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Don’t Miss Vitamin B12 Deficiency

Neural transmission requires substantial levels of Vitamin B12.  By looking at everyday “annual physical” labwork, we quickly saw that Cheryl’s B12 was likely VERY suboptimal (in the mid 300s).  That is, within reference range!  But not nearly optimal.  The drivers for her were unfortunately common:  insufficient stomach acid (hypochlorhydria) and ongoing use of the diabetes drug metformin (notorious for depleting B12).

Cheryl started a trial of 1000mcg methylcobalamin twice daily, and within two weeks, she had no pain.   Truly.  Inspired, she started to reduce her own medication.  And still no pain.  Needless to say, Cheryl was indeed wildly-satisfied.  She went on to accomplish many more aspects of wellness, but this was a perfect example of the power of Rapid Relief.  She also referred a few of her friends to my practice.

With pain relief in hand – as well as Cheryl’s heightened enthusiasm – we could move on to the main reason she sought my help: reversing her type 2 diabetes.  Some of you savvy practitioners have additional powerful tools to help with peripheral neuropathy (e.g. alpha lipoic acid); Cheryl eventually used this for a time too to help reverse her Type 2 diabetes, but taking full advantage of her immediate, available lab data helped to point to a true upstream root cause.

Be on the lookout for Vitamin B12 insufficiency (or even true clinical deficiency) in your clients.  This is one of the most common opportunities I see in my clients, not a surprise when you realize several common categories of clients who frequently benefit from Vitamin B12 support.  These include your clients who

  • are taking PPI (proton pump inhibitor) medications or other drugs to suppress stomach acid (and get triage relief from acid reflux).  Research is starting to showcase the increased risk of B12 deficiency with long-term use of these drugs, in particular, this study and this review may be of interest.
  • are ~60 years of age or older (see graph below) – as stomach acid production has typically declined dramatically by then and starts at an even earlier age in some
  • are taking the drug metformin to help manage their insulin resistance (typically once diagnosed with Type 2 Diabetes)
  • consume a strictly vegetarian or vegan diet (despite myths otherwise, active B12 is only available from organism sources)

1000mcg of methylcobalamin is a reasonable trial dose for your clients who wish to explore for 1-2 months for symptom relief from B12 support (e.g. Thorne, Pure Encapsulations, Jarrow).  Note: there are some individuals who benefit most from a combination of the methyl form with the adenosyl form (due to suboptimal internal conversion), but for most, the methyl form is quite effective.

What benefits might your clients see from optimal levels of B12?  Higher energy and physical stamina, improved memory and cognitive ability, relief from intermittent or chronic neuropathy (e.g. numbness or tingling in the extremities or other body parts), relief from cold hand/feet or cloudy thinking (from macrocytic anemia), relief from chronic cough (non-allergy-related),  increased overall sense of well-being (from higher levels of serotonin), more consistent and deeper sleep (especially in seniors), relief from wheezing (especially in children with asthma).

Common lab markers.  There are many more advanced markers to consider, but these two are typically run as part of an “annual physical” and can usually be covered by insurance and provided by almost any PCP upon patient request.

  • Serum Vitamin B12 (TRR: 250-800 ng/L (or pg/ml; these are the same units).  Given widespread insufficiency within this “normal” range, our clients should aim for true B12 sufficiency to be well into the upper half of that reference range.
  • Mean Corpuscular Volume – MCV (TRR: 80-100 fL).  For optimal circulation, MCV should be 90fL or less within range.  Higher values indicate larger red blood cells, and size is highly affected by sufficient access to both Vitamin B12 and Folate.  This is a type of cellular functional vs. serum marker that yields feedback on what a unique person’s body needs (vs. assuming a typical optimal level is ideal for a unique person – which is all a serum marker can offer).

Organic acids testing allows you to get even more targeted by looking at functional Vitamin B12 sufficiency marker for a unique person.  Learn more about methylmalonic acid here.

stomach acid graph

 

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Gina Millen
Gina Millen

Cheryl’s story is a testament to the importance of B12 for healthcare professionals. Long hours, high-stress environments, and medication use can deplete our B12 levels. I’ve personally seen the benefits of B12 supplements in managing my energy levels and overall well-being. It’s a must for us in the medical field. I’ve recommended a B complex to my colleagues, and they’ve found it helpful.

Jen Maraia
Jen Maraia

I have a 63yo F client whose main complaint is lifelong fatigue. I was wondering if it is prudent to check MMA with a high serum B12 of 1709 (RR 200-1100) on 5000mcg methyl B12. This client’s MCV was suboptimally high at 96.1 (RR 80-100). Homocysteine was 9.5 (RR <10.4). I’m trying to narrow down why the MCV is sub-optimally high. She is not on any drugs that would cause low stomach acid, but she is hypothyroid and obviously her age is likely at play here.

SAFM Team
Reply to  Jen Maraia

We cannot address specific client questions in these public posts’ Q&A threads. As you know, many factors can play into the feeling of energy (or lack thereof), and you are considering one of them by looking at the MCV marker and thinking about all the factors that may be affecting that. Here are a couple of posts where we explore that topic in more detail:
https://schoolafm.com/ws_clinical_know/mcv-early-clue-to-brewing-disease-dynamics/
https://schoolafm.com/ws_qa/mcv-and-anemia/
https://schoolafm.com/ws_clinical_know/cert_pearls/

Jenny Andrade
Jenny Andrade

I have a patient currently taking a PPI and is extremely reluctant to get off of it. We are working on eating hygiene and then we will start a VERY SLOW wean. While he is taking the PPI is it safe to supplement with HCL w/ betaine to help increase digestion? His B12 was 557 and he is hesitant to taking many supplements, so I am just trying to see if we could add in the HCL to increase his B12 levels versus a supplement at this time. Thanks!

SAFM Team
Reply to  Jenny Andrade

You may find this post on the root causes of acid reflux interesting:
https://schoolafm.com/ws_clinical_know/acid-reflux-truths-and-myths/
Typically, you would first work on the root causes that create the need for the PPI in the first place, and then you would start the PPI wean-off process alongside the prescribing physician. Depending on how long the patient has been on the PPI, one may want to support the protective stomach lining with mucilaginous herbs before introducing any HCl supplements, to minimize any adverse effects. In the case that you are describing it may be more beneficial to go with sublingual B12 in a lozenge or liquid form to bypass the typical GI tract absorption. This study may also be of interest to you: https://pubmed.ncbi.nlm.nih.gov/29499976/

Sarah
Sarah

What about someone with consistently low B12 levels and a high normal homocysteine (normal MMA), who is symptomatic with fatigue and brain fog? She has tried to supplement b12 even at tiny doses, but she develops what seems to be neuroinflammation with cognitive/recall deficits that can persist for weeks even after dosing is discontinued. We have tried methyl and hydroxycobalamin both with the same effect. I’ve wondered about the possibility of a cobalt allergy? Or is there a detox process that might be sluggish in some downstream process causing a buildup of toxic mediators? Interestingly, this patient also gets severe, hangover-type headaches with even small doses of CNS affecting mg (like glycinate). Maybe this is a related issue? I can’t seem to find any other reports of this kind of apparent toxicity from even a few micrograms of b12. Thanks for any help!

SAFM Team
Reply to  Sarah

This is a beautiful example of bio-individuality and that reference ranges are for the majority of people and are not always indicative of health/disease. You may be interested in this article that is relatively recent: https://pubmed.ncbi.nlm.nih.gov/31193945/ And your hunch about the cobalamin allergy may also be on the right track as there are a few reports of such cases in the literature. The toxicity may be at play as well. What truly stands out is the possibility of existing oxidative stress that gets exacerbated with the B12 addition. Thus, what else is missing for this person? What else is potentially causing oxidative stress? Is it their diet? Stress? Overexercise? Toxic burden, or imbalance in phases 1 and 2? I would encourage you to think in broader terms and ask more puzzle-piecing questions instead of trying to go after the correction of one consistently low value. Think about what is upstream of that symptom. Why this may be the case for this individual – is it consumption? is it an issue with absorption or delivery to the cells? What else is at play? Using the functional medicine approach and investigating the full picture of symptoms and health history may help you… Read more »

Daniela Lazzari
Daniela Lazzari

Can methylated B12 be harmful if a person has mercury toxicity? I read that methylcobalamin binds to mercury and we get a more toxic Mercury in the body?

SAFM Team

B12 is a key nutrient necessary to remove mercury from the body in the process of heavy metal detoxification. It can be harmful only if added too fast and/or when the detoxification pathways are not open or balanced, which could lead to oxidative stress overwhelm the system. There is an entire deep dive clinical course inside of SAFM devoted to this topic.

Yes, B12 has a high affinity to mercury and can bind this heavy metal when provided from food or in a supplement. These references may be of interest in this vein:
https://www.researchgate.net/publication/240860126_The_Link_Between_Vitamin_B12_and_Methylmercury
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC202093/

Farrar Duro

Hi Tracy, I was wondering if you had any recommendations for a pregnant patient with PCOS who is weaning off Metformin and wants to support her B12 status. What dosage of B12 would you recommend during pregnancy in this case?

SAFM Team
Reply to  Farrar Duro

Indeed, Metformin can lead to B12 depletion over time, but this does not always mean that everyone who takes this drug is B12-deficient. As a savvy practitioner, it is best to stay away from this type of black and white thinking. Therefore, it would be best to asses the B12 status of your client/patient by checking the serum B12 and the methylmalonic acid (MMA) status first and then decide if the supplementation is needed and what dose. This study will give you a better idea of what range to recommend:
https://bmjopen.bmj.com/content/7/8/e016434

Thuy
Thuy

A patient who has been taking methylated B12 for the last 2 months had her plasma B12 level checked and they came back recently >2000. It is way too above the reference level of 800. Her only complaints are a headache and low energy. Do you suggest stopping the methylated B12 since it is not getting to her cells? She did say her energy level is up when she is on Methylated B12, but the level is concerning. I appreciate your input. Thank you

SAFM Team
Reply to  Thuy

It is indeed not uncommon to have higher than normal serum levels of B12 while on a supplement – all this means is that the supplement is well digested and absorbed into the bloodstream. It is not indicative of B12 not being absorbed into the cells – to check that one would need to look at more functional, B12-dependent cellular markers such as methylmalonic acid (MMA), MCV in the CBC panel and homocysteine.

Dana J Camera

I have a 72 year old client that is a vegetarian with neuropathy, but her MCV is 86. I know that the MCV based on both folate and B12, but can someone still be b12 deficient with an optimal MCV? Any help would be appreciated! Thanks!

SAFM Team
Reply to  Dana J Camera

Yes, one can still have insufficient B12 even if their MCV looks optimal. MCV is a marker that depends on B12, folate, and iron and, especially when it is in the lower half of the reference range, it is possible that other nutrients are ‘making up’ for suboptimal B12 status. Given your client’s age and existing neuropathy, it would be appropriate to check more functional markers such as the homocysteine levels as well as the methylmalonic acid (MMA) to better asses the B12 status. Also, making sure that blood sugar regulation is in a healthy range is of top prority. High blood sugar and elevated levels of oxidative stress can be damaging to the nervous system, and other systems as well (eyes, kidneys, etc.). This may be of interest to you:
https://ashpublications.org/blood/article/106/11/3709/122255/Iron-Deficiency-and-Vitamin-B12-Folate-Levels-A
https://www.ncbi.nlm.nih.gov/pubmed/31490017
One needs to be also sensitive to your client’s choice of eating a vegetarian diet, as those tend to be low in B12:
https://www.ncbi.nlm.nih.gov/pubmed/30828450

Heidi Hudson
Heidi Hudson

Would you recommend the Adenylsyl/Hydroxy version of B12 for someone who likely has a problem with intrinsic factor over the methycobalamin type? I have a client who may have a serious deficiency, and I want to be able to make sure she is going to be able to utilize it as efficiently as possible as she does not want to take the shots.

Tom leous

Hi Tracy,
What about these super high mega shots of B12 … on the order of 5o,ooo “units” (Mg or Mcg?) that I hear some doctors doing.

I’m not sure, but don’t believe the body stores much B-12, so it seems to me that that a 1-time mega dose … esp. that high … to counter low CBC panel B12 number … may not be that effective at all, much of it being wasted.

Thanks!
Tom

Tom leous
Reply to  SAFM Team

Tks Tracy! Great perspectives here. Another Q 4 U Re: B12 or any other nutritional supplement (aside from low stomach acid or gut impairment that could cause nutritional malabsorption, etc. of a supplement), what’s your take on a supplement’s “biological availability”, overall potency, potential usefulness within the body? From what I’ve read, poor quality supplements can contain lower grade ingredients (e.g. cyanocobalamin vs. hydroxycobalamin), lower grade forms, use of many fillers in low grade supplement, or perhaps a coating on the pill that impairs breakdown (and thus absorption in the gut, etc.) The assumption is thus that all things being (relatively) equal, a higher-quality designed supplement might or will be more biologically available to the body than a lower/poor grade … and thus have a larger impact. Related to this, are you aware of any testing labs/services that test supplements for bio-availability levels allowing for some form of comparison between different supplement vendors? Thanks!

Abigail Hueber

Hi Tracy,

I have a newly pregnant client with very low B12 (225), she is also low in zinc and magnesium which suggests low stomach acid. I talked with her about taking some apple cider vinegar mid-way in a meal but she found that unrealistic for her lifestyle. Is taking Betaine HCL with pepsin appropriate during pregnancy? Are there any additional strategies to try?

Thank you,
Abby

Susan
Susan

(There is a typo in you article in the B12 units). I am type 2 diabetic, 20 years, on 2500 grams of metformin daily, no insulin. I am now on a low carb/high veg/moderate protein diet and want to reduce(eventually eliminate) metformin. I just ordered Berberine and had a question about B-12 supplementation. Do you think I am low in B-12? My doctor said according to the labs I am normal. Hmmm… I do have tingling in extremities, sometimes more often than others. I am 60. Thank you!! My VITAMIN B12 was 562 pg/mL.

Elise Girouard
Elise Girouard

Hi Tracy, First off, I am so grateful to have found this website and all of the incredible information you have put together. Thank you!! I have a female client who is 32 years old with suboptimal B12 (530) , low ferritin (20), low total D (38) and is taking metformin (prescribed for her PCOS, but she has not had any symptoms since having her first child a year ago) and wellbutrin who experiences headaches daily. She is relatively healthy and feels ok day to day except for the headaches. She is exploring the possibility that the headaches are related to jaw clenching and is trying out acupuncture and some other therapies related that she is hoping will help. She is working on eating more vegetables as well as buying better quality animal products and lowering her intake of processed foods and sugar (big sweet tooth). I read in a previous thread that low b12 and ferritin can both be a sign of low stomach acid. Do you think a good course of action would be to have her try to start taking betaine HCl/pepsin along with continuing to work on improving her diet? Or would you suggest supplementation with… Read more »

Tammy Ruggiero
Tammy Ruggiero

Have you heard of sublingual perque activated b12? http://www.perque.com/product_sheets/PERQUE-Activated-B-12-Guard.pdf?
Thoughts? And do you think that is good for daily use?

Tammy Ruggiero
Tammy Ruggiero

If you are doing B12 injections I assume this means we do not have to worry about doing with food…Am I missing something?

Christine Kramer

Hi Tracy,
What do you think about the B12 injections? Is 1000 mcg weekly sufficient for someone with B12 insufficiency?

Gayle Arnold
Gayle Arnold

Is the dosage for someone with suboptimal B12 1000mcg daily? The Jarrow B-Right says 1 pill daily with 100 mcg of B12 included. That would mean 10 pills daily.

Regina
Regina

Hello Tracy,
Thank you very much for expertise.

This patient is over 60 and about 10 years ago had stomach ulcer surgery.She does her best to eat healthy.
Thank you very much for expertise.

Regina
Regina

Hello Tracy,
i have a client who achieved 936 blood level of B12. What is the next step? Should they decrease the dose or take a break?
I aapreciate you for giving me your expertise.
Regina

Regina
Regina
Reply to  SAFM Team

Thanks a lot Tracy for reply. I’ll check if my client has these once on their labs. In general, what do you do when optimal level was reached?

Paula Youmell

A client who has neuropathy post chemotherapy: is this neuropathy related to B12 deficiency or is a toxic side effect of the chemo from damaging good cells?