering Hcy levels by folic acid,
vitamin B6 and vitamin B12 reduces the risk of vascular disease. As
suggested by Spence et al.,15 vitamin B12 may play an important role
in Hcy-related vascular disease, especially in the presence of folic
acid food fortication.19 However, the effect of multivitamin
supplementation for preventing vascular events has been subject to
 T. Huang et al. / Clinical Nutrition 31 (2012) 448e454
Table 4
The overall relative risks with 95% condence intervals of outcomes for patients treated with B vitamin supplementation compared with placebo.
Diseases Studies Fixed effects
N ES (95% CI)
CVD 15 0.98 (0.94e1.03)
CHD 14 0.98 (0.92e1.05)
MI 11 0.97 (0.90e1.05)
Stroke 15 0.88 (0.82e0.95)
Cardiovascular death 10 0.97 (0.91e1.02)
All cause mortality 16 0.99 (0.95e1.04)
much debate. Clinical trials have failed to show a benet from Hcy-
lowering therapy on CHD.43 The Heart Outcomes Prevention Eval-
uation 2 study reported that Hcy-lowering B vitamin therapy was
no better than placebo in terms of the primary composite outcome
of cardiovascular death, MI, and stroke, but the risk of stroke was
reduced.32,44 One study reported that Hcy-lowering therapy may
lower the incident risk of disabling stroke, but may not alter stroke
severity at discharge.19 A meta-analysis of RCTs comprising 16,958
participants showed that folic acid supplementation did not impact
on the risk of CVD or all-cause mortality.13 However, the meta-
analyis of, Wang et al.45 found that folic acid supplementation
signicantly reduced the risk of stroke by 18%. However, some
studies included in this meta-analysis did not use vitamin B6 or
vitamin B12. In agreement with previous ndings, we also found
a signicant protective effect of B vitamins supplementation on
stroke. Moreover, we found that there is no signicant benet or
harm of B vitamins supplementation with regard to the risk of CVD,
MI, CHD, cardiovascular death, or all-cause mortality.
The discrepancies between the RCTs of B vitamins supplemen-
tation for the prevention of CVD may have various explanations.
First, it is possible that populations without folate deciency may
not benet from folic acid supplementation. For example, one study
was conducted in a population of health professionals, who were at
a relatively low risk of folate deciency. These participants were
allowed to take the RDA of folic acid and B vitamins and were also
exposed to folic acid-fortied grain products during the course of
the trial.18 Future clinical trials of B vitamin supplementation are
needed in potentially at-risk subgroups. Populations with specic
genetic backgrounds which respond differently to supplementation
may contribute to these discrepancies. Second, RCTs may not avoid
residual confounding. Different personal behaviors may modify the
effects of dietary intake or supplement use on vascular disease.
Then, the duration of follow-up and sample size may also
contribute to differences between clinical trials. Third, trials to date
have examined the effects of B vitamin supplementation for
secondary prevention only. As suggested by Bazzano et al.,13 B
vitamin supplementation may have a protective effect for primary
rather than secondary prevention.
As with all meta-analyses, there are limitations to ours. First, in
order to increase statistical power, our meta-analysis combined
patients with different diseases and pooled data for different
ethnicities, albeit mostly European; genetic heterogeneity among
ethnically diverse populations can lead to unavoidable bias. Second,
we have not disaggregated by gender and the ndings may not be
the same for men and women; this is particularly relevant to all-
cause mortality, which includes cancer, since it is known that
nutrient supplements may increase the risk of breast cancer in
women.46 Third, differences in sampling protocols and methods of
Hcy measurement may have contributed to variation between
studies. Finally, exclusion of studies which did not provide
adequate information might contribute to the tested publication
bias. We also cannot exclude the possibility of bias related to the
exclusion of non-English language publications.
453
Random effects Heterogeneity
ES (95% CI) I2 (%) p-value
0.96 (0.90e1.02) 30.4 0.126
0.97 (0.87e1.07) 40.5 0.057
0.97 (0.88e1.06) 12.0 0.330
0.87 (0.79e0.95) 18.5 0.247
0.97 (0.91e1.02) 0.0 0.724
0.99 (0.95e1.04) 0.0 0.644
However, the present study has advantages: a), this updated
meta-analysis which has included ve current studies has greater
sample size and statistical power than previous meta analyses. b),
the updated meta-analysis of RCT represents evidence which is less
likely to be subject to confounding and bias than that from obser-
vational studies. c), no evidence of heterogeneity or publication
bias on testing was observed.
In summary, the present ndings indicate that B vitamin
supplementation can exert a signicant protective effect on stroke.
However, B vitamin supplementation is not demonstrably effective
in the secondary prevention of CVD or in the improvement of all-
cause mortality.
Conict of interest
The authors have no nancial/commercial conicts of interest in
this work.
Acknowledgments
This work was supported by a grant from National High Tech-
nology Research and Development Program of China (No.
N20080753), the National Natural Science Foundation of China (No.
30972464) and the Ph.D. Programs Foundation of Ministry of
Education of China (No. 20070335025).
T.H., B.Y., and D.L. designed research; T.H., B.Y., and Y.C. con-
ducted research; T.H., J.Y., and Y.C. analyzed data; T.H., J.Y., D.L wrote
the paper. T.H. had primary responsibility for nal content. All
authors read and approved the nal manuscript.
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