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Nutrition and Health (including climate and ecological aspects)

Folate and vitamin B12 status: temporal evaluation after mandatory fortification in Brazil



To perform temporal evaluation of folate and vitamin B12 status and their associated factors in a Brazilian population exposed to mandatory fortification.


Data from the cross-sectional population-based studies 2008 and 2015 Health Surveys of São Paulo, including individuals ≥ 20 years, both sexes, N = 549 in 2008 and N = 610 in 2015. Folate and vitamin B12 biomarkers status, B-complex supplements and medications use, and dietary intake were assessed.


Serum folate concentrations increased in the entire population, adults and older adults in 2015 compared to 2008, while serum vitamin B12 concentration increased only in older adults. B-complex supplement use raised in 2015, reflecting in serum vitamins status. Overall serum vitamin B12 deficiencies (<200 pg/mL) were 23.2% and 21.2%, while serum folate deficiencies (<4 ng/mL) were 4.1% and 1.5% in 2008 and 2015, respectively. The lowest quintile of serum folate (≤8.7 ng/mL) was positively associated with smoking and oral contraceptive use, while the highest quintile (≥17.8 ng/mL) was inversely associated with smoking and positively with B-complex supplement use. The odds of having vitamin B12 deficiency was inversely associated with B-complex supplement use, higher serum folate median, higher dietary vitamin B12 intake and positively associated with using oral contraceptive.


Overall deficiency of folate has decreased in 2015, being almost non-existent. Low vitamin B12 status presented similar proportions in the overall population comparing both periods, except for older adults. Different predictive variables were identified to better understand vitamins status outcomes in the most recent period of the study.

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We thank all participants of the study and researchers from GEIAS (“Grupo de Estudos Epidemiológicos e Inovação em Alimentação e Saúde”) and from GAC (“Grupo de Pesquisa de Avaliação do Consumo Alimentar”).


The Health Survey of São Paulo was supported by the São Paulo Municipal Health Department (Grant number 2013-0.235.936-0); National Council for Scientific and Technological Development (Grants numbers 481176/2008-0, 473100/2009-6, 472873/2012-1, 402674/2016-2) and the São Paulo Research Foundation (Grant number 2009/15831-0, 2012/22113-9, 2017/05125-7). This work was financed in part by the Coordination of Improvement of Higher Education Personnel–Brazil (CAPES)-Finance Code 001. CZP is supported by a CAPES’ research grant.

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Authors and Affiliations



CZP analyzed and interpreted the data, drafted the article and approved the final version; JS interpreted the data, drafted the article and approved the final version; CHS designed and carried out the study, drafted the article and approved the final version; RMF designed and carried out the study, drafted the article and approved the final version; DMLM analyzed and interpreted the data, drafted the article and approved the final version.

Corresponding author

Correspondence to Cecília Zanin Palchetti.

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The authors declare no competing interests.

Ethics approval

These studies protocols were approved by the Ethics Committee on Research of the Public Health School, University of São Paulo (certificates of presentation for ethical appreciation #26800414.1.0000.5421 for the 2008 ISA-Nutrition #30848914.7.0000.5421 for the 2015 ISA-Nutrition). All individuals were informed about the study and the written consent was obtained from each one.

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Palchetti, C.Z., Steluti, J., Sales, C.H. et al. Folate and vitamin B12 status: temporal evaluation after mandatory fortification in Brazil. Eur J Clin Nutr 76, 1266–1272 (2022).

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