"... Individuals with diabetes who develop vitamin B12 deficiency oftentimes have neuropathy. And that neuropathy is oftentimes also misdiagnosed because individuals with type two diabetes are at risk of diabetic neuropathy.”
In this episode, Dr. Roman Pawlak joins us to discuss all things Vitamin B-12! We talk about the associated deficiency, especially for those following vegetarian or vegan diets. We talk about signs and symptoms of deficiency and testing for VItamin B-12. He sheds light on this topic and provides valuable insights and tips on how individuals following a plant-based diet can ensure they are obtaining adequate amounts of this nutrient in their daily meals.
Dr. Pawlak is a current associate professor of nutrition at East Carolina University and the author of multiple books, including “Vitamin B12: Combating the Epidemic of Deficiency”. He has published numerous papers in leading American and international nutrition journals, such as the American Journal of Clinical Nutrition, and given lectures on five continents.
Shireen: Podcasting from Dallas, Texas. I am Shireen, and this is a Yumlish podcast. Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type 2 diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.
In this episode, Dr. Roman Pawlak talks to us about all things vitamin B12. We talk about the associated deficiency of vitamin B12, especially for those following vegetarian or vegan diets. We also talk about signs and symptoms of this deficiency and testing for vitamin B12. He sheds light on this very important topic and provides valuable insights and tips on how individuals following a plant-based diet can ensure that they are obtaining adequate amounts of this nutrient in their daily meals.
Dr. Roman Pawlak is a current associate professor of nutrition at East Carolina University and the author of multiple books, including Vitamin B12 Combating the Epidemic of Deficiency. He has published numerous papers in leading American and international nutritional journals, such as the American Journal of Clinical Nutrition and gives lectures on five continents. Welcome Dr. Pawlak.
Dr. Pawlak: Thank you. It’s good to be with you and with everyone.
Shireen: So, Dr. Pawlak diving right in. I’m so curious about your journey. Please tell us a bit more about your background and how you decided to have this interest in such a niche topic, which is vitamin B12.
Dr. Pawlak: I will be glad to do that. I’m sure the listeners will recognize right away that I speak with an accent.
I was born and raised, and I actually lived most of my life in Poland. When I was 33 years old, I had the opportunity to immigrate to Canada, and then from Canada I came to the United States. When I moved to Canada, I actually changed my profession and I decided to study nutrition. So, I studied at a few Canadian universities such as Canadian University College and Athabasca University.
And then I came to the U.S., and I studied at Andrews University, Oakland University and the University of Southern Mississippi. And already back in Poland almost four years ago, I became a vegetarian. And of course, vitamin B12 is a very important nutrient for vegetarians, vegans and anyone who is really on a plant-based diet.
And so, my interest in vitamin B12 developed from this necessity to understand this nutrient because the importance of this nutrient for vegetarians. Also at one point of time when I was already teaching nutrition and B12 at the time was not yet my primary interest, I was asked to write an article about vitamin B12.
This was for like a popular magazine. I agreed to do so, and I spent several weeks just reading the literature and researching, and I was learning stuff I didn’t know. And in fact, I was learning also something that was kind of contrary to what I thought was correct about this particular nutrient
And so, writing this article and researching the literature for this article was kind of like a springboard for me to take even a bigger interest in the nutrient, and eventually I started publishing and getting grants and researching this nutrient also in vegetarians and vegans and others.
Shireen: Lovely. You know, with that, Dr. Pawlak, take us back to the basics. What is vitamin B12 and why is it important to consume it? What role does it play in our health?
Dr. Pawlak: Vitamin B12 is one of the B vitamins. We have several B vitamins. I’m sure listeners have heard of vitamin B1, B2, B3, and there are others. Another somewhat maybe well-known nutrient from the B vitamins is folic acid.
Folic acid and vitamin B12 are cousins. They oftentimes mimic each other in terms of symptoms of deficiency. They play somewhat similar function. They prevent from similar health conditions such as, for example, neural tube defects, spina bifida and anencephaly. And these are congenital birth defects that offspring develop.
And so, it is a very important nutrient because it plays a role in the synthesis of an important nutrient an amino acid called methionine. And then the body uses methionine to synthesize other compounds. And also, methionine is converted to other compounds that are important for yet other compounds and there is a chain reaction. And if there is a breakage, in any of the chain reactions, then all kinds of health problems may develop.
Shireen: Can you speak a little bit to where we can find vitamin B12 for both plant eaters and then non plant eaters?
Dr. Pawlak: Yes, I will be glad to. Interestingly naturally speaking, vitamin B12 is found in foods that dieticians are telling us we should be consuming less of, or perhaps some of them we should be avoiding altogether. And so, meat, for example, is the primary source of vitamin B12 in a typical diet. And of course, again diet dieticians and health professionals are telling us that we should avoid processed meats.
We should limit red meat, for example. And so if we actually follow the recommendations, we should have limited intake of perhaps white meat and of fish. And these would be sources also of vitamin B12. Also, animal products such as eggs and dairy products, including milk contain naturally vitamin B12.
When it comes to plant sources, we have actually very few and only those products that are fortified with this vitamin. That means, synthetic form of this vitamin was added to products such as cereal, for example, some cereal. To nutritional yeast to different soya products such as, for example, tofu or some of those soya meat substitutes, as well as soya milk. These would be the sources.
Unfortunately., the dose of fortification is relatively low, and so this is why oftentimes in studies, vegetarians and especially vegans are actually found to have very low vitamin B12 and oftentimes below the criteria or cutoff of what we consider a deficiency.
And so, another source, likely the most reliable and the easiest way to obtain vitamin B12. Especially if you are a vegetarian, and even more importantly, a vegan, is to take a supplement.
Unfortunately, studies are also showing us that not all vegetarians or vegans use supplements of vitamin B12. In fact, some of them kind of resist the idea, the very idea they may be deficient in any nutrient regardless of what nutrient we are talking about.
Unfortunately, again, when we look at studies and these studies were conducted in the United States and in Europe and in other places. Very commonly vegetarians, and again, especially vegans are diagnosed with vitamin endometrial deficiency.
Shireen: So, let’s dive into the deficiency piece of it a little bit more. Can you speak to symptoms that people can look out for to understand if they’re deficient first?
Dr. Pawlak: Yes. So, there are some classic symptoms of vitamin B12 deficiency, but also vitamin B12 deficiency and or what we would call insufficiency. Which would mean slightly higher level than what is considered deficient, but perhaps inadequate higher. But inadequate in level may also cause problems that we may not be aware of, and we may not experience until months and or most likely years into the deficiency.
Let me begin with those and I will give you an anecdote. I was invited to go to Charlotte, North Carolina. It was the end of March of 2013, about 10 years ago. And I had two lectures, and this was, these lectures were for everyone, but there were a lot of vegetarians in the audience. And in between in the intermission, this elderly couple came to me just introduced themselves and chatted with me a little.
And then they told me that he had a quadruple bypass surgery not long ago. Then they assured that he had never eaten meat in his life. He was a lifelong vegetarian. Now they looked, I didn’t ask them how old they were, but they looked maybe about mid-seventies, and they asked me why would I have a need for bypass surgery? Not eating meat, right? Why would you develop heart problem?
Well, interestingly, I was invited back by the same organization, and I went there at the end of September of the same year. And again, I had a lecture and in between one lecture and another, another individual came to me and chatted with me a little.
And he told me that six months ago he had a stroke and then he said that he had been a vegetarian for more than 30 years. And then he asked me why would I develop stroke? And so, what we know today, in fact one of my publications deals with this. Vitamin B12 deficiency is a risk factor for developing cardiovascular disease, especially stroke, but also some type of heart complications.
Of course, we know that vegetarians and vegans have improved cardiovascular disease risk factors include improved profile. And so, they often think that they would never develop heart disease, and that’s what we would expect. Unfortunately, again, this is one of the symptoms. We also know that vitamin B12 deficiency is a risk factor for bone fractures, low bone density, and bone fractures.
Again, these are symptoms that we don’t know of until we have a heart attack, right? Or we break a bone. Now when it comes to kind of classic deficiency symptoms, these are grouped into several categories. So, for example, hematological symptoms that has to do with the blood. So, we may have elevated or larger than normal red blood cells, for example. And in fact vitamin B12 is essential for all blood cells synthesis.
So not just red blood cells may be impacted, but also white blood cells count, platelet count, and also a compound called homocysteine. I know this may be a new term for many listeners, but I’m going to repeat this term because this is an important term because a lot of complications that result from vitamin B12 deficiency have to do with this particular compound. Again, it is called homocysteine.
Elevated homocysteine is a risk factor for many health conditions, including those I already mentioned heart disease, bone fractures. But may also be detrimental for pregnant women under offspring may cause different problems for the fetus.
In addition to hematological symptoms, we have neurological symptoms, and these include stuff like thinning pins and needles. Feeling what is called restless leg syndrome. That means you go to sleep, and you may all of a sudden have uncontrolled leg room movement. Also, you may have hard time falling asleep, or you may wake up in the middle of the night. And then you have hard time falling asleep again.
These are all related to vitamin B12 deficiency and then there are others. There are symptoms in the oral cavity. For example, a classic symptom is called beefy tongue. Beefy because it looks like a red beef type of color, very red, and there is a specific type of shape, of the red spots in the tongue.
You may also develop different cracks here at the corner of the mouth. You may have inflamed and reddish color around the eyes. These are, again, dermatological and oral cavity type of symptoms. There are others developmental when we are talking about infants, toddlers, young children.
We know that when you are four months or so, maybe five months old, you should be sitting on your own right? When you are about one year, maybe a little past one year, you should be able to walk and maybe even run. And toddlers who have vitamin B12 deficiency, may not be able to even sit on their own.
They may have anorexia; they may fall off the growth charts. They may completely lose touch with the surroundings. I had a correspondence once with a mom who told me that the child completely did not, not only that didn’t react to any stimuli, didn’t react to her voice, nothing of that nature.
Fortunately, very quickly, we were able to restore her vitality and stuff like that with specific therapy that I recommended. There are many different symptoms, and they are manifested in different ways for different individuals.
I know that you focus a lot on diabetes also. Let me just mention that individuals with diabetes who develop vitamin B12 deficiency oftentimes have neuropathy. And that neuropathy is oftentimes also misdiagnosed because individuals with type two diabetes are at risk of diabetic neuropathy. And so, if you have type two diabetes and you develop neuropathy, it’s kind of normal because patients with diabetes develop neuropathy.
But in reality, many of these patients do not have diabetic neuropathy. They have vitamin B12 deficiency related neuropathy. And that neuropathy again, may, may be manifested with different neurological symptoms that include those I mentioned such as pins and needles and feeling pain, kind of deep pain in the nerve somewhere, these types of symptoms.
Shireen: Yeah, it is so hard to even distinguish that of what may be causing that neuropathy in diabetes, the vitamin B12 deficiency. Is there a test around it that can confirm a deficiency?
Dr. Pawlak: Yes. So, we would do hematological tests. We can measure vitamin B12 level. We can also measure homocysteine that compound that I mentioned. And homocysteine is somewhat reliable marker. Serum vitamin B12 is less reliable marker of vitamin B12 status. Homocysteine is a reliable marker, especially among those who consume adequate amount of this other B vitamin called folic acid.
So, if you are a vegetarian and a vegan, and you likely consume a variety of plant products including fruits, veggies, beans if you have increased homocysteine concentration, it would be more than likely a result of low vitamin B12 rather than low folic acid. There are other tests, for example metal malonic acid.
These tests are seldom utilizing clinical practice unless a patient is referred to hematologist or neurologist. And there are still other tests that are even less often used. Unfortunately, when you go to your primary care physician. Oftentimes they just order the white blood cell panel, which includes a test called or test for the size of red blood cells.
And they look at the size of red blood cells, and if it is not elevated, vitamin B12 deficiency is oftentimes ruled out. Unfortunately, this is a mistake because we know that at least in about one third of the population, regardless of how low vitamin B12 may get, we will never see it on this test that measure the size of red blood cells.
So, what is recommended for anyone who would like to test for vitamin B12 is that at least two different tests are performed. So that may be homocysteine and vitamin b12, for example. That way we can see if one is normal, the other is not. Then we may either contact yet another test, or at least just pre cautiously simply use either Vitamin Vitro supplement or injection to treat vitamin B12 deficiency.
This is because the tests that are available and are used in clinical practice are not very reliable, and those tests that are reliable are more expensive. Not as easily obtained. Not all labs conduct these tests, and that’s why two different markers or two different tests are recommended to take.
Shireen: We talked about deficiency. I kind of want to flip it to the other side and talk about what would be the downsides of consuming too much vitamin B12? Is it even possible to consume too much?
Dr. Pawlak: It is possible, but we very seldom see symptoms of excess of vitamin B12 intake and the symptoms of having too much vitamin B12 are not many, and mainly they have to do with dermatological issues.
So, you may kind of scratch yourself. You may see a little or redness, kind of like you would have an inflammation type of thing. And these are really, or this is really the, the most common one, which is again, not very common. So, when you look at, again, serum vitamin, B12 anything above 300. Whatever the units are on the test would be considered a good level of vitamin B12.
So only individuals who have at least 1000 or maybe even more than 1200 units. And only very small percentage of those develop these symptoms. So, vitamin B12 deficiency is much bigger problem than any risk for access. Let me mention another interesting new ones here, and that is some individuals may actually be deficient in vitamin B12.
And at the same time, they may have very high serum vitamin B12 level. This is because they may have another underlying condition. For example, if they have some type of liver problem, liver abnormality and or kidney problem, or even lung problem, or they may have cancer. These conditions cause the body to secrete large amount of a specific carriers in the blood of vitamin B12.
And so, you will see elevated vitamin B12 and yet symptoms of vitamin B12 deficiency. But it doesn’t mean these, these elevated tests does not mean that you actually have access of vitamin B12. And the symptoms oftentimes when not treat, when they’re treated with either supplements or injection, would disappear. It’s a very interesting nutrient with a lot of nuances.
Shireen: It is. It is. I see now why you’ve pursued so much research in this vitamin B12.
Dr. Pawlak: Yes. I always tell my students, I wonder why my colleagues study different nutrients, and not this one.
Shireen: My next question for you on this Dr. Pawlak is you mentioned vegetarians earlier. What are steps that vegetarians and vegans can take to ensure that they’re getting enough vitamin B12 in their diets? And what role should healthcare professionals play, such as dieticians and really educating patients about vitamin B12 and plant-based diets?
Dr. Pawlak: Well, good questions. I believe that all vegetarians and especially vegans should be using vitamin B12 supplements. And this should be done really from early on. So even when we are talking feeding toddlers and feeding young children, we should be ensuring that they use supplements because this is simply the easiest, the least expensive and the most reliable way to ensure that we have adequate vitamin B12.
Just to give an example, I buy my vitamin B12 supplements from Walmart pharmacy and in the container, you have 200 pills, and the cost is just a little bit over $4. So, $4 that you spent is good enough for a year or maybe a little bit more than a year.
I don’t take them every day. I take them every other day, and it is just that easy to do so. And I also believe that not using supplements, even if you ingest foods that are fortified with B12. Means placing yourself at risk of inadequate intake. And of course, that translates to inadequate level in the blood.
And you know, if you are lactating, say, translates into inadequate concentration in breast milk and so on and so on. And eventually you may develop symptoms. And even if you don’t feel symptoms, like I mentioned earlier, there are these symptoms that develop over time that we have no idea of that eventually you may experience. When it comes to what health professionals such as dieticians, physicians should play well again, number one, they should be up to date on the literature on vitamin B12 and the main recommendations.
I have to say, unfortunately, and suddenly this is not always the case. In fact, if you go to, even still today, to the National Library of Medicine website and you read the information on vitamin B12, it’s a short statement, and the statement contains three-part misconception about vitamin B12.
It includes in the statement, you’ll read the information that vitamin B12 deficiency is very rare. It’s nothing, but it’s actually very common. It is an epidemic of, you can even call it pandemic regardless, almost where you go. You find large proportions of populations. At risk and document have documented vital inhibitor deficiency.
But again, in consumers and patients learn from health professionals. And so, if health professionals spread misinformation, that’s not giving good information to the patients. Another thing is when it comes to especially physicians, physicians should be also a following recommendations. So, for example, since 2017, the American Diabetes Association has issued recommendation that anyone who is on Metformin and metformin is a drug that is prescribed for people with type two diabetes gestational diabetes, even those with pre-diabetes.
Those patients should be tested for vitamin B12 level and then prescribe either injection of B12 or supplements accordingly, according to the level, unfortunately, this is completely not followed. So, patients may be tested for B12 if they complain on about neurological symptoms rather than prophylactically testing them for B12 and then catching the low level earlier before any symptoms develop.
So, yes learning about the current information about the nutrient following the recommendations, and especially when it comes to vegetarians and vegans, definitely recommending that they use it because they come to those professionals for reliable advice.
Shireen: I’m going to try to squeeze in one more question before we wrap up. Dr. Pawlak. You mentioned the supplements in particular, and we get this question all the time, it, but is there a difference in dietary value of B12 from supplements versus food sources?
Dr. Pawlak: Well, thank you. Well, first we have to remember that again, when we are talking about anyone who is on a plant-based diet, whether that’s a vegetarian diet or even semi vegetarian, and especially vegans, you really have very few options because vitamin B12 is synthesized by bacteria.
And so, the reason why we find B12 in an egg or in a milk or in meat is because the B12 that is synthesized by bacteria is then eventually spreading to the muscles or milk and so on. Again, vegetarians and vegans don’t have this luxury. They have to rely on foods that are fortified. Like I mentioned earlier, these foods are few and the dose is very low.
And therefore, there was actually even a study, it was studied, done in Poland, the country of my region, in which young people and young people don’t have any problem with absorption of nutrients, including vitamin B12. And as we age, we actually lose also the ability to absorb vitamin B12. But these young people who were in their twenties were asked to ingest foods.
That contain vitamin B12 by fortification. And this experiment took place for five years. And over the entire five-year period, you had a steady decline of serum vitamin B12 levels. Which showed that again, it is simply inadequate to rely on these foods. And so, we can theorize that our obtaining nutrients from foods is better, and I actually prescribe to this idea.
When it comes to many other nutrients, say vitamin C for example. Some people use vitamin C supplements. I don’t think there is a need for that because we can obtain enough of vitamin C from diet. We can name a number of different nutrients and the same will be true for these nutrients. But for this particular nutrient, it is really an exception because we simply do not have vitamin B12 in plant foods.
Shireen: This is very informative, Dr. Pawlak, but unfortunately, we are toward the end of the episode. At this point, can you tell us how our listeners can connect with you and then just learn more about your work?
Dr. Pawlak: Absolutely. So, they can go to my website, which is a romanpawlak.com, www.romanpawlak.com. They can also find me on Facebook, but it is my personal page, so I don’t often post anything on whether vitamin B12 or vegetarian diets or, or things of that nature. They can email me directly if they have a question, email@example.com, and I have different articles on my website.
I have links to my publications on my website. I have some lectures also linked to my website. If they also type my name in YouTube, I have different lectures on YouTube, in English and in Polish. I still speak Polish somewhat fluently. If they would be interested in learning more about whether vitamin B12 or related topics, they can also find me on Dietician Central website.
Dietician Central, I believe it’s dot org. I have more than a dozen of different webinars on again, topics related to plant-based nutrition and vitamin B12 specifically. And lastly, they can also go to Orion publishing.org. And I can get my books, including the one you mentioned Vitamin B12, Combating the Epidemic of Deficiency.
But also, I have a book for vegetarian adults called in Defense of Vegetarianism, and then another one for pregnant and lactating women, and how to feed the young children called Vegan, Vegetarian, Mother and her baby.
Shireen: Lovely. And what we’ll do for our listeners, we will link up all of these different resources for you in the show notes, so you can find them there below this podcast episode so you can link to it and find these various websites.
And with that, Dr. Pawlak, thank you so very much for your time. For our listeners share with us whether you have experienced any difference in how you feel or function after taking vitamin B12 supplements. So, head over to our social media on Facebook, on Instagram, find this podcast post and comment below to let us know if you have experience, any difference in how you feel and function after taking vitamin B12 supplements.
And with that Dr. Pawlak, thank you so very much again.
Dr. Pawlak: Thank you very much. It was my pleasure.
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