B12 Deficiency: Causes, Symptoms & Treatment
written by
Veronica Max, APRN, FNP-C
TLDR: Vitamin B12 deficiency can manifest in mood disorders, fatigue, memory loss, confusion, shortness of breath, numbness, tingling and even heart palpitations. Deficiency can be detected with simple blood tests. If deficient, B12 can be safely replenished via whole foods, sublingual, transdermal, or intramuscular routes. We recommend avoiding cyanocobalamin in preference of activated forms: methylcobalamin, hydroxocobalamin, or adenosylcobalamin.
DEEP DIVE: WHY B12 IS IMPORTANT
Have you ever had a “senior moment?” Consider this: an estimated 40% of people over 60 years old are deficient in B12, which leads to cognitive decline, memory loss and even Alzheimer’s and dementia. The industrialized pharmaceutical-medical complex has accepted that a significant decline in our cognitive abilities is just part of getting older, when in many cases it may be something as simple as not getting, or absorbing, enough of the right kind of B12.
And if you think this is something that only impacts vegans and vegetarians, think again. And then keep reading…
Signs of B12 Deficiency
Do you suffer from any of the following symptoms?
Weakness, tiredness, or light-headedness
Rapid heartbeat or difficulty breathing
Poor memory or difficulty concentrating
Depression, anxiety, mania
Numbness and tingling of hands or feet
Difficulty with balance, poor coordination
Pale skin
Upset stomach or weight loss
Diarrhea or constipation
If you answered “yes” to any of the above, it might be time to get tested for B12 deficiency.
How common is B12 deficiency?
There are many different types of B vitamins and each has its own role in how your body functions. Vitamin B12 deficiency, commonly underdiagnosed by conventional medicine, is an increasingly common deficiency across a broad spectrum of our population.
B12 deficiency has been estimated to impact 1 in 31 US adults, at least 40% of people over 60 years old and may contribute to at least some of the symptoms we attribute to “normal” aging.
Vitamin B12 deficiency can affect almost every system and tissue in the body and is one of the most common reasons that people suffer from fatigue. It plays a vital role in the nervous system, red blood cell production, DNA synthesis, detoxification and the synthesis of hormones and neurotransmitters.
It cannot be manufactured in the human body and must be regularly obtained via animal proteins or fortified food products. Acid in the stomach is necessary to free vitamin B12 from animal proteins so that it can later be absorbed by the colon.
A B12 deficiency may be caused by:
Diets low in red meat, organ meat and/or fortified products
Low stomach acid (often caused by taking acid lowering medications)
Conditions that affect the small bowel (Crohn’s, Celiacs, parasitic infections, microbial overgrowth) and prevent absorption in the colon
Medications (Metformin, antacid medications, antibiotics)
How do you test for B12 deficiency?
B12 deficiency often goes undiagnosed. There are two reasons for this. First, most healthcare providers do not routinely test for it and two - the low end of the laboratory reference range is too low. It is well-established in the scientific literature that people with B12 levels between 200 pg/mL and 350 pg/mL—levels considered “normal” in the U.S.—have clear vitamin deficiency symptoms.
In Japan and Europe, the lower limit for B12 is between 500 and 550 pg/mL. Those levels are associated with psychological and behavioral symptoms, such as: cognitive decline, dementia, and memory loss.
In my clinical practice, I have seen many patients who have significant symptoms of low intracellular B12 and they still show “within normal range” on serum lab values. Serum homocysteine and methylmalonic acid are much more sensitive markers as they may show a deficiency earlier than serum B12.
If you think you may be deficient in B12, it is important to request several tests from your doctor:
CBC
Serum B12 and Folate
Homocysteine
Methylmalonic acid (MMA)
What can you do if you are B12 deficient?
Your lab results come back and you discover you’re deficient in B12. What do you do next?
Food first! Eat more food with B12
Mother Nature is brilliant and the complex dance she’s orchestrated in the human body is, in many ways, far beyond our current understanding.
When it comes to nutrients, She often packages complementary components together to prevent toxicity and imbalances or to ensure better absorption and nutrient activation. This is why I prefer a food-first approach.
Vitamin B12 can be found in large quantities in animal products, including meat and organ meats, poultry, fish, seafood, eggs, and dairy products. I tell my patients to strive for 1 serving daily of red meat and 1-2 servings of organ meat per week.
Can’t stomach beef liver? Don’t sweat it! Force of Nature Meats (innovators in the regenerative food space and Austin, TX locals) now offer “ancestral” ground beef and bison blends that incorporate ground liver and heart. While I wouldn’t recommend using these blends to make a burger, the unique flavor and texture can easily be disguised when making meatballs, taco meat, or your favorite Texas chili.
Oral B12 Supplements
If a food-first approach is not an option for you, you may choose to supplement with B12 or B Complex (includes B12 + several other B vitamins).
B12 comes in several forms – cyanocobalamin, methylcobalamin, hydroxycobalamin, or adenosylcobalamin.
Cyanocobalamin is the least expensive and most readily available form of B12. I avoid this form of B12–both because it contains cyanide (yes, cyanide!) and because it must be converted by your body to an active form–something that those with MTHFR (Methylenetetrahydrofolatereductase) mutation have difficulty doing.
Methylcobalamin is a great option for individuals with methylation issues. Be aware that approximately 2% of the population feels agitated after taking this formulation of B12.
Adenosylcobalamin is well tolerated by those with MTHFR and methylation sensitivity.
Hydroxocobalamin is often combined with adenosylcobalamin and is well tolerated by individuals with MTHFR mutations and those with methyl sensitivity.
Based on genetics and other factors unique to the individual, I may recommend methylcobalamin, hydroxocobalamin, or adenosylcobalamin, typically at a dose of 1000-2000mcg daily.
It’s also important to note that because of some of the factors mentioned above, many people have difficulty absorbing B12. For this reason, I prefer sublingual formulations (absorbed in the blood vessels under the tongue) over oral formulations (absorbed via the GI tract). In fact, studies have shown that sublingual B12 may be just as effective as B12 injections.
If you’re wondering why you haven’t previously heard this from your doctor, consider that in the insurance based and fee-for-service healthcare models; there are monetary incentives for B12 injections (i.e. they can bill/charge for an office visit on top of the injection). At UltraPersonal Healthcare, no such incentive exists! We get paid no matter how many times you do (or don’t) see us and unlimited visits are included in your membership.
Transdermal B12
Transdermal B12 is applied topically and absorbed via the skin. This non-invasive method of delivering B12 is a great option for kids and is available both over-the-counter and by prescription from specialty compounding pharmacies.
B12 Injections
Depending on the severity of the deficiency and factors affecting absorption, some people require intramuscular injections. These injections can be taught in the office and later administered at home.
Initially, injections are given once weekly and once symptoms are improving, maintenance of B12 may occur with as little as one injection every 4 weeks.
Final thoughts
As with oral supplementation, we avoid cyanocobalamin at UltraPersonal Healthcare and instead work with specialty pharmacies that compound more bioavailable/active forms of the nutrient.
Because B12 is a water soluble vitamin, getting too much is not a large concern. If you get more than what you need; you may just end up making expensive urine. However, it can be helpful to recheck labs in 8-12 weeks to ensure your B12 (and associated labs) are within optimal ranges.
Do you feel like you might not be getting enough B12?
If you’d like to share an experience or question about B12, comment below.
If you’re in Texas, in Austin or the Dripping Springs area, and are looking for a new primary care clinic give us a call @ (512) 489-9813
Are you ready to work with a provider who knows how to stay well (and can show you how too)?
Veronica Max, Founder & Primary Care Practitioner with a patient.