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  • Betty Wedman-St Louis, PhD, RD
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    Vitamin B12 and Celiac Disease

      Journal of Gluten Sensitivity Winter 2016 Issue - Originally published January 5, 2016

    Caption: Photo: CC--francois schnell

    Celiac.com 04/12/2016 - Vitamin B12 is a group of cobalt containing compounds described by Alan R. Gaby, M.D. in Nutritional Medicine called cobalamins. Methylcobalamin is the coenzyme form of B12 that is critical for human health. Hydroxocobalamin is a more stable form of B12 but it first needs to be converted to an active form before use in metabolism.

    Vitamin B12 is important in DNA synthesis, red blood cell formation, homocysteine metabolism and the production of S-adenosylmethionine (SAMe). Adequate B12 is essential for proper neurological and immune function.

    The importance of Vitamin B12 in health and anemia management began during the Depression era when animal protein foods were limited in the American diet. Three physicians who reversed pernicious anemia in dogs were awarded the 1934 Nobel Prize for medicine. Dr. George Hoyt Whipple and two other physicians fed the dogs and humans 1/2 pound of fresh liver per day as a means to control anemia.

    Animal proteins—meat, poultry, fish, eggs—are the sources of Vitamin B12 for humans. Plants do not need or produce B12. How B12 gets into your blood is a complex dance of stomach acids and intrinsic factors that starts with pepsin in the stomach splitting off the B12 from the protein compound. The intrinsic factor made by the parietal cells of the stomach attaches to the B12 to be shuttled to the ileum where receptors pull it into the blood.

    Once in the blood, B12 is picked up by transcobalamin to be carried to cells throughout the body. Any excess is stored in the liver or excreted in the urine.

    If inadequate intrinsic factor is available—loss from aging or proton pump inhibitor use—B12 deficiency symptoms such as macrocytic anemia, neurological disorders and psychiatric symptoms (memory loss, depression, confusion, paranoia) may occur. Severe B12 deficiency can result in intestinal damage, hyper-pigmentation of the skin, hypotension, and immune dysfunction.

    The Institute of Medicine indicates that only 2 to 4 mcg Vitamin B12 is needed daily. The average American diet contains 5-15 mcg per day according to NHANES studies. Vegetarians and infants breastfed by vegan mothers are at greatest risk of developing B12 deficiency.

    Other factors increase the risk of developing Vitamin B12 insufficiency. Achlorydria secondary to gastritic, gastric bypass surgery, and ileal resection for Crohn’s disease need assessment due to malabsorption. Apathy abounds throughout the medical community despite the 2009 Centers for Disease Control and Prevention statistics indicating 1 out of every 31 people over 50 being B12 deficient. With increasing numbers of gastric bypass patients and Crohn’s resections, this deficiency could be significantly higher.

    Adverse symptoms can first be noted with the CBC test indicating large RBC or macrocytosis—a folate and B12 deficiency. Other symptoms may include balance problems, numb hands and feet, leg pains, early onset dementia, pre-Parkinson’s-like disease, infertility and depression.

    Many physicians are poorly educated on Vitamin B12 importance since it is a vitamin and easy to treat. Treatment with methylcobalamin injections with few definitive ways to test efficacy seems to be a primary factor. A complete medical history assessing for gut inflammation, celiac disease, GERD, recent nitric oxide use in surgery, and genetic factors like MTHFR should trigger a closer look at B12 adequacy even with a normal homocysteine (HCY) plasma test. High levels of B12 on standard blood analysis usually indicates poor absorption and not intoxification of Vitamin B12. Elevated B12 results >800pg/ml frequently indicate PPI use or low stomach acid malabsorption. Lab results <350pg/ml may still be inadequate for a patient with celiac disease, gluten enteropathy or gastric bypass surgery, so supplementation should be considered.

    Medications matter when considering Vitamin B12 status. Below are common drugs that impair absorption:

    • Antacids- maalox, MOM, Mylanta, Tums
    • Histamine blockers- Zantac, Tagamet, Axid, Pepcid
    • Proton Pump Inhibitors- Prevacid, Prilosec, Nexium,. Omeprazole, Acidhex
    • Colchicine
    • Questran
    • Metformin, Glucophage
    • Celexa, Effexor, Elavil, Nardil, Paxil, Prozac, Zoloft, Wellbutrin
    • Ativan, Librium, Valium, Xanax
    • Viagra, Cialis, Levitra
    • Compazine, Haldol, Risperdal, Tegretal

    Vitamin B12 supplementation is probably the safest medical treatment available. Many people need B12 injections to show improvement in their symptoms. Effectiveness of injections depends more on frequency of administration than on amount given with each injection. Those who improve with injections rarely improve with oral or sublingual products no matter how large the dose because the routes of administration are not capable of achieving high enough absorption levels.

    Treatment with Vitamin B12 needs to be continued for life. Until more research on efficacy and safety of oral B12 is available, intramuscular daily or weekly injections should be considered a standard of care, especially in celiac disease and those with gastric bypass surgery.

    A 20 page handout on Digestive Wellness is available for $15 from Dr. Betty Wedman-St Louis, 17920 Gulf Blvd, Ste 606, St. Petersburg, FL 33708. It includes information on how GMO foods destroy health which will be covered in a future article.


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    The dogs in the experiment didn't have Pernicious Anemia. After World War I, doctors were interested in finding a way to more quickly reverse anemia (mainly the type caused by battle wounds), so they bled dogs and fed them different foods to see what worked the best. It turned out that liver worked the best. Liver happens to be high in iron, which the dogs were deficient in. Liver also happens to be high in B12, which Pernicious Anemia patients are deficient in and which is a vitamin that wouldn't be discovered for several more years. Pernicious Anemia was not well understood at the time. It was basically just lucky that liver helped correct both types of anemia.

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    The article stated that many physicians are poorly educated about B12. I found this to be sadly true. My terminal ileum had to be resected a year before I was diagnosed with celiac disease. That is where B12 is absorbed. I was advised that I would need regular injections. Ever since then 26 years ago, I've gotten injections. I have had to beg my family physician to test my blood levels regularly. At one point, when my level was in the normal range (about 200-1200) my physician told me I didn't need the injections anymore and wouldn't prescribe it. About 8 months later I was called on the carpet at school for a huge mistake I made teaching math. I had other symptoms that were neurological. When I saw my neurologist he asked what my B12 levels were. They were 200. "Normal" Long story short on his advice I keep my levels close to 1000 by getting an injection every 3 weeks. Every six months I have a blood test. If you have to fight for it, ask the doctor to put pernicious anemia down as the reason, or the test most likely will not get covered.

     

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    I have celiac disease and am not taking any of the medicines that would impair absorption. My B12 was just tested at >1500. I did not take my sublingual B12 supplement the day of the blood draw. I found this article very interesting but leaving me wondering what my test results mean.

    The article says, "High levels of B12 on standard blood analysis usually indicates poor absorption and not intoxification of Vitamin B12". Does this mean I need injections of B12? Further testing?

    Further clarification would be most welcome. Thank you for a well written and timely article.

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    I know that I suffer from B12 deficiency from time to time, and can often be alerted by mood changes. I take 8 1,000 mg sublingual methylcobalamin tabs and usually feel a positive effect within half an hour. I find I do not necessarily need it every day. I take medications and have 2-3 medical conditions which would lead to B12 loss, so am encouraged that I do not seem to have to stick a needle in myself. I did learn about the use of B12 from a severe Crohn's survivor.

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    I give this a 4 star, because I need more information. My B12 numbers are ridiculously high, am I understanding that the B12 is not absorbing? What should I do then? The doc was concerned I was getting too much. This may not be so according to this article. Why does the doc think I am getting too much? Shouldn't she know if I am getting too much or not absorbing? She told me to stop taking it. I am so confused. How do I talk to a doctor and have this investigated further?

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    I was diagnosed with B12 deficiency 15 years ago, I went from getting shots once a month to having to do them once a week. I was diagnosed with Celiac 3 years ago and always wondered if they were related somehow. Thanks for the arrival.

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  • About Me

    Betty Wedman-St Louis, PhD, RD is Assistant Professor, NY Chiropractic College, MS Clinical Nutrition Program Nutrition Assessment Course & Food Science Course.  She is author of the following books:

    • Fast and Simple Diabetes Menus, McGraw Hill Companies
    • Diabetes Meals on the Run, Contemporary Books
    • Living With Food Allergies, Contemporary Books
    • Diabetic Desserts, Contemporary Books
    • Quick & Easy Diabetes Menus Cookbook, Contemporary Books
    • American Diabetes Association Holiday Cookbook and Parties & Special Celebrations Cookbook, Prentice Hall Books

     

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