Readers have asked me to keep letting them know about these cases, so here it is:
A 62 year old woman in Switzerland, strict vegetarian, was found wandering the streets. Her delirium was determined to be vitamin B12 deficiency. She was treated with 1,000 µg injections weekly and within 4 weeks she had regained a stable mental status and returned to full-time work. (1)
It turns out that she had suffered from B12 deficiency on a number of previous occasions but without the neuropsychiatric symptoms. I hope she will start taking B12 and not rely on being found wandering the streets which might not end so well the next time.
I added one symptom, skin hyperpigmentation which is the darkening of the skin accompanied by even darker spots (1). The study is free to the public and you can see pictures (click here).
Interestingly, the discussion part of the paper points out that B12 deficiency interferes with the production of choline and choline-containing phospholipids. Perhaps this is why, or partially why, some vegans crave eggs (see To Quit or Not to Quit Veganism: Part Two), which are high in choline.
1. Cherqaoui R, Husain M, Madduri S, Okolie P, Nunlee-Bland G, Williams J. A reversible cause of skin hyperpigmentation and postural hypotension. Case Rep Hematol. 2013;2013:680459. doi: 10.1155/2013/680459. Epub 2013 Jun 11. | link
Another case of vitamin B12 deficiency in a vegan has been reported in the scientific literature. In this case, it was a 44-year old woman from Turkey (1).
She had been vegan for only 9 months (the report didn’t describe her diet prior to that). She developed gradually worsening paresthesia and tingling of both hands and feet for 6 weeks with a B12 level of 135 pg/ml (normal: 200 – 900) and a mean corpuscular volume of 110 fl (normal: 80-96 fl).
Intravenous B12 therapy was started at 1,000 µg/day for 2 weeks and once weekly thereafter. Complete clinical improvement occurred during two months and two months later there was a striking reduction of the MRI abnormalities.
I’m torn about continuing to blog about these cases because it seems almost gratuitous and I don’t want to bring people down.
• It reminds vegan to take their vitamin B12, and each time I publish one of these, some vegans who hadn’t heard this message might hear it for the first time.
• On VeganHealth.org, I tell people to subscribe to my blog or Twitter feed for any changes I make to VeganHealth.org so people know they’re not missing the latest info. (Speaking of which, here is a link to all the non-infant and toddler cases, Individual Cases of Deficiency.)
• I don’t want it to appear like I’m hiding these stories.
• It could be unnecessarily annoying or depressing to read these.
In browsing over the recent years, they only come out about one every six months, so it isn’t that often, though sometimes it seems like it.
If you have a strong opinion about this, I’d be interested in knowing. You can tell me not to post your comment (within the comment – they are moderated).
Gürsoy AE, Kolukısa M, Babacan-Yıldız G, Celebi A. Subacute Combined Degeneration of the Spinal Cord due to Different Etiologies and Improvement of MRI Findings. Case Rep Neurol Med. 2013;2013:159649. doi: 10.1155/2013/159649. Epub 2013 Mar 27. | link
Because bacteria produce vitamin B12 and fermented foods are generally fermented using bacteria, there are many rumors regarding vitamin B12 being in fermented foods. To my knowledge, no vitamin B12-producing bacteria is required for any fermented food and, therefore, any fermented food that contains vitamin B12 does so via contamination. Because the human colon contains vitamin B12-producing bacteria, it is possible for B12-producing bacterial contamination to occur during food preparation, particularly in places that do not have high levels of cleanliness. To my knowledge, no fermented plant food in Western countries has been found to contain relevant amounts of vitamin B12 analogues.
[snip – nothing new, but click here if interested.]
A 2010 paper from Korea (1) showed that Korean centenarians (people who live to be 100 years old) who ate only small amounts of animal products had normal vitamin B12 levels. The researchers measured the B12 content of plant foods using a biological assay and found many of the fermented foods and seaweeds to contain vitamin B12 analogues, which they considered to be active. They determined that the centenarians were getting about 30% of their B12 from plant foods and that it was a physiologically important amount.
This could be the case, especially given that the subjects ate fermented foods at almost every meal, much of which is homemade kimchi that, according to the researchers, is fermented for at least 10 months.
While this study is very interesting, unless kimchi produced in western countries is reliably shown to lower MMA levels, it would not be wise to rely on it as a significant source of vitamin B12.
1. Kwak CS, Lee MS, Oh SI, Park SC. Discovery of novel sources of vitamin b(12) in traditional korean foods from nutritional surveys of centenarians. Curr Gerontol Geriatr Res. 2010;2010:374897. doi: 10.1155/2010/374897. Epub 2011 Mar 8. | link
I do not take this lightly. A 7-year-old vegan boy from San Diego was found to have vitamin B12 deficiency severe enough to cause neurological problems (1).
In the months before he was admitted, he would engage in obsessive–compulsive behavior, including lining up his toys, repetitive stair climbing, and difficulty concentrating. Eventually he developed a widened gait (i.e., he couldn’t walk normally) and was taken to the hospital. His vitamin B12 level was 109 pg/ml (normal range is above 250 pg/ml).
Luckily, the child made an almost full neurological recovery after two months of vitamin B12 treatment.
The boy was also somewhat malnourished and had previously had teeth extracted due to “poor dentition.”
So where is the progress?
The progress is in the sensitive write-up performed by the researchers who did not disparage the vegan diet for children or try to convince the parents to feed the child animal products. Rather, they pointed out some benefits of a vegan diet for children, while cautioning that it needs fortification with vitamin B12.
Let’s hope this child makes a 100% recovery in both his neurological development and his teeth.
1. Crawford JR, Say D. Vitamin B12 deficiency presenting as acute ataxia. BMJ Case Rep. 2013 Mar 26;2013. | link
They found what they thought was active vitamin B12 in the following mushrooms (per 100 g of dry weight):
2.9 – 3.9 µg in black trumpet (Craterellus cornucopioides)
1.3 – 2.1 µg in golden chanterelle (Cantharellus cibarius)
1.3 µg in parasol (Macrolepiota procera)
.3 – .4 µg in porcini (Boletus spp.)
.2 µg in oyster (Pleurotus ostreatus)
.1 µg in black morels (Morchella conica)
The authors noted that 100 g of dry weight was the equivalent of about 1 kg of fresh mushrooms. They said that a moderate intake of black trumpet or golden chanterelle “may contribute slightly to the prevention of severe B12 deficiency in vegetarians.” They did not know why the mushrooms contained B12 and also did not test the mushrooms in humans to determine their ability to lower methylmalonic acid (MMA) levels.
As always, I will add a word of caution that vegans should not rely on any plant food for vitamin B12 until a number of batches have consistently lowered MMA levels in humans.
As promised last week, here is a write-up of the 2009 studies associating poor bone health with low B12 status in vegetarians. This is an important reason for lacto-ovo vegetarians, as well as vegans, to make sure they are getting a reliable source of vitamin B12.
“A 2009 cross-sectional study from Slovakia compared lacto-ovo vegetarian women to omnivores. They found that the vegetarians’ higher homocysteine (16.5 vs. 12.5 µmol/l; 78% vs. 45% were elevated) and lower vitamin B12 levels (246 vs. 302 pmol/l; 47% vs. 28% were deficient) were associated with significantly lower bone mineral density in the femur (1). Participants were not allowed to have been taking vitamin or mineral supplements. The researchers did not measure calcium intake or vitamin D status.
“Another 2009 cross-sectional study of German omnivores, lacto-ovo vegetarians, and omnivores, and Indian lacto-ovo vegetarians and omnivores found higher markers of bone turnover associated with low vitamin B12 status (2). The findings were no worse for the lacto-ovo vegetarians than the vegans, indicating that poor bone health can start with just moderate B12 deficiency. None of the participants were taking B12, calcium, or vitamin D supplements.”
1. Krivosikova Z, Krajcovicova-Kudlackova M, Spustova V, Stefikova K, Valachovicova M, Blazicek P, Nemcova T. The association between high plasma homocysteine levels and lower bone mineral density in Slovak women: the impact of vegetarian diet. Eur J Nutr. 2009 Oct 7. | link
2. Herrmann W, Obeid R, Schorr H, Hübner U, Geisel J, Sand-Hill M, Ali N, Herrmann M. Enhanced bone metabolism in vegetarians–the role of vitamin B12 deficiency. Clin Chem Lab Med. 2009;47(11):1381-7. | link
[Breaking news: A paper was released today showing vegetarians to have a lower risk of heart disease – I will write about that next week. Update: Click here.]
It’s raining B12 this week!
Yet another paper was released on vegetarians and vitamin B12, this time reviewing all the studies that have measured B12 status using methylmalonic acid (MMA) or holo-transcobalamin II levels (1).
Holo-transcobalamin II is thought to be a better predictor of vitamin B12 deficiency than blood B12 levels because it is the last refuge of B12 being transported to cells, while MMA levels are the best way to know that the cells are not getting enough vitamin B12 to function normally.
The review included 18 studies, eight of which were done on German vegetarians. The authors did not combine results from the studies, but rather provided a handy chart to see what each study found.
They concluded that all vegetarians – not just vegans – are at a significant risk of B12 deficiency and recommend a B12 supplement of 250 µg per day.
This is higher than what I recommend on a daily basis, which is 25 to 100 µg. I do not think this review provides enough evidence to change my recommendations, but I would not discourage anyone from taking 250 µg per day.
The authors state:
“Supplements, when taken in an adequate dose, are very effective in both the prevention and treatment of B12 deficiency and are very cost effective. However, many vegetarians, for different reasons, refuse to take B12 supplements. This is largely due to various misconceptions, including the belief that it takes many years for B12 deficiency to develop.”
The authors also noted a connection between low vitamin B12 status in vegetarians and low bone mineral density, citing a paper from 2009. Upon reading this, I thought “Ha, I remember that paper,” only to find out that the study I had written about in Bones, Vitamin D, and Calcium, was a different one from 2009! (2) The paper they cited (3) had flown under my radar, but never fear, I intend to review it for an upcoming post.
1. Pawlak R, Parrott SJ, Raj S, Cullum-Dugan D, Lucus D. How prevalent is vitamin B(12) deficiency among vegetarians? Nutr Rev. 2013 Feb;71(2):110-7. Epub 2013 Jan 2. | link
2. Krivosikova Z, Krajcovicova-Kudlackova M, Spustova V, Stefikova K, Valachovicova M, Blazicek P, Nemcova T. The association between high plasma homocysteine levels and lower bone mineral density in Slovak women: the impact of vegetarian diet. Eur J Nutr. 2009 Oct 7. | link
3. Herrmann W, Obeid R, Schorr H, Hübner U, Geisel J, Sand-Hill M, Ali N, Herrmann M. Enhanced bone metabolism in vegetarians–the role of vitamin B12 deficiency. Clin Chem Lab Med. 2009;47(11):1381-7 (Abstract only) | link
A study was just released out of the UK that measured the response of various markers of cyanocobalamin supplements in adults 65 years and older (1).
The study was a double-blinded, placebo-controlled study on 100 people with evidence of poor vitamin B-12 status. It used daily supplements in the amount of 10, 100, and 500 µg/day of cyanocobalamin for 8 weeks. The main marker of interest was urinary methylmalonic acid (uMMA) levels.
They found that 500 µg/day made a significant improvement in uMMA levels and most of that improvement was made in the first 2 weeks.
This result is in contrast to what the authors of the recent homocysteine meta-analysis said about cyanocobalamin taking 4 to 9 weeks to be converted to methylcobalamin. But, it should be noted, that the adenosylcobalamin co-enzyme form of vitamin B12 is required to reduce uMMA levels, not methylcobalamin. Methylcobalamin is required to reduce homocysteine levels and the 100 and 500 µg/day regimen also lowered homocysteine levels over the course of 8 weeks, though they did not say how long it took for the change to take place.
In a number of measurements, the ex-smokers improved more than the never-smokers. This is surprising because it would seem reasonable that, if there were any difference, ex-smokers would have more of a problem metabolizing cyanocobalamin than non-smokers.
Only 75-85% of the participants fully corrected their metabolic deficiency with 500 µg per day. It’s possible these people’s metabolic deficiency stemmed from a problem not related to vitamin B12.
The takeaway messages:
1. Even in people 65 years and older, cyanocobalamin worked in only two weeks time.
2. It might be a good idea to increase B12 recommendations for people 65 and older to 500 µg per day, rather than the 25 to 100 µg per day that I recommend for all adults.
3. Cyanocobalamin was effective even for ex-smokers. There were not enough current smokers in the study to determine the effectiveness for them.
1. Hill MH, Flatley JE, Barker ME, Garner CM, Manning NJ, Olpin SE, Moat SJ, Russell J, Powers HJ. A Vitamin B-12 Supplement of 500 μg/d for Eight Weeks Does Not Normalize Urinary Methylmalonic Acid or Other Biomarkers of Vitamin B-12 Status in Elderly People with Moderately Poor Vitamin B-12 Status. J Nutr. 2013 Feb;143(2):142-7. doi: 10.3945/jn.112.169193. Epub 2012 Dec 12. | link
Isn’t it great to be living in a time where there have been so many studies on homocysteine levels of vegans that someone can do a meta-analysis? We have officially arrived.
This past week, such a study was released by a team from the University of West London, School of Psychology, Social Work and Human Sciences. I have tracked most of this research, so their findings that vegans have higher homocysteine levels due to low B12 status came as no surprise. They included results from six cohort and eleven cross-sectional studies.
Ideally, you want your homocysteine levels below 10 µmol/l, with above 15 µmol/l being strongly associated with increased chronic disease (cardiovascular disease and early death).
The average homocysteine levels in the studies were (µmol/l):
However, there were a couple things that the authors concluded that did raise my eyebrows.
They expressed skepticism that fortified foods can prevent elevated homocysteine levels in vegans, due to the fact that fortified foods contain cyanocobalamin, rather than methylcobalamin. The authors said that it takes four to nine weeks for cyanocobalamin to be converted into methylcobalamin, the form needed to lower homocysteine.
Readers of my blog probably know that only in rare circumstances do I think it’s necessary to supplement with methylcobalamin rather than cyanocobalamin. I will address these author’s concerns in an upcoming post.
In discussing the one study that showed vegans to have healthy homocysteine levels, the authors say:
“The study by Haddad et al. concluded that, statistically, vegans had similar plasma tHcy to omnivores (i.e. 8·0 against 7·9 mmol/l, respectively) and serum vitamin B12 levels (i.e. 313 against 312 pmol/l, respectively). In this case, it was noted that 36 % of the participating vegans were users of vitamin B12 supplements, although the type, dosage and frequency of usage were not reported.”
However, Haddad et al. did give the average amount of vitamin B12 intake for the vegans and it was 6.0 µg for the vegan women and 5.0 µg for the vegan men (2). And the possibility that any of it wasn’t cyanocobalamin is low.
Stay tuned for more on the cyano wars…
1. Obersby D, Chappell DC, Dunnett A, Tsiami AA. Plasma total homocysteine status of vegetarians compared with omnivores: a systematic review and meta-analysis. Br J Nutr. 2013 Jan 8:1-10. [Epub ahead of print] | link
2. Haddad EH, Berk LS, Kettering JD, Hubbard RW, Peters WR. Dietary intake and biochemical, hematologic, and immune status of vegans compared with nonvegetarians. Am J Clin Nutr. 1999;70(suppl):586S-93S. | link