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Tag: Vitamin B12

  • Vegans and Iodine Deficiency Risk  | NutritionFacts.org

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    Most plant-based milks are not fortified with iodine.

    “Adequate dietary iodine is required for normal thyroid function.” In fact, the two thyroid hormones are named after how many iodine atoms they contain: T3 and T4. “Given that iodine is extensively stored in the thyroid gland itself, it can safely be consumed intermittently,” so we don’t need to consume it every day. However, our overall diet does need a good source of it. Unfortunately, the common sources aren’t particularly health-promoting: iodized salt and dairy foods. (Iodine-based cleansers like betadine are used on cows “to sanitize the udders, resulting in leaching of iodine in the milk.”) Iodine may also be added to cattle feed, and some commercially produced breads contain food additives with iodine.

    If you put people on a paleo-type diet and cut out their dairy and table salt, they can develop an iodine deficiency, even though they double their intake of seafood, which can also be a source of iodine. What about those switching to diets centered around whole plant foods? They also cut down on ice cream and Wonder Bread, and if they aren’t eating anything from the sea, like seaweed or other sea vegetables, they can run into the same problem.

    A three-year-old’s parents reported striving to feed her only the healthiest foods, and her diet included only plant-based, unsalted, and unseasoned foods. She got no unprocessed foods, but she also got no vitamin supplementation, which could be deadly. Without vitamin B12, those on strictly plant-based diets can develop irreversible nerve damage, but in this case, a goiter arose first, due to inadequate iodine intake.

    In another case of “veganism as a cause of iodine-deficient hypothyroidism,” a toddler became ill after weaning. Before weaning, he was fine because his mother kept taking her prenatal vitamins, which fortunately contained iodine.

    Most vegetarians and vegans are apparently unaware of the importance of iodine intake during pregnancy, “for the neurodevelopment of the unborn child, similar to their omnivorous counterparts.” The American Thyroid Association and the American Academy of Pediatrics have recommended that women, even just planning on getting pregnant, should take a daily supplement containing 150 micrograms (mcg) of iodine, yet only 60 percent of prenatal vitamins marketed in the United States contain this essential mineral. So, despite the recommendations, about 40 percent of prenatal vitamins don’t contain it. “Therefore, it is extremely important that women, especially when pregnant, breastfeeding, or planning a pregnancy, read the labels of their multivitamin supplements to ensure that they are receiving an adequate amount of iodine.”

    Women of reproductive age have an average iodine level of 110 mcg/liter, which is fine for nonpregnant individuals, but we’d really like women to get at least 150 mcg/liter during pregnancy. (It’s basically a 24-hour urine test, in which iodine sufficiency is defined as 100 mcg/liter of urine in nonpregnant adults; the average vegan failed to reach this in the largest study done to date, one out of Boston.)

    The recommended average daily intake is 150 mcg per day for most people, which we can get in about a cup and a half of cow’s milk. Regrettably, plant-based milks aren’t typically fortified with iodine and average only about 3 mcg per cup. Although many plant-based milks are fortified with calcium, researchers found in the largest systematic study to date that only 3 out of 47 were fortified with iodine. Those that were fortified had as much as cow’s milk, but those that weren’t fell short, as you can see at 3:30 in my video Are Vegans at Risk for Iodine Deficiency?. 

    Plant-based milk companies brag about enriching their milks with calcium and often vitamins B12, D, and A, but only rarely are attempts made to match iodine content. The only reason cow’s milk has so much is that producers enrich the animals’ feed or it comes dripping off their udders. So, why don’t plant-milk companies add iodine, too? I was told by a food scientist at Silk that my carrageenan video played a role in the company switching to another thickener. Hopefully, Silk will see this video, too, and consider adding iodine, or maybe another company will snatch the opportunity for a market advantage.  

    The researchers conclude that individuals who consume plant-based milks not fortified with iodine may be at risk for iodine deficiency, unless they consume alternative dietary iodine sources, the healthiest of which are sea vegetables, which we’ll cover next.

    Doctor’s Note:

    This is the first in a four-video series on thyroid function. The next three are: 

    For more on iodine, see the related posts below.

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    Michael Greger M.D. FACLM

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  • Is Creatine Safe and Efficient for High Homocysteine?  | NutritionFacts.org

    Is Creatine Safe and Efficient for High Homocysteine?  | NutritionFacts.org

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    Those on a healthy plant-based diet who have elevated homocysteine levels despite taking sufficient vitamin B12 may want to consider taking a gram a day of contaminant-free creatine.

    The average blood levels of homocysteine in men are about 1.5 points higher than in women, which may be one of the reasons men tend to be at higher risk for cardiovascular disease. Women don’t need to make as much creatine as men since they tend to have less muscle mass. That may help explain “the ‘gender gap’ in homocysteine levels.” If you remember from my previous video and as seen below and at 0:36 in The Efficacy and Safety of Creatine for High Homocysteine, in the process of making creatine, our body produces homocysteine as a by-product. So, for people with stubbornly high homocysteine levels that don’t respond sufficiently to B vitamins, “creatine supplementation may represent a practical strategy for decreasing plasma homocysteine levels”—that is, lowering the level of homocysteine into the normal range. 

    It seemed to work in rats. What about humans? Well, it worked in one study, but it didn’t seem to work in another. It didn’t work in yet another either. And, in another study, homocysteine levels were even driven up. So, this suggestion that taking creatine supplements would lower homocysteine was called into question. 

    However, all those studies were done with non-vegetarians, so they were already effectively supplementing with creatine every day in the form of muscle meat. In that way, researchers were testing higher versus lower supplementation. Those eating strictly plant-based make all their creatine from scratch, so they may be more sensitive to an added creatine source. There weren’t any studies on creatine supplementation in vegans to lower homocysteine until now. 

    Researchers took vegans who were not supplementing their diets with vitamin B12, so some of their homocysteine levels were through the roof. A few were as high as 50 when the ideal is more like under 10, for example. After taking some creatine for a few weeks, all of their homocysteine levels normalized. You can see the before and after in the graph below and at 2:04 in my video. 

    Now, they didn’t normalize, as that would have been a level under 10, but that’s presumably because they weren’t taking any B12. Give vegetarians and vegans vitamin B12 supplements, either dosing daily or once a week, and their levels normalize in a matter of months, as you can see below and at 2:20 in my video. However, the fact that you could bring down homocysteine levels with creatine alone, even without any B12, suggests—to me at least—that if your homocysteine is elevated (above 10) on a plant-based diet despite taking B12 supplements and eating greens and beans to get enough folate, it might be worth experimenting with supplementing with a gram of creatine a day for a few weeks to see if your homocysteine comes down. 

    Why just a single gram? That’s approximately how much non-vegetarians do not have to make themselves; it’s the amount that erased vegetarian discrepancies in blood and muscle, as you can see in the graph below and at 3:01 in my video, and how much has been shown to be safe in the longer term. 

    How safe is it? We can take a bit of comfort in the fact that it’s “one of the world’s best-selling dietary supplements,” with literally billions of servings taken, and the only consistently reported side effect has been weight gain, presumed to be from water retention. The only serious side effects appear to be among those with pre-existing kidney diseases taking whopping doses closer to 20 grams a day. A concern was raised that creatine could potentially form a carcinogen known as N-nitrososarcosine when it hit the acid bath of the stomach, but, when it actually put to the test, researchers found this does not appear to be a problem. 

    Bottom line: Doses of supplemental creatine up to 3 grams a day are “unlikely to pose any risk,” provided “high purity creatine” is used. However, as we all know, dietary supplements in the United States “are not regulated by the US Food and Drug Administration and may contain contaminants or variable quantities of the desired supplement” and may not even contain what’s on the label. We’re talking about “contaminants…that may be generated during the industrial production.” When researchers looked at 33 samples of creatine supplements made in the United States and Europe, they found that they all actually contained creatine, which is nice, but about half exceeded the maximum level recommended by food safety authorities for at least one contaminant. The researchers recommend that “consumers give their preference to products obtained by producers that ensure the highest quality control and certify the maximum amount of contaminants present in their products.” Easier said than done.

    Because of the potential risks, I don’t think people should take creatine supplements willy-nilly, but the potential benefits may exceed the potential risks if, again, you’re on a healthy plant-based diet and taking B12, and your homocysteine levels are still not under 10. In that case, I would suggest giving a gram a day of creatine a trying to see if it brings it down.

    The reason I did this whole video series goes back to “Risks of Ischaemic Heart Disease and Stroke in Meat Eaters, Fish Eaters, and Vegetarians Over 18 Years of Follow-Up: Results from the Prospective EPIC-Oxford Study,” which found that, although the overall cardiovascular risk is lower in vegetarians and vegans combined, they appeared to be at slightly higher stroke risk, as you can see in the graph below and at 5:06 in my video. 

    I went through a list of potential causes, as you can see at 5:11 and below, and arrived at elevated homocysteine. What’s the solution? A regular, reliable source of vitamin B12. The cheapest, easiest method that I personally use is one 2,500 mcg chewable tablet of cyanocobalamin, the most stable source of B12, once a week. (In fact, you can just use 2,000 mcg once a week.) And, again, a backup plan for those doing that but still having elevated homocysteine is an empirical trial of a single gram a day of creatine supplementation, which was shown to improve at least capillary blood flow in those who started out with high homocysteine levels. 

    In sum, plant-based diets appear to “markedly reduce risk” for multiple leading killer diseases—heart disease, type 2 diabetes, and many common types of cancer—but “an increased risk for stroke may represent an ‘Achilles heel.’ Nonetheless, vegans have the potential to achieve a truly exceptional ‘healthspan’ if they face this problem forthrightly by restricting salt intake and taking other practical measures that promote cerebrovascular [brain artery] health…Nonetheless, these considerations do not justify nutritional nihilism. On balance, low-fat vegan diets offer such versatile protection for long-term health that they remain highly recommendable. Most likely, the optimal strategy is to adopt such a [plant-based] diet, along with additional measures—appropriate food choices, exercising training, judicious supplementation [of vitamin B12]—that will mitigate the associated stroke risk.” And try not to huff whipped cream charging canister gas. Leave the “whippets” alone.

    This concludes my series on stroke risk. If you missed any of the other videos, see the related posts below.

    I’m assuming that nearly everyone taking their B12 will have normal homocysteine levels, so these last two videos are just for the rare person who doesn’t. However, those on a healthy plant-based diet with elevated homocysteine levels despite taking sufficient vitamin B12 should consider taking a gram a day of contaminant-free creatine, which should be about a quarter teaspoon.

    Where do you get contaminant-free creatine? Since regulations are so lax, you can’t rely on supplement manufacturers no matter what they say, so I would recommend going directly to the chemical suppliers that sell it to laboratories and guarantee a certain purity. Here are some examples (in alphabetical order) of some of the largest companies where you can get unadulterated creatine: Alfa Aesar, Fisher Scientific, Sigma-Aldrich, and TCI America.

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    Michael Greger M.D. FACLM

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  • Creatinine to Normalize Homocysteine in Vegetarians?  | NutritionFacts.org

    Creatinine to Normalize Homocysteine in Vegetarians?  | NutritionFacts.org

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    What are the consequences of having to make your creatine rather than relying on dietary sources?

    “Almost universally, research findings show a poor vitamin B12 status among vegetarians” because they aren’t taking vitamin B12 supplements like they should, which results in an elevation in homocysteine levels. This may explain why vegetarians were recently found to have higher rates of stroke, as you can see in the graph below and at 0:30 in my video Should Vegetarians Take Creatine to Normalize Homocysteine?.

    Of course, plant-based eating is just one of many ways to become deficient in vitamin B12. Even nitrous oxide (laughing gas) can do it in as little as two days, thanks to the recreational use of whipped cream canister gas. (I just learned about “whippits”!)

    When researchers gave vegetarians and vegans as little as 50 daily micrograms of cyanocobalamin, which is the recommended and most stable form of vitamin B12 supplement, their homocysteine levels, which had started up in the elevated zone, normalized right down into the safe zone under 10 mmol/L within only one to two months. Just 2,000 micrograms of cyanocobalamin once a week gave the same beautiful result, as you can see in the graph below and at 1:15 in my video. 

    Not always, though. In another study, even 500 daily micrograms, taken as either a sublingual chewable or swallowable regular B12 supplement, didn’t normalize homocysteine within a month, as shown below and at 1:24. Now, presumably, if the participants had kept it up, their levels would have continued to fall as they did in the 50-daily-microgram study.

    If you’re plant-based and have been taking your B12, but your homocysteine level is still too high (above 10 mmol/L), is there anything else you can do? Well, inadequate folate intake can also increase homocysteine, but folate comes from the same root as foliage. It’s found in beans and leaves, concentrated in greens. If you’re eating beans and greens, taking your B12, and your homocysteine level is still too high, I’d suggest taking 1 gram of creatine a day as an experiment, then getting your homocysteine levels retested in a month to see if it helped.

    Creatine is a compound formed naturally in the human body that is primarily involved with energy production in our muscles and brain. It’s also formed naturally in the bodies of many other animals. So, when we eat their muscles, we can also take in some of the creatine in their bodies through our diet. We only need about 2 grams of creatine a day, so those who eat meat may get about 1 gram from their diet and their body makes the rest from scratch. There are rare birth defects where you’re born without the ability to make it, in which case, you have to get it from your diet. Otherwise, our bodies can make as much as we need to maintain normal concentrations in our muscles.

    As you can see in the graph below and at 2:54 in my video, when you cut out meat, the amount of creatine floating around in your bloodstream goes down.

    However, the amount in your brain remains the same, as shown in the graph below and at 2:57. This shows that dietary creatinine doesn’t influence the levels of brain creatine, because our brain makes all the creatine we need. The level in vegetarian muscles is lower, but that doesn’t seem to affect exercise performance, as both vegetarians and meat eaters respond to creatine supplementation with similar increases in muscle power output. If vegetarian muscle creatine were insufficient, then presumably an even bigger boost would be seen. So, all that seems to happen when we eat meat is that our body doesn’t have to make as much. What does all of this have to do with homocysteine?

    As you can see below and at 3:36 in my video, in the process of making creatine, our body produces homocysteine as a waste product. Now, normally this isn’t a problem because our body has two ways to detoxify it: by using vitamin B6 or a combination of vitamin B12 and folate. Vitamin B6 is found in both plant and animal foods, and it’s rare to be deficient. But, vitamin B12 is mainly found in animal foods, so its level can be too low in those eating plant-based who don’t also supplement or eat B12-fortified foods. And, as I mentioned, folate is concentrated in plant foods, so it can be low in those who don’t regularly eat greens, beans, or folic-acid-fortified grains. Without that escape valve, homocysteine levels can get too high. However, if you’re eating a healthy plant-based diet and taking your B12 supplement, your homocysteine levels should be fine. 

    What if they aren’t? We might predict that if we started taking creatine supplements, our level of homocysteine might go down since we won’t have to make so much of it from scratch, producing homocysteine as a by-product, but you don’t know until you put it to the test. I’ll cover that next. 

    This is the eleventh in a 12-video series exploring stroke risk. If you missed the last two, see Vegetarians and Stroke Risk Factors: Vitamin B12 and Homocysteine? and How to Test for Functional Vitamin B12 Deficiency.

    This whole creatine angle was new to me. I had long worried about homocysteine levels being too high among those getting inadequate B12 intake, but I didn’t realize there was another potential mechanism for bringing it down other than with vitamin B. Let’s see if it pans out in my final video of the series: The Efficacy and Safety of Creatine for High Homocysteine. 

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    Michael Greger M.D. FACLM

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  • Testing for Vitamin B12 Deficiency  | NutritionFacts.org

    Testing for Vitamin B12 Deficiency  | NutritionFacts.org

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    Many doctors mistakenly rely on serum B12 levels in the blood to test for vitamin B12 deficiency.

    There were two cases of young, strictly vegetarian individuals with no known vascular risk factors. One suffered a stroke, and the other had multiple strokes. Why? Most probably because they weren’t taking vitamin B12 supplements, which leads to high homocysteine levels, which can attack our arteries.

    So, those eating plant-based who fail to supplement with B12 may increase their risk of both heart disease and stroke. However, as you can see in the graph below and at 0:47 in my video How to Test for Functional Vitamin B12 Deficiency, vegetarians have so many heart disease risk factor benefits that they are still at lower risk overall, but this may help explain why vegetarians were found to have more stroke. This disparity would presumably disappear with adequate B12 supplementation, and the benefit of lower heart disease risk would grow even larger.

    Compared with non-vegetarians, vegetarians enjoy myriad other advantages, such as better cholesterol, blood pressure, blood sugars, and obesity rates. But, what about that stroke study? Even among studies that have shown benefits, “the effect was not as pronounced as expected, which may be a result of poor vitamin B12 status due to a vegetarian diet. Vitamin B12 deficiency may negate the cardiovascular disease prevention benefits of vegetarian diets. To further reduce the risk of cardiovascular disease, vegetarians should be advised to use vitamin B12 supplements.” 

    How can you determine your B12 status? By the time you’re symptomatic with B12 deficiency, it’s too late. And, initially, the symptoms can be so subtle that you might even miss them. What’s more, you develop metabolic vitamin B12 deficiency well before you develop a clinical deficiency, so there’s “a missed opportunity to prevent dementia and stroke” when you have enough B12 to avoid deficiency symptoms, but not enough to keep your homocysteine in check. “Underdiagnosis of this condition results largely from a failure to understand that a normal serum [blood level] B12 may not reflect an adequate functional B12 status.” The levels of B12 in our blood do not always represent the levels of B12 in our cells. We can have severe functional deficiency of B12 even though our blood levels are normal or even high.

    “Most physicians tend to assume that if the serum B12 is ‘normal,’ there is no problem,” but, within the lower range of normal, 30 percent of patients could have metabolic B12 deficiency, with high homocysteine levels. 

    Directly measuring levels of methylmalonic acid (MMA) or homocysteine is a “more accurate reflection of vitamin B12 functional statuses.” Methylmalonic acid can be checked with a simple urine test; you’re looking for less than a value of 4 micrograms per milligram of creatinine. “Elevated MMA is a specific marker of vitamin B12 deficiency while Hcy [homocysteine] rises in both vitamin B12 and folate deficiencies.” So, “metabolic B12 deficiency is strictly defined by elevation of MMA levels or by elevation of Hcy in folate-replete individuals,” that is, in those getting enough folate. Even without eating beans and greens, which are packed with folate, folic acid is added to the flour supply by law, so, these days, high homocysteine levels may be mostly a B12 problem. Ideally, you’re looking for a homocysteine level in your blood down in the single digits.

    Measured this way, “the prevalence of subclinical functional vitamin B12 deficiency is dramatically higher than previously assumed…” We’re talking about 10 to 40 percent of the general population, more than 40 percent of vegetarians, and the majority of vegans who aren’t scrupulous about getting their B12. Some suggest that those on plant-based diets should check their vitamin B12 status every year, but you shouldn’t need to if you’re adequately supplementing. 

    There are rare cases of vitamin B12 deficiency that can’t be picked up on any test, so it’s better to just make sure you’re getting enough.

    If you do get your homocysteine tested and it’s still too high, up in the double digits despite B12 supplementation and eating beans and greens, I have a suggestion for you in the final videos of this series, which we’ll turn to next with: Should Vegetarians Take Creatine to Normalize Homocysteine? and The Efficacy and Safety of Creatine for High Homocysteine.

    How did we end up here? To watch the full series if you haven’t yet, check the related posts below. 

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    Michael Greger M.D. FACLM

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  • What About Homocysteine, Vitamin B12, and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    What About Homocysteine, Vitamin B12, and Vegetarians’ Stroke Risk?  | NutritionFacts.org

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    Not taking vitamin B12 supplements or regularly eating B12-fortified foods may explain the higher stroke risk found among vegetarians.

    Leonardo da Vinci had a stroke. Might his vegetarian diet have been to blame? “His stroke…may have been related to an increase in homocysteine level because of the long duration of his vegetarian diet.” A suboptimal intake of vitamin B12 is common in those eating plant-based diets (unless they take B12 supplements or regularly eat B12-fortified foods) and can lead to an increased level of homocysteine in the blood, which “is accepted as an important risk factor for stroke.”

    “Accepted” may be overstating it as there is still “a great controversy” surrounding the connection between homocysteine and stroke risk. But, as you can see in the graph below and at 0:57 in my video Vegetarians and Stroke Risk Factors: Vitamin B12 and Homocysteine?, those with higher homocysteine levels do seem to have more atherosclerosis in the carotid arteries that lead up to the brain, compared to those with single-digit homocysteine levels, and they also seem to be at higher risk for clotting ischemic strokes in observational studies and, more recently, bleeding hemorrhagic strokes, as well as increased risk of dying from cardiovascular disease and all causes put together. 

    Even more convincing are the genetic data. About 10 percent of the population has a gene that increases homocysteine levels by about 2 points, and they appear to have significantly higher odds of having a stroke. Most convincing would be randomized, double-blind, placebo-controlled trials to prove that lowering homocysteine with B vitamins can lower strokes, and, indeed, that appears to be the case for clotting strokes: Strokes with homocysteine-lowering interventions were more than five times as likely to reduce stroke compared with placebo.

    Ironically, one of the arguments against the role of homocysteine in strokes is that, “assuming that vegetarians have lower vitamin B12 concentrations than meat-eaters and that low vitamin B12 concentrations cause ischaemic stroke, then the incidence of stroke should be increased among vegetarians…but this is not the case.” However, it has never been studied until now.

    As you can see in the graph below and at 2:16 in my video, the EPIC-Oxford study researchers found that vegetarians do appear to be at higher risk.

    And no wonder, as about a quarter of the vegetarians and nearly three-quarters of the vegans studied were vitamin B12-depleted or B12-deficient, as you can see below and at 2:23, and that resulted in extraordinarily high homocysteine levels.

    Why was there so much B12 deficiency? Because only a small minority were taking a dedicated B12 supplement. And, unlike in the United States, B12 fortification of organic foods isn’t allowed in the United Kingdom. So, while U.S. soymilk and other products may be fortified with B12, UK products may not. We don’t see the same problem among U.S. vegans in the Adventist study, presumably because of the B12 fortification of commonly eaten foods in the United States. It may be no coincidence that the only study I was able to find that showed a significantly lower stroke mortality risk among vegetarians was an Adventist study.

    Start eating strictly plant-based without B12-fortified foods or supplements, and B12 deficiency can develop. However, that was only for those not eating sufficient foods fortified with B12. Those eating plant-based who weren’t careful about getting a regular reliable source of B12 had lower B12 levels and, consequently, higher homocysteine levels, as you can see below and at 3:27 in my video.

    The only way to prove vitamin B12 deficiency is a risk factor for cardiovascular disease in vegetarians is to put it to the test. When researchers measured the amount of atherosclerosis in the carotid arteries, the main arteries supplying the brain, “no significant difference” was found between vegetarians and nonvegetarians. They both looked just as bad even though vegetarians tend to have better risk factors, such as lower cholesterol and blood pressure. The researchers suggest that B12 deficiency plays a role, but how do they know? Some measures of artery function weren’t any better either. Again, they surmised that vitamin B12 deficiency was overwhelming the natural plant-based benefits. “The beneficial effects of vegetarian diets on lipids and blood glucose [cholesterol and blood sugars] need to be advocated, and efforts to correct vitamin B12 deficiency in vegetarian diets can never be overestimated.”

    Sometimes vegetarians did even worse. Worse artery wall thickness and worse artery wall function, “raising concern, for the first time, about the vascular health of vegetarians”—more than a decade before the new stroke study. Yes, their B12 was low, and, yes, their homocysteine was high, “suggest[ing] that vitamin B12 deficiency in vegetarians might have adverse effects on their vascular health.” What we need, though, is an interventional study, where participants are given B12 to see if that fixes it, and here we go. The title of this double-blind, placebo-controlled, randomized crossover study gives it away: “Vitamin B-12 Supplementation Improves Arterial Function in Vegetarians with Subnormal Vitamin B-12 Status.” So, compromised vitamin B12 status among those eating more plant-based diets due to not taking B12 supplements or regularly eating vitamin B12-fortified foods may explain the higher stroke risk found among vegetarians.

    Unfortunately, many vegetarians resist taking vitamin B12 supplements due to “misconceptions,” like “hold[ing] on to the old myth that deficiency of this vitamin is rare and occurs only in a small proportion of vegans.” “A common mistake is to think that the presence of dairy products and eggs in the diet, as in LOV [a lacto-ovo vegetarian diet], can still ensure a proper intake [of B12]…despite excluding animal flesh.”

    Now that we may have nailed the cause, maybe “future studies with vegetarians should focus on identifying ways to convince vegetarians to take vitamin B12 supplements to prevent a deficiency routinely.” 

    I have updated my recommendation for B12 supplementation. I now suggest at least 2,000 mcg (µg) of cyanocobalamin once weekly, ideally as a chewable, sublingual, or liquid supplement taken on an empty stomach, or at least 50 mcg daily of supplemental cyanocobalamin. (You needn’t worry about taking too much.) You can also have servings of B12-fortified foods three times a day (at each meal), each containing at least 190% of the Daily Value listed on the nutrition facts label. (Based on the new labeling mandate that started on January 1, 2020, the target is 4.5 mcg three times a day.) Please note, though, that those older than the age of 65 have only one option: to take 1,000 micrograms a day. 

    We started this series on what to eat and not eat for stroke prevention, and whether vegetarians really have a higher stroke risk. Check related posts for the last few videos that looked at specific factors.

    Stay tuned for: 

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    Michael Greger M.D. FACLM

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  • The 411 on Vitamin B12 | NutritionFacts.org

    The 411 on Vitamin B12 | NutritionFacts.org

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    Vitamin B12 is not made by plants or animals, but by microbes blanketing the earth. We presumably used to get B12 when we drank out of a mountain stream or sipped water from a well, based on studies showing vegetarians in developing countries who drink purified water appear to be at higher risk. Now, we typically chlorinate our water supply to kill off any bacteria. So, most of us don’t get a lot of B12 in our water anymore, but we don’t get a lot of cholera, either. That’s a benefit of living in a much more sanitary world. Vegetarians living in slums in lesser developed regions appear to have fewer B12 problems, though. Basically, the more hygienic our meals, the less B12 we get. Our fellow great apes, like gorillas, get all the B12 they need eating their own feces. I prefer supplements. So, how much should we get, which type is best, and how can we tell if we have a B12 deficiency?

    The Benefits of Vitamin B12

    We cannot mess around with getting vitamin B12. If we don’t get enough, we may face a wide range of disorders of the gut, blood, brain, and nervous system.

    Many case reports detail ways B12 can be life-changing. For instance, a 47-year-old woman had a five-year history of psychosis. She had been treated with antipsychotic drugs and was cognitively impaired and reported visual hallucinations. After her mother revealed that the patient had been following a strict vegan diet for seven years, vitamin B12 supplementation was started and her symptoms went away. She had lost years of her life lost in a psychotic haze—apparently just because she didn’t want to take a supplement.

    Vitamin B12 supplementation is mandatory for anyone eating plant-based diets and, as I’ll discuss later, for every one of us from age 65.

    Vitamin B12 Deficiency: Symptoms and Treatment

    As I discuss in my video The Symptoms of Vitamin B12 Deficiency, it can cause everything from abdominal distention and chronic diarrhea to shortness of breath and swollen, red, painful feet. It can also cause Parkinson’s syndrome–like symptoms, skin darkening (that resolved with supplementation), and bilateral useless hand syndrome, a condition I had never heard of before.

    Being deficient in B12 may also manifest in a variety of neurological symptoms—for example, numbness and tingling in the hands and feet, muscle cramps, dizziness, cognitive disturbances, difficulty walking, and erectile dysfunction—as well as fatigue and such psychiatric symptoms as depression along with psychosis.

    How can B12 deficiency be treated? Either with B12 supplements or B12-fortified foods.

    Suggested Vitamin B12 Dosage

    The official position of associations and governmental agencies is categorical and unequivocal: Supplementation of vitamin B12 is required for anyone on a vegetarian diet—even when consuming eggs and dairy—and I would extend that to include flexitarians eating only a few servings of meat a week.

    Who else should ensure they have a regular, reliable source of vitamin B12 by supplementing their diet with B12 supplements or B12-fortified foods? Those who’ve had bariatric surgery (which can sometimes impair absorption), those eating plant-based diets, and everyone from the age of 65.

    As I discuss in my video The Optimal Vitamin B12 Dosage for Adults, adults younger than 65 should take at least one 2,000 mcg (µg) supplement once a week, ideally as a chewable, sublingual, or liquid supplement taken on an empty stomach, or at least one 50 mcg (µg) daily supplement. As we age, our ability to absorb vitamin B12 may decline. So, for those 65 and older, the supplementation should probably be increased up to 1,000 mcg (µg) each day, as I discuss in my video The Optimal Vitamin B12 Dosage for Kids, Pregnancy, and Seniors.

    Pregnant and breastfeeding women can just follow my 50 mcg (µg) a day recommendation for nonpregnant adults or take 2,000 mcg (µg) a week, perhaps split into two doses to boost absorption. After infants are weaned, they can start on 5 mcg (µg) a day. From ages 4 through 10, kids can take half the adult dose of 25 mcg (µg) a day, then they can take 50 mcg (µg) a day or 2,000 mcg (µg) a week from age 11.

    Note that these doses are specific to cyanocobalamin, the preferred supplemental form of vitamin B12. (I discuss cyanocobalamin versus methylcobalamin below.)

    The Best Food Sources of Vitamin B12

    If you need supplemental B12 but don’t want to take supplements, you must rely on B12-fortified foods––eating three separate servings of B12-fortified foods a day, each ideally containing at least 190 percent of the “Daily Value” on the product’s nutrition facts label. As I discuss in my video The Healthiest Food Sources of Vitamin B12, B12-fortified nutritional yeast is a common food source, and there are all sorts of other B12-fortified options on the market, including plant-based meats and milks, breakfast cereals, and even energy drinks. 

    The Worst Food Sources of Vitamin B12

    What about various algae-type products, like spirulina, which are advertised as natural vitamin B12 sources? Not only do they not actually contain B12 that’s useable for humans, they may contain B12 analogues—look-alike molecules that can even block your absorption of real B12!

    Can Vitamin B12 Cause Side Effects?

    You don’t have to worry about taking too much vitamin B12. It’s water-soluble. So, at worst, you’ll just end up with more expensive pee. Injectable forms, though, can trigger acne.

    Methylcobalamin vs. Cyanocobalamin

    There are two main types of vitamin B12: methylcobalamin, marketed as methyl B12, and cyanocobalamin, typically marketed as just vitamin B12. Methylcobalamin is more expensive so it must be better, right? Wrong.

    As I discuss in my video The Best Type of Vitamin B12: Cyanocobalamin or Methylcobalamin, cyanocobalamin is the most used form, thanks to its high stability. Methylcobalamin is less stable and particularly susceptible to being destroyed after exposure to light.

    The one major exception may be kidney failure, though. Methylcobalamin may be better for those with impaired kidney function. It’s been speculated that oral methylcobalamin or injected hydroxycobalamin may also be preferable in smokers, though it has yet to be confirmed.

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    Michael Greger M.D. FACLM

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

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

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    For several months during the summer of 2022, my dog Scout vomited at 3 a.m. nearly every day. If you have a dog, you know the sound. And each time, she gobbled up her mess before I could get to it, making diagnosis of the cause difficult.

    The vet and I eventually settled on my hydrangeas as the source of the problem – but keeping Scout away from them didn’t work. She started to seem tired all the time – highly concerning in a typically hyper yellow Lab puppy.

    Then one day Scout vomited up a hairball – but not just any hairball. In dogs, hair normally passes easily through the digestive system, but this hairball was wrapped around a brillo pad that was too big to move through. Once this foreign object was removed, the overnight vomiting ended. Scout still needed treatment, though, for a different and surprising reason: The object had inhibited a step in her body’s absorption of vitamin B12. B12 is an essential nutrient involved in proper functioning of blood cells, nerves and many other critical processes in the body.

    I’m a registered dietitian, and I teach nutrition and food science to college students, but still I missed the B12 deficiency that was causing my puppy’s fatigue. Doctors can just as easily be blind to it in people – even though B12 deficiency is a common health problem that affects an estimated 6% to 20% of the U.S. population.

    B12 is scarce in the diet, and it is found only in foods from animal sources. Fortunately, humans need only 2.4 micrograms of B12 daily, which is equivalent to one ten-millionth of an ounce – a very, very small amount. Without adequate B12 in the body, overall health and quality of life are negatively affected.

    An array of vitamin B12-rich foods – all of which come from animals. <a href="https://www.gettyimages.com/detail/photo/vitamin-b12-containing-foods-royalty-free-image/511052342?phrase=B12%20foods&adppopup=true" rel="nofollow noopener" target="_blank" data-ylk="slk:photka/iStock via Getty Images Plus;elm:context_link;itc:0" class="link "><button class=

    Signs and symptoms

    One primary symptom of B12 deficiency is fatigue – a level of tiredness or exhaustion so deep that it affects daily life activities.

    Other symptoms are neurological and may include tingling in the extremities, confusion, memory loss, depression and difficulty maintaining balance. Some of these can be permanent if the vitamin deficiency is not addressed.

    However, since there can be so many causes for these symptoms, health care providers may overlook the possibility of a B12 deficiency and fail to screen for it. Further, having a healthy diet may seem to rule out any vitamin deficiency. Case in point: Because I knew Scout’s diet was sound, I didn’t consider a B12 deficiency as the source of her problems.

    How B12 is absorbed

    Research is clear that people who consume plant-based diets must take B12 supplements in amounts typically provided by standard multivitamins. However, hundreds of millions of Americans who do consume B12 may also be at risk because of conditions that could be hampering their body’s absorption of B12.

    B12 absorption is a complex multistep process that begins in the mouth and ends at the far end of the small intestine. When we chew, our food gets mixed with saliva. When the food is swallowed, a substance in saliva called R-protein – a protein that protects B12 from being destroyed by stomach acid – travels to the stomach along with the food.

    Specific cells in the stomach lining, called parietal cells, secrete two substances that are important to B12 absorption. One is stomach acid – it splits food and B12 apart, allowing the vitamin to bind to the saliva’s R-protein. The other substance, called intrinsic factor, mixes with the stomach’s contents and travels with them into the first part of the small intestine – the duodenum. Once in the duodenum, pancreatic juices release B12 from R-protein and hand it to intrinsic factor. This pairing allows B12 to be absorbed into cells, where it can then help maintain nerve cells and form healthy red blood cells.

    A 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 will not bind to the saliva’s R-protein, and the body’s ability to absorb it is inhibited. And there are hundreds of different drugs that can cause dry mouth, resulting in too little saliva production. They include opioids, inhalers, decongestants, antidepressants, blood pressure drugs and benzodiazepines, like Xanax, used to treat anxiety.

    The last three categories alone account for easily 100 million prescriptions in the U.S. each year.

    Another potential contributor to B12 deficiency is low levels of stomach acid. Hundreds of millions of Americans take anti-ulcer medications that reduce ulcer-causing stomach acids. Researchers have firmly linked the use of these drugs to B12 deficiency – although that possibility may not outweigh the need for the medication.

    Production of stomach acid can also decrease with aging. More than 60 million people in the U.S. are over age 60, and some 54 million are over the age of 65. This population faces a higher risk of B12 deficiency – which may be further increased by use of acid-reducing medications.

    Production of gastric acid and intrinsic factor by the specialized parietal cells in the stomach is critical for B12 absorption to occur. But damage to the stomach lining can prevent production of both.

    In humans, impaired stomach lining stems from gastric surgery, chronic inflammation or pernicious anemia – a medical condition characterized by fatigue and a long list of other symptoms.

    Another common culprit of B12 deficiency is inadequate pancreas function. About one-third of patients with poor pancreas function develop a B12 deficiency.

    And lastly, Metformin, a drug used by around 92 million Americans to treat Type 2 diabetes, has been associated with B12 deficiency for decades.

    Treatment for B12 deficiency

    While some health care providers routinely measure B12 and other vitamin levels, a typical well-check exam includes only a complete blood count and a metabolic panel, neither of which measures B12 status. If you experience potential symptoms of a B12 deficiency and also have one of the risk factors above, you should see a doctor to be tested. A proper lab workup and discussion with a physician are necessary to discover or rule out whether inadequate B12 levels could be at play.

    In the case of my dog Scout, her symptoms led the vet to run two blood tests: a complete blood count and a B12 test. These are also good starting points for humans. Scout’s symptoms went away after a few months of taking oral B12 supplements that 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 the B12 deficiency. Full recovery can take up to a year but is very possible with appropriate treatment.

    Treatment for B12 deficiency can be oral, applied under the tongue or administered through the nose, or it may require various types of injections. A B12 supplement or balanced multivitamin may be enough to correct the deficiency, as it was for Scout, but it’s best to work with a health care provider to ensure proper diagnosis and treatment.

    This article is republished from The Conversation, a nonprofit, independent news organization bringing you facts and trustworthy analysis to help you make sense of our complex world.The Conversation is trustworthy news from experts. Try our free newsletters.

    It was written by: Diane Cress, Wayne State University.

    Read more:

    Diane Cress does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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  • Need More Energy? Try These 5 Foods Full of Vitamin B12.

    Need More Energy? Try These 5 Foods Full of Vitamin B12.

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    This article was originally published on Clean Eating.

    Did you know vitamin B12 is often called “the energy vitamin”? Not only is vitamin B12 pivotal in keeping your blood and nerve cells healthy, but it’s also involved in making DNA – meaning it’s literally part of the material that makes up every single cell of your body. Studies have found Vitamin B12 helps athletes build muscle mass and improve endurance, reduce muscle fatigue, boosts production of red blood cells, and speed recovery. So, when you hear health professionals say vitamin B12 is kind of a big deal, we mean it!

    Now, there may be a “magic pill” for what seems like everything these days, including vitamin B12, but buyer beware. Vitamin B12 infusions offered by high-end shopping centers and spas tout a “natural” boost of energy for a pretty penny. But are they really necessary? Most likely, no. I will admit, I’m a bit biased in that I have a food-first, supplement-as-safety-net philosophy. But I still couldn’t fathom paying the $90 I’ve seen quoted per infusion when research shows there are staple foods you can easily eat more of to naturally increase your B12 levels.

    Skip the pricey infusions and instead try tweaking your diet. Consider adding these five foods into your meals to naturally increase your intake of vitamin B12. And, of course, always consult with your healthcare provider if you have any questions or concerns about your particular needs. Some lifestyles, such as vegan and vegetarianism, do require supplementation of B12 to ensure you are meeting your needs.

    5 Foods High in Vitamin B12

    The following foods all contain 20% or more of the recommended daily vitamin B12 intake (2.4 micrograms per day for adults). With these in your daily rotation, you can boost your energy and ensure you’re eating a well-rounded, nutrient-rich diet.

    (Photo: Clean Eating)

    1. Nutritional Yeast

    Did you know vitamin B12 is usually found in animal products and proteins, yet one of the richest sources is actually vegan? I’m not kidding! Nutritional yeast is a vitamin B12 powerhouse with a fourth cup providing anywhere from 8.3 to 24 mcg per serving, or about 346 to 1,000 percent of the daily value. While the amount varies from brand to brand, it’s without question worth it to add a little sprinkle of nutritional yeast to your pastas, popcorn, and sauces to help increase your B12 intakes, naturally.

    If you’re new to nutritional yeast, it has a flakey texture and blends well into dishes you’d like to impart a cheese-like flavor, all while keeping your recipes dairy-free.

    Salmon
    (Photo: Clean Eating)

    2. Salmon

    There’s more than just omega-3’s found inside delicious and nutritious seafood. A 3-ounce serving of cooked salmon provides 2.6 mcg of vitamin B12, or about 108 percent of the daily value! Plus, it also contains vitamin D, an important nutrient necessary for keeping your bones healthy.

    While salmon comes in a variety of convenient options, from smoked and refrigerated to cooked and canned, there are a plethora of ways to add more salmon into your busy routine.

    Ground beef

    3. Lean Ground Beef

    Along with an array of other important nutrients that support healthy living and aging, an 85 percent lean, 15 percent fat pan-browned three-ounce portion of ground beef contains 2.4 mcg of vitamin B12, or about 100 percent of the daily value. For individuals who struggle to get enough vitamin B12, choline, iron, zinc and protein in their diets, lean beef is an excellent addition that provides quite literally a lot of bang for your nutritional buck. It’s easy to prepare and pairs well with other nutrient-rich foods, like fruits and vegetables, that most Americans need to be eating more of.

    cows-milk
    (Photo: Clean Eating)

    4. Cow’s Milk

    Unless you have a food allergy or lifestyle preference, there’s no reason to remove cow’s milk from your diet. It’s high in vitamin B12, coming in at 1.3 mcg per 1 cup serving, or about 54 percent of the daily value. Dairy milk plays an important role in growth and development through supporting bone health, as well as regulating blood pressure.

    If milk isn’t your jam, you can still reap the benefits of dairy by including yogurt in your diet, too! A six-ounce container of yogurt contains 1 mcg of vitamin B12 too, or about 43 percent of the daily value.

    cereal
    (Photo: Clean Eating)

    5. Fortified Breakfast Cereal

    Quite possibly my favorite B12-rich food to recommend to families regardless of economic stance is fortified breakfast cereal. It’s convenient, available on multiple government food assistance programs and downright delicious. A serving (about 1 to 1 ¼ cups) of most standard fortified breakfast cereals provides about 25 percent of the daily value of vitamin B12, or about 0.6 mcg. Pair the cereal with cow’s milk and you get a double dose of vitamin B12!

    While there’s a wide variety of fortified breakfast cereals to choose from, I recommend choosing two. First, choose one that contains minimal added sugar, like a whole grain oat cereal. Then, choose a second that your family loves, usually with a tad more added sugar. Do a 70/30 blend of the whole grain oat with the “fun” cereal to create a nutrient rich bowl of goodness to start your day!

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    Mallory Arnold

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  • Vitamin B12: What It Can Do, and What It Can’t

    Vitamin B12: What It Can Do, and What It Can’t

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    SOURCES:

    Lauri Wright, PhD, RDN, national spokesperson, Academy of Nutrition and Dietetics and chair, department of nutrition and dietetics, University of North Florida.

    M. Elizabeth Swenor, DO, in charge of Lifestyle, Integrative, and Functional Medicine, Henry Ford Health System, Detroit.

    Mount Sinai: “Vitamin B12 (Cobalamin).”

    Merck Manual: “Vitamin B12 Deficiency.”

    National Institutes of Health Office of Dietary Supplements: “Vitamin B12.”

    Cleveland Clinic: “The Best Sources of Vitamin B12.”

    Harvard Medical School: “Vitamin B12 deficiency can be sneaky, harmful.”

    National Heart, Lung, and Blood Institute: “Pernicious Anemia.”

    International Journal of Cancer: “Biomarkers of folate and vitamin B12 and breast cancer risk: report from the EPIC cohort.”

    Memorial Sloan Kettering Cancer Center: “Vitamin B12.”

    National Health Service UK: “Complications – Vitamin B12 or folate deficiency anaemia.”

    Archives of Internal Medicine: “Folic Acid, Vitamin B6, and Vitamin B12 in Combination and Age-related Macular Degeneration in a Randomized Trial of Women.”

    American Academy of Dermatology: “Can oils, probiotics, or vitamins heal eczema?”

    Dermatology: “Association of Serum Vitamins with Eczema in US Adults (NHANES 2005–2006).”

    Mayo Clinic: “Vitamin B-12.”

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