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

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

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 this year, 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. 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 Additionally, the “normal range” on blood reports is outdated — it is much too low.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 folate 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 folate — 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 do it?

Someone very deficient should use the shots.  For best results it 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.

What can people do to protect themselves against being misdiagnosed?

Learn about B12 deficiency – know the signs and symptoms, know who is at risk, and look out for elderly people and ask to be tested.

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,

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.


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Leave a Comment

  • jean January 12, 2012, 7:50 am

    wow. this is an eye opener. makes a person want to take another look at what the symptoms are about when suffering from them. thanks for showing us this post.

  • Nicola January 12, 2012, 10:15 am

    I’ve recently began to suspect I have a vitamin B deficiency. There are few things that have led me to believe this. The biggest one was that I suffered from HG (severe morning sickness) in both my pregnancies & I’ve read that it is suspected that a vitamin B12 & B6 deficiency can contribute to this. Interesting article & timely for me.

  • Lourdes January 12, 2012, 11:33 am

    Very informative!

  • Leah January 12, 2012, 3:58 pm

    I just read an interesting article about B12 and how we used to get it from bacteria in our guts…

  • Karen January 12, 2012, 10:08 pm

    Thank you. thank you. Thank you! This article could not of come at a better time! I had no idea that a b12 deficiency could cause such a variety of problems. Again thank you!

  • Hannah K. January 13, 2012, 8:24 am

    B12 is so necessary and this is a great summary of what it is, why we need it, and the symptoms. One symptom I struggled with for a while was eye pain. I started taking a sublingual b12 spray every day and voila it went away.

    Thanks for the great info.

  • Mindy @ Too Many Jars in My Kitchen! January 13, 2012, 10:53 pm

    Thanks for sharing this interview! I was especially interested to hear about the range that is considered deficient. I’ve taken B12 shots on and off over the last few years which have really helped my energy levels. I was just tested recently and am glad to see I’m at 494 which puts me just in the low end of the normal range. I just picked up Sally’s book from the library and hoping to figure out how to get my B12 higher still. I wonder if I should keep supplementing to help. At one point, not quite 2 years ago my numbers were in the 600s when I was still taking the shots. I think I’ll go start reading the book!

  • marina January 16, 2012, 9:28 pm

    I will read this book. My 9 year old is taking under tongue b12 after she started having absence seizures. It is working great. Being a nutritionist, I think I will focus a lot more on b12 deficiency in my practice to try and raise awareness. I also had severe nausea in my 2 pregnancies, before I studied nutrition. Now I think it is because of b12 deficiency.

    • Jill January 16, 2012, 9:48 pm

      Hi Marina,
      I think you will find the book very interesting. The authors know so much about B12!

  • Country Gal January 17, 2012, 8:54 am

    Hello !
    I my B12 checked through blood test it was dangerously low and thats why I suffered from cronic muscle pain for a long time but the strange thing is everytime I had a blood test it didnt show up, well this time it did . I had no energy at all. B12 helps permote new red blood cell growth with in your body and my body was living on what red blood cells I had left not producing more or being absorbed properly more so my muscles and tendons were basically starving for new red blood cells, also I have IBS ! There are a lot of foods I can not eat or have to be careful how much in one week due to IBS ! B12 is naturally found in Red Meat, Eggs, Dairy and Fish the first three here I have to be careful as to not eat to much each week or it sets off my IBS ! So now I take a high dose of B12 suppliment and feel soo much better now !

    • Andrea (@FrSeed2Stomach) January 17, 2012, 10:23 am

      make sure it’s METHYL! also, you might want to try cutting down on wheat intake and other refined grains if you haven’t already. gluten is the root of a lot of IBS issues! I hope you get to the bottom of it and feel better soon!

    • Jill January 17, 2012, 12:07 pm

      Hi Country Gal,
      Thanks so much for sharing. your B12 must have been really low — but as you read in the interview, Sally thinks the range is way too low — so you may have been low but not enough to go out of the range until finally it did.

      I agree with Andrea — grains are very problematic for many IDS patients.

  • Andrea (@FrSeed2Stomach) January 17, 2012, 10:21 am

    I’m so glad you published this interview. When I stopped eating meat three and a half years ago, I did my research found a great sublingual methyl B-12 supplement that I take daily. I do eat eggs and dairy a few times a week and fish a few times a month, but there doesn’t seem to be any problem with ‘excessive’ B12, so I’m currently taking 3000 mcg/day. I get routine physicals and always ask my doc to check my B and D levels and follow up by doing my own research on the results just to make sure nothing’s overlooked. I know a lot of people have trouble with the idea of vegetarianism, but my health has never been better. I haven’t had a cavity since I went veg, have lost a lot of weight, and my cholesterol, triglycerides, and blood sugar always make doctors and nurses ask what I do to have such great blood! It’s a whole foods plant-based diet full of beans, seeds and nuts, whole grains (not flour), fruit, and LOTS of veggies!

    • An November 2, 2012, 10:46 am

      HI Andrea, I have been vegetarian for 6-7 years with a regular consumption of egg, fish and diary products. Back in 2009, I went to the doctor for my panic attack matter and my blood test showed that I have low B12 level (79). However the doctor did not seem to be worried at all and explained how to deal with panic attacks, only. In 2009, unconciously, I have started to consume meat in a very limited level. In 2012, I have been checking the numbness of my leg at the clinic, and they have checked my b12 level. It was low- at 115. So the doctor prescribed b12 supplements for the rest of my life. Now there are alot of discussion whether the vegetarian diet may cause b12 defficiency. So I wonder if my current problem with b12 is due to the fact that I was not consuming meat or any other specific b12 supplements, as you have mentioned you have been doing so? Neverthless, I had started consuming animal products including meat and unfortunately had to gave up my great vegetarian diet !

  • April @ The 21st Century Housewife January 18, 2012, 12:47 pm

    I really learned a lot from this post – I had no idea B12 deficiency was so epidemic. This sounds like a very interesting book. Thank you for sharing this with the Hearth and Soul hop.

  • Pamela January 18, 2012, 8:28 pm

    How timely your post is! My doctor, my boyfriend, and I all suspected that I have a B12 deficiency, but my test results came back yesterday and were “normal”. I was disappointed. After all, if it’s not a B12 deficiency — to which all evidence was pointing –then what is the cause of my symtoms? Your article made me realize that it CAN be a B12 deficiency, since the range of what is “normal” is off. Thank you!

    • Jill January 18, 2012, 9:08 pm

      Hi Pamela,
      Thanks for sharing! Make sure you get the other tests mentioned in the article!

  • An November 2, 2012, 10:53 am

    HI again, thanks for sharing all this info. so much in time.

    I have specific wondering on b12 addressed to all of you who have ever experienced b12 defficiency matters.

    Does b12 deffiency means having prenicious anemia? And, does it effects your life expectancy at any stage, if you are taking b12 supplements supervised by your doctor? Thank you all in advance.

    • Jill November 2, 2012, 11:07 am

      hi An,
      Certainly vegetarians are at risk for B12 deficiency. Panic attacks and numbness are also symptoms of deficiency. Pernicious anemia is a different condition. Changing diet to include more B12 and to support digestion and absorption of B12 is critical. Supplements are also needed. Subcutaneous injections are the cheapest and best way to do that.

      • An November 2, 2012, 12:51 pm

        Hi Jill, thanks alot for your response. Having b12 defficiency, does it means you have an anemia would that be pernicious or megalobastic? Or not neccesarily, in case it has been discovered ontime? thanks a lot for your time.

        • An November 2, 2012, 12:56 pm

          I mean is it usual that people will have b12 defficiency ONLY with no other complications, certainly if they started b12 supplements on time and in tact to maintain healthy life? Or there will be some kind of anemia in a long run, anyway? thanks for your respons in advance.

  • Susan Fey March 26, 2013, 1:18 pm

    Please also check out coconut oil as described by Dr. Mary Newport in her book “Alzheimers Disease, What if There is a Cure?”
    I am a health care worker and have tried and tested it out on 3 Alzheimer/dementia patients in which it reversed their symptoms and actually got a 91 year old woman out of hospice care I used it myself to completely reverse aphasia I was experiencing from a low fat diet. My brother with diabetes also had remarkable results astounding his doctor. The National Institute of Health had a grant request for small molecule designer drugs for a multitude of neurological illnessses. This indicates to me that they know that the coconut oil which is a medium chain triglyceride (a small fat molecule) works and rather than studying it are appealing to the pharmaceutical companies to develop a similar synthetic drug they charge billions for. I am writing this because I think it is a crime that our research dollars are going to support the drug companies instead of researching food products. I think NIH should be sued! thank you for bringing B-12 to public attention

    • Jill March 26, 2013, 1:48 pm

      Hi Susan,
      Thanks for your comments! This is amazing and I agree with you 100%!

    • Rich January 2, 2017, 1:01 am

      Hi Susan, my mother with advanced dementia is responding to sublingual methylcobalamin. Do you have any tips to help her based on your experience?

  • Silvana May 23, 2014, 8:26 am

    Please Help!! My dad has so many symptoms which seem similar to those described for B12 deficiency. He started with weak balance, falling, and now he is getting more and more confused and his memory is starting to lapse. I’m afraid they might diagnose him with Alzheimer’s. I mentioned the B12 to his family doctor and he said that he would conduct this test next week. Is there still hope? or is this the end for him?

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  • Stacy March 22, 2015, 1:38 pm

    What if B12 is High in the blood? but with MTHFR the methyaltion pathway blocked… B12 is not what it looks … is not active!

  • Chloe May 12, 2015, 12:03 pm

    I recently heard about a new oral prescription alternative to the injections called Eligen B12. I recently read that it works even if you don’t have intrinsic factor (so even if you don’t have normal gut absorption). Apparently it came out a month or two ago. Has anyone heard of it or tried it?

  • Kymm November 3, 2015, 10:31 pm

    Great article. This is a battle I’m presently facing…trying to find a doctor who will give me a prescription for methylcobalamin shots. Meanwhile am treating myself with 5 sublingual B12 tablets hourly, (60 a day) This temporary (I hope) solution is keeping me going, keeping me alive…