Could A Lack Of Vitamin B12 Be The Hidden Cause Of Your Health Problems?

A B12 deficiency can cause brain shrinkage, dementia, multiple sclerosis and developmental delays in children, says Sally Pacholok, author of "Could It Be B12?"

Sally M. Pacholok, R.N. and Jeffrey J. Stuart DO, authors of "Could It Be B12?: An Epidemic of Misdiagnoses" explain that a B12 deficiency can cause dementia, autism, depression and multiple sclerosis, "In the U.S., the medical community would rather place elderly patients on dementia drugs (i.e. Aricept, Namenda), than investigate possible underlying B12 deficiency."

Commitmentnow.com: What are some tell-tale signs that a person may not be getting enough B12?

Sally M. Pacholok, R.N., B.S.N.: B12 is one of the 13 vitamins that our body needs for health and life.  Playing an active role in methylation, vitamin B12 serves as a coenzyme for many processes, such as deoxyribonucleic acid (DNA) synthesis, fatty acid metabolism, and transmethylation of amino acids.  Vitamin B12 is essential for the production of neurotransmitters and phospholipids needed for normal brain function.  

It is critical for the production and maintenance of myelin in our nervous system.  Myelin is the fatty protective coating that surrounds our entire nervous system and makes up the white matter of our brain. If our myelin breaks down, the electrical impulses sent by our neurons can go haywire and become damaged.

Overtime, B12 deficiency wreaks havoc on the central and peripheral nervous systems, leading to paresthesia, weakness, tremor, difficulty with coordination and balance, dizziness, mood disorders, and dementia.  Damage to nerves of the eye can cause optic neuritis and atrophy, leading to visual disturbances or blindness.  A deficiency of this essential vitamin impairs and injures the nervous system, causing wide-ranging neurologic and psychiatric dysfunction, including spinal cord degeneration, peripheral neuropathy, spinal cord and brain demyelination, cognitive changes, and altered mental status.

Vitamin B12 is also is needed for the production of red blood cells and for a healthy immune system.  B12 deficiency can cause severe anemia and overtime if not identified patients will become so anemic that they may require blood transfusions. Because B12 deficiency is critical for our blood, a deficiency leads to fatigue, generalized weakness, and shortness of breath. 

Table 1:

Neurologic Signs & Symptoms            Psychiatric Signs & Symptoms
•    Paresthesias (numbness/tingling)   Depression            
•    Weakness of legs, arms, trunk        Irritability            
•    Unsteady or abnormal gait             Paranoia                
•    Balance problems                          Mania                
•    Difficulty walking                           Hallucinations        
•    Dizziness                                      Psychosis
•    Tremor                                         Violent behavior
•    Restless legs                                 Personality changes
•    Frequent falls                
•    Visual disturbances                Other Signs & Symptoms
•    Forgetfulness, memory loss        Anemia
•    Dementia                                 Fatigue
•    Impotence                               Generalized weakness
•    Incontinence                             Shortness of breath
                                                     Pallor

Commitmentnow.com:. Could the lack of B12 be at the root of Alzheimer's and other age-related problems? If so, what can be done about it? 

Sally: Yes.  It has been well-documented in medical textbooks and medical journals for over a century that B12 deficiency causes cognitive problems, foggy thinking, confusion, irritability, forgetfulness, depression, and personality changes.

For decades it has been shown that B12 deficiency causes brain atrophy (shrinkage) on brain CT and brain MRI scans in children.  The same is true for adults.  Many articles have been published in which severely B12 deficient adults had brain CT or MRI done which showed brain atrophy.  

In the U.S., the medical community would rather place elderly patients on dementia drugs (i.e. Aricept, Namenda), than investigate possible underlying B12 deficiency.  All patients presenting with dementia symptoms should always have B12 deficiency ruled out.  Patients who are found to be B12 deficient as well as those who fall in the gray zone (serum B12 200-450pg/ml) who are symptomatic will need aggressive treatment with hydroxocobalamin injections.

For general and cognitive health, prevention of anemia and fall-related trauma we recommend all older adults having a serum B12 greater than 1,000 pg/ml.  We describe this in detail in our book. 

Some patients may use a combination of high-dose sublingual B12 tablets or lozenges for therapy with injections.  Clinical exam and response will dictate the therapy chosen.  

Remember, the patient must always be tested first before B12 therapy is started (this includes patients or family starting B12 pills on their own). The patient as well as the patient’s doctor needs to know if B12 deficiency was the cause of the person’s signs and symptoms.  We cannot stress this enough.  You can’t start B12 therapy, and then take it away and test the person.  People are making the mistake of self treating with B12 and then wanting to know if B12 deficiency is the cause.  It is critical to know if B12 deficiency is the cause for a variety of reasons (i.e. proper diagnosis, proper treatment).

In 2008, the medical journal Neurology reported that low B12 causes brain atrophy (shrinkage) and is linked to cognitive impairment in the elderly.  There is a critical window of opportunity to treat B12 deficiency or permanent cognitive and nerve injury will result. This is why we need to be proactive about B12 deficiency education, screening, and treatment.  We also explain in our book why new guidelines and parameters are needed to change what is considered a “normal” serum B12 level.  Older adults need to be on high-dose B12 preventatively to prevent cognitive changes. 

What can be done?  We believe the following must be done regarding B12 deficiency—Education, prevention, advocacy, action and responsibility. We started B12 Awareness in 2009, and designated the month of September as B12 Awareness Month.  We believe the U.S. needs to pass legislation that recognizes September as B12 Awareness Month annually.  This way we can continue to educate the medical community and the public more effectively about the dangers of B12 deficiency.
Older adults are at greater risk for misdiagnosed vitamin B12 deficiency because they seek treatment for symptoms that could be caused by a deficiency of vitamin B12 or by another disorder that mimics B12 deficiency. 

The health care provider must consider vitamin B12 deficiency in the differential diagnosis and rule it out before making a diagnosis.  B12 deficiency symptoms are commonly blamed on preexisting medical problems and comorbid conditions.  For example, if a patient complains of numbness and tingling to their hands or feet, their physician may blame this on diabetes. 

Elderly people who fall because of dizziness, balance or gait disorders, or weakness, may have their physician blame old age and never investigate B12 deficiency as the culprit.  Elderly patients who are depressed, get put on antidepressants because their physician thinks they are because they are lonely or widowed, because the patient may complain of depression or the patient shows clinical signs and symptoms of depression.  
But is a gross error not to check older adults for B12 deficiency because it may be the actual cause of the person’s depression.  B12 will therefore be the proper treatment and prevent further poor health and mental decline.  If B12 deficiency is not identified and treated early, the patient risks further cognitive decline, fall-related trauma and permanent nerve damage. The damage caused by B12 deficiency is very slow and progressive.  It doesn’t happen over just a couple of months, but steadily over a year or two.  If left untreated, it leads to severe injury, disability, poor outcomes, and premature death.
 
Because the signs and symptoms of B12 deficiency are common for many disorders in the elderly, B12 deficiency must always be ruled out.  Falls are the leading cause of death in patients aged 65 and older, yet in the U.S. we do not rule out B12 deficiency in patients who present with falls.  We have found many elderly patients presenting to the emergency department from a fall causing major injury (femur, hip fracture) who have had a B12 deficiency which caused or contributed to the fall.  This poor practice must cease and a new standard of care must be implemented for the health and safety of senior citizens. 

Malabsorption of B12 is more common in those over 60 because about 30% of people in this age-group have atrophic gastritis, an inflammation and wasting of the stomach lining.  This condition drastically decreases production of gastric acid, which is needed to free vitamin B12 from animal proteins in food so it can be absorbed.  Older adults are also at higher risk for vitamin B12 deficiency if they use metformin (Glucophage), colchicine, alcohol, or potassium chloride or take medications that decrease gastric acid production, such as proton-pump inhibitors (omeprazole [Prilosec], Nexium, Prevacid), histamine blockers (Zantac), and antacids.  
    
Commitmetnow.com: What are some ways to include more B12 in one's diet?
 
Sally: Vitamin B12 is only found in animal products.  It is not present in fruits, vegetables or grains.  It is found in organ-meats, beef, poultry, and shellfish.  High sources are in liver, clams, and oysters.  It is also present in dairy products (milk, cheese, eggs).  However, don’t think you can avoid B12 deficiency by simply increasing your dietary B12 intake. The number one reason people are deficient is because they have a malabsorption problem.  Therefore, you could be eating all the foods listed above and still have a B12 deficiency. This is why testing and clinical exam are critical. 

Another group of people that are at risk for B12 deficiency are vegans and vegetarians, because the foods they consume are low or absent in B12.  They may have no malabsorption problems, but can run into trouble over time.  There are stores of vitamin B12 in the body from birth, but over an extended period, these stores become depleted, and can become depleted quicker from a variety of reasons (medications, nitrous oxide, autoimmune disease, gastrointestinal disease [i.e. Crohn’s disease, gluten enteropathy—celiac disease], gastrointestinal surgery [i.e. gastric bypass], alcohol, eating disorders, etc.).  

A particular area in which we are seeing a problem is in vegan and vegetarian mothers who breast feed.  Many mothers do not have enough B12 in their breast milk, which can place an infant at great risk for B12 deficiency.  This is why obstetricians should be screening all pregnant patients and educating them about B12 deficiency during pre-conception, pregnancy, and the post-partum periods.  This currently is not the standard of care.  We also believe that the current amount of B12 in prenatal vitamins is extremely low.  We question if the rate of autism has been steadily rising because of misdiagnosed B12 deficiency and poor governmental requirements for B12 in pregnancy and breast-feeding.  This is also made worse because the medical community is using out-dated “normal” B12 parameters.  Research into this is sorely needed.

Commitmentnow.com: Tell us about the link between multiple sclerosis and B12?

Sally: The signs and symptoms of MS and vitamin B12 deficiency are identical.  Prolonged untreated B12 deficiency can cause demyelination of the spinal cord and brain.  In medical text books, both vitamin B12 deficiency and multiple sclerosis are classified as demyelinating diseases.  B12 deficiency should never get to the stage of injury or demyelination, because unlike MS, B12 deficiency can be successfully treated (if diagnosed and treated early).  Late diagnosed or misdiagnosed B12 deficiency can cause permanent neurologic injury and disability. 

Because B12 deficiency and MS are both demyelinating diseases, and injure the myelin, they both share the same signs and symptoms.  Therefore, it makes sense that every patient that presents with these same neurologic symptoms should have B12 deficiency ruled out, especially because B12 deficiency has a definite cure if diagnosed and treated early.
We need to start treating patients whose serum B12 falls in the gray zone (200--450 pg/ml). This is because many patients in the gray zone are symptomatic and have a B12 deficiency.  Our current guidelines for B12 deficiency (<200 pg/ml) is out of date.  Physicians should not wait for the serum B12 to  go below  200 pg/ml when the patient is clinically symptomatic.    Allowing the B12 deficiency to progress under 200 pg/ml is poor practice.  The earlier the intervention and treatment, the better the outcome. 

Commitmentnow.com: Can a lack of B12 cause mental illness? What does your research reveal?

Sally: Yes.  Vitamin B12 is needed for the white matter of the brain and assists our brains neurotransmitters.  It has been documented in medical texts and thousands of respected published scientific medical articles (for over a century) that B12 deficiency causes an array of psychiatric manifestations.  Vitamin B12 deficiency was first named pernicious anemia, which caused apathy, memory loss, psychosis, and even dementia in patients.  It was named “pernicious” anemia, because before the discovery of vitamin B12, death was inevitable. 

Well over 50% of the patients we diagnose with B12 deficiency presenting to the emergency department are on anti-depressants.   What does this tell us?  That they have a physician who did not rule out B12 deficiency but didn’t hesitate to write a prescription for an anti-depressant. Therefore, they were symptomatic—and their health care provider missed the medical cause (B12 deficiency) of their symptoms. B12 deficiency causes psychiatric signs and symptoms that can include depression, irritability, paranoia, hallucinations, psychosis, violent behavior, forgetfulness, foggy-thinking and even postpartum depression.

Commitmentnow.com: What type of developmental delays and learning disabilities are caused by a lack of B12? What amounts do you feel children need to get past these delays and disabilities?

Sally: It is well known that vitamin B12 deficiency causes developmental delay and brain atrophy in infants and children.  This has been reported in medical journals and texts since the 1960’s.  The medical community (pediatricians, neurologists) is not routinely checking children who present with the first concern of developmental delay for B12 deficiency which is problematic and a clinical error.   

Vitamin B12 deficiency in infants and young children may produce the following neurologic and hematologic signs:
 
1.    developmental delay            
2.    developmental regression    
3.    poor socialization
4.    poor motor skills
5.    language delay
6.    speech problems
7.    lower IQ
8.    mental retardation
9.    irritability                
10.    weakness                
11.    hypotonia                
12.    ataxia                     
13.    apathy                    
14.    tremor    
15.    myoclonus of the head, limbs, and tongue                       16.    involuntary movements
17.    seizures
18.    anorexia
19.    failure to thrive
20.    poor weight gain
21.    poor head growth (microcephaly)    
22.    anemia (may be present but is not a requirement)
23.    pancytopenia
24.    macrocytosis (may be present but is not a requirement—and may be masked due to folic acid     supplementation or coexisting iron deficiency)
25.    abnormal brain MRI or CT:  cerebral brain atrophy, enlarged ventricles

All children with developmental delay or suspected autism must be screened for B12 deficiency before starting any B12 treatment.  Parents are making the mistake of self treating with B12 and then wanting to know if B12 deficiency is the cause.  It is critical to know if B12 deficiency is the cause for a variety of reasons.  We cannot stress this enough.  You can’t start B12 therapy, and then take it away and test the child.  Furthermore, if health care providers tell you to start B12 therapy, always insist on testing first. Infants and children need a serum B12 and a urinary methylmalonic acid test. 

Documentation of a B12 deficiency is critical and test results along with clinical exam will dictate B12 therapy.  In addition, the child’s physician should investigate the underlying cause if B12 deficiency is found.

Commitmentnow.com: What is the connection between B12 and autism? What advice do you have for parents of autistic children who want to address the B12 connection?

Sally: This is explained above in the last question.  We have coined the following term and believe that B12 Deficiency Acquired Brain Injury (BABI) is an unrecognized epidemic of the 21st century that deserves serious research and attention.
We encourage physicians treating developmentally delayed children to remember the ABCs –an acronym standing for the Autism B12 Connection.  Cobalamin (vitamin B12) deficiency is an easily treated disease that often goes undiagnosed in infants and young children, placing them at high risk for permanent brain injury. It is well documented that B12 deficiency causes developmental delay, hypotonia, failure to thrive, reduced IQ, and mental retardation.

Children with B12 deficiency exhibit speech, language, and social delays, as well as problems with fine and gross motor movement. Magnetic resonance imaging (MRI) scans reveal brain atrophy and structural abnormalities, which often times reverse after B12 therapy.

However, if the deficiency is diagnosed late, permanent impairment of intellectual functioning typically occurs even after treatment, and cognitive and language development often remain seriously retarded. 

The signs and symptoms of pediatric B12 deficiency frequently mimic those of autism spectrum disorders (ASDs). However, very few children presenting with autistic symptoms receive adequate testing for B12 deficiency.  While the medical literature is replete with cases of developmental disability and mental retardation stemming from B12 deficiency, we do not know how many children diagnosed on the autism spectrum actually have an undiagnosed cobalamin deficiency.

It is imperative that health care professionals screen at-risk and symptomatic children to prevent misdiagnosis, permanent brain injury, and life-long disability.  If health care providers would become educated and document the incidence of BABI, we could improve the health of our children worldwide.
     
Commitmentnow.com: What surprised you most about B12 as you began to do your research?

Sally: That this well-known medical disorder that won the Nobel Prize in Medicine in 1934, has been forgotten.

Physicians are not including ruling out B12 deficiency in their diagnostic work-ups, they are not screening patients who are at risk, they are not screening patients with beginning, moderate, or advanced symptoms, instead, patients are being misdiagnosed and prescribed the wrong medications.  Most shocking, however, was the attitude of the physicians when trying to educate or reeducate them about vitamin B12 deficiency.  They are uninterested, apathetic, irritated, egotistical, and resentful that perhaps they could be missing something.  They also fear liability (medical malpractice).   I am not creating a new disorder or reinventing the wheel.

Cobalamin (vitamin B12) deficiency is well established in medicine and physiology, and the outcomes of late diagnosis is well described in the medical literature. B12 deficiency is common and reported to affect 25% of the U.S. population.1  It strikes up to 15% (5.9 million) older adults greater that age 64.2  In 2009, the CDC reported one out of every 31 Americans greater than age 50 have a B12 deficiency. 

However, the CDC report underestimates the incidence by using a serum B12 cut-off range far too low (B12 < 200pg/ml) and not including patients in the gray zone.  The incidence in infants and young children is unknown, which is problematic.  
So how did we get so far off track?  Is it acceptable to allow this kind of practice to continue?  Of course not.   In no way am I stating that everyone has B12 deficiency.  Many patients, do however, and those patients who are symptomatic and at-risk deserve testing. 

Just as we screen for diabetes, elevated cholesterol, and thyroid disorders in symptomatic and at-risk patients—screening and treating B12 deficiency must return to practice.  Billions of health care dollars and millions of lives are at stake.  We need to promote early diagnosis and treatment to prevent neurologic injury, disability, poor outcomes, and premature death.  B12 deficiency also affects overall health, and causes cognitive decline and fall-related trauma.  I am shocked that the health care community (medical, nursing) has not opened their arms and embraced this disorder, thereby promoting public health.

I have reached out to governmental leaders and am equally shocked that they do not want to get involved to promote health and prevent injury in their constituents to save billions of health-care dollars. 

It is one thing for people to suffer from an incurable disorder.  It is quite another when a disorder has a cure (vitamin B12 deficiency) and we refuse to treat it—it is unacceptable and it is negligence. To add insult to injury, B12 deficiency is very cheap to treat, unlike other disorders.  However, if diagnosed in the late stages, B12 deficiency injury costs the patient, insurance company, government, and society enormous amounts of money.  Undiagnosed and misdiagnosed B12 deficiency is currently healthcare’s dirtiest little secret going on behind closed doors. 

Health care institutions are getting away with it because of ignorance, apathy, and a severe knowledge deficit.  We the public, as health care consumers, must band together and demand B12 screening and proper treatment.  Who will it take to become injured for this poor practice to change?  I have been fighting this battle for over 20 years.   I am hopeful that in 2012 B12 deficiency will be the Surgeon General’s newest “Call for Action.”

Visit www.B12Awareness.org

About the Authors: Sally M. Pacholok, R.N., BSN, an emergency room nurse with over 24 years of experience, received her bachelor’s degree in nursing from Wayne State University. In 1985, Pacholok diagnosed herself with vitamin B12 deficiency, after her doctors had failed to identify her condition.

Jeffrey J. Stuart, D.O., a physician who has practiced emergency medicine for 18 years, is board certified in Emergency Medicine. Stuart received his Doctor of Osteopathy degree from the Chicago College of Osteopathic Medicine.


Footnotes:

1.  Dharmarajan, T.S., Norkus, E.P.   Approaches to vitamin B12 deficiency:  Early treatment may prevent      devastating complications.  Post-graduate Medicine 2001;110(1): 99-105.

2.  Stabler, et al.  Vitamin B12 deficiency in the elderly: Current dilemmas.  American Journal Clinical Nutrition, 1997;66:741-9.Commitmentnow.com: What are some tell-tale signs that a person may not be getting enough B12?