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Vitamin B12 has the largest and most complex chemical structure of all the vitamins. It is unique among vitamins in that it contains a metal ion, cobalt. For this reason cobalamin is the term used to refer to compounds having vitamin B12 activity. Methylcobalamin and 5-deoxyadenosylcobalamin are the forms of vitamin B12 used in the human body (1). The form of cobalamin used in most nutritional supplements and fortified foods, cyanocobalamin, is readily converted to 5-deoxyadenosylcobalamin and methylcobalamin in the body. In mammals, cobalamin is a cofactor for only two enzymes, methionine synthase and L-methylmalonyl-coenzyme A mutase (2).
Cofactor for methionine synthase
Methylcobalamin is required for the function of the folate-dependent enzyme, methionine synthase. This enzyme is required for the synthesis of the amino acid, methionine, from homocysteine. Methionine in turn is required for the synthesis of S-adenosylmethionine, a methyl group donor used in many biological methylation reactions, including the methylation of a number of sites within DNA, RNA, and proteins (3). Aberrant methylation of DNA and proteins, which causes alterations in chromatin structure and gene expression, are a common feature of cancer cells. Inadequate function of methionine synthase can lead to an accumulation of homocysteine, which has been associated with increased risk of cardiovascular diseases (diagram).
Cofactor for L-methylmalonyl-coenzyme A mutase
5-Deoxyadenosylcobalamin is required by the enzyme that catalyzes the conversion of L-methylmalonyl-coenzyme A to succinyl-coenzyme A (succinyl-CoA), which then enters the citric acid cycle (see diagram). Succinyl-CoA plays an important role in the production of energy from lipids and proteins and is also required for the synthesis of hemoglobin, the oxygen-carrying pigment in red blood cells (3).
In healthy adults, vitamin B12 deficiency is uncommon, mainly because total body stores can exceed 2,500 mcg, daily turnover is slow, and dietary intake of only 2.4 mcg/day is sufficient to maintain adequate vitamin B12 status (see RDA below) (4). In elderly individuals, vitamin B12 deficiency is more common mainly because of impaired intestinal absorption that can result in marginal to severe vitamin B12 deficiency in this population.
Intestinal malabsorption, rather than inadequate dietary intake, can explain most cases of vitamin B12 deficiency (5). Absorption of vitamin B12 from food requires normal function of the stomach, pancreas, and small intestine. Stomach acid and enzymes free vitamin B12 from food, allowing it to bind to R-protein (also known as transcobalamin-1 or haptocorrin), found in saliva and gastric fluids. In the alkaline environment of the small intestine, R-proteins are degraded by pancreatic enzymes, freeing vitamin B12 to bind to intrinsic factor (IF), a protein secreted by specialized cells in the stomach. Receptors on the surface of the ileum (final part of the small intestine) take up the IF-B12 complex only in the presence of calcium, which is supplied by the pancreas (5). Vitamin B12 can also be absorbed by passive diffusion, but this process is very inefficient—only about 1% absorption of the vitamin B12 dose is absorbed passively (2). The prevalent causes of vitamin B12 deficiency are (1) an autoimmune condition known as pernicious anemia, and (2) a disorder called food-bound vitamin B12 malabsorption. Both conditions have been associated with a chronic inflammatory disease of the stomach known as atrophic gastritis.
Atrophic gastritis is thought to affect 10%-30% of people over 60 years of age (6). The condition is frequently associated with the presence of autoantibodies directed towards stomach cells (see Pernicious anemia) and/or infection by the bacteria, Helicobacter pylori (H. pylori) (7). H. pylori infection induces chronic inflammation of the stomach, which may progress to peptic ulcer disease, atrophic gastritis, and/or gastric cancer in some individuals. Diminished gastric function in individuals with atrophic gastritis can result in bacterial overgrowth in the small intestine and cause food-bound vitamin B12 malabsorption. Vitamin B12 levels in serum, plasma, and gastric fluids are significantly decreased in individuals with H. pylori infection, and eradication of the bacteria has been shown to significantly improve vitamin B12 serum concentrations (8).
Pernicious anemia has been estimated to be present in approximately 2% of individuals over 60 years of age (9). Although anemia is often a symptom, the condition is actually the end stage of an autoimmune inflammation of the stomach known as autoimmune atrophic gastritis, resulting in destruction of stomach cells by one's own antibodies (autoantibodies). Progressive destruction of the cells that line the stomach causes decreased secretion of acid and enzymes required to release food-bound vitamin B12. Antibodies to intrinsic factor (IF) bind to IF preventing formation of the IF-B12 complex, further inhibiting vitamin B12 absorption. About 20% of the relatives of pernicious anemia patients also have the condition, suggesting a genetic predisposition. It is also thought that H. pylori infection could be involved in initiating the autoimmune response in a subset of individuals (10). Further, co-occurrence of autoimmune atrophic gastritis with other autoimmune conditions, especially autoimmune thyroiditis and type 1 diabetes mellitus, has been reported (11, 12).
Treatment of pernicious anemia generally requires injections of vitamin B12 to bypass intestinal absorption. High-dose oral supplementation is another treatment option, because consuming 1,000 mcg (1 mg)/day of vitamin B12 orally should result in the absorption of about 10 mcg/day (1% of dose) by passive diffusion. In fact, high-dose oral therapy is considered to be as effective as intramuscular injection (4).
Food-bound vitamin B12 malabsorption
Food-bound vitamin B12 malabsorption is defined as an impaired ability to absorb food- or protein-bound vitamin B12; individuals with this condition can fully absorb the free form (13). While the condition is the major cause of poor vitamin B12 status in the elderly population, it is usually associated with atrophic gastritis, a chronic inflammation of the lining of the stomach that ultimately results in the loss of glands in the stomach (atrophy) and decreased stomach acid production (see Atrophic gastritis above). Because stomach acid is required for the release of vitamin B12 from the proteins in food, vitamin B12 absorption is diminished. Decreased stomach acid production also provides an environment conducive to the overgrowth of anaerobic bacteria in the stomach, which further interferes with vitamin B12 absorption (3). Because vitamin B12 in supplements is not bound to protein, and because intrinsic factor (IF) is still available, the absorption of supplemental vitamin B12 is not reduced as it is in pernicious anemia. Thus, individuals with food-bound vitamin B12 malabsorption do not have an increased requirement for vitamin B12; they simply need it in the crystalline form found in fortified foods and dietary supplements.
Other causes of vitamin B12 deficiency include surgical resection of the stomach or portions of the small intestine where receptors for the IF-B12 complex are located. Conditions affecting the small intestine, such as malabsorption syndromes (celiac disease and tropical sprue), may also result in vitamin B12 deficiency. Because the pancreas provides critical enzymes, as well as calcium required for vitamin B12 absorption, pancreatic insufficiency may contribute to vitamin B12 deficiency. Since vitamin B12 is found only in foods of animal origin, a strict vegetarian (vegan) diet has resulted in cases of vitamin B12 deficiency. Moreover, alcoholics may experience reduced intestinal absorption of vitamin B12 (2), and individuals with acquired immunodeficiency syndrome (AIDS) appear to be at increased risk of deficiency, possibly related to a failure of the IF-B12 receptor to take up the IF-B12 complex (3). Further, long-term use of acid-reducing drugs has also been implicated in vitamin B12 deficiency (see Drug interactions).
Inherited disorders of vitamin B12 absorption
Rare cases of inborn errors of vitamin B12 metabolism have been reported in the literature (reviewed in 5). Imerslund-Gräsbeck syndrome is an inherited vitamin B12 malabsorption syndrome that causes megaloblastic anemia and neurologic disorders of variable severity in affected subjects. Similar clinical symptoms are found in individuals with hereditary IF deficiency (also called congenital pernicious anemia) in whom the lack of IF results in the defective absorption of vitamin B12. Additionally, mutations affecting vitamin B12 transport in the body have been identified (14).
Symptoms of vitamin B12 deficiency
Vitamin B12 deficiency results in impairment of the activities of vitamin B12-requiring enzymes. Impaired activity of methionine synthase results in elevated homocysteine levels, while impaired activity of L-methylmalonyl-CoA mutase results in increased levels of a metabolite of methylmalonyl-CoA called methylmalonic acid (MMA). While individuals with mild vitamin B12 deficiency may not experience symptoms, blood levels of homocysteine and/or MMA may be elevated (15).
Diminished activity of methionine synthase in vitamin B12 deficiency inhibits the regeneration of tetrahydrofolate (THF) and traps folate in a form that is not usable by the body (see diagram), resulting in symptoms of folate deficiency even in the presence of adequate folate levels. Thus, in both folate and vitamin B12 deficiencies, folate is unavailable to participate in DNA synthesis. This impairment of DNA synthesis affects the rapidly dividing cells of the bone marrow earlier than other cells, resulting in the production of large, immature, hemoglobin-poor red blood cells. The resulting anemia is known as megaloblastic anemia and is the symptom for which the disease, pernicious anemia, was named (3). Supplementation with folic acid will provide enough usable folate to restore normal red blood cell formation. However, if vitamin B12 deficiency is the cause, it will persist despite the resolution of the anemia. Thus, megaloblastic anemia should not be treated with folic acid until the underlying cause has been determined (16).
The neurologic symptoms of vitamin B12 deficiency include numbness and tingling of the hands and, more commonly, the feet; difficulty walking; memory loss; disorientation; and dementia with or without mood changes. Although the progression of neurologic complications is generally gradual, such symptoms may not be reversed with treatment of vitamin B12 deficiency, especially if they have been present for a long time. Neurologic complications are not always associated with megaloblastic anemia and are the only clinical symptom of vitamin B12 deficiency in about 25% of cases (17). Although vitamin B12 deficiency is known to damage the myelin sheath covering cranial, spinal, and peripheral nerves, the biochemical processes leading to neurological damage in vitamin B12 deficiency are not yet fully understood (18).
Tongue soreness, appetite loss, and constipation have also been associated with vitamin B12 deficiency. The origins of these symptoms are unclear, but they may be related to the stomach inflammation underlying some cases of vitamin B12 deficiency and to the progressive destruction of the lining of the stomach (17).
The RDA for vitamin B12 was revised by the Food and Nutrition Board (FNB) of the US Institute of Medicine in 1998. Because of the increased risk of food-bound vitamin B12 malabsorption in older adults, the FNB recommended that adults over 50 years of age get most of the RDA from fortified food or vitamin B12-containing supplements (17).
|Recommended Dietary Allowance (RDA) for Vitamin B12|
|Life Stage||Age||Males (mcg/day)||Females (mcg/day)|
|Infants||0-6 months||0.4 (AI)||0.4 (AI)|
|Infants||7-12 months||0.5 (AI)||0.5 (AI)|
|Adults||51 years and older||2.4*||2.4*|
*Vitamin B12 intake should be from supplements or fortified foods due to the age-related increase in food-bound malabsorption.
As mentioned above, chronic atrophic gastritis and infection by H. pylori can cause deficiency in vitamin B12 secondary to malabsorption disorders (see Causes of vitamin B12 deficiency). However, the occurrence of H. pylori infection and chronic atrophic gastritis did not modify the five-year incidence of cardiovascular accidents (stroke and heart attack) or mortality in a large cohort study of nearly 10,000 men and women over 50 years old (19). Yet, vitamin B12 status was not assessed in this study, despite the high prevalence of vitamin B12 deficiency in older individuals.
Homocysteine and cardiovascular diseases
Epidemiological studies indicate that even moderately elevated levels of homocysteine in the blood raise the risk of cardiovascular diseases (CVD) (20), though the mechanism by which homocysteine may increase the CVD risk remains the subject of a great deal of research (21). The amount of homocysteine in the blood is regulated by at least three vitamins: folate, vitamin B6, and vitamin B12 (see diagram). An early analysis of the results of 12 randomized controlled trials showed that folic acid supplementation (0.5-5 mg/day) had the greatest lowering effect on blood homocysteine levels (25% decrease); co-supplementation with folic acid and vitamin B12 (500 mcg/day) provided an additional 7% reduction (32% decrease) in blood homocysteine concentrations (22). The results of a sequential supplementation trial in 53 men and women indicated that after folic acid supplementation, vitamin B12 became the major determinant of plasma homocysteine levels (23). It is thought that the elevation of homocysteine levels might be partly due to vitamin B12 deficiency in individuals over 60 years of age. Two studies found blood methylmalonic acid (MMA) levels to be elevated in more than 60% of elderly individuals with elevated homocysteine levels. In the absence of impaired kidney function, an elevated MMA level in conjunction with elevated homocysteine suggests either a vitamin B12 deficiency or a combined vitamin B12 and folate deficiency (24). Thus, it appears important to evaluate vitamin B12 status, as well as kidney function, in older individuals with elevated homocysteine levels prior to initiating homocysteine-lowering therapy. For more information regarding homocysteine and CVD, see the article on folate.
Although increased intake of folic acid and vitamin B12 is effective in decreasing homocysteine levels, the combined intervention of these B vitamins did not lower risk for CVD. Indeed, several randomized, placebo-controlled trials have been conducted to determine whether homocysteine-lowering through folic acid, vitamin B12, and vitamin B6 supplementation reduces the incidence of CVD. A recent meta-analysis of data from 11 trials, including nearly 45,000 participants at risk of CVD, showed that B-vitamin supplementation had no significant effect on risk of myocardial infarction (heart attack) or stroke, nor did it modify the risk of all-cause mortality (25). Other meta-analyses that included patients with chronic kidney disease have confirmed the lack of effect of homocysteine-lowering on risk of myocardial infarction and death. However, stroke risk was significantly reduced by 7%-12% with the B-vitamin supplementation (26, 27). Another meta-analysis of 12 clinical trials measuring flow-mediated vasodilation (FMD; a surrogate marker of vascular health) in response to homocysteine reduction revealed that B-vitamin supplementation was accompanied by an improved FMD in short-term <8 weeks) but not in long-term studies conducted in subjects with preexisting vascular diseases (28). Yet, some of the studies included in these meta-analyses did not use vitamin B12, and folate administration on its own has shown a protective role on vascular function and stroke risk (29). Besides, the high prevalence of malabsorption disorders and vitamin B12 deficiency in elderly individuals might warrant the use of higher doses of vitamin B12 than those used in these trials (30); in cases of malabsorption, only high-dose oral therapy or intramuscular injections can overcome vitamin B12 deficiency (4).
Folate is required for synthesis of DNA, and there is evidence that decreased availability of folate results in strands of DNA that are more susceptible to damage. Deficiency of vitamin B12 traps folate in a form that is unusable by the body for DNA synthesis. Both vitamin B12 and folate deficiencies result in a diminished capacity for methylation reactions (see diagram). Thus, vitamin B12 deficiency may lead to an elevated rate of DNA damage and altered methylation of DNA, both of which are important risk factors for cancer. A series of studies in young adults and older men indicated that increased levels of homocysteine and decreased levels of vitamin B12 in the blood were associated with a biomarker of chromosome breakage in white blood cells (reviewed in 31). In a double-blind, placebo-controlled study, the same biomarker of chromosome breakage was minimized in young adults who were supplemented with 700 mcg of folic acid and 7 mcg of vitamin B12 daily in cereal for two months (32).
A case-control study compared prediagnostic levels of serum folate, vitamin B6, and vitamin B12 in 195 women later diagnosed with breast cancer and 195 age-matched, cancer-free women. Among postmenopausal women, the association between blood levels of vitamin B12 and breast cancer suggested a threshold effect. The risk of breast cancer was more than doubled in women with serum vitamin B12 levels in the lowest quintile compared to women in the four highest quintiles (33). However, the meta-analysis of this study with three additional case-control studies found no protection associated with high compared to low vitamin B12 serum levels (34). A case-control study in Mexican women (475 cases and 1,391 controls) reported that breast cancer risk for women in the highest quartile of vitamin B12 intake (7.3-7.7 mcg/day) was 68% lower than those in the lowest quartile (2.6 mcg/day). Stratification of the data revealed that the inverse association between dietary vitamin B12 intake and breast cancer risk was stronger in postmenopausal women compared to premenopausal women, though both associations were statistically significant. Moreover, among postmenopausal women, the apparent protection conferred by folate was only observed in women with the highest vitamin B12 quartiles of intake (35). However, more recent case-control and prospective cohort studies have reported weak to no risk reduction with vitamin B12 intakes in different populations, including Hispanic, African American and European American women (36, 37). A meta-analysis of seven case-control and seven prospective cohort studies concluded that the risk of breast cancer was not modified by high versus low vitamin B12 intakes (34). There was no joint association between folate and vitamin B12 intakes and breast cancer risk. Presently, there is little evidence to suggest a relationship between vitamin B12 status and breast cancer. In addition, results from observational studies are not consistently in support of an association between high dietary folate intakes and reduced risk for breast cancer (see the article on Folate). There is a need to evaluate the effect of folate and vitamin B12 supplementation in well-controlled, randomized, clinical trials, while considering various factors that modify breast cancer risk, such as menopausal status, ethnicity, and alcohol intake.
Neural tube defects (NTD) may result in anencephaly or spina bifida, which are mostly fatal congenital malformations of the central nervous system. The defects arise from failure of embryonic neural tube to close, which occurs between the 21st and 28th days after conception, a time when many women are unaware of their pregnancy (38). Randomized controlled trials have demonstrated 60% to 100% reductions in NTD cases when women consumed folic acid supplements in addition to a varied diet during the month before and the month after conception. Increasing evidence indicates that the homocysteine-lowering effect of folic acid plays a critical role in reducing the risk of NTD (39). Homocysteine may accumulate in the blood when there is inadequate folate and/or vitamin B12 for effective functioning of the methionine synthase enzyme. Decreased vitamin B12 levels and elevated homocysteine concentrations have been found in the blood and amniotic fluid of pregnant women at high risk of NTD (40). The recent meta-analysis of 12 case-control studies, including 567 mothers with current or prior NTD-affected pregnancy and 1,566 unaffected mothers, showed that low maternal vitamin B12 status was associated with an increased risk of NTD (41). Yet, whether vitamin B12 supplementation may be beneficial in the prevention of NTD has not been evaluated (42).
The occurrence of vitamin B12 deficiency prevails in the elderly population and has been frequently associated with Alzheimer's disease (reviewed in 43). One study found lower vitamin B12 levels in the cerebrospinal fluid of patients with Alzheimer's disease than in patients with other types of dementia, though blood levels of vitamin B12 did not differ (44). The reason for the association of low vitamin B12 status with Alzheimer's disease is not clear. Vitamin B12 deficiency, like folate deficiency, may lead to decreased synthesis of methionine and S-adenosylmethionine (SAM), thereby adversely affecting methylation reactions. Methylation reactions are essential for the metabolism of components of the myelin sheath of nerve cells as well as for synthesis of neurotransmitters (18). Other metabolic implications of vitamin B12 deficiency include the accumulation of homocysteine and methylmalonic acid, which might contribute to the neuropathologic features of dementia (43).
A large majority of cross-sectional and prospective cohort studies have associated elevated homocysteine concentrations with measures of poor cognitive scores and increased risk of dementia, including Alzheimer's disease (reviewed in 45). A case-control study of 164 patients with dementia of Alzheimer's type included 76 cases in which the diagnosis of Alzheimer's disease was confirmed by examination of brain cells after death. Compared to 108 control subjects without evidence of dementia, subjects with dementia of Alzheimer's type and confirmed Alzheimer's disease had higher blood homocysteine levels and lower blood levels of folate and vitamin B12. Measures of general nutritional status indicated that the association of increased homocysteine levels and diminished vitamin B12 status with Alzheimer's disease was not due to dementia-related malnutrition (46). In a sample of 1,092 men and women without dementia followed for an average of 10 years, those with higher plasma homocysteine levels at baseline had a significantly higher risk of developing Alzheimer's disease and other types of dementia. Specifically, those with plasma homocysteine levels greater than 14 micromol/L had nearly double the risk of developing Alzheimer's disease (47). A study in 650 elderly men and women reported that the risk of elevated plasma homocysteine levels was significantly higher in those with lower cognitive function scores (48). A prospective study in 816 elderly men and women reported that those with hyperhomocysteinemia (homocysteine levels >15 micromol/L) had a significantly higher risk of developing Alzheimer's disease or dementia. Although raised homocysteine levels might be partly due to a poor vitamin B12 status, the latter was not related to risk of Alzheimer's disease or dementia in this study (49).
A recent systematic review of 35 prospective cohort studies assessing the association between vitamin B12 status and cognitive deterioration in older individuals with or without dementia at baseline did not support a relationship between vitamin B12 serum concentrations and cognitive decline, dementia, or Alzheimer's disease (50). Nevertheless, studies utilizing more sensitive biomarkers of vitamin B12 status, including measures of holo-transcobalamin (holo-TC; a vitamin B12 carrier) and methylmalonic acid, showed more consistent results and a trend toward associations between poor vitamin B12 status and faster cognitive decline and risk of Alzheimer's disease (51-55). Besides, it cannot be excluded that the co-occurrence of potential confounders like elevated homocysteine level and poor folate status might mitigate the true contribution of vitamin B12 status to cognitive functioning (45).
High-dose B-vitamin supplementation has been proven effective for treating hyperhomocysteinemia in elderly individuals with or without cognitive impairment. However, homocysteine-lowering trials have produced equivocal results regarding the prevention of cognitive deterioration in this population. A systematic review and meta-analysis of 18 randomized, placebo-controlled trials examining the effect of B-vitamin supplementation did not find that the decrease in homocysteine level prevented or delayed cognitive decline among older subjects (56). A more recent randomized, double-blind, placebo-controlled clinical trial in 900 older individuals at high risk of cognitive impairment found that daily supplementation of 400 mcg of folic acid and 100 mcg of vitamin B12 for two years significantly improved measures of immediate and delayed memory and slowed the rise in plasma homocysteine concentrations (57). However, supplemented subjects had no reduction in homocysteine concentrations compared to baseline, nor did they perform better in processing speed tests compared to placebo. Another two-year, randomized, placebo-controlled study in elderly adults reported that a daily regimen of 800 mcg of folic acid, 500 mcg of vitamin B12, and 20 mg of vitamin B6 significantly reduced the rate of brain atrophy compared to placebo treatment (0.5% vs. 3.7%). Interestingly, a greater benefit was seen in those with high compared to low homocysteine concentrations at baseline, suggesting the importance of lowering homocysteine levels in prevention of brain atrophy and cognitive decline (58, 59). The authors attributed the changes in homocysteine levels primarily to vitamin B12 (59). Finally, the most recent randomized, double blind, placebo-controlled trial in over 2,500 individuals who suffered a stroke showed that the normalization of homocysteine concentrations by B-vitamin supplementation (2 mg of folic acid, 500 mcg of vitamin B12, and 25 mg of vitamin B6) did not improve cognitive performance or decrease incidence of cognitive decline compared to placebo (60). Currently, there is a need for larger trials to evaluate the effect of B-vitamin supplementation on long-term outcomes, such as the incidence of Alzheimer's disease.
Observational studies have found as many as 30% of patients hospitalized for depression are deficient in vitamin B12 (61). A cross-sectional study of 700 community-living, physically disabled women over the age of 65 found that vitamin B12-deficient women were twice as likely to be severely depressed as non-deficient women (62). A population-based study in 3,884 elderly men and women with depressive disorders found that those with vitamin B12 deficiency were almost 70% more likely to experience depression than those with normal vitamin B12 status (63). The reasons for the relationship between vitamin B12 deficiency and depression are not clear but may involve a shortage in S-adenosylmethionine (SAM). SAM is a methyl group donor for numerous methylation reactions in the brain, including those involved in the metabolism of neurotransmitters whose deficiency has been related to depression (64). Severe vitamin B12 deficiency in a mouse model showed dramatic alterations in the level of DNA methylation in the brain, which might lead to neurologic impairments (65). This hypothesis is supported by several studies that have shown supplementation with SAM improves depressive symptoms (66-69).
Increased homocysteine level is another nonspecific biomarker of vitamin B12 deficiency that has been linked to depressive symptoms in the elderly (70). However, in a recent cross-sectional study conducted in 1,677 older individuals, higher vitamin B12 plasma levels, but not changes in homocysteine concentrations, were correlated with a lower prevalence of depressive symptoms (71). Few studies have examined the relationship of vitamin B12 status, homocysteine levels, and the development of depression over time. In a randomized, placebo-controlled, intervention study with over 900 older participants experiencing psychological distress, daily supplementation with folic acid (400 mcg) and vitamin B12 (100 mcg) for two years did not reduce the occurrence of symptoms of depression despite significantly improving blood folate, vitamin B12, and homocysteine levels compared to placebo (72). However, in a long-term randomized, double-blind, placebo-controlled study among sufferers of cerebrovascular accidents at high risk of depression, daily supplementation with 2 mg of folic acid, 25 mg of vitamin B6, and 500 mcg vitamin B12 significantly lowered the risk of major depressive episodes during a seven-year follow-up period compared to placebo (73). Although it cannot yet be determined whether vitamin B12 deficiency plays a causal role in depression, it may be beneficial to screen for vitamin B12 deficiency in older individuals as part of a medical evaluation for depression.
High homocysteine levels may affect bone remodeling by increasing bone resorption (breakdown), decreasing bone formation, and reducing bone blood flow. Another proposed mechanism involves the binding of homocysteine to the collagenous matrix of bone, which may modify collagen properties and reduce bone strength (reviewed in 74). Alterations of bone biomechanical properties can contribute to osteoporosis and increase the risk of fractures in the elderly. Since vitamin B12 is a determinant of homocysteine metabolism, it was suggested that the risk of osteoporotic fractures in older subjects might be enhanced by vitamin B12 deficiency. A meta-analysis of four observational studies, following a total of 7,475 older individuals for 3 to 16 years, found a weak association between an elevation in vitamin B12 of 50 picomoles/L in blood and a reduction in fracture risk (75). A randomized, placebo-controlled trial in 559 elderly individuals with low serum levels of folate and vitamin B12 and at increased risk of fracture evaluated the combined supplementation of very high doses of folic acid (5 mg/day) and vitamin B12 (1.5 mg/day). The two-year study found that the supplementation improved B-vitamin status, decreased homocysteine concentrations, and reduced risk of total fractures compared to placebo (76). However, a multicenter study in 5,485 subjects with cardiovascular disease or diabetes mellitus showed that daily supplementation with folic acid (2.5 mg), vitamin B12 (1 mg), and vitamin B6 (50 mg) lowered homocysteine concentrations but had no effect on fracture risk compared to placebo (77). Another small, randomized, double-blind trial in 93 individuals with low vitamin D status found no additional benefit of B-vitamin supplementation (50 mg/day of vitamin B6, 0.5 mg/day of folic acid, and 0.5 mg/day of vitamin B12) on markers of bone health over a one-year period beyond that associated with vitamin D and calcium supplementation. Yet, the short-scale of the study did not permit a conclusion on whether the lowering of homocysteine through B-vitamin supplementation could have long-term benefits on bone strength and fracture risk (78). A large intervention study conducted in older people with no preexisting conditions is under way to evaluate the effect of B-vitamin supplementation on markers of bone health and incidence of fracture; this trial might clarify whether B vitamins could have a protective effect on bone health in the elderly population (79).
Only bacteria can synthesize vitamin B12 (80). Vitamin B12 is present in animal products, such as meat, poultry, fish (including shellfish), and to a lesser extent dairy products and eggs (1). Fresh pasteurized milk contains 0.9 mcg per cup and is an important source of vitamin B12 for some vegetarians (17). Those strict vegetarians who eat no animal products (vegans) need supplemental vitamin B12 to meet their requirements. Recent analyses revealed that some plant-source foods, such as certain fermented beans and vegetables and edible algae and mushrooms, contain substantial amounts of bioactive vitamin B12 (81). Together with B-vitamin fortified food and supplements, these foods may constitute new alternatives to prevent vitamin B12 deficiency in individuals consuming vegetarian diets. Also, individuals over the age of 50 should obtain their vitamin B12 in supplements or fortified foods (e.g., fortified cereals) because of the increased likelihood of food-bound vitamin B12 malabsorption with increasing age.
Most people do not have a problem obtaining the RDA of 2.4 mcg/day of vitamin B12 in food. According to a US national survey, the average dietary intake of vitamin B12 is 5.4 mcg/day for adult men and 3.4 mcg/day for adult women. Adults over the age of 60 had an average dietary intake of 4.8 mcg/day (42). However, consumption of any type of vegetarian diet dramatically increases the prevalence of vitamin B12 deficiency in individuals across all age groups (82). Some foods with substantial amounts of vitamin B12 are listed in the table below along with their vitamin B12 content in micrograms (mcg). For more information on the nutrient content of specific foods, search the USDA food composition database.
|Food||Serving||Vitamin B12 (mcg)|
|Clams (steamed)||3 ounces||84.1|
|Mussels (steamed)||3 ounces||20.4|
|Mackerel (Atlantic, cooked, dry-heat)||3 ounces*||16.1|
|Crab (Alaska king, steamed)||3 ounces||9.8|
|Beef (lean, plate steak, cooked, grilled)||3 ounces||6.9|
|Salmon (chinook, cooked, dry-heat)||3 ounces||2.4|
|Rockfish (cooked, dry-heat)||3 ounces||1.0|
|Milk (skim)||8 ounces||0.9|
|Turkey (cooked, roasted)||3 ounces||0.8|
|Brie (cheese)||1 ounce||0.5|
|Egg (poached)||1 large||0.4|
|Chicken (light meat, cooked, roasted)||3 ounces||0.3|
*A three-ounce serving of meat or fish is about the size of a deck of cards.
Cyanocobalamin is the principal form of vitamin B12 used in oral supplements, but methylcobalamin is also available as a supplement. Cyanocobalamin is available by prescription in an injectable form and as a nasal gel for the treatment of pernicious anemia. Over-the-counter preparations containing cyanocobalamin include multivitamins, vitamin B-complex supplements, and single-nutrient, vitamin B12 supplements (83).
No toxic or adverse effects have been associated with large intakes of vitamin B12 from food or supplements in healthy people. Doses as high as 2 mg (2,000 mcg) daily by mouth or 1 mg monthly by intramuscular (IM) injection have been used to treat pernicious anemia without significant side effects (84). When high doses of vitamin B12 are given orally, only a small percentage can be absorbed, which may explain the low toxicity (4). Because of the low toxicity of vitamin B12, no tolerable upper intake level (UL) has been set by the US Food and Nutrition Board (17).
A number of drugs reduce the absorption of vitamin B12. Proton-pump inhibitors (e.g., omeprazole and lansoprazole), used for therapy of Zollinger-Ellison syndrome and gastroesophageal reflux disease (GERD), markedly decrease stomach acid secretion required for the release of vitamin B12 from food but not from supplements. Long-term use of proton-pump inhibitors has been found to decrease blood vitamin B12 levels. However, vitamin B12 deficiency does not generally develop until after at least three years of continuous therapy (85, 86). Another class of gastric acid inhibitors known as Histamine2 (H2)-receptor antagonists (e.g., cimetidine, famotidine, and ranitidine), often used to treat peptic ulcer disease, has also been found to decrease the absorption of vitamin B12 from food. It is not clear whether the long-term use of H2-receptor antagonists could cause overt vitamin B12 deficiency (87, 88). Individuals taking drugs that inhibit gastric acid secretion should consider taking vitamin B12 in the form of a supplement because gastric acid is not required for its absorption. Other drugs found to inhibit vitamin B12 absorption from food include cholestyramine (a bile acid-binding resin used in the treatment of high cholesterol), chloramphenicol and neomycin (antibiotics), and colchicine (medicine for gout treatment). Metformin, a medication for individuals with type 2 diabetes, was found to decrease vitamin B12 absorption by tying up free calcium required for absorption of the IF-B12 complex (89). However, the clinical significance of this is unclear (90). It is not known whether calcium supplementation can reverse vitamin B12 malabsorption; therefore, calcium supplementation is not currently prescribed for the prevention or treatment of metformin-induced vitamin B12 deficiency (91). Previous reports that megadoses of vitamin C destroy vitamin B12 have not been supported (92) and may have been an artifact of the assay used to measure vitamin B12 levels (17).
Nitrous oxide, a commonly used anesthetic, oxidizes and inactivates vitamin B12, thus inhibiting both of the vitamin B12-dependent enzymes, and can produce many of the clinical features of vitamin B12 deficiency, such as megaloblastic anemia or neuropathy. Since nitrous oxide is commonly used for surgery in the elderly, some experts feel vitamin B12 deficiency should be ruled out prior to its use (6, 15).
Large doses of folic acid given to an individual with an undiagnosed vitamin B12 deficiency could correct megaloblastic anemia without correcting the underlying vitamin B12 deficiency, leaving the individual at risk of developing irreversible neurologic damage (17). For this reason, the Food and Nutrition Board of the US Institute of Medicine advises that all adults limit their intake of folic acid (supplements and fortification) to 1,000 mcg (1 mg) daily.
A varied diet should provide enough vitamin B12 to prevent deficiency in most individuals 50 years of age and younger. Strict vegetarians and women planning to become pregnant should take a multivitamin supplement daily or eat fortified cereal, which would ensure a daily intake of 6 to 30 mcg of vitamin B12 in a form that is easily absorbed. Higher doses of vitamin B12 supplements are recommended for patients taking medications that interfere with its absorption (see Drug interactions).
Older adults (> 50 years)
Because vitamin B12 malabsorption and vitamin B12 deficiency are more common in older adults, the Linus Pauling Institute recommends that adults older than 50 years take 100 to 400 mcg/day of supplemental vitamin B12.
Written in March 2003 by:
Jane Higdon, Ph.D.
Linus Pauling Institute
Oregon State University
Updated in January 2014 by:
Barbara Delage, Ph.D.
Linus Pauling Institute
Oregon State University
Reviewed in April 2014 by:
Joshua W. Miller, Ph.D.
Professor and Chair, Department of Nutritional Sciences
Rutgers, The State University of New Jersey
Copyright 2000-2014 Linus Pauling Institute
The Linus Pauling Institute Micronutrient Information Center provides scientific information on the health aspects of dietary factors and supplements, foods, and beverages for the general public. The information is made available with the understanding that the author and publisher are not providing medical, psychological, or nutritional counseling services on this site. The information should not be used in place of a consultation with a competent health care or nutrition professional.
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