A Discussion of Vitamin B12
Agatha M. Thrash, M.D.
With many people switching to a vegetarian diet, the question sometimes arises: "Where does one get vitamin B12 if he takes no animal products?" A few laboratory animals deprived of vitamin B12 may develop serious neurological disorders. Since this vitamin in the human dietary has been said to be limited to foods of animal origin it is assumed by some that it would be hazardous for human beings to live on a strictly vegetarian diet.
At this point, science and revelation seem to be in opposition. Man was given a strictly vegetarian diet in the Garden of Eden. It was intended to supply his food needs forever. Were Jesus to appear in His humanity today, He might say, "Ye do err, not knowing the testimonies. It is written, the grains, the fruits, nuts, and vegetables contain all the nutritive properties necessary to make good blood" (CD 313). We conclude, therefore, that we are not dependent on animal products to supply the nutrients the body needs.
On the other hand, if vitamin B12 is actually required for the making of good blood, we can accept the fact that vitamin B12 is obtainable in the diet recommended above. In CH 63, we are told, "You should use the most simple food prepared in the most simple manner, that the fine nerves of the brain be not weakened, benumbed, or paralyzed." It seems reasonable, therefore, that any neurological problems experienced by vegetarians might be the result of a wrong lifestyle that we have not yet fully determined, instead of a diet deficient in vitamin B12. For this reason, we institute a very simple diet plan consistent with inspired counsel, even for those who have no medical problems. Some of the special advantages of a simple diet, particularly for the young, are presented in CH 63-65. The simplest diet should not be denied to those who need or want its benefits.
The Model for Vegetarian Diets
Many have observed that after adopting a very simple diet, food is enjoyed with greater relish than formerly when a more complex diet was taken. There are others besides certain Seventh-day Adventists who use a completely vegetarian diet. One group of these, the Vegans, who for religious or moral reasons take no animal products of any kind, have been used as a prototype for all strict vegetarians. However, there are often marked differences in the health habits of Seventh-day Adventists and Vegans. Seventh-day Adventists believe that humans were created in the image of God, and that a total program of good health is needed to protect the human mechanism. Vegans, on the other hand, have simply dropped the use of animal products because they believe in a humane philosophy toward all animals. They may, if they choose to do so, adopt a lifestyle which allows them to smoke, eat between meals, drink alcohol or caffeine beverages, use rich foods, spices, and other stomach irritants, and otherwise live unhealthfully. They cannot, as a group, be considered a proper example of vitamin B12 metabolism because of the habits of life which bring on a greater need for vitamin B12 or cause the body to be unable to hold onto its vitamin B12.
In defense of vegans, however, the following can be presented: "Vegans in the United Kingdom who for ethical reasons eat no foods of animal origin have pursued their dietary practices out of choice and not economic necessity for years and even lifetimes. While the few clinical studies made so far in Britain and the United States have not been able to identify any real differences in the health of Vegans, compared with omnivores, a study group at the University of Surrey, England has been studying Vegans and omnivores with an eye to the effects of these widely differing diets in the treatment of heart disease. They suggest, tentatively, that a vegan-type diet plus vitamins B12 and D, may be the one of choice for victims of ischemic heart disease, angina pectoris, and certain hyperlipidemias." (T. A. B. Sanders et al. "Studies of Vegans, Etc.," American Journal of Clinical Nutrition, 31:805-813, May, 1978; Nutrition Notes 76, Summer, 1978, p. 8).
Vegetarians Need Less Vitamin B12
Among Vegans the levels of vitamin B12 in the blood have been shown to be between 60 and 320. Yet, these "low" levels are not associated with signs of vitamin B12 deficiency. In contrast to these levels, certain lactovegetarians have been shown to have levels of 115 to 450, whereas those eating meat in the same general ethnic group have 170 to 550. The mean values of these three groups of the Vegans, lacto-vegetarians, and non-vegetarians run like this: 166, 227, and 325. Now the Vegans, the lactovegetarians, and the non-vegetarians maintained these blood levels even though they took a diet that was fortified with vitamin B12. This particular study of blood levels indicates that the Vegans do not need a greater level than that represented in the blood, 60 to 320. The blood level of 60 would be considered in a non-vegetarian to be deficient, and it is quite likely that a person who eats meat, drinks alcohol, or smokes, may at a blood level of 60, experience symptoms of vitamin B12 deficiency. Apparently, there is a factor in a vegetarian diet that offsets the need for an excessively high level of vitamin B12. Since the original diet designed for man was vegetarian, we can regard the high blood levels of B12 seen in many who eat meat as being abnormally high, and possibly pathologically elevated as will be discussed. Clearly, laboratory normals for B12 blood levels should be based on individual lifestyle, with vegetarian levels probably the ideal.
Vegetarians Have Better Vital Statistics
In 1970 Ellis and Montgriffo reported a study on 26 Vegans, 12 males and 14 females, compared with controls chosen from the omnivorous public, to match as closely as possible the Vegan subjects with regard to age, sex, weight, height, and occupation. The Vegans were lighter in weight than the controls. There were no abnormal symptoms or signs of significance in the Vegans. The mean male Vegan serum cholesterol was 181 as compared to mean male control level of 240, definitely an elevated value. Urea levels were higher in controls than in the Vegans. The serum vitamin B12 level on a non-fortified diet in the Vegans was in the range of 30 to 650, with a mean of 236. In the control group, it was 120 to 740 with a mean of 441.
The various reports could as well be understood to illustrate that there is an abnormally high level of serum B12 in non-vegetarians as to assume that there is an abnormally low level in vegetarians. It should not be assumed that the so-called "low level of vitamin B12" in those who use no animal products represents a pathologically low level. It may be that there is a metabolic load in those who use animal products causing them to require an especially high level of vitamin B12. Vitamin B12 elevation in the serum has been found in certain serious diseases, and should not be empirically regarded as especially desirable.
The Vegans in the study did not appear to need any more vitamin B12 than they already had in the serum, since they did not respond in any way to shots of B12 in large doses. Also, there were no symptoms of vitamin B12 deficiency.
Others with Megaloblastic Anemia
Megaloblastic anemia, the kind of anemia of vitamin B12 deficiency, can occur in individuals taking oral contraceptives. In the Southern Medical Journal, February 1975, there is a report of just such an individual. Also, there have been several reports of Asian immigrants, solely vegetarian, who have developed megaloblastic anemias. These individuals are from among the Hindu immigrants to Britain, and are notorious for their use of spices and other stomach irritants. However, it is possible that there exists some other factor or type of abuse of the health which could result in the improper metabolism of vitamin B12. It is curious that there is no folklore among this population group to draw the attention to any untoward effects of the dietary customs while they were living in India. This leads one to believe that as they immigrate they may leave behind a certain way of life or some type of vegetarian food that they have been using, or that they may have adopted certain injurious dietary practices, such as the increased use of fat or sugar or other refined foods, which lead to an increased need for vitamin B12. As late as 1975, there was no evidence of vitamin B12 deficiency among East Indians taking as little as 0.16 micrograms of vitamin B12 per day. We emphasize, therefore, a lifestyle that will keep gastrointestinal malfunction to a minimum. Close attention should be given to the physiological principles of digestion such as the proper combination of foods, the time of day that one eats, the varieties of food that one serves at a meal, the concentration (caloric density or degree of refinement) of the individual food items, as well as carefulness in eating slowly and chewing well.
Practically all cases of vitamin B12 deficiency occur in individuals who use animal products quite generously. Therefore, we can say that a dietary deficiency is not the usual cause of clinical syndromes involving low blood levels of vitamin B12. Even when pure vegetarians have a low vitamin B12 level by currently understood laboratory standards and by comparison with those who eat meat and other animal products, they have no deficiency stigmata.
In the Journal of the American Medical Association 229:703, August 5, 1974, appears this interesting statement: "An ironic 'in-joke' among hematologists goes something like this: 'Look at the sales of vitamin B12! We must be missing a lot of pernicious anemia.' In truth, there isn't much pernicious anemia in this country, but there is a lot of B12 in [the] American deltoid and gluteus." A later issue of the JAMA 231:289, for January 20, 1975, carries additional information: Vitamin B12 deficiency "occurs in subjects who fail to absorb vitamin B12 from the diet and in those who have inadequate dietary intake, usually associated with poor vitamin storage. The latter group is composed mostly of alcoholic patients with liver disease. After B12 combines with intrinsic factor (from the stomach) it is absorbed by the ileum. Hence, poor absorption results from the lack of intrinsic factor, from disease or removal of the ileum, or, less commonly, from successful competition for available vitamin B12 by bacteria (blind loop syndrome) or parasites (fish tapeworm). Only the last of these is likely to be cured.... The other two produce permanent malabsorption of vitamin B12. Parenteral replacement therapy which bypasses the intestinal block is needed for the rest of the patient's life. Interruption of treatment inevitably leads to relapse after one to five years...."
We should emphasize that vitamin B12 deficiency or pernicious anemia is a rare disorder.It is uncommon to find it in any segment of our population. Hemolysis of red blood cells and improper storage of vitamin B12 by the liver may also be essential features of the syndrome. Other causes are suspected, among them certain toxic substances. There is much more that is unknown than is known about B12 and its metabolism in the body.
Generally, the liver stores 1000 to 1500 micrograms of vitamin B12. A normal liver should be capable of storing that much vitamin B12 for up to 12 years. If a person has a sick liver for any reason, his ability to store vitamin B12 is greatly impaired.
The signs of pernicious anemia (PA) include a group of symptoms that may be present in a host of other diseases. The disease results in a deficiency of vitamin B12 in the blood. The typical patient with PA is a tall, somewhat elderly male, with premature greying of the hair and large ears. He generally has blue eyes, a fair complexion, and is of Nordic extraction. PA is a rare disease and requires a battery of laboratory tests to make the diagnosis. It should not be entered into lightly or undertaken by the unskilled. After many laboratory tests and medical consultations, the diagnosis of B12 deficiency can usually be made with certainty. Then it is mandatory that monthly shots be taken for the rest of the lifetime of the individual - no small chore. The symptoms can be readily seen to be nonspecific, that is, associated with many other disorders, and include the following: diarrhea, flatulence, sore tongue, decreased appetite, nausea, anemia, dizziness, unsteadiness on the feet, strange sensations on the skin, poor mental concentration, shortness of breath, swelling of the hands or feet, and mental or physical fatigue.
Pernicious anemia is a disease of many suspected causes, hemolytic, metabolic, enzymatic, or gastrointestinal. It is also possible that a toxic substance is involved. The urine in cases of PA has been reported to contain a toxic factor. This fact complicates our understanding of PA. One of the puzzling things about PA is that prior to the time when liver was used in the treatment of PA, spontaneous remissions occurred in about 86% of cases. The question of the role of toxins loomed up as quite important. The well-marked signs of increased blood destruction which are found in PA could be caused by toxins. Some researchers believe that the destruction of blood (hemolysis) is a primary cause of the anemia, rather than the secondary effect of faulty blood construction. The dietary deficiency theory fails to explain adequately the spontaneous remissions occurring in the absence of liver or other anti-anemic factors in the diet. It is quite possible that it is not primarily the vitamin B12 metabolism defect that causes the PA, but some other factor.
Some cases of PA were reported to be abnormally susceptible to the blood destructive action of elevated fats in the serum. This excessive sensitivity leads to the destruction of blood cells by the digestive products of fat. This was proposed as only one manifestation of a general disturbance of fat metabolism in PA. Other evidences of fat problems are as follows: (1) a striking variation in cholesterol and related constituents in the nervous system. (2) The diarrhea associated with sprue, as well as with B12 metabolism defect, is attributed to the action of the long chain fatty acids derived from fat breakdown as well as to the short chain fatty acids arising from starch fermentation. (3) In the Indian immigrants into Great Britain who have been reported to be suffering from B12 deficiency, a high fat or refined starch intake may play an etiologic role in their problem.
The serum of patients with untreated PA contains a factor which inhibits the ripening of megaloblasts to red blood cells. The macrocytic anemia occurring in association with intestinal strictures and blind loops of various kinds which may be accidents or may be from surgical intervention of some kind, also give evidence for a toxic substance or bacterial growth. We know that the bacterial flora changes in the intestinal tract with the introduction of a different type of diet, such as the pure vegetarian diet. It could be that one of the reasons why persons eating animal products need more B12 is that the bacterial content of the gastrointestinal tract is altered in such a way as to cause the extra B12 requirement.
It should be emphasized that PA and related metabolic states are not simple or well understood. A considerable body of evidence suggests that dietary deficiency is not the primary defect in sprue or in idiopathic steatorrhea, two other macrocytic anemias. In spite of the fact that in certain cases of tropical sprue dietary deficiency appears to play a role, it must be recognized that this disease may develop in persons consuming bountiful and mixed diets, and does not usually affect both husband and wife even though they consume the same diet. There is no doubt that infections or abuse of the health may hasten the malabsorption defect. The gradual upward extension of abnormal intestinal flora from the cecum to the small bowel, to duodenum and finally to the stomach, has been considered by many as making possible bacterial competition for the absorption of vitamin B12. It is interesting that bacteria can be cultured from the stomach contents of achlorhydric patients, whereas this is never the case in those who have normal stomach levels of hydrochloric acid.
Are High Vitamin B12 Levels in the Blood a Pathologic Sign?
Generally, we do not advise the routine use of B12 supplements. In animal studies there have been cases of increased cancer production in animals that are on a high intake of B12. It is noted that animals taking B12 have increased granulocytic proliferation such as occurs in chronic myelogenous leukemia. In the past, hematologists have used the high serum B12 levels that leukemia patients exhibit as an aid in making the diagnosis of leukemia. Other malignant conditions have been associated with high B12 in the serum. Two patients with metastatic cancer were described who showed very high levels of B12 and transcobalamin. An increased B12 level was found in a case of ulcerative colitis. While these are not generally regarded to indicate that a high level of B12 caused the malignancies and ulcerative colitis, we know that overnutrition in other nutrients does tend to promote the formation of cancer and other diseases.
Our inspired counsel consistently advocates that concentrated nutrients should be used sparingly. It would seem wise to avoid large vitamin B12 supplements both on the basis of science as well as revelation. If vitamin B12 supplements are not considered entirely innocuous, the question then arises as to whether one should eat largely of certain foods known to contain vitamin B12 in order to insure a high blood level. Animal products would seem to represent a logical answer to the question. Yet, there are many references in the Spirit of Prophecy which indicate that disease in the animal kingdom will make it necessary to give up even milk and eggs. Surely the facts indicate that we are well into the time when animal products are no longer safe.
I see no reason why an occasional light sprinkle of food yeast on a salad should cause metabolic problems. The generous use, however, of food yeast, as by the teaspoonful, can lead to elevated uric acid in the blood. For those who do not receive an ill-effect from the sugar in commercial soy milk, a small quantity used occasionally is probably not harmful. Yet, even these supplements are not essential for normal persons as will be discussed next.
Sources of B12 for the Vegetarian
All vitamin B12 on this planet is eventually traced to synthesis by microorganisms, certain bacteria, and fungi (Actinomycetes). The B12 is then available to animals that eat the microorganisms or their products, or grow the germs in their digestive tracts. The B12 is stored in their tissues and secreted in their milk. Where does a human who eats neither the microorganisms directly, nor any animal products get his vitamin B12? There are several non-animal food sources of vitamin B12. While these sources may not be constant, it appears that they occur with sufficient regularity to supply the minute quantities of vitamin B12 that are needed by those who are not using animal products and are not abusing their health in a way that would necessitate taking larger quantities of vitamin B12. These include wheat, soybeans, many common greens, olives, various fruits, and several other foods that occasionally have vitamin B12 either in the food or on the food. For our purposes, it does not matter whether the food has incorporated the vitamin B12 within its structure or whether it is a contaminant on the surface. Any way it is eaten, it is available to the body systems.
A non-food source of vitamin B12 is bacterial growth in the mouth, around the teeth and gums, in the nasopharynx, around the tonsils and in the tonsillar crypts (the tubular depressions in the tonsils), in the folds at the base of the tongue, and in the bronchi and peribronchial glands. It is evident that this source alone will supply sufficient quantities of B12 for the very small requirement of a total vegetarian.
Causes of Increased Vitamin B12 Need
In the book published in 1969, called The Megaloblastic Anemias, by Dr. I. Chanarin, page 317, it is stated that "megaloblastic anemia due to uncomplicated dietary deficiency has yet to be demonstrated in man." I believe this to be the case to the present time. There are, however, a few reports of individuals who abuse their health, those who have metabolic defects either in absorption or storage of vitamin B12, and those who have a variety of chronic conditions, who take no animal products and have developed metabolic problems involving vitamin B12. We do not require large quantities of B12 unless certain conditions exist. These include the following:
- Meat and other animal products in the diet causing an apparent requirement to maintain excessively high levels of B12.
- Drugs or chemicals used which destroy B12 (nicotine, alcohol, caffeine, many over-the-counter and prescription drugs).
- A disease exists such as pernicious anemia, atherosclerosis, liver disease, or diabetes.
- Excessively high or low blood levels of vitamin C.
- A high intake of fat.
- Oral contraceptives.
- An absence of certain other nutrients, especially calcium.
- Advanced age.
- Conditions such as cancer, surgery of the stomach or small bowel, a chronic infection such as tuberculosis, malaria, or intestinal parasites.
- Low thyroid function.
It has been shown that high levels of ascorbic acid can lead to vitamin B12 deficiency. From the Journal of the American Medical Association, October 6, 1975, page 24: "Doctors Herbert and Jacob made the observation that ascorbic acid (vitamin C) in quantities in excess of 0.5 grams will destroy between 50% and 95% of vitamin B12 content in food." The report of this study on 90 subjects in Cleveland appeared in the Journal of the American Medical Association, 230:241, in 1974. A number of these 90 individuals were also taking oral crude liver extract or other substances containing substantial amounts of vitamin B12. Even so, the taking of vitamin B12 did not protect them against its destruction by excessive vitamin C intakes.
Have Confidence in the Testimonies
And now, having considered the issue from the standpoint of science, I must conclude that even if I were not convinced that vitamin B12 supplements are unnecessary and the use of animal products is undesirable, I have yet to take into account the inspired word which declares that every element of nutrition that we need to make good blood can be obtained from fruits, vegetables, and whole grains (CD 322). We can certainly have confidence in the unchangeableness of the inspired word, especially as compared to the most changeable science we have, nutrition.
Shall we not raise the standard high and follow the Lord boldly, not expecting that our food will hurt us? For Seventh-day Adventists the greatest issue that faces our day is not vitamin B12, but that of confidence in the completeness and veracity of the Testimonies that have come to us from God. At untold expense to heaven these Testimonies were especially given that we might know truth. These counsels far surpass anything that we receive from our own research or from the vacillating science of nutrition. No subject in nutrition is more poorly understood than that of the metabolism of vitamin B12. Great changes have been made in just the past few years in our understanding of vitamin B12. Surely, this fact should lead us to rely far more heavily on the Testimonies than on changeable nutrition teachings. There are numerous inspired statements which indicate that there are three classes of foods that will sustain life and will not bring disease. These are fruits, vegetables, and whole grains (CD 267, etc.). On page 209, written in 1899, is the following prediction: "The light given me is that it will not be very long before we shall have to give up using any animal food, even milk will have to be discarded." We were instructed to wait until the circumstances (perhaps such things as diseases and pollution) demanded giving up milk and eggs, and until the Lord prepared the way - perhaps through food technology, long-distance shipping, and the birth of the science of nutrition early in the century. These factors have been developed well enough since about 1930 to make it possible for milk and eggs to be discarded with safety. Some are waiting for an announcement from heaven that milk and eggs are unsafe. It is unlikely that this is the idea intended by the words, "when the time comes God will reveal this." (CD 359) Similarly, we do not expect an angel to appear to tell us how to develop marketing and transportation. Yet, the Lord is instrumental in these matters and prepared the way for all to see.
The very thought of the diseases that can be carried by eggs and milk should be sufficient reason for those who have been taught to be as fastidious in their dietary habits and the niceties of life as have Seventh-day Adventists, to omit these articles from the diet. We are admonished to stay well within the safe areas in all matters having to do with our Christian witness. It is only a matter of time until it will be generally recognized that milk and eggs are unsafe. What kind of faith will be required then, when the world agrees that serious disease is being transmitted by milk and eggs, and that we can live without them? Shall we not accept the light we now have? It is quite possible to obtain all elements of nutrition from fruits, vegetables, and whole grains. Shall we not as a group of people say, "We can show you the way. We have already demonstrated its feasibility. Our Heavenly Father specially instructed us!" Certainly, our desire to participate in the demonstration of good health that must come before we can be translated to the heavenly Canaan would lead us to prepare ourselves and our churches for this event. It seems to me that the fear over B12 is misplaced. Let us teach the people everywhere how to cook without using milk or eggs. Let us put the emphasis on simplicity (not overeating, chewing well, and eating slowly, and many other important factors) and abandon fear and agitation about vitamin B12.
". . . Remember that a disciple is to do the will of his master. We are not to reason in regard to results; for then we should be kept ever busy, and ever in uncertainty. We must take our stand to acknowledge fully the power and authority of God's word, whether or not it agrees with our preconceived opinions we have a perfect Guidebook. The Lord has spoken to us; and whatever may be the consequences, we are to receive His word and practice it in daily life, else we shall be choosing our own version of duty and shall be doing exactly the opposite of that which our Heavenly Father has appointed us to do." MM 255-256.
Man was given a strictly vegetarian diet in the Garden of Eden. Fruits, nuts, grains, and vegetables were intended to supply his food needs forever. These food groups supply all the nutritive properties necessary to make good blood.
2. Any neurological problems or anemia suffered by persons on a strictly vegetarian diet usually have some other cause than that of vitamin B12 deficiency in the diet.
3. Abuse of the health in any way can result in increased wastage of vitamin B12. Vegans and East Indians sometimes engage in health habits which destroy the ability of the body to utilize or conserve its B12.
4. Practically all cases of pernicious anemia (vitamin B12 deficiency) occur in individuals who use animal products generously. B12 deficiency is a poorly understood disease.
5. Pernicious anemia is a rare disorder, and a difficult laboratory diagnosis, and should not be made by the unskilled.
6. Strict vegetarians have a lower level of vitamin B12 in the blood serum than do ovolactovegetarians or non-vegetarians. At a blood level of 60 a non-vegetarian usually shows deficiency signs, a vegetarian will not until below 30. High blood levels of B12 are often associated with the presence of serious disease.
7. Strict vegetarians generally have better biochemistries and blood pressure levels.
8. A high fat or high refined starch intake may play a role in Indian immigrants into Great Britain who have been reported to suffer from B12 deficiency. The bacterial flora of the intestinal tract change with a change in diet.
9. All vitamin B12 is eventually traceable to production by microorganisms, bacteria, or fungi. These microorganisms grow in the digestive tract, around the teeth and gums, in the tonsils and peribronchial structures, in the GI tract, in the soil and air, and are present in rainwater. B12 is often found in olives, greens, grains, fruits, and vegetables.
10. Things that cause increased need of B12 are the eating of animal products; the use of drugs, caffeine, nicotine, and alcohol; a variety of diseases; excessively high or low levels of vitamin C; a high intake of starch or fat, oral contraceptives, too little calcium, and a low thyroid function.
11. We are commanded to teach the people everywhere how to cook without using milk or eggs. Nutrition knowledge and food commerce make possible a vegan-type diet.
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