This is a story about testing for a deficiency in vitamin B12, which can cause serious problems. It can occur in individuals who are unable to absorb B12 from food (i.e. people with gastritis, people using medication to treat heartburn over a long period, or those who have had gastric bypass surgery) or those who do not consume any B12 in their diet (i.e. vegetarians). For a number of reasons, B12 deficiency is more common in the elderly. Levels of B12 can be determined using either blood or urine tests. Adequate B12 levels can usually be maintained through the diet or daily multivitamin use. B12 deficiency requires medical intervention and will involve either larger oral doses or injections of B12.
However – while true B12 deficiency should be treated, there is not an unrecognized epidemic of B12 deficiency occurring. Many people with low B12 levels are healthy. While this article serves to remind people to be mindful about vitamin B12, its tone sounds an alarm that, for most, is unwarranted. In so doing, it is a classic case of journalistic disease-mongering. It hypes a vitamin deficiency as a state of disease. Most people who see a primary care physician with complaints such as those described would be diagnosed by a complete blood count (CBS) test as having vitamin B12 deficiency, followed by specific testing for B12 deficiency.
The story singles out one testing facility and offers a phone number and website for that facility. It touts a newly-published book. The headline of the story was “Confusion surrounds B12 deficiency.” We’re not sure much of that confusion was cleared up by this story.
Costs to assess B12 status are provided ($35 for blood test, $90-$200 for urine) as well as a web site where one can order a urine assessment of B12 without a prescription. However, no mention was made of the inexpensive and routine blood count (“CBC”) which can help screen for this vitamin deficiency. (A note of caution: The story also provides contact information for a commercial establishment for testing. How was this establishment chosen? Are their costs representative?) Costs for shots ($1.25) and pills ($1/month) are provided along with the caveat that insurance coverage for these varies
Different approaches to treatment (oral vs. injectable) are not compared. Statements such as “Some experts say that shots are the best way to treat those who are deficient, at least initially” provide no quantitative information.
No harms associated with increasing intake of B12 are mentioned. The Institute of Medicine of the National Academy of Sciences has not established a Tolerable Upper Intake Level for this vitamin because Vitamin B12 has a very low potential for toxicity. No mention was made that self treatment initiated though self requested testing for B12 deficiency could result in inadequate treatment in the case of an individual who was B12 deficient and attempted to self treat with an over-the-counter vitamin preparation.
While several experts in the B vitamins are quoted they did not comment specifically on whether most people with vague symptoms should be screened for this problem. There is an absence of evidence informing the content of this article. The book “Could it be B12? An Epidemic of Misdiagnoses” (price and publisher included in the article) appears to be the genesis for this story. Its content does not appear to be peer reviewed and the review suggests sensationalized accounts of undiagnosed B12 deficiency.
This article provides a strong sense that undiagnosed vitamin B12 deficiency is at the root of the problem for those with non-specific medical complaints. Notwithstanding that B12 deficiency can be a problem, especially for those with certain medical conditions or treatments, and while mentioning that “nine out of 10 people with low B12 levels are actually healthy and don’t need intervention”, the overall tone of this article is alarmist. In addition, there is no frame of reference for what it takes to become vitamin B12 deficient such as the time someone would need to eat a vegan diet in order to become deficient.
There is no reference to peer reviewed sources of information on this topic nor any mention of research studies supporting the contentions presented. While vitamin B12 deficiency can be a serious medical problem, there is a lack of documentation for the claims made in this article.
The treatment options of “shots or pills” are inadequately dealt with in this article in terms of why one might choose one over the other, or specific reasons why one would be the mode of treatment required (i.e. for individuals with a complete absence of intrinisic factor, injected B12 would be needed).
Two options for testing are provided, though without support for the contention that the blood test is inaccurate up to 50% of the time or estimates of sensitivity and specificity of the urine assay.
A list of food sources of vitamin B12 is provided in the article; however, though mention is made of pills or shots as a means of treating B12 deficiency, it is not clear that a physician’s prescription is required for the shots and that the pills typically available over-the-counter are not sufficient for the treatment of B12 deficiency.
The article provides the historical context for vitamin B12 deficiency and treatment. Neither diagnosis nor treatments are novel.
We can’t judge whether the article relied solely or largely on a news release. We can say that the story gave free publicity to the testing laboratory and to promoters for the book touted in the article.
Systematic, Criteria-Driven
Monday at #ADA2021, an infectious disease epidemiologist, a journalist, and a researcher shared perspectives on communication of risk in the era of COVID-19: http://ow.ly/ROfR30rMeE7 @AstleyCM @garyschwitzer @berthahidalgo @ADA_DiabetesPro
Shoutouts to @susan_bewley @drkevinknopf @MichaelBaum11 in this call for more than fawning coverage from press releases for these kinds of stories.
Also, linked history inside goes back 5 years just on Grail apparently trying to become Holy Grail. https://twitter.com/garyschwitzer/status/1408849696416841731
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