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Vitamin B12

(Cobalamin)

What is vitamin B12?

Vitamin B-12 (cobalamin) plays an essential role in red blood cell formation, cell metabolism, nerve function and the production of DNA, the molecules inside cells that carry genetic information.

Food sources of vitamin B-12 include poultry, meat, fish and dairy products. Vitamin B-12 is also added to some foods, such as fortified breakfast cereals, and is available as an oral supplement. Vitamin B-12 injections or nasal spray might be prescribed to treat vitamin B-12 deficiency.

Vitamin B-12 deficiency is not common in the U.S. However, people who follow a vegetarian or vegan diet might be prone to deficiency because plant foods don't contain vitamin B-12. Older adults and people with digestive tract conditions that affect absorption of nutrients also are susceptible to vitamin B-12 deficiency.

Left untreated, a vitamin B-12 deficiency can lead to anemia, fatigue, muscle weakness, intestinal problems, nerve damage and mood disturbances.

The recommended daily amount of vitamin B-12 for adults is 2.4 micrograms (mcg). Most people can get enough vitamin B-12 in the foods they eat. But people who follow a vegetarian or vegan diet should eat nutritional yeast and other foods fortified with vitamin B-12. Or they can take a low-dose multivitamin that includes 2.4 mcg of vitamin B-12. Higher doses are suggested only in those with a vitamin B-12 deficiency.

How does my body absorb vitamin B12?

Two things need to happen for your body to absorb vitamin B12 from the food you eat.

Hydrochloric acid in your stomach removes vitamin B12 from the food it was in.

Vitamin B12 combines with something called intrinsic factor, a protein made by your stomach.

Vitamin B12 is then able to be absorbed by your digestive system.

What is vitamin B12–deficiency anemia?

Vitamin B12–deficiency anemia, also known as cobalamin deficiency, is a condition that develops when your body can't make enough healthy red blood cells because it doesn't have enough vitamin B12. Your body needs vitamin B12 to make healthy red blood cells, white blood cells, and platelets. Since your body doesn’t make vitamin B12, you have to get it from the foods you eat or from supplements.

You can get vitamin B12 deficiency if you can’t absorb vitamin B12 due to problems with your gut or if you have pernicious anemia, which makes it difficult to absorb vitamin B12 from your intestines. Without enough vitamin B12, blood cells do not form properly inside your bone marrow, the sponge-like tissue within your bones. These blood cells die sooner than normal, leading to anemia.

Who does vitamin B12 deficiency affect?

Any person can develop vitamin B12 deficiency at any age. People who are 60 years old or older are more likely to have vitamin B12 deficiency compared to other age groups.

How common is vitamin B12 deficiency?

Approximately 1.5% to 15% of people have vitamin B12 deficiency. Here are the percentages of people who have vitamin B12 deficiency based on age ranges:

At least 3% of people aged 20 to 39 years old.

At least 4% of people aged 40 to 59 years old.

At least 6% of people who are 60 years or over.

What are the symptoms of vitamin B12–deficiency anemia?

Vitamin B12 deficiency can cause physical, neurological and psychological symptoms. The symptoms of vitamin B12 deficiency can develop slowly and can get worse over time. Some people may have no symptoms despite having a low level of vitamin B12 in their bodies. People with vitamin B12 deficiency can have neurological symptoms and/or damage without anemia (lack of red blood cells).

General physical symptoms of vitamin B12 deficiency can include:

Feeling very tired or weak.

Heart palpitations and shortness of breath

Experiencing nausea, vomiting or diarrhea.

Constipation, diarrhea, or gas

Not feeling as hungry as usual.

Weight loss.

Bluish or gray-brown nails.

Having a sore mouth or tongue.

Having yellowish skin.

Neurological symptoms of vitamin B12 deficiency can include:

Numbness or tingling in your hands and feet.

Vision problems.

Muscle weakness

Having a hard time remembering things or getting confused easily.

Having a difficult time walking or speaking like you usually do.

Psychological symptoms of vitamin B12 deficiency can include:

Feeling depressed.

Feeling irritable.

Experiencing a change in the way you feel and behave.

What are the four stages of B12 deficiency?

The stages are:

Stage I: Low serum level. You have low levels of vitamin B12 in your blood. You have no B12 deficiency symptoms.

Stage II: Low cell-store. You have low levels of B12 in your cells.

Stage III: Biochemical deficiency. You have higher levels of the chemicals homocysteine and methylmalonic acid and decreased DNA synthesis, leading to neurological and psychological symptoms, like confusion, mood swings, problems walking or talking, and irritability.

Stage IV: Clinically evident deficiency. You get macrocytic anemia or very large red blood cells. These aren't functioning properly. You usually feel tired and weak, as well as have the earlier neurological and psychological symptoms.

What causes vitamin B12–deficiency anemia?

You can develop vitamin B12–deficiency anemia if you do not eat enough food with vitamin B12, such as if you follow a strict vegetarian or vegan diet. But this is rare. In the United States, vitamin B12–deficiency anemia is most often due to other risk factors.

You can develop vitamin B12 deficiency for the following reasons:

Lack of intrinsic factor: Intrinsic factor is a protein made in the stomach, which helps the body absorb vitamin B12. People who have pernicious anemia do not produce intrinsic factor. Pernicious anemia is more common in people with northern European or African ancestry. You may develop vitamin B12–deficiency anemia if your body is not able to absorb enough vitamin B12 from the foods you eat. Older adults are more likely to have digestive problems that make it harder to absorb vitamin B12.

Lifestyle habits: Drinking too much alcohol can make it harder for your body to absorb vitamin B12. For men this is more than two drinks in a day. For women, it’s more than one drink in a day.

Medicines: Taking certain medicines can make it harder for your body to absorb vitamin B12 over time. These include some heartburn medicines and metformin to treat diabetes.

Medical conditions: Some medical conditions can raise your risk of vitamin B12–deficiency anemia.
These include:

Autoimmune diseases, such as celiac disease, type 1 diabetes, and thyroid disease

Chronic pancreatic disease

Genetic conditions, such as Imerslund-Gräsbeck syndrome, inherited intrinsic factor deficiency, and inherited transcobalamin deficiency

Intestinal and digestive conditions, such as ulcerative colitis, Crohn’s disease, and Helicobacter pylori infection

Vitiligo

Stomach surgery: Surgery on your stomach or intestines, such as weight-loss surgery or gastrectomy, can make it harder for your body to absorb vitamin B12.

How do you prevent vitamin B12 deficiency?

Most people can prevent vitamin B12 deficiency by consuming foods and drinks that have vitamin B12. Vitamin B12 deficiency due to diet is rare in the U.S. Most people can prevent it by eating enough meat, poultry, seafood, dairy products, and eggs.

Options for consuming vitamin B12 include:

Animal food products: Red meat, fish, poultry, eggs, milk and other dairy products all contain vitamin B12.

Fortified foods: Fortified foods are foods that have certain vitamins and nutrients added to them that they don’t naturally have. Fortified foods include certain breakfast cereals, nutritional yeast, plant milk and certain bread. Be sure to check the food label (nutritional facts) to see if the food has been fortified with vitamin B12.

Vitamin B12 dietary supplements: Many multivitamins have vitamin B12. There are also supplements that only have vitamin B12. Ask your healthcare provider or pharmacist to help you choose which supplement is best for you.

Other things you can do to help prevent vitamin B12 deficiency include:

Avoid alcohol: Frequent alcohol consumption can damage your digestive system and make it difficult for your body to absorb vitamin B12.

Do your best to manage your digestive disease: If you have a digestive disease such as Crohn’s disease or celiac disease, be sure to follow your healthcare provider’s instructions to stay healthy.

How much vitamin B12 do you need each day?

You can get vitamin B12 from animal foods, which have it naturally, or from foods that have been fortified with it. These include:

Meat

Fish

Poultry

Milk

Eggs

Fortified breakfast cereals

Fortified breads

Fortified nutritional yeasts

Fortified plant milks

The recommended daily amounts of vitamin B12 depend on your age, your sex, and whether you are pregnant or breastfeeding. Your healthcare provider can look at your medical history to help determine how much vitamin B12 you need each day.

Life Stage	Recommended Amounts
Birth to 6 months	0.4 mcg
Infants 7–12 months	0.5 mcg
Children 1–3 years	0.9 mcg
Children 4–8 years	1.2 mcg
Children 9–13 years	1.8 mcg
Teens 14–18 years	2.4 mcg
Adults	2.4 mcg
Pregnant teens and women	2.6 mcg
Breastfeeding teens and women	2.8 mcg

Medication interactions

Taking certain medicines can interfere with the absorption of vitamin B12.

These include:

Antibiotics, Tetracycline -- Vitamin B12 should not be taken at the same time as tetracycline because it interferes with the absorption and effectiveness of this medication. Vitamin B12 should be taken at different times of the day from tetracycline. All vitamin B complex supplements act in this way and should be taken at different times from tetracycline. In addition, long-term use of antibiotics can lower vitamin B levels in the body, particularly B2, B9, B12, and vitamin H (biotin), which is considered part of the B complex vitamins.

Proton pump inhibitors -- used to reduce stomach acid; include esomeprazole (Nexium), lansprazole (Prevacid), omeprazole (Prilosec), rabeprazole (Aciphex)

Anti-seizure medications -- including phenytoin (Dilantin), phenobarbital, primidone (Mysoline)

Bile acid sequestrants -- used to lower cholesterol; include colestipol (Colestid), cholestyramine (Questran), and colsevelam (Welchol)

H2 blockers -- used to reduce stomach acid; include cimetidine (Tagamet), famotidine (Pepcid AC), ranitidine (Zantac)

Metformin (Glucophage) -- medication taken for diabetes

Chemotherapy medications -- particularly methotrexate

Colchicine -- used to treat gout

How is vitamin B12–deficiency anemia diagnosed?

To screen for vitamin B12–deficiency anemia, your healthcare provider may order blood tests to see whether you have low hemoglobin or vitamin B12 levels.

Healthy and Abnormal Blood Levels in Adults
Hemoglobin, g/dL	Normal	Men: 13 or higher Women: 12 or higher
Hemoglobin, g/dL	Anemia	Men: 12 or lower Women: 11 or lower
Vitamin B12, pg/mL	Normal	400 or higher
Vitamin B12, pg/mL	Vitamin B12-deficiency	200 or lower (although levels may be normal in some cases

Tests to screen for vitamin B12-deficiency anemia.

A complete blood count measures hemoglobin.

Another blood test measures vitamin B12 levels in the blood.

You may still have the condition even if your vitamin B12 levels are normal.

How is vitamin B12–deficiency anemia treated?

If your doctor diagnoses you with vitamin B12–deficiency anemia, your treatment will depend on the cause and seriousness of your condition. Some people need lifelong treatment.

Different therapies can be used to treat anemia.

Vitamin B12 medicine can be prescribed by your provider for you to take by mouth or as a nose spray or a shot. These supplements can help increase the levels of vitamin B12 in your body. For serious vitamin B12–deficiency anemia, your doctor may recommend vitamin B12 shots until your levels are healthy.

Blood transfusions to treat serious vitamin B12–deficiency anemia in combination with vitamin B12 treatment.

Your care provider may also recommend you make some changes to your eating habits to help increase the amount of vitamin B12 in your diet.

Some symptoms may take months to improve, depending on how serious they are. Some symptoms related to the brain or the nerves, such as numbness and tingling, may not go away even with treatment.

What is the fastest way to fix B12 deficiency?

The fastest way is to change your diet. Liver, clams, oysters, nutritional yeast, salmon, tuna, and ground beef are all very high in vitamin B12. Another option is start taking B12 supplements which usually have megadoses of the vitamin.

What happens if vitamin B12–deficiency anemia is not treated?

Vitamin B12–deficiency may cause serious complications, such as bleeding, infections, and problems with your brain or nerves that may be permanent. Babies born to mothers who have vitamin B12–deficiency may have developmental delays and birth defects of the brain and spinal cord.

Prognosis

What is the prognosis (outlook) for vitamin B12 deficiency?

The prognosis for people with vitamin B12 deficiency depends on how early the deficiency is diagnosed and treated. If the vitamin B12 deficiency is caught early, most symptoms improve with treatment. Depending on the cause of your vitamin B12 deficiency, you may have to only take medication for a short amount of time, or you may have to take medication for the rest of your life.

If vitamin B12 deficiency is left untreated, it can cause lasting side effects that affect the nervous system and brain. More severe side effects of vitamin B12 deficiency include:

Peripheral neuropathy.

Degeneration of the spinal cord.

Paralysis.

Bowel incontinence and/or urinary incontinence.

Erectile dysfunction.

Depression.

Paranoia and delusions.

Memory loss.

Living With

When should I see my healthcare provider?

If you experience symptoms of vitamin B12 deficiency or are at risk for developing vitamin B12 deficiency, contact your healthcare provider to see if you should take a blood test to measure your vitamin B12 level. If you have already been diagnosed with vitamin B12 deficiency and are experiencing new or concerning symptoms, be sure to reach out to your healthcare provider.

One Final Note..

Vitamin B12 is an important vitamin that your body needs to be healthy. Most people can prevent vitamin B12 deficiency by consuming enough of it in their diet. If you have risk factors for developing vitamin B12 deficiency or are experiencing symptoms, be sure to contact your doctor to get a blood test to check your levels.
Vitamin B12 is a water-soluble vitamin that you must obtain through diet, supplements, or injections.

It’s responsible for many bodily functions and may benefit your health in various ways, such as by preventing major birth defects, supporting bone and eye health, and maintaining healthy skin and hair.

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