You Ever Needed to Know about B12
So this is not a B12 article that simply consists of information gathered from existing sources that my personal biases resonate with, like so many of the B12 articles out there (a good researcher should have no biases when seeking the truth/reality). While the purpose of this article is not so much to explain why there is so much contradictory B12 information, and instead it seeks to educate you about the facts surrounding B12 (which is what can really impact your health), if you read between the lines, and understand that people are subject to human nature which can include taking positions that support their personal philosophies, personal preferences, and personal beliefs, you may find some clues as to why some people can write a B12 article that contains both 100% spot-on information and some incorrect information too.
Some vegan health educators and laypeople (especially raw food vegans) claim that vegans do not have to worry about B12, or that supplementation is not the answer. Research, and my clinical experience, clearly show that plant-based foods are not a sufficient and reliable source of B12, and that most vegans, even raw food vegans, become deficient at some point if they do not supplement in some form. But why is this? We obviously weren't designed to require nutritional supplements. Where is B12 supposed to come from? This article will attempt to answer this hotly debated question.
Turns out, there is B12 in any food that contains quantities of the B vitamin complex, but previously we were just not able to assay these tiny amounts. Today, more modern technology has allowed us to discover that there is B12 in those foods rich in the B complex vitamins. But, it is not enough to rely on for our B12 needs! And that's the take-home point. So just because there is some B12 in some plant-based foods is not proof that this is where we're designed to get our B12 from. So when someone tells you that there's B12 in fruits, don't argue the point, simply ask them, "but is it enough to supply us with what we need?" Because that's what matters!
And maybe millions of years ago, when stress levels were lower than they are today, and therefore our B12 needs were lower, and we also got some naturally occurring B12 from the water we drank, and we were active enough ("appropriately active") to eat enough food to get enough protein to make enough Intrinsic Factor (needed to utilize the B12 we make), then, yes, maybe this amount of B12 was enough along with what our bodies made to provide us with all the B12 we needed. But that was millions of years ago. Let's deal with the point in time where we're living now. Let's deal with reality. And in reality, there are many reasons why meat-eaters, vegetarians, vegans, and raw foodists should test their B12 levels and correct insufficiencies/deficiencies, especially since long-term deficiencies can cause vascular injury and irreversible neurological damage.
And by-the-way, the
little bit of soil that may contain B12 that may be on the fruits and
veggies you're eating (by not washing them), is not a source of B12 for
B12 is a water-soluble B vitamin that's vital for carbohydrate metabolism and energy production, also playing an important role in the formation of healthy red blood cells, and in all neurological functions. B12 is made by a microbe a bacteria; it is produced by microorganisms. B12 is the only nutrient that contains a trace element cobalt which gives it its chemical name of cobalamin. We require cobalt, although it is utilized only in the form of B12. And if you want to get technical, B12 is not really a vitamin; we just call it that for the sake of convenience; this is why from this point forward you'll see me calling it just "B12" (same for "vitamin" D). And by-the-way, since your body needs cobalt to make B12, if there's not enough in the foods you eat because of the way they are grown, your body won't be able to make enough B12, and this is one of the contributing factors to why raw foodists have B12 deficiencies.
The good news is: We can make it ourselves! But among the many controversies surrounding B12, there is the argument that, although Intrinsic Factor (needed to absorb B12) is produced in our stomachs, and that our intestines are known to produce B12, the B12 is produced too low down in the intestines to be absorbed by our bodies. But this argument was disproved by research decades ago and is nothing more than a theory, and a disproven one at that. Indeed, in a 1999 version of Human Anatomy and Physiology, it states quite clearly that we do indeed absorb B12 through our small intestines. So this is how we're supposed to be able to get B12. I say "supposed to" because there are some things we do that prevent this from happening.
1. Consuming poisonous
liquids (alcoholic beverages)
Reasons your body
may not have enough B12
1. Your body is not
making enough and/or you're not swallowing enough
Those who are at particular risk of B12 deficiency are people who...
...avoid common B12
fortified foods (such as raw food vegans or macrobiotic vegans)
Being that I just mentioned it, it comes to mind that low B12 levels (a high uMMA) can have as a contributing factor, low iodine levels. Anyone with a low B12 status (I'm not talking about your B12 blood level here) should get an iodine test done. But even if you have an "okay" B12 status, this does not automatically mean that your iodine level is also okay; in reality, based on all the people I've tested for iodine, everyone should get their iodine level checked (fully 100% of the folks I've tested thus far have had low iodine levels to some degree, which is not surprising when you understand how this can be so). Now here's the kicker: MDs will do a spot iodine urine test to check your iodine, but this is not indicative of the body's iodine tissue sufficiency level, which is a much better indicator of your iodine status (just as an MMA test is better than a B12 blood test). So a 24-hour iodine loading test is best for diagnostic purposes, but it should come as no surprise that the most diagnostically relevant tests are not covered by insurance, and are not available everywhere. In fact, only two labs in the U.S. do the 24-hour iodine loading test, and I'm one of a small number of practitioners who recommends it, and knows how to assess the results as it relates to corrective measures. And iodine may actually be more problematic than B12 because our body can't make it; and the RDI for iodine is too low for iodine sufficiency (more on the shortcomings of the RDIs below). But iodine is a story for another article; I digressed only because of the prevalence of iodine insufficiency/deficiency and its importance to optimal health.
More on the Intrinsic Factor
To be properly assimilated, the B12 your body makes or that you swallow must be combined with a mucoprotein enzyme called the Intrinsic Factor, which is normally present in gastric secretions made in the stomach. If Intrinsic Factor production is impaired, B12 utilization will not take place, no matter how much B12 is made in our body. One interesting reason for insufficient Intrinsic Factor production which I mentioned above is when someone is eating a low-fat, and thus low-protein diet, and they're not active enough to warrant eating enough food to provide enough of all the Essential Amino Acids the building blocks of protein so there may not be enough of this important mucoprotein enzyme that is strangely called the Intrinsic Factor. It should be noted that a B12 supplement placed under the tongue (sublingual) does NOT require the Intrinsic Factor for the B12 to be utilized by the body as some raw food educators state (and personally, I wouldn't take the advice of someone who says not to bother to test for B12 unless and until you experience symptoms. This incredibly irresponsible advice should be self-evident, so test preactively and not reactively.)
In the U.S., a B12 blood test is standard-of-care for testing B12. The range is 211 - 946 pg/mL, meaning 211 is the low end of the "okay" range. But the low end is now thought to be too low; in Japan, where their cases of dementia are much less than in the U.S., their low end is 500. But, even if you test at 500, you may still be too low, utilization-wise; here's why.
Spirulina, algae, and all sea vegetables do not have active B12 once they are dried. They instead have a significant amount of B12 "analogs" (look like real B12 but are non-functional due to heat processing), and these inactive analogs compete with active B12, crowding them out of B12 receptor sites ("parking spaces" on cells), thus lowering one's B12 status. This is why the standard B12 blood test can show an "okay" result, while a uMMA test shows poor B12 status; the B12 blood test can't distinguish between active and inactive B12, and unfortunately most doctors are not aware of this (so educate them; some will thank you, and some will look at you scornfully). (Note: Even if you don't consume dried sea veggies, you can still have an "okay" B12 blood test and a "not okay" B12 status.)
A better test is for your B12 status, which shows your body's utilization of B12, and not merely how much B12 is in circulation in your blood, which is what the standard B12 blood tests looks at. This is done by testing a substance that directly reflects how well your body is utilizing B12. And this substance is MMA (Methylmalonic Acid). It can be a blood test or urine test, with the urine test being better because it is done more often than the blood test so there's more data, and you can do the urine test yourself at home and mail it to a lab but the MMA blood test must be done in a lab or doctor's office. Normal uMMA is between 0.00-3.56 µmol/mmol Cr (the small letter u in uMMA means it's a urine test), and the lower, the better. If it's higher than 3.56, you are definitely B12 deficient or not utilizing the B12 your body is making in your digestive tract. How much higher would determine how much B12 to take therapeutically. Also, if your result is 3.55 this does not mean that you are fine B12-wise, and you should still correct the B12 insufficiency by looking at those lifestyle practices that can interfere with your body making and absorbing B12. (Note: You may be doing everything "right" but have a demand for B12 that your body simply can't supply because of today's higher amounts of stress that your body was never designed to deal with; this is another reason for poor B12 status and the need for B12 supplementation.)
If all you can get is a sMMA test (blood test, the "s" is for serum), the range there is 0-376 nmol/L (0.00-0.38 µmol/l), with the lower, the better.
For obvious reasons, the MMA test is considered the Gold Standard for B12 level testing, but there is another test that can also reveal a B12 deficiency: a homocysteine blood test (sHCY). If it's elevated, you may have a B12 deficiency.
(hyperhomocysteinemia) also happens with deficiencies in B6 or folate*,
which may affect people who eat a horrible diet, and some vegetarians
and vegans, but raw foodists are not likely to be low in these nutrients,
so doing a sHCY test may also be a good indicator of your B12 status if
you're getting enough B6 and folate. But elevated homocysteine can also
occur when an animal-based diet is eaten, especially meat because it contains
a higher amount (than a plant-based diet) of an amino acid called methionine
which can have the effect of raising homocysteine into the unhealthy range.
So if non-vegans want to test their B12, the MMA test is the way to go. But since they are eating foods humans are not designed to eat, getting a homocysteine test too can let them know if they need to cut back on their animal eating so they don't risk heart disease and deterioration of their arteries and nerves (when homocysteine is high, it acts as a nerve and blood vessel toxin and can accelerate atherosclerosis, the primary cause of heart attacks and strokes).
And FYI, the normal range for sHCY is 2.2-13.2 µmol/l, with single digits being the best. Levels of homocysteine in typical Western populations are about 12, and although this is in the "normal" range, it is not necessarily a healthy level. If you're at 22 for a while, you are five times as likely to have a fatal heart attack as someone with a consistent reading of 8... that's five times more, not five percent more. (What I'm implying here is that homocysteine is a better marker for cardiovascular disease than cholesterol, but since there are no drugs that can lower homocysteine like there are for cholesterol, this could be a reason why the homocysteine test is not part of a basic panel blood tests that are done when doing a general check-up. With what is known about homocysteine, shame on the medical industry.)
So a sHCY test is
another good tool in your toolbox because high homocysteine levels are
connected with the potential for heart disease, arterial destruction and
neurological pathologies. Other diseases associated with an elevated homocysteine
are: Alzheimer's and age related hearing loss (due to low B12), neural
tube defects (due to low folate), recurrent loss of pregnancy, and, you
guessed it, premature death.
A note on assessing
your need for supplementary B12 by simply taking some for a while and
seeing how you feel: This does not appear to be a good idea. I have found
this to be too subjective a "test". A number of folks who tried
this and concluded that they were fine, who then got tested (uMMA test)
were in reality, not fine. A few had used oral (swallowed) B12,
so the "no effect" was understandable for the reasons given
below, but most had used a good quality sublingual. And when I was diagnosed
with a rather low B12 deficiency, and then took therapeutic amounts of
B12, and retested a week later, and was then okay, I didn't feel any better
when I took the B12. So this method is not a reliable way to test your
1. The methylcobalamin form of B12 is used by the enzyme methionine synthase to change homocysteine into methionine. When this enzyme is not working, our homocysteine level increases, and as I said earlier, this is associated with increased risk of heart disease and deterioration of the arteries and nerves (don't you just love my gentle reminders).
2. Another function of B12 is as a coenzyme in using 5-deoxyadenosylcobalamin in the enzyme methyl malonyl-CoA mutase in the conversion of methyl malonyl-coA to succinyl-CoA. I mention this complicated stuff as an example of what you don't need to know (and that I do my homework). But seriously, this function of B12 is why there's a direct correlation between a low B12 status and a high MMA level, and it's why the MMA test is the Gold Standard for B12 testing.
For the sake of completeness, I should add that it's often said that there's only one reason MMA can be high, and that's due to a bad B12 status. But there are some other documented reasons attributed to high MMA such as genetic defects, kidney failure, low blood volume, dysbiosis (microbial imbalances in the GI tract), pregnancy, and hypothyroidism. But since some of these conditions can themselves have as a contributing factor a low B12 status, and since some of these conditions can cause a low B12 status (by requiring larger than normal amounts of B12), when your MMA test result is high, it's a good idea to figure that your B12 status is low, and to supplement to correct it, and then retest MMA in a month to see if it came down.
Some people might think that if they are fine, B12-wise, then there's no reason to get a reliable supply of B12 via supplementation for the time being. The problem with this is that you never know when you will hit the point in which MMA or homocysteine levels start to rise. They may stay low for years, months, or only weeks after they are tested and found to be normal. There is no test that can tell you how long your B12 status will be adequate if your body is not getting/making a reliable source of B12. So those people who subscribe to the "better to be safe than sorry" philosophy may either test their B12 status on a regular basis, or simply supplement with B12 as a hedge against deficiency. Those people who'd rather not take a supplement unless absolutely necessary should obviously test their MMA on a regular basis. It's not recommended to wait until signs of a B12 deficiency appear to do something about it, which brings me to...
I've heard it said that proactive (precautionary) testing is not necessary, and to wait for symptoms to manifest before testing. From my experience, this is not a wise thing to do. In fact, let me be blunt, this advice is irresponsible, and the only good thing about it is, it says something very telling about the person who gives such advice (calls into question the correctness of their teachings in general). As far as the recommendation itself, first, you may not realize you're having a problem until a B12 deficiency gets far enough along to where you experience symptoms; the damage from a B12 deficiency doesn't start at the onset of symptoms, it starts prior to them. And if and when you do notice something is going on, and you try to self-diagnose without testing, you may draw the wrong conclusions, and while you're proceeding down the wrong corrective path, the B12 deficiency is getting worse. And considering that damage may be done that doesn't affect you now, but will affect you in the future, the prudent thing to do would be to keep tabs on your B12 status. And you can also get a uMMA test done once, and supplement from then on if the deficiency was potentially problematic, semi-serious or serious (although follow-up testing is a wise thing to do to make sure you're taking enough and/or taking it often enough).
There are a variety of symptoms of B12 deficiency. An early symptom can be low energy. But be careful when attempting to self-diagnose; if you read this, and realize you have low energy, you may assume you're low in B12, but there are other contributing factors to low energy, low iodine being one of the major ones (because of how it affects metabolism and hormones). So when self-diagnosing, it's prudent to get a second opinion (from someone who doesn't have a bias against nutritional supplementation).
Initial symptoms of B12 deficiency can include:
There can also be certain neurological manifestations that occur when the deficiency increases, including:
And if impaired memory and behavior changes are "pre-Alzheimer's", normalizing the B12 level ASAP may prevent full-blown Alzheimer's which is irreversible. Yes, some of the neurological symptoms can lead to irreversible damage if they go on too long; for example, deep myelination (the erosion of the protective sheath around the axons of neurons). And it's important to note that impaired mental function can occur before any of the other B12 symptoms.
Many of the above symptoms can be due to things other than low B12 status, and if this is the case, testing your MMA may rule out low B12 as a cause, which is diagnostically significant. It's also important to note that high homocysteine levels have no symptoms, so you can be B12 deficient, increasing your risk of vascular damage because of elevated homocysteine without experiencing any noticeable symptoms, underscoring the importance of testing (the first symptom of long-standing, elevated homocysteine can be a fatal heart attack).
If your uMMA shows you to be low in B12 (because it's high), corrective steps should be taken.
B12 from pills: There are two types: oral (swallowed), and sublingual (under-the-tongue, sometimes called "chewable" but don't chew them). Sublingual is preferred because the B12 gets absorbed directly into the bloodstream (oral B12 is not a reliable source of supplemental B12 because it doesn't work for a lot of people). And then there are the two popular forms of B12: cyanocobalamin and methylcobalamin. Without going into a lot of unnecessary detail, the "methyl" form is the one to take. Methylcobalamin is the active form of B12, which means it works immediately in the body when absorbed, and is delivered efficiently to nerve tissues. Cyanocobalamin is the cheaper of the two. In the rare case when the methyl form doesn't normalize MMA, then try adenosylcobalamin (aka dibencozide). Yes, sublingual tablets will contain tableting agents and maybe a flavoring, and some people will bristle at the thought of putting such things in their body, but on balance, it's better to not have a B12 insufficiency/deficiency; a healthy body is more than capable of dealing with the tiny bit of "other ingredients" that it has no use for.
B12 from injections: There are two basic reasons that warrant invasively piercing the skin with a needle to get B12 (it may seem like I have a bias against injections, but read on). In rare instances, a sublingual B12 won't work, and it is then that B12 injections are called for, but again this is rare, and a follow-up MMA test after you've supplemented for a month with tablets will confirm effectiveness (this is another reason why follow-up testing is a good idea). The other rationale for an injection is if you are at the doctor's office when (s)he goes over the test results, and you are found to be dangerously low... a "no time to waste" scenario. But if you have a choice between resolving a low B12 condition with either injections or sublingual tablets, the less damaging choice is advised (injections also contain preservatives which are worse than the "other ingredients" listed on the sublingual bottle in my opinion... hey look, one of the rare instances of me rendering an opinion!). Studies of people with severe B12 deficiencies have shown that sublingual doses of 1,000 micrograms per day for two months worked as well as 1,000 microgram injections given repeatedly, so if you're not experiencing any symptoms of B12 insufficiency/deficiency, correcting a low B12 status with a sublingual supplement may be preferable to injections. And remember, the body's alarm bells go off whenever the skin is pierced. And while speaking with a "progressive" medical doctor, he said that if you can avoid being medically cut or punctured, do so. I agree.
B12 from transdermal patches: Not effective enough, usually does not lower MMA enough, a hit-or-miss thing regarding different brands, in short, not recommended for resolving a B12 deficiency. Why do so many non-traditional "health educators" recommend them? Well, because they sell them, and the profit margin is way higher than tablets (this is why I used quotation marks around "health educators"). Since I don't sell supplements or participate in affiliate programs, there is no conflict-of-interest regarding my supplement recommendations.
B12 from drops: There are B12 drops, but from what I've been able to gather, the tablets are better absorbed. And my clinical experience regarding efficacy has been with the tablets (recommendations at the end of this article). I mention this because the supplement industry is not regulated in the same way as the pharmaceutical industry; when a bottle of Tylenol says it has 100 mg of acetaminophen per tablet, you can take that to the bank. But just because a bottle of B12 drops says it has 1,000 mcg of methylcobalamin per drop doesn't necessarily mean it has 1,000 mcg of methylcobalamin per drop. Sad, but true, and yet another reason to do follow-up testing.
Depending on the depth of the B12 insufficiency based on a B12 test, you'd either take daily sublingual tablets of either a low or high dosage, or an injection. I'm hoping you can go with the tablets.
A non-supplement way of raising your B12 level is to live in such a way that your B12 needs come down. This involves lowering both your emotional stress level and your physiological stress level by living in a more healthful manner, and by not consuming the things that interfere with B12 production in the body that I mentioned earlier (which allows increased B12 production).
I've heard it recommended that if you find you do indeed have a B12 insufficiency/deficiency, that you do a therapeutic water-only fast, and that this will correct the absorption problem. Sometimes this works, and sometimes it doesn't. Firstly, if the absorption problem was due to a genetic defect concerning the production of Intrinsic Factor, a fast will not resolve this. Secondly, if the low B12 issue was caused by the inclusion of the things that interfere with B12 being made in the body, a fast will not resolve this either, as the person will sometimes continue his "normal" dietary habits after he recovers from the fast. So B12 levels may come up just after a fast, but this can be temporary. And it goes without saying that if the low B12 level is because of a low cobalt level, a fast will obviously make matters worse.
And even if a fast, followed by healthful living habits, can eventually correct a B12 absorption issue, if the low B12 reading was low enough, it's prudent to correct the level pre-fast, or post-fast at the latest (remember, in Nature, such a low B12 level would never have happened, so this very low B12 level is, in effect, an unnatural situation, and using one unnatural situation supplementation to deal with another unnatural situation is a kind of balance in itself, yes?). So since, in some cases, fasting is not an alternative to resolving low B12 levels with supplementation, it may be a good idea to correct the insufficiency/deficiency with supplementation whether you fast or not... this is a case of "better to be safe than sorry".
Additionally, I don't recommend nutritional yeast as a way to raise B12 status because the only way nutritional yeast contains B12 is if it's been fortified with it... nutritional yeast does not contain any naturally occurring B12. So now you have the issue of which form of B12 was added and how much of it is bioavailable. So the safest and healthiest approach is a combination of healthful living habits and B12 supplementation if necessary or as a hedge against a future deficiency.
When B12 was discovered, and when a lack of it was linked to "pernicious" anemia (macrocytic anemia), it was mandated by the U.S. government that B12 be added to the populations' food supply. So B12 was then sprayed onto cereal as it was dispensed into its box at the packaging plant, and it was added to many other foodstuffs as well. This ended the high rate of pernicious anemia. But the amount used was just enough to prevent the worst-case scenario; it wasn't enough to prevent the chronic degenerative conditions that are now being directly linked to long standing B12 insufficiencies conditions that affect cognitive functioning and other neurological issues for example. (See "A word about published B12 requirements and Recommended Daily Intakes" above).
Some people are reluctant to take a supplement as they see this as admitting the inferiority of their diet, or because they've been taught that they don't need to take supplements as long as they don't cook what they eat (which is incorrect). But since it's a safe bet that the majority of the vegan and raw food community will, over time, run the risk of a B12 insufficiency/deficiency and an increased homocysteine level if there's no supplementation with a reliable B12 source, the solution to possible B12 problems is to get your MMA levels checked regularly. If your levels continue to be fine without any form of supplementation, that's great, but that is rarely the case for one reason or another. If your levels become low, then supplementation of some form should be considered if robust health is a priority.
And to those who say to simply just supplement in the first place, no testing needed, here's my problem with that. If a person absolutely can't afford to get a uMMA test (about $149), then, yes, this advice comes under the heading of "better to be safe than sorry". But what if the amount of B12 you decide to take is not enough? Without testing, you won't know. And because you're taking some B12, you may not get to the point of a full-blown dangerous B12 deficiency, but you could bump up against a B12 insufficiency where your body doesn't have enough B12 to operate at its full potential, which could translate to not having the best odds of avoiding a diagnosis of something serious in your future. A B12 level isn't an "okay / not-okay" scenario.
You can obtain the uMMA test for B12 status from Normal Clinical Labs by following the instructions here... (I do not participate in any affiliate programs so I make no money from this test.)
Which B12 supplement
you use really depends on the results of the uMMA test. If you're low
but not too low, you might consider this one...
NOTE: I'm not recommending Vitacost as a supplier. In fact, I'm always trying to find better ones... ones that not only have a decent price, but have "fresh" stock. iherb.com, and luckyvitamin.com may be better suppliers. And the above B12 is also sold at Whole Foods.