Vitamin B12 deficiency in Australian residential aged care facilities

Prevalence, associated factors, and impact of vitamin B12 deficiency in older medical inpatients

PURPOSE

This retrospective cohort study aims to explore the prevalence of vitamin B12 deficiency in older hospitalized adults and identify key factors associated with this deficiency, as well as its impact on frailty and functional decline.

METHODS

Data were collected from older adults (≥65 years) sequentially admitted to the Internal Medicine Department of a tertiary university hospital. Clinical and laboratory characteristics, including age, sex, somatometric data, cause of admission, past medical history, chronic medication use, and laboratory tests, were recorded. Frailty and functional status were assessed using the Fried Frailty Scale (FFS), Clinical Frailty Scale (CFS), Barthel Index, and Katz Index. Vitamin B12 levels on admission were categorised as deficient (<200 pg/ml), borderline (200-300 pg/ml), normal (300-999 pg/ml), and high (≥1000 pg/ml).

RESULTS

A total of 894 patients were included. The median age was 83 years and 487 (54.5%) were females. The prevalence of vitamin B12 deficiency was found in 9.1%, while 17.3% of the sample had borderline levels. Multivariate analysis identified polypharmacy (≥5 drugs), low albumin levels/Geriatric Nutritional Risk Index (GNRI), and nursing home residency as independent factors associated with low B12 levels. Multivariate analyses showed that B12 deficiency was significantly associated with higher frailty rates and lower functional status.

CONCLUSION

Vitamin B12 deficiency is prevalent among hospitalized older patients and is significantly associated with increased frailty and reduced functional status. These findings underscore the importance of routine screening for B12 deficiency in this vulnerable population to improve clinical outcomes and quality of life.

Vitamin B12 deficiency and neuropsychiatric symptoms in Lebanon: A cross-sectional study of vegans, vegetarians, and omnivores

BACKGROUND

Vitamin B12 deficiency is responsible for a variety of complications, particularly neurological/neuropsychiatric complications, including depression, irritability, paresthesia and insomnia. Since vitamin B12 is found in animal-derived products, vegans/vegetarians are at a greater risk for developing vitamin B12 deficiency.

AIMS

This study aims to investigate the occurrence of vitamin B12 deficiency among a sample of adult Lebanese population, with a particular emphasis on assessing the severity of its neurological/neuropsychiatric signs and symptoms, especially among vegans/vegetarians.

METHODOLOGY

A cross-sectional study was conducted among a sample of 483 Lebanese adults. Data was collected through a standardized questionnaire that included socio-demographic characteristics, the Patient Health Questionnaire-9 (PHQ-9), Generalized anxiety disorders-7 (GAD-7), and the Insomnia Severity Index (ISI) scales.

RESULTS

Among the participants, 11.4% were in the vegan/vegetarian group, and about 43.1% had vitamin B12 deficiency. After analyzing the PHQ-9, GAD-7 and ISI total scores, higher scores were reported in participants with vitamin B12 deficiency, compared to individuals with normal vitamin B12 serum levels (p < 0.001). Regarding the diet type, vegans/vegetarians were more susceptible to developing depression compared to omnivores (mean scores of 11.92 vs 8.02 on the PHQ-9 scale, respectively, with p < 0.001). Of the patients with vitamin B12 deficiency, 81.1% reported having paresthesia compared to 43.7% of individuals with no vitamin B12 deficiency (p < 0.001).

CONCLUSION

Vitamin B12 deficiency in Lebanon is notably high and is linked to an increased risk of developing depression, generalized anxiety disorder, insomnia, and paresthesia. Vegans/vegetarians exhibit a higher susceptibility to developing depression compared to omnivores, whereas the risk of developing insomnia, generalized anxiety disorder and paresthesia was statistically insignificant when comparing vegans/vegetarians to omnivores.

Diagnosis, Treatment and Long-Term Management of Vitamin B12 Deficiency in Adults: A Delphi Expert Consensus

Background/Objectives: Vitamin B12 deficiency can cause variable symptoms, which may be irreversible if not diagnosed and treated in a timely manner. We aimed to develop a widely accepted expert consensus to guide the practice of diagnosing and treating B12 deficiency. Methods: We conducted a scoping review of the literature published in PubMed since January 2003. Data were used to design a two-round Delphi survey to study the level of consensus among 42 experts. Results: The panelists agreed on the need for educational and organizational changes in the current medical practices for diagnosing and treating B12 deficiency. Recognition of clinical symptoms should receive the highest priority in establishing the diagnosis. There is agreement that the serum B12 concentration is useful as a screening marker and methylmalonic acid or homocysteine can support the diagnosis. Patient lifestyle, disease history, and medications can provide clues to the cause of B12 deficiency. Regardless of the cause of the deficiency, initial treatment with parenteral B12 was regarded as the first choice for patients with acute and severe manifestations of B12 deficiency. The use of high-dose oral B12 at different frequencies may be considered for long-term treatment. Prophylactic B12 supplementation should be considered for specific high-risk groups. Conclusions: There is a consensus that clinical symptoms need to receive more attention in establishing the diagnosis of B12 deficiency. B12 laboratory markers can support the diagnosis. The severity of clinical symptoms, the causes of B12 deficiency, and the treatment goals govern decisions regarding the route and dose of B12 therapy.

Comparison of biomarker for diagnosis of nitrous oxide abuse: challenge of cobalamin metabolic parameters, a retrospective study

BACKGROUND

Recreational use of nitrous oxide (N₂O) leads to neurological disorders including combined subacute degeneration of spinal cord, psychological disorders, and thrombosis. Serum or urine N₂O assays could not be routinely performed. Hence, it is necessary to investigate other biological markers such as metabolic markers. We aimed here to challenge the three main biological markers used for the diagnosis of nitrous oxide abuse as total vitamin B12, homocysteine, and methylmalonic acid.

METHODS

We retrospectively collected clinical and biological data from 52 patients with known, documented chronic N₂O abuse and associated clinical signs (peripheral neuropathy disability score or thrombosis event). Sera and plasma total vitamin B12, methylmalonic acid (MMA), and homocysteine were performed to identify the most specific marker of chronic N₂O intoxication and related clinical outcomes.

RESULTS

Plasma homocysteine was almost consistently increased in case of N₂O chronic consumption, whereas MMA increase and total vitamin B12 decrease are not systematically found. Our results showed that none of the markers are correlated with levels of N₂O consumptions. However, homocysteine and MMA are correlated with clinical severity, but MMA seems to be a better marker of clinical severity.

CONCLUSION

There is no specific marker of nitrous oxide abuse according to levels of consumption, total vitamin B12 decrease could not be used either as consumption or as severity marker. However, we showed that homocysteine is consistently increased and could be used as marker of recent N₂O consumption. On the other hand, we showed that MMA could be used as a marker of clinical gravity.

Deficiência de vitamina B12 e fatores associados em idosos institucionalizados

Resumo Objetivo Avaliar a frequência de deficiência de vitamina B12 e fatores associados em idosos institucionalizados. Método Analisamos 65 idosos, com idade média de 80±9 anos (61-113), de uma instituição geriátrica filantrópica de longa permanência. A dosagem sérica de vitamina B12 foi analisada e classificada em: normal (≥299 pg/mL), limítrofe (200-298 pg/mL) e deficiência (<200 pg/mL). Foi analisada a associação com tempo de permanência na instituição, declínio cognitivo e funcional, uso regular de biguanidas e inibidores de bomba de prótons, considerados fatores de risco para hipovitaminose B12, utilizando os testes de análise bivariada (paramétrica e não paramétrica) e regressão de Poisson. Resultados A deficiência de vitamina B12 estava presente em 21,5% e valores limítrofes em 32,3% da amostra. Dentre os idosos, 52,9% apresentavam demência de causas diversas, 49,2% hipertensão arterial, 29,2% com anemia (21,5% normocítica, 4,6% microcítica e 3,1% macrocítica), 18,5% diabéticos; 27,7% faziam uso de polifarmácia, com 12,3% em uso de metformina e 16,9% com inibidores de bomba de prótons. No modelo multivariado não houve associação entre a deficiência de vitamina B12 com as variáveis estudadas. Conclusão Observamos uma frequência importante de valores limítrofes e baixos de vitamina B12 nos pacientes dessa instuição geriátrica de cuidados permanentes, porém sem associação com os fatores de risco para sua deficiência estudado, o que torna importante a inclusão da dosagem sérica dessa vitamina na rotina de exames laboratoriais desse grupo.

What is the cobalamin status among vegetarians and vegans in Australia?

Water-soluble vitamin B12 (cobalamin) plays a vital role in normal blood function and neurological functioning. Clinical and subclinical B12 deficiency has been notably reported in vegans, vegetarians, the elderly and metformin-treated diabetics. Currently, the prevalence of cobalamin deficiency among vegans and vegetarians in Australia is lacking; data on dietary intake including supplements and nutritional status are also limited. The increasing multiculturalism of Australia has seen an influx of imported foods, of which some may contain considerable vitamin B12. However, values for such foods are not included in the food composition databases. This review highlights the need to update the food composition database with culturally diverse foods containing vitamin B12. Moreover, the need for assessing dietary intakes and status using the most current best evidence and best practice on nutritional indicators (biochemical and functional biomarkers) to estimate the risk of deficiency and/or depletion is discussed.

Post renal transplant anemia: severity, causes and their association with graft and patient survival

Background

Post transplantation anemia (PTA) is common among kidney transplant patients. PTA is associated with increased graft loss and in most studies with increased mortality. However, the effect of the severity of anemia on this associations was not thoroughly evaluated.

Methods

Patients who underwent kidney transplantation in Rabin Medical Center (RMC) were included in the study. Data were collected during the years 2002–2016. Anemia was defined as hemoglobin (Hb) level less than 12 g/dL in women and less than 13 g/dL in men, in accordance with World Health Organization (WHO) criteria. Severe anemia was defined as hemoglobin lower than 11 g/dL. Primary outcome was a composite of patient and graft survival. We used univariate and multivariate models to evaluate association between severity and specific causes of anemia with the outcomes. As the risk associated with anemia changed over time we analyzed the risk separately for the early and the late period (before and after 1251 days).

Results

Our cohort included 1139 patients, 412 (36.2%) of which had PTA and 134 (11.7%) had severe anemia. On multivariable analysis, severe anemia was highly associated with the primary outcome at the early period (HR 6.26, 95% CI 3.74–10.5, p < 0.001). Anemia due to either AKI & acute rejection (11.9% of patients) or infection (16.7%), were associated with primary outcome at the early period (HR 9.32, 95% CI 5.3–26.41, p < 0.001 and HR 3.99, 95% CI 2.01–7.95, p < 0.001, respectively). There was non-significant trend for association between anemia due to Nutritional deficiencies (29.1%) and this outcome (HR 3.07, 95% CI 0.93–10.17, p = 0.067).

Conclusion

PTA is associated with graft loss and mortality especially during the first three years. Anemia severity affects this association. An anemia workup is recommended for PTA.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1244-y) contains supplementary material, which is available to authorized users.

The Effect of Whey and Soy Protein Isolates on Cognitive Function in Older Australians with Low Vitamin B12: A Randomised Controlled Crossover Trial

Whey protein isolate (WPI) is high in vitamin B₁₂ and folate. These and other related markers (holotranscobalamin, methylmalonic acid and homocysteine) have been linked with cognitive health. This study explored the efficacy of WPI for improving cognitive function via delivery of vitamin B₁₂. Moderately vitamin B₁₂-deficient participants aged between 45 and 75 years (n = 56) were recruited into this randomised controlled crossover trial. Participants (55% female) consumed 50 g whey (WPI; active) or soy protein isolate (SPI; control) for eight weeks. Following a 16-week washout phase, they consumed the alternative supplement. Consumption of WPI significantly improved active B₁₂ and folate status but did not result in direct improvements in cognitive function. However, there was evidence of improvement in reaction time (p = 0.02) and reasoning speed (p = 0.04) in the SPI condition for females. Additional analyses showed that changes in active B₁₂, HcY and folate measures during WPI treatment correlated with improvements in cognitive function (all p < 0.05). Results indicate that WPI itself did not result in improved cognitive function but some evidence of benefit of SPI for females was found. However, consistent with previous research, we present further evidence of a role for active B₁₂, HcY and folate in supporting cognitive improvement in adults with low B vitamin status.

Micronutrient Food Fortification for Residential Care: A Scoping Review of Current Interventions

PURPOSE

Malnutrition is common in residential care environments, primarily due to poor intake. Micronutrient deficiency, although poorly investigated to date, is also reported to be high. Improving the nutrient density of consumed foods is a potential mechanism to promote increased nutrient intake. A scoping review was conducted to: (1) explore the evidence on micronutrient food fortification strategies, (2) identify candidate nutrients and food vehicles for successful food fortification, and (3) identify gaps for future research.

METHODS

The scoping review framework of Arksey and O'Malley was used. A comprehensive search strategy of 4 electronic databases (MEDLINE, EMBASE, CINAHL, and Web of Science) was completed. Two reviewers were involved in screening and data extraction for all selected articles.

RESULTS

A total of 4394 relevant articles were identified for screening, and application of inclusion/exclusion criteria resulted in 6 food fortification studies (8 citations; 1 study had 3 citations). Overall, vitamin D (n = 5 studies) and calcium (n = 4 studies) were the most common micronutrients fortified; milk products, margarine, bread, and pureed foods were fortification vehicles. Most studies fortified below the RDA recommendation and did not include clinical outcomes. Samples were small and intervention periods were short (3-6 months).

CONCLUSIONS

Fortification is a viable strategy for improving the nutrient density of foods consumed in residential care. Although disparate, this literature suggests the potential for further undertaking of fortification to prevent micronutrient deficiencies among residents and future research should consider multinutrient preparations and clinical outcomes.

Biomarkers and Algorithms for the Diagnosis of Vitamin B12 Deficiency

Vitamin B12 (cobalamin, Cbl, B12) is an indispensable water-soluble micronutrient that serves as a coenzyme for cytosolic methionine synthase (MS) and mitochondrial methylmalonyl-CoA mutase (MCM). Deficiency of Cbl, whether nutritional or due to inborn errors of Cbl metabolism, inactivate MS and MCM leading to the accumulation of homocysteine (Hcy) and methylmalonic acid (MMA), respectively. In conjunction with total B12 and its bioactive protein-bound form, holo-transcobalamin (holo-TC), Hcy, and MMA are the preferred serum biomarkers utilized to determine B12 status. Clinically, vitamin B12 deficiency leads to neurological deterioration and megaloblastic anemia, and, if left untreated, to death. Subclinical vitamin B12 deficiency (usually defined as a total serum B12 of <200 pmol/L) presents asymptomatically or with rather subtle generic symptoms that oftentimes are mistakenly ascribed to unrelated disorders. Numerous studies have now established that serum vitamin B12 has limited diagnostic value as a stand-alone marker. Low serum levels of vitamin B12 not always represent deficiency, and likewise, severe functional deficiency of the micronutrient has been documented in the presence of normal and even high levels of serum vitamin B12. This review discusses the usefulness and limitations of current biomarkers of B12 status in newborn screening, infant and adult diagnostics, the algorithms utilized to diagnose B12 deficiency and unusual findings of vitamin B12 status in various human disorders.

Vitamin B12 status in older adults living in Ontario long-term care homes: prevalence and incidence of deficiency with supplementation as a protective factor

Vitamin B12 (B12) deficiency, although treatable, impacts up to 43% of community-living older adults; long-term care (LTC) residents may be at greater risk. Recommendations for screening require further evidence on prevalence and incidence in LTC. Small, ungeneralizable samples provide a limited perspective on these issues. The purposes of this study were to report prevalence of B12 deficiency at admission to LTC, incidence 1 year post-admission, and identify subgroups with differential risk. This multi-site (8), retrospective prevalence study used random proportionate sampling of resident charts (n = 412). Data at admission extracted included demographics, B12 status, B12 supplementation, medications, diagnoses, functional independence, cognitive performance, and nutrition. Prevalence at admission of B12 deficiency (<156 pmol/L) was 13.8%; 47.6% had normal B12 (>300 pmol/L). One year post-admission incidence was 4%. Better B12 status was significantly associated with supplementation use prior to LTC admission. Other characteristics were not associated with status. This work provides a better estimate of B12 deficiency prevalence than previously available for LTC, upon which to base protocols and policy. Prospective studies are needed to establish treatment efficacy and effect on health related outcomes.

Risk of dementia in elderly patients with the use of proton pump inhibitors

Drugs that modify the risk of dementia in the elderly are of potential interest for dementia prevention. Proton pump inhibitors (PPIs) are widely used to reduce gastric acid production, but information on the risk of dementia is lacking. We assessed association between the use of PPIs and the risk of dementia in elderly people. Data were derived from a longitudinal, multicenter cohort study in elderly primary care patients, the German Study on Aging, Cognition and Dementia in Primary Care Patients (AgeCoDe), including 3,327 community-dwelling persons aged ≥ 75 years. From follow-up 1 to follow-up 4 (follow-up interval 18 months), we identified a total of 431 patients with incident any dementia, including 260 patients with Alzheimer's disease. We used time-dependent Cox regression to estimate hazard ratios of incident any dementia and Alzheimer's disease. Potential confounders included in the analysis comprised age, sex, education, the Apolipoprotein E4 (ApoE4) allele status, polypharmacy, and the comorbidities depression, diabetes, ischemic heart disease, and stroke. Patients receiving PPI medication had a significantly increased risk of any dementia [Hazard ratio (HR) 1.38, 95% confidence interval (CI) 1.04-1.83] and Alzheimer's disease (HR 1.44, 95% CI 1.01-2.06) compared with nonusers. Due to the major burden of dementia on public health and the lack of curative medication, this finding is of high interest to research on dementia and provides indication for dementia prevention.

[Vitamin B12 deficiency in the elderly]

The prevalence of vitamin B12 deficiency increases with age. Patients with dementia and spouses of patients with dementia are at special risk for the development of vitamin B12 deficiency. In a normal diet this vitamin is present only in animal source foods; therefore, vegans frequently develop vitamin B12 deficiency if not using supplements or foods fortified with cobalamin. Apart from dementia, most of these manifestations are completely reversible under correct therapy; therefore it is crucial to identify and to treat even atypical presentations of vitamin B12 deficiency as early as possible. This article deals with the physiology and pathophysiology of vitamin B12 metabolism. A practice-oriented algorithm which also considers health economic aspects for a rational laboratory diagnosis of vitamin B12 deficiency is presented. In cases with severe neurological symptoms, therapy should be parenteral, especially initially. For parenteral treatment, hydroxocobalamin is the drug of choice.