Vitamin B12 deficiency - A 21st century perspective

Valeriana jatamansi jones improves depressive behavior in CUMS mice by modulating vitamin B12-related ileal homeostasis

ETHNOPHARMACOLOGICAL RELEVANCE

Valeriana jatamansi Jones (V. jatamansi) is a traditional Chinese medicine (TCM). It was recorded in Diannan Bencao, Compendium of Materia Medica and some local medical books and was described as useful in treating insomnia, distraction, poor mental health, vomiting and diarrhea.

AIM OF THE STUDY

To investigate whether the antidepressant effect of V. jatamansi may operate through modulating vitamin B12-related ileal homeostasis using a chronic unpredictable mild stress (CUMS) mouse model.

MATERIALS AND METHODS

A CUMS-induced depression model was established in mice for five weeks, after which V. jatamansi extracts were administered for three weeks. At week eight, the forced swimming test and novelty-suppressed feeding test were conducted. H&E staining assessed ileal pathology, while 16S rDNA sequencing analyzed changes in ileal microbiota. Additionally, B12 in serum, cubilin (CUBN) and amnionless (AMN) in ileal tissue, methionine synthase (MS) and homocysteine (Hcy) in the hippocampus were measured using ELISA, and the correlations between them and ileal microbiota were explored.

RESULTS

Mice in the model group exhibited significant depressive behavior. However, after treatment with V. jatamansi, immobility time and feeding latency were improved. H&E staining demonstrated the repairing effect of V. jatamansi on the ileum regarding tissue damage. The alpha and beta diversity of the ileal microbiota were regulated and converged to the normal group. Additionally, V. jatamansi modulated B12, CUBN, AMN, MS, and Hcy levels. Correlation analysis showed that there are certain correlations between a variety of microorganisms and B12-related factors.

CONCLUSION

These findings suggest that the mechanism of V. jatamansi in treating depression may be through repairing depression-associated intestinal damage. This repair process may affect the intestinal absorption and microbial production of B12. By reversing the reduction of serum B12, V. jatamansi ultimately reduces the infiltration of Hcy into the CNS.

Effects of a Novel Dispersible Supplement Containing 2500 IU of Vitamin D and 1000 µg of B12 in Restoring Vitamin D and B12 Insufficiency: A Multicenter, Randomized Controlled Trial

BACKGROUND/OBJECTIVES

Vitamins D and B12 play a crucial role in maintaining bone health, immune function, and neurological integrity. Combined deficiencies in these vitamins can lead to severe health consequences. Current treatment approaches, such as dietary changes and single-vitamin supplementation, often fail to address these deficiencies comprehensively. This study evaluates the effectiveness of concurrent vitamin D and B12 supplementation to correct these insufficiencies.

METHODS

A prospective, multicenter, randomized controlled trial was conducted in Greece from October 2024 to December 2024. Participants aged 20 to 80 years, with insufficient levels of 25-hydroxyvitamin D (serum < 20 ng/mL) and B12 (serum < 250 ng/L), were eligible for inclusion.

RESULTS

A total of 124 patients were randomized into three groups: one receiving vitamins B12 and D in a single supplement (2500 IU + 1000 mcg), one receiving separate doses of each vitamin (2000 IU + 1000 mcg), and a control group receiving no supplementation. The results demonstrated a significant increase in B12 and 25-hydroxyvitamin D levels among the supplemented groups. Particularly, participants in the combined supplementation group showed higher average serum levels of both vitamins. By the end of this study, 37.1% of those in the combined supplement group achieved adequate vitamin levels, compared to 29.4% in the separate supplementation group.

CONCLUSIONS

In conclusion, combined supplementation may improve patient adherence and compliance, leading to better health outcomes for individuals with combined vitamins D and B12 deficiencies.

Effect of inulin on structural, physicochemical, and in vitro gastrointestinal tract release properties of core-shell hydrogel beads as a delivery system for vitamin B12

In this study, core-shell hydrogel beads were developed as a controlled-release delivery system for vitamin B12. Vitamin B12-loaded microgels (MG) were prepared using gellan gum (GG). Core-shell hydrogel beads were produced by incorporating MG into pea protein isolate (PPI) and sodium alginate (AL) matrix filled/coated with different concentrations (0 %, 1 %, 3 %, 5 %, and 10 %) of inulin (IN). Based on XRD analysis, MG was successfully incorporated into core-shell hydrogel beads. In FE-SEM and FT-IR analyses, the smoother surface and denser structure of the beads were observed as IN concentration increased due to hydrogen bonds between IN and the beads. The encapsulation efficiency increased from 68.64 % to 82.36 % as IN concentration increased from 0 % to 10 %, respectively. After exposure to simulated oral and gastric conditions, core-shell hydrogel beads exhibited a lower cumulative release than MG, and a more sustained release was observed as IN concentration increased in simulated intestinal conditions.

The epidemiologic associations of food availability with national incidence and disability rates of idiopathic pediatric epilepsy

BACKGROUND

The epidemiology of idiopathic pediatric epilepsy globally continues to be defined. To date there has been no evaluation of how national food availability may associate with the incidence and disability-adjusted life years (DALYs) lost from this condition. Correspondingly, the aim of this study was to define if such associations exist.

METHODS

Incidence and DALY rates of pediatric patients with idiopathic epilepsy were abstracted by country from the Global Burden of Disease database. Data regarding food availability parameters were identified and abstracted from the Food Systems Dashboard database. Associations were tested using univariate and multivariate regression analyses.

RESULTS

There were sufficient data in a total of 175 countries. Mean incidence rate and DALYs lost across these countries were 62.3 per 100,000 and 189.2 per 100,000 respectively. Across all countries, higher incidence rates of idiopathic pediatric epilepsy were statistically associated with lower supply of nuts and seeds (P = 0.04), and higher prevalence of moderate or severe food insecurity (P = 0.03). Similarly, higher DALYs lost due to idiopathic pediatric epilepsy were statistically associated with lower supply of fish (P = 0.03), higher supply of starchy roots (P = 0.03), and higher prevalence of moderate or severe food insecurity (P < 0.01). When categorizing countries based on income-status, there was a decrease and divergence in significant associations found between high income versus low-middle income countries.

CONCLUSIONS

There are many possible novel associations between national food availability and the incidence rate and DALYs lost due to idiopathic pediatric epilepsy across the world, which may be more pronounced and divergent based on income.

Micronutrient Status in Patients with Severe Obesity Before and After Laparoscopic Sleeve Gastrectomy

Background: Micronutrient deficiencies (MNDs) are commonly reported after bariatric and metabolic surgery, including laparoscopic sleeve gastrectomy (LSG). Nevertheless, the micronutrient status changes over time and the influence of sex or initial body mass index (BMI) on these changes are less explored. This study aims to investigate the changes in micronutrient levels at 6 and 12 months after LSG and the potential influence of sex or baseline BMI (≥40 kg/m2) on these changes in patients submitted to LSG. Additionally, the frequency of MNDs before and at 12 months after the procedure was investigated. Materials and methods: Fifty patients with obesity underwent LSG and were assessed anthropometrically and nutritionally at baseline and at 6 and 12 months, respectively, after LSG. The changes in micronutrients levels over time were tested by a linear mixed model. Results: Vitamin B12 and vitamin D [25(OH)D] did not change significantly, while iron (p < 0.001), calcium (p = 0.01), and parathormone (p < 0.001) differed significantly from baseline to 12 months after LSG. Ferritin significantly decreased from baseline to 6 months and 12 months after LSG (LS-means, 95% CI: 202 [163, 240] vs. 160 [130, 191] vs. 150 [115, 185]). Sex or initial severe obesity (BMI ≥ 40 kg/m2) exhibited significant modifying effects for 25(OH)D and calcium, respectively. The 25(OH)D levels increased significantly in men, but not in women, while the calcium plasma concentration changed significantly only in patients with initial severe obesity. No significant changes over time were found for MNDs' frequency (p > 0.05). The most consistent deficiency frequency was observed for 25(OH)D both before and after LSG. Conclusions: Overall, our findings revealed changes in micronutrient status across the follow-up period, except for vitamin B12. Variations in 25(OH)D levels were reported exclusively in men, suggesting that they depend on sex. The calcium plasma concentration showed significant changes exclusively in patients with BMI ≥ 40 kg/m2. MNDs' frequency was not significantly altered during the study follow-up. Our results reinforce the need for developing national dietary guidelines tailored for Romanian patients following LSG.

Parkinson's disease and vitamins: a focus on vitamin B12

Parkinson's disease (PD) has been linked to a vast array of vitamins among which vitamin B12 (Vit B12) is the most relevant and often investigated specially in the context of intrajejunal levodopa infusion therapy. Vit B12 deficiency, itself, has been reported to cause acute parkinsonism. Nevertheless, concrete mechanisms through which B12 deficiency interacts with PD in terms of pathophysiology, clinical manifestation and progression remains unclear. Recent studies have suggested that Vit B12 deficiency along with the induced hyperhomocysteinemia are correlated with specific PD phenotypes characterized with early postural instability and falls and more rapid motor progression, cognitive impairment, visual hallucinations and autonomic dysfunction. Specific clinical features such as polyneuropathy have also been linked to Vit B12 deficiency specifically in context of intrajejunal levodopa therapy. In this review, we explore the link between Vit B12 and PD in terms of physiopathology regarding dysfunctional neural pathways, neuropathological processes as well as reviewing the major clinical traits of Vit B12 deficiency in PD and Levodopa-mediated neuropathy. Finally, we provide an overview of the therapeutic effect of Vit B12 supplementation in PD and posit a practical guideline for Vit B12 testing and supplementation.

An Unusual Case of Hemolytic Anemia: A Case Report

Vitamin B12 deficiency is a potentially severe condition with clinical manifestations ranging from nonspecific symptoms, such as asthenia and glossitis, to severe hematological problems, including pancytopenia and megaloblastic anemia. One of the rare phenomena associated with this condition is pseudo-thrombotic microangiopathy (pseudo-TMA), which can mimic diseases such as thrombotic thrombocytopenic purpura (TTP), leading to possible misdiagnosis and inappropriate treatment. In this article, we present the case of a 62-year-old man with a history of intravenous drug use, untreated hepatitis C, smoking, and alcoholism. The patient was admitted to the emergency department with progressive asthenia, fever, and disorientation. Laboratory findings revealed severe pancytopenia, schistocytes on the peripheral blood smear, and elevated lactate dehydrogenase levels, suggesting a microangiopathic condition. After investigation, a severe deficiency of vitamin B12 and folate was identified, and the condition was diagnosed as pseudo-TMA secondary to this deficiency. The treatment consisted of intramuscular vitamin B12 administration, resulting in the gradual normalization of the blood count and resolution of symptoms. This case highlights the importance of considering vitamin B12 deficiency in the differential diagnosis of patients with hemolytic anemia and thrombocytopenia, avoiding unnecessary interventions, such as plasmapheresis, and allowing for a quick and effective recovery with appropriate vitamin replacement.

Vitamin B12 deficiency in long-term metformin treated type 2 diabetic patients: Prevalence and risk factors in a Tunisian population

Objectives: To determine the prevalence of vitamin B12 deficiency in a Tunisian population with type 2 diabetes (T2D) on metformin treatment for more than three years and to identify its risk factors. Methods: This is a cross-sectional study conducted on 257 patients with T2D treated with metformin for at least three years. Patients were divided into two groups according to their vitamin B12 status. Low vitamin B12 was defined as ≤ 203 pg/mL. Results: The mean age of the patients was 59.8  ±  7.9 years. The mean duration of metformin use was 10.2  ±  5.2 years. The mean vitamin B12 level was 294.9  ±  156.4 pg/mL. The prevalence of vitamin B12 deficiency was 28.4%. Male gender, HbA1c < 7% and hyperhomocysteinemia were significantly associated with vitamin B12 deficiency (respectively p  =  0.02, p < 0.001, p < 0.001). Homocysteine level was negatively correlated with vitamin B12 level (r  =  -0.2, p  =  0.001). Dose and duration of metformin treatment, peripheral neuropathy and anemia were not associated with vitamin B12 deficiency. On multivariate analysis, HbA1c < 7% and hyperhomocysteinemia were independently associated with vitamin B12 deficiency (respectively OR = 3.2, 95%CI  =  [1.6-6.3] and OR = 2.3, 95%CI  =  [1.2-4.2]). Discussion: The prevalence of vitamin B12 deficiency in patients with T2D on metformin treatment was high. Hyperhomocysteinemia is associated with vitamin B12 deficiency suggesting that the deficit occurs at the tissue level.

O-glycosylation is essential for cell surface expression of the transcobalamin receptor CD320

CD320 is a cell surface receptor that mediates vitamin B12 uptake in most tissues. To date, the mechanisms that regulate CD320 expression on the cell surface are not fully understood. In this work, we studied CD320 expression in transfected human embryonic kidney (HEK) 293 and hepatoma HepG2 cells. By glycosidase and trypsin digestion, monensin and brefeldin treatment, western blotting, flow cytometry, and lectin binding, we found that CD320 underwent N- and O-glycosylation and sialylation, resulting in a ∼70-kDa band that formed a high-molecular-weight complex on the cell surface. Site-directed mutagenesis altering Asn126, Asn195, and Asn213 residues, individually or together, abolished N-glycosylation in CD320 but did not block its intracellular trafficking and expression on the cell surface in HEK293 and HepG2 cells. In contrast, treatment of the cells with Ben-gal, a structural analog of GalNAc-α-1-O-Ser/Thr, inhibited O-glycosylation and cell surface expression of CD320 and decreased vitamin B12 uptake. Analysis of CD320 deletion mutants indicated that O-glycosylation sites in a Ser/Thr-rich region near the transmembrane domain were important for CD320 expression on the cell surface. These results reveal an important role of O-glycans, but not N-glycans, in the intracellular trafficking and cell surface expression of CD320, providing new insights into the cellular mechanisms in regulating CD320 function and vitamin B12 metabolism.

Vitamin B12 protects necrosis of acinar cells in pancreatic tissues with acute pancreatitis

Pharmacological agents regarding the most optimal treatments of acute pancreatitis remain. One-carbon metabolism nutrients as therapeutic agents in many diseases might be involved in acute pancreatitis. The roles are acquired exploration in acute pancreatitis. We utilized Mendelian randomization to assess the causal impact of folate, homocysteine, and vitamin B12 (VB12) on acute pancreatitis. Wild-type and corresponding genetically modified mouse models were used to verify the genetic correlating findings. A negative association between genetically predicted serum VB12 levels and risks of acute pancreatitis was identified in human population. The transcobalamin receptor (TCblR)/CD320 gene ablation that decreased cellular VB12 uptake and ATP production in pancreatic tissues promoted necrosis, resulting in much severe pathological changes of induced acute pancreatitis in mice. VB12 pretreatment and posttreatment dramatically increased ATP levels in pancreatic tissues and reduced the necrosis, then the elevated levels of amylase in serum, the levels of CK-19, the activity of trypsin, and T lymphocyte infiltration in pancreatic tissues, prevented the pancreatic gross loss and ameliorated histopathological changes of mouse pancreases with induced acute pancreatitis. The results reveal that VB12 is potential as a therapeutic agent to inhibit tissue injuries and adaptive inflammatory responses in the pancreas in patients with acute pancreatitis.

Biological properties of vitamin B12

Vitamin B12, cobalamin, is indispensable for humans owing to its participation in two biochemical reactions: the conversion of l-methylmalonyl coenzyme A to succinyl coenzyme A, and the formation of methionine by methylation of homocysteine. Eukaryotes, encompassing plants, fungi, animals and humans, do not synthesise vitamin B12, in contrast to prokaryotes. Humans must consume it in their diet. The most important sources include meat, milk and dairy products, fish, shellfish and eggs. Due to this, vegetarians are at risk to develop a vitamin B12 deficiency and it is recommended that they consume fortified food. Vitamin B12 behaves differently to most vitamins of the B complex in several aspects, e.g. it is more stable, has a very specific mechanism of absorption and is stored in large amounts in the organism. This review summarises all its biological aspects (including its structure and natural sources as well as its stability in food, pharmacokinetics and physiological function) as well as causes, symptoms, diagnosis (with a summary of analytical methods for its measurement), prevention and treatment of its deficiency, and its pharmacological use and potential toxicity.

Assessment of vitamin B12 and homocysteine levels in pregnant women admitted for delivery and cord blood samples of their newborn babies: a multicenter study

BACKGROUND

Vitamin B12, an indispensable micronutrient, is pivotal in numerous physiological processes, with particular significance during pregnancy and fetal development. The increasing adoption of vegetarian diets and the economic challenges associated with accessing animal-based food sources contribute to the prevalence of vitamin B12 deficiency. This study aims to examine the levels of vitamin B12 and homocysteine in pregnant women upon admission for delivery and to analyze corresponding cord blood samples from their newborn infants in a substantial sample within the Istanbul metropolitan area.

MATERIALS AND METHODS

This cross-sectional multicenter study included women aged ≥16 years admitted for delivery and their newborns ≥34 weeks. The demographic data and the results of complete blood counts within the previous 24 hours before birth were recorded. Vitamin B12 and homocysteine levels were measured in maternal and cord blood samples. The study parameters were compared between the groups based on the mothers' and babies' homocysteine and vitamin B12 levels.

RESULTS

The study included 832 pregnant women and 832 neonates. Anemia affected 36% of pregnant women, with a higher frequency in mothers with vitamin B12 deficiency. Seventy-eight mothers and 48.9% of neonates showed Vitamin B12 levels below 200 pg/mL, while elevated homocysteine levels were observed in 30% of mothers and 26% of neonates. Maternal vitamin B12 deficiency was significantly correlated with cord blood B12 deficiency and elevated homocysteine. The median cord blood vitamin B12 level was inversely correlated with the number of previous pregnancies.

CONCLUSION

Vitamin B12 deficiency is extremely common in pregnant women before delivery, significantly correlating to cord blood homocysteine and vitamin B12 levels. However, homocysteine alone is not a reliable marker for maternal vitamin B12 status. Implementing strategies to detect vitamin B12 deficiency and supplying adequate vitamin B12 supplementation during pregnancy holds the potential to enhance maternal and neonatal health in Türkiye.

Metformin Use and Vitamin B12 Deficiency in People with Type 2 Diabetes. What Are the Risk Factors? A Mini-systematic Review

Background and Aim: Metformin is recommended as the first-line agent for the management of type 2 diabetes following lifestyle and dietary changes. The long-term use of metformin has been associated with vitamin B12 deficiency. The aim of this review is to investigate the effect of metformin on vitamin B12 levels and identify any risk factors. Method: A literature search was conducted using MEDLINE, PubMed and ProQuest Central. Selected articles were peer-reviewed articles, written in English and published from 2015 and onwards. Excluded articles were case reports, reviews or meta-analyses, as well as those with no access to full text. Results: In total, 21 articles were included. There was a significant association between metformin use and vitamin B12 levels in 17 studies, while 4 studies found no such association. The risk factors examined were metformin dose, treatment duration, patient age and patient ethnicity. Conclusion: In summary, metformin use was associated with lower vitamin B12 concentrations, and higher doses and longer durations of treatment increase the risk of vitamin B12 deficiency. Routine vitamin B12 screening is recommended, prioritizing higher-risk patients. Further research is needed to identify when to initiate monitoring.

Comparing Holotranscobalamin and Total Vitamin B12 in Diagnosing Vitamin B12 Deficiency in Megaloblastic Anemia Patients

Background Megaloblastic anemia is characterized by abnormally large red blood cells caused by a deficiency in either vitamin B12 or folic acid, both of which are essential for DNA synthesis. Vitamin B12 insufficiency can lead to severe neurological damage, making early identification of vitamin B12 deficiency crucial to prevent irreversible harm. Vitamin B12 deficiency results in decreased levels of holotranscobalamin (Holo-TC) and increased levels of methylmalonic acid (MMA). Methylmalonic acid is considered the gold standard for diagnosing B12 deficiency because it is a specific marker that rises when B12 is insufficient, even when serum B12 levels appear normal. Elevated MMA levels reflect impaired B12 metabolism, making it a critical tool for early detection and intervention. Previous research indicates that Holo-TC, the active form of vitamin B12 available to cells, is a more specific diagnostic tool for early vitamin B12 deficiency than total B12. This study aims to determine the diagnostic validity of total vitamin B12 and Holo-TC using MMA as the gold standard in patients with megaloblastic anemia. Methods A total of 95 megaloblastic anemia patients were selected from Jinnah Hospital and Lahore General Hospital, Lahore, Pakistan, after receiving approval from the ethical review committees. This was a cross-sectional study. Whole blood, serum, and urine samples were collected in ethylenediamine tetraacetic acid (EDTA) vials, gel vials, and urine containers, respectively. The EDTA samples were used for complete blood count measurements using a hematology analyzer (Sysmex-XT 1800i, Sysmex America, Inc., Mundelein, IL), while serum and urine samples were employed for the detection of serum folic acid, cobalamin, Holo-TC, and MMA levels through manual enzyme-linked immunosorbent assay (ELISA) techniques. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Holo-TC and cobalamin were calculated. Results The majority of patients fell within the age group of 20-70 years, with 57% of them being females and 43% males; Holo-TC exhibited a sensitivity of 98.9% and specificity of 50.00%, with a PPV of 98.90% and NPV of 50%. Vitamin B12 demonstrated a sensitivity of 63% and specificity of 50%, with a PPV of 98.33% and NPV of 2.85%. The diagnostic accuracy of Holo-TC and vitamin B12 was observed to be 97.8% and 63%, respectively.  Conclusions Between the two, Holo-TC displays higher diagnostic accuracy than vitamin B12 and can serve as the primary test for patients suspected of having vitamin B12 deficiency.

An Introduction to the Complete Blood Count for Clinical Chemists: Red Blood Cells

BACKGROUND

The most frequently ordered laboratory test worldwide is the complete blood count (CBC).

CONTENT

In this primer, the red blood cell test components of the CBC are introduced, followed by a discussion of the laboratory evaluation of anemia and polycythemia.

SUMMARY

As clinical chemists are increasingly tasked to direct laboratories outside of the traditional clinical chemistry sections such as hematology, expertise must be developed. This review article is a dedication to that effort.

Acute Mental Disorder Caused by Vitamin B12 Deficiency Eight Years After Total Gastrectomy

Vitamin B12 deficiency can cause a variety of diseases. The most common disease is macrocytic anemia, but it has also been found to be a cause of psychiatric disorders. The causes of deficiency are varied, and diagnosis is often difficult. Here, we report a patient who developed mental disorders due to vitamin B12 deficiency after total gastrectomy. A 37-year-old female, eight years after total gastrectomy, was withdrawn at her workplace, talking and acting abnormally. The family had seen unusual behavior for three days. The patient had no particular history of mental illness. The possibility of herpes encephalitis was suspected, and the patient was referred to our hospital, but there were no specific findings in the head on imaging examination. Blood tests showed no macrocytic anemia. Spinal fluid cytology and electroencephalography showed no specific findings, and herpes DNA was negative. Metabolic factors such as vitamin deficiency were considered, and intravenous vitamin replacement therapy was initiated. The psychiatric symptoms improved rapidly after vitamin B12 supplementation was started. On the fifth day of her hospitalization, it was discovered that her vitamin B12 level at the time of admission was extremely low. Typically, vitamin B12 deficiency is associated with macrocytic anemia, but in this patient, serum iron was also decreased, indicating a mixed anemia, making the diagnosis difficult. The patient had undergone a total gastrectomy for gastric cancer eight years ago, and the psychiatric symptoms were thought to be due to impaired vitamin B12 absorption caused by intrinsic factor deficiency. Since then, oral replacement therapy and intramuscular injection have been continued without recurrence of symptoms. Disturbances of consciousness may have many causes, but when there is a history of gastrectomy, we should also consider vitamin B12 deficiency when examining patients.

Crystal structure of methyltransferase CbiL from Akkermansia muciniphila

Akkermansia muciniphila is a mucin-degrading probiotic that colonizes the gastrointestinal tract. Genomic analysis identified a set of genes involved in the biosynthesis of corrin ring, including the cobalt factor II methyltransferase CbiL, in some phylogroups of A. muciniphila, implying a potential capacity for de novo synthesis of cobalamin. In this work, we determined the crystal structure of CbiL from A. muciniphila at 2.3 Å resolution. AmCbiL exists as a dimer both in solution and in crystal, and each protomer consists of two α/β domains, the N-terminal domain and the C-terminal domain, consistent with the folding of typical class III MTases. The two domains create an open trough, potentially available to bind the substrates SAM and cobalt factor II. Sequence and structural comparisons with other CbiLs, assisted by computer modeling, suggest that AmCbiL should have cobalt factor II C-20 methyltransferase activity. Our results support that certain strains of A. muciniphila may be capable of synthesizing cobalamin de novo.

Vitamin B12 deficiency in diabetic patients treated with metformin: A narrative review

Metformin is the most prescribed oral hypoglycemic drug and is considered by many health practitioners as the first-line treatment for non-insulin-dependent diabetes mellitus (T2DM). It is used either as a monotherapy or adjuvant to other anti-hyperglycemic agents. Most of its side effects are usually mild and self-limiting. However, several studies have shown an association between the use of metformin and low vitamin B12 levels in diabetic patients. The current review aimed to provide a literature review of the current published reports on the association, the possible mechanisms, and the related individualized risk factors that might lead to this incidence. The most accepted mechanism of the effect of metformin on vitamin B12 level is related to the absorption process where metformin antagonism of the calcium cation and interference with the calcium-dependent IF-vitamin B12 complex binding to the ileal cubilin receptor. In addition, many risk factors have been associated with the impact of metformin on vitamin B12 levels in diabetic patients such as dose and duration where longer durations showed a greater prevalence of developing vitamin B12 deficiency. Male patients showed lower levels of vitamin B12 compared to females. Black race showed a lower prevalence of vitamin B12 deficiency in metformin-treated patients. Moreover, chronic diseases including T2DM, hyperlipidemia, coronary artery disease, polycystic ovary disease (PCOD), obesity, and metformin therapy were significantly associated with increased risk of vitamin B12 deficiency.

Vitamin B12 Deficiency Manifesting As Pancytopenia, Lymphadenopathy, and Fever: A Clinical Mimic of Hematologic Malignancies

Pancytopenia is a complex medical condition characterized by decreased levels of red blood cells (RBCs), white blood cells (WBCs), and platelets (PLTs). It can arise from impaired production, peripheral destruction, or a combination of both. The causes of pancytopenia range from reversible factors like infections and medication reactions to irreversible conditions. Vitamin B12 deficiency is a notable reversible cause that can take years to manifest in adults due to stored reserves. However, deficiencies caused by impaired absorption, especially due to the lack of intrinsic factors (IFs), can lead to rapid deterioration within two to five years. A healthy 39-year-old male with an athletic lifestyle presented with symptoms such as dizziness, nausea, vomiting, palpitations, and fainting over a few days. These symptoms were preceded by weeks of persistent body aches, headaches, weakness, daily fevers, chills, and night sweats. Vital signs were stable. The physical examination revealed conjunctival pallor and lymphadenopathy in the submandibular and superficial cervical regions. Initial blood tests showed normocytic anemia (Hgb 4.9, MCV 80), leukopenia (2.99), thrombocytopenia (142), and elevated liver enzymes (AST 199, ALT 96, and total bilirubin of 2.04). The peripheral smear showed tear-drop cells and hypochromic cells. The initial impression was hematologic malignancy, including but not limited to leukemia, lymphoma, or myelofibrosis given clinical findings such as B-symptoms like night sweats, neck lymphadenopathy, and subjective daily fever, along with pancytopenia. The patient received a bolus of normal saline and a transfusion of two units of packed RBCs. CT scans of the chest, abdomen, and pelvis showed no adenopathy or splenomegaly. Although initial clinical assessment pointed toward a potential hematologic malignancy, comprehensive testing, including SPEP, reticulocyte count/fraction, serum folate, and serum vitamin B12, revealed only severe vitamin B12 deficiency, with a level of less than 150, with the presence of IF antibodies. Treatment involved intensive in-patient vitamin B12 injections followed by a detailed outpatient regimen. The patient completed a daily dose of vitamin B12 injections for seven consecutive days, followed by weekly injections for the next four weeks. Subsequent laboratory results demonstrated an increase in WBC count to 8.39, Hgb level to 13.2, and PLT count of 249, indicating a continued positive response to the vitamin B12 replacement therapy. In summary, pancytopenia poses a diagnostic challenge that demands careful evaluation of patient data and comprehensive testing. Vitamin B12 deficiency, which encompasses pernicious anemia (PA), is among the reversible factors to consider. This aspect holds significance before opting for more invasive measures like a bone marrow biopsy. Nutritional deficiencies need to be considered first as differentials in pancytopenia, even in the absence of typical signs of vitamin B12 deficiency (like macrocytosis and hypersegmented neutrophils) and in the presence of compelling clinical indications pointing to a hematologic malignancy.

Exploring the Association between Serum B Vitamins, Homocysteine and Mental Disorders: Insights from Mendelian Randomization

Previous studies show that B vitamins and homocysteine (Hcy) may be associated with mental disorders, but the accurate causal relationship remains unclear. This study aimed to elucidate the potential causal relationship of serum B vitamins and Hcy levels with five common mental disorders through a two-sample Mendelian randomization (MR) study. In this MR analysis, 50 single-nucleotide polymorphisms (SNPs)-13 related to folate, 17 to vitamin B6, 8 to vitamin B12 and 12 to Hcy-were obtained from a large-scale Genome-Wide Association Studies (GWAS) database and employed as instrumental variables (IVs). The MR analyses were conducted using the inverse variance weighted (IVW), weighted median (WM), MR-Egger methods and sensitivity analyses were further performed to test the robustness. This MR study found a suggestive causal relationships between serum vitamin B12 levels and the risk of anxiety disorders (odds ratio (OR): 1.34, 95% confidence interval (CI): 1.01-1.78, p = 0.046) and bipolar affective disorders (OR: 1.85, 95% CI: 1.16-2.96, p = 0.010). However, folate, vitamin B6 and Hcy levels may not be causally associated with the risk of mental disorders. In conclusion, this study reveals that elevated serum vitamin B12 levels might suggestively increase the risk of anxiety and bipolar affective disorders, even though horizontal pleiotropy cannot be completely eliminated. The potential implications of our results warrant validation in larger GWAS based on diverse populations.

The Importance of the FUT2 rs602662 Polymorphism in the Risk of Cardiovascular Complications in Patients after Kidney Transplantation

The FUT2 gene encodes an enzyme called α-1,2-fucosyltransferase, which is involved in the formation of blood group antigens AB0(H) and is also involved in the processes of vitamin B12 absorption and its transport between cells. FUT2 gene polymorphisms are associated with vitamin B12 levels in the body. Vitamin B12 deficiency associated with hyperhomocysteinemia is a major risk factor for cardiovascular diseases (CVDs), which are one of the main causes of death in patients after kidney transplantation. The aim of our study was to determine the impact of the rs602662 (G>A) polymorphism of the FUT2 gene on the functionality of transplanted kidneys and the risk of CVD in patients after kidney transplantation. The study included 402 patients treated with immunosuppression (183 patients taking cyclosporine (CsA) and 219 patients taking tacrolimus (TAC)). The analysis of the FUT2 rs602662 (G>A) polymorphism was performed using real-time PCR. Patients with CsA were more likely to be underweight (1.64% vs. 0.91%) and obese (27.87% vs. 15.98%), while those taking TAC were more likely to be of normal weight (39.27%) or overweight (43.84%). No statistically significant differences were observed comparing the mean blood pressure, both systolic and diastolic. The renal profile showed a higher median urea nitrogen concentration in patients with CsA (26.45 mg/dL (20.60-35.40) vs. 22.95 mg/dL (17.60-33.30), p = 0.004). The observed frequency of rs602662 alleles of the FUT2 gene was similar in the analyzed groups. The A allele was present in 43.7% of patients with CsA and 41.1% of those taking TAC (OR = 0.898; 95% CI: 0.678-1.189; p = 0.453). In the group with CsA, the GG genotype was present in 32.2% of patients, the GA in 48.1% and the AA in 19.7%. A similar distribution was obtained in the TAC group: GG-33.8%, GA-50.2%, and AA-16.0%. An association of genotypes containing the G allele with a higher incidence of hypertension was observed. The G allele was present in 65% of people with hypertension and in 56% of patients with normal blood pressure (p = 0.036). Moreover, the evaluation of the renal parameters showed no effect of the FUT2 polymorphism on the risk of organ rejection because the levels of creatinine, eGFR, potassium, and urea nitrogen were prognostic of successful transplantation. Our results suggest that the rs6022662 FUT2 polymorphism may influence the risk of cardiovascular diseases.

Prevalence of vitamin B 12 deficiency and associated factors among primary school children: North East Ethiopia: multicenter cross-sectional study

BACKGROUND

The prevalence of Vitamin B12 deficiency is common and is more frequent in low- and middle-income countries with a poor or inadequate diet of animal foods. In Ethiopia, researches related to the status of micronutrients in children are limited. Therefore, this study aimed to assess the prevalence of vitamin B12 deficiency and associated factors among primary school children.

METHODS

A cross-sectional study design was conducted from January 10-February 30/2023. A total of 514 students were selected using a systematic random sampling technique. Face-to-face interviews using a structured questionnaire, document review, anthropometric measurement, and laboratory studies were implemented to collect data. Data was analyzed by STATA version 14 and summarized by using frequency tables and graphs. Logistic regression analysis was done to identify factors associated with vitamin B12 Deficiency.

RESULTS

About 34% of the students were found to have vitamin B12 deficiency. Not Consuming animal products (AOR = 1.83, 95% CI:1.20-2.79) and low body mass index (AOR = 1.62, 95% CI:1.05-2.47) were associated with vitamin B12 deficiency.

CONCLUSIONS

The study revealed a notable high deficiency of vitamin B12 in primary school students. Consumption of animal products and BMI were identified as statically significant associated factors with serum concentration of vitamin B12.

Reversible Hyperpigmentation in a Patient With Vitamin B12 Deficiency

Hyperpigmentation is a recognized sign of vitamin B12 deficiency that resolves after vitamin repletion. We present the case of a 58-year-old female with neuropsychiatric symptoms who developed progressive darkening of her hands and feet. A diagnosis of vitamin B12 deficiency secondary to pernicious anemia was made and her symptoms and hyperpigmentation resolved following vitamin repletion. Clinicians should consider vitamin B12 deficiency in the differential diagnosis of palmoplantar hyperpigmentation, as early treatment can avert permanent disability in these patients.

Vitamin B12 Supplementation in Psychiatric Practice

PURPOSE OF REVIEW

Vitamin B12 (B12, cobalamin) deficiency has been associated with neuropsychiatric symptoms, suggesting a role for B12 supplementation both as a treatment for psychiatric symptoms due to B12 deficiency and as an augmentation strategy for pharmacological treatments of psychiatric disorders. This critical review discusses the major causes of B12 deficiency, the range of psychiatric and non-psychiatric manifestations of B12 deficiency, the indications for testing B12 levels, and the evidence for B12 supplementation for major psychiatric disorders.

RECENT FINDINGS

We find that high-quality evidence shows no benefit to routine B12 supplementation for mild depressive symptoms or to prevent depression. There is very limited evidence on the role of B12 supplementation to augment antidepressants. No high-quality evidence to date suggests a role for routine B12 supplementation in any other major psychiatric disorder. No formal guidelines indicate when clinicians should test B12 levels for common psychiatric symptoms, in the absence of major risk factors for deficiency or cardinal symptoms of deficiency. No robust evidence currently supports routine B12 supplementation for major psychiatric disorders. However, psychiatrists should be aware of the important risk factors for B12 deficiency and should be able to identify symptoms of B12 deficiency, which requires prompt testing, medical workup, and treatment. Testing for B12 deficiency should be considered for atypical or severe psychiatric presentations.

Subacute combined degeneration of the spinal cord with cerebellar lesions: A case report

RATIONALE

Subacute combined degeneration of the spinal cord is a degenerative disease of the central and peripheral nervous systems caused by vitamin B12 deficiency, mainly involving the spinal cord posterior, lateral, and peripheral nerves, but rarely involving the cerebellum.

PATIENT CONCERNS

A 41-year-old woman presented with a 2-year history of walking unsteadily. Her hematologic examination revealed megaloblastic anemia and vitamin B12 deficiency. Electromyography showed multiple peripheral nerve damage (sensory fibers and motor fibers were involved). Imaging examination showed long T2 signal in the cervical, thoracic and lumbar spinal cord and cerebellum. Gastroscopy revealed autoimmune gastritis.

DIAGNOSES

Subacute combined degeneration of the spinal cord.

INTERVENTIONS

By supplementing with vitamin B12.

OUTCOMES

The patient's symptoms of limb weakness, diet, and consciousness were improved, and the muscle strength of both lower limbs recovered to grade IV.

LESSONS

The symptomatic people should seek medical treatment in time to avoid further deterioration of the disease. When esophagogastroduodenoscopy is performed as part of routine physical examination in asymptomatic people, it should be checked for the presence of autoimmune gastritis. Early diagnosis can prevent irreversible neuropathy.

Manifestations and Treatment of Hypovitaminosis in Oral Diseases: A Systematic Review

This review's objective is to examine the findings from various studies on oral signs and symptoms related to vitamin deficiency. In October 2023, two electronic databases (Scopus and PubMed) were searched for published scientific articles following PRISMA principles. Articles eligible for inclusion in this review had to be published in English between 2017 and 2023, be original studies, and involve human subjects. Fifteen studies were included in this review: three examining oral symptoms of vitamin B12 deficiency; one assessing vitamin B complex and vitamin E for recurrent oral ulcers; one investigating serum vitamin D levels in recurrent aphthous stomatitis patients; three exploring hypovitaminosis effects on dental caries; two measuring blood serum vitamin D levels; one evaluating vitamin B12 hypovitaminosis; three investigating hypovitaminosis as indicative of gingival disease; one focusing on vitamin deficiencies and enamel developmental abnormalities; one assessing vitamin deficiencies in oral cancer patients; one examining vitamin K as an oral anticoagulant and its role in perioperative hemorrhage; and one evaluating vitamin effects on burning mouth syndrome. Despite some limitations, evidence suggests a correlation between vitamin deficiencies and oral symptoms. This systematic review was registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) database (202430039).

The effect of red blood cell disorders on male fertility and reproductive health

Male infertility is defined as a failure to conceive after 12 months of unprotected intercourse owing to suspected male reproductive factors. Non-malignant red blood cell disorders are systemic conditions that have been associated with male infertility with varying severity and strength of evidence. Hereditary haemoglobinopathies and bone marrow failure syndromes have been associated with hypothalamic-pituitary-gonadal axis dysfunction, hypogonadism, and abnormal sperm parameters. Bone marrow transplantation is a potential cure for these conditions, but exposes patients to potentially gonadotoxic chemotherapy and/or radiation that could further impair fertility. Iron imbalance might also reduce male fertility. Thus, disorders of hereditary iron overload can cause iron deposition in tissues that might result in hypogonadism and impaired spermatogenesis, whereas severe iron deficiency can propagate anaemias that decrease gonadotropin release and sperm counts. Reproductive urologists should be included in the comprehensive care of patients with red blood cell disorders, especially when gonadotoxic treatments are being considered, to ensure fertility concerns are appropriately evaluated and managed.

Vision Loss as a Presenting Symptom of Vitamin B12 Deficiency

Nutritional optic neuropathy is a rare and often overlooked factor leading to bilateral, symmetrical, and gradual visual impairment. This condition falls within the category of metabolic neuropathies. We documented a case involving bilateral nutritional optic neuropathy attributed to pancytopenia associated with vitamin B12 deficiency. A healthy 65-year-old Indian woman reported a bilateral, progressive, painless decline in vision over the past six months. She had a history of reduced oral intake for the preceding year and denied experiencing any gastrointestinal or constitutional symptoms. Bilateral visual acuity was 1/60. Examination revealed pale optic discs with attenuated vessels in both eyes and a cup-disc ratio of 0.3. The blood analysis showed low indices and a deficiency in serum vitamin B12. Despite undergoing treatment, her vision remained impaired due to the chronic nature of the condition. This case highlights the importance of identifying visual symptoms in an elderly woman experiencing malnutrition caused by inadequate dietary habits, which leads to bilateral nutritional optic neuropathy.

Serum vitamin B12, distal symmetrical polyneuropathy and anaemia in type 2 diabetes: the Fremantle Diabetes Study Phase 2

BACKGROUND

There are limited data relating to the effects of metformin-associated vitamin B12 deficiency on the risk of distal symmetrical polyneuropathy (DSPN) and megaloblastic anaemia in well-characterised community-based cohorts.

AIMS

To assess inter-relationships between metformin therapy, vitamin B12 deficiency assessed using serum active B12 concentrations, and DSPN and anaemia in 1492 Fremantle Diabetes Study Phase 2 (FDS2) participants with type 2 diabetes.

METHODS

Prevalence rates of vitamin B12 deficiency (total <80 pmol/L, active <23 pmol/L) and borderline deficiency (total ≥80 and ≤200 pmol/L, active ≥23 and ≤35 pmol/L) were determined using baseline sera. The relationship between vitamin B12 status and both DSPN and anaemia was assessed using multivariable analyses.

RESULTS

Most FDS2 participants (94.4%) were vitamin B12 replete (total serum concentration >200 pmol/L, active >35 pmol/L), 2.0% were deficient (total <80 pmol/L, active <23 pmol/L) and the remainder (3.6%) borderline. Although metformin treatment increased the odds of deficiency (4.2%, 3.1% borderline) in a dose-dependent fashion (odds ratio (95% confidence interval) 39.4 (4.90-316) for >2000 mg daily compared with no treatment; P < 0.001), there was no significant association between vitamin B12 status and DSPN, anaemia (haemoglobin ≤130 g/L males, ≤120 g/L females), haemoglobin concentration or mean corpuscular volume (P ≥ 0.147). Metformin increased the likelihood of anaemia, especially at high doses, independent of vitamin B12 deficiency.

CONCLUSIONS

Since nutritional sources likely attenuate metformin-associated vitamin B12 malabsorption and its clinical sequelae in developed countries such as Australia, there is no need for routine/opportunistic serum vitamin B12 screening in metformin-treated patients.

Autoimmune Atrophic Gastritis: A Clinical Review

Autoimmune atrophic gastritis (AAG) is a chronic condition characterized by the presence of atrophy in the oxyntic mucosa due to anti-parietal cell antibodies. This review provides a comprehensive and up-to-date overview of autoimmune atrophic gastritis, reporting recent evidence on epidemiology, pathogenesis, diagnosis, clinical presentation, risk of malignancies, and management. The prevalence of AAG has been estimated at between 0.3% and 2.7% in the general population. The diagnosis of AAG is based on a combination of the serologic profile and the histological examination of gastric biopsies. Patients with AAG are often asymptomatic but can also have dyspeptic or reflux symptoms. The atrophy of the oxyntic mucosa leads to iron and vitamin B12 malabsorption, which may result in anemia and neurological affections. Autoimmune atrophic gastritis is associated with an increased risk of type I neuroendocrine tumors (NETs) and gastric cancer, with an incidence rate of 2.8% and 0.5% per person/year, respectively. Management is directed to reinstate vitamins and iron and to prevent malignancies with endoscopic surveillance. In conclusion, atrophic autoimmune gastritis is an infrequent condition, often asymptomatic and misdiagnosed, that requires an early diagnosis for appropriate vitamin supplementation and endoscopic follow-up for the early diagnosis of NETs and gastric cancer.

Impact of metformin treatment on cobalamin status in persons with type 2 diabetes

Over the last decades, low vitamin B12 status has been reported in individuals with type 2 diabetes mellitus (T2DM). Metformin, the first-line therapy for lowering blood glucose, is the main driving factor behind this association. Although the relationship between vitamin B12 deficiency and metformin is well established, results of studies on the exact effect of the dose and duration of the therapy remain inconsistent. Additionally, a lack of consensus on the definition of vitamin B12 deficiency adds to the conflicting literature. The objectives of this review were to analyze and synthesize the findings on the effects of metformin dose and duration on vitamin B12 status in patients with T2DM and to outline the potential mechanisms underlying metformin's effect on vitamin B12. Metformin therapy has adversely affected serum vitamin B12 concentrations, a marker of vitamin B12 status. The metformin usage index (a composite score of metformin dose and duration) might serve as a potential risk assessment tool for vitamin B12 screening in patients with T2DM. Considering the health implications of suboptimal vitamin B12 status, vitamin B12 concentrations should be monitored periodically in high-risk patients, such as vegans who are receiving metformin therapy for T2DM. Additionally, it is prudent to implement lifestyle strategies concurrent with metformin therapy in individuals with T2DM, promoting an overall synergistic effect on their glycemic control.

Can supplementing vitamin B12 improve mental health outcomes?: a literature review

AIM

This study reviews research into the effects of the supplementation of B12 in the prevention and recovery of mental illness, and the potentiation of psychotropic medication.

METHODOLOGY

This literature review follows a systematic approach to searching databases CINAHL, EMBASE, Medline, and PsycINFO where 287 non-duplicated articles results were received. Appropriate articles were identified through title and abstract screening and inclusion and exclusion criteria were applied. Five articles were chosen to address the research question following critical appraisal. Thematic analysis was then conducted.

FINDINGS

This review identified five randomised controlled trials into the supplementation of various doses of B12 in conjunction with folic acid and B6. The supplement was measured against post-stroke depression prevention, the reduction of symptoms of depression in woman with cardiovascular disease, the effect on negative symptoms in schizophrenia, the reduction and prevention of depression in older adults, and the potentiation of psychotropic interventions. The papers reviewed showed inconclusive results, but evidence to support sub-groups and specific high-risk groups. Strong evidence showed supplementation of B12, folic acid and B6 has high rates of preventing post-stroke depression.

CONCLUSION

The findings show that this area of research is still to be developed. The effects of B12 supplementation with other B vitamins on mental health have shown to be inconclusive. There is a case for its use to be considered within certain patient groups to aid recovery of mental health or in some high-risk patient groups. Recommendations are made for further research into high-risk groups of people that may have symptoms or symptoms that could be improved through the supplementation of B12.

The origin of vitamin B12 levels and risk of all-cause, cardiovascular and cancer specific mortality: A systematic review and dose-response meta-analysis

BACKGROUND

Vitamin B12 is essential to human but the implications of serum vitamin B12 level for mortality in clinical practice remain unclear. We conducted a systematic review and dose-response meta-analysis to quantify the relationship between vitamin B12 levels and the risk of all-cause, cardiovascular, and cancer mortality.

METHODS

Electronic databases of PubMed, Embase, and the Cochrane Library Central Register of Controlled Trials were searched from inception through May 2023. Two reviewers independently extracted individual study data and evaluated the risk of bias among the studies using the Newcastle‒Ottawa Scale. To examine a potential nonlinear relationship between the vitamin B12 levels and all-cause mortality, we performed a two-stage random effects dose‒response meta-analysis.

RESULTS

Twenty-two cohort studies (92,346 individuals with 10,704 all-cause deaths) were included. A linear trend dose-response analysis showed that each 100 pmol/L increase in serum vitamin B12 concentration was associated with a 4 % higher risk of all-cause mortality in the general population (adjusted HR 1.04, 95 % confidence interval CI 1.01 to 1.08; n = 8; P non-linearity = 0.11) and a 6 % higher risk for all-cause mortality in older adults (adjusted HR 1.06, 95 % CI 1.01 to 1.13; n = 4; P non-linearity = 0.78). Current evidence was mixed for the association between serum vitamin B12 concentration and cardiovascular mortality and was limited for cancer mortality. The meta-analysis of cohort studies showed a positive association between a high serum vitamin B12 concentration (>600 pmol/L) and all-cause mortality (adjusted HR 1.50, 95 % CI 1.29 to 1.74; n = 10; p < 0.01), CVD mortality (adjusted HR 2.04, 95 % CI 0.99 to 4.19; n = 2; p = 0.02), except cancer mortality (adjusted HR 1.56, 95 % CI 0.82 to 2.95; n = 3). Similarly, serum vitamin B12 concentrations (400-600 pmol/L) were associated with increased all-cause mortality (adjusted HR 1.34, 95 % CI 1.10 to 1.64; n = 9; p < 0.01).

CONCLUSIONS

Serum vitamin B12 concentration was positively associated with the risk of all-cause mortality, especially among older adults, with a linear increasing trend. These findings suggested the primary cause of elevated level of serum vitamin B12 concentration should be timely identified and effectively managed in clinical practice.

Dietary supplement use among lactating mothers following different dietary patterns - an online survey

BACKGROUND

Breastfeeding is important for the healthy growth and development of newborns, and the nutrient composition of human milk can be affected by maternal nutrition and supplementation. In Germany, iodine supplementation is recommended for all lactating mothers, and docosahexaenoic acid (DHA) supplementation is recommended for mothers with inadequate or no fish intake. Vitamin B12 supplementation is required for strict vegans during lactation, and other nutrient supplementation may be necessary depending on the individual's nutritional status. To address the lack of data on dietary supplements used by lactating mothers following a vegetarian or vegan diet, an online survey was conducted in Germany, with a focus on iodine, DHA, and vitamin B12.

METHODS

Study participants were asked to report whether they followed specific dietary patterns (omnivorous [OM], vegetarian [VT], vegan [VN]) as well as their use of dietary supplements. Relationships between diets and supplement use were analyzed using chi-square tests.

RESULTS

2054 lactating women were included (1240 OM, 410 VT, and 404 VN) in this analysis. Within OM, VT and VN, at least one dietary supplement was taken by 67.3%, 84.9% and 98.0% respectively (p < 0.001). Overall, 53.2% OM, 66.8% VT, 88.4% VN reported taking at least one supplement containing iodine (p < 0.001). 54.6% OM, 61.7% VT and 58.2% VN reported supplements containing vitamin B12, while 34.1% OM, 40.2% VT and 38.6% VN mentioned supplements containing DHA (p < 0.05).

CONCLUSION

More than half of the participants reported the use of supplements during lactation with the highest proportion in vegans. However, over one third of the mothers did not report supplementing with iodine, regardless of their dietary pattern and most participants also did not report DHA supplements. It is worrisome that a high number of vegans did not report vitamin B12 supplementation, but this could be partly due to issues with reporting. It is crucial to provide further education to breastfeeding mothers about the importance of taking micronutrient supplements, especially for those following a vegetarian or vegan diet. This will help ensure that mothers and their breastfed infants receive optimal nutrition for a healthy development.

Vitamin B12 Deficiency Disguised As Hemolytic Anemia: A Case Presentation

This case report describes an 18-month-old male presenting with hemolytic anemia and lethargy, who was ultimately diagnosed with severe vitamin B12 deficiency. The child exhibited global developmental delays, including a lack of speech and walking skills. Initially suspected as intravascular hemolytic anemia, the normal reticulocyte count led to further investigation, which revealed low cobalamin (vitamin B12) levels. The patient received vitamin B12 injections, resulting in normalized cobalamin levels. Additional evaluations ruled out metabolic disorders and other etiologies for his anemia. Follow-up laboratory testing showed improved hemoglobin levels, and the patient was discharged with plans for close monitoring. The case emphasizes the importance of considering vitamin B12 deficiency in children, particularly those with developmental delays and anemia. Early diagnosis and treatment are crucial for preventing long-term neurological consequences associated with severe and prolonged cobalamin deficiency. Healthcare professionals should be aware of the impact of nutrient deficiencies on growth, development, and brain maturation in pediatric populations.

Vitamin B12 Deficiency Presenting as Psychotic Symptoms in a Psychiatry Department: A Case Report

Vitamin B12 deficiency is a metabolic disorder affecting the functions of hematopoietic system and nervous system. It manifests as a wide spectrum of anemia and nervous system symptoms, but psychotic symptoms are rare. We report a case of a 34-year-old man with an unbalanced diet who initially presented with psychotic symptoms. Prompt remission was achieved through vitamin B12 repletion, ultimately leading to a diagnosis of mental disorder caused by vitamin B12 deficiency. The patient provided his written informed consent to participate in this study. This case report emphasizes the importance of ruling out vitamin B12 deficiency in patients with psychotic symptoms instead of directly diagnosing schizophrenia, especially in cases where diet is unbalanced.

Macro-Vitamin B12 as Cause of Falsely Elevated Cobalamin Levels

Introduction

High blood concentrations of vitamin B12 are often caused by over-supplementation. However, there are instances in which augmented vitamin B12 levels are seen in the absence of supplements. Macro-vitamin B12 is an underrated cause of supra-physiological cobalamin plasma levels.

Case description

A 70-year-old man was referred to an ambulatory internal medicine centre because of high vitamin B12 levels yet he denied taking supplements. An X-ray showed a tumour in the right upper lobe of the lung, which triggered further examinations. An MRI scan of the brain came back normal as well as a CT scan of the abdomen, and colonoscopy. The pulmonologist requested a PET-CT scan, which showed an isolated 18-FDG uptake in the area of the lung mass that was detected earlier. The patient underwent surgery with adjuvant cis-platinum and gemcitabine and is still making good progress. The vitamin B12 levels persisted after successful treatment of lung adenocarcinoma; determination of vitamin B12 after PEG (polyethylene glycol) precipitation showed normal concentrations.

Discussion

A high vitamin B12 plasma concentration in the absence of vitamin supplementation can be a daunting diagnostic problem for the internist, as there are several possible underlying causes. In this case the diagnosis of lung carcinoma was made, the patient was treated appropriately, yet this pathology had no correlation with the cobalamin levels.

Conclusion

A high vitamin B12 concentration can be the impetus of thorough medical inquiries. Internists should be careful not to forget macro-vitamin B12 as a possible source of falsely elevated vitamin B12 values.

LEARNING POINTS

When encountering an otherwise unexplainable B12 hypervitaminosis, the diagnosis of macro-vitamin B12 should be taken into account to avoid unnecessary extensive medical examinations.PEG precipitation can distinguish between a 'real' high vitamin B12 and macro-vitamin B12.A high vitamin B12 concentration is no guarantee for adequate cobalamin storage. In case of suspicion, a vitamin B12 measurement after PEG precipitation should be considered.

Low vitamin B12 levels may predict the risk of ischemic stroke: A cross-sectional study

BACKGROUND

To examine serum vitamin B12 concentrations in relation to the risk of ischemic stroke among hospitalized patients in the Department of Neurology.

METHODS

We performed a cross-sectional study involving 2,212 inpatients discharged from the Department of Neurology of the First Affiliated Hospital of Chongqing Medical University, from January 2020 to January 2022. The results of laboratory assays such as serum vitamin B12, homocysteine, and folate levels were measured. Logistic regression analysis was used to investigate the association between serum vitamin B12 concentrations and ischemic stroke, with adjustment for a number of relevant demographic and lifestyle factors and comorbidities.

RESULTS

A total of 961 (43.4%) patients had an ischemic stroke. In the fully adjusted model, logistic regression analysis suggested a positive association between serum vitamin B12 levels<150 pg/mL (aOR: 1.42; 95% CI 1.02-1.97; p = 0.035), serum vitamin B12 150-300 pg/mL (aOR: 1.37; 95% CI 1.11-1.68; p = 0.003) and the prevalence of ischemic stroke. Furthermore, an inverse association was observed between serum vitamin B12 levels ≥ 900 pg/mL (aOR: 0.38; 95% CI: 0.19-0.77; p =0.007) and the prevalence of ischemic stroke. Moreover, the cut-off value of vitamin B12 concentration was 316.4 pg/mL and the discrimination power of the score evaluated by AUC-ROC was 0.71 (95%CI 0.68-0.73, p<0.001) in the vitamin B12 and ischemic stroke.

CONCLUSION

Findings suggest that low vitamin B12 levels may predict the risk of ischemic stroke, early and timely supplementation of vitamin B12 can improve the short-term prognosis of ischemic stroke patients.

A Case of Subacute Degeneration of the Spinal Cord Due to Vitamin B12 Deficiency Triggered by Nitrous Oxide Use

In this case report, we discuss a young female who presented to the emergency department with a recent onset of weakness, paraesthesia, and gait disturbance suggestive of peripheral neuropathy and gait ataxia. This was attributed to the occasional use of recreational nitrous oxide (N2O) over the past 10 months. Subacute combined degeneration of the spinal cord is a condition affecting the lateral and posterior columns of the spinal cord, mainly caused by demyelination. The use of recreational N2O depletes the levels of vitamin B12 thus leading to this demyelination of the nervous system. Physical examination revealed T6 and T7 and L3 and L4 sensory deficits bilaterally with hyporeflexia in bilateral knee and ankle reflexes with reduced power in the left lower limb as well as a spastic gait. Her vitamin B12 levels were low (98 g/dL). MRI spine showed a high signal in the posterior cord/ dorsal column. The patient made good recovery post-intramuscular B12 administration and physiotherapy with planned outpatient neurology rehabilitation.

Effect of Vitamin B12 Replacement Intervals on Clinical Symptoms and Laboratory Findings in Gastric Cancer Patients after Total Gastrectomy

The management of patients with vitamin B12 deficiency after total gastrectomy (TG) remains controversial. We aimed to evaluate the effect of vitamin B12 replacement intervals on the clinical characteristics in these patients. The data from patients who received vitamin B12 supplementation after TG between 2007 and 2018 at the National Cancer Center, Korea, were retrospectively evaluated. Vitamin B12 deficiency was defined as a serum vitamin B12 level of <200 pg/mL or urine methylmalonic acid level > 3.8 mg/gCr. The patients were divided into a regular replacement group (patients received an intramuscular injection or oral medication regularly), and a lab-based replacement group (patients received vitamin B12 intermittently after checking the level). The symptoms and biochemical parameters were compared between these groups. The regular and lab-based replacement groups included 190 and 216 patients, respectively. The median vitamin B12 replacement intervals were 1 and 9 months, respectively (p < 0.001). After replacement, the regular replacement group had higher vitamin B12 levels than the lab-based replacement group (p < 0.001). However, the serum hemoglobin level showed no significant changes. After replacement, there was no significant difference in the proportion of the symptomatic patients between the groups. Replacing vitamin B12 with a lab-based protocol may be sufficient for TG patients.

Metformin-Induced Vitamin B12 Deficiency in Patients With Type-2 Diabetes Mellitus

Diabetes mellitus (DM) is the most common metabolic disease worldwide. Hence, the prevalence of the disease continues to increase across the globe. Metformin is used as a first-line oral hypoglycemic drug to keep control of type-2 DM (T2DM) in adults. Diabetic patients on metformin have been largely seen to be suffering from a deficiency of vitamin B12. It is a water-soluble vitamin mainly obtained from animal food like meat. At the basic cell level, it acts as a cofactor for enzymes essential for DNA synthesis and neuroprotection. As a result, vitamin B12 deficiency can show clinical effects such as progressive demyelination, peripheral neuropathy and haematological abnormalities (such as macrocytic anaemia and neutrophil hypersegmentation). Various studies also show a relation between vitamin B12 insufficiency and metformin-treated T2DM patients as decreased absorption of vitamin B12. There could be a severe complication of vitamin B12 deficiency in T2DM patients. The use of proton pump inhibitors, gastric bypass surgery, older patients and patients with a higher red blood cell turnover are factors that hasten the depletion of vitamin B12 reserves in the liver. Methylmalonic acid and homocysteine levels can be measured to identify vitamin B12 insufficiency at its early stage if blood vitamin B12 levels are borderline. The action of metformin on vitamin B12 absorption and its potential mechanisms of inhibition will be the main topics of discussion in this review. The review will also discuss how vitamin B12 deficiencies in T2DM patients using metformin affect their clinical results.

Imaging Aspects of Toxic and Metabolic Myelopathies

Metabolic and toxic myelopathies usually occurs due to several different causes. Metabolic myelopathy usually occurs due to deficiency of a nutrient, such as vitamin B12. Toxic myelopathy occurs secondary to the exposure to an external toxic agent. Although they may have a difficult diagnosis, determination of the specific cause of myelopathy is of utmost importance, because many causes are amenable to treatment. Although they have many clinical, electrophysiologic, and neuropathologic similarities, imaging may aid in the suspicion of toxic or metabolic myelopathy. The aim of this article, is to review the imaging features of the main toxic and metabolic myelopathies.

Exploiting Potential Probiotic Lactic Acid Bacteria Isolated from Chlorella vulgaris Photobioreactors as Promising Vitamin B12 Producers

Lactic acid bacteria (LAB) have been documented as potential vitamin B12 producers and may constitute an exogenous source of cobalamin for the microalga Chlorella vulgaris, which has been described as being able to perform vitamin uptake. Hence, there is an interest in discovering novel B12-producing probiotic LAB. Therefore, the purpose of the current work was to perform a phenotype-genotype analysis of the vitamin B12 biosynthesis capacity of LAB isolated from C. vulgaris bioreactors, and investigate their probiotic potential. Among the selected strains, Lactococcus lactis E32, Levilactobacillus brevis G31, and Pediococcus pentosaceus L51 demonstrated vitamin B12 biosynthesis capacity, with the latter producing the highest (28.19 ± 2.27 pg mL-1). The genomic analysis confirmed the presence of pivotal genes involved in different steps of the biosynthetic pathway (hemL, cbiT, cobC, and cobD). Notably, P. pentosaceus L51 was the only strain harboring cobA, pduU, and pduV genes, which may provide evidence for the presence of the cobalamin operon. All strains demonstrated the capability to withstand harsh gastrointestinal conditions, although P. pentosaceus L51 was more resilient. The potential for de novo cobalamin biosynthesis and remarkable probiotic features highlighted that P. pentosaceus L51 may be considered the most promising candidate strain for developing high-content vitamin B12 formulations.

Vitamin B12 Status in Rural Adolescent School Girls in Mysuru, India: A Community-Based Cross-Sectional Study

Almost 56% of Indian adolescent girls aged 15-19 years suffer from anemia. Adolescent age is a period of many significant physiological changes that increase nutritional demand, and they remain at risk for nutritional deficiencies. Our aim is to assess the prevalence of Vitamin B12 deficiency among school-going adolescent girls aged 13-16 years of rural Mysore. This study was a cross-sectional study, conducted in two high schools in rural Mysuru. Adolescent girls aged 13-16 years were included. The chosen subjects underwent complete hemogram, peripheral smear examination, and vitamin B12 level estimation. Out of 98 subjects enrolled, 40.81% were found to be deficient in vitamin B12. Macrocytes and hyper-segmented neutrophils were found to have statistically significant (P value < 0.001) relationship with vitamin B12 deficiency. The relationship between vitamin B12 deficiency with either type of diet and anemia was statically insignificant (P > 0.05). The prevalence of vitamin B12 deficiency among rural adolescent girls in Mysuru is high. Other causes of nutritional anemia apart from iron deficiency, such as vitamin B12 deficiency, must be considered in the etiology of anemia and optimally treated. It is recommended to further strengthen the adolescent national health programs and food fortification programs.

Nutritional Assessment of Plant-Based Meat Products Available on Hong Kong Market: A Cross-Sectional Survey

BACKGROUND

Plant-based meat (PBM) takes up ever-increasing market shares and draws great attention from both customers and retailers these days. However, little is known about the nutritional quality of PBM products.

OBJECTIVE

This study intended to profile and evaluate the overview nutrition of PBM with equivalent meat products on the Hong Kong market.

METHODS

We conducted a cross-sectional survey of 274 PBM and 151 meat products from 27 different brands on the Hong Kong market in October 2022. The nutritional differences between PBM and meat products were assessed using analysis of covariance (ANCOVA) and two independent sample t-test. The nutritional quality of PBMs was evaluated according to nutrient reference value, front-of-package (FoP) criteria and nutritional score.

RESULTS

PBM had relatively lower energy density, total fat, saturated fat, protein, and salt compared to meat. According to the FoP criteria, 91.36%, 17.88%, and 99.34% of PBMs were labeled as medium to high in fat, salt, and sugar, respectively. Through ingredient analysis of 81 PBM products, soy and canola were the main source of protein and fat.

CONCLUSIONS

PBM products have a roughly better nutrient quality compared to muscle-based meat, though there is still potential for further refinement in terms of production, consumption, and regulation.

A Simple Vitamin Deficiency With Life-Threatening Complications: A Case of B12 Deficiency and Hyperhomocysteinemia-Induced Thrombosis

While macrocytic anemia is common in vitamin B12 deficiency, rarely, pancytopenia and hemolytic anemia can occur. Homocysteine levels are elevated in severe B12 deficiency, and this is linked to thrombus formation with potentially life-threatening complications. We present a patient with severe vitamin B12 deficiency complicated by hyperhomocysteinemia and obstructive shock from pulmonary embolism. A 56-year-old male with no medical history presented to the hospital with altered mentation. The patient's family stated he was experiencing bilateral paresthesias of his lower extremities, progressive depression, anxiety, and insomnia. Initial vitals were blood pressure of 76/36, heart rate of 70 beats per minute, respiratory rate of 14, and temperature of 36.3 degrees Celsius. He was intubated due to severe encephalopathy. Relevant labs indicated severe macrocytic anemia, thrombocytopenia, decreased B12 levels, elevated methylmalonic acid, and elevated homocysteine. Imaging demonstrated a right common femoral vein thrombosis and subsegmental pulmonary emboli. Peripheral blood smear revealed schistocytes, anisopoikilocytosis, and decreased platelet count. The patient required fluid resuscitation, antibiotics, and multiple blood products. Vitamin B12 was administered intramuscularly, which improved the anemia. Esophagogastroduodenoscopy (EGD) demonstrated gastritis. Gastric and duodenal biopsies were negative for Helicobacter pylori and celiac disease. He was negative for intrinsic factor (IF) antibodies but had elevated gastrin levels. An intravenous unfractionated heparin infusion was started when the platelet count was above 50000. The patient was extubated after seven days. Heparin was transitioned to apixaban and an inferior vena cava (IVC) filter was placed. Hyperhomocysteinemia is a known pro-thrombotic factor that can lead to the development of venous thromboembolism. B12 malabsorption can stem from inflammatory bowel disease, celiac disease, gastritis, pancreatic insufficiency, gastrectomy, gastric bypass surgery, or antibodies to IF. While this case showed gastritis and negative IF antibodies, gastrin levels were elevated, indicating a mixed picture. This highlights the challenge of definitively diagnosing pernicious anemia as the cause of vitamin B12 deficiency. Vitamin B12 deficiency may lead to critical illness in which thromboembolism develops secondary to hyperhomocysteinemia.

From Weakness to Wellness: A Rare Case of Severe Pancytopenia and Vitamin B12 Deficiency

Vitamin B12 (cobalamin) deficiency is a commonly seen nutritional deficiency that presents with a broad spectrum of clinical symptoms. In this report, we describe a case of a 49-year-old female patient who presented to the emergency department with sudden onset of a syncopal-like episode, generalized weakness, and severe pancytopenia, who was subsequently diagnosed with vitamin B12 deficiency upon admission. The patient underwent a thorough evaluation to exclude alternative etiologies for her presentation. Her clinical symptoms and blood count significantly improved after six days of treatment with vitamin B12 supplementation. While vitamin B12 deficiency is a commonly recognized issue, healthcare providers should be aware of its infrequent presentations. Our case serves as a reminder to clinicians to remain vigilant for acute onset manifestations and consider vitamin B12 deficiency as a differential diagnosis for the early management of pancytopenia.

TFOS Lifestyle: Impact of nutrition on the ocular surface

Nutrients, required by human bodies to perform life-sustaining functions, are obtained from the diet. They are broadly classified into macronutrients (carbohydrates, lipids, and proteins), micronutrients (vitamins and minerals) and water. All nutrients serve as a source of energy, provide structural support to the body and/or regulate the chemical processes of the body. Food and drinks also consist of non-nutrients that may be beneficial (e.g., antioxidants) or harmful (e.g., dyes or preservatives added to processed foods) to the body and the ocular surface. There is also a complex interplay between systemic disorders and an individual's nutritional status. Changes in the gut microbiome may lead to alterations at the ocular surface. Poor nutrition may exacerbate select systemic conditions. Similarly, certain systemic conditions may affect the uptake, processing and distribution of nutrients by the body. These disorders may lead to deficiencies in micro- and macro-nutrients that are important in maintaining ocular surface health. Medications used to treat these conditions may also cause ocular surface changes. The prevalence of nutrition-related chronic diseases is climbing worldwide. This report sought to review the evidence supporting the impact of nutrition on the ocular surface, either directly or as a consequence of the chronic diseases that result. To address a key question, a systematic review investigated the effects of intentional food restriction on ocular surface health; of the 25 included studies, most investigated Ramadan fasting (56%), followed by bariatric surgery (16%), anorexia nervosa (16%), but none were judged to be of high quality, with no randomized-controlled trials.