What do Alzheimer’s disease, multiple sclerosis, autism, depression, schizophrenia, diabetic neuropathy, infertility, developmental disabilities in children, strokes, heart attacks and cancer all have in common? It is vitamin B 12 deficiency, although we could add, it is vitamin B 12 deficiency misdiagnosis. Because B 12 deficiency affects all body systems, it can masquerade as many other diseases. In addition to neuropathy and psychiatric problems it can manifest as shortness of breath, fatigue, generalized weakness, anemia, poor digestion, GERD-like symptoms, constipation, diarrhea, weight loss, recurrent miscarriages, infertility, osteoporosis, poor wound healing and poor immune response. Patients with B 12 deficiency may have a few or many of these symptoms and most times they are easy to blame on other disorders or pre-existing conditions.

Despite this, B 12 deficiency is very rarely taken into account when diagnosing any of these disorders. According to the authors of the book “Could it be B 12? An epidemic of misdiagnoses” Sally M. Pacholok R.N., B.S.N. and her husband Jeffrey J. Stuart, D. O., doctors are not educated in it, so they fail to test for it. The authors assert that 40% of seniors with severe mental and physical problems are suffering from B 12 deficiency. ‘Millions of people labeled as having many severe and uncurable disorders could actually be victims of the easily diagnosable, treatable and, in its early stages, completely curable B 12 deficiency.’ In their book they explain their alarm at how B 12 deficiency is very common, not only in seniors and middle-aged people but in teens, children and infants.

In what follows we will look in depth at vitamin B 12, what it is, how it is absorbed, sources of B 12 as well as best supplemental forms. We will also look at how B 12 deficiency could affect your heart as well as other systems in the body. We will also look at how the ‘Heart and Body Extract’ and other products from ‘Healthy Hearts Club’ are a perfect supplement to take with vitamin B 12.

We will start with the story of how Sally Pacholok, R. N. became aware of what she calls ‘an epidemic of misdiagnoses’.

A nurse’s intuition

Sally shares her personal story with B 12 deficiency to show how getting a diagnosis is not always easy. How many times was she misdiagnosed? Not just one, but three times and by three different doctors.

It all started when she was only 19. She was the picture of health, or so she thought, she had no idea that an invisible disease was attacking her body. The first clue came when she went for a pre-employment physical examination. When the examining physician reviewed her blood tests, he commented on her abnormally large red blood cells and sent her on her way. Looking back, she realizes that the fact that this test came back positive is what saved her life. She asserts many people are not so lucky and ‘suffer neurological damage decades before their blood tests become abnormal, and by then it’s too late’. In her case, the doctor simply dismissed this blood abnormality as low folic acid. One month later, another doctor commented on how large her red blood cells were but concluded the lab results were ‘insignificant’.

Two years later, in nursing school she bought a manual describing laboratory tests and their meanings. The manual outlined two major problems associated with large red blood cells, folic acid deficiency and B 12 deficiency. Since her diet was rich in B 12-rich meat but low on folate-rich vegetables, she understood why the doctor had commented on the folate, but he had never considered B 12 deficiency as well. She also learned that most cases of B 12 deficiencies stem from malabsorption, not diet. Because of this, she persuaded a doctor to order tests for folate and B 12. That night, as she mentioned the tests to her parents she learned her grandfather had been diagnosed with pernicious anemia, the most well-known, although not the only symptom of B 12 deficiency. His grandfather was misdiagnosed as having leukemia, but upon insistence he received a second opinion and this time he was diagnosed correctly. He was treated for it and his condition was reversed. Learning this, when her results came back she was prepared to learn her B 12 would be low. She started being treated with shots. Her insistence to have this rechecked is what saved her life.

However, that wasn’t the end of her story. Two years later, even after being diagnosed with B 12 deficiency, she visited a doctor who questioned her diagnosis. The doctor could not believe pernicious anemia could be found in such a young patient. Upon her insistence, he ran some tests and was surprised to find out that was the case. If it had not been for her nursing training, and her insistence, her B 12 shots would have stopped, damaging her for life.

It was her own experience with the disease that caused her to want to know more. She started doing research and became an expert on the topic. She found out that studies from the 1980’s revealed that more than a third of people with B 12 deficiency show no evidence in routine blood tests. Her husband, an emergency medicine physician also got involved and did studies on the percentage of patients in his department who were deficient in B 12. What they found was the alarming number of undiagnosed cases. They learned how B 12 deficiency plays a role in so many seemingly hopeless problems and how unexpensive the treatment is. All of this was very exciting but their excitement didn’t last very long when they found out doctors simply didn’t care about it, despite the tests available for its diagnosis. She was forced to drop the subject or lose her job.

She continued to see so many patients with obvious B 12 deficiency being labeled as ‘nuts’ and being written off as ‘hopeless cases’. As soon as she had to write the discharge papers for another patient, her anger hit a critical high. She knew these patients would end up some day back in the hospital with strokes, dementia, depression, fall related trauma, etc due to B 12 deficiency. She couldn’t live with herself knowing that a couple of tests could prevent serious cases of disabilities even death and nothing was being done about it. They wrote the book to bring awareness about this disease, hoping things can change.

In the book they share their concern for what they consider a lack of awareness about B 12. They explain that despite the fact that B 12 deficiency is considered an ‘old man’s disease’, it can strike any person at any age.

Why is it so hard to diagnose B 12 deficiency? 

During her career as a nurse she sees many cases of misdiagnosed diseases. In many cases she sees patients getting worse to the point of getting into a vegetative state from which they never recover.

There are several reasons she has observed that lead to this:

1. Doctors are trained to recognize only the blood abnormality, a classic sign of B 12 deficiency known as ‘macrocytosis’, which is characterized by the presence of large, immature red bloods cells. However, it has been well documented that B 12 deficiency damages the brain, spinal cord, peripheral nerves and the nerves of the eye, often before blood abnormalities appear. Doctors who think of B 12 deficiency in terms of anemia only will miss the majority of cases and will fail to recognize the neuro-psychiatric signs and symptoms.  In their opinion, physicians must be aware that macrocytic anemia is a late sign of vitamin B 12 deficiency, frequently occurring long after potentially irreversible neurological damage has been done. The common and striking neuropsychiatric manifestations of B 12 deficiencies like depression, altered mental state, dementia, psychosis, vertigo, tremor, neuropathy, visual problems, extremity weakness, dizziness, balance problems, and gait disorders have long been forgotten by physicians. This is tragic according to the authors because their research shows that in the 18th century B 12 deficiency was a known and accepted fact among doctors. There are reports of autopsies done on patients with pernicious anemia where there was great degree of damage to the spinal cord. Similarly, there are many medical articles describing neurological symptomatology preceding the classic blood signs. In their opinion, clinicians either ignore this or have forgotten.
2. The name ‘pernicious anemia’ is misleading. ‘Pernicious anemia’ was coined in 1872, 50 years before B 12 deficiency was discovered. The medical community kept the name for historical purposes, adding to the confusion. Due to this, physicians believe that to have B 12 deficiency a patient must have anemia, which is not completely accurate.
3. Practice mistakes of the past. Many physicians remember the days when thousands of patients got B 12 shots whether they needed them or not. Their justified scorn for this practice leads them to overreact now by making the opposite mistake, failing to realize B 12 deficiency is a serious medical disorder. In this respect, the authors mention that when diagnosis-related groups started in the 1980’s, physicians billing for B 12 shots had to prove there was a disease that justified the need for the shots. Because doctors were not testing to see if patients needed the shots or not, many stopped the injections for fear of legal consequences. Many doctors also administered the shots to get insurance money from their patients. All of this has given B 12 a bad name in the medical community.
4. The serum B 12 test ‘normal’ low limit that physicians consider is 200 pg/ml, or below 180 pg/ml. However, the fact that symptoms of neurological damage start showing even with this ‘normal’ low is a cause of concern . This practice even increases costs because in these cases doctors have to order more expensive tests to ‘prove’ the deficiency. These additional tests have limitations (MMA, Homocysteine, holo-TC), can actually confuse the misdiagnoses, delay treatment and possibly cause physicians to stop what was already started.
5. The proper definition of ‘subclinical’ and ‘clinical’ are not being followed, causing confusion, late diagnoses and misdiagnosis of B 12 deficiency. The authors assert that the CDC statement ‘Most health providers are far less likely to screen and diagnose the majority of patients with subclinical or midly symptomatic  B 12 deficiency’ is confusing. ‘Subclinical’ means without symptoms, so it cannot be compared to ‘mildly symptomatic’ which refers to those patients with a clinical disease. In doing so they are trying to minimize symptoms. The authors have observed that many physicians fail to recognize the signs and label the patients as subclinical, withholding treatment. Some other statements made by the CDC are misleading and can misguide physicians. For example, the statement that ‘unexplained signs should be evaluated’ can lead doctors to believe that diagnosed diseases like neuropathy, anemia, dementia, etc do not to be tested for B 12 deficiency. The authors have found that in many cases B 12 deficiency is the cause of these diseases, in other cases both B 12 deficiency and the disease co-exist. They also feel the CDC statement that the ‘MMA and homocysteine tests can be used to confirm deficiency in case of ambiguous initial results’, causes doctors to not treat patients that show normal levels in both, even when they still have symptoms. Lastly, the statement that ‘Clinical B 12 deficiencies are relatively rare’ is particularly troubling because in their experience that is not the case.
6. Lack of universally accepted screening protocol for vitamin B 12 deficiency. In the authors’ opinion, physicians and other health professionals are failing to address B 12 deficiency, ignoring patients’ symptoms and discharging them without diagnosing the cause of their symptoms. They also claim orthopedic surgeons should be involved, because not only B 12 deficiency will cause falls, but B 12 is needed for proper healing of bone fractures. Many doctors may assume the lack of healing is due to age or debility, when it could be just B 12 deficiency.
7. Outdated treatment protocols. Treatment protocols were developed more than fifty years ago, when researchers were more focused on resolving the blood disorder rather than the neuropsychiatric symptoms. This is the reason why treatment with injections is performed monthly. But many patients assert these are not enough, therefore the dose is very individual, some patients might need injections every weak, others every month. The irony of all this is that many physicians prescribe narcotics much more liberally than they do B 12 for patients that are highly symptomatic. Unlike narcotics, B 12 is not addictive and doesn’t have any side effects.
8. Doctors order blood transfusions before they perform the tests to check for B 12 deficiencies. Doing so they mask abnormalities and can misdiagnose the neurological symptoms related to B 12 deficiency: tingling, and burning in hands and feet, memory loss, depression, personality changes, dizziness, loss of balance, even dementia.
9. High levels of folic acid can hide B 12 deficiencies. With the government mandate in 1998 to introduce folate to foods, this made B 12 deficiencies harder to recognize even though it helped in lowering spina bifida and related birth defects. Because of all these reasons, the authors feel physicians need to be educated on the neurological presentation of B 12 deficiency. By learning to identify risks and obtaining a real diagnosis and treatment before it is too late and making B 12 screening, not just inaccurate blood counts, a part of our health protocol, many people can be spared unnecessary suffering.

What is B 12 and why is it so important?

Vitamins are tiny molecules that participate in thousands of chemical reactions, build your tissues and organs, provide you with energy from the food you eat, clean the toxins from your body, protect you against infections, repair damage and allow your cells to communicate with one another. Some vitamins are fat soluble and can be stored, others are water soluble and need to be provided on a daily basis through foods. From all the 13 different vitamins the body needs to stay alive and be healthy, B 12 is unique. What makes B 12 unique is also what makes it harder to absorb. One of the unique things about B 12 is that is has a trace element of cobalt, therefore the name cobalamin. Vitamin B 12 is the only vitamin made in the gut of animals, not found in plants or sunlight. Therefore it is obtained through meat, poultry, fish, eggs, dairy, fortified foods or supplements. However, for many people this is not enough. Despite the tiny amount needed (2-4 mcg) it is very easy to become deficient in it, even people ingesting plenty amounts of this vitamin.

Why is B 12 difficult to absorb?

This has to do with the complex pathway vitamin B 12 follows. Any block in this pathway can cause B 12 levels to plummet. This pathway is as follows:

1. B 12 from animal foods is bound to proteins and needs to be freed. To split B 12, the protein pepsin is required, which is produced in enough amounts only if there is enough stomach acid.
   
2. Intrinsic factor, a protein made in the stomach is also needed for later use in the intestine.
3. Other proteins called R-binders take the B 12 into the small intestine.
4. With the help of enzymes called pancreatic proteases, intrinsic factor latches onto the B 12 and carries it to the last section of the small intestine, the ileum. Cells lining the ileum have receptors that grab onto the B 12 Intrinsic factor complex pulling it to the bloodstream.
5. In the blood, another protein, transcobalamin II, carries B 12 to the different cells of the body and the excess to the liver for storage. Any breakdown in this process will affect B 12 absorption, one of these is pernicious anemia an autoimmune disease that used to cause death. This disease occurs when the body stops producing intrinsic factor which makes the B 12 consumed useless.

A far more common source of B 12 deficiency is atrophic gastritis, inflammation and deterioration of stomach lining which reduces the production of stomach acid needed to separate B 12 from protein, a problem made worse by antiacids or PPI’s (proton pump inhibitors). Elderly people have smaller number of cells that produce intrinsic factor.

Other risk factors are gastric bypass surgery and stomach surgery which cause loss of the cells that produce intrinsic factor. Intestinal surgery removes the ileum where receptors that absorb B 12 are located. Crohns’s disease, celiac disease, alcohol, medications, GERD drugs, ulcer drugs, diabetes medications. Also, mercury can keep B 12 from reaching the cells where it is needed. This is all despite supplementing with B 12.

The National Institute of Health asserts that only 100 mcg out of 500 mcg is absorbed by healthy people. People with neurological symptoms need B 12 shots at least initially, until problem is controlled then they need monitored by their physicians on a regular basis.

Who is at greatest risk for B 12 deficiency?

Vegetarians, vegans, people over 60, gastric or intestinal surgery patients, people who use antiacids or PPI’s (proton-pump inhibitors), H 2 blockers, metformin and other diabetes drugs or any medication that interferes with B 12 absorption. Also, anorexics or bulimics, alcoholics. Patients with pernicious anemia in the family or iron deficiency anemia, sickle cell anemia. Other reasons for deficiency are any digestive disorder that causes malabsorption, any auto-immune disorder, women with a history of infertility or miscarriages, infants born to B 12 deficient women.

All the symptoms listed here have many other causes, so these need to be considered but because B 12 deficiency is one of them, it needs to be addressed too.

According to the authors, it is alarming to see many of us consider things like forgetfulness or falling a ‘normal’ part of aging, when in many occasions it is a sign of B 12 deficiency. Over the age of 60 vitamin B 12 deficiency is very common.

Additionally, in 30 % of cases B 12 deficiency is due to atrophic gastritis, inflammation or wasting away of the stomach lining which decreases the ability to make stomach. Doctors normally treat stomach upsets in elderly people with antiacids, which drop their acid levels even lower or they consider their symptoms part of a pre-existing condition. Neuropathy due to B 12 deficiency if left untreated will become a major disability and even cause death.

How B 12 deficiency attacks the body

B 12 deficiency takes many guises depending on age, genetics and the length and severity. Because it is progressive, signs and symptoms may take years to develop. Signs and symptoms include:

1. Mental changes: Depression, memory loss, dementia, intellectual deterioration, irritability, apathy, sleepiness, paranoia, personality changes. In children, developmental delay or autistic behavior.
2. Neurological:
   • Pain, tingling and or numbness in legs, arms, trunk or other area, etc. Diminished sense of touch, pain and /or temperature.
   • Loss of position sense (awareness of body position)
   • Weakness in legs, arms, etc.
   • Tremor, symptoms mimicking Parkinson’s or multiple sclerosis, incontinence, paralysis, vision changes, damage to optic nerve.
3. Heart health: Ischemic attacks, strokes, coronary artery disease, heart attacks, congestive heart failure, palpitations, orthostatic hypertension (low blood pressure when standing up which can cause fainting and falls), deep vein thrombosis, pulmonary embolism.
4. Immunologic: poor wound healing, increased susceptibility to infections, increased risk of cancer, poor antibody production after vaccines.
5. Gastrointestinal: Indigestion (feeling full after small meals), abdominal pain, constipation, diarrhea, gastroesophageal reflux disease (GERD), gastric stasis, weight loss (in some people).
6. Musculoskeletal: Fractures, osteoporosis, suppressed activity of osteoblasts (cells that build bone).
7. Genitourinary: Abnormal PAP smears, urinary incontinence, impotence, infertility.
8. Additional signs: shortness of breath, weakness, chronic fatigue, loss of appetite, weight loss or anorexia, tinnitus, premature gray hair.

The reason for all these symptoms is B 12 plays roles in the health of nerves, brain, blood, immune system and DNA formation. Specially, B 12 deficiency strikes the nervous system, damaging the myelin, which is linked to mental problems like memory loss, depression and dementia. As B 12 deficiency progresses, the immune system also follows because it can no longer produce enough disease fighting white blood cells making the sufferer a target for viral and bacterial infections. The gastrointestinal system suffers as well because the body cannot make enough cells to replace your intestinal lining. Also anemia will make the sufferer fatigued. B 12 deficiency also causes a breakdown in detoxification pathways that keep homocysteine levels from raising up, increasing risks of coronary artery disease, stroke and blood clots. The good news is that if caught in time it can be prevented. If you have any of these signs you can get tested to make sure.

Protecting yourself: are you at risk for B 12 deficiency? 

C. Everett Koop, M.D. former surgeon general of the United States asserts “an informed patient is the best patient. My advice to people has always been ‘Take charge of your health’. Now it’s more important than ever because with managed care, no one else is’.

According to the authors, since so many people suffer from B 12 deficiency and it’s so hard to get an accurate diagnosis, each of us should take matters in you own hands. In what follows we will explain how to determine if one is a candidate for B 12 deficiency and what to do if that is the case.

The good news is that treatment can cost under $50 a year and if caught in time it can save lives. If you receive a late diagnosis, it is even more critical that you receive aggressive methyl-B 12 injectable therapy. Some patients with late diagnoses see great improvements within weeks or months, some even a complete reversal of neurological damage. The sooner the better. Sometimes the diagnosis is made too late. In case of doubt, they insist “don’t hesitate, find out!”

Calculating your odds

B 12 deficiency doesn’t have any visible signs like having a rash does, instead there are symptoms and risk factors of deficiency that make B 12 deficiency more likely. Everybody should be familiar with them and if spotted, the next step would be to call the doctor.

The following is a checklist of risk factors and a point score to assign to each:

1. Neurological symptoms. If you have any of the symptoms listed here give yourself 2 points, for any additional you have add another point.
   1. Do you experience ‘pins and needles’ feeling or numbness/burning feet, hands, legs and/or arms?
   2. Have you been diagnosed with diabetic or peripheral neuropathy
   3. Do you suffer from weakness in your arms/legs?
   4. Do you experience light-headedness or dizziness?
   5. Are you prone to falling or fall frequently?
   6. Have you noticed unusual changes in your ability to move? for example, do you walk clumsily or with feet wide apart, or have difficulty writing legibly?
   7. Have you noticed problems with your memory or thinking?
   8. Do you have trouble knowing where various parts of the body are if you are not looking? like trouble walking in the dark if you cannot see your feet?
   9. Does your sense of touch or perception of pain appear distorted
   10. Has your doctor ever told you that you have muscular spasticity? (lack of coordination and excessive muscle contraction)
   11. Do you have a tremor?
   12. Do you suffer from incontinence (urinary or fecal)?
   13. Do you suffer from impotence?
   14. Do you have visual impairment, visual loss?
2. Psychiatric symptoms. If you have any of the symptoms listed below, give yourself two points. For each additional symptom you have give yourself an additional point.
   1. Have you noticed any personality changes? For example more irritability or not ‘being yourself’
   2. Are you unusually apathetic or depressed or have suicidal thoughts?
   3. Do you suffer from hallucinations or delusions?
   4. Do you exhibit violent behavior?
   5. Have you been diagnosed with psychosis, mental illness, like schizophrenia or bipolar disorder?
   6. Do you find yourself becoming more paranoid about other people’s actions or intentions?
3. Hematological signs (abnormalities of the blood cells). If you have any of the symptoms listed below, give yourself two points. For each additional symptom you have give yourself an additional point.
   1. Has your doctor ever told you that your red blood cells are abnormally large (macrocytosis)?
   2. Has your doctor ever told you that you have abnormally small red blood cells, an iron deficiency or iron deficiency anemia?
   3. Has your doctor ever told you that you are anemic? Do you have low platelets or low white blood cell counts?
4. Gastrointestinal risk factor. If you have any of the symptoms listed below, give yourself two points. For each additional symptom you have give yourself an additional point.
   1. Have you been diagnosed with inflammation and/or wasting of the stomach lining (gastric atrophy)?
   2. Have you been diagnosed as having low stomach acid?
   3. Do you suffer from gastritis?
   4. Do you suffer from ulcers?
   5. Have you been diagnosed with gastroesophageal reflux disease (GERD)?
   6. Do you have diverticulosis?
   7. Have you been diagnosed with precancerous gastrointestinal growths or gastrointestinal cancer?
   8. Have you undergone a gastrointestinal resection (partial or complete gastrectomy), undergone a gastric bypass surgery for weight loss, or had either partial or complete removal of your ileum (last part of the small intestine)?
   9. Have you been diagnosed with a malabsorption syndrome (Crohn’s disease, inflammatory bowel disease, irritable bowel syndrome, or celiac disease?
   10. Do you have a family history of pernicious anemia?
   11. Have you been diagnosed with small bowel overgrowth?
   12. Have you been diagnosed with a tapeworm or other gastrointestinal parasite?
5. General risk factors. If you have any of the following factors , give yourself a point.
   1. Are you 60 or over?
   2. Do you have a thyroid disorder, or any auto-immune disease?
   3. Have you ever had cancer? Have you undergone chemotherapy or radiation therapy?
   4. Have you undergone surgery, including dental, in which nitrous oxide was used?
   5. Do you abuse nitrous oxide as a recreational drug?
   6. Are you a vegan or follow a macrobiotic or raw food diet?
   7. Are you an alcoholic?
   8. Are you taking acid reducers, H 2 blockers, anticonvulsants, Phenobarbital, potassium supplements, birth control pills, colchicine, neomycin, methotrexate, cholestyramine, colestipol or aminosalicylic acid?
6. Other signs often associated with B 12 deficiency. If you have any of the signs below give yourself one point.
   1. Do you suffer from fatigue, lack of energy, or weakness?
   2. Do you suffer from generalized weakness?
   3. Have you experienced a loss of weight or loss of appetite?
   4. Do you suffer from chest pain, shortness of breath with small exertion?
   5. Are you unusually pale, grayish, or yellow skin color?
   6. Do you have a sore, inflamed or ‘beefy red’ tongue?
   7. Do you suffer from tinnitus (ringing in the ears)?
   8. If you are a female, has your doctor told you that your Pap Smear showed abnormal cells (cervical Dysplasia)?
   9. Do you suffer from infertility?

Add all the points. If your score is less than 3 points your risk is low. If this is your case it means your B 12 levels are probably fine, but this doesn’t guarantee that as you age they will stay that way. Keep checking your levels every year and be aware of the symptoms. If you scored 3-6 points your risk is moderate, in this case you need B 12 screening. Make an appointment with your doctor and get tested. If greater than 7 your risk is high, there is no time to waste, call your doctor as soon as possible and get tested. If your doctor is skeptical be assertive. Your doctor must rule out other diseases that mimic B 12 deficiency.

Regardless of your scores, you also need to be tested if you suffer from any neurological disorder, have chronic pain, have an occlusive vascular disorder, have a history of stroke, pulmonary embolism, heart attack, coronary artery disease or deep vein thrombosis. People with anemia, history of alcoholism, kidney problems, liver problems, people on dialysis need to have urinary MMA test along with the serum B 12 because these disorders give falsely elevated serum B 12 results.

Avoid self-testing

Self-treating possible symptoms of B 12 deficiency before undergoing tests will make it difficult to diagnose the disease by affecting the lab results. If you have any symptoms get tested before you start supplementing with B 12 supplements. After testing, your doctor can determine if you have B 12 deficiency and start treatment. Once tested you can begin with over the counter high dose lozenges while waiting for test results, but not before. Depending on the results your doctor will prescribe OTC lozenges or injections. If you have been taking B 12 and still have symptoms you still need to be tested. Make sure you tell your doctor and interrupt your supplementation before the test. If you have been supplementing and you feel improvement, you may still have tests done, your doctor may want to tweak your treatment depending on the physical exam.

Testing 

The tests the authors recommend are, in order of effectiveness, as follows:

1. The serum B 12 test with the updated range > 450 pg/ml or 332 pmol/L. There is much controversy as to what is a normal result for this test. Because of this, this test is used together with the rest mentioned below. The problem with this test is that the ‘normal’ low (200 pg/ml) is actually low and needs to be raised to at least 450 pg/ml according to them ‘because deficiencies begin to appear in the cerebral spinal fluid below 550 pg/ml”. Normal serum B 12 should be greater than 550 pg/ml. In the case of brain and nervous system disorders and in older patients, serum B 12 levels should be maintained near of above 1,000 pg/ml.
2. MMA: The Methylmalonic acid test also has limitations and can result in false readings, so this test needs to be done in conjunction with serum B 12.
3. HoloTC: Holotranscobalamin test. Raising the levels of the serum test would make this test unnecessary. This is true for all the other tests.
4. Homocysteine test: Elevated homocysteine levels can indicate deficiencies in B 12, B 6 and folic acid. This test is not necessary to test for B 12 deficiency but it is a valuable adjunct to the B 12 serum test.

The authors feel the many different OTC B 12 products (lozenges, pills, drops, nasal gels, skin patches, gums, drinks, etc) do not come with a guarantee they will be effective for each individual case. Therefore, they recommend shots. Something else in favor of injections is the fact that they are cheaper than the oral doses if you get the self injectable form hydroxocobalamin. If a loved one uses injections, the caregiver can inject the doses and thus avoid forgetting them. In her own experience, shots take minutes to prepare and they are simple to administer.

How to interpret tests results

Reference ranges for diagnostic tests are as follows:

Deficient: <200pg/ml

Borderline: 200-270 pg/ml

Normal: 271-870 pg/ml

Clinical laboratories express values in ‘picograms per milliliter’ (Pg/ml). (Sometimes they also use ‘nanograms per liter’, ng/L).

In some research studies B12 values are measured in ‘picomoles per liter’ (pmol/L). To convert from one to another, you can follow this formulas:

pgmol/L = pg/ml x 0.738

pg/ml = pmol/L divided by 0.738

ng/L = pg/ml

What does all this mean for your heart?

Sally Pacholok also recognizes the important contribution that Dr. McCully’s research provided when he discovered homocysteine in young children. She asserts ‘More than thirty years after Dr. McCully’s research, researchers around the world are proving the link between elevated homocysteine and heart disease’. According to her research, there is a tremendous avalanche of publications, about twenty to thirty per month totaling over 1,500 publications on homocysteine and vascular heart disease. According to the ‘Journal of Longevity’ Dr. McCully’s research has been a turning point in health science. Sally Pacholok believes that if he had not been so persistent in the face of criticism by his peers, ‘this entire facet of cardiovascular health might have remained hidden and many instances of circulatory problems might have remained mysteries’.

In our last article, we went into detail about how homocysteine can wreak havoc on our cardiovascular system, putting us at risk for coronary artery disease, heart attacks, strokes and deep vein thrombosis. Sally Pacholok also explains the importance that properly diagnosing B 12 deficiency can have for cardiovascular diseases. During her career as a nurse, she has seen many cases of cardiovascular patients who were misdiagnosed. 

During her research, she found many instances of misdiagnosed heart disease. In an article from the ‘Thrombosis Journal’, doctors describe a 27 year old man who went to the hospital complaining of ongoing and progressive lower extremity weakness, numbness and abnormal sensations in both legs. On the second day of admission, still with no diagnosis, the man started complaining of crushing chest pain and shortness of breath and started sweating profusely. His EKG showed he was having a heart attack, so he underwent emergency angioplasty. The surgeon found a large blood clot in his left coronary artery and inserted a stent. Doctors started the man on aspirin, a blood thinner and other cardiac medications. The next day, his echocardiogram showed reduced left ventricular function at 45%. Despite the successful cardiac stent placement he continued to complain of difficulty breathing and shortness of breath. A CT of the man’s chest revealed multiple small blood clots in this left lower lung. His blood work revealed macrocytic anemia and elevated LDH which are classic signs of B 12 deficiency. His serum B 12 was very low at 158 pg/ml and he had normal serum folate. His homocysteine was severely elevated. At this point the man’s doctors tested him for pernicious anemia. They found that he was positive for anti-intrinsic factor antibodies and started him on B 12 therapy. Seven days after his heart attack, a repeat echocardiogram showed normal left ventricular function. After ten days of B 12 therapy his homocysteine decreased dramatically from 105 to 12.9 umol/L. His neurological signs and symptoms gradually improved and after his hospital stay he was transferred to a physical therapy rehabilitation center not only to address his cardiovascular event, but to address the original neurological problems caused by chronic severe B 12 deficiency.

Cases like this are not rare, they have been reported world wide, yet few doctors consider the B 12-homocysteine connection when treating cardiac or occlusive vascular disorders. In cases like these, it boils down to the patient and family being assertive and insisting on B 12-homocysteine testing. If you are reading this and have observed signs of what could be B 12 deficiency, you would be wise to be tested for B 12 and add B 12 to your ‘Heart and Body Extract’ health protocol.

As we saw in our previous blog, excess homocysteine causes your blood vessels to lose elasticity, making it harder for them to dilate and damaging their inner lining. This damage allows cholesterol, collagen and calcium to attach to the inner walls of your blood vessels, where they can form sticky deposits called arteriosclerosis plaques. These plaques narrow your arteries and drastically increase your risk of suffering deadly disorders such as heart attacks, strokes, blood clots, carotid and renal artery stenosis or aneurysms. Homocysteine is also an oxidant that decreases the production of nitric oxide, a substance crucial to healthy blood vessels function which decreases the incidence of arteriosclerosis and high blood pressure. It is the B vitamins B 12, B6 and folic acid that convert the toxic homocysteine into a non-toxic aminoacid with the help of the liver. Being deficient in these vitamins allows homocysteine to build up and wreak havoc. According to B 12 expert Ralph Green, M.D. “For each 5 umol/L increment in total plasma homocysteine there is a corresponding increase of about 40% in the relative risk of developing coronary artery disease”. Again, supplement with these B vitamins and the products at ‘Healthy Hearts Club’ are a perfect winning combination for your heart. The ‘Female Balance Extract’ contains two important B vitamins, B 5 and B 3 and the ‘Ginseng Extract’ is a general tonic that works well with the B complex. The ‘Gland Extract’ is equally a great product that complements great with the B vitamins. It has nutrient and digestive properties, increases absorption and utilization of nutrients and stimulates the glandular system of the body. All of these products can assist your heart in lowering homocysteine levels because B 12 works best when taken with the whole B complex.

Increasing numbers of doctors are aware of the dangers of high homocysteine and the benefits of folic acid therapy. Unfortunately, few do fully understand the critical role vitamin B 12 plays in detoxifying homocysteine. According to the authors, people with high homocysteine levels often respond fully only when they are given large amounts of B 12 as well. The reason for this is that people deficient in B 12 cannot assimilate folic acid properly and as a result much of the folic acid is trapped in an inaccessible form. Many cardiologists prescribe only folic acid to patients with high homocysteine levels or give a multivitamin containing small amounts of B 12 . This is often ineffective because a few micrograms of B 12 cannot correct a significant deficiency. If you have high homocysteine levels your doctor needs to test you to determine if a B 12 deficiency exists. Proper treatment of homocysteine may include high doses of folic acid, vitamin  B 12 and B 6.

A considerable amount of research is being done on the topic. Some of this research has shown that high levels of homocysteine are associated with a subsequent risk of myocardial infarction (heart attack) independent of other coronary risk factors. Just a 5% increase in homocysteine makes it three times more likely for a person to suffer heart attacks. Vitamin supplementation, according to research, can be used to treat high levels of homocysteine. Similarly, in the ‘New England Journal of Medicine’ Norwegian researchers followed 587 patients and found a strong relation between plasma homocysteine levels and overall mortality. Another study of more than 400 patients who had suffered a heart attack or unstable angina showed that the death rate from cardiac disease was more than twice as high for patients with higher homocysteine. Finally, another study performed by physician David Wald and his colleagues studied the effects of a common gene variant that raises homocysteine levels concluding that the association of homocysteine and cardiovascular disease is causal.

Similarly, in women, even young women, high homocysteine levels has been shown to nearly double the risk of stroke. The magnitude of the increase in stroke risk was similar to that of smoking a pack of cigarettes a day. Dozens of additional studies corroborate these findings, implicating high homocysteine is one of the most powerful cardiovascular risk factors ever identified. Luckily this is easy to treat. One recent study tested the effects of supplementation with folic acid alone, B 12 alone and folic acid B 12 together. Research showed that all three approaches worked but the combination approach yielded the most remarkable results with plasma total homocysteine reduced by 38.5 %. Evidence shows that the same impressive results can be achieved by the majority of people who stick with the vitamin regiment. In my opinion, it is important to stress that B 12 should be taken with the whole B complex because all the B vitamins work together.

Additional studies on the effectiveness of the homocysteine therapy show lowering homocysteine can dramatically lower the risk of death or debility. We can list the following:

In a study of patients that had undergone angioplasty to correct coronary artery stenosis (narrowing of the arteries). After one year, the researchers reported the incidence of major adverse events was one third in the treatment group.

In a separate six month double blind study a Swiss research group administered folic acid, B 6 and B 12 to a group of patients who had undergone successful coronary artery angioplasty. The rate of restenosis (re-narrowing of the arteries) was significantly lower and the group had less than half the need for a repeated procedure on the targeted lesion. The researchers concluded the vitamin treatment, with minimal side effects, should be considered as adjunctive therapy for patients undergoing coronary angioplasty. 

In another study, Australian researchers reported 90% reduction in cardiovascular events in people with homocystinuria who received homocysteine lowering therapy.

Similarly, researchers in the United Kingdom and Norway evaluated 89 men, ranging in age from 39 to 67 with existing coronary artery disease to determine if oral B vitamins would have an effect on the health of the arteries. After eight weeks of treatment with folic acid and vitamin B 12, the subjects’ plasma homocysteine levels dropped significantly compared to levels in similar men taking a placebo. In addition, the arteries of men taking the vitamins dilated more efficiently in response to blood flow demands. These findings, the researchers concluded, ‘support the view that lowering homocysteine through B vitamin supplementation may reduce cardiovascular risk‘.

Physician Tedd Mitchell shares his testimony of how his grandfather died at the age of 50 of a massive heart attack and his father had a quadruple bypass in his 50’s, even though they were non-smokers, had no high blood pressure, diabetes, high cholesterol or obesity. After learning about homocysteine he decided to get checked and lo and behold…, his homocysteine was significantly elevated. As a result of this he changed his life style, started taking supplements of folic acid, B 12 and B 6 after which his homocysteine levels became normal. All this evidence shows how simple, non-toxic preventive measures like this may be one of the most powerful and simple preventive measures we can implement for people at risk for cardiovascular disease. While many patients are told to stop smoking, exercise, lose weight and lower their cholesterol, many patients with heart attacks do not have these risk factors. Similarly, many people who seemingly are in good health are suffering from strokes, blood clots, etc at earlier ages. Many of these people carry very common gene variants that can cause their homocysteine levels to rise to dangerous levels. For these people, early and accurate testing for high homocysteine and low B 12 levels might mean the difference between dying young and leading a long healthy life.

These reports are exciting because they indicate that homocysteine-reducing vitamin therapy, an inexpensive, simple, and safe treatment may significantly reduce the rate of cardiovascular disease. What is more, these studies used low dose oral B 12 which is less effective than high dose B 12 in patients with existing deficiencies. They also used oral tablets, which are less effective than B 12 lozenges or injections, and used cyanocobalamin, which does not stay in the body as effectively as the bioactive form methylcobalamin.

The authors assert that in order for researchers to fully understand B 12, studies need to include serum B 12 levels in the ‘normal’ low or perform urinary MMA testing of subjects. People who discover their homocysteine levels to be high should not take any chances.

Despite all this evidence, the medical community shows mixed feelings toward the effectiveness of lowering high homocysteine. However, the authors believe that if early testing for high homocysteine became common place, it would be possible for such life threatening vascular events in young people to become far more rare. “We might be able to help hundreds of thousands of people who can be treated with vitamins at a very early age, before they ever begin to develop blood vessel lesions that can cause premature heart attacks, blood clots or strokes. Identifying B 12 deficiencies that can lead to high homocysteine levels would also have huge health benefits.” the authors assert.

As a practicing physician and nurse, Sally Pacholok does not see cardiologists including B 12 in their cardiac work-ups. The few cardiologists that order homocysteine tests typically treat high levels only with folic acid. She does not see internists or general practitioners testing for B 12 deficiency either or ordering homocysteine levels although they have no problem ordering numerous lipid profiles for cholesterol. She sees hundreds of cardiac patients coming through the emergency department who have been prescribed high doses of folic acid but no B 12. She shares the real story of a 56 year old man who complained of chest pain. He had a history of a previous heart attack, non-insulin dependent diabetes, GERD, depression and five stents. He was borderline anemic, he complained of numbness and tingling in his feet but his doctors had told him it was due to diabetes. He had been taking a PPI for five years, an antidepressant for three years, a cholesterol lowering agent and a multivitamin prescribed by his doctor for he last five years. He had all the symptoms of B 12 deficiency. The doctor ordered tests including  B 12 and homocysteine. The results indicated normal renal function and his lipid profile was picture perfect. He was found deficient in B 12 and his homocysteine levels were very elevated, all the evidence showed that this is what caused his significant coronary artery disease and poor health. Had the doctors tested his B 12 levels, all of this could have been avoided.

If you are at risk, get tested

Given the evidence that high homocysteine is a risk factor for vascular disease in both young and old people, screening for B 12 should be commonplace for people at risk. Homocysteine should also be routine for senior citizens, pregnant women and people with diabetes, patients with renal disease, auto-immune disease, thyroid disease. Also people that use of medications that raise homocysteine levels like lipid lowering drugs, metformin, anticonvulsants etc, people who already have a diagnosis for cardiovascular disease should be tested for homocysteine and B 12. Patients with high homocysteine levels should be evaluated for underlying B 12 deficiency and should be treated with standard doses of folic acid, B 6 and B 12. “Even people in the upper range of what’s considered normal should be started on homocysteine-lowering therapy, because levels only 12% above the highest normal level are linked to a threefold increase in the risk of heart attack.”

Equally important when the patient undergoes homocysteine lowering therapy is the need to insist that you doctor first obtains a baseline B 12 and urinary MMA. As the authors have noted, folic acid corrects the anemia and enlarged red blood cells that doctors generally look for when checking for B 12 deficiency, but does nothing to stop the neurological damage caused by depleted B 12 stores. B 12 testing will allow doctors to tailor the homocysteine lowering program to the patient’s individual needs. In some cases, high-dose oral B 12 will be sufficient. In others, injected B 12 will be necessary. This is all to say doctors cannot merely guess how much B 12 is enough for each patient, therefore the need for adequate testing.

Treatment

In the authors’ opinion, B 12 injections are preferable to oral B 12 because of the difficulty with absorption. In the case of neurological symptoms, injections are absolutely necessary. The authors have personally seen that in these cases high doses of oral B 12 do not work.

There are three forms of supplemental vitamin B 12: cyanocobalamin, hydroxocobalamin and methylcobalamin. Current evidence shows that the retention of hydroxocobalamin is three times superior to that of cyanocobalamin 28 days after injection. Also, methycobalamin is superior to hydroxocobalamin for neurological disease but it is not widely used in the United States. Japanese studies show methylcobalamin bypasses several potentially problematic steps in B 12 metabolism. In addition, methylcobalamin provides the body with essential methyl groups that reduce oxidation. Oral methylcobalamin is retained better than cyanocobalamin in the liver and other tissues.

In addition, there are concerns about the use of cyanide based vitamin B 12 derivative, which has to be detoxified and cleared by the liver. Some people with certain conditions like ‘Leber’s hereditary optic neuropathy (LHON), hepatitis sufferers, smokers  and children with inborn errors of B 12 metabolism should not take the cyanide form of B 12. In all these cases, hydroxocobalamin has an antagonistic effect on cyanide.

Whether it is the methylcobalamin or the hydroxocobalamin form, what it is important to know is that in severe cases (auto immune pernicious anemia, gastric or ileal surgery patients) the treatment needs to be continued for life.

B 12 deficiency is a publich health crisis, particularly in the Baby Boomers generation.

The oral versus the injected forms

While there is a need for more research on the topic, there are small studies showing that daily high-dose oral B 12 (2,000 mcg) was effective in producing hematologic and neurologic responses as a standard injectable regimen with patients with B 12 deficiency. Proving that, in some cases oral B 12 can replace injections. For patients with a variety of symptoms, more research is needed comparing oral and injectable forms of B 12.

Regarding the dose, most B 100 supplements may contain 6 mcg of B 12 versus the 2,000 mcg the authors consider to be a normal dose. To this, we need to add we don’t know how much of it is absorbed, all of which might prove fatal for many patients. Adding the fact that the efficacy of injections has been well studied, which cannot be said of many over the counter B 12 products, the authors lean toward the injectable form as the best form.

Treatment for B 12 deficiency is very inexpensive. One year costs $36 when patients administer the injections themselves. High-dose methyl-B 12 lozenges (2,000mcg) can cost between $48-72 a year depending on the brand. This is far cheaper than having to treat a demented patient with undiagnosed B 12 which could be over 1,000 a year, or 60,000 a year for a Alzheimer’s patient, multiple sclerosis or developmental disability.

Don’t quit

Taking B 12 for a few weeks only will not solve the problem, not in the case of severe cases. In these cases, the patient will have to take them for the rest of their life. Once they have been regular taking their B 12 shots, your levels will stay normal for several months even years. This is because B 12 is stored in the liver, however, this is not a reason to stop treatment. Eventually, the symptoms will come back if treatment is stopped. The authors also advise to always keep medical records, specially when switching doctors. They recommend to be assertive with doctors that are not knowledgeable about B 12.

Spread the word

It’s not unusual for B 12 deficiency to run in families, so if someone is diagnosed with this disorder, they should let their relatives know. In most cases, several other cases of deficiency are usually discovered.

According to the ‘Centers for Disease Control and Prevention’, June 29, 2009 “Vitamin B 12 deficiency should be on our radar screen …Prevention, early detection and treatment of B 12 deficiency are important public healthy issues, because they are essential to prevent development of irreversible neurological damage which can impact quality of life”