What you should know about vitamin B12 deficiency: problems with detecting and treating a vitamin B12 deficiency.

Detecting a vitamin B12-deficiency

The difficulty of detecting a vitamin B12 deficiency starts at the standard vitamin B12 serum test that is used:

B12-Serum test

The B12 serum test is the standard test performed by general practitioners to detect a vitamin B12 deficiency. This test has the following issues:

• Reliability:
  The Serum B12-test measures the level of all the vitamin B12 in the blood, both active and inactive forms. The body only uses the active vitamin B12. In general, only 5-20%¹ of vitamin B12 in the blood is active. This means that 80 to 95% of the vitamin B12 in the blood is inactive!
  Since it is unknown how much of the measured vitamin B12 by a serum B12 test is active, the test offers no definitive answer about vitamin B12 deficiency.
• Low minimum values in the Netherlands:
  In the Netherlands, a vitamin B12 value below 200 ngl/L is considered a vitamin B12 deficiency. However, scientific evidence shows that a value below 745 pgl/L causes degradation of the cerebral and spinal fluid. ^{3 4}
  The NHG (The Dutch College of General Practitioners) consider values up to 340 ng/L as a grey zone⁵.
  If your vitamin B12 level is within this grey zone, your general practitioner may choose to start treatment. Worldwide, a lot of B12 authorities consider <40 to <600 ngl/L as a grey zone ⁶
  

  B12 serum level	Interpretation
  < 200 ng/L	Vitamin B12 deficiency (in the Netherlands)
  < 340 ng/L	Grey zone according to NHG 5
  < 400 to < 600 ng/L	Grey zone B12 (according to authorities worldwide) 6
  < 745 ng/L	Scientifically proven grey zone s3 4

Key message NHG: Key message NHG Methylmalonic acid test and, to a lesser extent, the Homocysteïnetest. ⁵

B12-symptoms

There is a difference between symptoms that have been scientifically proven to be caused by a vitamin B12-deficiency and symptoms that are related to a vitamin B12 deficiency according to the NHG.

According to the NHG, only the following symptoms are related to a B12-deficiency:⁵

• Anemia (macrocytic anemia), Macrocytosis, enlarged red blood cells with megaloblastic changes)
• Neurological disorders (ataxia, paresthesias)
• Neutrophil hypersegmentation
• Myelopathy, neuropathy or cognitive dysfunction (50% of people with a vitamin B12 deficiency suffers from this, but this disorder is not typical for a B12 deficiency)

The following scientific claims have been sufficiently proved according to the European Commission:⁷

• Vitamin B12 contributes to healthy cell division
• Vitamin B12 is required for the production of red blood cells
• Vitamin B12 contributes to a well-functioning immune system
• Vitamin B12 reduces fatigue and exhaustion
• Vitamin B12 contributes to a well-functioning homocysteine metabolism
• Vitamin B12 contributes to a well-functioning nervous system
• Vitamin B12 contributes to optimal mental functioning

Sciences have proven over 150 symptoms more that can be related to a vitamin B12 deficiency, for these symptoms check out the list of symptoms.

It makes sense that a vitamin B12 deficiency can cause so many symptoms, since vitamin B12 contributes to, among others, a healthy cell division and the production of red blood cells.

Because there is no test which can diagnose a vitamin B12 deficiency with absolute certainty, a test treatment is often initiated. This test treatment can be done with injections or lozenges.

Treatment B12 deficiency

Treatment of a vitamin B12 deficiency may be done with injections or lozenges (oral supplementation).

The NHG states: In patients presenting with symptoms and a vitamin B12 level below 200 ng/L, treatment with 1000microgram a day should be initiated. This can be taken orally, even if pernicious anaemia is present, because with this high dose the absence of intrinsic factor is sufficiently countered by passive diffusion. ^5 9 10 11 

Forms of vitamin B12

There are 4 forms of vitamin B12:

• Cyanocobalamin
• Hydroxocobalamin
• Methylcobalamin (active form)
• Adenosylcobalamin (active form)

Mostly a conversion problem

Cyanocobalamin and Hydroxocobalamin are both forms of vitamin B12 that have to be converted by the body (into Methylcobalamin and Adenosylcobalamin). A vitamin B12 deficiency mostly arises because of a conversion problem in the gastrointestinal tract. The body cannot converse vitamin B12 into the active form and therefore cannot transport it properly into the bloodstream.

When can I expect results?

A conversion disorder mostly causes a vitamin B12 deficiency in the gastrointestinal tract, which may have been going on for years. Therefore, symptoms will not resolve overnight. Most people experience positive effects after 6 to 12 weeks of taking vitamin B12 supplements. Depending on your physical and mental condition, you may notice a change earlier or later.

Detoxifying with vitamin B12

During the first 6 to 8 weeks of taking vitamin B12 supplements, it is important to drink 6 to 8 glasses of water a day. The body will start to detoxify and by drinking 6 to 8 glasses of water a day, your body can appropriately get rid of the toxics.

Treatment: Injections

A vitamin B12 deficiency can be treated with vitamin B12 injections. The procedure of vitamin B12 injections is as follows in the Netherlands:
The first 5 weeks you receive 2 injections a week.
After that, you continue with 1 injection a week and this interval will slowly be expanded.
The B12 deficiency foundation states a minimum frequency of an injection once every 2 months is required. ¹² 

In the Netherlands, injections contain 1000mcg of Hydroxocobalamin. In Belgium, two types of injections are used: one containing 1000mcg Hydroxocobalamin and another one containing 1000mcg Cyanocobalamin. Hydroxocobalamin has a preference. In Germany and Italy, injections contain the active form of vitamin B12: Methylcobalamin and Adenosylcobalamin. The address of the pharmacy where you can get these injections can be found here.

Important when being treated with injections:

• Do not start expanding the interval of injections until all of your complaints caused by a vitamin B12 deficiency are resolved.
• Listen to your body when reducing the dosage of injections. Injections should be reduced to an amount by which you don’t experience complaints. If the complaints return, ask for an increase of injections. Some people require only 1 injection every 2 months, while others will continue to require 1 injection twice a week.
• Don’t stop with your treatment solely based on an appropriate vitamin B12 level in your blood. Because of the injections your vitamin B12 level will rise to an adequate level. Listen to your body and your symptoms.
  Your vitamin B12 deficiency developed because of a reason, and as long as this cause exists, it is important to take vitamin B12 supplements. Therefore, most people require a lifetime of vitamin B12 supplementation.
• Pay attention to folic acid or folate (active form of folic acid). Vitamin B12 and folic acid/folate use each other in order to function in the body. If you solely supplement vitamin B12, then your folic acid value will decrease. Because these vitamins use each other, the scientific effects of folic acid and vitamin B12 largely correspond. This also means that most symptoms of a folic acid deficiency and a vitamin B12 deficiency are similar.

Treatment: Lozenges

A vitamin B12 deficiency can be treated with vitamin B12 lozenges. When taking vitamin B12 sublingually, it will be directly absorbed into the bloodstream through the oral mucosa, with this bypassing the conversion problem in the gastrointestinal tract.

It is important to take an active form of vitamin B12, such as Methylcobalamin or Adenosylcobalamin. The body will have to convert other forms of vitamin B12 (Cyanocobalamin and Hydroxocobalamin) into the active form.

Important when taking lozenges:

• Take the active forms of vitamin B12: Methylcobalamin and Adenosylcobalamin.
• Use both active forms of vitamin B12. Dietary vitamin B12 is converted into both Methylcobalamin AND Adenosylcobalamin by the human body. They each are responsible for different processes in the body.
• Don’t start reducing your dosage until the symptoms caused by a vitamin B12 deficiency are resolved.
• Listen to your body when reducing the dosage. Your daily dose should be reduced to an amount where you don’t have any complaints.
• Don’t stop with your treatment solely based on an appropriate vitamin B12 level in your blood. Because of the lozenges your vitamin B12 level will rise to an adequate level. Listen to your body and your symptoms.
  Your vitamin B12 deficiency developed because of a reason, and as long as this cause exists, it is important to take vitamin B12 supplements. Therefore, most people require a lifetime of vitamin B12 supplementation.
• Pay attention to folic acid or folate (active form of folic acid). Vitamin B12 and folic acid/folate use each other in order to function in the body. If you solely supplement vitamin B12, then your folic acid value will decrease. Because these vitamins use each other, the scientific effects of folic acid and vitamin B12 largely correspond. This also means that most symptoms of a folic acid deficiency and a vitamin B12 deficiency are similar.

Lozenges in combination with injections

You can combine injections with lozenges. You should always discuss this with your general practitioner.

A lot of people combine injections with lozenges because they notice a higher dose of vitamin B12 is needed to resolve their symptoms. Or because the interval between injections is too long and their vitamin B12 deficiency symptoms are reoccurring.

High levels of vitamin B12

Humans and other mammals are all born with a serum B12 level of about 2710 ng/L, which decline gradually throughout life.¹³ 

Doctor John Dommisse states: ‘‘The one major step that would bring B12 deficiency back into the mainstream of medicine and psychiatry would be the general recognition that the normal range should be regarded as 813 to 2710 ng/L. Below 745 to 813 ng/L, deficiencies start to appear in the cerebrospinal fluid, as shown by several papers over the past 20 to 30 years.’ ¹³ 

Dommisse states that older adults ought to have a vitamin B12 level of at least 813 to 2710 ng/L. For children, he recommends a level of 1355 to 2710 ng/L. ¹³ 

Vitamin B12 is a water-soluble vitamin. Any vitamin B12 consumed in excess will be excreted in the urine.

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