Dr. Angela Hunt ND
For a while now, we in the north have known that vitamin D deficiencies are common in our society. It is recommended that all Canadians take 600 IU daily of the sunshine vitamin to maintain general health[i]. Health Canada also stopped screening for vitamin D deficiencies in the general public because everyone was showing up to be deficient[ii]. However, as our society works to keep their vitamin D levels up, another common vitamin deficiency could be going under the radar. Vitamin B12 is an essential vitamin that plays a key role in nerve function, energy, memory, and thought processing. As important as Vitamin B12 is, our screening methods in Canada could be missing most deficiencies. Research from the Tufts University Framingham Offspring Study suggests that 40% of people between the ages of 26 and 83 have plasma B12 levels in the low normal range – a range at which many experience neurological symptoms[iii]. What this study doesn’t discuss is how the “ranges” of B12 might be set far too low, so that the percentage of people with a B12 deficiency is actually higher than 40%.
Issues with Screening Methods
The main issue with vitamin B12 deficiency is how we screen for it. The normal range posted by most Canadian labs is from 170-600 pmol/L. These lower and higher end values are based on averages taken from the surrounding local populations; they are not based on research. The concern is that if the sample population used to calculate the normal range has chronically low levels of B12, then the recommended normal range will also be lower than optimal. In Canada, your physician is unlikely to discuss B12 deficiency with you if your B12 is even slightly above 170 pmol/L. However, in Japan and Europe, if your lab value is below 500 pmol/L, your physician may recommend taking B12 supplements[iv]. Why is this? In Europe and Japan the vitamin B12 range is based on which B12 levels are correlated with deficiency symptoms (discussed below) instead of randomly selected populations.
Symptoms of B12 Deficiency
The symptoms that result from not having enough B12 can be subtle to severe. What is important to remember about these symptoms is that you may be experiencing them even if your B12 levels on your blood work come back “normal”. Here are some signs that your B12 levels are suboptimal[v]:
- Numbness or tingling in hands, legs and feet
- Anemia (low red blood cell count)
- Swollen tongue
- Difficulty thinking or memory loss
- Anxiety or depression
If you checked off a few of the above symptoms even with normal B12 on your blood work you may want to discuss supplementation with your healthcare provider.
Causes of B12 Deficiencies
So it seems that most of us don’t have adequate levels of vitamin B12, but how come? Here are some of the top culprits[vi]:
- Taking a proton-pump inhibitor (such as Nexium or Prevacid) or H2 blocker (such as Pepcid or Zantac)
- Taking metformin (a diabetes drug)
- Being vegetarian or vegan
- Having weight-loss surgery (gastric bypass)
- Drinking large amounts of alcohol
- Pernicious anemia (autoimmune condition)
- Low stomach acid or gastritis (inflammation of the stomach)
- Intestinal dysbiosis (having the wrong bacteria living in your gut)
- Leaky gut syndrome
As we age our digestive system becomes less efficient. It is common for me to see people over 60 complain of heartburn, indigestion and bloating. The main culprit for these symptoms in this population is low stomach acid. New research shows a substantial age-related decrease in stomach acid production, with stomach acid levels dropping 40 to 60% after the age of 65[vii]. This can lead to a plethora of digestive issues, including alarmingly significant malabsorption of specific nutrients. In order to absorb B12 from our food we need a lot of stomach acid. If acid levels are sub-par this vitamin is one of the first things to get left out. This is especially interesting because so many vitamin B12 deficiency symptoms mimic symptoms of general aging, such as memory loss, fatigue, poor concentration and decreased mobility. Could these highly common symptoms of aging actually be from a widespread B12 deficiency?
Vitamin B12 can be an effective treatment for neuropathy. Neuropathy is destruction of nerve tissue due to a variety of causes, including B12 deficiency, diabetes, Lyme disease, medication side effects, heavy metal exposure, autoimmune diseases and injury. Japanese studies indicate that B12 injections are more effective than pills in treating neurological sequelae of B12 deficiency, and that it may be better absorbed because it bypasses several potential problems in the B12 absorption cycle.
How do I increase my B12 levels?
If you think you may be experiencing some B12 deficiency symptoms there are a few options you can try to increase your levels:
- Eat more B12 rich foods. Foods like tuna, beef (grass fed), eggs, clams, oysters, eggs, cottage cheese, salmon and sardines all have high levels of B12. Looking at this list it becomes apparent why a vegan diet doesn’t usually have adequate levels of vitamin B12. Also, it is important to remember that if a person’s stomach acid is low they will not absorb B12 well from the above foods sources and supplementation could be required.
- Supplementation. In general, we recommend a sublingual B12 supplement in methylcobalamin form. The dosage depends on the patient and you are best to speak to a health professional about what dose is right for you.
- Injection. This route is the most effective as it bypasses the digestive symptoms. It is important to inject the biologically active form of B12 called methylcobalamin. Methylcobalamin’s cheaper counterpart Cyanocoblamin, is not as active in one’s body. Injections are typically done in the arm and should be administered based on a patient’s symptoms. Some people will require injections every 2 weeks in the beginning but most will only need one every few months once adequate levels have been reached.
There are a lot of issues surrounding vitamin B12: Our current screening methods for deficiencies are inadequate, the symptoms of suboptimal levels vary greatly, and one always needs to question how much is being absorbed gastrointestinally. I think the best thing a person can do is educate themselves about the potential symptoms and under supervision of their healthcare provider try a trial run of either supplementation or injection. Observe how you feel and continue to monitor symptoms. Our bodies are great at telling us what they need through symptoms and we simply only need to listen to it.
[i] Health Canada DRI for Vitamin D3 http://www.hc-sc.gc.ca/fn-an/nutrition/vitamin/vita-d-eng.php
[ii] Understanding Changes to OHIP Coverage of Vitamin D Testing http://www.health.gov.on.ca/en/public/programs/ohip/changes/docs/MOH_Vitamin_D_fact_sheet.pdf
[iii] Plasma vitamin B-12 concentrations relate to intake source in the Framingham Offspring study
KL Tucker, S Rich, I Rosenberg et al. 2000 – Am Soc Nutrition
[iv] Jpn. J. Psychiatry Neurol. 1988 Mar:42(1):65–71
[v] Havard Health- http://www.health.harvard.edu/blog/vitamin-b12-deficiency-can-be-sneaky-harmful-201301105780
[vi] Havard Health- http://www.health.harvard.edu/blog/vitamin-b12-deficiency-can-be-sneaky-harmful-201301105780
[vii] Young DG. A stain for demonstrating Helicobacter pylori in gastric biopsies. Biotech Histochem 2001 Jan;76(1):31-4.