If high folic acid aggravates vitamin B12 deficiency what should be done about it?

Relationship of Vitamin B12 Levels With Different Degrees of Obesity and Diabetes Mellitus

INTRODUCTION

The potential influence of micronutrient status on obesity should be considered. Nevertheless, previous research examining the relationship between serum vitamin B12 levels and obesity has yielded inconclusive results. The objective of this study was to investigate the associations between serum vitamin B12 levels and obesity and diabetes mellitus (DM) in a population consisting of persons aged 18 years and older.

METHODS

A retrospective case-control research was undertaken on a sample of 1024 individuals aged 18 years and older who were admitted to a tertiary healthcare facility (Recep Tayyip Erdoğan University Education and Research Hospital, Rize) for either overweight-related issues or routine check-ups. The primary objective of this study was to assess the B12 levels of these individuals. The researcher recorded the body mass index (BMI) and history of DM for all subjects.

RESULTS

The study comprised a total of 1024 participants, consisting of 834 females and 190 males. The levels of vitamin B12 in women were found to be 308±113 pg/mL, while in men, the levels were 304±125 pg/mL. The results of the statistical analysis indicate that there is no statistically significant disparity in vitamin B12 levels between males and females (p=0.748). There was a statistically significant positive correlation seen between age and B12 levels; however, the magnitude of this connection was found to be minor (p=0.000, R2=0.017). The study findings revealed that out of the 1,024 individuals evaluated, 179 individuals exhibited B12 levels below 200, while 845 individuals displayed vitamin B12 levels above 200. The study findings indicated that there was no statistically significant distinction observed in the occurrence of obesity and DM in relation to vitamin B12 deficiency (p = 0.938, p = 0.08, respectively).

CONCLUSION

The results of this study offer empirical support for the notion that there is no significant difference in vitamin B12 levels between individuals afflicted with obesity and diabetes and those unaffected by these conditions. Interestingly, it was shown that serum B12 levels exhibited a modest increase with advancing age.

Elderly Patient With Hematological and Neurological Manifestations of Undetermined Origin: A Diagnostic Dilemma of Pernicious Anemia

Pernicious anemia (PA) is a chronic inflammatory destructive disease of parietal cells of predominantly the gastric fundus. It leads to vitamin B12 (cobalamin) deficiency secondary to a deficiency of intrinsic factors. Despite the medical advances nowadays, diagnosing PA can be challenging. This report highlights a neglected case of PA with ongoing subacute combined degeneration of the cord (SCDS) in an elderly patient. An 86-year-old lady with multiple comorbidities was referred to the hematology outpatient clinic for refractory anemia for the last two months. At first, her general practitioner (GP) treated her as a case of anemia of chronic disease but without improvement. Her initial clinical assessment revealed hematological and neurological manifestations of undetermined origin, including global weakness, hypertonia, and hyperreflexia with sensory deficits, especially in the lower limbs. On investigation, the hemoglobin level was 9 g/dL with high indirect bilirubinemia and lactate dehydrogenase (LDH). Despite the normal mean corpuscular volume (MCV) and peripheral blood smear, positive anti-intrinsic factor and parietal cell antibodies tests were subsequently reported, suggesting the diagnosis of PA. As a result, she was commenced on lifelong parenteral cobalamin replacement therapy. On follow-up visits of three months, she illustrated a clinical recovery in fatigability and paranesthesia. As expected, the laboratory parameters revealed a rise in hemoglobin level (11 g/dL) and serum vitamin B12 (418 pg/mL). However, she remained bedridden with spastic limbs. Clinicians should have a high index of suspicion since PA is a rare disease with variable clinical presentations. The optimal management approach is by a multidisciplinary care team of internists, neurologists, gastroenterologists, and hematologists.

A Pilot Study on the Prevalence of Micronutrient Imbalances in a Dutch General Population Cohort and the Effects of a Digital Lifestyle Program

Maintaining an adequate micronutrient status can be achieved by following a complete, diverse diet. Yet, food trends in Western countries show suboptimal consumption of healthy nutrients. In this study, we explored the prevalence of vitamin and mineral imbalances in a general population cohort of Dutch adults and evaluated the effect of a digital lifestyle program on the nutritional status and nutrition health behaviors of these individuals. A micronutrient panel was measured in 348 participants, alongside a dietary assessment. One hundred users subsequently underwent a remeasurement. We identified at least one nutritional imbalance in 301 individuals (86.5%). A total of 80% improved and normalized B6, 67% improved folate, 70% improved B12, and 86% improved vitamin D. Iron abnormalities were corrected in 75% of the participants. In conclusion, this study found that micronutrient deficiencies of easily obtainable vitamins through diet or supplementation such as B vitamins and vitamin D were more prevalent than expected in a Dutch population. This can partly be explained by insufficient consumption of food groups rich in B vitamins. Our preliminary results in those remeasured after a digitally enabled lifestyle intervention show these imbalances can be corrected with adequate behavioral support complemented with supplementation where needed.

Review of Vitamin B12 deficiency in pregnancy: a diagnosis not to miss as veganism and vegetarianism become more prevalent

Vegetarianism and veganism are increasingly popular. The Food Standards Agency, biennial Food and You Survey of adults aged 16 years and over living in the UK, found that between 2012 and 2018 the proportion of people who reported never consuming dairy products had increased from 2% to 5%. However, veganism risks development of vitamin B12 deficiency as it is not available from plant sources. Moreover, its impact may be slow to be detected because body stores of vitamin B12 can last years. There is currently no published guidance on antenatal diagnosis and management of vitamin B12 deficiency. This paper reviews the metabolism, diagnosis and treatment of vitamin B12 in pregnancy. It concludes that national screening policymakers should consider introducing screening for B12 deficiency into the Antenatal and Newborn Screening Programmes for mothers and their infants if at risk of vitamin B12 deficiency. In the interim, national policy should be developed for prophylactic vitamin B12 supplementation in high-risk groups around the time of pregnancy.

Energy Expenditure and Changes in Body Composition during Submarine Deployment-An Observational Study "DasBoost 2-2017"

The present study was designed to objectively assess the effects of 3-months submarine deployment on behavioural and metabolic determinants of metabolic health. In 13 healthy, non-obese volunteers, we using stable isotope dilution, and plasma and urinary biochemistry to characterize metabolic health before and after a 3-month submarine deployment. Volunteers worked in 6-h shifts. After deployment, we observed reduced fat-free mass (mean ± SD, -4.1 ± 3.3 kg, p = 0.003) and increased adiposity (21.9 ± 3.2% fat mass to 24.4 ± 4.7%, p = 0.01). Changes in fat-free mass were positively associated with physical activity (+0.8 kg per 0.1 increase in PAL, p = 0.03). The average physical activity level was 1.64 ± 0.26 and total energy expenditure during deployment was 2937 ± 498 kcal/d, while energy intake was 3158 ± 786 kcal/d. Fasting glucose (p = 0.03), and triglycerides (p = 0.01) declined, whereas fasting free fatty acids increased (p = 0.04). Plasma vitamin D and B12 concentrations decreased (-14%, p = 0.04, and -44%, p = 0.001, respectively), and plasma calcium, and magnesium increased (+51%, p = 0.01, and +5%, p = 0.02). Haemoglobin was unchanged, but haematocrit decreased (-2.2 ± 2.1%, p = 0.005). In conclusion, submarine deployment impairs fat-free mass maintenance and promotes adiposity. High physical activity may prevent the decline in fat-free mass. Our study confirms the need to counteract Vitamin D and B12 deficiencies, and suggests impairments in erythrocyte metabolism.

Energy Expenditure and Changes in Body Composition during Submarine Deployment-An Observational Study "DasBoost 2-2017"

The present study was designed to objectively assess the effects of 3-months submarine deployment on behavioural and metabolic determinants of metabolic health. In 13 healthy, non-obese volunteers, we using stable isotope dilution, and plasma and urinary biochemistry to characterize metabolic health before and after a 3-month submarine deployment. Volunteers worked in 6-h shifts. After deployment, we observed reduced fat-free mass (mean ± SD, −4.1 ± 3.3 kg, p = 0.003) and increased adiposity (21.9 ± 3.2% fat mass to 24.4 ± 4.7%, p = 0.01). Changes in fat-free mass were positively associated with physical activity (+0.8 kg per 0.1 increase in PAL, p = 0.03). The average physical activity level was 1.64 ± 0.26 and total energy expenditure during deployment was 2937 ± 498 kcal/d, while energy intake was 3158 ± 786 kcal/d. Fasting glucose (p = 0.03), and triglycerides (p = 0.01) declined, whereas fasting free fatty acids increased (p = 0.04). Plasma vitamin D and B12 concentrations decreased (−14%, p = 0.04, and −44%, p = 0.001, respectively), and plasma calcium, and magnesium increased (+51%, p = 0.01, and +5%, p = 0.02). Haemoglobin was unchanged, but haematocrit decreased (−2.2 ± 2.1%, p = 0.005). In conclusion, submarine deployment impairs fat-free mass maintenance and promotes adiposity. High physical activity may prevent the decline in fat-free mass. Our study confirms the need to counteract Vitamin D and B12 deficiencies, and suggests impairments in erythrocyte metabolism.

Effects of altered maternal folate and vitamin B12 on neurobehavioral outcomes in F1 male mice

Maternal folate and vitamin B₁₂ status during pregnancy may influence development of central nervous system (CNS) in the offspring. Very little attention has been paid to understand the combined effects of both the vitamins during pregnancy. The present study was designed to evaluate the biochemical and behavioral outcomes following alterations in folate and vitamin B₁₂ levels in C57BL/6 mice. The female mice were fed with different combinations of folate and vitamin B₁₂ whereas; males were fed with normal diet for 4 weeks. The mice were mated and the pregnant mice received the same diets as before pregnancy. The F1 male mice were further continued on maternal diet for 6 weeks following neurobehavioral and biochemical assessment. The body weight of the F1 male mice was significantly decreased in the mice that received folate and vitamin B₁₂ deficient diet. Altered cognitive functions were observed in the folate and B₁₂ deficient F1 male mice as assessed by Morris water maze and novel object recognition tests. Spontaneous locomotor activity was decreased in F1 male mice fed with folate and B₁₂ deficient diets. Elevated homocysteine levels and decreased hydrogen sulfide levels were also observed in the brain of F1 male mice on folate and B₁₂ deficient diets. However, GSH and GSSG levels were increased in the brain of the animals supplemented with folate deficient diet with different combinations of B₁₂. The study suggests that exposure of female mice to folate and vitamin B₁₂ deficiency during pregnancy effects in-utero development of fetus, which further leads to behavioral anomalies in adult life and is sufficient to cause impaired cognitive behavior in the subsequent generation. Thus, elucidating the role and importance of maternal dietary folate and B₁₂ ratio during pregnancy.

Cobalamin and Folate Status among Breastfed Infants in Bhaktapur, Nepal

Cobalamin and folate are crucial micronutrients during infancy and they are required for growth and cognitive development. Due to the monotonous and predominantly vegetarian-based complementary feeding and poor maternal micronutrient status, infants from low- and middle-income countries are susceptible to cobalamin deficiency. However, data on plasma cobalamin and folate and the functional markers methylmalonic acid and total homocysteine from breastfed infants in Nepal are still needed. We collected plasma samples from 316 6–11-month-old breastfed infants with a length-for-age of less than minus one z-score and analyzed blood for plasma folate, cobalamin, methylmalonic acid and total homocysteine concentrations. Cobalamin deficiency (plasma cobalamin <148 pmol/L) was found among 11%, whereas 24% of the infants had plasma cobalamin concentrations between 148–221 pmol/L. Elevated total homocysteine (>10 µmol/L) and methylmalonic acid (>0.28 µmol/L) indicating functional cobalamin deficiency were found among 53% and 75% of the infants, respectively. Based on a combined indicator of cobalamin status, 58% were found to have low cobalamin status. However, folate deficiency (<10 nmol/L) was not found as the lowest value of plasma folate was 20.7 nmol/L. It is important to examine the extent to which poor cobalamin status during infancy has immediate or long-term consequences.

Nutrition in the Very Old

The population of older adults aged 85 years and over (the very old) is growing rapidly in many societies because of increases in life expectancy and reduced mortality at older ages. In 2016, 27.3 million very old adults were living in the European Union, and in the UK, 2.4% of the population (1.6 million) were aged 85 and over. Very old age is associated with increased risks of malnutrition, multimorbidity, and disability. Diet (nutrition) is a modifiable risk factor for multiple age-related conditions, including sarcopenia and functional decline. Dietary characteristics and nutrient intakes of the very old have been investigated in several European studies of ageing to better understand their nutritional requirements, which may differ from those in the young-old. However, there is a major gap in regard to evidence for the role of dietary patterns, protein, vitamin D and other nutrients for the maintenance of physical and cognitive functioning in later life. The Newcastle 85+ Study, UK and the Life and Living in Advanced Age, New Zealand are unique studies involving single birth cohorts which aim to assess health trajectories in very old adults and their biological, social and environmental influences, including nutrition. In this review, we have updated the latest findings in nutritional epidemiology with results from these studies, concentrating on the diet-physical functioning relationship.

Hair Mercury Level is Associated with Anemia and Micronutrient Status in Children Living Near Artisanal and Small-Scale Gold Mining in the Peruvian Amazon

Anemia has been widely studied in global health contexts because of severe nutritional deficiency, and more recently, inflammatory status, but chemical exposures are rarely considered. Until recently, "anemia" was used synonymously with "iron deficiency anemia (IDA)" in global health settings. However, only 50% of anemia cases worldwide are IDA. Environmental toxicology studies of anemia risk have generally focused on populations in developed countries, albeit with high exposure to environmental toxicants, such as lead or cadmium. In the developing world, toxicant exposures commonly coexist with other risk factors for anemia. In particular, artisanal and small-scale gold mining (ASGM) communities are at risk for dietary methylmercury exposure through contaminated fish consumption, and for anemia due to food insecurity and infectious and chronic diseases. Here, we report analysis of total hair mercury content, hemoglobin, and serum micronutrient levels in children < 12 years of age (N = 83) near ASGM in the Peruvian Amazon. Forty-nine percent (N = 29/59) of those aged < 5 years were anemic (< 11 g/dL) and 52% (N = 12/23) of those aged 5-11 years (< 11.5 g/dL). Few children were stunted, wasted, or micronutrient deficient. Median total hair mercury was 1.18 μg/g (range: 0.06-9.70 μg/g). We found an inverse association between total mercury and hemoglobin (β = -0.12 g/dL, P = 0.06) that persisted (β = -0.14 g/dL, P = 0.04) after adjusting for age, sex, anthropometrics, and vitamin B₁₂ in multivariate regression. This study provides preliminary evidence that methylmercury exposure is associated with anemia, which is especially relevant to children living near ASGM.

Exploring Vitamin B12 Deficiency in Sleeve Gastrectomy from a Histological Study of a Cadaveric Stomach and Ileum

INTRODUCTION

Vitamin B12 deficiency is more commonly found among patients who have undergone Roux-en-Y gastric bypass (RYGB) as compared to those with post-sleeve gastrectomies (SG). The major difference between SG and RYGB is that the latter greatly bypasses the stomach whereas the former simply reduces the gastric volume.

PURPOSE

The aim of this article was to study the stomach and the distal ileum histologically in a cadaver with SG to explain the higher rate of incidences of vitamin B12 deficiency seen in patients post-RYGB relative to patients post-SG. Since the stomach is the major variable in these two procedures, we hypothesize that it has the ability to regenerate and increase its surface area to compensate for the loss of its volume in SG patients.

MATERIAL AND METHODS

Tissue biopsies and hematoxylin and eosin stains were performed from various anatomical locations of the GI tract, specifically the gastric fundus, body, and antrum, and from the distal ileum of the small intestine of a cadaver with SG and another without SG (control).

RESULTS

Compared with the control, the SG cadaver's gastric tissue biopsies were significant for chronic gastritis and hypertrophy of the muscularis externa layer. More importantly, parietal cell hyperplasia and deeper mucosal glands were also noted in the SG cadaver supporting the hypothesis.

CONCLUSIONS

The compensatory role of an intact stomach, given its ability to regenerate parietal cells and increase its numbers in the gastric fundus and body, can be better appreciated in a gastric-sparing procedure such as SG versus RYGB in terms of limiting vitamin B12 deficiencies.

Role of folic acid in nitric oxide bioavailability and vascular endothelial function

Folic acid is a member of the B-vitamin family and is essential for amino acid metabolism. Adequate intake of folic acid is vital for metabolism, cellular homeostasis, and DNA synthesis. Since the initial discovery of folic acid in the 1940s, folate deficiency has been implicated in numerous disease states, primarily those associated with neural tube defects in utero and neurological degeneration later in life. However, in the past decade, epidemiological studies have identified an inverse relation between both folic acid intake and blood folate concentration and cardiovascular health. This association inspired a number of clinical studies that suggested that folic acid supplementation could reverse endothelial dysfunction in patients with cardiovascular disease (CVD). Recently, in vitro and in vivo studies have begun to elucidate the mechanism(s) through which folic acid improves vascular endothelial function. These studies, which are the focus of this review, suggest that folic acid and its active metabolite 5-methyl tetrahydrofolate improve nitric oxide (NO) bioavailability by increasing endothelial NO synthase coupling and NO production as well as by directly scavenging superoxide radicals. By improving NO bioavailability, folic acid may protect or improve endothelial function, thereby preventing or reversing the progression of CVD in those with overt disease or elevated CVD risk.

Intakes of Folate and Vitamin B12 and Biomarkers of Status in the Very Old: The Newcastle 85+ Study

Very old adults are at increased risk of folate and vitamin B12 deficiencies due to reduced food intake and gastrointestinal absorption. The main aim was to determine the association between folate and vitamin B12 intake from total diets and food groups, and status. Folate or vitamin B12 intakes (2 × 24 h multiple pass recalls) and red blood cell (RBC) folate or plasma vitamin B12 (chemiluminescence immunoassays) concentrations were available at baseline for 731 participants aged 85 from the Newcastle 85+ Study (North-East England). Generalized additive and binary logistic models estimated the associations between folate and vitamin B12 intakes from total diets and food groups, and RBC folate and plasma B12. Folate intake from total diets and cereal and cereal products was strongly associated with RBC folate (p < 0.001). Total vitamin B12 intake was weakly associated with plasma vitamin B12 (p = 0.054) but those with higher intakes from total diets or meat and meat products were less likely to have deficient status. Women homozygous for the FUT2 G allele had higher concentrations of plasma vitamin B12. Cereals and cereal products are a very important source of folate in the very old. Higher intakes of folate and vitamin B12 lower the risk of "inadequate" status.

Folate and neural tube defects: The role of supplements and food fortification

Periconceptional folic acid significantly reduces the risk of neural tube defects. It is difficult to achieve optimal levels of folate by diet alone, even with fortification of flour, especially because flour consumption in Canada is slightly decreasing. Intermittent concerns have been raised concerning possible deleterious effects of folate supplementation, including the masking of symptoms of vitamin B12 deficiency and an association with cancer, especially colorectal cancer. Both concerns have been disproved. The Canadian Paediatric Society endorses the following steps to enhance folate intake in women of child-bearing age: encouraging the consumption of folate-rich foods such as leafy vegetables, increasing the level of folate food fortification, taking a supplement containing folate and B12, and providing free folate supplementation to disadvantaged women of child-bearing age. These recommendations are consistent with those of the Society of Obstetricians and Gynaecologists of Canada.

Micronutrients in pregnancy in low- and middle-income countries

Pregnancy is one of the more important periods in life when increased micronutrients, and macronutrients are most needed by the body; both for the health and well-being of the mother and for the growing foetus and newborn child. This brief review aims to identify the micronutrients (vitamins and minerals) likely to be deficient in women of reproductive age in Low- and Middle-Income Countries (LMIC), especially during pregnancy, and the impact of such deficiencies. A global prevalence of some two billion people at risk of micronutrient deficiencies, and multiple micronutrient deficiencies of many pregnant women in LMIC underline the urgency to establishing the optimal recommendations, including for delivery. It has long been recognized that adequate iron is important for best reproductive outcomes, including gestational cognitive development. Similarly, iodine and calcium have been recognized for their roles in development of the foetus/neonate. Less clear effects of deficiencies of zinc, copper, magnesium and selenium have been reported. Folate sufficiency periconceptionally is recognized both by the practice of providing folic acid in antenatal iron/folic acid supplementation and by increasing numbers of countries fortifying flours with folic acid. Other vitamins likely to be important include vitamins B12, D and A with the water-soluble vitamins generally less likely to be a problem. Epigenetic influences and the likely influence of micronutrient deficiencies on foetal origins of adult chronic diseases are currently being clarified. Micronutrients may have other more subtle, unrecognized effects. The necessity for improved diets and health and sanitation are consistently recommended, although these are not always available to many of the world's pregnant women. Consequently, supplementation programmes, fortification of staples and condiments, and nutrition and health support need to be scaled-up, supported by social and cultural measures. Because of the life-long influences on reproductive outcomes, including inter-generational ones, both clinical and public health measures need to ensure adequate micronutrient intakes during pregnancy, but also during adolescence, the first few years of life, and during lactation. Many antenatal programmes are not currently achieving this. We aim to address the need for micronutrients during pregnancy, the importance of micronutrient deficiencies during gestation and before, and propose the scaling-up of clinical and public health approaches that achieve healthier pregnancies and improved pregnancy outcomes.

Effectiveness of the National Program of Complementary Feeding for older adults in Chile on vitamin B12 status in older adults; secondary outcome analysis from the CENEX Study (ISRCTN48153354)

BACKGROUND

Older people are at increased risk of vitamin B12 deficiency and the provision of fortified foods may be an effective way to ensure good vitamin B12 status in later life.

AIM

To evaluate the effectiveness of a vitamin B12 fortified food provided by a national program of complementary food for older people on plasma vitamin B12 levels.

SUBJECTS AND METHODS

A random sub-sample of 351 subjects aged 65-67 y from a large cluster randomised controlled trial provided blood samples at baseline and after 24 months of intervention. The intervention arm (10 clusters 186 participants) received a vitamin B12 fortified food designed to deliver 1.4 μg/day, while the control arm did not receive complementary food (10 clusters, 165 participants). Serum vitamin B12 and folate levels determined by radioimmunoassay were used to estimate the effect of intervention on vitamin B12 levels, adjusting for baseline levels and sex.

RESULTS

Attrition at 24 months was 16.7% and 23.6% in the intervention and control arms respectively (p = 0.07). Over 24 months of intervention, mean (95% CI) serum vitamin B12 decreased from 392 (359-425) pmol/dL to 357 (300-414) pmol/dL (p < 0.07) in the intervention arm and from 395 (350-440) pmol/dL to 351 (308-395) pmol/dL in the control arm. There was no significant effect of the intervention on folate status.

DISCUSSION

Our findings suggest that foods fortified with 1.4 μg/daily vitamin B12 as provided by Chile's national programme for older people are insufficient to ensure adequate vitamin B12 levels in this population. Chile has a long and successful experience with nutrition intervention programs; however, the country's changing demographic and nutritional profiles require a constant adjustment of the programs.

A vitamin/nutriceutical formulation improves memory and cognitive performance in community-dwelling adults without dementia

Adults of both genders without dementia consumed a nutriceutical formulation ("NF," consisting of folic acid, B12, Vitamin E, S-adenosylmethionine, N-acetyl cysteine and Acetyl-L-carnitine), previously shown to improve cognitive performance in Alzheimer's disease, or placebo. Participants receiving NF but not placebo improved statistically and clinically in the California Verbal Learning Test II and the Trail-Making Test. Both groups improved further during a 3-month open-label extension. Additional individuals displayed identical improvement during a separate 6-month open-label trial. Performance declined to baseline following withdrawal of NF, and statistically improved when participants resumed taking NF. Additional participants receiving NF but not placebo demonstrated improvement within 2 weeks in Trail-making and Digit-Memory tests; both groups improved in a 2-week open-label extension. An increased percentage of participants > or = 74 years of age did not show improvement with NF, which may relate to age-related difficulties in adsorption and/or basal nutritional deficiencies, or age-related cognitive decline during the course of this study. These findings support the benefit of nutritional supplements for cognitive performance and suggest that additional supplementation may be required for the elderly.