Vitamin B12 deficiency is a common health problem that can have serious consequences – but doctors often overlook it

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Fatigue can be a sign of a possible B12 deficiency. Maca and Naca/E+ via Getty Images
In the summer of 2022, my dog ​​Scout vomited at 3am almost every day for several months. If you have a dog, you know the sound. And every time, she gobbled up her mess before I could reach her, making diagnosing the cause difficult.
The vet and I finally settled on my hydrangeas as the source of the problem - but keeping Scout away from them didn't work. She seemed tired all the time - very concerning for a typical hyper yellow Lab puppy.
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Then one day Scout vomited a hairball - but not just any hairball. Hair normally passes easily through the digestive system in dogs, but this hairball was wrapped around a Brillo pad that was too large to move through. Once this foreign body was removed, the nighttime vomiting stopped. However, Scout still required treatment for another and surprising reason: the subject had inhibited a step in her body's absorption of vitamin B12. B12 is an essential nutrient involved in the proper functioning of blood cells, nerves, and many other critical processes in the body.
I'm a registered dietitian and teach nutrition and food science to college students, but I still missed the B12 deficiency that was causing my pup's fatigue. Doctors can just as easily blind people to it — although B12 deficiency is a common health problem, affecting an estimated 6% to 20% of the US population.
B12 is scarce in the diet and is only found in foods of animal origin. Luckily, humans only need 2.4 micrograms of B12 daily, which is one ten-millionth of an ounce — a very, very small amount. Without enough B12 in the body, overall health and quality of life are negatively impacted.
A range of foods rich in vitamin B12 – all of which come from animals. photka/iStock via Getty Images Plus
signs and symptoms
A primary symptom of B12 deficiency is fatigue — a level of tiredness or fatigue so deep that it interferes with activities of daily living.
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Other symptoms are neurological in nature and may include tingling in the extremities, confusion, memory loss, depression, and difficulty balancing. Some of these can be permanent if the vitamin deficiency is not corrected.
However, because there can be so many causes of these symptoms, healthcare providers may overlook the possibility of B12 deficiency and not look for it. In addition, a healthy diet seems to rule out vitamin deficiencies. Case in point: Knowing that Scout's diet was healthy, I didn't consider B12 deficiency to be the cause of her problems.
How B12 is absorbed
Research is clear that people on a plant-based diet need to take B12 supplements in amounts typically provided by standard multivitamins. However, hundreds of millions of Americans who consume B12 may also be at risk due to conditions that could interfere with their body's absorption of B12.
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B12 absorption is a complex, multi-step process that begins in the mouth and ends at the other end of the small intestine. When chewing, our food is mixed with saliva. When food is swallowed, a substance in saliva called R-protein — a protein that protects B12 from being destroyed by stomach acid — travels with the food to the stomach.
Certain cells in the lining of the stomach, called parietal cells, secrete two substances that are important for B12 absorption. One of these is stomach acid – it breaks down food and B12, allowing the vitamin to bind to the R protein in saliva. The other substance, called intrinsic factor, mixes with the contents of the stomach and travels with it to the first part of the small intestine - the duodenum. Once in the duodenum, pancreatic juice releases B12 from R protein and passes it to intrinsic factor. This pairing allows B12 to be taken up into cells, where it can then help maintain nerve cells and form healthy red blood cells.
B12 deficiency typically involves a breakdown at one or more of these points on the way to absorption.
Risk factors for B12 deficiency
Without saliva, B12 does not bind to the R protein in saliva and the body's ability to absorb it is inhibited. And there are hundreds of different medications that can cause dry mouth, which leads to low saliva production. These include opioids, inhalers, decongestants, antidepressants, blood pressure medications, and benzodiazepines like Xanax, which are used to treat anxiety.
The last three categories alone account for a good 100 million recipes in the USA every year.
Another potential factor in B12 deficiency is low levels of stomach acid. Hundreds of millions of Americans take anti-ulcer drugs that reduce stomach acids that cause ulcers. Researchers have firmly linked the use of these drugs to B12 deficiency — although that possibility may not outweigh the need for the drugs.
The production of stomach acid can also decrease with age. More than 60 million people in the US are over 60 years old and about 54 million are over 65 years old. This demographic is at higher risk of B12 deficiency — which can be further increased by taking acid-reducing medications.
The production of gastric acid and intrinsic factor by the specialized parietal cells in the stomach is crucial for the absorption of B12. But damage to the lining of the stomach can prevent production of either.
In humans, compromised gastric mucosa results from gastric surgery, chronic inflammation, or pernicious anemia—a medical condition marked by fatigue and a long list of other symptoms.
Another common cause of B12 deficiency is inadequate pancreatic function. About a third of patients with poor pancreatic function develop B12 deficiency.
Finally, metformin, a drug used by around 92 million Americans to treat type 2 diabetes, has been linked to B12 deficiency for decades.
Treatment of B12 deficiency
While some healthcare providers routinely measure B12 and other vitamin levels, a typical exam only includes a complete blood count and metabolic panel, neither of which measures B12 status. If you are experiencing possible symptoms of B12 deficiency and also have any of the risk factors above, you should see a doctor to get tested. A proper laboratory test and a discussion with a doctor are needed to determine or rule out whether inadequate B12 levels might be a factor.
My dog ​​Scout's symptoms prompted the vet to run two blood tests: a full blood count and a B12 test. These are also good starting points for humans. Scout's symptoms disappeared after a few months of oral B12 supplementation, which also contained an active form of the B vitamin folate.
In humans, the type of treatment and length of recovery depend on the cause and severity of B12 deficiency. Full recovery can take up to a year, but is very possible with appropriate treatment.
Treatment for B12 deficiency can be given by mouth, under the tongue, or through the nose, or it may require different types of injections. A B12 supplement or balanced multivitamin may be enough to correct the deficiency, as was the case with Scout, but it's best to work with a healthcare provider to ensure proper diagnosis and treatment.
This article is a re-publication of The Conversation, an independent non-profit news site dedicated to sharing ideas from academic experts. It was written by: Diane Cress, Wayne State University. Do you like this article? subscribe to our weekly newsletter.
Continue reading:
Diet can affect mood, behavior and more - explains a neuroscientist
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Diane Cress does not work for, advise, own any interest in, or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations other than her academic appointment.

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