An Epidemic of Misdiagnoses

Sally M. Pacholok, R.N.

Jeffrey J. Stuart, D.O.




About the Authors

Sally Pacholok, R.N., BSN, an emergency room nurse with eighteen years of experience, received her bachelor's degree in nursing from Wayne State University. Prior to entering the field of nursing, she received an Associate's Degree of Applied Science with magna cum laude honors. She is also an Advanced Emergency Medical Technician (A-EMT), and worked as a paramedic prior to and during nursing school. She has worked in health care for a total of twentyfive years, and has cared for thousands of patients. In addition, she is an Advanced Cardiac Life Support (ACLS) provider, and has assisted instructors at a local community college in training paramedics in ACLS. She is a Trauma Nursing Core Course (TNCC) Provider, an Emergency Nurse Pediatric Course (ENPC) Provider, and a member of the Emergency Nurses Association (ENA).

In 1985, Pacholok diagnosed herself with vitamin B 12 deficiency, after her doctors had failed to identify her condition. As a result, she is passionate about the need to educate the public about the dangerous consequences of this hidden and aU-too-common disease.

Jeffrey J. Stuart, D.O., a physician who has practiced emergency medicine for twelve years, is board certified in this field. He is also. certified in Advanced Trauma Life Support, Advanced Cardiac Life Support (ACLS), Advanced Pediatric Life Support, and Neonatal Resuscitation. Stuart received his Doctor of Osteopathy degree from the Chicago College of Osteopathic Medicine. His training includes field amputation and hazardous materials decontamination, and he has also participated in training sessions with the Detroit Metropolitan Airport SWAT·team. Dr. Stuart participated in visual brain research at the National Institute of Mental Health in Bethesda, Maryland, in 1987, and was involved in cholesterol metabolism research at the Rockefeller University Hospital in New York City in 1985. He is a member of the American Osteopathic Association, the American College of Osteopathic Emergency Physicians, the Macomb County Osteopathic Society, and the Michigan Osteopathic Association.



I. Neurological Manifestations (+2) paresthesia

(+2) weakness (extremity)

(+2) dizziness, lightheadedness (+2) syncope

(+2) falling

(+2) abnormal gait/ataxia (+2) mental status change (+2) confusion/disorientation (+2) dementia'

(+2) diminished proprioception

(+2) distorted touch/pain perception (+2) impaired vibration sense

(+2) muscular spasticity

(+2) tremor

(+2) +Babinski or +Lhermitte's sign (+2) paralysis

(+ 1) incontinence (urinary/fecal) (+ I) impotence

n. Hematologic Manifestations Deficiency

(+2) anemia'

(+2) macrocytosis

(+2) ovalocytes or eliptocytes

(+2) neutrophil hypersegmentation (+1) anisocytosis

(+ 1) leukopeni a

(+1) thrombocytopenia (+ 1) microcytosis

III. Psychiatric Manifestations (+2) depression

(+2) hallucinations

(+2) delusions

(+2) violent behavior (+2) personality changes (+2) psychosis

(+2) apathy

(+2) paranoia

(+2) irritability

(+2) schizophrenia

rv. Gastrointestinal Diseases (+2) gastric atrophy

(+2) hypochlorhydria/ach lorhydria (+2) gastritis.

(+2) ulcers

(+2) inflammatory bowel disease (+2) diverticulosis

(+2) gastrointestinal neoplasms (+2) gastrointestinal resections (+2) malabsorption syndromes (+2) small bowel overgrowth (+2) diphyllobothrium infection (+2) Zollinger-Ellison syndrome

(+2) pancreatic exocrine insufficiency (+2) Imerslund-Graesbeck syndrome (+2) Crohn's disease (regional enteritis) (+2) Celiac disease (gluten enteropathy)

Cobalamin Deficiency Risk (CDR) Score Low 11Sk: less than 3, Moderate risk: 3 to 6, High risk: more than -6 ,

(+2) GERD ,

V. Population at Risk

(+1) age sixty years or greater

(+2) family history of pernicious anemia (+2) Eating disorders (anorexia, bulemia) (+2) gastric bypass

(+1) history of thyroid disorders

(+1) history of autoimmune disorders (+1) history ofIDDM

(+ 1) history of cancer, chemotherapy, or

- radiation therapy

(+ i) administration of nitrous oxide (+2) vegans or vegetarians

(+1) prescribed medications: (antacids, 'Hz-blockers, potassium chloride, phenytoin, metfonnin, proton pump inhibitors, cholestyrarnine, colchicine)

, (+1) on folic acid therapy

VI, Disorders with Possible Underlying Cbl Deficiency* (+2) Alzheimer's disease

(+2) multiple sclerosis

(+2) peripheral neuropathies (+2) AlDS dementia complex (+2) hyperhomocysteinemia (+2) congestive heart failure (+2) autism

(+2) fibromyalgia

(+2) patients on hemodialysis (+2) vertigo

(+2) Meniere's disease (+2) infertility

(+2) chronic fatigue syndrome

(+1) history of occlusive vascular disorders

(TIA, CVA, Ivil, PE, DVT) (+1) thalassemia trait

(+ 1) iron deficiency

(+ 1) alcoholism

(+ 1) polycythemia

(+1) radiculopathy from back disorder/injury (+ 1) chronic pain with drug seeking behavior

VII. Other Manifestations of Chi Deficiency (+ I) fatigue/lack of energy

(+ 1) generalized weakness

(+ I) weight losslloss of appetite (+1) constipation or diarrhea

(+ 1) optic neuritis

(+ 1) orthostatic hypotension

(+ 1) chest pain/exertions! dyspnea (+1) hepatomegaly or splenomegaly

(+ 1) poor wound healing/ulcer/decubitus (+1) premature graying

, (+1) hyperpigmentation (+1) pallor

(+1) glossitis

(+1) tinnitus '

(+1) vitiligo

(+ 1) cervical dysplasia

"(Some of these disorders/conditions can he mistakenly diagnosed in c-ases where symptoms actually stem from Bll deficiency, Others, such as hemodialysis, can contribute to the' risk ofBn deficiency, In a number of these conditions, B". deficiency needs to he investigated as an underlying cause.) .

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memory problems or mental illness, injections administered in the office or by a family member are far more reliable than oral supplements which patients may forget to take. Also, some patients object to taking an increased number of oral medications, whi!e others have problems swallowing tablets, or have sensitive stomachs and can easily be nauseated by oral supplements. (High-dose sublingual B12 may be an option for these patients.)

With the development of virtually painless microfine needles, the only significant drawback to injected B 12-injection pain-has been greatly reduced. Moreover, patients can easily learn to inject themselves; making injected B 12 much less expensive than oral supplements.

The argument for injections is simple: Given that injectable B12 is safe, effective, inexpensive, and virtually painless (and also eliminates the issue of compliance if shots are administered at the physician's office), why take a chance on oral formulations that may not be as effective? In cases of temporary B 12 deficiency due solely to poor diet, however, oral supplementation is, of course, effective, once normal B 12 levels have been reestablished and any other reasons for the deficiency have been carefully ruled out.

Current evidence indicates that byclE~~Gl~~~jfllIIfi:ro1 is<sUP'@l1cr10 ~'j~, :- ,anoc0'5alal~, and methylcobalamin may be superior to hydroxocobalamin for neurologic disease. Lee notes in Wintrobe s Clinical Hematology, "1:' -$t\1l~'i:et~ntri.:0,11l @fhyaFoxGGQ",bal,amin is bette' than tfbat 0f,€y· . ~ ,'anocol'mlamm;\ twenty-eight days after injection, retention still is nearly three times greater. In addition, JftY.4r,,?~0§0b:at~Lmin 1'SS\1ller~. aSv'roilabi€'rtoq ciel"s~an· ·sr.PF~ee~ed more effie1enll1 y: tHe ."

Methylcobalamin (available at compound pharmacies, with or without preservatives) is not yet widely used in the United States, but Japanese studies indicate that it is even more effective in treating" neurological sequelae of BI2 deficiency. Its greater efficacy presumably stems at

. least in part from the fact that, like hydroxocobalamin, it does not need to be decyanated-and, in addition, unlike either hydroxocobalamin or cyanocobalamin, it doe~ 110t need to be reduced to the (+ 1) state (the only form that can cross the blood-brain barrier). Thus, it bypasses several potentially problematic stages in Bl2metabolism. furthermore, methylcobalamin provides the body with methyl groups essential for various



biological oxidation-reduction reactions. Studies show that a small oral . dose of rnethylcobalamin results ih a greater accumulation of cobalamin in the liver than an oral dose of cyanocobalamin, and that methylcobal, amin is retained approximately three times longer in tissues than cyanocobalamin.

history of gastric surgery, aware of the need to continue treatment for life. It is important, too, to provide them with documentation that will make it easier for them to obtain treatment in the future, if they rieed to switch doctors. Also, encourage the hospitals with which you are affili-


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atedto develop protocols for effective B}2 screening. B}2 deficiency is a public health crisis, and it is crucial=-particularly as .the huge Baby Boomer generation ages=-that we develop appropriate standards of care in order to acknowledge,.address, and handlethis crisis,


We iinelthatp:t:€scribir:Ig 8J 3 Q JiIirl vial ef hydrox0€obalam'. 1,000 mcg/ml works well ]€)f patients seltf-administering theirBl~ The, cost is approximately $38 if a patient has no insurance, and the cost of a co-pay for patients with insurance. One bottle will last two years or less, depending on the expiration date. The bottle needs to he stored between 59 to 86 degrees Fahrenheit. Unfortunatelypharmaceutical companies do not make 10 ml vials of'hydroxocobalamin, but this may change in the future. Cyanocobalamin is supplied in either 1 ml vials ($1.00 per vial of 1,000 mcg/ml) or 10ml vials ($10.00 per 10 m1 vial of 1,000 mcg/ml). (prices are 2005.)

An obligation for all specialties

We're often told, as emergency department (ED) staff, that comprehensive testing for B 12 deficiency is inappropriate in our setting. Yet a significant percentage of our "repeaters'v=the patients who come. in month after month suffering from mental status changes, syncope, chest pain, anemia, weakness, dizziness, or fractures caused by falls-care likely to be suffering from a B 12 deficiency that is causing or exacerbating their health problems.

We believe that the ED is an appropriate place for B 12 testing. We have an ethical obligation to rule out B12 deficiency in ED patients who present with high-risk signs and symptoms, and we've saved the health and lives of many patients by doing this, so we encourage ED staff to order tests when indicated-but ideally, this diagnosis should occur in the office of a primary care physician or specialist who can provide longterm follow-up.

~~H2 cl'-'ff€i€l1ey is a- problem dra_ sNouHdr The ident~fieillraF1'~r oceatea , @~g" ,hef~~-=i't, 'CaNses symptom~ seFlolls 6N@Ngh ·t@·.retqf[1Feeinumgeae-Y' ~ care. In the great majority of cases, B12 deficiency develops slowly, and




to be administered, rather than a single dose." Lee also notes that some people are "short responders," whose serum B 12 concentrations may drop _ to dangerously low levels within two weeks of an injection.

During initial treatment, serum potassium concentration may fall significantly within the first forty-eight hours after an Injection, and then gradually rise to normal levels over the next few weeks. Patients with borderline or low potassium levels should receive potassium supplements before therapy is initiated, to protect against arrhythmias, Temporary drops in plasma iron levels may also occur.and a transient increase in paresthesias is sometimes experienced. Hypokalemia and thrombocytosis could occur upon conversion of severe megaloblastic to normal erythropoiesis with B 12 therapy. Therefore, serum potassium levels and the plateletcount should be monitored during therapy.

was as effective in producing hematologic and neurologic responses as a standard injectable regimen in patients with ;S 12 deficiency. This study strongly supports the view that oral B 12 at doses of 2,000 meg can replace injection therapy in some situations. Although this was a very small study with only thirty-three patients, it .did use MMA and Hcy markers, demonstrating a reduction in these two metabolites.l '

This study is consistent with findings from the 1950s and 1960s, which showed that 1 percent of thd oral B 12 dose consumed is absorbed via an alternate pathway, in .. elevant of intrinsic factor or a functioning

- -

ileum. It also is consistent with Clinical practice in Sweden, where oral

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Bl2 maintenance therapy has been used for more than twenty-five years.

However, we believe that additional research is needed to confirm



BI2'S crucial roles

~~""_ f€W n~c .0 's ~ aware OP the fu'll;.<rahKe-crf pro15fenrs~ flia't, can ~

, s' em fnilffi 12 lCf~e-ieln~M., and we frequently encounter skepticism when we tell physicians thattheir patients' low B 12 levels could be responsible for symptoms as diverse as dementia, heart disease, muscle weakness, and infertility. But deficient B 12 levels c,an indeed affect almost every system of the body, because cobalamin plays .an integral role in a wide range of neurologic, hematologic, immunologic, metabolic, vascular, and reproductive functions including the following:

" the division of all cells

.. numerous enzymatic reactions

• the synthesisof nucleic acids, the transmethylation of amino acids, and the metabolism of carbohydrates and fatty acids.

o ~aiIftel'l1i!!!£~ al'lea1t1n.rY.i\ne:r,;V€H1S ~St.€l-m, because it maintains the .~' hi surrounding the central and peripheral ner- . VOliS systems

o the proper function of folic acid, because it allows folic acid to assist in converting the amino acid homocysteine (Hey) into the essential amino acid methionine. If vitamin B 12 is not present, folic acid becomes "trapped" and cannot fimction properly, leading to dangerously elevated levels of toxic homocysteine"

Because B 12 deficiency severely impairs many systems in the body, and because it is so easily treated, doctors should make it a point to routinely identify and heat its victims. This is particularly crucial now, as the "Baby Boomer" generation ages into its senior years-the years of highest risk for B12-deficiency-related problems.

B 12 metabolism: a complex pathway

111 its natural state, cobalamin occurs only in animal products. Unlike other vitamins, this large molecule must undergo several major steps

"When folic acid "trapping" occurs, Hey is not converted intomethionine, and Hey levels begin to rise, The accumulation of Hey in the blood is toxic to blood vessels, causing plaque formation which leads to occlusive vascular disorders such as coronary artery disease (CAD), myocardial infarctions (M!), cerebral vascular accidents (CVA), transient ischemic attacks (TIA), deep vein thromboses (DVT), and carotid and renal artery stenosis,

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Information for Physicians


.JElik.l_Flur,z"YB 1'2 deafen Gol~«./f§(JVs .ao"fnit-one q l{CiFfer-o 'pthe..1:J. ~;Pf1p.u~

l{[fon and is more common in the elderly and in. adults with several pre-

. ..

disposing conditions .... Health-care professionals need to recognize that

vitamin B 12 deficiency is often undetected and can lead to devastating and irreversible complications. Early treatment is effective and prevents disability from, hematologic or neuropsychiatric complications, or both." -T. S. Dharmarajan, M.D., and Edwarcl P. Norkus, Ph.D., in Postgraduate Medicine'

In the emergency department, we never know who will come through our doors next. On a typical shift our patients could include a confused elderly woman, a man complaining of chest pains, a young woman with puzzling' neurological symptoms, a elderly man with a hip fracture,'a pregnant woman suffering a miscarriage, a young man in the grip of an acute episode of paranoia, a depressed and suicidal patient, a stroke victim, an AIDS patient or diabetic 'crippled by neuropathy, or a child whose diagnosis is listed as "failure to thrive."

As we look over these patients' records, we see the obvious battery of , tests-X rays, blood tests, psychiatric evaluations, EKGs, MRls, CT scans, What we don't see,. however, is evidence that a significant percentage of the patients who present with possible signs and symptoms of B 12 defi.ciency-iric1uding all of the patients we just described above-shave been tested for this common, simple-to-treat, and potentially deadly problem.

Obviously, only a minority of the patients we treat have symptoms

caused by deficient B 12' However, this ~ ·Qblen.ta1Jt¢'1ts. a ueh a ~2-5 m'~r'"

i?e:ef1t 0¥th ~p@l'Jul~? causing a rem;rkan eaiTay of debilitating and dan-



B 12 .deficiency isn't like the measles or a sprained ankle. There's no obvious symptom, like a red rash 01: a swollen joint, which allows you (or your doctor) to make an instant diagnosis. Instead" there are risk factors and symptom patterns that can strongly implicate deficient Bl2 as a culprit. To know if you're at risk for B 12 deficiency, you need to recognize these risks and symptoms. If you spot them, your next step should be to call your doctor,

How can you tell if you're at risk? On the following pages, you'll find a checklist of the risk factors and symptoms most often associated with B 12 deficiency, along with a point score to assign to each of these. To make the checklist easier to use, we've divided it into categories, To determine your risk, add up your point score for all of the categories, and


check it against the scoring chart at the end. If you are filling in the

questionnaire for a loved orie, simply answer as that person would. ' ,

Are You at Risk?

1. Neurological Symptoms

If you have any of the symptoms listed below, give yourself two points, If you have more than one of the symptoms listed be- 10H{ give yourself another pointfor each additional symptom.

, ,

• Do you experience a "pins and needles" feeling or numbness

in your feet, hands, legs, 'and/or arms?

o Have you been diagnosed with diabetic or peripheral neur-


o Do you suffer from weakness in your arm's and/or legs? D Do you experience Iight-hcadcdness or dizziness?

D Are you prone to falling or do you fall frequently?

o Have you or others noticed anyunusual changes in your ability to move-' for instance, do you walk, clumsily, or with " your feet wide apart, or have difficulty writing legibly?

e Have you noticed problems with your memory or thinkirigfor instance, increased difficulty in remembering names or dates, or more trouble in adding numbers, balancing your checkbook, or making change? Do you sometimes become



. confused or disoriented? Do you suffer from memory problems or other symptoms of dementia?

o Do ·you have trouble lrnowing where various parts of your body are, if you aren't looking? (For instance, do you have trouble walking in the dark, when you can't see your feet?) e Does your sense of touch, or your perception of pain, appear distorted?

o Has a doctor ever told 'you that you have muscular spasticity (lack of coordination and excessive muscle contraction)?

o Do you have a tremor?

o Do you suffer from urinal), incontinence or impotence?

2. Psychiatric Symptoms

If you have' any of the symptoms listed below, give yourself two points .. If you have more than one of the symptoms listed be- 10H~ give yourself another point for each additional symptom.

• 0 Have you undergone any unusual personality changes-for instance, do your friends say that you're "not acting like yourself"-· or do you find that you are more irritable than usual?

o Are you unusually apathetic or depressed, or have you ever been diagnosed with depression (including postpartum depression)? Have you ever had suicidal thoughts?

.. Do you ever experience hallucinations or delusions?

. .

o Do you ever exhibit violent behavior?

o Have you been diagnosed with any other form of psychosis 01: mental illness, including schizophrenia or bipolar disorder?

. 0 Do you find yourself becoming more paranoid about other people's actions or intentions?

3. Hematologic Signs (Abnormalities of the blood cells)

. If you have any of the signs listed below; give yourself two points.

If you have more than one of the signs listed below. give yourself another point for each additional symptom.

D Has a doctor ever told you that you have abnormally small


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red blood cells, an iron deficiency, or iron deficiency anemia?

a Has a doctor ever told you that you are anemic (low blood count or low hemoglobin)? Do you have low platelets, or a low white blood cell count?

o Has a doctor ever told you that .your red blood cells are abnormally large (macrocytosis)?

4. Gastrointestinal Risk Factors

If you have any of the risk factors listed below, give yourself twopoints. If you have more than one of the risk factors listed below; give yourself another point for each additional symptom.

e Have you been diagnosed with inflammation and/or wasting

of the stomach lining (gastric atrophy)?

o Have you been diagnosed as having low stomach acid?

o Do you suffer from gastritis?

o Do you suffer from ulcers?

o Have you been diagnosed with gastroesophageal reflux dis-

, ,

ease (GERD)?

o Do you have diverticulosis?

o Have you been diagnosed with precancerous gastrointestinal growths or gastrointestinal cancer?

o Have you undergone a gastrointestinal resection (partial or complete gastrectomy), undergone a gastric bypass surgery for weight loss, or had either partial or complete removal of your ileum (last part of the small.intestine)?

o Have, you been diagnosed with a malabsorption syndrome . (Crohn's disease, inflammatory bowel disease, irritable bowel , syndrome, or celiac disease [gluten enteropathy])?

o Do you have a family history of pernicious anemia (an autoimmune disease)?

.. Have you been diagnosed with small bowel overgrowth?

o Have you been diagnosed with a tapeworm or other gastrointestinal parasite?







S·. General Risk Factors

If yo it have any of the risk factors listed below. give yourself one point.

I -.1




II Are you over the age of sixty?

• Do you have a thyroid disorder, or do you have an autoimmune disorder-for instance, lupus, insulin-dependent diabetes, rheumatoid arthritis, Hashimoto"s thyroiditis, Graves'

. , .

disease, Addison's disease, hypogammaglobulinemia, or a-

gammaglobulinemia, ?

• Have you ever had' cancer? Have you undergone chemotherapy, or undergone radiation therapy?

D Have you ever undergone surgery (including dental surgery)

. in which nitrous oxide was used?

o Do you abuse nitrous oxide as a recreational drug?

o Are you a vegan or vegetarian? a Are you an alcoholic?

o Ar~ you taking any of the following medications: H-2 blockers (Pepcid, Zantac, Tagamet, Axid), potassium chloride (K.dur), Glucophage, Glucovance, proton pump inhibitors. (Nexium, Prevacid, Prilosec, Protonix), birth control pills, colchicine, Questran, neomycin, or drugs that treat tubercu ... .losis?


6. Other Signs/Symptoms often Associated with B 12 Deficiency If you have any of the signs or symptoms listed below; give yourself one point.

o Do you suffer from fatigue, lack of energy, or weakness?

.. .

o Do, you suffer from generalized weakness? .

• Have you experienced a loss of weight or loss of appetite?

• Do you suffer from chest pain, or froin shortness of breath . with exertion (e.g., walking from your bed to the toilet or to

your kitchen)? f

G Do you have areas of skin hypopigmentation (unusually 'light spots), or have you been diagnosed with vitiligo?

o Are you unusually pale, ordo you have a lemon-yellow skin color?


o Do you have a sore) inflamed, or "beefy red" tongue? D Do you suffer from tinnitus (ringing in the ears)?

o If you are female) has a doctor ever told you that your Pap smear showed abnormal cells (cervical dysplasia)?

o Do you suffer from infertility?

To Calculate Your Score:

Add the points in every category. Your score is:

Low Risk: with less than 3 points Moderate Risk: with 3 to 6 points

High Risk: if your points are greater than 6

What should you do now?

If you scored in the low-risk range, and you do not have any of the medical conditions listed in the section following this one, your B 12 levels are probably fine. Remember, however, that as you age, your B 12 levels may drop-meaning that a healthy level today won't guarantee that you're safe two years from now-so be aware of the symptoms and risk factorswe've described, and have your B12 and Ivllv1A levels checked if you develop any of them.

If you scored in the moderate-risk range and are not experiencing any symptoms) wait until your next doctor's appointment and then insist on having a urinary MMA test. If you're actively suffering from any symptoms that could be caused by insufficient BIb however, make an appointment as soon as possible. If B 12 deficiency is indeed the culprit, catching it early may lead to a complete remission of symptoms.

If you scored in the-high-risk range, there is no time to waste: Call your doctor) and get the earliest appointment possible. Onc~ you're there, make sure you receive urinary :MMA testing (discussed later in.this chapter). If-your doctor is skeptical or resistant, be assertive-and, if neces-

- -

sary, find another doctor.

Are -there specific medical conditions that put me at risk?

Regardless of your score on this questionnaire, we believe that if you currently suffer from, or have suffered from, any of the following conditions, you need to be tested for B 12 deficiency:



ciency, and if you're over sixty, you have up to a 40 percent chance of having potentially dangerous low B 12 levels.

How Commom Is B 12 Deficiency?

It's important to note that most of the studies mentioned below underestimate the prevalence of deficiency, beoauseas we'll explain later-many deficient people have normal serum B]2 levels.

Tufts University researchers, analyzing data from the large-scale Framingham Offspring Study, found that nearly 40 percent of participants between the ages of twenty-six and eighty-three had plasma B 12 levels in the "low normal" rangea level at which some people begin experiencing neurological symptoms. Nearly 9 percent had outright deficiency, and 16 percent exhibited near-deficiency. Remarkably, low serum B 12 was as common in younger participants as in the elderly.'

Smaller studies report that 15 to 20 percent of seniors have a vitamin B 12 deficiency.

A recent study found that 40 percent of hospitalized elderly patients had low or borderline serum B12 levels.e

Over 80 percent of long-term vegans who do not adequately supplement their diets with B12, and over SOp-ercent of long-term vegetarians show evidence suggestive of B 12 deficiency (see Chapter 6). 3,4

important toknow a little about what vitamins are-and why B 12 is unique,

Your body needs thirteen different vitamins in order to stay alive . and healthy. These tiny molecules participate in thousands of chemical reactions that build your ·tissues and organs, provide you with energy from the food you eat,. clean the toxins from your body, protect you against infections, repair' damage, and allow your cells to communicate with each other.




nesses, and who have incurred huge medical expenses as well, due to the non-diagnosis or late diagnosis of their B 12 deficiency.

We want it to be perfectly clear, at the outset of this book, that B 12 isn't a "magic bullet." The symptoms we've outlined have many causes, and B12 deficiency is only one of them. But patients and doctors need to be aware that B12 deficiency often does cause these symptoms, and that doctors who fail to rule it out may be condemning millions of patients to unnecessary debility or even death. Conversely, the brief amount of time and money required to identify B 12 deficiency is a small investment to make-and whether you're a doctor or a medical consumer, it may be the

rare disorder called. Leber's hereditary optic neuropathy-should never take--rcyaflOcobalamin, one specific form of Bl2. Information about safe forms of B12 treatment for these individuals is contained in Chapter 11 .

. Notes

1. Study cited in "B12 deficiency may be more widespread than thought," Judy McBride, Agricultural Research Service website, U.S. Department of Agriculture, August 2, 2000. 000802.htm.

2. Shahar, A., Feiglin, L., Shahar, D. R, Levy, S., and Seligsohn, U. High prevalence and impact of subnormal serum vitamin B 12 levels in Israeli elders admitted to a geriatric hospital. Journal of Nutrition, Health and Aging(2001) 5:124-7.

3. Crane, M.G., Register, U. D., Lukens, R H., and Gregory, R. Cobalamin . (CBL). Studies on two total vegetarian (vegan) families. Vegetarian Nutrition;' An International Journal 1998,2(3):87-92.

4. Bissoli, L., Di Francesco, v., Ballarin, A., Mandragona, R., Trespidi, R, Brocco, G., Caruso, B., Bosello, 0., and Zamboni, M. Effect of vegetarian diet on homocysteine levels. Annals of Nutrition and Metabolism 2002, 46(2):73-9.

5. Ordower, G. "Batavia woman mkes appeal to Bush," Daily Herald, January 6, 2005.


Your body can't make vitamins by itself, so it depends on you to provide them by eating the right foods. Some (the fat-soluble vitamins)

Of the thirteen vitamins your body needs, one is vitamin B 12' It

Among its distinctions, B 12 is the only vitamin that contains a trace

high in B12, augmented with a supplement, isn't sufficient for many people.

In fact, while you need only a tiny, tiny amount ofB12 each day (two to four micrograms or about a millionth of an ounce), it's remarkably easy to become deficient in this nutrient. While deficiency often occurs in vegans or vegetarians who fail to take the light supplements, the majority of B12-deficient people eat plentiful amounts of the vitamin=si's just that their bodies can't absorb or use it.

Why? Because to get from your mouth into your bloodstream, vitamin B 12 must follow a complex pathway, and a roadblock in any part of that pathway can cause your B12levels to plummet. Here's a highly simplified explanation of this pathway:

1, The vitamin B 12 in your food is bound to animal proteins, and first must be freed. To split the B 12 and the protein apart,

* In fact, as we'll explain later, several plants that some supplement manufacturers claim are high in B 12' such as spirulina and tempeh, actually contain "pseudo-Bi," analogues that block the uptake of the real vitamin, sometimes causing dangerous deficiencies.


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