Posts Tagged ‘vitamin B12’

Analyzing blood chemistry can be a very helpful tool in determining what a patient needs to improve their health, and of course why a patient is experiencing certain signs and symptoms. A patient will often bring in their blood work to me and tell me that the doctor who ordered the tests said everything was normal. Whether or not I agree that their tests are normal, these patients never understand what all the tests mean and how to interpret them. Of course, that’s the doctor’s job, but there are many patients out there who do want to understand and wish their doctor would explain the meaning behind them. Because of this, I decided to write a series of articles explaining what these blood markers mean and how they are relevant.

There are hundreds of tests that can be ordered via blood, but the basics are a “Complete Blood Count” (CBC) and (comprehensive) “Metabolic Panel”. Very often a lipid (or cholesterol) panel is ordered as well. In this first article I’ll go over how to read and understand the red blood cell markers that are included in a CBC.

A CBC reports three different cell types in the blood: 1) red blood cells, 2) white blood cells, and 3) platelets.

Let’s begin. Red blood cells are responsible for delivering oxygen from the lungs to the body tissues, and to take up carbon dioxide from the tissues and bring it to the lungs. The CBC includes information on seven different aspects of red blood cells (RBC). I’ll go over each individually.

1) “Red Blood Cells” (RBC) – This value refers to the actual number of RBC in a given sample size. When this is decreased, it means there is an insufficient number of RBC available to supply adequate amounts of oxygen to the tissues. This would be considered “anemia”. There are many types of anemia that may be present and describing each is beyond the scope of this article. Also, keep in mind that someone can be anemic and have a normal number of RBC. Red blood cells can be low in number because of iron-deficient diets, blood loss [normal (as in menstruation) or traumatic or pathological], malabsorption, pregnancy, or during growth spurts. An increased number of RBC is more rare to see, and that would typically be a result of dehydration. This is because dehydration would increase the concentration (or total number) of RBC in sample of blood that has a low amount of water in it. Additionally, RBC may be increased due to a bone marrow disorder (where RBC are made), low atmospheric oxygen (e.g.: high altitude areas), poor lung function, or a malignancy.

2) “Hemoglobin” (Hgb) – Hemoglobin is the oxygen and carbon dioxide-carrying portion of the RBC and is responsible for giving blood it’s red color. As the name suggests it is composed of heme, which contains iron, in addition to the protein “globin”. The amount of Hgb in the RBC is directly related to the amount of oxygen the RBC can carry. When Hgb is low, it usually indicates (iron-deficiency) anemia. And as with RBC, if it is high, it would usually indicate dehydration or the other conditions mentioned above.

3) “Hematocrit” (HCT) – The HCT is the percentage of RBC in the entire blood sample, and therefore is a measurement of RBC production. This would be low in most types of anemia and high in a dehydrated person or the other conditions mentioned above regarding RBC and Hgb.

4) “Mean Corpuscular Volume” (MCV) – The MCV is a measure of the average size of the RBC. This marker is key for identifying anemia and differentiating between the many types of anemia. Red blood cells start out large and shrink in size as they mature to become fully functional. If the MCV is high (meaning the RBC are larger than normal), it typically indicates a deficiency of folic acid and/or vitamin B12 because these are the two nutrients required for RBC to mature (and shrink in size). When the MCV is low (meaning the cells are smaller than normal), it usually indicates iron deficiency as there is actually less volume to the cell because there is less mass with insufficient amounts of iron. There are other reasons this value can change due to other types of anemia, which is beyond the scope here.

5) “Mean Corpuscular Hemoglobin” (MCH) – The MCH is a measure of the average amount of Hgb in each RBC. This value helps with determining the severity of anemia. MCH is typically low in iron-deficiency anemia and might be high in B-12 and/or folate-deficiency (megaloblastic – meaning large cells). It would be high in megaloblastic anemia because the cell is larger and therefore has the ability to contain more Hgb.

6) “Mean Corpuscular Hemoglobin Concentration” (MCHC) – The MCHC is (just what it sounds like) a measure of the concentration of Hgb in a given amount of RBC, and will most likely be low or high for the same reasons as MCH. This value is especially useful in monitoring therapy for anemia.

7) “Red Blood Cell Distribution Width” (RDW) – The RDW is a value that measures the average size of all the RBC present in the sample. A low RDW would indicate that most RBC are too small as in the case of iron-deficiency. And a high RDW would point to there being too many large RBC as in B12 and/or folic acid-deficiency anemia. It would certainly be too high or low because of other types and causes of anemia.

Keep in mind that this article does not cover all types and causes of anemia. It is intended as a guide to understanding the terminology used on blood tests and some of the most common reasons for abnormally high or low values. Additionally, the reference ranges for normal values can, and often do, vary from lab to lab. This is because the reference ranges are typically determined from averages that the labs have constructed based on the many samples that they have tested. As a result, I usually find these ranges too wide to assess the risk for disease before it develops. When the blood values are outside of the lab’s reference ranges, a disease (or disease process) is usually already in place. I prefer to assess blood work using more narrow, “functional” ranges that can detect disease before it is “full-blown”, and to prevent disease.

Clinical pearl: when a patient is doing “everything right” for themselves (i.e.: diet, exercise, proper supplements, etc.) but they do not respond to those treatments; usually a sub-clinical anemia can be found. Without proper oxygen supply to the body’s tissues, there is little to no chance the body will be able to heal or function better.

Dr. Robert D’Aquila – NYC Chiropractor – Applied Kinesiology

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Let’s talk about two common types of anemia I see in my patients.  They are self explanatory like iron-deficiency anemia.  Megaloblastc anemia refers to a deficiency of folic acid and/or vitamin B12, and pernicious anemia refers to B12-deficiency specifically.

Every single cell in your body requires folic acid and vitamin B12 in order to “mature” and therefore function properly.  All cells start off immature (and large in size) and become smaller when they mature.  Thus, the term “megaloblastic” refers to the fact the cells stay large in size (mega) without these vitamins. “Macrocytic anemia” is also a term for this condition.

In regards to folic acid deficiency, we run in to some of the same situations as in iron-deficiency – when asking the question: Why is their a deficiency?

The answers are either: a) insufficient consumption of foods containing folic acid; b) lack of absorption; c) an inability to convert folic acid to its active form, and d) complications of its utilization from certain drugs.

In regards to answer “a”, you must obviously consume folic acid through the foods you eat. Some of the best foods that contain high amounts of folic acid (or folate as it is referred to when in food) are: lentils, beans peas, broccoli, spinach, collards, okra, asparagus, and citrus fruits.

As far as answer “b”, regarding absorption – this could result from:

1) Your intestinal villi are literally clogged up due to poor food choices, thus not allowing for absorption of folic acid (and most definitely other nutrients as well).  To “fix” this, you would need to change your diet, and probably have to take supplements that would help detoxify the small intestine.  Examples would be a whole food diet and/or fiber (to “scrub” them clean), bentonite clay (to absorb the toxins), and/or mucilaginous herbs that could help “dissolve” out the toxins.

2) Digestive conditions that can compromise the absorption of folic acid (and any nutrients) are: Crohn’s disease, ulcerative colitis, irritable bowel syndrome, leaky gut syndrome, colon cancer, and perhaps others.

Now for answer “c”.  Folic acid (or folate) needs to be converted to 5-methyltetrahydrofolate (5-MTHF) in order to actually perform its necessary functions at the cellular level.  This inability to convert usually results from a genetic defect. If there is a genetic defect, you may have to take a dietary supplement that contains the converted form.

The medications that interfere with folic acid utilization are: anticonvulsants (dilantin, phenytoin, and primidone), metformin (for diabetes), sulfasalizine (for Crohn’s disease and ulcerative colitis), triamterine (a diuretic), and barbituates.

Wait!  A few more things regarding less common causes (that I see) of folic acid deficiency are: alcohol abuse, kidney dialysis, and liver disease.  And as you’ll see below, more is required during pregnancy and lactation to prevent neural tube defects in the fetus; and for the growing baby.

Let’s now discuss vitamin B12 deficiency.  Why would someone be deficient?  The answers here are either: a) insufficient consumption of foods containing vitamin B12; b) failure to properly absorb B12; c) lack of a substance called intrinsic factor in the stomach (related to absorption); and d) inactive or oxidized B12.

Let’s start with answer “a”. Please be aware that B12 is only contained naturally in animal foods!  You can get certainly get it in vegetarian food sources, but that means it has been “fortified”.  Also, even though the algae product known as spirulina lists B12 on the label; apparently it is simply an analogue of B12 and may actually cause you to become even more B12 deficient.  Read this is you are concerned.  Foods high in B12 are basically every animal product known.

Answers “b” and “c” relate to an inability to absorb B12.  One possibility is for the same reasons as folic acid.  See above. Additionally, vitamin B12 requires a substance called intrinsic factor which is produced by (parietal) cells in the stomach, in order for proper absorption.  Stomach tumors, atrophic gastritis, pancreatic enzyme insufficiency, resection of the part of the small intestine that absorbs B12, autoimmunity towards the stomach cells or intrinsic factor itself, and an excess consumption of alcohol may be prevent B12 absorption through intrinsic factor complications.  See a reference here on the above.  “Pernicious anemia” refers to B12-deficiency anemia when the cause is specifically related to atrophic gastritis/destruction of parietal cells or destruction of intrinsic factor (usually from an autoimmune reaction).

Lastly, I’ll talk about “d”.  Vitamin B12 is known as cobalamin.  This is because the mineral cobalt a necessary part of the B12 complex.  B12 needs to be converted to methylcobalamin or hydroxycobalamin to actually get used properly, which depends on genetic factors.  If this conversion does not occur, B12 will be inactive.  Also, a person under oxidative stress (too many free radicals) may cause cobalt to become oxidized and again not allow B12 to work properly.  In this case, it’s possible to have normal B12 levels on blood analysis, but it will be inactive at the cellular level and thus not work. These people will need to decrease their exposure to free radicals; and mostly likely have to supplement with antioxidants and B12 also.

RDA’s for folic acid and B12 are in the following charts provided by the National Institutes of Health:

Folic Acid

Males and Females
1-3 150 N/A N/A
4-8 200 N/A N/A
9-13 300 N/A N/A
14-18 400 600 500
19+ 400 600 500

Vitamin B12

Males and Females
1-3 0.9 N/A N/A
4-8 1.2 N/A N/A
9-13 1.8 N/A N/A
14-18 2.4 2.6 2.8
19 and older 2.4 2.6 2.8

In conclusion, symptoms of folic acid deficiency are as follows: fatigue, diarrhea, loss of appetite, weight loss, weakness, sore tongue, headaches, heart palpitations, irritability, forgetfulness, and high blood levels of homocysteine (to be discussed in another article).

Symptoms of vitamin B12 deficiency are: fatigue, weakness, constipation, loss of appetite, weight loss, numbness and tingling in the hands and feet, difficulty maintaining balance, depression, confusion, dementia, poor memory, and soreness of the mouth or tongue.

Blood tests can be run to determine folic acid and B12 status.  Especially a complete blood count (with “random distribution of weight” or RDW; and “mean corpuscular volume” or MCV) to check for the red blood cells’ size and associated anemias.  A blood test can also confirm a problem with the gene associated with failure to convert folic acid to its active form.

Vitamin B12 can be measured in blood, but remember if your cobalt has been oxidized, it can show normal levels when in fact the B12 isn’t working.  Methylmalonic acid is a good test (and rarely or never run) for B12 status.

And finally, homocysteine levels can spot a folic acid and/or B12 deficiency.  Homocysteine is related to cardiovascular and neurological problems.  Again, I’ll discuss that in another article.

I also use in-office, applied kinesiology muscle tests when I suspect deficiencies in these vitamins. HOWEVER, I still consider it prudent to use blood tests to see exactly what my patient’s levels are.

ANOTHER VITALLY IMPORTANT POINT! The blood lab’s ranges are often too wide to pick up sub-clinical deficiencies in these vitamins, that may still be causing your symptoms. I use narrower functional ranges for myself and my patients.

Proper food choices and quantities and/or supplements can correct deficiencies.  HOWEVER, do not take more than 1,000 micrograms of folic acid without B12.  This is because folic acid supplementation this high can trigger B12 deficiency symptoms.  In particular, it can cause IRREVERSIBLE nerve damage because of B12 deficiency.  Most supplements contain both vitamins together to prevent this. And the only supplements I’ve seen with 1,000 micrograms (and NO B12) in one tablet or capsule are prescription only. Go figure.

Well, that’s a lot to consider for just two vitamins.  But then again, they are obviously extremely important!

Some information in this article was derived from the National Institutes of Health website.

Dr. Robert D’Aquila – NYC Chiropractor – Applied Kinesiology

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