The Meat of B12 Deficiency: Interview with Sally M. Pacholok, R.N., B.S.N.

Autoimmunity & Healing Diets

Jan 11
B12 deficiency, vitamin B12

Vitamin B12 deficiency can mimic the symptoms of several serious neurological diseases such as multiple sclerosis, chronic fatigue syndrome and postpartum depression or even psychosis.

Unfortunately, some of those cases are misdiagnosed because the “standard of care” in this country does not include a simple and cheap serum B12 test, unless the patient is clearly malnourished or has documented macrocytic anemia.

Most doctors do not correlate the blood results with the patient clinical picture, instead, they just read a blood test. This has led to the B12 deficiency epidemic we are facing today.

In a phone conversation with Sally Pacholok, coauthor of the book, Could It Be B12? An Epidemic of Misdiagnoses, I had an opportunity to ask some questions about her extensive knowledge of vitamin B12. After hearing her lecture at the Weston Price Conference in Dallas, I realized that B12 is a complex vitamin, with a lot of steps in its absorption.

A problem at any one of the many steps may cause malabsorption and subsequent deficiency. Therefore, it’s much more common than one would think.

Vitamin B12 must be obtained through diet.  It is a critical cofactor for the production of red blood cells and in the maintenance of the myelin sheath surrounding and protecting nerve cells.  It is also necessary for DNA synthesis. Vitamin B12 deficiency results in damage to the brain, spinal cord, and peripheral nerves, including the optic nerve of the eye.

Sally, from your lecture at the Weston Price conference I can tell how passionate you are about this subject. Here are my questions.

Why is B12 frequently misdiagnosed and untreated?

First and foremost, there is a severe knowledge deficit in health practitioners.  They have incomplete information about B12, they are using old guidelines, and they are treating lab reports instead of patients. Additionally, the “normal range” on blood reports is outdated – it is much too low. Furthermore, when treatment is given, it is usually too little too late.

When early scientists first discovered B12 deficiency they fixated on blood tests.  Consequently treatment was according to the patient’s bloodwork.  Now we know that neurological deficits proceed the hemotologic changes. If you wait for the blood test to show a deficiency, there will already be neurological damage.

Another reason is because there is very little training in nutrition in medical schools. Many times a patient presenting with depression will automatically be treated with antidepressants instead of being tested for B12 deficiency.

Additionally, B12 screenings are not included for older adults who fall or are at risk of falling, older adults who have cognitive changes or dementia, patients presenting with mental illness or depression, or patients who are pregnant or breastfeeding.

What conditions present with the same or similar signs and symptoms as B12 deficiency?

B12 deficiency can mimic multiple sclerosis, chronic fatigue syndrome and postpartum depression/psychosis, any mental illness, developmental disabilities or autistic—like symptoms in children. Any neurological symptoms are suspect, such as, neuropathy or nerve pain, numbness and tingling, or stroke-like symptoms. Sometimes it may present as balance problems, especially in the elderly.

What are the causes of B12 deficiency?

That is complicated because the absorption of B12 is complicated. You need to have a functioning stomach. You need HCl and intrinsic factor, a functioning pancreas,  small intestine and liver. If any one of these structures are not functioning correctly, it will affect how B12 is absorbed or if it is absorbed at all.

The most common reason for deficiency is non-absorption of B12.

Often, medications are a cause of B12 deficiency.  Particularly, proton pump inhibitors, as they decrease the production of HCl which is needed in the first steps of B12 absorption. Even over-the-counter antacids, if taken for long periods of time may cause B12 deficiency. Many people are taking these medications and do not know that they will deplete B12.

The diabetics drug metformin disrupts the last step in B12 absorption, which involves a receptor and transport protein to transport B12 into body.

Type 1 diabetics (and most type 2) are autoimmune and pernicious anemia is B12 autoimmune disease. Once you have one autoimmune process in the body, others may develop.

Any disruption in the digestive process will cause B12 deficiency.

For instance, elderly people generally have a lessening of their stomach acid and this will start to affect absorption of B12. Any eating disorders such as anorexia or bulimia may also affect absorption. Diets that eliminate animals products like vegetarian and especially vegan diets will cause B12 deficiency. Anyone malnourished will be at risk for B12 deficiency.

Pregnancy will cause a strain on the nutrition of the mother and that is why it is so important that B12 is ruled out in pregnant women. But OB’s generally only check for iron. When they check the blood, a B12 deficiency will cause larger red blood cells (macrocytosis) but iron deficiency causes small red blood cells (microcytosis) so that it evens out and disguises B12 deficiency. Also, they supplement with folic acid during pregnancy and this will also disguise a B12 deficiency.

B6, B12 and folic acid all work together. B12 has also been found to be involved with neural tube defects, even in presence of folic acid – surprise surprise – prenatal vitamins do not have enough B12.

How does B12 deficiency affect developing babies and children?

Any child with developmental delay should be tested (before being given supplementation so that you will have a baseline to work from). In chapter 12 of my book I talk about B12 deficiency and B12 Acquired Brain Injury (BABI) which has yet to be recognized in autistic community.

The signs and symptoms of autism are identical to B12 deficiency!!! They are; developmental delay or regression, cognitive problems, language delay, speech problems, seizures, involuntary movements, tremor, weakness, hypotonia, apathy – irritability, anorexia, failure to thrive.

There are also metabolic problems such as trans-cobalamin 2 deficiency and also metabolic errors in metabolism. These are genetic problems and may cause death in infancy.  There is also high homocysteine and high methymalonic acid and this also may cause death or anemia if not treated.

What are the tests needed to confirm a B12 deficiency?

The cheapest test is serum B12. However, the reference range is off. It is 200 – 1000 and you are not considered deficient unless it is under 200. Deficiency needs to be defined as anything under 450.

Serum homocsyteine and urine methymalonic acid are a little more specific – these last two tests will be positive in people who have serum B12 under 450, but are still not 100% accurate. Sometimes a test is not 100%. We need to raise the range of serum B12.

Studies have tested cerebral spinal fluid and B12 is lower there than in the blood. Serum B12 must be 550 in order to have a good amount of B12 in the CSF.

B12 should be supplemented when serum B12 is under 450 (not 200 as it is now) – bloodwork must be correlated with patient presentation of signs and symptoms.

Additionally, cobalamin has 3 analogs; transcobalamin 1,2 and 3 – the blood result is all three combined, but only transcobalamin 2 is active and it is only 20% – so the other analogs can fictitiously raise the blood level. You can’t overdose on B12 – it is water soluble. That is why the level needs to be raised to 450.

What foods will provide B12?

All animals foods; organ meats, beef, chicken, fish, shellfish, pork, dairy, eggs.

Is supplementation necessary in a person eating a whole food diet with animal products?

Yes — because so many people have malabsorption problems, especially when there are symptoms.

If supplementation is necessary, what is the best way to supplement B12?

Someone very deficient should use B12 shots.  For best results, the dose is twice a month shots of 1000 mcg or 1 mg. Typically the doctor gives this, but patients can give it to themselves by prescription. It is given subcutaneously like insulin. Hydroxylcobalamin for infants and children with inborn errors  cost under $40 for a 1 year supply.

Sublingual high dose of 1000mcg is also used.  Methylcobalamin is absorbed better. B12 will work for some people under the tongue – but people with small intestine disease will not do well with oral supplementation as it will not be absorbed well.

Methyl cobalamin does come in a cream but still has to be studied. And price is inflated. Still have to correlate signs and symptoms with blood levels because don’t forget that blood may only show other analogs.

Can you tell us a little about B12 Awareness and your goals?

We are trying to make a B12 Awareness Week or Month through the legislative process. Congress needs to recognize the critical nature of B12 deficiency with an annual day or week. If they did recognize it, we would organize educational seminars in schools and hospitals. We would give interviews on radio, television and blogs. This is a world wide problem we need to get the media involved. But so far the medical community as well as the media have been very resistant.

Thank you so much Sally. This has been a real eye opener. Once again it seems that our health officials are not looking out for us. They would rather sentence people to severe neurological and other health problems that cost billions in medication, care and disability, when, in fact, the cure may be simple and cheap B12. Pharmaceutical companies don’t want MS, or depression to go away – they are making billions from it. That’s something to think about. What do you think? Leave a comment and let me know!

Sally Pacholok, R.N., B.S.N, an emergency room nurse with 24 years of experience, received her bachelor’s degree in nursing from Wayne State University in Detroit, Mich. Prior to entering the field of nursing, she received an Associate’s Degree of Applied Science with magna cum laude honors. She was also an Advanced Emergency Medical Technician (A-EMT), and worked as a paramedic prior to and during nursing school. She has worked in health care for a total of 32 years, and has cared for thousands of patients. In addition, she is an Advanced Cardiac Life Support (ACLS) provider, and has assisted instructors at a local community college in training paramedics in ACLS. She is a Trauma Nursing Core Course (TNCC) Provider, an Emergency Nurse Pediatric Course (ENPC) Provider and a member of the Emergency Nurses Association (ENA).

For more information on Could It Be B12? An Epidemic of Misdiagnoses (Quill Driver Books, March 2011) or to arrange an interview with authors Sally M. Pacholok and Jeffrey J. Stuart, please contact Jaguar Bennett at Quill Driver Books, (800) 345-4447, [email protected]

Sally Pacholok can be reached at

Could  it be B12? by Sally M. Pacholok, R.N., B.S.N., and Jeffrey J. Stuart, D.O may be purchased here.

Photo: Permission Granted





Like what you read? Join the community!

Inspire Your Real Food Healing Journey with my FREE Grain-Free Meals e-Cookbook and Getting Started email series and newsletter! Unsubscribe anytime. Privacy Policy

(30) comments

Add Your Reply