{"id":6582,"date":"2015-04-27T07:44:54","date_gmt":"2015-04-27T12:44:54","guid":{"rendered":"https:\/\/wholehealthchicago.com\/?p=6582"},"modified":"2022-06-08T20:48:09","modified_gmt":"2022-06-09T01:48:09","slug":"b12-deficiency-still-americas-1-missed-diagnosis","status":"publish","type":"post","link":"https:\/\/wholehealthchicago.com\/blog\/2015\/04\/27\/b12-deficiency-still-americas-1-missed-diagnosis","title":{"rendered":"B12 Deficiency: Still America\u2019s #1 Missed Diagnosis"},"content":{"rendered":"\n<p>Over the years of writing Health Tips, I was surprised to discover that one I\u2019d written a few years ago about vitamin <a href=\"https:\/\/wholehealthchicago.com\/blog\/2021\/02\/22\/six-commonly-missed-diagnoses-b12-deficiency-2\" target=\"_blank\" rel=\"noreferrer noopener\">B12 deficiency<\/a> had received the most comments and questions from readers. Since there have been some interesting developments in both the diagnosis and treatment of B12 deficiency, and since B12 deficiency remains so common, this seems like a good opportunity for some updates.<\/p>\n\n\n\n<p>The symptoms of low levels of vitamin B12 can been pretty vague. You\u2019re just not feeling right and you\u2019re tired, maybe a little depressed, a bit achy. Your digestion might somehow feel off and you\u2019re not thinking clearly. Balancing a checkbook becomes an exercise in higher math.<\/p>\n\n\n\n<p>Your doctor\u2019s empathetic, not at all dismissive of your symptoms, but after a physical exam and some apparently appropriate tests with normal results she can\u2019t find anything really wrong. On the surface, this is reassuring. After all, the main reason we go to doctors is to ascertain that nothing serious is going on.<\/p>\n\n\n\n<p>Still, could she be overlooking something?<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>All about B12<\/strong><\/h3>\n\n\n\n<p>One of the eight B vitamins, B12 is involved in the metabolism of every cell in your body. Years ago B12 was called \u201cmaturation factor\u201d because cells need B12 to mature from being young and ineffectual whippersnappers to fully functioning, mature cells. Imagine a child, about seven years old, who\u2019s stuck at that age and can\u2019t grow into adolescence and later adulthood. Now imagine a magical substance that will allow her to grow and mature. That\u2019s vitamin B12.<\/p>\n\n\n\n<p>In fact, B12 is so potent a factor in cell maturation that some of the original studies on it showed that cells in the bone marrow (where blood is manufactured) when deliberately deprived of B12 could mature in <span style=\"text-decoration: underline;\">just a few hours<\/span> when B12 was added. This phenomenon explained how B12-deficient patients reported feeling magically rejuvenated within a day or two of their first B12 injection.<\/p>\n\n\n\n<p>Years ago, I read that the late Bruno Bartoletti, conductor of the Lyric Opera orchestra, would not go onstage unless he\u2019d had a B12 injection earlier that day. At the time, I thought it was a placebo effect. Now I think differently.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>B12 deficiencies<\/strong><\/h3>\n\n\n\n<p>Three major systems in your body are affected by B12 deficiency: your blood, nervous system, and, less often, gastrointestinal tract. These three are targets because their cells either have a high turnover rate (blood and intestinal lining) or need a lot of B12 to function smoothly (nervous system). The symptoms of low B12 are related to each of these areas.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Low B12\u2019s effect on blood is a specific type of anemia called megaloblastic&nbsp;anemia (as distinct from the more common iron deficiency anemia). A megaloblast is&nbsp;an immature, undeveloped red blood cell, large and bulky (megalo=large, blast=immature form). Remember, B12 is needed for this cell to mature, so with insufficient B12 megaloblasts accumulate in your bone marrow and large red cells called macrocytes appear in your blood. Symptoms are the same as for anemia from any cause: fatigue, breathlessness, and lightheadedness. Your skin becomes a pale yellow, most likely because the red cells that do make it to maturity are very fragile and easily broken, releasing their yellow bilirubin pigment.<\/li><li>In the nervous system, B12 deficiency causes symptoms affecting the nerves&nbsp;(numbness, tingling, tremors, balance problems) and the mind (depression, brain&nbsp;fog, mood swings, and, in rare cases, hallucinations and psychosis).<\/li><li>In the GI tract, deficiency can cause digestive symptoms and weight loss because you\u2019re not absorbing food efficiently.<\/li><\/ul>\n\n\n\n<p>The irony is that with all these there\u2019s usually just one predominant symptom, and making a connection to low B12 can easily be delayed until other symptoms start to appear. For example, if your only symptom is tingling in your hands, you might undergo all sorts of diagnostic tests before your doctor thinks \u201cMaybe we should check her B12&nbsp;level.\u201d<\/p>\n\n\n\n<p>But even if you manage to get your doctor to test your B12 level, you\u2019re only halfway there because the blood test is just not very good.<\/p>\n\n\n\n<p>The normal range for B12 in the US is 200 to 800 pg (picograms)\/milliliter of blood. But it\u2019s been shown that symptoms can begin as low as 400 pg\/ml, so the US \u201cnormals\u201d are definitely not OK. In Europe and Japan, anything below 550 pg\/ml is considered abnormal. Therefore, if your level is, for example, 350 pg\/ml, your doctor reads a printout for you that reports \u201cnormal B12\u201d and she doesn\u2019t initiate treatment. I\u2019ve had patients come in with B12 levels of 201 pg\/ml with the word \u201cnormal\u201d scribbled across it by the doctor.<\/p>\n\n\n\n<p>A far better test for early B12 deficiency is measuring your blood levels of methylmalonic acid (MMA) because this will&nbsp;show the very first sign that something\u2019s amiss with B12. You can have a perfectly normal B12 level, but if your MMA is elevated B12 deficiency troubles are on the horizon. The real problem is that you\u2019ll have to ask for an MMA test without sounding like a smartass who\u2019s been spending too much time on the internet<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>What causes B12 deficiency?<\/strong><\/h3>\n\n\n\n<p>The list of causes is lengthy, but by far the most common is dietary. Vegetarians who aren\u2019t paying attention to the B12 in their food choices will have downward-drifting B12 levels, and virtually all vegans not taking vitamin B12 supplements ultimately develop deficiencies. Even vegan organizations acknowledge it\u2019s not possible to get adequate B12 while following a strictly vegan diet, and that\u2019s because the richest sources are animal products.<\/p>\n\n\n\n<p>Other causes of B12 deficiency include pernicious anemia, an uncommon (and spookily&nbsp;named) autoimmune disease that destroys parietal stomach cells. These cells produce a&nbsp;substance called intrinsic factor, necessary for B12 absorption. Also, since you need stomach acid to absorb B12, long-term use of acid-suppressing proton pump inhibitors (such as Nexium, etc.) can lead to B12 deficiency, as can chronic intestinal conditions such as Crohn\u2019s disease, celiac disease, and intestinal parasites.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>The missed diagnosis<\/strong><\/h3>\n\n\n\n<p>The main danger of missing a diagnosis of low B12 is that, while quite rare, the damage to your nerves and even brain can be permanent. Other serious consequences: your anemia can get so severe it causes heart failure and collapse. Or you could be misdiagnosed with a major depressive disorder or even psychosis and take unneeded psychiatric medications for months (or years) before someone notices you look yellowish and you\u2019re finally diagnosed with megaloblastic anemia.<\/p>\n\n\n\n<p>There are three reasons why this diagnosis is missed:<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>Although it\u2019s not an expensive test, B12 isn\u2019t measured during routine blood tests.&nbsp;Doctors generally don\u2019t order a B12 evaluation if there\u2019s no evidence of anemia&nbsp;(which would be picked up on a routine blood test). However, the fatigue and&nbsp;nervous system and GI symptoms can precede anemia by months.<\/li><li>Doctors rarely ask (and patients rarely volunteer) information about their eating&nbsp;habits. In medical school, we\u2019re taught that the US diet is plenty good enough to&nbsp;prevent any vitamin deficiencies. To which I now respond, \u201cHa!\u201d I agree most of us&nbsp;eat plenty of food (obesity levels are still on the rise), but it\u2019s often food whose&nbsp;nutritional value has been castrated. Also, all vegetarians and vegans should be&nbsp;regularly tested for possible B12 deficiency, but if your doc doesn\u2019t know your eating&nbsp;habits you won\u2019t be tested.<\/li><li>Taking the B vitamin folic acid (folate) or eating a lot of <a href=\"https:\/\/www.globalhealingcenter.com\/natural-health\/folic-acid-foods\/\" target=\"_blank\" rel=\"noreferrer noopener nofollow\">folate-containing&nbsp;foods<\/a> without adding B12 can actually mask the symptoms of a developing B12&nbsp;deficiency. Although folate will keep your blood count normal even if your B12&nbsp;is falling, the folate will not protect your brain and nervous system. You\u2019ll have no&nbsp;evidence of megaloblastic anemia (because of the folate), but symptoms of&nbsp;numbness, tingling, balance problems, and emotional issues will continue unchecked. By eating so many folate-containing green vegetables, beans, and lentils, vegetarians and vegans inadvertently mask their own slowly developing B12 deficiency.<\/li><\/ol>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Treatment is easy<\/strong><\/h3>\n\n\n\n<p>It\u2019s virtually impossible to take too much B12 as any excess of this water-soluble&nbsp;vitamin is eliminated via urine. Nutritional guru Alan Gaby, MD, has commented that the only way too much B12 will kill you is if you fill your bathtub with it and drown.<\/p>\n\n\n\n<p>Foods high in B12 are animal products: meat, poultry, seafood, dairy, and eggs, with eggs&nbsp;having the least. Because all animals store B12 in their livers, eating liver is an excellent, though not particularly popular, treatment for B12 deficiency. Your grandmother or great grandmother likely remembers a time when her doctor told someone in the family to eat more liver.<\/p>\n\n\n\n<p>Although B12 injections have been used for decades as the fastest way to raise B12\u00a0levels, the latest research is saying that well chosen forms of oral B12 will probably work just as well. The <a href=\"https:\/\/whcstore.vitogenix.com\/product\/integrative-therapeutics-b12-active-cherry-flavored-30-count\/935\">Integrative Therapeutics product <\/a><a href=\"https:\/\/whcstore.vitogenix.com\/s\/search?q=B12%20Active\" target=\"_blank\" rel=\"noreferrer noopener\">B12 Active<\/a> is a chewable, cherry-flavored tablet containing 1,000 mcg of methylcobalamin. Taken daily, it generally restores B12 levels to a normal range in one month.<\/p>\n\n\n\n<p>This brings up another confusing point. Most B12 in both injections and pills is called cyanocobalamin, which, yes indeed, does contain a totally nontoxic form of Agatha Christie\u2019s favorite murder weapon, cyanide. But what\u2019s the difference between the two? When it comes to raising your personal B12 levels, both work equally well. To be honest, the main reason for the prevalence of cyanocobalamin is cost. Totally synthetic, cyanocobalamin is cheap to make.<\/p>\n\n\n\n<p>Methylcobalamin, the natural B12 form that your body actually prefers because it doesn\u2019t have to detoxify the cyano part, is simply more expensive to manufacture. However, there is one completely new cyanocobalamin product worth mentioning. Eligen B12&nbsp;(available by prescription) contains B12 combined with a carrier called salcaprozate that&nbsp;enhances B12 absorption into the stomach. B12 levels go up as quickly as they do with injections so you can avoid your doctor\u2019s needles. However, I suspect Eligen B12 is not superior to the Integrative Therapeutics product mentioned above.<\/p>\n\n\n\n<p>I think this all answers most of the questions and comments that followed my previous B12 article, but if you have more send them along.<\/p>\n\n\n\n<p>Be well,<br><em>David Edelberg, MD<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Over the years of writing Health Tips, I was surprised to discover that one I\u2019d written a few years ago about vitamin B12 deficiency had received the most comments and questions from readers. Since there have been some interesting developments in both the diagnosis and treatment of B12 deficiency, and since B12 deficiency remains so [&hellip;]<\/p>\n","protected":false},"author":2087,"featured_media":30281,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[204,2,3,2315,2314,43],"tags":[1385,1740,1741,1742],"class_list":["post-6582","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-b","category-blog","category-knowledge-base","category-most-comments","category-most-view","category-nutrition-nutritional-supplements-vitamins-herbal-remedies","tag-b12","tag-b12-deficiency","tag-cyanocobalamin","tag-methylcobalamin"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.9 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\r\n<title>B12 Deficiency: Still America\u2019s #1 Missed Diagnosis<\/title>\r\n<meta name=\"description\" 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