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.

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Reference

1. Crawford JR, Say D. Vitamin B12 deficiency presenting as acute ataxia. BMJ Case Rep. 2013 Mar 26;2013. | link

A 2012 study from the Watanabe group (1) was released today on PubMed. I have added the following to B12 in Tempeh, Seaweeds, Organic Produce, and Other Plant Foods.

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.

Support JackNorrisRd.com

I greatly appreciate direct donations – you can enter any amount:

If button doesn’t work, please click through to website. Thank you!

If you buy anything from Pangea through this link, you not only support me, but also the good people at Pangea who painstakingly research their products to minimize any impact on animals, the earth, and workers.

Amazon.com Gift Cards – E-mail Delivery

Vegan for Life: Everything You Need to Know to Be Healthy and Fit on a Plant-Based Diet from Amazon.com

Reference

1. Watanabe F, Schwarz J, Takenaka S, Miyamoto E, Ohishi N, Nelle E, Hochstrasser R, Yabuta Y. Characterization of Vitamin B(12) Compounds in the Wild Edible Mushrooms Black Trumpet (Craterellus cornucopioides) and Golden Chanterelle (Cantharellus cibarius). J Nutr Sci Vitaminol (Tokyo). 2012;58(6):438-441. | Link

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.

VeganHealth.org’s Bones, Vitamin D, and Calcium updated:

“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.”

References

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.

References

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.

Reference

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):

omnivore – 11.0
lacto-ovo vegetarian – 13.9
vegan – 16.4

Average vitamin B12 levels were (pmol/l):

omnivore – 303
lacto-ovo vegetarian – 209
vegan – 172

This was no surprise as most of the vegans in these studies were not taking vitamin B12 supplements or eating fortified foods, B12 being an important part of keeping homocysteine levels in check (see Mild B12 Deficiency – Cardiovascular Disease & Homocysteine for more information).

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…

References

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

Question:

What B12 Supplement Should I Take?

Answer:

I get this question all the time, so I finally decided to write up a blog post to point people to.

Cyanocobalamin

Cyanocobalamin is the most common form of B12 supplement and is the form found in fortified foods. It doesn’t occur much in nature, but it is the most stable form of vitamin B12, and the cheapest. It has been the most studied form and has consistently been shown to be effective. Unless there are extenuating circumstances, I recommend that people take cyanocobalamin as their B12 supplement.

Cyanocobalamin contains a molecule of cyanide, but the amount of cyanide in cyanocobalamin supplements is so small as to be physiologically insignificant (more info).

Some people have cyanide metabolism defects, and they should not take cyanocobalamin. If you are asking yourself right now if you might be one of those people, you can assume the chances are close to zero.

People with cyanide poisoning should not take cyanocobalamin. If you have not previously suspected that you might have cyanide poisoning, then you can assume you don’t have it.

People with chronic kidney problems should probably take a non-cyanocobalamin form of B12 (more info).

Finally, cigarette smokers might want to take a non-cyanocobalamin form of vitamin B12 as they can build up cyanide in their system. This is theoretical – I have never come across a vegan cigarette smoker who reported vitamin B12 deficiency based on taking cyanocobalamin and the Institute of Medicine has concluded that “The effect of smoking on the B12 requirement thus appears to be negligible (1).” (More info.)

Methylcobalamin & Adenosylcobalamin

Methylcobalamin is one of the two co-enzyme forms of vitamin B12, the other being adenosylcobalamin (known by many other names, including “dibencozide”). When I first got into the B12 issue, dibencozide was all the rage, now it’s methylcobalamin for some reason. The two forms have different functions in the body and both are necessary (more info).

Methylcobalamin is promoted by some alternative health practitioners and the supplement industry as superior to cyanocobalamin, primarily because it is a co-enzyme form of vitamin B12.

Based on many studies and case reports in the scientific literature in which cyanocobalamin has successfully cured vitamin B12 deficiency, it appears that the body can convert cyanocobalamin into methylcobalamin without any problem. The body also has to convert methylcobalamin or cyanocobalamin into adenosylcobalamin for B12 to carry out all of its functions. (A fourth form of vitamin B12, hydroxocobalamin, is the form typically found in animal products and B12 injections; it must also be converted into the co-enzyme forms.)

But is there any harm in taking methylcobalamin over cyanocobalamin? Probably not, but methylcobalamin is thought not to be as stable as cyanocobalamin and therefore higher doses are recommended, a minimum of 1,000 µg per day. Recommendations for cyanocobalamin are much lower (more info).

Some people with chronic fatigue report getting more relief from adenosylcobalamin than either methylcobalamin or cyanocobalamin (more info), while other people report feeling better only when taking both co-enzyme forms (adenosyl- and methyl-).

Cyanocobalamin supplements are ubiquitous, cheap, and well-studied, while methyl and adenosyl are much more of an unknown entity. Unless you have a good reason to be using them, I recommend cyanocobalamin.

Living Food Vitamin B12

Some companies claim to have a natural, living, plant, or raw source of vitamin B12. The B12 can come from seaweed or other unstated sources. Unless a label lists the source of vitamin B12 as cyanocobalamin, methylcobalamin, adenosylcobalamin, or hydroxocobalamin, I would not rely on it.

Specific Brands of Vitamin B12

I do not have recommendations regarding any specific brands of vitamin B12 supplements. As far as cyanocobalamin goes, I assume all sublingual or chewable tablets to be effective. I do not have an opinion on B12 skin patches or sprays.

As far as methylcobalamin supplements, as I stated above, I’m not as confident about them, and I have no opinion on any specific brand name.

Are B12 Supplements Vegan?

Yes. (More info.)

References

1. Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 2000.

Have had two questions in the last two days from people asking whether they can get vitamin B12 from cooked fortified foods. To answer them, I updated Vitamin B12: Are You Getting It – Vegan Sources:

Tucker et al. (2000, USA, 13) found that vitamin B12 from fortified breakfast cereals and dairy products was associated with better vitamin B12 status than was B12 intake from red meat, poultry, and fish, leading the researchers to suspect that the B12 from meat might be damaged by cooking. The B12 in animal foods tends not to be cyanocobalamin, the form used in fortified foods and that is more stable during cooking. For example, in an acid medium (pH 4-7), cyanocobalamin can withstand boiling at 120° C (1).

Even so, for people wondering whether they are destroying the B12 in their fortified foods by cooking, we do not have enough evidence to know for certain, so it is safest to make sure you rely on uncooked sources of vitamin B12.

1. Personal communication, March 6-7, 2002 with Dr. Fumio Watanabe, Kochi Women’s University, Department of Health Science, 5-15 Eikokuji-cho Kochi 780-8515 Japan.

13. Tucker KL, Rich S, Rosenberg I, Jacques P, Dallal G, Wilson PW, Selhub J.
Plasma vitamin B-12 concentrations relate to intake source in the Framingham
Offspring study. Am J Clin Nutr. 2000 Feb;71(2):514-22. | link

A vitamin B12 toothpaste in Germany, developed in conjunction with the German Vegetarian Society, successfully improved vitamin B12 status (link: B12 toothpaste makes vegans smile).

Since people brush their teeth two times or more per day (one would hope), toothpaste can be a good way to get B12 multiple times a day. And because vitamin B12 is much better absorbed in multiple doses throughout the day, toothpaste could enhance absorption over eating B12 only once per day (or less). I am somewhat surprised that enough B12 is swallowed from toothpaste to make it a reliable source, but assuming their data was accurate, it appears plenty is absorbed.

Maybe it will come to the U.S. soon…

Thanks, Chris!

I just updated Mild B12 Deficiency – Cardiovascular Disease & Homocysteine with the following from a study that just came out:

A 2012 randomized, placebo-controlled, crossover clinical trial tested B12 supplementation’s effects on flow-mediated dilation (FMD) of the brachial artery and intima-media thickness (IMT) of the carotid artery, both of which are markers of cardiovascular disease (1). The study was done in Hong Kong and there were 50 vegetarians, two of whom were vegan. Twelve subjects (24%) had serum vitamin B-12 between 203-406 pg/ml and 35 subjects (70%) < 203 pg/ml. After 12-week periods of 500 µg of B12 per day, average homocysteine levels went from 16.7 to 11.3 µmol/l. Brachial artery FMD significantly increased and carotid IMT significantly decreased, both of which improves cardiovascular function, after vitamin B12 but not after placebo treatment. These positive effects appeared to be better correlated with the correction of vitamin B12 deficiency than with the lowering of homocysteine. The authors noted that the effects “on carotid intima-media thickness was quite subtle and of uncertain biological significance.”

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Check out Plant-Based on a Budget for inexpensive yet tasty vegan recipes!

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I was surprised that with 500 µg B12 per day, homocysteine levels did not decrease even further, especially since these participants were shown to have good folate status. The study contained no control group of non-vegetarians, so it’s not clear if the same results would be found for non-vegetarians, though rarely do non-vegetarians have an average homocysteine level as high as 16.7 µmol/l.

In any case, this appears to be the first direct evidence on cardiovascular function to show that mild vitamin B12 deficiency could have a negative effect.

None of the participants experienced side effects, including skin reactions, while on the B12 supplementation regimen.

Reference

1. Kwok T, Chook P, Qiao M, Tam L, Poon YK, Ahuja AT, Woo J, Celermajer DS, Woo KS. Vitamin B-12 supplementation improves arterial function in vegetarians with subnormal vitamin B-12 status. J Nutr Health Aging. 2012;16(6):569-73. | link