Episode #12 So What's the Big Deal About Vitamin B-12?
So in the last podcast we talked about a plant-based diet and how to start that conversation and how to implement the plant based diet to achieve benefits. One of the commonly seen nutritional deficiencies in a plant-based diet is vitamin B 12 deficiency. Vitamin B-12 deficiency however, is not just common in those living in a plant-based diet.
Another cause of Vitamin B12 deficiency includes poor absorption.
Vitamin B 12 absorption is often impaired by some of the most commonly prescribed prescription medications such as Metformin, beta blockers and proton pump inhibitors. These medications can decrease the absorption of vitamin B 12, by blocking or even eliminating a protein called the intrinsic factor. The intrinsic factor is required to absorb vitamin B 12. Other medications that can block the absorption of vitamin B 12 include some of the older antiepileptics, including phenytoin, Depakote, colchicine, antibiotics and anti-inflammatories. Do you happen to prescribe any of these medications? This just adds to the fact that pharmaceuticals should be used judiciously and not used to treat side effects of medications or just because the patient insists upon having some type of medication.
So what’s the big deal? Why do we care about B12 so much? Well, because B12 is vital to neurological function and red blood cell production. I think that the nervous system and blood production are pretty important. The nervous system controls sensation, perception, energy, mood, cognition and most everything else in our body. As for the red blood cell production, we know that red blood cells carry oxygen. Without proper oxygenation, we will suffer from poor endurance, fatigue and myalgias.
When one of the most common complaints of primary care, in addition to many specialty practices is fatigue, and vitamin B 12 is a common contributor to fatigue, you should be checking Vitamin B12 in your patients.
I became fascinated with the impact of vitamin B 12 deficiency on patients during my time working as a provider in a neurology practice. We had patients referred for stroke like symptoms, neuropathy and even fatigue. The common denominator in many of these patients was a vitamin B 12 deficiency. The most significant case that I was able to observe both the effects of deficiency and the benefit of replenishment was in a gentleman that was sent for ataxia. He literally could not walk a straight line. He came down the hall with the assistance of his wife, because without her he would zigzag from wall-to-wall. He had a high steppage take gait due to a loss of perception of where his feet were. Now, many of you know that when you are evaluating a patient with neurologic dysfunction you go for patterns. Typically stroke like events occur unilaterally, neuropathic dysfunction is bilateral. And ataxia that causes you to not be able to walk a straight line is typically from something in the central nervous system, not the peripheral nervous system. So, this gentleman was very perplexing, as he did not have diabetes, he did not have a stroke on MRI and displayed conflicting presentation of neurologic processes contributing to his symptoms. There was a standard lab panel that we drew for anyone coming into the office with neurologic dysfunction and B 12 was included in the panel. His B12 level was 127. That was the only abnormality found. Of course, I was skeptical that replenishing B12 was going to return this gentleman to full function. We did, however, initiate Parenteral vitamin B 12 therapy and had him return in six weeks. His levels had increased to 700 and he had complete resolution of his symptoms, except for some decreased sensory to touch in the most distal part of the lower extremities. To say the least, I was blown away by this! He had also had improvement in his energy levels and cognitive function, which he had not realized had gotten so low until he was feeling good again.
From that point on, I have checked a vitamin B12 level on every patient that complains of numbness, tingling, fatigue or memory impairment. Some things you may find on examination, prior to such a profound presentation is decreased vibratory sensation, slow reflexes, decrease in sensation to light touch and temperature in the extremities, and abnormalities of the tongue. For vitamin B 12 deficiency’s to get to this level of extreme nature, the patient would’ve had to go through all of their vitamin B 12 stores in the liver and no longer be absorbing any type of vitamin B 12 from their diet.
A treatable vitamin B 12 level with injections, is 300 or less. Between 350 and 450, I will advise a sublingual type of B 12 that is absorbed by the oral mucosa, as opposed to the stomach. When you have lost the intrinsic factor that helps with vitamin B 12 absorption, it does not ever come back and you will not be able to absorb vitamins taken orally that need to be broken down in the stomach. If the levels continue to climb with a sublingual or a mucosal absorbable type B12 such as that in a gummy or drop, then injections aren’t necessary.
Elevated homocysteine levels can be seen in vitamin B 12 deficiency. An elevated homocysteine level indicates an increased risk of cerebrovascular disease. If vitamin B 12 is depleted and homocysteine levels are increased, be sure to use folic acid in addition to vitamin B 12 replenishment.
B12 depletion in alcoholics is quite common. The irritation to the gut and intestines from alcohol can block the absorption of nutrients. Often times, patients will not tell you the amount of alcohol they truly drink for fear of judgment. If you do observe a macrocytic anemia, associated with a B12 deficiency, discuss the causes of vitamin B deficiencies cautiously. Mention it in a way that will get them to think about it. This may help them to be more honest and upfront with you about alcoholism or more willing to take vitamin repletion.
Another consideration with B12 deficiency in alcoholism is that alcohol is a diuretic and B12 is a water-soluble vitamin. This makes excretion of vitamin B 12 occur at a higher rate in alcoholics. These vitamin B deficiency’s in alcoholics can also lead to metabolic dementia and Alzheimer’s type dementia.
On the subject of vitamin B 12 being a water-soluble vitamin, this adds security to the treatment plan. I will initially give vitamin B 12 1000 µg subcutaneously or intramuscularly once a week for four weeks followed by once per month there after to maintain vitamin B 12 levels. Some patients will continue to deplete their stores of vitamin B 12 quickly and require injections every two weeks. This is something for you to monitor. I will monitor the vitamin B12 levels every six months once B12 deficiency has been established and treatment has begun.
Sources of vitamin B 12 from your diet include primarily animal resources, such as liver and organ meats, egg yolks, tuna and salmon. For those on a plant-based diet, nutritional yeast is a valuable source of vitamin B 12. If they are not consuming enough through their diet, oral supplementation with 1000 µg daily would be fine as well. The parenteral replenishment is most often used once there is depletion, rather than as prevention.
As you know, I do have a wellness and weight management program that I offer online. Vitamin B 12 is covered in this program for considerations in weight management. That is because it is very significant for boosting metabolism and overall wellness. Once you increase your energy levels and boost your metabolism, you feel more like exercising and it enhances your motivation towards weight loss efforts. I did not speak specifically of lipotrohpic injections in that course. I will not speak of all of the vitamin Bs in this podcast either. We will save that for a future discussion. I will tell you that they are very significant due to the boost in metabolism and easy to obtain from a compounding pharmacy. My patients absolutely love the lipotrophic injections. Depending on what area of the country you are in, there are many valuable resources for compounding pharmacies. I am on the East Coast and find that some of the West Coast pharmacies charge an insane amount to ship to this area. I am currently putting together a program for the use of adjunct of therapies in wellness and weight management. This will include the supplemental resources of certain vitamins, lipotrophic injections, IV nutrition therapies and peptides. I know that seems like a lot to include into one program, but if you’re going to add one, you should add them all. They are a great ancillary source of income and they are very, very effective. if you have not already gathered this from my podcast, I do not believe in gimmicks, bad, quick fixes or anything that is going to let the patient down. I will not ruin my reputation or risk my patients health for a dollar. Anything that I promote and put into a course for you, I assure you I have researched at great length before I have offered that to my patients.
You have heard in previous podcasts, that I like to practice what I preach. That means, if I will not administer these protocols, supplements and treatment options to myself, my closest family and friends, I will not offer it to my patients or promote it to my colleagues. There are many gimmicks out there. There’s plenty of people who are trying to take advantage of you. I have lost a lot of money in the short term studying these things, but I consider it a gain in the end because I did not hurt anyone or take advantage of anyone by implementing something that is not effective.
I do hope that you’ve taken away some information on the importance of vitamin B 12 in your patients. You will make such a big difference in the lives of so many if you check that vitamin B 12 level and begin to treat them appropriately. It will boost your metabolism, boost their energy and eliminate a myriad of symptoms they may be experiencing.
If you have found this valuable to you and your practice, you might want to check out my Phytonutrient and Micronutrient module from the wellness and weight management course that I have made available as an individual course for you. You can find that at nphealthinterventions.com/phytonutrients
I would of course like you to take the entire program and get all of the information that you need to make a big difference in your patients, but I understand if you’re a little hesitant or not sure if it’s something you want to dive into. That’s why I will release some of these modules as appropriate with the topics we are currently discussing.
Have a great week! May it be filled with many Health Interventions!
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