Are you a dedicated vegetarian or vegan? Perhaps you decided to follow a plant-based diet to improve your health but over time you’ve started to experience troubling symptoms such as brain fog, fatigue, poor memory, and even numbness or tingling in your hands and feet—issues you never had previously. If you can relate, then you may have a vitamin B12 deficiency.
Research indicates that vitamin B12 deficiency is far more prevalent than previously estimated, with at least 40 percent of Americans demonstrating suboptimal levels, and millions more going undiagnosed altogether. The consequences of B12 deficiency are serious and can cause irreversible damage if left untreated.
Read on to learn about the health implications of B12 deficiency and why it is significantly underdiagnosed, the best methods for testing your B12 status, and how to optimize your B12 intake with food and supplements.
What a B12 Deficiency Means for Your Health
Vitamin B12 works with folate to synthesize DNA and red blood cells and assists in the production of myelin, which protects your nerve cells (neurons) and regulates nerve impulse transmission. A deficiency of vitamin B12 can have significant health implications for multiple body systems.
Vitamin B12 deficiency is exceedingly common—especially if you’re following a vegan diet. Find out how to tell if you have a deficiency and learn how eating nutrient-dense foods can help you correct it. #nutrientdeficiency #vegetarian #vegan
The classic association of vitamin B12 deficiency with macrocytic anemia, a condition in which red blood cells are larger than normal due to impaired cell division, speaks to the importance of vitamin B12 for regulating DNA synthesis. However, anemia is but one symptom of B12 deficiency. There are many other B12 deficiency symptoms that occur long before anemia sets in, including:
- Dementia
- Cognitive decline
- Memory loss
- Brain fog
- Depression
- Cardiovascular problems
- Peripheral neuropathy (numbness, tingling, burning in the hands, legs and feet)
- Impaired immune function
- Infertility
- Developmental and learning disabilities
Unfortunately, many of these symptoms are often mistaken for other health conditions, including Alzheimer’s disease and multiple sclerosis. As a result, B12 deficiency is often missed by physicians in the clinical setting, with serious implications for patients’ long-term health.
If You Have an Undiagnosed Deficiency, You’re Not Alone
B12 deficiency is far more common than most healthcare practitioners and the general public realize. A study from Tufts University found 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 neurological symptoms can occur. Nine percent had an obvious B12 deficiency, and 16 percent exhibited “near deficiency.” (1) Surprisingly, the researchers also discovered that low B12 levels were just as common in young people as in the elderly.
Given the prevalence of B12 deficiency, why aren’t more clinicians and health organizations drawing attention to this serious problem? The answer lies in the fact that B12 deficiency is significantly underdiagnosed. Here’s why it’s frequently missed:
- B12 status is not routinely tested by most physicians.
- Serum B12, the conventional marker of B12 status, only drops in the later stages of B12 deficiency. Relying on serum B12 testing misses many, if not most, people who have an insufficient B12 intake.
- The low end of the laboratory reference range for serum B12 is too low. This is why most studies underestimate the true levels of deficiency.
- The standard serum test for B12 measures the total amount of B12 in the blood but does not rule out functional B12 deficiency. (A “functional” deficiency means that B12 levels are too low for optimum health, but symptoms like anemia may not yet be apparent or diagnosable.) (2) The determination of functional B12 deficiency requires other measures that are infrequently used by physicians.
New and Improved Testing Methods for B12
Fortunately, new, more sensitive tests for B12 deficiency are now available, including tests for methylmalonic acid (MMA) and holotranscobalamin II (holo-TC). Studies using these improved methods of B12 assessment reveal much higher levels of deficiency than studies using only serum B12 testing.
MMA
MMA is a compound in the body that helps with metabolism, via a vitamin B12-dependent enzyme; if MMA levels are high, it suggests that vitamin B12 is lacking. There are two ways to have MMA measured: in the blood serum and in the urine. (3) Some experts believe that urinary MMA is superior to serum MMA as a biomarker of B12 deficiency because MMA is more concentrated in urine than in the blood. However, elevations in urinary MMA can also be caused by kidney dysfunction. Serum MMA, on the other hand, can be elevated in the presence of small intestinal bacterial overgrowth.
If you decide to undergo MMA testing to determine your B12 level, your current health status matters. I recommend urine MMA if you have SIBO, whereas serum MMA is a better option if you have a history of kidney dysfunction.
Holo-TC
B12 is transported around the body by two proteins: transcobalamin II (TCII) and haptocorrin. Eighty percent of B12 is bound to haptocorrin, while only 20 percent is bound to TCII. Holo-TC, the marker that measures TCII, falls almost immediately after B12 intake drops. Serum B12, by comparison, measures total cobalamins (a name for cobalt-containing compounds, like B12). But it measures mostly haptocorrin, and doesn’t decrease until B12 deficiency has been going on for some time.
Homocysteine
Homocysteine is an amino acid in the blood. It’s a marker of B12 deficiency when elevated, though not exclusively. Elevated homocysteine can also be caused by folate and vitamin B6 deficiencies. Homocysteine is more sensitive than serum B12; however, if it is high, you will need additional testing to determine whether the cause is B12, folate, or B6 deficiency.
Holo-TC, MMA, and homocysteine are considered measures of functional B12 deficiency because they reflect whether B12 is being appropriately utilized in the body.
Your Best B12 Testing Option
So, which one of these markers is best?
- Holo-TC is the earliest, most sensitive indicator of B12 deficiency.
- Urinary MMA and homocysteine typically don’t become elevated until the mid to late stages of B12 deficiency.
- Serum B12 is the least sensitive indicator and usually doesn’t fall until the final stage of B12 deficiency.
While holo-TC testing is often the best way to catch an early B12 deficiency, it isn’t widely available in the United States (though it is in Europe). Here, we generally rely on a combination of serum/urine MMA, homocysteine, and serum B12 testing.
If you choose to get a serum B12 measurement, you will need to refer to a different range than the one provided by the lab when interpreting your results. Although most labs define deficiency at <200 pg/mL, it is well documented that many people experience signs and symptoms of B12 deficiency at levels between 200 pg/mL and 350 pg/mL. (4) Also, be aware that a high serum B12 does not necessarily rule out a functional B12 deficiency, which is best detected with MMA or holo-TC.
The same is true for homocysteine. The lab range often goes up to 15 nmol/L, but research has shown that a homocysteine level of 10 to 15 nmol/L is a substantial risk factor for heart disease, and that relationship is linear—the higher the homocysteine, the higher the risk. (5)
The Earlier You Notice a Deficiency, the Better
There are four stages of B12 deficiency, and the earlier B12 deficiency is detected in the progression of these stages, the more likely it is that the symptoms can be prevented or reversed.
Stages I and II
During the first two stages of a deficiency, your plasma and cell stores of B12 become depleted, and the concentration of holo-TC is reduced. Holo-TC is the only available marker for assessing the first two stages of B12 depletion. It’s likely that you won’t experience any noticeable symptoms if you’re in stages I or II.
Stage III
This stage of functional B12 deficiency is characterized by elevated homocysteine and urinary MMA concentrations in the blood. Serum homocysteine and serum/urine MMA are the best markers for detecting Stage III deficiency. At this stage, some people will experience mild symptoms like fatigue or brain fog, but others may not notice any signs or symptoms.
Stage IV
If you’re in the fourth stage of a deficiency, you’ll experience clinical signs, such as anemia, fatigue, and brain fog. Serum B12 and other markers of Stage IV deficiency may not decrease until this point. For some Stage IV patients, the cognitive and neurological symptoms are so severe that many believe they have Alzheimer’s or Parkinson’s disease. (6)
As you can see, signs like macrocytic anemia and symptoms like peripheral neuropathy or brain fog do not appear until the final stage of B12 deficiency. Stages I and II of depletion can precede deficiency (Stages III and IV) by months or even years!
To complicate matters further, the physical manifestations of B12 depletion can take years to appear. In the case of neurological symptoms, it may be too late to reverse them by the time the late stage of deficiency has been reached. (This particularly serious for children and young adults whose brains are still developing, as well as any adult at risk for Alzheimer’s or dementia.)
What Is a Normal B12 Level?
As I mentioned before, the cutoff for serum B12 of 200 to 230 pg/mL, used by most studies and labs, is too low. Other studies suggest that B12 levels greater than 400 pg/mL, double the accepted lower limit of normal, boost the beneficial metabolic effects of B12 and prevent neurological damage.
Importantly, research also indicates that at least one-third of B12 in serum is not cobalamin, the metabolically active form of B12 in humans, but corrinoids, which are not metabolically active. This profound finding means that some people with “normal” serum B12 may actually be deficient because the test is counting metabolically inactive corrinoids as B12.
As a rule of thumb, if your serum B12 level is between 200 and 350 pg/mL, B12 deficiency may be a problem. Just remember that a normal serum B12 does not rule out functional B12 deficiency, which can only be assessed with holo-TC, MMA, and homocysteine.
If You’re a Vegetarian or a Vegan, You Should Be Concerned about B12 Deficiency
Vitamin B12 is found almost exclusively in animal foods. For this reason, vegetarians and vegans are highly prone to B12 deficiency. While early studies showed that vegetarians and vegans had only slightly higher rates of deficiency than omnivores, these studies used relatively insensitive markers, such as serum B12, and less stringent cutoffs for holo-TC, MMA, and homocysteine.
For example, one study that used serum B12 (the less sensitive method) indicated that 7 percent of vegetarians and 52 percent of vegans were B12 deficient, whereas when holo-TC was used, deficiency was detected in 77 percent of the vegetarians and 92 percent of the vegans. (7, 8)
Essentially, conventional B12 testing is missing 70 percent of vegetarians and 40 percent of vegans that are B12 deficient! This is a massive oversight that may have devastating consequences for the long-term health of both vegetarians and vegans.
Interestingly, I have noticed in my clinic that other signs of B12 deficiency, such as elevated mean corpuscular volume (a marker known as MCV), can be obscured in vegetarians and vegans. This occurs because vegetarians and vegans often have iron deficiency and a high folate intake; these factors lower MCV and effectively “cancel out” any increase that B12 deficiency would cause. (9) Calcium deficiency, which is common in vegans, can also lead to B12 deficiency because free calcium is required for the absorption of B12. (10) The possibility of multiple nutritional deficits is just one reason to think twice about following a vegetarian or vegan diet.
Omnivores: You Need to Pay Attention to B12, Too
While rates of B12 deficiency are much higher in vegetarians and vegans than in omnivores, that doesn’t mean it’s rare in omnivores. Approximately one in 20 omnivores is B12 deficient. (11) B12 deficiency is also more common in people with risk factors like:
- Gut problems that decrease intestinal absorption of B12
- Past or present use of gastric acid-suppressing medications, metformin, or antibiotics
- A history of miscarriage and infertility
Vegans: You May Need More Supplementation Than You Think
Proponents of vegan diets promote B12 supplementation as the solution to B12 deficiency. However, supplements do not always solve the problem. In fact, research indicates that even well-educated vegetarians and vegans are not supplementing adequately!
Presumably well-educated vegetarians and vegans at a summer camp in the Netherlands were found to have serum B12 levels less than 200 pmol/L, a level associated with reduced DNA synthesis and other harmful metabolic effects. In another study, vegans taking B12 supplements demonstrated a paltry average level of 192 pmol/L.
Furthermore, the rate of B12 deficiency in vegans who supplemented with B12 was higher than in vegans who didn’t supplement! It is not clear why vegans who supplemented had higher levels of deficiency, but it could be due to the interference of supplemental B12 with active B12 levels. (12) In both of these studies, the subjects were from vegetarian/vegan societies and thus likely to be better educated than the general population. However, this did not prevent them from having a B12 deficiency. (If you need help choosing proper supplements, see the last section of this article for more specifics.)
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Your Kids Need B12 throughout Childhood
Women who consume vegetarian and vegan diets during pregnancy and breastfeeding and families that feed their children vegetarian and vegan diets during infancy and childhood are playing with fire and increasing their children’s risk of serious developmental and health problems.
Vegetarian Moms: You Need to Get Enough B12 during Pregnancy
If you’re pregnant and you have a B12 deficiency, your child could have low B12 throughout infancy and childhood. The longer a mother has been a vegetarian, the higher the likelihood she’ll have low serum and breast milk B12 levels that correlate with a deficiency in her infant. (13, 14, 15)
High homocysteine resulting from low maternal B12 status may promote neural tube defects and congenital heart defects in utero. (16)
The Impact of a Deficiency for Your Child
The prevalence of B12 deficiency is 67 percent in American children, 50 percent in New Zealand children, and 85 percent in Norwegian infants who have followed vegetarian or vegan diets their entire lives. (17) This is extremely concerning, as B12 deficiency can have “extensive, severe, and irreversible” consequences for brain and body development in children. (18)
B12 deficiency impairs fluid intelligence, spatial ability, and short-term memory in children; in fact, vegan children score lower than their omnivorous peers in all of these areas. (19)
B12 deficiency in children leads to:
- Poor school performance
- Depression
- Weakness
- Fatigue
- Nerve damage
- Failure to thrive
Even if a vegan or vegetarian child switches back to a diet that includes animal products, they may not be able to reverse all of the problems that come with low B12. A study of kids raised on a vegan diet found that they were still B12 deficient years after they started eating animal products. (20)
B12 deficiency also has serious health repercussions for adults. Notably, it raises homocysteine, a risk factor for cardiovascular disease, dementia, and Alzheimer’s disease. (23) Ironically, many vegetarians and vegans choose a plant-based diet to reduce their risk of cardiovascular disease, yet several studies have shown that homocysteine levels are higher in vegetarians than omnivores and higher in vegans than vegetarians. (24) Vegetarians and vegans with low vitamin B12 status are at risk of developing circulatory health problems regardless of their favorable profile of traditional heart disease risk factors. (25)
What to Do If You Think You Have a Deficiency
The first step I recommend is to get a holo-TC and/or urinary MMA test. If either of them is abnormal, you should immediately take steps to increase your B12 levels. There are two ways to do this:
- Eat B12-rich foods
- Supplement
How to Get More B12 in Your Diet
B12 contains a trace element (cobalt), which is why it’s also called cobalamin. Cobalamin is produced in the gut of animals and is found almost exclusively in animal foods. Some of the best sources of B12 are:
- Liver
- Clams
- Oysters
- Mussels
- Fish eggs
- Octopus
- Fish
- Crab and lobster
- Beef
- Lamb
- Cheese
- Eggs
A common myth among vegetarians and vegans is that it’s possible to get B12 from plant sources like:
- Seaweed
- Fermented soy
- Spirulina
- Brewer’s yeast
Nearly all seaweed tested has been revealed to contain vitamin B12 analogs (that is, chemically similar) called cobamides that block the intake of—and increase the need for—true B12. (26) The one exception is a combination of dried purple laver (nori) and wild mushrooms, which were shown in one study to reduce MMA.
Using a Supplement
Cyanocobalamin is the most frequently used form of B12 supplementation in the United States. But recent evidence suggests that hydroxocobalamin is superior to cyanocobalamin, and methylcobalamin may be superior to both—especially for neurological disease. This is because methylcobalamin bypasses several steps in the B12 absorption cycle and, unlike cyanocobalamin, readily crosses the blood-brain barrier. (27, 28) On top of that, methylcobalamin provides the body with methyl groups that play a role in various biological processes critical to overall health.
We now know that the dose of B12 in a supplement needs to be 100 times higher than the RDA of 2.4 micrograms/mL to be effective (this comes to approximately 250 micrograms/day). If you’re deficient, your dose should be even higher, at approximately 500 micrograms/day.
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@jaqueline I used 23andMe for MTHFR. I’m from Canada and I don’t know if you can access from the UK.
FYI I’m using a naturopath now who is B12 savvy. GPs and specialists are generally out to lunch in this regard. He has created a “cocktail” injectable containing B1/6/12 5-MTHF + some other stuff.
Best of Luck!!!
I believe that people in the UK can order 23andme tests. I think I saw information about placing international orders on their website (23andme.com).
I am thinking about ordering a test. The price is now permanently $99, much lower than it was a few years ago.
@Points,
Where on the 23andme test is the MTHFR listed? I can’t seem to find it.. but if you do any reading on Phoenix Rising or anything people seem to be seeing a lot of stuff on their 23andMe that I am not seeing. Any advice?
Thanks,
Lindsay
Hi Lindsay,
I tried to post for you 5 internet links to explanations that I’ve saved about MTHFR and how to figure it out with the 23andme test, but this site didn’t let that go through. Maybe they have a policy about hyperlinks to other sites. I’ll try to type it out in words, so you can find them online.
a. look for the “genetic testing and snps” forum on phoenix rising
b. look for the 23andme forum on the mthfr -period- net site
c. look at the site called snpedia
d. look at the US goverment site on genetic testing at
ghr -period- nlm -period- nih -period- gov -backslash- gene -backslash- MTHFR
e. look at the mthrfsupport website under the nov 2012 article about 23andme
Hi Lily!
Thanks so much for your efforts and reply. I finally figured it out yesterday and low and behold I am compound hetero for both of the MTHFRs that matter. I feel at once relieved that it is not all in my head and discouraged after reading so many horror stories with how those mutations relate to failed pregnancies. Oh well.. I will keep on keeping on and will be certain to not just randomly stop taking the B12 and folate supps like I had in the past!
Thanks again,
Lindsay
Hi chris, I was diagnosed with b12 deff a year and half ago, this was after approx 10 – 12 years or more of going to and thro to GP with many symptoms, mainly to be told its all in my head or look at me as though I was mental and making it up. Finally my b12 was tested and was 133 and low folate (don’t recal the results) I had b12 jabs once a week for 10 weeks the first 5 was cynocolbamin and the next 5 was hydrocolbamin (sorry if not spelling these right but think u will all know wat I mean) then week after my last jab my bloods was taken and test results for b12 was 886. GP then stayed I only needed jabs 3 monthly as my b12 levels was now very high, just to add that after about the 6 week of having my initial 10 jabs I was starting to heal and this continued as by the 10th week I was so much better not perfect but a lot of symptoms had eased a lot. Part way through week 2 of not having a b12 jab I was starting to get symptoms back to the point that end of week 2 symptoms seemed worse than before I started jabs. Went back to GP and although I got him to agree to give me another jab and also agree to give me them monthly he did not agree that my symptoms could be b12 related. I had 1a month for 3 months then bloods tested yet again this time b12 at 931 so again GP wanted to give 3 monthly even though I stated that I was just about dealing with the monthly jab as week 2 symptoms all back with force. Agreed on 2 monthly but also sent me to see rheumatologist and neurologist. Rheuma said possible fibromyalgia but only once all other avenues had been exhausted and neuro though it to be hnnp but shock tests stated different. Neuro said in end he thinks symptoms vitamin related. I hav had tests twice for PA but negative. I possibly have nearly every b12 symptom listed and same with fibro as they are very similar. GP have now diagnosed me with fibro just over 5 weeks ago. She one of the younger GP today as meds for fibro not working he is in the same mind as me as is it fibro or b12 he seemed bit sceptical it being fibro. I just wish I get a firm diagnosis so I can at least hav a name for wat I got. I hav asked over and over for active b12 test and but they ignore me. I would like to know if anyone knows if the MTHFR mutation test is available in the uk as I hav been told on sites that should test for this and also if MMA test is available in uk as I do not want to ask GP for these and for them to think I hav gone mad. Just to add my sister b12 is 33, and several other members of family hav low b12, my mums is 220. My 3 older children are showing symptoms but not tested and my 6 year old daughter is showing a lot of symptoms but they refrain from testing her and say its calcium and to give her more but I’m so certain it’s b12 and would like to jump on it ASAP if she has. Look forward to hearing from anyone x.
Jacqueline,
Your story sounds very similar to mine! I am sorry you are having to go through all of this! Have you asked your doc for the MTHFR test? I didn’t even know the mutation existed until my Internist asked if she could test for it after years of low b12 and other symptoms. I have since learned of the 23andme testing, but I got mine through a regular medical lab and ended up not paying a dime after insurance.
Jacqueline, I believe that people in the UK can order 23andme tests. I think I saw information about placing international orders on their website (23andme.com). The price (before shipping & handling is added in) is 99 US dollars (around 60 British pounds or so). If you wish to order a test on one or more of your family members at the same time as you order your personal test, they give a discounted rate.
There is a video on youtube.com of a BBC regional news program about an NHS doctor who was diagnosing some of his patients with low B12 and giving them frequent injections, and he was investigated by the General Medical Council (or some such body) and stopped from practicing for a time. He had to jump through all kinds of hoops to prove he was not doing any harm and that he was doing something medically valid.
Hi Lilly, yes I know of this doctor and have spoken to him. He offered to send me down the American B12 vials which he said is so much better than the one my doctor is giving me but that I had to get my doctor to give his permission for this but my GP states he cannot due to insurance reasons. I would go to use this GP but he is at the other end of the country. I have also asked about the MTHFR test but having active b12 test done first (of which I had to get referral from my doc but I have to pay for) then they will talk to me about the MTHFR test.
Jacquline,
I started showing symptoms of tingling and numbness in my toes 8 yrs. ago. Neuro’s thought I had MS, but MRI’s showed I didn’t. Then they thought it be fibromyalga, but no. Two years went by before a dr. took tests and found out my B12 level was 41. By then there was permanent nerve damage. My legs and feet have spasticty, stiffness, spasms and my balance is bad. I have to use a cane and/or walker since I’m a fall risk. People out there laugh when I tell them it’s from a B12 deficiency. I had to go through monthly series of b12 shots for years. But the past few years I found a nasal spray of b12 called nascobal and you take it once a week and my level has been in the 700’s.
Now anyone out there interested in nascobal should consult their dr. cuz he/she may not recommend it but it works for me and no more shots!
Hi Chris,
Just a few suggestions in terms of helping readers find this second, more-recent blog post on B12:
I first visited your site about two weeks ago for a short while, and at that time I skimmed through a number of your article titles, noting that you’d written two B12 posts (the one from last year, the one from this year).
Today, I tried to find the two B12 posts again by using an internet search engine to search for “Kresser” and “B12”, and only the earlier post came up. So I went to that post and clicked on your internal topic classification tag of “B12”, thinking that your second post would also have been assigned that tag, but under your classification tag of “B12”, only your first post is listed on your site. I then went to your site’s search box and typed in B12, but I don’t think that it came up that way, either. I was starting to wonder if my brain fog was tricking me into thinking that you’d written two posts on this topic, though you hadn’t! I think that, in the end, what I had to do was go back out to a generic search engine and find a link to this post via a mention on someone else’s paleo blog about your views on B12!
Because I believe that this 2013 follow-up post adds a lot of value and is good to read in conjunction with the original 2012 B12 post (which is one of your most popular posts, I note), I would encourage your web team to associate additional, relevant tags (like “B12”) with this post, to directly mention the existence of this follow-up post at the end of your first B12 post (and include the hyperlink there), etc.
Not only is it helpful to the reader to learn the contents of both posts, but I think you only mention your 4-supplement protocol in the second post (which is the information that I was trying so diligently to re-locate today!), and you may want to put an addendum paragraph in the first B12 post to give your 4-supplement recommendations — and to supply your Amazon links — directly on that page, since it’s a more highly-trafficked article.
FYI –
First one is tagged as: b12, cobalamin, deficiency, epidemic, vegan, vegetarian
Second one doesn’t seem to have any tags (?)
By the way, I’m not sure why (maybe it’s the nearly-1000 comments), but that first B12 post takes a long time to load on my computer (although I have a fast internet connection) and it sometimes freezes my Internet Explorer (whilst no other page on your site seems to do that). Either that happens, or I get a warning window saying that a script on the page is taking too long to run and do I want to cancel it. This will also unwittingly detour readers away from that page. Maybe it’s something easy to fix by the technical folks?
Thank you for your generous sharing of information and your extending of caring help to people, not only on this site, but also in the wider world. 🙂
Thanks for the insight. I added the tags, let me know if that changes anything!
Hi Laura,
Thank you for responding!
Unfortunately, the tags do not seem to be here on this post.
Even though I still can’t see any tags here, I thought that maybe they were associated with this post but just “silent”, or maybe they were really on this page and I was simply overlooking them (which is definitely possible!), so I went over to your first post on B12 (which earlier I had said was published in 2012, but now I see that actually it was published May 6, 2011) and clicked on the “b12” tag that appears at the end of that post (it’s in this line “Tagged as: b12, cobalamin, deficiency, epidemic, vegan, vegetarian”) and unfortunately, what comes up under the B12 tag is only that 2011 post. So there seems to be a technical issue with the tagging.
I don’t mean to harass you about this – it’s not for my sake, as I have the posts saved in my Internet Favorites. I am only letting you folks know this because many casual visitors to the site who read the first B12 post will have no way of knowing that Chris wrote a second, updated, advanced post about B12 twenty months after he wrote the first one, and that he provided in the second one a suggested set of supplements to take, which he did NOT do in the first post.
The comments section of that first B12 post is still going strong (even this week there have been several new comments there), but the majority of the people who participate in those comments probably do NOT know about this second post which provides Chris’ updated thoughts on B12 and provides, for the first time, Chris’ suggested B12 supplementation routine. And even if readers of that post search Chris’ blog to see if there are other posts on B12, this second post is not listed in those search results.
Also, just for the sake of the site’s earning potential, it would seem beneficial for you to allow site visitors to learn about your suggested 4 supplements for B12 replenishment and to have access to your Amazon hyperlinks to them, so the visitors, if they so choose, can use those links to buy the supplements, giving your site a small cut from the retailer in the process.
Hi Lily,
Thank U so much for your generous and valuable input to these posts.
Like many others I was completely unaware of this 2nd post and did in fact recently post on the previous one- seeking for help in fine tuning my supplement regime.
Thank U for posting on the 1st article + over here to alert us all- U R a star!
Would highly recommend that Chris himself writes a comment on the 1st post to let everyone know that he has a second article & one that states some of the other supplements to be taken together with Methyl Cobalamin B12 sublinguals.
On another note- its the 1st time Im reading that we need Trimethylglycine!?!
Last week I started taking B12 Enzymatic Therapy 1/4 tablets (ie 250mcg) + Solgar Folate 1/2 tablet (ie 200 mcg) in addition to a Multi Vitamin & 2 Bananas daily- but after just 4 days I felt drained from the lack of good sleep! Im B12 & D Deficient & my recent Bone Mineral Density DEXA report indicates I have Osteoporosis at 41 years old despite a very active exercise & balanced diet regime!
TKS & God Bless U,
Mark
Yes, so thankful Lily pointed out this second post, and I second all of her suggestions above to get this one in the radar of readers. I have read every comment on both posts and it’s clear there are many, many people out here who have this issue and can use this very valuable information. It has helped me in so many ways, I can’t thank you enough — both the information itself, the suggestions that were applicable to me, and the connection to others who have a lot of experience with this issue. Thanks!
Mark – are you celiac? Celiacs are commonly deficient in B12 and of course, prone to osteporosis (many of whom dont know they are celuacs until they are diagnosed with osteo).
Mark and Felicia,
I’m so glad that my notice on the other thread helped you to find Chris’ updated B12 recommendations (and the further reader discussions) on this page!
===
Mark,
This is just a conjecture, but it sounds as if you may need more potassium than what 2 extra bananas can provide. That feeling of fatigue/needing to sleep a lot might mean that your potassium has been all used up by the methylation. Potassium is available in many stores in 99 mg tablets, and you can also order tablets of larger milligram quantities online (for example, from amazon, swansonvitamins.com, etc.)
About the TMG/betaine component of Chris’ 4-supplement recommendation, please see my comment further down this page quoting a BBC article from 7 April suggesting that standalone betaine supplements may cause health problems. I am hoping that Chris will address this claim, either in the reader comments here, or in the reader comments under his “eating red meat” article/blogpost that he published a few days ago.
I’m having trouble with the Jarrow subling b12 5k. That area under my tounge feels very raw and almost burned. Any suggestions for different brand? Has this happened to anyone else?
Deborah, I have read on another forum that this supplement and ones that are similar can do this to people’s mouth tissue, and they also can erode nearby tooth enamel, because of citric acid and other non-active ingredients these lozenges are made with (in order to make the taste more palatable, I guess).
I have a bottle of Natural Factors B12 methylcobalamin sublingual that has no flavors, colors, citric acid, artificial sweeteners, etc. (I think that brand might also have B12 sublinguals of the same dosages, 1000 and 5000 mcg, that do have that extra stuff in them, so read the labels carefully if you are thinking of purchasing these). I am very pleased with it, in terms of not affecting my mouth tissues or my teeth, but I have gotten the feeling from reading various discussions in various forums about B12 deficiency that the Natural Factors methylcobalamin is not very highly regarded (in terms of its perceived potency) by experienced users of B12 supplements (such as Freddd and folks who swear by his B12 replenishment protocol).
Before I had come across Chris Kresser’s 2 blog postings about B12 or the other specialist websites that go in-depth about B12 replenishment (and thus I didn’t yet know that there are several supplements that should be taken ALONG WITH full-strength methylcobalamin), I had been taking a 1000 mcg tablet of the Natural Factors methylcobalamin daily for 2 weeks with no problem, and the first steps of healing were really seeming to take place (in terms of my particular deficiency symptoms), but then I suddenly had a “potassium crash” that put me out of commission for about 36 hours (constant heart palpitations, lasting muscular cramps in my back and neck, feeling totally drained), which I guess meant that the methylcobalamin in the Natural Factors must have been doing *something* powerful in my body!
I tried to find out what was happening to me and discovered that this kind of crash was common with methylcobalamin (this potential potassium imbalance, called hypokalemia, is even mentioned on the Wikipedia page for B12 deficiency, which I had actually read before I started taking the B12 supplement, but I had just not paid enough attention to that part). I rested, ate as many foods as I could find in the house that are high in potassium, and stopped taking the B12 until I could get some potassium tablets locally. (I’ll have to order the other two supplements online because they are not available where I live).
Chris,
After years of b12 deficiency, I have a new doctor that tested me for the mthfr mutation. I tested positive for a compound heterozygous mutation. I’m learning info as I go. I’m now on methylfolate and methylb12. Can you give any nutritional advice? Also I’ve read a lot on epigenetics…is thissomething I can “turn off” after proper methylation supplements?
Hi Chris,
I have MS but I inject B12 every 3 days because if I don’t I crash – numbness in hands, fatigue, worsening of spasticity and gait issues. Serum level at 1400 and doc thinks I’m crazy. MMA came back negative but clearly I have a B12 problem as I experience big improvements in numbness, spasticity, balance etc. Help!
Thanks in advance, P
What about your vit. D level? A friend of mine who has MS does the same thing with vitamin D, every day like 5000UI. A famous London neurologist prescribed it for her after a bad attack, and she’s okay, her recent brain scan showed no declension.
I am 8 weeks pregnant with my second child and keep waking up with tingling and numbness in my hands. I had this problem while nursing my first as well. I was vegetarian/vegan for 15 years. My B12 tests have always been on the lowest end of “normal”, so I guess I’ve been deficient for a long time. Are there any special supplementation considerations I should make while pregnant? Or will the recommendation above work for me?
Hello Chris,
I’m very glad to hear that sublingual B12 is better than injections. I used to get injections and then developed reactions to them. I would break out in cystic acne about a half hour after and I now think this might be do to with my histamine intolerance. As I understand it, B12 can raise histamine levels. If this is the case, would sublingual be better for me since it is not as concentrated?
Thank you
Amy,
My sense of what Chris said was that sublinguals work better for some people than injections — I’m not yet convinced that they are 100% better for everyone based on my own experience, what I’ve learned from practitioners, and what people are saying here. For one thing, some people react to the other ingredients in sublinguals and some do well with injections while others do not, does that make sense? My sense is that it is a highly individual situation, but it is well worth being open-minded to all the options.
Hello Amy! I also developed cystic boils on my forehead after getting B12 injections. I would like to hear more about your health history. I have been gluten free for 4 years (per a genetic test), hypothyroid, anemic… Maybe we could help one another. 🙂
About a year ago I was eating a mostly vegan diet after being a vegetarian for a year. As soon as I learned vitamin B12 was only found in animal products, I sought out a supplement. While I eat pastured meat every 2 weeks and consume eggs almost daily now, I still like to take my supplement because I am sure I have some catching up to do, if you will. I take a SISU 1000 mcg methylcobalamin tablet daily, normally with a meal. However, I am wondering if I should be taking this pill on an empty stomach? I have had some low stomach acid lately (not new to me), which I am working on (this is actually how I came across your site), and was worried that if stomach acidity is important for B12 supplement absorption, that I may not be absorbing any of the supplement. Does it matter if I take it with food or not? and is stomach acidity important?
Heya Chris,
I don’t eat meat, but would prefer as much as possible to get all my vitamins and minerals naturally – what would be the most effective way of getting sufficient B12 while eating as little meat as possible?
I have been considering eating wild game, in the form of Biltong once in a while. I tried this a couple of years ago and was very ill – it had been quite some time since I ate it, but maybe less for the first time next time! How much do you think I would have to eat each month to give me the required amount of B12?
Thanks!!
Jose
Jose: clams, oysters, mussels and liver are the most concentrated sources of B12. 3 ounces of clams is equal to 1,401% of the daily value (DV) and 3 ounces of liver is equal to about 1,214% of the DV. So in theory one 3-ounce serving per week of either of those would be sufficient. (However, that’s assuming optimal absorption, assimilation, co-factors, etc. — which is often not a safe assumption.)
Dr. Chris, Do you have any articles on the types of meat that are best for b12 and how often to eat, of course it would be a generalization. It would be nice to have a basic understanding of what is average to compare and contrast with my current diet.
Thanks
Clams, mussels, oysters and liver are the highest sources; then lamb, beef and venison.
I’m a 31M and just started having peripheral neuropathy and quad weakness for the last two months. I also deal with lots of anxiety and heart palpitations. Since my symptoms started, I’ve tried acupuncture, liver cleanses, juicing, more raw foods, removing a newly purchased memory foam topper, and and started supplementing with multi-vitamin, Nordic Naturals Ultimate Omega, 5-7 k IU of Vit D3, and magnesium. I *just* started 200 mg of Doctor’s Best stabilized R-Lipoic acid.
I even bought a glucometer to test my after meal blood sugars (my fasting blood sugar had been 90 twice, was 83 recently and my hemoglobin a1c was 5.4.) After meal blood sugars never went over 140 over a week of testing so it doesn’t sound like high blood sugars.
My Vitamin B12 level was 679 PG/ml, my folate, RBC is 364 mg/nl and my Vitamin D was 24 ng/ml. Been tested for Lyme, sjogren’s, lupus, gluten intolerance, etc and all came back negative.
Could it be a b12 and or folate deficiency all along?
Any suggestions Chris? Love the blog!
You suggest egg but most studies show that the B-12 in eggs is not very bio available ?
Dr Chris,
I am 61 and not taking any meds and supplement with methlylcobalimin, TMG, and folate, among other things. I eat eggs and/or meat every day. Yet my homocysteine levels are elevated at 13 umol/L. My weight is normal and I also exercise. Any suggestions on how to reduce homocysteine?
Thanks, Michael
Vit B6 (pyridoxine) disposes of homocysteine, B12 and folate just cycle it back to methione from which it is formed.
Hi Chris, a friend pointed me to your site. A few years ago I had a near-fatal brain trauma (“died” and later “came back”) and have not recovered. At the time my neurologist said there was nothing nutritionally that would help. I have not recovered and have some level of brain damage, as well as quickly degenerating nervous, endocrine, immune, and musculoskeletal function, as well as have body-wasting. Probably more issues, these are just most obvious. Have seen nearly 100 specialists/doctors/nutritionists/alternative practioners/therapists and after they take the “well-intended” stab at diagnosis and treatment, they have all ultimately just called me humpty-dumpty. Starting in 2009 I followed the Clean Program religiously for a few years, did the fresh juicing, smoothies, proper calorie management, and supplemented to the very best I could, given advice and impairments. And it ended up have no beneficial effect. My body does not seem to tolerate or digest anything anymore. At some point, do you advise we just throw a hail-mary and hope for the best? best.
Mary,
Check this out: http://www.ncbi.nlm.nih.gov/pubmed/23100196
Not nutritional therapy, but appears to be acting as a “good” drug in this case because it is improving symptoms by improving function. Google a bit more about this. In some cases, long-lasting results (years) are achieved in as little as a single injection, even in cases of up to 10-year old brain trauma. Worth considering.
David, appreciated. Good to see trials underway and will discuss next time visiting doctor. As far as B12, was taking before and ordered some to try again, then will see. Maybe it will help some. Best to you.
Hope all goes well. If you’re able to try the drug therapy, I would be extremely interested to hear of how it works out for you. If you’re so inclined, you can get in touch with me through my website: http://www.reforminghealth.com. -David
Chris, My family eats a mostly vegetarian diet, except we eat alot of pastured eggs. I want to make sure we are getting the vitamins and minerals we need. What kind of supplements do your recommend for people like us, and where’s a good source that we can trust to tell us exactly what nutrients a body needs–children as well as adults?
B12, iron, zinc, retinol (active vitamin A) and EPA/DHA are the most common nutrients vegetarians are deficient in.
Chris first and foremost thank you for the info you provide. How do we keep the more natural approach to medicine and raise the standards of the current Doctors.
I have the MTHFR variant. I know because in Sept 1999 I developed a blood clot. I was 35 at the time and had not been married a year yet.
I was on coumadin for 2 1/2 yrs and hemorrhaged.
I have been doing the supplementation ever since with B complex and extra folic acid, B12, B6 , E, Magnesium, Fish oil, zinc .
Hi Chris,
Do you ever see recovery of patients with peripheral neuropathy due to low vitamin b12? Is there anything else one can do besides normalize b12 levels to try to recover? Thanks
Hi Jens: yes, I have in quite a few patients. It’s definitely worth a try. You may want to read up on methylation defects and check into either Rich Van Konyenberg’s or Fredd’s protocols. Google them; they’ll come up.
Just a note to say that Rich and Freddd’s protocols changed over the years, and several versions of them are still on the internet, in discussion threads that can be very long, with people still contributing to them years after they were started (and it’s all so complicated anyway, at least when you are new to this subject like I am!)
Therefore, be careful when looking Freddd and Rich’s recommendations up on internet search engines — try to find the most recent version of their protocols.
I may be wrong, but as far as I have discovered, these are the most recent versions:
Rich’s: http://forums.phoenixrising.me/index.php?threads/revised-simplified-methylation-protocol-august-25-2012-revision.19050/
[Note: Sadly, it seems that Dr. Van Konyenberg passed away a few months ago, so this is the last version of his protocol.]
Freddd’s: http://forums.phoenixrising.me/index.php?threads/the-stages-of-methylation-and-healing.21725/
(note: That specific thread by Freddd is quite complex and technical, and I do think there are shorter descriptions around of his current B12 thinking – I’m not able to find a concise one right now though. Do make sure to look for posts by him that are from the last couple of months, because he has changed some of his hypotheses and some of his product recommendations relatively recently.)
I had suffered from depression and anxiety since I became a vegetarian, and then being paleo only helped my symptoms slightly. I started supplementing with Nutri-Dyn’s Phytomulti multivitamin, which contains a high dose of methylcobalamin and this has made a huge difference. A chiropractor had previously had me supplementing with cyanocobalamin and this caused my serum levels of B12 to skyrocket to way above the desirable range, but my symptoms didn’t improve, potentially because I have methylation issues and was not absorbing any of that type of B12. The methyl- type definitely helps some of us while the cyano- version does not.
Hi Chris,
Thank you for the article. Is there any harm in supplementing with B12 at your recommended maintenance dose for a ‘trial’ without lab confirmation of deficiency? I am paleo (PHD-esque) 1+years but was a veggie for a couple of years prior…