What do all of these chronic diseases have in common?
- Alzheimer’s, dementia, cognitive decline, and memory loss (collectively referred to as “aging”)
- Multiple sclerosis (MS) and other neurological disorders
- Mental illnesses like depression, anxiety, bipolar disorder, and psychosis
- Cardiovascular disease
- Learning or developmental disorders in kids
- Autism spectrum disorder
- Autoimmune disease and immune dysregulation
- Cancer
- Male and female infertility
Answer: Their signs and symptoms can all be mimicked by a vitamin B12 deficiency.
An Invisible Epidemic
B12 deficiency isn’t a bizarre, mysterious disease. It’s written about in every medical textbook, and its causes and effects are well-established in the scientific literature.
However, the condition is far more common than most healthcare practitioners and the general public realize. Data from a Tufts University study suggests that 40 percent of people between the ages of 26 and 83 have plasma B12 levels in the low normal range—a range at which many experience neurological symptoms. Nine percent had an outright nutrient deficiency, and 16 percent exhibited “near deficiency.” Most surprising to the researchers was the fact that low B12 levels were as common in younger people as they were in the elderly. (1)
That said, this type of deficiency has been estimated to affect about 40 percent of people over 60 years of age. It’s entirely possible that at least some of the symptoms we attribute to “normal” aging—such as memory loss, cognitive decline, and decreased mobility—are at least in part caused by a deficiency.
Why Is It Underdiagnosed?
This is why most studies underestimate true levels of deficiency. Many deficient people have so-called “normal” levels of B12.
Yet, it is well-established in the scientific literature that people with B12 levels between 200 pg/mL and 350 pg/mL—levels considered “normal” in the U.S.—have clear vitamin deficiency symptoms. (2) Experts who specialize in the diagnosis and treatment of a deficiency, like Sally Pacholok, R.N., and Jeffrey Stuart, D.O., suggest treating all patients that are symptomatic and have B12 levels less than 450 pg/mL. (3) They also recommend treating patients who show normal B12 levels but also have elevated urinary methylmalonic acid (MMA), homocysteine, or holotranscobalamin, which are other markers of a deficiency in vitamin B12.
B12 deficiency can mimic the signs of Alzheimer’s, dementia, multiple sclerosis, and several mental illnesses. Find out what this vitamin does and learn how to treat a deficiency. #B12 #B12deficiency #cognitivedecline
In Japan and Europe, the lower limit for B12 is between 500 and 550 pg/mL. Those levels are associated with psychological and behavioral symptoms, such as:
- Cognitive decline
- Dementia
- Memory loss (4)
Some experts have speculated that the acceptance of higher levels as normal in Japan and the willingness to treat levels considered “normal” in the U.S. explain the low rates of Alzheimer’s and dementia in that country.
What Is Vitamin B12 and Why Do You Need It?
Vitamin B12 works together with folate in the synthesis of DNA and red blood cells. It’s also involved in the production of the myelin sheath around the nerves and the conduction of nerve impulses. You can think of the brain and the nervous system as a big tangle of wires. Myelin is the insulation that protects those wires and helps them to conduct messages.
Severe B12 deficiency in conditions like pernicious anemia (an autoimmune condition where the body destroys intrinsic factor, a protein necessary for the absorption of the vitamin) used to be fatal until scientists figured out death could be prevented by feeding patients raw liver, which contains high amounts of B12. But anemia is the final stage of a deficiency. Long before anemia sets in, deficient patients will experience several other problems, including fatigue, lethargy, weakness, memory loss, and neurological and psychiatric problems.
The Stages of a Deficiency
B12 deficiency occurs in four stages, beginning with declining blood levels of the vitamin (stage I), progressing to low cellular concentrations of the vitamin (stage II), an increased blood level of homocysteine and a decreased rate of DNA synthesis (stage III), and finally, macrocytic anemia (stage IV). (5)
Common B12 Deficiency Symptoms
The signs can look like the symptoms of several other serious disorders, and the neurological effects of low B12 can be especially troubling.
Here are some of the most common vitamin B12 deficiency symptoms:
- Tingling or numbness in the hands and feet
- Brain fog, confusion, and memory problems
- Depression
- Premature aging
- Cognitive decline
- Anemia
- Weakness
- Fatigue
- Reduced appetite and weight loss
- Constipation
- Trouble balancing (6)
Children can also show symptoms, including developmental issues and learning disabilities if their B12 levels are too low.
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Why Is It So Common?
The absorption of B12 is complex and involves several steps—any of which can go wrong. Any of the following can cause B12 malabsorption:
- Intestinal dysbiosis
- Leaky gut and gut inflammation
- Atrophic gastritis or hypochlorhydria, or low stomach acid
- Pernicious anemia
- Medications, especially proton pump inhibitors (PPIs) and other acid-suppressing drugs
- Alcohol
- Exposure to nitrous oxide, during either surgery or recreational use
This explains why a deficiency can occur even in people eating large amounts of B12-containing animal products. In fact, many of my patients that are B12 deficient are following a Paleo diet where they eat meat two or three times daily.
Who Is at Risk for a Deficiency?
In general, the following groups are at greatest risk for a deficiency:
- Vegetarians and vegans
- People aged 60 or over
- People who regularly use PPIs or acid-suppressing drugs
- People on diabetes drugs like metformin
- People with Crohn’s disease, ulcerative colitis, celiac, or IBS
- Women with a history of infertility and miscarriage
Note to Vegetarians and Vegans: B12 Is Found Only in Animal Products
You cannot get B12 from plant-based sources. This vitamin is only found in animal products. That’s why vegetarians and vegans need to know the signs of deficiency—and the steps necessary to fix the problem.
A common myth among vegetarians and vegans is that it’s possible to get B12 from plant sources like:
- Fermented soy
- Spirulina
- Brewers yeast
However, plant foods said to contain B12 actually contain B12 analogs called cobamides that block the intake of and increase the need for true B12. (7) That explains why studies consistently demonstrate that up to 50 percent of long-term vegetarians and 80 percent of vegans are deficient in B12. (8, 9)
Seaweed is another commonly cited plant source of B12, but this idea is controversial. Research indicates that there may be important differences in dried versus raw purple nori; namely, raw nori may be a good source of B12, while dried nori may not be. One study indicated that the drying process used for seaweed creates B12 analogs, making it a poor source of the vitamin, while animal research suggests that dried nori can correct a B12 deficiency. (10, 11) Seaweed may provide B12, but it’s not clear if those benefits are negated when that seaweed is dried. I recommend caution for that reason.
The Impact of a Deficiency on Children
The effects of B12 deficiency on kids are especially alarming. Studies have shown that kids raised until age six on a vegan diet are still B12 deficient even years after they start eating at least some animal products. In one study, the researchers found an association between a child’s B12 status and their performance on testing measuring:
- Spatial ability
- Fluid intelligence
- Short-term memory
Researchers found that formerly vegan children scored lower than their omnivorous counterparts in each area. (12)
The deficit in fluid intelligence is particularly troubling, the researchers said, because this area impacts a child’s ability to reason, work through complex problems, learn, and engage in abstract thinking. Defects in any of these areas could have long-term consequences for kids.
I recognize that there are many reasons why people choose to eat the way they do, and I respect people’s right to make their own choices. I also know that, like all parents, vegetarians and vegans want the best for their children. This is why it’s absolutely crucial for those that abstain from animal products to understand that there are no plant sources of B12 and that all vegans and most vegetarians should supplement with B12.
This is especially important for vegetarian or vegan children or pregnant women, whose need for B12 is even greater. If you’re not willing to take a dietary supplement, it may be time to think twice about your vegetarian or vegan diet.
How to Treat a Deficiency
One of the greatest tragedies of the B12 epidemic is that diagnosis and treatment are relatively easy and cheap—especially when compared to the treatment patients will need if they’re in a late stage of deficiency. A B12 test can be performed by any laboratory, and it should be covered by insurance. If you don’t have insurance, you can order it yourself from a lab like DirectLabs.com.
As always, adequate treatment depends on the underlying mechanism causing the problem. People with pernicious anemia or inflammatory gut disorders like Crohn’s disease are likely to have impaired absorption for their entire lives and will likely require B12 injections or high-dose oral cobalamin indefinitely. This may also be true for those with a severe deficiency that’s causing neurological symptoms.
Typically in the past, most B12 experts recommended injections over high-dose oral cobalamin for people with pernicious anemia and an advanced deficiency involving neurological symptoms. However, recent studies have suggested that high-dose oral or nasal administration may be as effective as injections for those with B12 malabsorption problems. (13, 14)
Try Supplementing
Japanese studies indicate that methylcobalamin is even more effective in treating neurological symptoms and that it may be better absorbed because it bypasses several potential problems in the B12 absorption cycle. (15, 16) On top of that, methylcobalamin provides the body with methyl groups that play a role in various biological processes important to overall health.
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Change Your Diet
Nourishing your body through whole food is the best way to get the vitamins and nutrients you need. If you’re low on B12, try eating some vitamin-rich foods like:
- Liver
- Shellfish
- Clams
- Oysters
- Organ Meats
Eating other kinds of seafood, like octopus, fish eggs, lobster, and crab, can also help you attain normal B12 levels. If you’re seafood-averse, you can also get this vitamin from:
- Lamb
- Beef
- Eggs
- Cheese
It’s important to note, though, that the amount of B12 in these foods is nowhere near as high as the levels in shellfish and organ meats.
What to Do if You’re Experiencing Vitamin B12 Deficiency Symptoms
If you suspect you have a deficiency, the first step is to get tested. You need an accurate baseline to work from.
If you are B12 deficient, the next step is to identify the mechanism causing the deficiency. You’ll probably need help from a medical practitioner for this part. Once the mechanism is identified, the appropriate form (injection, oral, sublingual, or nasal) of supplementation, the dose, and the length of treatment can be selected.
So, next time you or someone you know is “having a senior moment,” remember: It might not be “just aging.” It could be B12 deficiency.
Fred or Freddd?
With all due respect, do you have a spell check or editor of any sort? — it would help readability of your vast and wordy comments. Further, you seem to have become the de facto owner of this subject/blog (Chris may want to close comments if he’s abandoned the desperate people who come here, maybe?). With respect to this, in your own words here, can you please share your personal biography and credentials?
Also, what EXACTLY are you referring to Jarrow B12 in your LAST comment? You went crazy recommending this product and ONLY now you mention it’s no longer the 5 star you promoted? Please explain yourself to the people who are desperate for help and following your every word. Thank you
With all due respect to those you mentioned, thank you for this Paula, my thoughts exactly!!
Hi Paula,
Fred has done nothing but offer up some good information and help here.
I don’t quite understand your comment, I have been waiting for Fred to comeback for more information and now you are being rude trying to chase him off.
I don’t see you offering up quality information, have you ever heard if you don’t have anything good to say…..
Plus I’m sure Chris has a lot of things on his plate and that he didn’t abandon anybody. I didn’t see anywhere where he stated that he would answer all of the comments. He puts up great free information that I am very much appreciate.
As far as the Jarrow b12 Fred clearly stated that for some reason it isn’t working as well as it used to and that he would look into it when he gets back home, that seems pretty clear. What more explanation does he need to give?
I don’t mean to come across rude but there are people on here that are looking for help and whether you agree with the comments or not that doesn’t mean you should be rude and chase off Fred or state that Chris should shut down the comment section.
Hi Bill,
My thoughts, I don’t think Paula is trying to be rude. I myself am one that looks for any and all information regarding my issues with B12 deficiency which have now resulted in Subacute Combined Degeneration of the Spinal Cord. Some of us do take people on their every word especially when we have been dealing with a health issue for a very long period of time and we crave answers. Asking for Freds credentials/biography is not a bad thing?? (Thanks for sharing about yourself below Fred!)
I know that Chris is extremely busy and while I do appreciate Freds vast knowledge, I felt that his comments were maybe “overtaking” Chris’ forum as there were not many responses from Chris?? I in no way wish for Chris to close the comment section!!! His having this forum is why I came here in the first place. I think we are all entitled to our opinions good/bad or blunt, be it Fred with his help or Paula her comments. Fred has been through alot and has taken charge of his health and has a wealth of information WOW! I look forward to moving forward and continuing to read and listen to everyone here.
Sorry Julee …… I replied under the wrong comment!!
I reply directly into these boxes. Because of decades of progressing Subacute combined degeneration becaUSe of years of b12 deficienciey becasue of the ignorance that prolmugates the statements about b12 that are typically seen I have lost about 90% of my fine motor coordination in my fingers,
Products change beyond my control.. What was great for 9 hyears and one of the best has becpome very mediocre. I don’t go crazyin any direction, I report it the way I see it from my experience and that of others. I have a drivers license nd a high school diploma. I have no credentials of any kind that matter to anybody. You you will have to trust your own judgment. Has anybody certified that you do critical thining?
I have worked as a systems analyst, software designer and vendor and group health paln consultant for 30 years, cured myself from decades of CFS, ME, FMS and loads of other thionghs. t one point i was days away from a wheel chair. I solved my problem that over 100 docs has absolutely zero clue. It’s demonstrably fits the pattern of millions of others of chronically ill in the USA. Thjere are lots of desparate people here. If you are a betting man then then I would be willing to bet that 90% of the desperate (as I used to be) people here could be “normal’ in a year if they were to stop believing\ the nonsense. I answer only becaus I am empathic with all the des[paragte people who’s lives are being destroyed by these pseudo vitamins and man made deficiency diseases.
Only NOW do I mention the Jarrow problem. I don’t norice you mentioning it sooner. What are you trying to infer? About a month ago somebody mentioned it to me. I checked it out and performed A tral and sure enough, it is now an inferior brand. You right here are the fi\rst to hear it. I don’t have any authority TO TELL YOU WHAT TO DO, i’M NO HELP AT ALL. any true beliefs in this. I jiust report the facts as I see and understand them and have helped thousands. You may choose to consider what I say or not. If you are looking for some authority to tell you what to do, I’m not that person. If you have self responsibity and can do critical thinking then maybe you can benefit. I deal in pragmatic results. You can argue about authority all you want so include me out. Since authority has avsolutely nothing to do with correctness or effectiveness what “authorithy” has to say about b12 and folate is so totally wrong it will kill thousands and make millions ill completely because what the authorioty has to say is terribly wrong. Follwoin g authority 9 years ago I was dying. I took my cyancobalamin and folic acid like a good little dying idiot. I weighed nearly 300 pounds, dying of congestive heart faiure, vomiting daily with loss of 80% of muscle mass. Now I am 200 pounds, having taken off 95 pounds of water, 50 pounds of fat and put on 50 pounds of muscle. Instead of being in a wheelchair, I can climb mountains, hike 2000 feet of vertical up and down every day and am heaklthiest ever in my life. At 64 I would be pleased to challange you to a 10k road race, 9 years ago I couldn’t have walked 500 yards. Good luck.
Hi Shadedwillow
Periodic injections of cyanocbl or hydroxcbl are the worst possible b12 thereapy that occasionaly works a little. Random brands fromn the viotamin store are no better. Right now I am willing tn identfy one brand, Enzymatic therapy Infusion. When held under the lip for 45[-180 minutes it will be more effective than ANY injection from ANYBODY. It is pretty clear that while initial injections of cyanocbl or hydroxcbl may work a little once or twice, the bodies abilty to methylate the inactive coblamines into active b12s becomes rapoidly exhausted and then a person may develop 300-400 b12 deficiencies while the pseudo-b12, cyanocbl, may work on 1 or 2 symptoms.
As the type of b12 injected into the muscle, is almost totally the worthless inactive form of cobalamin injected into the muscle, it is shear unadulterated nonsense that injecting the wortheless cobalamin is any use at all becasue it is going onto the muscle. it is absorbed from the muscle in 30 minutes and 50% excreted by kidneys in the first 30 minutes and an addtional 50% of remaining each 30 minutes for the next 4 hours reducing the retained inactive cyanocbl to about 10mcg AFTER 24 HOURS.
Just take the ENZYMATIC THERAPY b12 INFUSION, 1-10 PER DAY, 45-200 minutes each.The OTHER kind of essential active b12 is adenosylcobalamin for the mitochoindria and muscles. The Soiurce Naturals or Dibol Dibencozide (different name same stuff are both effective used under lip for 45-120 mioutes in which 15-33% is absiorbewd as opposed to 1% if chewed and swallowed. In otherwords a long slow under the lip method can deliver 33 times as miuc h actiove vitamin to your bodsy and that makes a difference. In approximcately 20%+ of people Metafolin lack is preventing them being able to utiolize or retaIN ACTIVE B 12S.
Hi Fred,
Did something happen with the Jarrow methyl b12 that caused you not to recommend it?
Hi Bill,
Something has changed with the Jarrow mb12. I don’ty know what or when. It was mentioned to me two months ago anb otu the time I was noticing the possibility too and I performed some tests that I could and it is now at best 3 star. After I get back home after laborday I will investigate the problem.
It stopped working well for quite a few people starting several months ago, me included. What hjappened is not yewt clear, butr something did. I have removed it in my program and am improving again. So JARROW IS NOW 3 STARS OR LESS AND not recommended. i WILL CONTINUE INVESTIGATING
Is this the one you are referring to Fred? It’s a chewable, but you say leave under the tongue?
http://www.amazon.com/B12-Infusion-30-Chewable-Tablets/dp/B0012HCCNS
I have been taking B12 Injections for 2 yrs. First it started weekly, bi-weekly and then monthly. I am still doing monthly injections. My levels have been slow to rise and have recently plummeted back down from 520 to the 386 within a 6 month period. The number itself is not what concerns me, but the sudden drop. I am being told to take an additional supplement under my tongue. I do not know what the underlying issue may be, nor does my physician give me any underlying conditions. I’m trying not to throw my physician under the bus since she is treating the issue…I would just like to know what the issue may be.
Any suggestions for a sudden drop of B12 like that with monthly shots?
Linda,
Is your doc willing to treat you?
Im 65 yrs old and never had my b12 checked. I have suffered for years from almost all the symtoms but just thought they were something else. I do have problems in my back that I know of because of a cat scan I had 3 yrs ago. The past couple of years, I have had a lower back pain and am finding it sometimes very painful to walk. My legs are very weak and the tingle and hurt even the tops of my feet and all the way up the leg. My memory is getting very bad, like how to spell a word or what I got up to do etc. If it hadnt been for a recent health crisis in my daughter, I would have just thought old age! She was losing all strength in her legs and had tests for M.S. She is now in a wheelchair until the damage is repaired from b12 defiency!!! I had my test done and my level is 86!!! This is in Canada.. This is a very serious level, isnt it? Any suggestions or advice??
Hi all, Im new to the discussion board.
Im 22 year old and I was diagnosed with Vitamin b12 deficiency November last year. my b12 count was 81 and folic acid 2.2. (I was told normal b12 level should be between 500 – 1000 and folic acid 15-20) I was feeling constantly tired and completely out of energy, and was getting pains in my legs also that felt similar to growing pains i got as a child!). Ive been reading through most of the other comments made by others and there symptoms seem much more severe compared to mine. Anyhow the doctor explained that my body wasn’t absorbing the vitamin b12 from the food i was eating. i began receiving the injections, i had 6 injections within the space of 2 weeks and then 1 every month. They did begin to work and i started to feel as though i was gaining a little more energy, I could concentrate more when i was at work etc. but then after having b12 injections it took me ages to switch off on a night and actually go to sleep sometimes i would be up til 2/3am and have to be up for work at 7….so id get up for work feeling exhausted and tired and back to square one. I work with children in a nursery so need all the energy i can get!.
i decided against getting the injections, they were just not working out for me, eating a healthy balanced diet and getting a good night sleep seems to be working out just fine for me at the moment. When i told my doctor I did not want to receive the injections anymore he did not seem very happy with me, he was quite insistent that i take the shots and said it would effect me in the long run and made me feel if i didn’t have one then i would become ill.
I do have a question..
Does B12 help your immune system and to help fight against infections?? or is it simply just to help b12 get into your body to gain energy. My doctor is very pressuring every time i have went with a problem, he always says the cause of me keep getting virus’s and infections is due to me not getting my b12 injections and i feel pressurised t get the injections. Im only 22 and don’t like the thought of getting injections for the rest of my life it just doesn’t feel natural.
within the past 2 month i have suffered with a kidney infection, ear infection, and a throat infection..all needing antibiotics to treat them. is it true that this could be caused by not getting my b12 injections?
and do you have any suggestions as to what could be making me more prone to catching bugs and infections? I’m beging to think there may be something up with my immune system and thats its more than just the b12 that my doctor keeps ranting on about..
(I take a small packed lunch to work with me and My mum prepares lovely meals for me for when i return home from work. Ive recently bought some b12 vitamin tablets (my doctor is insistant that they will not work) and starting next week im going to start eating more healthier to try to include all the vitamins i need to help keep me healthy and drink plenty of water) – Hoping to see a change in myself. Thanks for listening
Would be gratefull for any advice and help x
Yes. It does. If you don’t treat your B12 deficiency your nerves will deteriorate and you will lose feeling in your feet and hands and who knows what else. You need to read up on it. Try treating your sleeplessness with Melatonin. If you cannot get Vitamin B12 from your food, you can’t get it from a pill either and they don’t call it pernicious anemia for nothing. It means DEADLY anemia. The reason the pills and food won’t work for you is your stomach isn’t producing intrinsic factor and without that you cannot process B12 orally. Get the shots!!! Don’t end up like me with numb feet. Dear god, do you know how many of us wish we had a doc that would take our B12 seriously? Be thankful!
Since we are all so reliant on these blood tests to not only try to determine what is wrong with us but also to check our status on a regular basis I think it is worth mentioning a common mistake blood drawers make.
A tourniquet should be placed on your arm for about a minute and a venipuncture should begin. As soon as a tube is placed and blood begins to flow the tourniquet should be REMOVED. To leave the tourniquet in place during a blood draw can cause what is called hemoconcentration and it alters blood chemistry. Potassium results can be totally skewed just by waiting to remove the tourniquet for instance…. making the results worthless.
I don’t know about you but very often when I’ve gotten blood work the tourniquet is left on until the last tube or left on for several minutes. Now instead of taking time to argue I reach up and pull the tourniquet off when the blood begins to flow while the nurses hands are occupied. I get objection half the time as if I’ve done something wrong but I’m sure they’d argue. An argument they’d lose. I’ve already tried to tell them and they are convinced I don’t know what I’m talking about and this includes doctors!
REMOVE THE STRAP if you want accurate blood work!!
Sooo very glad to read your comments on the ridiculous range that is considered ‘normal’ for serum B12 levels. I’m an RD and developed pernicious anemia about 12 years ago. My B12 was 152; so the MD didn’t even consider B12 deficiency as the reason for my excruciating lower leg/foot pain, my shortness of breath, my extreme malaise, depression, visual hallucinations, etc, etc…every B12 deficiency symptom-I had it. Anyway, I finally requested my own chart (was working in a hospital/clinic at the time) to see if I could figure out my own problem. When I saw the low-“normal” B12 level, I requested that it be re-checked and, just 5 weeks after that first level was done, my B12 was 120. Then I had quite a challenge getting someone to take it seriously and treat it. In the end, I had to use expletives to get an MD’s attention….really! When I phoned a clinic MD and he asked what he could do for me, I said, “I’d like some f—-king B12 and I’d like it today, please.” This got his attention and I was seen and given an injection that day….finally. Since then, I’ve had a thing about education lay and professional people about B12 deficiency and about ferreting it out in general. I always check the MCV in every patient I see. If there’s not a recent one, I ask for one. If possible, I get a B12 level on anyone with deficiency symptoms. Sometimes, they are too confused to even recite their symptoms due to the effects of deficiency. Anyway…thanks for the mention.
Kudos to you Catherine! I know I was confused and my level was 233. My malaise, depression, anxiety- all gone now that I am on shots. I wish I could say the same about my foot neuropathy. It’s so important to educate as many people as we can about this nightmare. I buy copies of “Could it Be B12” and give them away with the request that after the person reads the book, they hold onto it until they hear of someone who has symptoms and they give it to that person for free, with the same request made of them.
hi one and all, I’m very new to this. My B12 level was read at 185 3 months ago, and my doctor ignored it. I then had a change in doctor, she noticed the level, retook the blood test, and the level had already sunk to 135. she has administered me a supplement, which is be taken for 3 further months, at which point I will be tested again. should i rather just ask her to administer shots?
I am new to this discussion board, but thank you to everybody for your posts/stories. I will admit that I haven’t read everybody’s post, but plan to.
I am nearly 49 years old and have known that I am Vit B12 deficient since at least 1987. I have always been easily fatigued and unable to play sports, etc. When a smart doc checked my level it was nearly undetectable that year. After several repeats – still barely nothing. I started IM replacement (after a big medical work up) – but was not good with follow up (honestly). One thing after another – not taking care of myself – I was diagnosed with Grave’s Disease in 2000 and underwent radioactive ablation for that. Over the course of many years, I developed muscle fasciculations, wasting, SEVERE EMG changes and psychological issues – depression, anxiety, etc. Two and a half years ago I slipped two discs in my neck (while rolling over in bed!) that look on MRI like I was in a severe auto accident. I had emergent surgery to remove the pressure off of my spinal cord. I believe that it’s because of my neuromuscular disease from B12 deficiency that my spinal muscles were so weak that it caused the slip.
Fast forward to today- I found Nutrition, Chris Kresser and the Paleo Diet. I have started the B12 protocol for a severely altered Metametrix Organic acid profile. My energy production markers were abnormal (high/very high), my B complex markers the same, and my MMA was high as well. My Neurotransmitter metabolism markers were high as well as my detox indicators (very high). My Orotate and alpha hydroxybutyrate were nearly off the charts, the latter suggesting Glutathione deficiency.
Since starting the B12 protocol, I have developed HORRIFIC cramping in my muscles – legs and back mostly. It feels as though I’ve been running a marathon (not that I’d ever know what that feels like). Do any of you have suggestions regarding this? I am on K gluconate (200 mg/day), SAME-e 200mg/day (Jarrow), Methyl Guard -one twice a day (Thorne) and Dibencozide once a day (Source Naturals); I am to start the Methyl B12 tomorrow as per the protocol.
I should also tell you that I have had a cardiac arrythmia (tachycardia all of my life) for which I am on a Beta blocker as well as Klonopin 1.0 mg (for myoclonic jerks while trying to fall asleep) since 1985. I know that both of these medications can deplete CoQ10 so no surprise with my Organic acid profile.
Sorry to ramble – I just can’t believe that I’ve let myself get to this point. I have known for YEARS about the B12, would inject it – go off of it, like I said, and then start it back up (Not to say that cyanocobalamin would have been the right thing to take anyhow); I can’t believe the damage that this has caused. I need to know that there is light at the end of this very dark tunnel…..
I must also tell you that I’m a physician (a Pediatrician) who struggles to go into work every day. I am only working about 60% over the past year due to neuropathic pain from my neck injury. Please tell me that it’s going to get better…………thanks for taking the time to read this and thanks in advance for any advice that you can give me. I understand that we all have unique experiences that make our “stories” our own and that nobody necessarily will respond to a specific generlized protocol. We all have to find out what’s best for us. Thanks to Chris Kresser for discovering the severity of this and for getting me on the track to recovery (I hope!!!). Again, I appreciate anything that any of you can offer me.
Karl, You’re not taking enough potassium. I’ve had intermittent leg cramps for more than two years, and they became more frequent/severe on the B12 protocol until I raised my K intake. You should aim for 2000 mg/day as a start, and adjust from there. Buy K-gluconate by the pound and mix it 1/2 tsp per cup of water. You can also use potassium chloride (Morton Salt Substitute), but it’s very unpleasant.
Here are some other things I’ve found helpful for cramps:
… magnesium – 400 mg/day or more – Magnesium is essential to recovering from a potassium deficiency. I prefer Mg glycinate. You may have good luck with another chelator, but this one works best for me. Avoid NOW Mg-K-aspartate. That’s the only one that made my symptoms worse.
… calcium – Some people report fewer cramps when taking calcium. It always makes my symptoms worse, so I don’t take any.
… sodium – If your sodium level gets too low, your kidneys will dump potassium to keep electrolytes in balance. Don’t skimp on salt.
… carbs – If you’re on a super-low-carb diet, try raising your carb intake to 50g/day. I found that 35g is too low, but 50g or more reduced the frequency of cramps. (Since I eliminated caffeinated coffee, I was able to lower my carb intake to ~5g/day with minimal cramps. I still have to watch my K intake.)
… no caffeine – Once you’re cramp-free, you can experiment to find your tolerance for coffee. I can only have about 2 oz per day of high-test. Decaf coffee is OK for me.
… vitamin E – I’ve seen reports that 1200 IU/day helps with cramps. It didn’t help me.
… naproxen – I don’t like taking it because of the potential kidney damage, but one at bedtime knocks out the cramps for a whole night. Consider this a last resort.
(Both vitamin E and naproxen act as COX inhibitors. It may be that other anti-inflammatory supplements may help on the same pathway. I plan to try curcumin next.)
Thanks Mike. I’m doing significantly better today. I’ve never felt this good since ——-I can remember. It’s just so hard to believe that I’ve gone this long and hadn’t addressed it to the fullest degree. I want to shout out to every person that I know to make sure that they take their own health into their own hands and not to accept life “as is”. Since adding the K gluconate my BP has even normalized and I’m off of BP Rx. It’s amazing what the human body can do when given the right fuel. I am so blessed that there are practitioners such as Chris Kresser out there that are willing to spread the news and offer hope. I’m in the midst of my Master’s in Clinical Nutrition right now. Can’t wait to be able to give back…………By the way – I am nervous about going higher on my K dosing. (It’s the physician in me- call me a sissy but I know the potential hazards). I realize that my metabolism is altered and I’ve read all the postings why I need more -it still scares the crap out of me!
Ok, so the symtoms are identified: inability to absorb B12, pernicious anemia, etc. But what is causing this? We know it stems from an inability to absorb b12 in the gut, but what causes that? Is it genetic? is it vaccines? is it GMO foods? is it stress? is it ??? What is causing all this b12 deficiency?
thanks,
Tony
Thank you for the information. Turned out that my MMA was normal! I am already feeling better after taking the shots each night for a week. I wonder if my doc specifically ordered the cyano or if I could get the better brand that you indicated. Thanks again for all your help through these posts.
My doc ordered an MMA blood test. My B12 levels already showed that they were low (190, I think) and my homocysteine levels were elevated (17, I think). Why would an MMA test need to be done? Would it show anything other than what I already know– that I am B12 deficient and need to take injections (which I am already doing).
Hi Lucy,
as the injections are usually inactive hydroxycbl or cyanocbl, they may not work well, quickly or at all. The MMA shows when the mitochondria are in failure mode needing adenosylb12
(dibencozide) and/or l-carnitine fumarate. Elevated Hcy levels can be casued by lack of methylb12, lack of methylfolate or lack of p5p (active form of inactive b6) and shows that the DNA replication process is broken prevednting cell formation and healing in many circumstances. About 99% of the time the right brand of sublingual methylb12 and adenosylb12 are 100 to 10,000 times more effective than hydroxycbl/cyanocbl. They along with Metafolin will restore DNA replication and healing within 3 days causing potassium to plunge as healing starts. The potassium needs to be spuplemented. With MMA being generated, adenosylb12 can casue ATP generation in the mitochindria to start in less than an hour. Just the basic 3 itemsd will work about 90% of time until they induce another deficiency which almost always happens.
b12 and glutatione again
How far down the line do you go to stop glutathione precursors?
Alpha lipoic acid?
Selenium?
Milk thistle?
Vitamins c and e?
I have even read that b12 and folate are precursors.
Bill, I have the same question. As far as I understand, impaired Glutathione production is a serious methylation issue, and I really don’t understand why would the supplements that work to increase its levels impair normal utilization of B12 and Folate… very confusing.
I’ll try to wrap it up reasoanably concisely. I supplied the data and Rich V. supplied the biochemistry and it was what I hypothecized. The only precursors that so far have proven to be a problem so far are whey, NAC and l-glutamineAND NAC. The problem is probably dose related. The amounts produced by the methylation process of b12 and folate and other things like C produce normal amounts and no problems. So let’s look at the process itself that is the problem. After the glutathione is taken or the precursors and glutathione is in the blood, it combines vwih adenosylcobalamin, methylcobalamin and hydroxycobalamin, further oxidizing it. glutathionylcobalamin is totally inactive. To convert it back to active b12 requires an enzyme which not everybody has and available ATP which is often in short supply in a person lacking sufficient adenosylb12. Further there is a total of at most about 5mg of b12 in most bodies. 500mg of glutathione could convert every mg of b12 to inactive cobalamin 100 times over. So even if it is converted via an upjhill energy transaction to mb12 again, there is another glutathione molecule waiting to convert it to glutathionylcobalamin instantly. The glutathionylcobalmin is excreted about 10 times faster than mb12 and adb12 estimated by observing tmy urine thousands of times following injections and measuring the color exactly to compare amounts of b12 in the urine. So when there is no active b12 in the cell the methylfolate is then flushed out in a process called the “methyl trap”. I was not able to overcome this even taking 30mg of mb12 injections as 3x10mg a day and 4000mcg of metafolin. After discontinuing it then when I took 16mg of Metafolin the deficiency symptpms started retreating in hours and I then had mb12 startup reaction all over again with the 10mg injection, having not had any b12 startup at all for 5 years at that point. We had 10 people doing the trial, all of thwem having good to excellent results in proigress with the active b12 protocol. A few were taking NAC and l-glutatmine, a couple taking whey, a few taking glutathione IV infusions and a few taking oral reduced glutathione. Every one of them had essentially the same response, induced b12 and folatge deficiencies getting worse and wrose until discontinued and corrected with larger than normal methylfolate and mb12/adb12 and the possiblity of startup responses all over again, which I did have. I also had a big potassium drop all over again as methylation and cell formation started up again, Now almost 3 years later I still have not recovered fully from all the neurological damage the glutathione casued. Popularly the name of that effect caused by NAC is “NAC detox reaction” or some such and for glutathion it’s “glutathione detox reaction”. As it isn’t detox at all that misnomer causes the problems to be continued indefinitely and worsening until it potentially damges a person severely. The symptoms are those of folate deficiency symptoms starting in potentially hours followed by mb12 deficiency symptoms which start in hours to a couple of weeks and adb12 deficiency symptoms which may take 6 months to start.
People who appear to benefit are typically those that find the startup of mb12 and/or methylfolate and a few orther things “unbearable” and the like. A specific grouping is so super hypersensitive to l-carnitine and/or adb12. In the mb12/methylfolate sensitive group glutathione puts a stop to it in minutes to hours, again verifying it is shurtting down the b12 and folate which is causing an unbearable neurological startup, and it appears fully neuropsyc, not psychological. For these two groups of people being in b12 and folate deficiencies is more comfortable than going through healing..
Fred, I had asked previously, but you didn’t respond. I am taking NAC because I’m a smoker. Although my B12 is high, my body doesn’t seem to be absorbing it. Is this due to taking the NAC?
Hi Fred,
Thanks for getting back with me so fast and for the wealth of information.
I found your protocol and have been reading all of your writings for the last four days. I stopped the NAC, whey protein, a multi mineral complex that had glutamic acid in it and thorne b complex that had calcium folinate in it.
Four days ago I upped my dosage of methylfolate (wrong brand Life Extension), upped my jarrow b12 and started on some potassium. I don’t have all of the supplements for your protocol but I was already taking most of them and the rest will be here tomorrow. When I took the jarrow b12 before I only had it in my mouth for approx. ten minutes, I’m sure just learning the proper way to take it would help a lot of people.
The first three days I was wiped out severely fatigued but today was one of the best days I have had fatigue and brain fog wise in a long time. A lot of the time I’m so fatigued and brain fogged you can just see it all over my face, every once in a while for a day or a half of a day every couple of weeks I come out of it and you can see the life back in my eyes. Today was one of those days and I really think it had to do with your protocol. I’m excited about that because I’m just getting started with it and like I said I don’t even have all of the supplements yet.
I have been on a paleo diet for the last four months and I have lost weight and feel healthier but for the last month I have felt more fatigued and my restless leg syndrome has been worse. I was thinking this was just something my body was going thru in the healing process. But after reading your protocol I realized about a month ago I started taking NAC and drinking raw milk with whey protein everyday to increase glutathione in my body. So what you have said about it seems right one so far.
I have a couple of questions that I was hoping you could answer if you have the time. I know you wrote that NAC, whey protein, Glutamine, and folic acid were the only ones so far that messed up the methylation cycle but I had a few more supplements that I take and I was hoping you could tell me if you think there is any chance they could cause a problem.
Raw milk although not a supplement I have read where it helps with your glutathione levels. Do you think that drinking a 12oz glass a day could be of concern?
Next is just a list of supplements, do you see anything on this list that could cause a problem?
Astaxanathin
DHEA
Formadrol extreme (it’s an anti estrogen supplement)
Skullcap
Curcumin phytosome
Phosphatidyl serine
Pygeum extract
L tyrosine
Mucuna pruriens
Thanks for your help,
Concerning b12 and glutathione
How am I going to get my glutathione levels up if I can’t take precursors because it will sweep folate and b12 from my body?
Does that mean I shouldn’t exercise because that increases glutathion?
I shouldn’t drink raw milk?
Whey protein will make me lose folate and b12?
Glutathione seems to be very important for a healthy body, I have been taking precursors to try to improve my brain function hoping this will alleviate some of my restless legs symptoms which seem to be from either low dopamine levels or poor dopamine uptake.
Any help on this subject would be appreciated.
My restless leg syndrome was magnesium deficiency. I fixed that and away it went… I’ve read that iron deficiency can also cause it as well.
As can iron overload, which is a lesser-known cause.
For the last four months I have been taking 800mg a day of magnesium glycinate and it hasn’t helped my restless leg syndrome at all. I took high dosages of iron for a couple of months and it didn’t help either, I have tried many things to get rid of it even stupid stuff like putting a bar of soap in my bed. Many people say that a bar of soap stopped them from having restless legs and even though it sounds stupid when your desperate you will try anything.
It’s not just an an annoyance it is like being tortured. I only get it at night or if I am very fatigued during the day I have been taking ultram every day for years because of it and I would really like to stop, I’m sure that it’s not the healthiest thing to do but I couldn’t get by without it.
I’m now hoping that if I can improve this methylation cycle that it will have an effect on the restless leg syndrome.
From what I have researched it seems to be clear that it’s dopamine that’s causing the problem, either not enough produced or something wrong with the receptors.
Off the subject a little bit here.
I’m not sure that Chris Kresser will ever have time to read this but if you do I would like to thank you.
I have been on a paleo type diet for four months and I feel healthier and I have lost 25 lbs.
I listen to all of your podcast and read all of your articles because I like the way you research the different topics and change what you said before when you learn something new.
I have listened to most of the paleo community’s podcast and read a lot of what they have written. There is a lot of good information out there but I like your approach and information that you put out is the best.
Thanks,
Hi Bill,
Withion a week of getting the Enzymatic Therapy b12 Infusion, the Source Natural Dibencozide (adenosylb12), Metafolin, omega3 oils, l-carnitine fumararte and methylation startup/healing startup has started (low potassium signals startup) glutathione will be getting made very adequately. Lack of glutathione is a signal of broken methylation along withg 600 signa;lsd. it is not a cause, it is an effect. Glutathione will restore itself natrually as soon as methylation startup ovccurs. With Enzymatic Therapy mb12 and metafolin methylation typicalyl starts up in 4 hours to 3 days. With hydroxycobalamin, cyanocbl, folic acid and folinic acid methylation may never startup and my be made even worse. Don’t believe the myths of glutathione or you may be damagedyu it as I was.
Hi,
I’m a 37 yr old mother of 3. I was diagnosed with pernicious anemia, Peripheral neuropathy and B12 deficieny back in February. After MRI/MRA, NCT and several blood tests, they started me on the sublingual B12. My level was 138. I was taking 5000mcg a day. I was no longer tired and the tingling had somewhat subsided. After about a month, the symptoms came back. So much so that in my sleep my arm and hand would be so cramped from tingling that my fingers would be clinched to a fist almost. I was tested again and my B12 was well over 2000. They put me on the sublingual at 1000mcg a week. I’ve done that on and off since then. I was ok for a month or two but now the symptoms are back. When will this vicious cycle end??? Should i be on injections instead? My neurologist also told me that i may have to repeat the NCT test over again to ensure there was no nerve damage. Is that true? That was the most cruel test i’ve ever done! Not looking foward to it.
Just looking to a long term solution.
thanks,
Symptoms responding to methylb12 start coming back after 3 days without mb12. It takes 9 months of continuous use of mb12 and other nneeded items, to complete 1 round of healing . Lots of things willl start another round of healing if you add them etc. It takes 5 years if no backtracking to make the neurological healing complete, if it completes. I’m 9 years into it and inject 10mg 3x per day of mb12 to hold the damage of subacute combined degeneration at a more or less constant level. It never heals more and comes back stronger with the first missed dose. Your best chance is to get it the first time because each time one does a stop and start the heak\linfg response is weaker and less complete. Continue for life or you will just get the damage all over again. You may need both kinds, adb12 and mb12 as well as Metafolin and some other nutrients. for best healing.
Thanks for your article. 51 y.o. husband just had B12 done and it was at the low end of normal. Now he is going for more testing. We are not vegan . He is not anemic. We follow a good diet with meats, fish, poultry, fruits veggies, eggs, low on grains and sugar. Not much in the way of processed food. Doesn’t drink or smoke. Would not have found this if a work health screen would not have indicated a high bilirubin level. Thankfully we have a doc who listened when I asked to check B12. Finally feel like we might be getting somewhere with the fatigue and other issues.
Can you have normal RBC count but still be B12 deficient even though serum tests say otherwise?
I just recently got out of the hospital after what one doc called a TIA and another said could possibly be a migraine. I fell, couldn’t talk, swallow, my tongue felt incredibly thick– I had numbness and tingling in my right arm, dizziness and queasiness. MRI and CT were okay. Homocysteine levels were high.
I got a second opinion from another neurologist and it turned out that my B12 level was something like 190 (may have been 160… can’t remember). Since my “episode” I have felt terrible. My body aches, my arm still tingles from time to time, I’m exhausted, and I feel as if I am living in a fog. I want to get back to my normal, busy life.
My 2nd opinion doc prescribed oral B12 pills, but they have been making my stomach cramp and I’ve felt sick while taking them. This morning, he switched it over to injections. Although I am scared at the thought of taking shots, I am ready to do whatever I can to get everything back on track!
What made my levels drop so suddenly? I have a small spot on my stomach that both previous docs said was most likely melanoma. I am seeing a surgeon tomorrow about that. Can melanoma make B12 drop? How soon will the injections start to make a difference in how I feel?
Thanks for reading, and I’d appreciate any advice. This is a whole new ballgame for me!
Hi Lucy,
If the form of b12 was EFFECTIVE for you, methylb12 and adenosylb12 are the most effective for the most people. If it was effective it almost immediately induces any of several other deficiencies. The two almost 100% that get set off are potassium decrease which can make you horridly sick and which can be quickly relieved with 500mg of potassium or so. The other most common will be an induced folate deficiency relieved by Metafolin. These can occur by the second or third day after start an effective b12 as the cell formation apparatus starts up. Both of these could leave you feeling sick. An injection of hycbl or cyanocbl is unlikely to have that same effect as a sublingual mb12 or adb12 tablets. A typical balance of nutrients for those who experience this startup for people with normal folate handling is 50-5000mcg of mb12/adb12, 2000-3000mg of potassium titrated by effect, 2400-4000 Metafolin titrated by effect. If a person has folic acid or folinic acid assimilation problems then they may need 6000-8000mcg or 12,000-30,000mcg of Metafolin for sufficiency and healing of specific symptoms such as IBS, angular cheilitis and other folate deficiency characteristics.
So, (just to make sure I am clear) the only way to know for sure that I am taking the effective dose is if I AM sick afterwards due to the regulated B12 “inducing” other deficiencies?
I know the prescription is 1000 mcg of Cyanaocobalamin.
Hi Lucy,
People with mb12/adb12 and/or methylfolate deficiencies often have a whole lot of nonspecific and highly variable symptom including all of the chronic fatigue syndrome and fibromyalgia range of symptoms and then a lot including neuropathies. Generally they affect every system because one of the main subsets of activity gone wrong is that there is what is often called a “partial methylation block” and basically a lot of cells postpone being made piling up unrepaired damage. When the methylfolate/mb12/adb12 needed to form new cells are present the rate of cell formation goes way up, a flag of healing. The most common result is the sudden dropping of the serum potassium level. However, with “normal” typically being 3.5-5.0 and “dropping potassium” symptoms start about 4.2-4.3 in some people, like sudden night time spasms and other symptoms as potassium drops to what can become dangerous levels. So don’t disregard symptoms. There is a list of such symptoms somewhere above here on this page that can help distinguish between potassium and methylfolate low level symptoms. With Metafolin a little bit of it can start a lot more healing than can be maintained by that same amount so folate insufficiency symptoms occur.. So yes, these two flags of healing starting can also be troublesome if ignored. Follow the hints of healing which can be unpleasant while it is happening. However, taking potassium rapidly relieves low potassium symptoms and so does Metafolin with methylfolate insufficiency. Mb12 itself increases neurological awareness of all the problems, pains, emotions etc and the things that come up first are often the ones that disappear first. Cyanocobalamin is about 1% as effective as Jarrow or Enzymatic Therapy methylb12 taken daily. Brand and type matters a lot, makes all the difference in the world, literally.
Hi Fred, so glad I caught you… I read a lot of your comments and most of it makes sense to me and I have a lot of symptoms that ppl here describe.
Here is a riddle:
My last too B12 tests showed as too high – more than 2000! So First my physician told me to take less of the B vitamin supplement (MegaFoods B complex – which if food based).
Second time I tested, I didn’t take this – or the Multi Vitamin that I also take – the day before the test, and it showed up as more than 2000 again. I also checked serum folate – came up 17.7, which is normal.
Fred, do you have any advise for me, may be you came across a situation like this?
My Doc told me to not only stop my B complex, but also a Multi that I am taking. It is a Multi Vit-A-Min by Emerald Labs and has Coenzyme Folic Acid (L-5 Methyl Tetrahydofolate) and B12 as Methylcobalamin, both of which if I understand you correctly are active bioavailable sources.
Hi Kira,
Telling somebody to stop b12 because the serum level is 2000pg/ml is total nonsense. It is built upon a non-understanding of b12 based on 60 years of research of inactive cobalamins, cyanocbl and hydroxycbl. A study in the UK a few years ago that admitted people based on SYMPTOMS, not test results. The average before treatment was over 700pg/ml with the higher folks over 1500pg/ml. 62% of the people who responded to methylb12 and healed their neuropathies would have been excluded from the trial by test results such as “high” serum level. 2000pg/ml as “high” is a statistical artifact that is meaningless. If one is looking for a level that has no deficiency symptoms look for a level over 15,000pg/ml. A 1mg injection (IM) causes an instantaneous serum level of 200,000pg/ml. A piece of liver or a plate of clams can raise a persons serum level by a 1000pg/ml. I maintain my serum level at about 200,000pg/ml 24/7 by subcutaneous injection of 10mg 3x per day as that is what is needed to maintain my nervous system because of previous deficiency damage. A serum level above 2000pg/ml is quite normal for anybody taking a supplement. The target for monthly injections (which keeps people alive as zombies but doesn’t heal them) is 300pg/ml at the end of the month. This is a level that I had 200 symptoms at and was dying from. I never went lower than that. A serum level of 5000ml/pg or thereabouts in a person who isn’t taking a supplement is generally caused by liver damage. People with CFS/FMS/MS/ALS/Parkinson’s/SupraNuclearPalsy all have genetically low cerebral fluid b12 levels no matter what the body level is and so have all this neurological damage that is casued over decades of deficiency. Further the serum level doesn’t tell active from junk cobalamin. Plants have 18 cobalamins that are not active in humans though they are absorbed and excreted. Even the active b12 test is pretty useless becasue most of the healing appears to be done with unbound b12 distributed by diffusion in the body while the diffusion is driven by high serum level like 200,000pg/ml. Even 100mcg absorbed from sublingual mb12 can temporarily increase serum level to 20,000pg/ml for an hour, and a deficienct person will feel that quickly. A trial is the only way to tell if mb12/adb12 can help as stated by study after study. I can point at research showing why every single test they use only shows how much damage already exists, and can’t show adequacy or sufficiency.
I would have to agree about the accuracy or rather inaccuracy of the active B12 test. I had one done which stated my B12 levels were high, so I stopped taking B12. Next time round, my RBC count had fallen again. I’m still having problems as in the question below.
So is the best way to get the high levels is to just use more sublingual mb12?
Thnx for your prompt reply Fred.
Even though I am not taking “junk” B-12, its the methyl form, would you say that I should continue and add the Folate as per your general recommendation?
I just ordered this one, hope its OK?
http://www.iherb.com/Doctor-s-Best-Best-Fully-Active-Folate-Featuring-Quatrefolic-400-mcg-90-Veggie-Caps/38067?at=0
Hi George, In all likelihood your daughter is just fine. The symptoms you describe sound neurological, (which could be from the food I suppose) which is why I posted a reply.
As a young girl (11), I experienced TIAs for two months prior to having a stroke. When you have a TIA (trans ischemic attack), your symptoms are transient. Mine lasted for no more than 5 minutes or so, then back to normal. My symptoms were slurred speech, slow reaction, nausea, sensitivity to noise and light, and one sided weakness. That’s why your post raised a red flag to me.
It is so unusual for a healthy child to have a stroke, but it happens, one in a million or two. I’m proof of that. Unfortunately, my TIAs weren’t recognized (I’m sure because it’s so rare) and now I have to cope with the effects of a stroke.