Update: Severely deficient? Check out our B12 supplement.
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Vitamin B12 deficiency is now a raging, worldwide epidemic. From vegans to omnivores, young to elderly, people from the entire demographical spectrum are suffering from it. Just look at the numbers. 39% of the subjects in the Framingham Offspring Study had levels that are borderline deficient.
The tragic thing is, B12 deficiency can easily be misdiagnosed and become absolutely catastrophic. Watch this video if you have the time:
This is no joke we’re talking about. But what is B12 deficiency exactly? What are its symptoms, causes and how the heck do we treat it? Well, here’s your ultimate resource to B12 vitamin deficiency.
What Is Vitamin B12 Deficiency?
Vitamin B12 (aka cobalamin) is of extreme importance. Naturally produced by the gut bacteria of animals that feed on the cobalt of the soil (hence its name), it is essential to our life and health. How essential?
You need it to form red blood cells and grow tissues. You need it for optimized homocysteine levels. You need it to synthesize and repair your DNA and the myelin sheath, a fatty layer guarding your nerves. When nerve fibers aren’t protected — brain, spinal cord and peripheral damage results.
As you can see, B12 is absolutely crucial for maintaining healthy nervous and immune systems. So crucial that a severe vitamin B12 deficiency can lead to permanent nerve damage and psychiatric conditions.
But getting plenty of B12 from food isn’t always enough.
Vitamin B12 must follow a complex pathway of a number of steps for it to be absorbed. Normal function of the stomach, pancreas and small intestine, with their acids and enzymes, are required for proper absorption. Any problem in any step of the pathway may lead to malabsorption, and deficiency.
Chronic stomach inflammation, for example, is often associated with deficiency in B12. The inflammation gives rise to autoimmune reactions that damage the digestive system, often damaging the body’s ability to absorb vitamin B12. Intestinal malabsorption, rather than low dietary intake, can actually explain most cases of deficiency in vitamin B12.
I should also mention that B12 deficiency occurs in four stages. It begins with declining blood levels (stage I), progressing to low cellular concentrations (II), and then to an increased homocysteine levels in the blood and a decreased rate of DNA synthesis (III), and finally macrocytic anemia (IV).
When early scientists discovered B12 deficiency, they concentrated on blood tests. Treatment therefore was a function of the patient’s blood work. But we now know that neurological changes precede hematologic changes. If you wait for anemia to show up, there will already be neurological damage.
This deficiency has been called a “silent epidemic”. It won’t present with severe symptoms at the beginning, but once discovered it may have already caused damage. The nerve system can’t regenerate itself, and once heavy neurological symptoms have kicked in, normal function may not return.
Let’s go through the symptoms and signs of vitamin B12 deficiency.
Vitamin B12 Deficiency Symptoms List
Many symptoms of B12 deficiency are also symptoms of other diseases, so if you have some of them don’t jump off your chair. But the more symptoms you have, the more likely you are to have a deficiency of vitamin B12.
Neurologic Signs and Symptoms of Vitamin B12 Deficiency
B12 deficiency neurological symptoms are the most dangerous, indicating an advanced deficiency. They must be treated with B12 injections urgently, with daily or every-other-day shots until symptoms stop improving. Neurological symptoms of B12 deficiency are:
- Numbness and tingling of the tongue, hands, thighs or feet.
- Difficulty walking.
- Memory loss, forgetfulness, difficulty recalling names or words.
- Disorientation, dizziness, confusion.
- Dementia with or without mood changes.
- Intellectual deterioration.
- Concentration difficulties.
- Abnormal reflexes.
- Balance, coordination and/or speech problems (Ataxia).
- Unsteady walking, falling.
- Tremor.
- Tinnitus, ringing or buzzing in the ears.
- Impaired pain perception.
- Nocturnal cramping.
- Changes in taste and smell.
- Sharp nerve shocks in either side of the body.
- Spinal nerve pain, commonly in the lower back and neck.
- Optic atrophy, visual disturbances, blurred vision, nystagmus, blindness.
- Paralysis.
These symptoms appear because B12 deficiency strips off the myelin sheath that covers cranial, spinal and peripheral nerves. And although progression of neurologic symptoms is gradual, once they have been present for a long time they may not be reversed with treatment.
Neuropsychiatric B12 Deficiency Signs and Symptoms
- Psychosis.
- Hallucinations.
- Delusions.
- Depression.
- Suicidal ideation.
- Mania.
- Anxiety.
- Paranoia.
- Irritability.
- Apathy.
- Personality changes.
- Inappropriate sexual behavior.
- Violent or aggressive behavior.
- Schizophrenic symptoms.
- Sleep disturbances or insomnia.
Hematological Symptoms of Deficiency of Vitamin B12
- Anemia.
- Macrocytosis (large red blood cells).
- Pale skin.
- Dry or cracked sores in the corners of the mouth.
- White spots, usually on the outside forearm skin.
- Hyper/hypo pigmentation of the skin.
- Hyper segmented neutrophils.
- Poor wound healing.
- Breathlessness, asthma, wheezing.
- Chronic fatigue, general weakness.
Gastrointestinal Symptoms of Vit B12 Deficiency
- Loss of appetite, weight loss, malnutrition, anorexia.
- Poor digestion, bloated feeling after eating normal or even small meals.
- Irritable bowel syndrome, constipation, diarrhea.
- Gastric reflux disease.
- Giardiasis (infection of the intestine).
- Inflammation of the pancreas (Pancreatitis).
- Decreased stomach acid.
- Delayed gastric emptying (Gastroparesis).
- Helicobactor pylori infection.
- Small intestinal bacterial overgrowth.
- Malabsorption syndromes like Crohn’s or Celiac disease.
- Liver disease.
- Diphyllobothrium latum (fish tapeworm).
Vascular B12 Vitamin Deficiency Symptoms
- Orthostatic hypotension (low blood pressure when standing up).
- Chest pain.
- Increased heart rate when changing from supine to upright position.
- Heart palpitations.
- Enlargement of the heart.
- Stroke (Cerebral vascular accident).
- Mini stroke (Transient ischemic attack).
- Heart attack (Myocardial infarction).
- Narrowing of the arteries (Occlusive arterial disease).
- Blood clotting, commonly in the legs (Deep vein thrombosis).
- Blockage of an artery in the lungs (Pulmonary embolism).
Any Additional Signs & Symptoms of B12 Deficiency?
Vitamin B12 deficiency also affects the musculoskeletal, endocrinological, immunological, respiratory, genitourinary, and dermatological systems. Other side effects of B12 deficiency that deserve mentioning:
- Increased susceptibility to infections.
- Difficulty swallowing.
- Premature greying, hair loss, dry or lifeless hair.
- Poor antibody production after vaccinations.
- Incontinence.
- Decreased libido.
- Increased urinary tract infections.
- Hypothyroidism.
- Osteoporosis.
- Fractures.
- Muscular spasms and cramps.
- Bleeding from the gums (gingival bleeding).
- Oral ulcers.
- Brittle nails.
- Decreased activity of osteoblasts (cells that build bone).
- Restless legs.
- Weakness of legs, arms, trunk.
- Glossitis, swollen/sore tongue.
- Fainting, lightheadedness.
- Enlarged spleen (splenomegaly) or liver (hepatomegaly).
Special Vitamin B12 Deficiency Symptoms In Men & Women
Vit B12 deficiency symptoms specific for women:
- Infertility.
- Recurrent miscarriage.
- Abnormal PAP smears.
- Intrauterine growth retardation.
- Post-natal depression.
And men:
- Infertility.
- Impotence.
- Low sperm motility.
- Low sperm count.
Signs & Symptoms of Vitamin B12 Deficiency in Infants & Children
- Developmental delay or regression.
- Decreased muscle tone (Hypotonia).
- Poor weight and/or height gain, a general failure to thrive.
- An abnormally small head.
- Intellectual disabilities, lower IQ.
- Language delay or speech problems.
- Poor motor and coordination skills.
- Poor socialization.
- Difficulty in walking or writing.
- Apathy, lethargy, irritability.
- Mood disorders and psychotic behavior (here’s an example).
- Weakness, fatigue, tiredness.
- Tremor.
- Involuntary movements.
- Abnormal sensations.
- Tics.
- Pigmented skin.
- Chronic constipation.
- Epileptic seizures (fits).
- Vision abnormalities.
- Anorexia, loss of appetite or other eating disorders.
- Severe food allergies or sensitivities.
- Anemia.
- Stroke.
- Rooting reflex kept for more than 4-6 months of age.
- A diagnosis of Celiac, thyroid disorder or other autoimmune diseases.
- A diagnosis of any neurological, psychiatric or behavioral disorder.
It is critical you educate yourself. Many of the symptoms mentioned are not uncommon (even psychosis and cognitive decline), but doctors and psychiatrists are often not even aware B12 deficiency can cause this. In such cases, you may never be tested for a deficiency. Which brings us to…
Vitamin B12 Deficiency Misdiagnosis
When B12 deficiency starts affecting the nerves, it is often misdiagnosed and its symptoms are blamed on other conditions (sometimes on themselves):
- Alzheimer.
- Parkinson.
- Multiple sclerosis (where myelin is stripped off, much like B12 deficiency).
- Autism.
- Bipolar disorder.
- ADHD.
- Diabetic neuropathy.
- Vertigo.
- Chronic fatigue syndrome.
- Chronic pain disorder.
- Psychosis.
- Functional neurological disorder.
- Schizophrenia.
- Depression.
- Fibromyalgia.
- Myalgic encephalomyelitis.
- Mini-strokes.
- Crohn’s disease.
- Irritable bowel syndrome.
- Optic neuritis.
- Folate deficiency.
- Infertility.
- Hypothyroidism.
But why is B12 deficiency misdiagnosed in first place?
- Extremely poor B12 knowledge among doctors and health care professionals leading to symptomatic people, especially non-elders, not being tested at all. For example, very often a patient complaining about depression will be automatically prescribed antidepressants instead of being tested for B12 deficiency.
- In most countries, the current “normal levels range” for serum B12 is way too low. Symptomatic patients with levels that are in the grey zone (250-450) aren’t treated, even though deficiencies begin to appear in the cerebrospinal fluid below 550 (see this and this). Some places won’t even treat you if your B12 is over 100, which is absolutely insane.
- Serum B12 blood test isn’t reliable. This is because it shows both active and inactive forms of B12. Methylmalonic acid (MMA) and holotranscobalamin tests are much more reliable, yet rarely used.
- Doctors usually wait for enlarged red blood cells and/or macrocytic anemia to be present. But that is the last, advanced stage of B12 deficiency. At this point, some of the damage can’t be reversed.
- Clinicians ignore the neurological effects of B12 deficiency and assume falling or having cognitive degeneration are part of “normal aging”. Therefore, elder adults aren’t screened for deficiency.
- Similarly, B12 screening isn’t included neither for mental health patients nor for pregnant or breastfeeding women, groups that are at real risk of B12 deficiency levels.
- It is assumed meat eaters get enough B12 from their diet, so doctors don’t even bother checking for B12 deficiency.
- Vitamin B12 deficiency symptoms in adults over 65 are very often misdiagnosed because clinicians blame those symptoms on other, coexisting medical conditions.
- Just a speculation, but I’m wondering if the fact that early treatment for B12 deficiency is so cheap compared to late detection — where expensive medications and tests have to be given — has anything to do with doctors being so unbelievably misinformed.
Remember, the effects of vitamin B12 deficiency are gradual and symptoms may take years to develop. And while your signs can always stem from other causes, it is crucial that your doctor rules B12 deficiency out due to the very real potential for misdiagnosis. You have been warned.
Vitamin B12 Deficiency Anemia
Here’s what happens when you experience a B12 anemia:
You have low red blood cell count or hemoglobin, that red pigment in your blood that carries oxygen and makes it red. Because you’re deficient, your skin becomes pale. Your heart tries to make up for that low delivery of oxygen to the tissues by increasing its rate (even palpitate) to pump more blood.
Because of that lack of oxygen, you feel weak and fatigued, the way you’d feel if you were put on the altitudes of Mount Kenya without gradual preparation. You’re absolutely miserable. Even a tiny bit of effort drains your energy.
Does this sound familiar?
This can all happen because of a lack of vitamin B12. Leave it untreated for enough time and the myelin layer around your nerves may be stripped off completely, leaving you with permanent neurological damage.
Wait a second, Reggie! Isn’t that what’s called ‘pernicious anemia’?
Even though pernicious anemia (aka vitamin B12 deficiency anemia) is often used to refer to all cases of anemia resulting from B12 deficiency, technically it should only describe cases resulting from the absence or inhibition of intrinsic factor in the stomach, preventing B12 from being absorbed.
Pernicious anemia is most often due to autoimmune attacks on the cells that produce intrinsic factor in the stomach. Anemia is really just a symptom, the whole condition is just the final stage of a gradual autoimmune inflammation of the stomach called atrophic gastritis.
If this progressive destruction “only” causes a reduced secretion of the acids and enzymes needed to free food-bound B12 (without affecting intrinsic factor), then you technically don’t have pernicious anemia and can treat it with the free crystalline form of B12 (any supplement).
If, however, intrinsic factor was affected, then the only way of treatment is vitamin B12 shots. Pernicious anemia used to be fatal, but injectable B12 bypasses the intestinal absorption, literally giving new life to patients.
That loss of enzymes, acids and intrinsic factor may also be due to surgical removal of any part of the stomach. Which brings up the question…
What causes vitamin B12 deficiency actually?
Vitamin B12 Deficiency Causes
To fully understand the mechanics of this deficiency, you need to know what causes B12 deficiency in first place. There are a few possibilities:
Low intake of B12.
The most obvious of causes of vitamin B12 deficiency. Vegans and vegetarians are especially at high risk, together with their infants and kids. There are no reliable vegan sources of B12, and no vegetarian should live without regular B12 supplementation. Even the Vegan Society supports this.
Other examples are anorexic/bulimic people or the underprivileged who just can’t afford enough B12 rich foods. Some persons have increased demands, like people with hyperthroidsm, chronic hemolytic anemia, multiple myeloma, myeloproliferative disorders, neoplasms, and pregnant women.
Impaired absorption.
This can either be food-bound cobalamin malabsorption (as it often is with elderly patients), an impaired ability to absorb B12 from food (with no problem absorbing it from its free form in supplements) or complete malabsorption (pernicious anemia). These are caused by problems in any of the steps involved in the absorption of B12.
One common cause is atrophic gastritis, a condition where the parietal cells in the stomach are damaged. If intrinsic factor can no longer be produced, you’ll eventually have pernicious anemia and a severe B12 deficiency even if you consume huge amounts of B12.
Other possible causes of malabsorption are H.Pylori Gastritis, a common infection of the stomach, as well as surgical removal of any part of the stomach that may have parietal cells (like in cancers or weight loss surgeries).
Diseases like achlorhydria, the outdated Antrectomy + Vagotomy procedure and a rare genetic disorder called Mucolipidosis type IV can also cause a malabsorption by lowering acid production in the stomach.
Impaired absorption can also arise from the pancreas, where the enzyme that frees B12 from is complex is absent or inhibited. Cystic fibrosis, chronic alcoholism, Zollinger-Ellison syndrome, and pancreatic cancer are all examples for possible contributors.
Problems in the small intestine can also cause malabsorption, because it is where the B12-Intrinsic factor complex is absorbed. That’s where it is freed and attached to Transcobalamin-II to be circulated in the blood for utilization by various organs. Anything wrong in its ileum can cause a deficiency.
In Celiac disease, for example, the lining of the ileum is damaged and cannot take up B12. In Crohn’s disease, the immune system attacks the gastro intestinal tract, affecting literally any of its parts. Surgical removal of the ileum is another obvious example.
Personally? My gut (heh) feeling tells me that the massive consumption of grains, especially those with gluten, has a lot to do with malabsorption syndromes and B12 deficiency being a silent worldwide epidemic.
Parasite infestation or bacteria overgrowth.
Some worms may make their way into our intestines and take up many of the nutrients from our foods, effectively competing with our gut for B12. One common example is fish tapeworm, found around Canada and Alaska. Gastrointestinal parasitic infestation (like Giardiasis) can behave similarly.
Overgrowth of the normally present bacteria in the gut may also lead to B12 deficiency. If your normal gut flora overgrowths, it will start consuming your B12. Bacterial overgrowth may be the result of disease like diverticulosis, where sac-like dilatations form in the gut with bacteria accumulating there.
Medications.
Some drugs interact with B12 and decrease its blood serum levels, either by inhibiting its availability or by causing a greater excretion. The most famous one is Metformin, a drug used widely for the management of diabetes. According to reports, about 30% of the patients (!) taking this drug for a long period eventually develop a B12 deficiency. According to one study:
Long-term use of metformin in DPPOS was associated with biochemical B12 deficiency and anemia. Routine testing of vitamin B12 levels in metformin-treated patients should be considered.
Other problematic drugs are salicylates (aspirin), anti-tuberculosis drug isoniazid, epilepsy drugs phenobarbital, pheytoin and primidone, gout drug colchicine, AIDS drug zidovudine, and drugs that lower the acidity of the stomach (like those given to patients with reflux disease). B12 supplementation in all these patients is necessary.
Also, anyone who is given B12 for the treatment of a deficiency should not be given certain antibiotics (those of the aminoglycoside group, like gentamicin and tobramycin). These decrease the efficacy of B12.
Toxins.
B12 helps remove toxins from the body. Alcohol, for instance, is a toxin, and chronic alcoholism significantly reduces B12 levels in the blood.
Another example is Nitrous Oxide (N20, ‘Laughing gas’), which irreversibly oxidizes the cobalt ion of B12 from its active state to an inactive state, rendering it useless to the body. The effects of prolonged use of N20 (either as anesthesia for surgeries/dental work/etc or as ‘hippy crack’) can have devastating consequences, including rapid neuropsychiatric deterioration.
Another common toxin that wouldn’t do any good to your B12 stores is cyanide in cigarettes. Also, people undergoing chemotherapy are at an increased risk of B12 deficiency and should supplement.
Genetic problems.
As always, there’s also a genetic contributor, at least to some degree. If the genes responsible for B12 metabolism are affected, absorption of B12 could be hampered. Eight such genes have been identified so far.
Maternal deficiency.
Babies born to mothers who were deficient prior to conception or during their pregnancy/nursing may end up deficient themselves. Unlike adults, they have no stores of B12. If a baby is born to and then breastfed by a B12 deficient mother, therapy must be given urgently. The effects of B12 deficiency on children raised on a vegan diet are especially scary. One study finds:
a significant association between cobalamin [b12] status and performance on tests measuring fluid intelligence, spatial ability and short-term memory with formerly vegan kids scoring lower than omnivorous kids in each case … reasoning, the capacity to solve complex problems, abstract thinking ability and the ability to learn. Any defect in this area may have far-reaching consequences for individual functioning.
Vitamin B12 Deficiency Risk Groups
Now that you know what symptoms B12 deficiency can lead to, and because of all the above causes of B12 deficiency, you can see why it’s essential to test the following groups for a deficiency even before symptoms show up:
- Elderly individuals. Around 20-30% of people above 50 develop atrophic gastritis, a disease which reduces B12 absorption, as stated earlier. This is confirmed by numerous studies.
- Children, mostly those with developmental delays. It can take years before a B12 deficiency develops in adults, because our body stores B12 in our organs (especially the liver). Children, in contrast, don’t have rich stores and a deficiency can get very vicious with them, very quickly.
- Pregnant/lactating women. Fetuses and breast-fed infants draw out nutrients from their mothers. These women should be taking extra B12.
- Vegetarians/vegans. Vegetarians and vegans consistently show lower B12 levels, with estimates that up to 80% of long-term vegans are B12 deficient. Overall, no vegetarian should live without supplementing.
- Those with gastrointestinal surgery. If you had any surgery where a part of your stomach or ileum was removed (including surgeries for weight loss purposes), you’re likely to need a lot more B12 than before.
- People on certain medications. Proton pump inhibitors, H2 blockers, antacids, Metformin, or any other medication which can interfere with B12 absorption. If you take any of these, you should supplement. Those undergoing chemotherapy or using nitrous oxide (laughing gas) regularly should also be supplementing with B12.
- People with a history of eating disorders.
- Anyone with gastrointestinal diseases, Anyone diagnosed with a disease that may cause malabsorption of nutrients, for example Crohn’s, ulcerative colitis, irritable bowel syndrome, and Celiac.
- Anemic people.
- Women with post-natal depression or a history of infertility/multiple miscarriages should be immediately screened for B12 deficiency.
- Heavy smokers or alcoholics.
Vitamin B12 Deficiency Test
So, how do we actually test for B12 deficiency? The most common test is serum B12, the amount of B12 flowing in the blood. This test isn’t optimal.
The first problem I have is that it doesn’t record what’s going on at the cellular level. Second, it records all B12 in the blood, both active (transcobalamin II) and inactive analogues (transcobalamin I and III). Inactive, inaccessible B12 can fictitiously raise our blood level, representing as much as 80% of it.
Another problem is that many countries set the bar way too low, often missing desperately deficient people. Some countries accept levels as low as 100 while people show symptoms on triple that amount. Japan, to their credit, set the lower limit to 500, and their willingness to treat levels considered “normal” in the rest of the world may explain their low rates of dementia diseases.
What’s my solution?
MMA test.
Relax, I’m not going to send you on a Mixed Martial Arts duel with Conor McGregor. I’m talking about methylmalonic acid. You may be able to order a test as a follow-up to a blood test showing B12 in the lower end of the normal range. MMA is a much more accurate test (often the confirmatory, with 99% accuracy!) in indicating a vitamin B12 deficiency.
But what exactly is MMA?
Methylmalonic acid is a substance necessary for your metabolism and energy production. One of the benefits of B12 is that it helps the conversion of one of its forms, methylmalonyl CoA, to succinyl Coenzyme A. If you’re deficient in B12, then MMA levels begins to rise in both the blood and urine.
MMA test may be ordered by itself or along with a test for homocysteine, an amino acid produced by the chemical conversion of methionine. It may rise to toxic levels if B12, B6, B9 (folate) and magnesium are low, and even moderately elevated homocysteine levels are a strong risk factor for many diseases.
If your B12 level is mildly low, and your MMA and homocysteine levels are high, then you may have an early or mild vitamin B12 deficiency. If only homocysteine levels are elevated (and not MMA), then you may actually have a folate deficiency. If both MMA and homocysteine levels are fine, then chances for a B12 deficiency are very slim.
A few caveats:
- The levels of MMA measured do not necessarily reflect the severity or progression likelihood of the deficiency.
- If you have kidney disease, then you may have falsely high levels of MMA in your blood (and falsely low levels in the urine). The kidneys are needed to properly excrete it in the urine.
- MMA can be detected both in the blood and in the urine. However, the urinary test is better. First, those who have neurological damage due to B12 deficiency excrete significantly higher amounts of MMA than those who don’t, so this test can judge one’s path toward aquiring permanent neurological deficits. Second, serum MMA is raised in conditions other than B12 deficiency, such as renal insufficiency, thyroid disease, bacterial overgrowth in the small intestine, pregnancy, and others.
- Moderately to severely increased levels of MMA may be seen in infants with a rare inherited disease called methylmalonic acidemia.
- There might be a high variation in MMA levels when measured over time.
If MMA tests aren’t available at your clinic, you may order a private urinary MMA test through Dr. Eric Norman’s site (founder of the uMMA test). If you’re going for uMMA, opt for less than 3.60 mmol/mol creatinine. If you’re going for a serum MMA test, opt for less than 0.04 nmol/mL.
Also, ask your doctor to test for folate (vitamin B9), ferritin (iron storage), and do a full blood count. The important of this can’t be stressed enough, because B12 and folate need each other and a healthy level of iron is crucial.
The Shilling Test
This test is done to find the cause of your B12 deficiency after it had been confirmed through the uMMA/serum B12 test. You’ll be given B12 and its excretion will be checked in the urine, and you’ll then have to go through a couple of testing stages until your doctor finds out the cause of your deficiency (stomach/pancreatic issues, bacterial overgrowth, pernicious anemia, etc).
Do know that many places have stopped performing the Schilling test, because B12 injections are inexpensive, safe, and are the preferred treatment for most B12 deficiency causes anyway.
Vitamin B12 Deficiency Treatment
Treating B12 deficiency early on can often completely reverse symptoms. However, if diagnosed late, neurological symptoms like dementia and other nerve injuries are typically irreversible. According to this study:
There may be a time-limited window of opportunity for effective intervention in patients with cognitive dysfunction and low serum cobalamin.
Let me repeat:
The earlier you treat your deficiency, the more likely you are to avoid permanent damage.
But how exactly do you treat B12 deficiency?
Well, it depends.
Can your body absorb B12 through the stomach? Then any B12 supplement will work. Tablets, sprays, gel, anything. Do you have food-bound cobalamin malabsorption? Then high-dose oral/nasal administration may be effective. Do you lack intrinsic factor entirely (pernicious anemia)? You’ll most probably need B12 injections for life. No other supplement should be used in that case.
Still haven’t identified the culprit of your B12 vitamin deficiency?
Then don’t waste time and just use the injections. Your myelin coating is being stripped off and your nerve protection is deteriorating. Regardless of what’s causing your deficiency, B12 shots are always the superior way to replenish your stores rapidly. They’re very safe, and you can’t overdose on B12.
Also, regardless of the cause, someone very deficient should still inject, at least in the beginning. Yes, oral tablets will raise your serum B12 levels, but they might not affect cellular levels and repair nerve damage. You can’t take that risk and you need to build up B12 levels fast. High-dose methylcobalamin B12 injections are the most efficient way of delivering B12 into the tissues.
And remember, prevention is the best treatment for vitamin B12 deficiency. The greatest tragedy is how cheap and easy early treatment is compared to the consequences. So the next time you feel unbelievably tired, remember it might not be just “aging”. It could be a B12 deficiency. Go test yourself.
P.S. If you want to learn more about B12 deficiency in a fun way, I recommend the movie Sally Pacholok, which you can only watch in Vimeo. Based on the true story of Sally and her book “Could it Be B12?”. It’s a great watch:
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That’s it, fellas. Took me a couple of months to compile this resource. If you believe it can be helpful to someone you know, by all means share it with them. And if you have any question, use the comments section below.
This article is part of a larger guide: Vitamin B12.
Fabulous!!!! Really fascinating post about B12. I especially liked all of the information about how it helps improve neurological function. Have you seen the movie “Limitless”, it sort’ve made me think of that NZT drug in that movie. Nature knows what our body’s need. I’ve been upping my D3 this winter to keep from getting sick, and it seems to be helping.
I’ve suffered from severe b12 deficiency symptoms for very, very long. The problem is that they look so similar and appear in so many other conditions as well, which makes the whole part of identifying a deficiency so hard.
I had a blood test done last week and was diagnosed on Monday. I started injections yesterday (Tuesday). I had to switch doctors because my first GP would just “listen” and tell me that if I would just exercise, I would lose weight and have more energy…So I did. I went to the gym 5x a week for no less than one hour. I was eating no more than 1200 calories a day and never lost more than 5 pounds in the span of 3 months. That’s when I decided that something else HAD TO BE wrong. If I was eating a lot fewer calories and working out 100% more than I was before and not losing weight, surely there was something “deeper” causing the problem. At this point, I know what’s wrong and I’m being treated. I haven’t seen any results at the time of this writing because I’ve only had two injections. My doctor told me on Monday that he is going to order more blood tests to see if he can find WHY I have a malabsorption issue. That’s what really needs to be found out. Until then, I hope the injections work. I have to have 1x daily for a week, then 1x week for a month and then 1x monthly for the rest of my life. I will also be taking oral supplements when I start monthly injections.
You’re very right about how this condition can be under-diagnosed and how it mimics a lot of other diseases. I hope you’re still taking the B12 shots and oral supplements!
Eating 1200 calories plus exersise for a grown adult with responsibilities isn’t healthy nor sustainable. No, it’s not even healthy if you’re trying to lose weight. Yes, b12 is important but it’s a no brainer why you don’t have energy. Eat more
I am taking Coumadin for heart rhythm, I want to start B12 tablets would this cause any problem?
Please consult your doctor.
Hmmm, isn’t Coumadin (Warfarin) a blood thinner? If so, I’d assume you’d actually need more B12 supplementation if you take it, since B12 is responsible for producing red blood cells.
A friend was getting Vitamin B12 injections and one year ago, they were discontinued due to a “Medicare Cut” in florida. Is this true that the Medicare could cut this treatment for her? From your information, I see that once the deficiency is corrected, the injections can slow down to one a month. Please reply.
As I wrote one my B12 shots guide, a lot of new regulations came up in the U.S last two years and made B12 injections very hard to attain. Depending on the cause of her deficiency, yes, injections can slow down, but in some cases may be needed for lifetime.
Could you please tell me the contact information of Dr. Aqsa Ghazanfar, where does she see patients, the address of her clinic or contact info of any sort (email address , phone no). Secondly where can i buy that book (B12 Deficiency Survival Handbook) in Pakistan. Thanks, Javaria.
Dr. Ghazanfar now works in a hospital in Ireland. As for the book, you can buy it on Amazon. Save shipping costs by getting the Kindle version.
With all those reasons for vitamin b12 deficiency, I still don’t get how it is actually absorbed…? And is there any way for it to be absorbed without intrinsic factor AND without injections that bypass it?
Vitamin B12 is freed in the small intestine, where R-proteins are degraded by pancreatic enzymes. It then binds to IF (intrinsic factor) which is secreted by special cells in the stomach. Receptors on the ileum take up this IntrinsicFactor-B12 complex and move it forward. Actually B12 can be absorbed by passive diffusion, but it is a very inefficient process, with only about 1% (if anything) of doses being absorbed.
My 50 % hairs became white… is it because lack of vitamin B12 ? I am a vegetarian.
It may very well be (since you asked, I assume you’re a young person), especially since you’re a vegetarian. I suggest you go through a B12 deficiency test.
Any vitamin b12 deficiency diet that you recommend? Something that will go along well with treatment? Thanks!
I have b12 deficiency tingling, how many injections should i take?
I am extremely happy to know your concern for the health care of the human beings on the earth. Service to mankind is service to God. I pray to God and wish to fructify all your efforts in this pursuit.
Functional B12 Deficiency? Was diagnosed as B12 deficient in February and given 6 loading shots, but once on maintenance dose (one every 3 months) I got a lot worse. In October, was given blood tests and although by then B12 was over 2000, MMA levels were also high: so Functional B12 deficiency diagnosed. I can’t find much on this subject, but what I have found doesn’t explain low initial plasma B12 reading or suggest what long-term treatment needed. Please can you help me?
Hi Dr, I have been tested b12 low – 206, lab reference for good is 211-948. But, I am taking antibiotics while taking this test. Also, considering it is too close to optimal , is it good start with supplement or shots? Or do I need to take test again. Thanks.
Can low B12 be the result of overuse of paint thinner, varnishes and stains?
If I was tested as deficient 5 years ago via serum b12 level (<145) and received zero treatment as well even less food consumption since. How can all bloodwork be normal? B12 serum (239) and MMA are normal now?
If I have mild macrocytic anemia and blood test results improve about a week of taking vitamin b12 orally, does that mean I can stop taking vitamin b12 once the levels are at normal range? Or do I still need to take more vitamins for the next few months or so to replenish the vitamin b12 in the liver?
Thank you so much for the very much needed education. I care for my grandmother and it just seems like she’s being tossed from one Dr to another with no answers. I feel more concern and more in control of her care now.
This was very helpful! My daughter is 14, in 2016 it all started with heavy periods lasted 7 days, colds and acid reflux lots of stomach, back, rib pains, strep throats, bladder infection, she had kidney reflux as an infant and acid reflux had to be on low iron formula to stop puking. Her pains grew in back, ribs, stomach lots of fevers puking did ultrasound in January 2017, Feb. 2017 she had gallbladder removed. Full of stones, July 2017 took her to ER with severe back, neck, stomach, rib, arm, leg pain had numbness down right side arm, leg to her toes could not feel pinky toe. Blurred vision too. Treated her for dehydration. Pain come and goes daily Her doc. Diagnosed her in September 2017 with ADHD combined type, I talk to daughters school councilor, the principal, her teachers and superintendent. (Its a small school) They helped me decided to put her on vyvanse 20 and 30 mg started oct 2017. Her mood swings were bad, focusing on anything was gone she would make impulse decions, grades plumbed. After putting her on ADHD meds she was her self till November 2017 had to up meds because slowly she was going back wards, it worked again till Feb. 2018 she had lost her breath, chest hurt bad I had to pick her up from school. Took her to doc said anxiety attack. Made appointment with a councilor and physiatrists because doc. Thinks she has bipolar on top of all of this. She start playing volleyball in Feb. 2018 she still had all those pains and pushed though them to play for her school. March 19th she calls me at work to come get her stomach hurts bad nausea just so sick again, From Aug 2016- to march 2018 she took Ranitidine 75mg- 150mg and Omeprazole 20mg rapid release this helped stop stomach pain but not the other pain. Took her straight to doc. After I picked her up from school. I’m a wreck I’m so tired of her hurting every day new stuff happening to her and constantly waking me up with screams for me to come help I’ve had it I cried to doc to figure this out she is getting worse with stomach and all pain I told her my consern for side effect of omeprazole is severe back pain took her to eye doc because of blurry vision needed glasses got them, April 2018 took a bag test to check for bacteria in stomach that was negative. April 13 2018, took blood test for kidney, liver, thyroids, and iron. Her iron was low everything else was good. My mom had low iron anemia, that day I decided to take her off all meds and put her on vitamin supplements High in iron and got iron rich foods switch to water only. Because that is what mom did. We made appointment for mental docs to get her inrolled to start seeing them, asked them to wait to put her on meds till we get GI scope done to see what she finds in my daughters stomach, so all of stomach, back pain slowed way down ribs still hurt bad started her on melitonen 1 mg to help her sleep she has not woke me up. June 1,2018 got strep again, June 16 came home from swimming in a lake, sick to stomach, nausea, fever sore throat, back pain and ribs not wanting to eat or drink. Next day still in pain, heart started racing off and on vision blurry again till 19, had diarrhea 16-25 went to doc on 26th severe pain on left side that kidney she had problems with as a child was hurting, told her new symptoms along with her bruising very easy. (We were playing rough together I smaked her on her upper left thigh she ran away like she normally does I sat down and she came back with a perfect hand print of a very dark bruise I cried ran got ice asked if I hurt her she said no it does not hurt, it looked so bad ten min later gone.) Took uraine sample said a little dehydrated no infection. Sent us home to drink lots of water before going to get scope on 26th she had to be put to sleep with IV so needed good viens, she forced water down said it tasted funny and when she drank it acid would come back up, I kept making her till day of GI scope. She has been tired for 2 days woke up slowly got ready because everything was just hurting so bad we prayed scope would find anything to help her. Got scope done on esophagus, stomach, upper intestant it was all good nothing abnormal was seen by eye took samples of stomach anyways to send to lab, my daughter was in recovery sleeping GI doc tells me all this and says I’m gonna put her on IBS and anxiety medication. I told her no fax everything to her doctor because she has a psychiatrist appointment for ADHD, anxiety and bipolar. Don’t want to mix meds till I talk to all my daughters doctors. Also I brought up anemia her low iron the bruise she had. I asked if my daughter was going to heal right because she was leaving with my sister to go 3 states away to my other sister for a week. She said she will be fine. She orded more blood work to test for blood on how fast it would clot Went to recovery got my daughter that was being so mean yelling at people to go get me she was done with them. I don’t like when she wakes up from anistesia she is mean. We went to my sister dropped her off left after she ate then laid down. I drove my 2 hrs home mad, disappointed, stressed, depressed, down right tired that I’m at start again, came home went to bed slept from 2 pm to 10 am next day called my daughter wanted to review her feelings, pains for the day she was fine no pains she slept all that time too told her what doc said she was confused didn’t know why scope didn’t show anything. I told her I was going to do research on everything I’ll find something. So I did got B12, iron deficiency with enlarged spleen a lot. So I decided to get ahold of my ex husbands sister told her everything, she said all the girls had gall bladder removed early, they all had kidney reflux that went away, all anemic with B12, vitamin D and low iron deficiency, every symptom my daughter has they been through it one had enlarged spleen waited to long but fixed self with high B12 injections every day then controlled it by mouth. Chewable D Tablets she told me its all different now that I need to talk to her doc and have her checked. So I’ve been looking for 2 days got to this site read all of it and it makes sense of all my daughter is going through. I talk to her doctor Monday updating family history there is a lot and have her test for or look at lab results from GI doc. Get her on a food plan so she can eat more. Thanks for your knowledge on this very helpful.
I’m looking for a second opinion please. My 16 YR old daughter has been diagnosed with CFS & has felt fatigued for 2 years. Her GP offers little advice, saying she’ll get better in time. A CFS specialist ordered tests which showed a folate level of 2.4 for which she takes 5mg folic acid. Her B12 is 217, being advised she is within the normal range with no need for supplementing. Her ANA titre levels are 1/40 but my daughter shows signs of rheumatoid issues. I would be grateful for your opinion. Thank you
ask your cfs doctor for a referal to fibromyalgia doctor not a easy task one with real exper. fibro and cfs often are found together.take a look at fibromyalgia network wealth of knowlege there dont overlook the chatrooms.
Let me add a couple things, which I thought you might find of interest: MTHFR & Intrinsic Factor antibody. I didn’t see either discussed anywhere, yet they are common enough, and disguise/mask the B12 def. problem.
My wife’s serum B12 levels are ‘above average’ to ‘high’ (737 to 1,484), yet she is B12 deficient.
She has tested positive for the MTHFR gene (C667T) mutation, and for the IF antibody.
I finally found a doctor interested in looking at the ‘pieces of the puzzle’ I had compiled. My wife’s long-term blood test trends show consistently low WBC & reticulocyte count, and high MCV & MCH. We already knew about the MTHFR, then this doctor ordered the IF antibody test no other doctor had ever considered. Voila, she tested positive for that, too!
Apparently, the B12 deficiency is keeping her system from producing enough new/developing blood cells, and those that were made were too large & disformed. After 10 days of MeCbl injections, she will take a blood test next week to see if there has been any improvement in the numbers. (Damn, I hope the MeCbl works. This has been a 10-year quest.)
PS: I ordered a vial of your powder yesterday. Looking forward to trying it.
I have Pernicious Anemia and I take 2500mg of sublingual B12 every other day. My recent blood test came back with >2000 pg/ml. Do I need to continue to take the sublingual and how often?
Hello I’m 38yo AA female and my doctor has discovered that I have a B12 deficiency. I just tested and it was 21, this number has me terrified when I see 500 and up is normal…..all my life every doctor was confusing my symptoms with my high blood pressure. (dizzy, fainting, forgetful, hot flashes etc) Anyway, I have had 3 months of weekly B12 injections along with taking 50,000 units of Ergocalciferol once a week. Now after four months of treatment, my doctor says I’m still not absorbing the B12. Is there any way I can get around the infusions? I just can’t believe my levels only increased by 11….4 months prior it was 10 and now 21. that’s a lot of treatments for those little results.
Take the active form of b12 called methylcobalamin. find the subliminal form that dissolves on the tongue. You should be able to find it at any vitamin store or online.
Aloha!
In a search for more information about a questionable diagnosis of a Vitamin B-12 deficiency, I saw a book listed on Amazon with you as one of the authors, which lead me to this site.
I would greatly appreciate a non-binding answer to a question I have pertaining to a vitamin B-12 deficiency that appeared after sustaining a spinal cord injury.
My apologies for being a bit long-winded, but this doesn’t seem to be a… simple thing.
Me: 45YO caucasian male; 4.5+ years post acute SCI (C3 ASIA D)
Among the many questions I have, the one that stands out the most is this: if an individual (me) has a single blood test which shows a low- extremely low, even- yet it is the only test which came up with this result, is that sufficient for establishing a “Vitamin B-12 deficiency: as a diagnosis? (B-12 levels increased in response to B-12 supplementation and have not dropped three to fours years since stoping supplementation.
Other than an SCI with an acute onset (under 1 hour), I am not in a risk or high-risk population for developing a B-12 deficiency (i.g. I am pregnant mother, infant, elderly, have Chrohns or Celiac Disease or one who does not consume animal protein).
AND FINALLY… the question:
Q: That said, if an individual is tested- among other things- for Vitamin B-12 and the result comes back below the normal limit, does or should that in itself result in a diagnosis of “Vitamin B-12 Deficiency”?
I would greatly appreciate any (non-binding) response you may have and you have my expressed permission to share this question with any other parties if necessary in order to answer the above question.
Thank you and I look forward to hearing from you!
– Tom
Hi,
I have coeliac, diagnosed 14 years ago. I have been on B12 and folac acid tablets 5mgs for about 12 years. Due to the coeliac disease I got pernicious anaemia. I have the injections every three months. In December 2015 I had a blood test and my B12 was500 and fine. I have just been told by my doctors that I don’t need the folic acid as my B12 blood results in June of this year were 1500 extremely high. I then checked up and I had the injection on the 7th June and my blood test on the 14th June. so could this be why the level is high. Also could you tell me whether I could start absorbing B12 by way of food when before with the coeliac I couldn’t.
Thank you,
Dawn.
Hi
I am really grateful for your article on vitamin B 12 deficiency , an eye opener . But I still feel that this knowledge is still very limited among most of the practicing doctors.
People like you r doing
a great service to the suffering patients.
With warm regards
Shankar
Wow, I shared this on Facebook; everyone needs to see it! My doctor had me on Metforim for years and while he tested me two years ago, said I was normal, but I was at 200. Two years later, I can’t eat and feel terribly week and sick; prior to this I had complained of feeling weak and tired but he blamed it on middle age, etc. I keep complaining, and he ends up testing me, and I am deficient at this point and anemic. He gave me one shot and told me to take supplements. I have neuropathy (and since I am diabetic, it may be in part due to that, though my diabetes has been well-controlled and my new internist is doubtful). I have switched doctors, but I have to go and see a neurologist too. Monday I am having a colonoscopy and endoscopy. My new doc things everything loops back to the B12 and says I may not recover but is hopeful; I am really worried about the eating as it seems to have really impacted my GI track. I can’t eat much and will be tested for gastroparesis soon as well. Have that dragging leg, too, the doctor spoke about. I am really hoping for some kind of recovery. My new doctor will test me in October to see what my recovery looks like (last test it had gone up and there was improvement). I worry though that what I need are shots and how to convince my doctor to give them to me. I am off the Metforim and looking into other options. I wish I had known…
Hi, I’m in UK and since diagnosis I’ve had 4 injections, another due tomorrow, but mine aren’t monthly, my doctors believe 3 monthly injections are enough, each time a month before I’m due I start getting symptoms, this time it’s been horrendous, dizzy spells now turned to vision disturbance, loss of balance, can’t get my words out or concentrate. They only test nhs patients for total b12 my total two months after injection was 980 but I’ve read only 20-25% of that is active. Closer to the next injection it’s been a total 247 and 480 that’s total not active and the doc just says anyone coming to them with reading like that wouldn’t even been getting injections so they won’t do them closer together than three months. Where as others I know in UK had a weeks worth of intensive injections then have one a month, the UK NHS is truly a postcode lottery, ok if you live in the right place. I’m at my wits end. Considering private testing (ironically offered buy NHS hospital in London) and if that doesn’t help my case with the GP then I am going to consider ordering and injecting myself ??. Thank you so much for every bit of info you have put on here. Going to get my 15 year old mildly autistic (high functioning) son tested too, aside from his autism he had a stroke at age 6 because of a narrowed cerebral artery, I’m now thinking could possibly be b12 related.
Hello,
Is only pure vegetarian only deficient B12?.
Is non vegetarian also may be deficient B12?
I just went to my physician yesterday for ongoing numbness and tingling in my feet and among the several lab tests he ordered were my b-12 levels. I’m now very interested in the results. I’ve been concerned about neuropathy and would be interested to learn more about it and any links to b-12 deficiencies. I learned from Regev’s posts that b-12 does in fact help with the myelin sheathing on nerves. There is a lot to research on this, so I will use a bad pun and the words of Sherlock Holmes to say, “The game is a-foot”! ?
Where do these parasites come from and how is one tested for them? (Blood, urine, stool)
Well there are two main parasites that cause B12 deficiency – Giardia and the fish tapeworm. The former is acquired via the feco-oral route and the latter is acquired by eating infected fish. Tests to diagnose an infestation with these parasites usually require stool tests. If diagnosis can’t be made by this simple test, other more complicated tests may be required (for example, testing for antibodies, etc).
Hello! I am suffering from recurrent chemical pregnancies at around 4 weeks, barely pregnant. My B12 was 1129 and my folate was greater than 20. Is this bad? My midwife who ordered the tests was not concerned. I have celiac disease. I am waiting on my blood iron results as I have tingling in my hands and feet following my miscarriage last week and have been pale and weak.
I just find out something more about b,12.l have b12.my foc injury every three month
I am very frustrated right now because I’ve been on B12 shots for years diagnosed with a B12 issue with pernicious anemia and malabsorption. November last year a doctor took me off the shots cause said it was normal range at 404. Last shot was Oct 2018. Taken off all shots in November 2018. Went to doctor sick with Bronchitis on Feb 28 in 2019. Bad cough. Labs done and B12 was still in normal range and dr would not put me back on the shots even though I asked. Still coughing I went back to dr today and dr. said again no b12 shots unless she could establish an issue with the B12 so no shots yet. Trying over the counter B12 vitamins but not feeling well still. Is there a doctor in the Lexington, KY area that understands B12 vitamin issue? If I don’t find one soon things are just going to get worse I am afraid. I have diabetes and liver problems, etc. and was started out on Metphormin but am now on something different only because I told the dr. I wanted to put on something else at the time. Not many doctors know anything about Vitamin B12 which is so sad because so many could be helped if the drs knew.
This is nothing short of a scandal. If you have Pernicious Anemia (malabsorption of B12 through the stomach), you need shots for life! Tell your doctors that after a series of injections, of course you’re going to have plenty of B12 flowing in the bloodstream, but that doesn’t necessarily mean you have enough B12 in the cellular level. Unfortunate cases like these are the reason I started supplying B12 for injections through this site. Check it out here and let me know how it goes. Good luck, mate.
P.S I just returned from the Bourbon trail in Kentucky, loved it =)
One of those other drugs you e been put on isn’t methotrexate is it. My husbands father was put on that and he developed a cough and chest discomfort, then started loosing his voice. Turns out it’s very likely the lung cancer he died of was caused by the methotrexate he took (which is apparently an anti cancer drug ?) he was taking it for arthritis. Just wanted to check that with you because we all know the sooner you find these things out the better. Couldn’t not say anything just incase.
I am 38 yrs female and I have pigmentation and I am vegetarian and never taken supplements of b12 ,here in India even doctor don’t understand these things, can anyone tell which test can should I go through that can check all levels of deficiency ..
if you were on injections before giving birth its VERY IMPORTANT to know that gas and air will render youruseless as it inactivates it. so you should of had top ups to protect you from what you would have lost. You do need to take folic acid and a bcomplex to support your jabs also there are other vitamins.
This post is so eye opening. I am a 28 year old female and have been on birth control for over a decade which I believe has caused my B12 depletion as I have no other medical issues and eat a healthy well rounded diet.
Recently, while I have been under a lot of stress, I began to have periodic tingling and numbness in my legs and feet and a feeling of weakness. I had a blood test done in which my B12 level was 350, very low as I eat fish, red meat and dairy often. I cannot believe my doctors have not voiced concern about my birth control being the possible culprit, and have also looked at me like I am feigning this symptoms. I read high stress can also create my symptoms/b12 depletion so it could be a combination. I strongly agree with this article about B12 level requirements being way too low (I’m from the US). Doctors really need to upgrade and enhance their knowledge on vitamin and mineral deficiencies before blowing you off or attributing symptoms to a more serious condition, thus increasing anxiety.
Food for thought! My 98 year old mom, who takes warfarin, among other prescriptions, has been informed recently that her b12 level is 188 and should be at least 350. Doctor wanted to give her injections but as I was not sure whether they consisted of cyanide or methyl group, leaned toward lozenges. Was advised by her doctor to take 1000 mcg. a day. However, reading the above post I am wondering if this is sufficient.
I need help. I have ordered B12injections but dont know the dossage
Is for energy and increased metabolism. .please email me with your response…dose for twice a week injections. .for response to B12 question
Thank you
If you’re deficient and anemic without any neurological symptom, doctors will usually give you methyl B12 shots of ~1,000mcg every other day for 2 weeks, followed by maintenance shots every 2-3 months. When you do have neurological symptoms, you’ll be given the shots every other day until symptoms stop improving (which indicates the best possible reversal of neuro-psychiatric damage), and then a shot every 1-2months. In any case, I don’t recommend going off the daily shots as long as you have symptoms. If you ordered the shots purely for metabolic benefits and extra energy, you might be disappointed – B12 works only when you’re deficient. It’s like gasoline – your car won’t run faster if you filled the tank from half to full.
Hi, I went to the doctors 7 weeks ago following some stress at work resulting in dizziness when at work, difficulties swallowing and haemorrhoids all ading to the tension I was feeling following a stressful period at work. A blood test was taken and the doctor said I scored 190 when the range was 200+ and he would now have to keep an eye on me with an annual test as my stomach is not absorbing b12. He told me not to change my diet and I have been doing yoga to help with dizziness. The doctor signed me off work for 2 months and advised me to change my job. I am 50 and the symptoms are improving since I have stayed off work. I am also doing nordic walking. Any advice appreciated. My doctor told me not to worry but I was alarmed once I googled b12 deficiency when not absorbed in stomach etc.
The B12 Deficiency Survival Handbook: Fix Your Vitamin B12 Deficiency Before Any Permanent Nerve and Brain Damage Paperback 6 Jan 2014