Vitamin B12: Under Appreciated

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Vitamin B12: Under Appreciated

 

© Dr. Richard A. Kunin MD,

 

I have recently treated over half a dozen patients

whose lives have been ruined by vitamin B12

deficiency--a preventable disorder. In every case

there was medical error and/or patient ignorance and

skepticism leading to permanent harm. It is easy to

miss the diagnosis of vitamin B12 deficiency. In the

first place, it is a vitamin and our medical education

is not only weak on vitamin diagnosis, it often

reviles those doctors who treat with vitamins.

 

For example, B 12 injections are generally considered

unnecessary, just one step short of quackery, by peer

review committees and health insurance claims

reviewers. Even if the patient feels better, the

powers that be still condemn the practice as a form of

suggestibility and placebo effect. No question about

it: doctors are discouraged from treating with vitamin

B12 unless there is documentary evidence, such as

macrocytic anemia, with large sized red cells, over

100 microns in volume, or a B12 blood test less than

115 pg/ml (billionths of a gram per milliliter).

Unfortunately the laboratory signs are not always that

clear. Then the doctor’s experience must take over.

 

Vitamin B12 is an essential co-factor for two vital

enzymes.

1. MMA (methylmalonyl CoA mutase). If B12 is

deficient, methylmalonic acid cannot be converted to

succinate, a necessary step in the utilization of

odd-numbered fatty acids, those ending with a 3 carbon

propionic acid group, rather than the usual 2 carbon

acetic acid group. As a result methylmalonic piles up

in the blood, blocked from its normal metabolism into

succinate, which can be oxidized in the citric acid

cycle, thus producing energy in the form of ATP.

 

In other words, without adequate B12 fats do not enter

the carbohydrate cycle. As a result, there is a drop

in energy level and a tendency to hypoglycemia, low

blood sugar.

 

2. Methionine synthetase: necessary for recycling the

essential amino acid, methionine, by transferring a

carbon atom to homocysteine. There is no other

mechanism to make this methyl carbon transfer except

by means of B12; hence B12 deficiency causes two

chemical problems here: homocysteine accumulates in

the blood, and methionine becomes scarce at the same

time.

 

* Homocysteine is bad because it binds copper,

literally attracting it out of its reaction sites in

collagen, and thus unraveling collagen, the bio-glue

that holds tissues together, especially the intimal

lining of blood vessels. This internal damage can

cause blood vessel leaks, clots and deposits. If the

coronary arteries are affected it can cause heart

attack; in the cerebral arteries it causes strokes,

and any damaged artery is liable to enlarge, forming

an aneurysm, which can rupture. In a large vessel,

such as the aorta, this can cause sudden death.

 

* A shortage of methionine causes deficiency of a

vital enzyme, SAM, that

is S-Adenosyl-Methionine, which becomes

homocysteine by giving up its active methyl carbon in

the manufacture of several essential body chemicals

(see below). The re-cycling of methionine from

homocysteine by means of capturing a methyl from

methyl-THF is an equally key step in order to conserve

methionine, which otherwise comes only from the diet.

B12 is required to transfer the methyl carbon from

methyl-folate (mTHF) and in the process serves also to

activate folic acid for several other vital functions,

such as nucleic acid synthesis. By giving up a methyl

group, methyl THF becomes THF, which is

interconvertable with four other sub-types of folic

acid.

 

* Deficient B12 status therefore blocks the

utilization of methyl-THF, which can rise to above

normal levels of folic acid blood tests. That is a

tip-off to B12 deficiency.

 

* Low THF is a serious deficiency, associated with

birth defects and increased incidence of cancer. The

connection is obvious once you know that THF is

required for synthesis of nucleic acid components, the

purine and pyrimidine bases, from which DNA and RNA

are formed.

 

 

 

SAM is also vital for the production of adrenalin (a

neurohormone); creatine (a muscle energy source);

choline, an acetyl-choline component

(neuro-transmitter); phosphatidyl-choline, a lecithin

(cell membrane repair); and polyamines spermine and

spermidine (stimulate cell growth and repair).

 

If these relationships seem complicated they are; but

the practical effects of B12 activity are

straight-forward:

1. Nucleic acid synthesis (healing, manufacture of all

body cells, especially red blood cells, DNA, and

antibodies;

2. Activation of the vitamin, folic acid, (redoubles

anti-cancer effect and together they support synthesis

of myelin, the insulating covering of nerves;

3. Synthesis of SAM (most powerful natural

anti-depressant-via epinephrine);

4. Recycling of methionine (conserves this scarce

amino acid, permits lower protein intake);

5. Removal of toxic homocysteine (thus protecting

against collagen damage in blood vessel lining, hence

protects against atherosclerosis and aneurysm

(damage), and hypertension (spasm);

6. Protection from copper deficiency otherwise caused

by homocysteine (thus protects against heart damage

and arrhythmia, diabetes, chronic fatigue);

7. Efficient oxidation of fats, so that methylmalonic

acid and propionic acid do not accumulate. These

organic acids deplete the vitamin Carnitine, and this

causes fatigue, loss of muscle tone and simulates

depression.

8. Production of myelin, the insulation of nerves.

Repair of nerves prevents damage to the spinal cord

and brain, so-called subacute combined degeneration.

This involves pain (early) and loss of muscle

perception and vibration sense (late) in the hands and

feet. It also causes mental impairment, typically with

paranoia and depression, is similar to Alzheimer’s. In

fact, about 30 percent of patients with Alzheimer’s

actually have B12 deficiency.

 

If B12 is so important, why is there such medical

skepticism and resistance to its use? As recently as

1989, the Journal of the American Medical Association

saw fit to publish a featured article devoted to

persuading patients to stop taking B12

injections--even though the patients claimed good

results . The setting of the study was a clinic

serving over 1200 patients and recently taken over by

new owners. A records audit showed120 patients had

been receiving B12 injections regularly; however only

4 of the 120 met the medical criteria for receiving

vitamin B12 therapy. The authors accepted only four

indications for prescribing this vitamin: 1)

pernicious anemia; 2) deficiency documented by

laboratory test; 3) a history of gastric surgery; 4)

intestinal disease with malabsorption.

 

The authors real motivation for performing the study

is that the health insurance companies were refusing

payment for B12 injections. The authors did not seem

opposed to the practice, saying only " The use of

cyanocobalamin (B12) injections for patients without

documented deficiency has been a common practice both

ridiculed and indulged by the medical profession. " On

the other hand, they referred to an insurance review

agency that rejected more than 75% of almost 3000

cyanocobalamin injection claims for payment. There

lies the problem. Insurance companies do not

" indulge. " Lawyers and accountants do not think like

doctors. Money comes before comfort in the

bureaucratic mind, and the doctor-patient relationship

gets little credence when it comes to substantiating

benefits. That’s just the way it is.

 

Historically vitamin B12 was first recognized in

relation to pernicious anemia; however in this study,

80 percent of the patients were motivated by weakness

and fatigue, not anemia, and the average benefit was

rated as " good " . In fact, these patients reported a

high level of effectiveness for most of the 25

indications listed in the study. They authors

concluded: " It is likely that this injection-seeking

behavior was reinforced and perpetuated by the

perception of benefit. Past recipients of

cyanocobalamin who perceived little or no benefit

would be less likely to return for repeated injections

and, thus, would be less likely to be included in the

study. "

 

If that paragraph seems obtuse, it is a classic of

medical obtuseness. The point is that the patients who

came back for repeat injections were the responders to

B12. That is understandable. What is not is the

cynicism of the authors--who reflect a majority of the

medical-political establishment, a bureaucratic

dragon, dead-set against giving an admittedly harmless

treatment that the patients consider helpful, because

it doesn’t fit current medical dogma, e.g. the four

indications considered " acceptable. " In fact, the

bottom line of this clinical study is: " Despite the

generally high perceived value of the injections, a

majority of those approached (25 of 48) were willing

to consider discontinuing them, at least temporarily. "

 

The implication of this report is that patients do not

know what is good for them and that clinic

administrators do. This report ignores the inherent

bias involved when those with a financial interest in

a medical business write and publish a report that

justifies terminating a treatment for 116 of 120

patients, not because the patients rejected the

treatment as ineffective, but because the laboratory

test results didn’t support the benefits the patients

claimed to get!

 

This violates a fundamental tenet of medical teaching:

" never diagnose a patient on the basis of laboratory

evidence alone. " Diagnosis must be in the context of

the history, examination (including laboratory

testing), clinical trials and follow-up that are part

and parcel of rational and scientific medical

practice.

 

The hidden tragedy of this report is that it pits the

doctor against his own patients. In fact the authors

admitted that 41 of these 120 patients dropped out of

the clinic and sought medical help elsewhere. That is

a 33% drop-out rate, about the same drop-out rate that

medical practices are seeing across America as

patients switch to alternative and non-medical health

practitioners, mainly chiropractors, acupuncturists

and nutritionists.

 

Patients rightfully want to be helped and they want to

be respected. We all do. Especially when we are sick

and feeling bad. It is the arrogance and inflexibility

of medical orthodoxy that threatens to topple the

entire medical profession and turn it into a mindless

public health system, run by text-book bureaucrats and

computerized robots. I don’t think the American people

will buy it; but that doesn’t seem to have gotten

across to the medical-political-bureaucratic people

who have just designed the Kennedy Kassebaum bill,

which reflects the psychology of this study by

defining " unnecessary services " as medical fraud. This

is the criminalization of medicine.

 

Prove it, you say! The bill increases penalties from

$2000 (already high) to $10,000 per infraction; and

potential jail time has been increased from 2 years to

10. If B12 and other nutrient therapies are

" unnecessary, " the hottest game in town may soon be:

" Cops and Docs. " If you wonder why doctors seem

uninterested in nutrition, perhaps this gives you an

idea why. Not until our legislators wake up and give

back our medical rights, such as the right to have a

treatment when we find that it is beneficial, even

though the regulations deny it, are you really the

master of your own medical care. Who is the ultimate

master of your body? You or a politician, bureaucrat

or lobbyist, whose rules satisfy their interests, not

necessarily yours.

 

Vitamin B12 does not fit the mold of the deficiency

diseases theory, or the one-disease-one-drug model of

medicine that is taught in medical schools. The most

important medical fact about vitamin B12 is that

deficiency does not show up only as anemia. In fact,

in many cases there is no anemia, only neurological

symptoms, such as numbness in the extremities,

inability to walk and stay in balance, especially at

night or in the dark, and serious personality changes,

such as depression and paranoia. Unlike the anemia,

which always responds to B12 replacement, if the nerve

and brain symptoms are not treated promptly the damage

is likely to be permanent.

 

Pernicious anemia is a serious disease. The bone

marrow produces large numbers of defective cells,

called megaloblasts, along with a reduced number of

normal and more durable ones. As the disease

progresses, the normal cells are increasingly replaced

by large cells, macrocytes, so the average size of the

circulating red cells increases by 25 to 50 percent.

Doctors recognize pernicious anemia by these large

sized cells in a blood smear.

 

Unfortunately, doctors are taught to diagnose and

treat the anemia and it is all too common that

physicians, even experienced psychiatrists, overlook

the nerve symptoms and treat the paranoia as

depression or schizophrenia, with drugs rather than a

vitamin. Two cases were published in 1984. in which

EEG brain waves and mental symptoms were reversible

with B12 therapy This convinced the authors that all

patients with dementia should be checked for B12. That

message has not gotten through.

 

One reason is that most doctors expect to find B12

problems in patients past age 60; and therefore may

fail to consider it in younger folks. One of my

patients was only 28 when B12 deficiency reached a

critical state. Patricia had been able to cover-up her

mental fuzziness and depression for years but the pain

in her extremities finally drove her to seek medical

help. Somehow the diagnosis was missed at two medical

centers. Only after she had a severe progression of

spinal cord damage following anesthesia for

laparoscopic surgery did the diagnosis become obvious.

 

Anesthetic agents, such as nitrous oxide (laughing

gas) and halothane and enflurane, destroy vitamin B12.

This pushed her into severe deficiency and within a

few weeks she lost muscle sense in her extremities,

became unable to walk and unable to control her

bladder. Despite ongoing treatment for over ten years

now, she remains confined to a wheel-chair, evidently

for life.

 

Some recovery is possible. Mary, a school-teacher, was

placed on a hospital psychiatric ward when she became

depressed and paranoid. When she complained of leg

pains, the medical team were led astray by the fact

that she is diabetic, since this condition also can

present as nerve symptoms. It was only after several

months, as her mental condition deteriorated into

severe confusion and dementia the diagnosis of B12

deficiency was obvious. By that time she too was in a

wheel-chair. By the time she consulted me she was

better but on crutches, barely able to get along on

her own. Happily, she has responded very well to

nutrient support, especially the use of Carnitine,

Coenzyme Q, Ginkgo, glutamine and, of course B12

injections. Her mental acuity has improved, she is not

depressed or paranoid--and she is able to walk with a

cane.

 

Another unhappy fate was that of a 72 year old

real-estate sales woman, whose son I had treated after

adverse reaction to PCP 20 years earlier. He had

improved from the paranoia and confusion that had

disabled and hospitalized him, but he never regained

his full intellect and was never able to be fully

self-supporting as a result. I didn’t make the

connection to his mothers galloping senility,

forgetfulness, depression, inability to cope with her

business that quickly became disabling until her

laboratory tests came back showing low B12 under 100

ng/L. and the co-dependent vitamin folic acid, was

also very low. Her deterioration came on after she

underwent surgery for pain in her feet and toes.

Naturally the laminectomy didn’t help, the pain was

undoubtedly due to neuropathy, which was obvious at my

physical exam a year later.

She also had panic attacks after the surgery, made

much worse by pneumonia. A 60 year smoker, she was

treated with Prednisone for emphysema until she

consulted me. The combination of low B12 and high

smoke exposure probably accounted for her considerable

loss of vision, a concentric field defect. That year

was so full of sickness they remembered a viral

illness, Herpes zoster, only as an afterthought!.

 

She seemed better after large oral doses of B12 (2500

mcg) and folic acid (10 mg). Repeat blood testing

showed B12 581 mcg, mid-range normal, and folic acid

39 ng, above normal. She was able to absorb these

vitamins. But she refused injections and failed to

follow-up with me, choosing instead her family doctor.

Four years later I heard from her son that she was

placed in a long-term-care facility due to Alzheimer’s

dementia and anemia, a combination typical of B12

deficiency. Here is the way her son wrote of his view

of her condition: " She had some problem metabolizing

foods to get the nutrients from them. Possibly a lot

of her condition could be from nutritional

deficiencies--and lack of exercise and worry.

 

While I don’t agree that exercise and freedom from

worry would cure her dementia, my heart aches for this

family: a woman too confused to treat herself; a son

too discredited by his own chronic disability to gain

the ear of his father and the family physician after 4

years of trying, even though he had a rough idea of

the problem; and a husband who has lose his wife. Most

of this could have been avoided.

 

©2000 Richard A. Kunin, M.D.