What do we know about vitamin B12 deficiency?

Victoria, British Columbia by night. (Dr. Noorali Bharwani)
Victoria, British Columbia by night. (Dr. Noorali Bharwani)

Even after more than 100 years, vitamin B12 (cobalamin) is still the subject of intense research.

Vitamin B12 plays an important role in red blood cell formation, cell metabolism, nerve function and the production of DNA. As we know, the function of DNA is to store all of the genetic information that a person needs to develop, function, and reproduce.

Vitamin B12 is also necessary for normal bone marrow and central nervous system function. The vitamin is absorbed in the distal ileum (where the small bowel joins the large bowel). Its absorption in the distal ileum requires intrinsic factor.

Where can you find intrinsic factor?

Intrinsic factor is a natural substance normally found in the stomach. Lack of intrinsic factor leads to vitamin B12 deficiency and pernicious anemia, and can cause brain and nervous system problems. There may be cognitive decline. There may be peripheral neuropathy. Quite often the presentation can be very suttle and potentially serious.

Vitamin B-12 deficiency is associated with dementia and low cognitive function, but it’s not clear whether vitamin B-12 supplements might help prevent or treat dementia.

The discovery of vitamin B12

“The discovery of vitamin B12, the elucidation of its role in metabolism, and the effects and treatment of its deficiency occurred in distinct phases over more than 100 years, and it was the subject of two separate Nobel Prizes,” says an article in Ann Nutr Metab 2012 (The discovery of vitamin B12 – authors Scott and Molloy).

The next advance was made with the discovery that a gastric component, which was named intrinsic factor, was missing in pernicious anemia. Many years later, intrinsic factor was found to be a glycoprotein that formed a complex with vitamin B12, promoting its absorption through ileal receptors.

The article says vitamin B12 is still the subject of intense research and, in particular, its role in preventing some irreversible neurological lesions remains unclear.

The incidence of vitamin B12 deficiency increases with age. The condition affects five to 20 per cent of adults older than 60 years.

The main source of vitamin B12 is animal-based foods such as meat, fish, eggs, and dairy products. In addition, some vegetable-based foods have been fortified with vitamin B12.

Individuals who do not consume these foods are more susceptible to vitamin B12 deficiency.

Other common causes include autoimmune gastritis (which causes pernicious anemia), malabsorptive states (e.g., pos-gastrointestinal surgery), and certain medications like metformin, proton pump inhibitors and histamine-2 receptor antagonists.

Managing B12 deficiency

The recommended daily amount of vitamin B12 for adults is 2.4 micrograms. Most people get enough of it from a balanced diet.

But it is important to recognize that certain segment of the population is vulnerable to be B12 deficient. If left untreated, vitamin B12 deficiency can lead to anemia, fatigue, muscle weakness, intestinal problems, nerve damage and mood disturbances.

All people over 65 years of age who are malnourished, all people in institutions or psychiatric hospitals, and all people with hematological or neuropsychiatric symptom should have their serum B12 levels measured.

Older adults, vegetarians, vegans and people who have conditions that affect their ability to absorb vitamin B12 from foods might benefit from the use of oral supplements.

Vitamin B12 supplements also are recommended for women who are pregnant or breastfeeding. Vitamin B12 is transferred through the placenta to the fetus during pregnancy and through breast milk after birth. Infants who drink breast milk from a mother who consumes adequate amounts of vitamin B12 or infants who drink infant formula, will receive enough vitamin B12.

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Wasting Money on Fish Oil and Vitamin Supplements

Gaudi's depiction of breasts. (Dr. Noorali Bharwani)
Gaudi's depiction of breasts. (Dr. Noorali Bharwani)

Omega-3 supplements (fish oil supplements) are popular. The global market of these pills is valued at three billion dollars. More billions are spent by consumers on other supplements like vitamins and minerals. Experts say this kind of money can be used for better health by doing what is proven to be good for your heart, brain and rest of the body.

Smart way to meet your omega-3 needs is to eat healthy. There is no need to spend money on the pills.

Omega-3s are a family of essential fatty acids that play important roles in our body and may provide a number of health benefits. It is important to know, omega-3s are not produced in our body. We must get them from our diet because they are essential for our good health.

The three most important types of omega-3 are ALA (alpha-linolenic acid), DHA (docosahexaenoic acid), and EPA (eicosapentaenoic acid). ALA is mainly found in plants, while DHA and EPA occur mostly in animal foods and algae.

Common foods that are high in omega-3 fatty acids include fatty fish, fish oils, flax seeds, chia seeds, flaxseed oil, and walnuts.

People take fish oil to reduce the risk of heart attacks and strokes, to treat high triglycerides and high blood pressure, and to improve symptoms of rheumatoid arthritis.

What is the evidence?

There are about 3,000 scientific clinical trial reports on the benefits of omega-3 fatty acids. When teams of researchers scrutinized the most reliable of these studies, they concluded that the treatment potential of these supplements is minimal to nil. In a few cases, inconclusive.

Health Canada recommends you eat at least five ounces (150 grams) of cooked fish every week. You can also get EPA and DHA omega-3 fatty acids from eggs, fish oil supplements and EPA and DHA-enriched foods.

Evidence in the population generally does not support a beneficial role for omega−3 fatty acid pills in preventing cardiovascular disease (including myocardial infarction and sudden cardiac death) or stroke. If you’re healthy and at low or average risk for heart disease, chances are you don’t need an omega-3 supplement (in the form of pills), provided you eat fish often.

Is it healthy to take vitamins and minerals on a regular basis?

Six years ago (December 17, 2013) an editorial in the Annals of Internal Medicine titled, “Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements” said despite sobering evidence of no benefit or possible harm, use of multivitamin supplements has increased among U.S. adults.

Three articles in this issue of the Annals address the role of vitamin and mineral supplements for preventing the occurrence or progression of chronic diseases.

The article concluded, β-carotene, vitamin E, and possibly high doses of vitamin A supplements are harmful.

Other pills like folic acid and B vitamins, and multivitamin and mineral supplements are ineffective for preventing death or sickness due to major chronic diseases.

The Annals editorial says although available evidence does not rule out small benefits or harms or large benefits or harms in a small subgroup of the population, they believe the case is closed – supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful. These vitamins should not be used for chronic disease prevention. The editorial says, “Enough is enough.”

If you are a well-nourished healthy adult then you should not waste your money on vitamins and mineral pills.

According to Health Canada, more than half of Canadians use supplements vitamins, natural remedies and homeopathic methods. In Canada, The Natural Health Products Directorate was created in 1997 to regulate the industry. Millions of Canadians are spending millions of dollars on these supplements. Has this made Canadians healthy?

Here is a good example of immense wastage of tax dollars. A study published in the medical journal JAMA Internal Medicine (July 15, 2019) says, “Almost two-thirds of Ontario seniors who received vitamin B12 shots had no evidence of a B12 deficiency.” This needlessly cost the province’s health-care system $45.6 million annually.

Readers are cautioned not to stop using any pills without consulting their physician. If you are regularly taking omega-3 fatty acid pills, vitamin and mineral pills or injection then consult with your doctor to review your meds.

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Vitamin D and Respiratory Infections

A walk on the beach in Maui. (Dr. Noorali Bharwani)
A walk on the beach in Maui. (Dr. Noorali Bharwani)

A research article in the British Medical Journal (BMJ February 15, 2017) says vitamin D supplementation is safe and it protects you against acute respiratory tract infection.

The object of the study was to assess the overall effect of vitamin D supplementation on risk of acute respiratory tract infection, and to identify factors modifying this effect.

The researchers looked at the results of 25 eligible randomized controlled trials (total 11,321 participants, aged 0 to 95 years).

They found vitamin D supplementation reduced the risk of acute respiratory tract infection among all participants.

The article says acute respiratory tract infections are a major cause of global morbidity and mortality and are responsible for 10 per cent of ambulatory and emergency department visits in the USA and an estimated 2.65 million deaths worldwide in 2013.

Vitamin D deficiency is associated with many conditions, including bone loss, kidney disease, lung disorders, diabetes, stomach and intestine problems, and heart disease. Vitamin D supplementation has been found to help prevent or treat vitamin D deficiency.

Vitamin D, often called the sunshine vitamin, is mainly obtained from sun exposure of our skin. However, Canadians are not getting enough of sunshine vitamins. Supplements are necessary to obtain adequate levels because a person’s diet has minimal impact, says Osteoporosis Canada website (New Vitamins D Guidelines 2010).

“Canadians are at risk of vitamin D deficiency from October to April because winter sunlight in northern latitudes does not allow for adequate vitamin D production,” says Julie Foley, president & CEO of Osteoporosis Canada. She goes on to say that because vitamin D requirements for an individual may vary considerably depending on many factors, it’s very important to check with your physician about how much vitamin D you should be taking.

Vitamin D is essential to the treatment of osteoporosis because it promotes calcium absorption from the diet and is necessary for normal bone growth. Some research suggests it may also ward off immune diseases, infection and cancer.

How much vitamin D should you take each day?

The new guidelines recommend daily supplements of vitamin D 400 to 1000 IU for adults under age 50 without osteoporosis or conditions affecting vitamin D absorption. For adults over 50, supplements of between 800 and 2000 IU are recommended.

Coming back to our topic – Do vitamin D supplements help prevent respiratory tract infections?

An editorial comment in the British Medical Journal (15 February 2017) says clinically useful effect of vitamin D on respiratory infection remains uncertain despite hints in the new analysis mentioned earlier in this column.

The editorial goes on to say, “Eight trial level meta-analyses have examined this topic since 2012, with conflicting findings: three reported benefits and five no consistent benefits.” The editorial conclusion is… we need more trials to prove the point that vitamin D supplements protect against respiratory infection.

In the meantime there is no reason to avoid taking vitamin D everyday as indicated earlier. There is no doubt vitamin D is required for many more reasons than just preventing lung infection.

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Our Seductive Desire for a Magic Pill

Sunset on a desert tour of Dubai. (Dr. Noorali Bharwani)
Sunset on a desert tour of Dubai. (Dr. Noorali Bharwani)

There are so many pills in the market that are touted as “magic pills” to keep you healthy, make you strong and boost your physical and sexual powers. But are they any good? Are they safe?

Health supplements are a $1.4-billion industry in Canada, but product testing is questionable, says a CBC report. Supplement products have increased dramatically, from about 4,000 types in 1994 to more than 55,000 in 2012. Roughly half of all US adults say they have used at least one supplement in the past month, most commonly vitamins.

Health Canada confessed to CBC’s Fifth Estate program that most herbal and vitamin supplements are approved for sale in Canada on “weak evidence”. The report also says more than 90 per cent of new products are approved within 10 days.

There is intense pressure from the supplements industry, anxious to cash in on the latest health-care trends. About three-quarters of Canadians regularly take natural health products such as vitamins, minerals, fish oil and herbal remedies, a 2010 Ipsos-Reid survey found.

Research in New Zealand published earlier this year found that 83 per cent of fish oil supplements tested exceeded maximum industry standards for rancidity. And recent tests by CBC’s Marketplace showed that four of seven fish oil supplements tested showed signs of rancidity.

Products for weight loss or increased energy accounted for the most ER visits. These products caused 72 per cent of problems involving chest pain or irregular or too-fast heartbeats, and they were the culprits in more than half of visits among patients ages 5 to 34. Bodybuilding and sexual-enhancement products also led to cardiac symptoms in many seeking ER help.

Marketplace (November 12, 2015) also found Vitamin C products make illegal claims. Canadians are constantly misled into thinking Vitamin C fights colds. Marketplace found Vitamin C products that make health claims are not allowed by Health Canada. While independent testing is done in the US to verify the accuracy of supplement ingredients, similar testing is not done in Canada. So what you take may not be safe.

University of Guelph botanist Steven Newmaster and his team conducted DNA tests on 44 herbal supplements bought in Canada and the US. Their study, published in the journal BMC Medicine in October 2013, found that nearly 60 per cent of the supplements contained ingredients not listed on the label and 32 per cent were outright frauds.

Subsequently, New York Attorney General Eric Schneiderman commissioned his own DNA tests of supplements sold by four major chains in the US. His study produced even more disturbing results, and Schneiderman ordered the retailers to stop selling the supplements, says CBC report. But no action by Health Canada.

The New England Journal of Medicine (October 2015) says supplements send 23,000 people to hospitals each year in the US. Products for weight loss or increased energy accounted for the most ER visits. So be careful before you consume any supplement not ordered by your doctor.

Best thing you can do for yourself is to exercise regularly, eat lots of fruits and vegetables, eat fish, meditate and do yoga. Don’t be seduced by a magic pill!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!