The four stages of vitamin B12

deficiency
Given up animal foods? How to ensure you don’t get to
stage four. The damage could be irreversible.

If you recently switched to a 100% plant-based diet,

you can relax for quite some time. The adult liver can
store enough vitamin B12 to last 1–5 years. But after that,
and without “careful planning”, your health could suffer
serious and irreversible damage.

You often hear and read that a plant-based diet can be a healthy
one, with enough careful planning. Unfortunately, further details
of what that entails are not always forthcoming. So, in the interests
of ensuring a carefully planned plant-based diet, I outline below
the four stages of vitamin B12 deficiency — and how to make sure
you don’t get to stage four.

Vitamin B12, also known as cobalamin because it contains the

trace element cobalt, is not found in plant foods. It is made by
bacteria in the guts of animals and migrates from gut to muscle. A
water-soluble vitamin, B12 is crucial to the brain and nervous
system, red blood cell formation and DNA.

The central nervous system is especially vulnerable to vitamin B12

deficiency.

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Writing in the British Medical Journal in 2013, researchers
describe the case of a 25-year-old man with low blood (or more
accurately, serum) B12 and myelopathy.

Myelopathy, a general term for degeneration of the spinal cord, is

the most common neurological syndrome of vitamin B12
deficiency and is a sign of early stage four deficiency. If detected in
time, the condition is fully reversible.

The man in question sought medical help for a tingling sensation

in both hands that had spread up his arms. Described as a “strict
vegetarian”, he was treated immediately with B12 injections,
which led to a rapid resolution of his symptoms. As the
researchers conclude:

“Early diagnosis and treatment are crucial in order to prevent the

irreversible damage to the nervous system.” (Verma et al)

You will only become aware of any symptoms at stage 4.

Stage 1
This is when “serum depletion” becomes evident. It is possible to
detect low levels of the B12 carrier protein TCII. TCII levels drop
within just a few days of absence of the vitamin.

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Stage 2
As stage one progresses to stage 2, low vitamin B12 can be
detected at a cellular level. Like stage 1, there are no discernible
symptoms.

Stage 3
At this stage, there is another detectable change in the blood.
Levels of an amino acid called homocysteine begin to rise above
normal, creating a condition sometimes called
‘hyperhomocysteinuria’. It’s a see-saw act: as B12 levels
rise, homocysteine levels fall, and vice versa.

All about homocysteine

Raised homocysteine (Hcy) in the blood is an indication of B12
deficiency.

Normal homocysteine metabolism is regulated by a trio of B

vitamins: B12, folate (B9) and vitamin B6, working together as
cofactors. To lower blood levels of Hcy, you just need a regular and
adequate intake of these three vitamins.

Deficiency of B6 is uncommon, as this vitamin is widely

distributed in a broad range of foods. Folate deficiency is more
common, and can be reversed by eating lots of leafy green
vegetables, such as spinach and kale, though the richest dietary
source is offal, especially beef liver. Beans are also a good source.

Vitamin B12 is the tricky one, the one most likely to be missing
from diet.

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Because vitamin B12 is found exclusively in animal source foods,
the most vulnerable groups are vegetarians and vegans.

I should add at this point that B12 deficiency can be brought about
by other causes other than avoidance of animal source foods and I
cover this in a separate article on the subject. But dietary
avoidance is the main cause of deficiency.

B12 deficiency was once thought to be rare in vegetarians but

is now known to be common among people on all the different
vegetarian variations. Researchers have observed stage 3
deficiency in over 60% of vegetarians.

Stage 4
This is the clinical deficiency stage — signs and symptoms start to
appear. Some of these are more serious than others, and some are
more obvious than others.

Early, mild symptoms of stage 4 vitamin B12 deficiency include:

 Fatigue

 Depression

 Anxiety

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  Loss of appetite

 Pallor

 Hair loss

 Numbness or tingling in the hands and feet

 Poor memory.

Memory problems and slow mental processes are the most

commonly reported cognitive problems associated with deficiency
of this vitamin.

Both the blood and the central nervous system are most likely to
be affected at this stage. Megaloblastic anaemia is not uncommon.
This is a condition in which abnormal red blood cells are produced
by bone marrow.

“Megaloblastic anemia resulting from cobalamin deficiency may

also be associated with neurological symptoms. The initial

neurological symptom may be tingling or numbness in the hands

or feet. Additional symptoms develop over time including balance

or gait problems, vision loss due to degeneration (atrophy) of the

nerve that transmits impulses from the retina to the brain (optic

nerve), and mental confusion or memory loss.”

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One possible neurological outcome is myelopathy, as experienced
by the young man documented in the British Medical Journal.
There may also be neuropathy (nerve damage) and
dementia. Peripheral neuropathy (damage to nerves in the body’s
extremities) is seen in 25% of patients with vitamin B12 deficiency.

A major concern is a form of myelopathy that affects the spinal

cord called ‘subacute combined degeneration’ (SCD). Myelin
sheaths and axons are destroyed in the white matter of the spinal
cord. The myelin is the protective layer wrapped around the nerve.
Fortunately, SCD:

“.. is usually reversible, if diagnosed and treated early.”

Another indication of stage 4 deficiency is depression.

One study compared vitamin B12 levels in 100 vegetarians with

100 omnivores. Vitamin B12 was significantly lower in the
vegetarian group, and the frequency of depression was 31%
compared with 12% in the omnivores. Psychosis was found in 11%
of the vegetarians compared with 3% of the omnivores. The
researchers concluded that:

“Vegetarians have vitamin B12 deficiency and are more prone to

developing neuropsychiatric and neurological problems.”

(Kapoor et al).

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In older people, cognitive function may decline, and dementia
arise. The elderly — whether vegetarian or omnivore — are
vulnerable to B12 deficiency, a factor that can be easily overlooked
when symptoms of dementia arise. It is estimated that 10%–15%
of people over the age of 60 have vitamin B12 deficiency.

A number of such cases have been reported in the press. In 2011,

the New York Times reported the case of an 85-year-old woman
who was diagnosed with Alzheimer’s after becoming increasingly
confused and forgetful. Fortunately, she was tested for vitamin
B12, and found to be deficient. After receiving weekly B12
injections, she recovered her mental health sufficiently to continue
living independently and alone.

Last year (2018), the Journal of Alzheimer’s Disease published a

Consensus Statement on the link between B12 deficiency and
dementia. The researchers concluded that screening for raised
homocysteine should be carried out in memory clinics, and people
found to have high levels should be offered supplementary B
vitamins. Apparently, this is something that already happens in
Sweden.

If left untreated, stage four will progress to irreversible damage to

the central nervous system.

The three stages of careful planning

Despite the potentially devastating consequences of untreated
vitamin B12 deficiency, it is possible to continue on a plant-based
diet if you know what you are doing. This means being informed of
alternative sources of B12, and making sure you have enough of
those sources.

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Stage 1: Get tested
If you are at all concerned about your B12 status, I recommend
that your first step should involve testing.

There are two tests that are quite useful — blood (serum) vitamin
B12 and homocysteine levels.

A blood vitamin B12 test may provide an early warning sign that
you have low levels of this vitamin, and have arrived at stage 1
and/or 2, and are possibly heading towards stage three.

If you have high homocysteine (stage 3) you probably want to

know about it. Fortunately, it’s a relatively straightforward test
that you can do it at home.

If you’re in the UK, don’t expect your doctor to arrange a test for
you. (Though you can always ask.) Your alternative option is to
arrange a private test. For details of how to go about this, see York
Laboratories or Genova Diagnostics. Below is a sample report
from York Laboratories.

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What is deficiency?
The recommended daily amount of B12 is 2.4mcg in the US and
1.5mcg in the UK. These are estimates based on what is thought
sufficient to prevent megaloblastic anaemia.

Stage 2: Take the right supplements

Nobody absorbs all the vitamin B12 they consume. Even

omnivores can only expect to digest and absorb around 50% of
this vitamin from meat and fish.

Although vegetarians generally eat dairy foods and eggs, the

quantity of B12 is quite low in these foods, and the absorption rate
is not great either. That would explain why they are frequently
deficient in this vitamin, but not to the same extent as vegans.

There are various forms of B12, natural and synthetic. The type
most commonly used in supplements is cyanocobalamin, a
synthetic form not found in nature. It is cheap, so popular with
manufacturers. The body has to convert it into methylcobalamin, a
natural form.

So, if you are already taking a B12 supplement, check the label to
see what form it’s in. Oral vitamin B12 supplements overall have a
low absorption rate — 0.5% — 4%. That is why supplements of this
vitamin generally tend to be made in very high doses. An oral dose
of 1000mcg, which is quite typical, delivers around 5–40mcg of
B12. Researchers suggest an oral dose of 50–100mcg daily, or
2,000mcg weekly, for healthy vegetarian adults, taking into
account the rate of absorption.

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“Vegetarians should thus take preventive measures to ensure

adequate intake of this vitamin, including regular consumption of

supplements containing B12.” (Pawlak et al).

Stage 3: Cast a cynical eye over fortified foods.

Sometimes processed food manufacturers add vitamin B12 (along
with other nutrients) to their products, so that they can make a big
deal of this on the packaging. Personally, I think this is very
misleading, as you might (reasonably) assume that fortification
eliminates the need to take additional supplements. The truth is,
fortification is usually made with low amounts of the synthetic
form of B12.

“In some countries, certain foods are fortified, such as breakfast

cereals, with Cbl. However, the quantities used are quite variable

and the consumption of such foods cannot guarantee sufficiency

in the absence of other sources.” (Rizzo et al)

I contacted a few companies, who confirmed that they fortify with

the artificial form cyanocobalamin, including the manufacturer of
an oat ‘milk’ who helpfully added in their email to me that:

“… we assume that people who are lacking in this vitamin take

supplements, hence we believe that cyanocobalamin is effective
for the majority of our consumers.”

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In short, I would define “careful planning” as informed
supplementing, preferably with natural vitamin B12 and at a level
sufficient to ensure adequate absorption. Fortified foods are fine if
you like that sort of thing, but don’t see them as a guarantee of
adequate B12 provision, or a guarantee against the irreversible
damage of stage four deficiency.

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