Vitamin B12 quackery

The Pediatric Insider

© 2012 Roy Benaroch, MD

Here at The Pediatric Insider, we’re about science. Medicines and other treatments need to be tested. We want reliable proof that something works and is safe before we recommend it. We don’t like the false dichotomy of “alternative medicine”. If there is good evidence that it works, it’s medicine. If it doesn’t work, it’s quackery.

It doesn’t matter who’s doing the quacking. A quack is a quack, even if there’s a medical diploma on the wall.

The story: a woman brings in her teenage daughter, complaining that the girl is tired a lot. It turns out that mom herself has had some blood tests that showed a low vitamin B12 level, so her doctor is giving her regular B12 injections. Can her daughter get some, too?

I realize that B12 injections are common. Many docs administer these, and many adults get these—probably some of you reading this. So what’s the science behind this practice?

Vitamin B12 deficiency is a real thing. It can occur because of a poor diet, or because some medications (like acid blockers) interfere with absorption. Or it can occur because of a specific autoimmune disorder called “Pernicious Anemia.” Whatever the cause, the health consequences of vitamin B12 deficiency can include anemia, neuropathy, irritability, and depression.

There is a simple blood test to measure vitamin B12 levels, though the levels in the blood don’t always correlate with whether there is enough B12 levels in the cells themselves. We can test for this, too, indirectly, through other blood tests including methylmalonic acid and homocysteine levels. So we can, in fact, know if a person is truly deficient. These confirmatory tests are rarely done.

Instead, many adults are told that their vague symptoms of tiredness or fatigue are caused by B12 deficiency, instead of actually trying to address genuine issues like insufficient sleep, sleep apnea, overreliance on caffeine, and depression (to name a few of the many genuine causes of fatigue.)

It gets worse. The treatment of B12 deficiency, as has been established from studies done in the 1960s, is ORAL B12. That’s right. Pills. Injections of B12 are not necessary—oral supplements work well, even in pernicious anemia. They’re cheap and they work. I suppose a very rare patient, say one who has surgically lost most of their gut, could require injections. But the vast majority of people with genuine B12 deficiency can get all of the B12 they need through eating foods or swallowing supplements. No needles needed.

So why this fetish with injections? From the patient’s point of view, shots feel more like something important is going on. Placebos need rituals—with acupuncture, for instance, the elaborate ritual creates an illusion of effectiveness. And from the doctor’s point of view, injections reinforce dependence on the physician, creating visits and cash flow.

So: people seem to think they feel better with injections, and the doctor makes a little cash, and everyone’s happy. So what’s the harm in that?

I think it’s wrong to knowingly dispense placebos, even harmless ones. We doctors like to criticize the chiropractors and homeopaths. We point fingers. They’re the quacks. We’d better take a close look at what we’re doing, first. Our placebos are sometimes far more dangerous than theirs.

More importantly, people should be able to expect more from physicians. Patients come to us for genuine answers—if they wanted a witch doctor, they would have found one. I think we need to hold ourselves to a higher standard than a huckster at the carnival. We’re not here to promise that we’ve got all the answers. We are here to be honest, and to use the best knowledge that science has to offer, using  genuine compassion and thought. Let’s leave the quacking to the quacks. We’ll stick with real medicine.

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27 Comments on “Vitamin B12 quackery”

  1. aglol Says:

    Great post Roy. Coincidently I was just watching the BBC series Doc Martin who articulated the same thing. With less grace, but equally succinct! Thanks for these ongoing interesting and informative posts!

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  2. Elias Says:

    I don’t think there is anyone who would not understand what Dr Roy is potraying – doctors and patients alike.

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  3. Mark Malone Says:

    Use a Liposomal B12 instead of injections.. Liposomes deliver supplements into the blood stream without injections.. I use some great products from MaxHealth Labs.

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  4. Dr. Roy Says:

    Liposomes are tiny fat bubbles that are indeed useful for delivering some medications to target tissues. But B12 is water soluble. It is not miscible in fat, cannot be carried by liposomes, and can readily and inexpensively be absorbed by the gut. Liposomal B12 makes even less sense than injected B12.

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  5. Years ago (many years ago) we were taught that a common reason for B12 deficiency is lack of intrinsic factor–that substance that binds to exogenous B12 to make it usable (hence, those s/p gastric bypass surgery or elderly that lost some intrinsic factor required injections as the root issue was gut absorption). Not so? What’s odd is that B12 is ubiquitous–except for vegans, so a B12 deficiency should be quite rare.

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  6. Dr. Roy Says:

    The prototypical illness that leads to B12 deficiency is pernicious anemia, an auto-immune disorder that destroys the parietal cells in the stomach, leading to a complete lack of intrinsic factor. Without intrinsic factor, it was thought, people can’t absorb dietary b12 from the gut. So injections are necessary.

    However, research even from the 1960s showed that with a high oral load of B12, there is plenty of gut absorption even in the absence of intrinsic factor. Pernicious anemia can be treated just as well orally as with injections. From the references I posted above, there are very few people who actually require injected B12.

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  7. Delighted to read an article from a doctor determined to follow the evidence. And what does the evidence say in this case? Well, I’m afraid to say that you didn’t do your research.
    1) acupuncture works. We don’t know why it works, but it does. The same applies to many alternative medical treatments, right up to the point when they become mainstream. It’s funny – we use leeches again, only in a scientific way not the way they used them in the Middle Ages; we use a chemical from the bark of a birch tree (aspirin); most of modern medicine were discovered because some witch doctor, somewhere, used them and when the “white man” appeared and investigated, science told us it worked. Science is exactly what it says it is – the application of knowledge.
    Of course there are quacks, but can I just ask you? The evidence says that 50% of diagnostic tests in USA healthcare are completely superfluous, and many wonder if they are simply a way to increase the physician’s income. Sounds like quackery to me….
    2) Absorption: B12 can be short in the body for a number of reasons. The most common is a failure to absorb. This can be because of lack of IF, or it can be because of changes to the gut wall (eg Crohn’s disease, or other inflammation). In both cases, I’m afraid, injections are necessary. You may also not be able to digest the proteins and release B12, due to lack of acid (eg antacids and PPIs).
    3) Shortage in the diet is more common than it was, which i put down to agricultural practice and food processing practice. For example, microwaves destroy B12. But before you throw out the microwave at home, the abattoir uses one too – so you might as well take supplements. If the shortage is in the food then oral supplements will help, of course
    4) genetic factors affecting uptake. 8 genes are involved in the absorption, transport, and utilisation of B12 – conveniently labelled TC I to TC VIII (for those who have forgotten your Roman Numerals, the V is a symbol for a whole hand (5) with the thumb separate from the rest of the fingers, which in turn are together). 4a) the threshold blood level of 200ng/L is wrong. The Framingham Offspring Study showed that the threshold should probably be around 350ng/L, and even then 15% of people suffering from B12 deficiency were above this.
    4b) the blood test (CBLA) is wrong. Ralph Carmel published a paper at the end of last year illustrating that all calibrations were based on the old Radioisotope dilution assay, and that CBLA which replaced it consistenty gives false negatives (in one case giving a reading of B12 > 1000ng/L when the rd assay gave a reading below 200ng/L and the patient had clear deficiency signs)
    4c) TC II in the blood can be mutated, in which case you need much higher blood serum B12 in order for it to pass across the cell membrane into the cell.
    4d) any of the subsequent TCs can be mutated, reducing transport across cell walls, transport in cell cytoplasm, transport and utilisation in mitochondria etc. In all of these cases, much higher levels of B12 in the blood lead to pretty much normal function in spite of the mutation
    4e) all in all, about 40% of the caucasian population have significant mutations on the TC genes, of whom about half show signs and symptoms because they have a lower than excessive intake of B12. This ties in with our own observations that around 1 in 5 people in the whole population have the symptoms you describe AND RESPOND TO B12 REPLACEMENT THERAPY – surely the best way to confirm a diagnosis.
    5) we find that oral supplements can usually stabilise a person and prevent the symptoms deteriorating, but we find that around 2/3 of people with confirmed B12 deficiency need injections in order to get better. Of course this means less spend on anti-depressants, pain killers, and other symptom modifying (and often expensive) drugs, and the pharma companies probably don’t like us.
    6) we find that around 50% of our patients need injections every month – based on the time before the symptoms start to return. 25% need injections less frequently (eg every 2 months, every 3 months). 25% need injections more frequently (fortnightly, weekly, every 2 days, twice a day). Why the variation? Don’t know, though it is probably due to their ability to absorb – as you know Dr Roy, B12 from storage (probably floating free in the blood stream not combined with TC II) gets secreted into the gut and then reabsorbed to activate it. So if reabsorption doesn’t work well, then you are going to lose a lot of B12 very quickly
    IN CONCLUSION
    Some people are fine on oral supplements, but we find (with over 1000 patients’ experience) that around 2/3 respond better, even getting better, with injections. That’s the evidence.

    Liked by 1 person

  8. Dr. Roy Says:

    Long comments aren’t necessarily referenced comments, and sciencey word-salad isn’t the same as science.

    “Science is exactly what it says it is – the application of knowledge.”

    Wrong, and an appalling misunderstanding for someone who claims to have a PhD. Science is method of understanding the natural world by objective measurements and the creation and testing of hypotheses to confirm that they are predictive and accurate. It is not the application of knowledge. That would be “engineering”, “techno-science”, or “know-how.” For example, when truly objective criteria are applied to acupuncture, it falls flat– sham acupuncture is as good as “real” acupuncture, meaning it is all an elaborate placebo. Alt-med defenders seem to like their elaborate placebos, but that is not scientific support.

    Since you claim to have over 1000 patients’ experience, why don’t you publish this information in a peer-reviewed journal to expand everyone’s knowledge?

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  9. Hugo Minney (PhD) Says:

    Thank-you. I don’t think there’s anything that I can add at this point.

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  10. Hugo Minney (PhD) Says:

    Since I am a guest on this web site, I will leave politely and let you have your party in peace. It is a shame that real evidence, based on actual clinical practice, is so little in evidence on this site. But there’s a long history – who was it who said “I never let facts get in the way of a good story”?

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  11. The research regarding oral B12, dated from the 1960’s is based on studies of short duration and involving participants over the age of 60 with no mention whether there is neurological involvement. There are later research articles (1988 and 2002) that state more in depth research of a longer duration needs to be done to support a finding that oral B12 treatment for pernicious anaemia is as effective as IM injections. I refer specifically to the use of oral cyanocobalamin tablets which is the B12 used in the studies in the 1960’s.

    In the treatment of vitamin b(12)-deficiency anemia: oral versus parenteral therapy, LA Lane and C Rojas-Fernandez states “Oral cyanocobalamin replacement may not be adequate for a patient presenting with severe neurologic manifestations that could have devastating consequences if the most rapid-acting therapy is not used immediately. Studies to date have not adequately addressed oral treatment in these patients; therefore, parenteral cobalamin is preferable in neurologically symptomatic patients until resolution of symptoms and hematologic indices”.

    Treatment of vitamin b(12)-deficiency anemia: oral versus parenteral therapy, LA Lane and C Rojas-Fernandez 2002 Jul-Aug;36(7-8):1268-72.

    Yoshio Mitsuyama and Hiroshi Kogoh also state that: “The vitamin B12 (VB12) parameter was studied in the serum and cerebrospinal fluid (CSF) of 14 demented patients. Eleven of these patients were in a state of dementia of the degenerative type such as Alzheimer’s disease, Senile Dementia and Pick’s disease. The serum VB12 concentration in all the patients was within normal limits, I.e. 500–1,300 pg/ml. There was no significant difference between the CSF-VBl2 levels and the severity of dementia. The serum and CSF-VB12 levels of the demented patients did not show any significant elevation after the oral administration of CH3–Bl2, 2 mg per day. On the other hand, there was a marked elevation of both the serum and CSF-VB12 after an oral medication (2 mg per day) plus intramuscular administrations (500 μg per day). These results confirm that the intramuscular administration of CH3–B12 is an effective way to get a higher value of the serum and CSF-VB12 levels.”

    Psychiatry and Clinical Neurosciences
    Volume 42, Issue 1, pages 65–71, March 1988
    Serum and Cerebrospinal Fluid Vitamin B12 Levels in Demented Patients with CH3—B12 Treatment—Preliminary Study—
    Yoshio Mitsuyama M.D.*, Hiroshi Kogoh M.D.

    The Pernicious Anaemia Society with a membership of over 7000 members has been in existence since 2005. During that time, there have been only three members who have been able to manage without parenteral treatment. Two members use high strength methylcobalamin sublingual lozenges and the other member uses nascobal spray, a nasal spray sold in the United States. All three members do not have neurological damage.

    I disagree with you when you say that many doctors administer B12 injections. On the contrary, the PAS has members who have had B12 injections stopped because of a high B12 level. B12 is not toxic and what their doctor fails to take into consideration is that a high B12 level will not remain high once the B12 injection is stopped. Furthermore, the serum B12 test is seriously flawed with a high percentage of errors.

    We have had members sectioned under the Mental Health Act (or similar Act in the UK) because they have had B12 injections stopped or their doctor has refused to believe that a B12 deficiency will cause psychosis. So, I disagree with you when you say many doctors administer B12 injections.

    B12 deficiency is a serious disorder, often unrecognized by the medical profession. It is unthinkable that in the year 2013, people are still dying from a condition that is so easily treated but it does happen. It is becoming more prevalent in children as the youngest members of the PAS are siblings, aged 18 months and 3 years when their mother joined the PAS on their behalf.

    My daughter has pernicious anaemia and she self-injects. She doesn’t have a fetish about needles. She gets no joy from injecting herself. In fact, when she was doing IM injections she would have to pysch herself up to do the injection. She has switched to subcutaneous injections which are less invasive.

    B12 injections are as life-saving as insulin injections. There is no difference because diabetics can use oral medication provided they do not have the more serious form of diabetes. Why then the discrimination against B12 injections. No two people who have pernicious anaemia or B12 malabsorption are identical as to their need for B12 and/or damage caused by B12 deficiency. If B12 deficiency is discovered early enough then I will admit that perhaps oral B12 would be the treatment of choice. Sadly, this is not the case at all because our members have had to wait years for a diagnosis, the majority having a wait of 5 years before being diagnosed with a B12 deficiency, the result being for some of our members irreversible neurological damage.

    I agree with Hugo Minney’s conclusion. The 3 members we have who use oral cobalamin manage their deficiency and symptoms fine. However, the balance of our members are unable to manage on oral cobalamin and need B12 injections in order to have a good quality of life.

    Liked by 1 person

  12. Dr. Roy Says:

    I agree pernicious anemia is a serious disorder. It is also very, very rare.

    Ordinary B12 deficiency is far more common, and can easily be treated orally. You’ve provided some cut-n-paste info referring to patients with “severe neurologic manifestations” of B12 deficieny. Fine, give them parenteral B12. I’m not talking about people with severe illness here.

    You say “I disagree with you when you say that many doctors administer B12 injections.” That’s just silly. You disagree that the sky is blue? Of course many doctors give B12 injections. I don’t think it even makes sense to question that. Sure, disagree with me that they’re unnecessary. But whether it’s happening or not? That’s kind of self-evident, by the comments here and on the repost on KevinMD.

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  13. I acknowledge that veterinary B12 deficiency is a little OT, but seems relevant here. Dogs with exocrine pancreatic insufficiency are also unable to absorb oral B12, for three scientifically documented reasons: 1) lack of intrinsic factor; 2) intestinal mucosal damage; 3) (common in EPI dogs) small-intestinal dysbiota resulting in B12 uptake by bacteria.
    I suspect we could apply some of this knowledge to humans with EPI, IBD or other gastrointestinal disorders.

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  14. Leslie Weller Says:

    Apparently B12 can be part of a liposomal hydrogel….who knew?

    Pharmazie. 2011 Jun;66(6):430-5.
    Topical application of liposomal cobalamin hydrogel for atopic dermatitis therapy.
    Jung SH, Cho YS, Jun SS, Koo JS, Cheon HG, Shin BC.
    Source
    Korea Research Institute of Chemical Technology, Daejeon, Korea.
    Abstract
    Topical vitamin B12 was shown to be effective for atopic dermatitis. However, vitamin B12 itself is light sensitive and has low skin permeability, thus reducing its therapeutic effectiveness. In the present study, we prepared a liposomal hydrogel of adenosylcobalamin (AdCbl), a vitamin B12 derivative, and investigated possible beneficial effects of AdCbl on atopic dermatitis using an NC/Nga murine atopic dermatitis model. AdCbl was loaded into liposomes prepared by a thin film hydration method using a pH gradient method that employed citric acid buffer solution. This resulted in AdCbl-loaded liposomes that were 106.4 +/- 2.2 nm in size. The loading efficiency was 40% (of the initial AdCbl amount). Lipo-AdCbl had enhanced skin permeability, being about 17-fold compared with AdCbl-gel. Topical administration of Lipo-AdCbl-gel to 2,4-dinitrochlorobenzene (DNCB)-induced atopic dermatitis-like skin lesions in NC/Nga mice ameliorated lesion intensity scores, dorsal skin thickness, and total serum IgE in a concentration-dependent manner. Other preparations, including AdCbl solution, AdCbl cream, liposomes alone, and a mixture of AdCbl solution and liposomes had little effect. Taken together, our findings indicate that Lipo-AdCbl-gel has protective effects against atopic dermatitis symptoms, and suggest that it may be of benefit in the treatment of human inflammatory skin diseases.

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  15. Dr. Roy Says:

    That study was of a skin preparation, to treat a skin disease; they didn’t even look for systemic absorption. I’m not sure if that product could deliver B12 to someone who was B12 deficient.

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  16. Leslie Weller Says:

    I was not suggesting that it could deliver systemically. Simply pointing out that B12 could be part of an effective liposomal product.

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  17. Robert christ Says:

    Thanks for the info dr Benaroch. One of my rules of thumb when trying to determine weather sometHing somebody is trying to push is legitimate is how simply they can articulate a point and weather they can put it into lay mans terms anybody can understand. You did a great job of this. Some of the commenters on the other hand glazed me over with long winded posts and baffled me jargon which is good reason to be weary of what they are promoting.

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  18. Hello!

    I’m not going to use big words – because it makes the whole situation far more confusing than it already is.

    The problem here is that Chinese Whispers have been piled on to myth and for the last, ooh, 90 years or so, medicine in general has been selectively misinterpreting the illness. They have also been misinterpreting the title in both contexts of “pernicious” and “anaemia”.
    This is a historical assignation, dating from when the illness could only be diagnosed after the anaemia appeared.What the illness actually causes is neurological degeneration – whether the anaemia is present or not. The anaemia bit is a big red herring.

    It is neither rare, not does it have much to do with today’s diagnostic criteria of Pernicious anaemia or the dreaded intrinsric factor antibodies – it can happen to anyone who has a malabsorption problem and is not getting enough B12 through to their cells.

    There is no one test or even 4 of them, which will accurately measure if a person has a B12 deficiency causing neurological damage. Contemporary medicine is learning that they cannot rely on science and are having to revert to observation.

    Neuro problems can range from vision issues to pins and needles, numbness, proprioception issues and a whole other bunch of stuff that most doctors and patients will put down to ‘getting older’ until things get undeniable bad.

    You might try, if you are a member, having a peek at a recent clinical review in the BMJ. It’s Vitamin B12 Deficiency by Hunt et al. which is causing a bit of a stink because doctors are finally realising that they have been misdiagnosing a potentially serious condition. What they are also realising is that the powers that be who are providing the guidelines and training in the matter, are now leaving them holding the proverbial ‘baby’. If a doctor misses something like this, then they are the ones at the sticky end.

    It may be worth your while forgetting everything you thought you knew about B12 deficiency and starting from scratch. Because it’s starting to hit the fan…

    And a Happy New Year to you.

    Liked by 1 person

  19. Peter Noll Says:

    I have not found a scientific study on the effectiveness of liposomal B12.

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  20. Susan Wheeler Says:

    I have pernicious anaemia and am living proof that the serum B12 test is inaccurate. I need weekly injections of hydroxocobalamin which I have learned to do myself with the blessing of my GP who prescribes weekly B12 on prescription and I can tell you for sure that oral supplementation does not work for me. It is wrong of you to assume that all people are the same and you are putting people at risk with your comments.

    I suffered paranoia and severe iron deficiency anaemia. I went undiagnosed for 2 years. Eventually I got a blood test showing that I tested strongly positive for parietal cell antibodies – my serum B12 result was 185 “normal”.

    We are all different, genetically. I find your article above rather offensive as we have been calling for more scientific research for the last 7 years. I know that without my injections my “megaloblastic madness” returns. Even with 5mg methylcobalamin and 5mg folic acid and B6 – I can feel a huge difference 24 hours after an injection and know when I need them. It is something I have learned to live with and manage and I am managing well working in a Path Lab.

    There is scientific evidence that intrinsic factor antibodies at high titre interfere with the serum B12 result. The Axis-Shield company have produced the Active-B12 Holo-TC test. There is evidence regarding homocysteine.

    I think if you really are an experienced doctor you will understand that one cap does not fit all and I think it would be appropriate for you to withdraw your comments from the Internet.

    Liked by 1 person

  21. Susan Wheeler Says:

    I would like to add that pernicious anaemia is not as rare as you suspect.

    Liked by 1 person


  22. Hello Dr Benaroch,

    I’m following up on this thread to bring you up to speed on the latest scientific developments relative to B12 deficiency and which appear to have arisen from the clinical review I linked to last year.

    In October 2015 the BMJ released new Best Practice guidelines relative to B12 Deficiency.
    I have linked to the Prognosis section here: http://bestpractice.bmj.com/best-practice/monograph/822/follow-up/prognosis.html

    I am not writing to debate your original article or opinion at the time it was written, because I am aware that many medical professionals are of the same opinion as yourself and that is your choice. I would though contradict your statement that the subject of B12 deficiency belongs in the domain of ‘alternative’ medicine. Clearly it does not, and clearly much has been overlooked and contemporary clinicians now have the opportunity to learn something from the scientific developments.

    I hope both you, and your readers, find my link enlightening.

    Best regards.

    Liked by 1 person

  23. Dr. Roy Says:

    Dollywagon, the link points to material behind a paywall.

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  24. Hello Dr Benaroch

    Try this (I don’t know why the other didn’t work)
    http://bestpractice.bmj.com/best-practice/monograph/822/diagnosis/step-by-step.html

    This is recently released guidance.

    From your response I’m taking it that you didn’t read the first link I put up last year, so I don’t want to go over old ground before you’ve had time to take it in.
    This is the prognosis relating to the new findings:
    http://bestpractice.bmj.com/best-practice/monograph/822/follow-up/prognosis.html

    All the best and thank you for putting up my responses.

    Liked by 1 person

  25. Dr. Roy Says:

    Those links are also behind a paywall. You will find that if you delete your cookies, you won’t be able to get to this pay site until you re-enter your credentials.

    If you can find a link that works, I’ll be happy to edit your 1st post along these lines and take out this back-and-forth-

    Like


  26. Hello again,

    It shouldn’t be behind a paywall – this is BMJ (British Medical Journal) Best Practice guidelines. It’s not like a study which has limited access – besides which, I’m not logged in!

    Anyway, upshot:
    Serum B12 test is inaccurate. I think I can actually quote a GP from the Responses section of the initial review which gives a clear indication of the general reaction:
    “This review raises enough clinical questions to be quite genuinely alarming. A respondent has already noted that the authors, without batting an eyelid, state that serum B12 (the only measure of B12 routinely available in primary care) is insensitive to point of being unreliable for the purpose for which it is deployed. ” Ben Bradley GP 14th September 2014 – BMJ Vitamin B12, Hunt et al.

    And, neuro symptoms and haematological symptoms are now being viewed as separate issues and the neuro response to standard treatment protocolsn as opposed to the haematological response.

    Best Practice prognosis;

    “Vitamin B12 deficiency can cause devastating neurological disease and severe haematological disorders. Early diagnosis and prompt treatment may reverse neurological disease. Unfortunately, many cases are irreversible and clinical disease may not respond to adequate therapy. Early diagnosis in the near-asymptomatic stage can be critical in preventing permanent neurological damage.

    Megaloblastic anaemia

    Prompt treatment in patients with megaloblastic anaemia due to vitamin B12 deficiency can completely reverse the process. Brisk reticulocytosis occurs within 1 week of initiating treatment.”

    BMJ Vitamin B12 Best Practice 19th October 2015.

    They also give a good breakdown of the neuro symptoms to watch out for which are likely not to respond to the current protocols.

    Liked by 2 people

  27. Samia Says:

    Hi, Dr. Roy. What is wrong with placebos? How is it that some non-orthodox doctors (and some MDs, too) are able to evoke a placebo response in their patients? I’m of the “if it works it works” outlook. Like a turntable for playing vinyl records: I don’t care if it’s a high cost top-of-the-line direct drive motor that does the trick or a well trained squirrel on a treadmill.

    About Vit. B12 injections. I really don’t know what to think anymore, when there is so much conflicting “evidence”. Your comments make sense, but then others have come along and discounted them. Maybe it’s all he-said, she-said and let’s all hope for the best in trying to be healthy.

    Thank you.

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