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Vitamin B12 Deficiency: Incidence and Consequences
Vitamin B12 deficiency easy to avoid
KINGSTON, CANADA. Many older people suffer from a deficiency of vitamin B12 (cobalamin). A low intake of animal protein, the use of medications to reduce stomach acid, a Helicobacter pylori infection, an inflammation of the stomach lining, and problems with the pancreas can all contribute to the development of a deficiency.

Medical researchers at Queen's University now report that daily supplementation with a multivitamin containing 2.6 – 37.5 micrograms of vitamin B12 is enough to prevent a cobalamin deficiency in most older healthy people. Their study involved 242 active, relatively healthy men and women aged 65 years or older. Sixty-six (27.3 per cent) of the volunteers had been taking a daily multivitamin containing 2.6 – 37.5 micrograms of vitamin-B12 for at least six months.

All volunteers had blood samples drawn for the measurement of cobalamin level as well as the levels of the related metabolites methylmalonic acid (MMA), homocysteine (HCYS) and methylcitric acid (MCTR).

Thirty- seven (15.3 per cent) of the 242 participants were deficient in cobalamin (level below 165 pmol/L). Of these 37 only 2 were taking multivitamins. An elevated level of MMA was found in 53 participants of whom 46 (87 per cent) were not taking multivitamins. An elevated level of homocysteine was found in 17 participants of whom 16 were not supplementing.

The researchers conclude that oral supplementation with 25 micrograms/day or higher may be sufficient to prevent vitamin B12 deficiency in a large proportion of older people. They caution though that their findings cannot be extrapolated to frail or sick old people who may require larger doses to avoid deficiency.

Garcia, Angela, et al. Is low-dose oral cobalamin enough to normalize cobalamin function in older people? Journal of the American Geriatrics Society, Vol. 50, August 2002, pp. 1401-04
Vitamin B12 deficiency and ulcer drugs
DENVER, COLORADO. Researchers at the University of Colorado School of Pharmacy warn that prolonged use of acid-suppressing drugs such as cimetidine (Tagamet), ranitidine (Zantac) and omeprazole (Losec) can lead to a serious vitamin-B12 deficiency. They cite the case of a 78-year-old non-vegetarian, white woman with GERD (gastroesophageal reflux disease) who had been taking cimetidine or ranitidine for 4.5 years. She was started on cimetidine (300 mg four times daily) in February 1990, which was changed to ranitidine (150 mg twice daily) in April 1993. Her vitamin B12 level was normal (413 pg/mL) in August 1992, but by June 1994 it had decreased to 256 pg/mL and her homocysteine level had increased dramatically to 27.3 micromol/L. Note: A homocysteine level above 10 micromol/L vastly increases the risk of atherosclerosis and stroke with a 5 micromol/L increase corresponding to a 70 per cent increase in the risk of heart disease and a 50 per cent increase in stroke risk.

The patient was started on 1000 micrograms/day of sublingual vitamin B12 supplementation and by November 1994 her level was back up to 517 pg/mL and her homocysteine level was down to 20.3 micromol/L. Further improvements were observed in March 1998 when her vitamin B12 level was up to 629 pg/mL and homocysteine was down to 13.9 micromol/L. The researchers point out that other studies have shown that omeprazole also lowers vitamin B12 levels and conclude that older people on long-term acid-suppressing drugs should be monitored for vitamin B12 deficiency and supplement if necessary.

Ruscin, J. Mark, et al. Vitamin B12 deficiency associated with histamine2-receptor antagonists and a proton-pump inhibitor. Annals of Pharmacotherapy, Vol. 36, May 2002, pp. 812-16

Diabetes drug linked to vitamin B12 deficiency
A Wisconsin doctor reports a case of a 63-year-old man who developed a severe vitamin-B12 deficiency after having taken metformin (Glucophage) for five years. Replacing the metformin with sulfonylurea and taking 1000 mg of cyanocobalamin (vitamin B12) for two months reversed the deficiency. Dr. Mary Ann Gilligan estimates that 10 to 30 per cent of patients on metformin develop a vitamin B12 deficiency and points out there is some evidence that calcium supplementation will prevent it.
Archives of Internal Medicine, Vol. 162, February 25, 2002, pp. 484-85

Helicobacter pylori and vitamin B12 deficiency
ANKARA, TURKEY. It is estimated that more than 50 per cent of adults in developed countries are infected with the Helicobacter pylori bacterium. H pylori has been implicated in stomach ulcers, indigestion (dyspepsia), gastritis (inflammation of the stomach lining), stomach cancer, and MALT lymphoma. About 10-15 per cent of adults over 60 years of age are affected by a vitamin B12 (cobalamin) deficiency. Researchers at the Turkish Military Medical Academy now provide convincing evidence that the two are linked. A detailed study of 138 patients with vitamin B12 deficiency and anaemia discovered that 77 (58 per cent) of the patients had a H pylori infection. Eradication of this infection successfully cured the anaemia and reversed the vitamin B12 deficiency in 31 (40 per cent) of the 77 infected patients. The researchers conclude that a H pylori infection can cause a vitamin B12 deficiency and that this deficiency, in many cases, can be totally eliminated by eradicating the infection. EDITOR'S NOTE: Memory loss, fatigue, and mental confusion are often the first indicators of a vitamin B12 deficiency.
Kaptan, Kursad, et al. Helicobacter pylori - Is it a novel causative agent in vitamin B12 deficiency? Archives of Internal Medicine, Vol. 160, May 8, 2000, pp. 1349-53
Stopeck, Alison. Links between Helicobacter pylori infection, cobalamin deficiency, and pernicious anaemia. Archives of Internal Medicine, Vol. 160, May 8, 2000, pp. 1229-30 (editorial)

Vegetarians are vitamin B12 deficient
SYDNEY, AUSTRALIA. It is generally assumed that vitamin B12 deficiencies are rare among people consuming a varied diet. However, there is some question whether vegetarians get enough B12 as it is not present in plants. Researchers at the Sydney Adventist Hospital have just completed a study aimed at resolving this question. Their study involved 245 Adventist ministers who were either lactoovovegetarians or vegans. The average age of the ministers was 46 years (range 22 to 80 years) and most of them had been vegetarians for over 20 years. The study participants filled out a diet questionnaire and had a fasting blood sample drawn for a 20-test biochemical profile including vitamin B12 concentrations. The mean vitamin B12 level was 199 pmol/L and 73 per cent of the ministers had a level below the recommended lower limit of 221 pmol/L. Vitamin B12 concentrations were also measured in a control group of 53 ministers who consumed fish, poultry or red meat on a regular basis. In this group 40 per cent had vitamin B12 concentrations below the recommended lower limit; this indicates that vitamin B12 deficiency is widespread even among non-vegetarians.

Additional tests showed that the vitamin B12 deficiencies observed among lactoovovegetarians were due to dietary deficiencies rather than to malabsorption. The researchers conclude that as many as 73 per cent of Australian vegetarians are vitamin B12 deficient and recommend that they increase their intake either from vitamin B12-containing foods (animal products), from supplements or from vitamin B12- fortified foods.
Hokin, Bevan D. and Butler, Terry. Cyanocobalamin (vitamin B-12) status in Seventh-day Adventist ministers in Australia. American Journal of Clinical Nutrition, Vol. 70, September 1999, pp. 576S- 78S

Vitamin B12 deficiency and breast cancer
BALTIMORE, MARYLAND. Researchers at the Johns Hopkins University report that women with breast cancer tend to have lower vitamin B12 levels in their blood serum than do women without breast cancer. The researchers determined vitamin B12 concentrations in blood samples obtained in 1974 and in 1989 and compared the levels found in 195 women who later developed breast cancer with the levels found in 195 women free of cancer. They found that postmenopausal women with the lowest serum levels of vitamin B12 had a 2.5-4.0 times greater likelihood of being in the breast cancer group than did women with the highest levels. The researchers found no correlation between breast cancer risk and serum levels of folic acid, vitamin B6, and homocysteine.

In a subsequent review of the findings Dr. Sang-Woon Choi, MD of Tufts University points out that serum levels of folate are a poor indicator of levels in tissues and that it may well be that there is a correlation between folate levels in breast tissue and breast cancer risk. Dr. Choi speculates that a vitamin B12 deficiency may lead to breast cancer because it could result in less folate being available to ensure proper DNA replication and repair.
Wu, K., et al. A prospective study of folate, B12, and pyridoxal 5'-phosphate (B6) and breast cancer. Cancer Epidemiol. Biomarkers Prev., Vol. 8, March 1999, pp. 209-17
Choi, Sang-Woon. Vitamin B12 deficiency: a new risk factor for breast cancer? Nutrition Reviews, Vol. 57, August 1999, pp. 250-60

Vitamin B12 deficiency linked to neuropsychiatric abnormalities
KINGSTON, CANADA. Dr. Dianne Delva, MD, Assistant Professor of Family Medicine at Kingston University, reviews the evidence for and against routine supplementation with vitamin B12 (cobalamin) in the elderly. Several studies have shown that anywhere from 5 to 15 per cent of elderly people suffer from a vitamin B12 deficiency. Although the only formally recognized disorder linked to a cobalamin deficiency is megaloblastic anaemia, it is now becoming clear that many neurological and psychiatric symptoms may also be caused by a vitamin B12 deficiency. Ataxia (shaky movements and unsteady gait), muscle weakness, spasticity, incontinence, hypotension, vision problems, dementia, psychoses, and mood disturbances are but a few of the disorders which have recently been linked to possible vitamin B12 deficiencies. Dr. Delva points out that these disorders may occur at vitamin B12 levels just slightly lower than normal and considerably above the levels normally associated with anaemia. She also cautions that the blood level of cobalamin is an unreliable indicator of deficiency and that tissue levels of the vitamin may be quite low even though the blood levels are normal. The best test of cobalamin deficiency involves measuring the blood levels of homocysteine and methylmalonic acid. If the level of these two precursors to the metabolic reactions controlled by cobalamin are high then the vitamin B12 level is low. Vitamin B12 deficiencies may be treated by injections of the vitamin or by oral supplementation. Oral supplementation is just as effective as injections in most people and a lot less expensive. An oral dose of 100-250 micrograms/day is usually adequate although patients with absorption difficulties may need 1000 micrograms/day. Cobalamin has no known toxic effects.
Delva, M. Dianne. Vitamin B12 replacement - To B12 or not to B12? Canadian Family Physician, Vol. 43, May 1997, pp. 917-22

Vitamin B-12 deficiency common in older people
MOLNLYCKE, SWEDEN. Swedish researchers have discovered that many older people are deficient in vitamin B-12. Their study involved 368 men and women aged 75 years or older. Analysis of blood serum showed that 11 per cent of the participants were deficient in cobalamin (vitamin B-12). The researchers point out that a vitamin B-12 deficiency has been linked to neuropsychiatric disorders such as memory loss and dementia. The researchers discovered several cases of gastritis (inflammation of the lining of the stomach) and two cases of celiac disease among patients with low serum values of cobalamin. They conclude that routine screening for a vitamin B-12 deficiency is justified in the case of older people.

In a separate letter to the Journal of the American Geriatrics Society doctors from the Union Memorial Hospital in Baltimore report on a case of vitamin B-12 deficiency. The patient, an 85-year-old man, had developed progressive memory loss and lethargy over a two-year period. Although his serum level of vitamin B-12 was within the currently accepted range, the doctors decided to proceed with vitamin B-12 therapy. The patient received an intramuscular injection of 1000 micrograms of vitamin B-12 for three consecutive days, then 1000 micrograms weekly for a month, and then one injection every month. By the fifth injection his mental status had vastly improved and his lethargy had completely vanished. The doctors conclude that the levels of serum vitamin B-12 concentrations currently considered normal in the United States may be too low and should be reassessed. The lower limit of 200 pg/mL is based on the level that causes abnormalities in the blood (pernicious anaemia). In contrast the lower limit in Japan and some European countries is 500-550 pg/mL and is based on the level that causes mental manifestations such as dementia and memory loss. The doctors suggest that a trial of vitamin B-12 therapy is warranted in patients with borderline cobalamin serum levels as it is effective and inexpensive.
Eggersten, Robert, et al. Prevalence and diagnosis of cobalamin deficiency in older people. Journal of the American Geriatrics Society, Vol. 44, No. 10, October 1996, pp. 1273-74
Goodman, Mark, et al. Are U.S. lower normal B-12 limits too low? Journal of the American Geriatrics Society, Vol. 44, No. 10, October 1996, pp. 1274-75

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