Further to deniseinmilden 's post I decided to risk my credit card and subscribed to the free trial of The Times to get the article. Here it is, for better or for worse!
There are a lot of comments, some of which he replies to, sadly I can't reproduce them here.
But I think it's good news in terms of the NICE draft guidelines getting a mention - even if they are inadequate at this present time, an article will stoke debate in the general public. Got to be a good thing. I know the doctors at my surgery are talking about it, because a nurse told me.
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Vitamin B12 deficiency is underdiagnosed — here’s what to look for
Dr Mark Porter
Monday July 17 2023, 5.00pm, The Times
The last thing a beleaguered NHS needs is more custom, but that’s not the responsibilty of the National Institute for Health and Care Excellence (Nice) and is unlikely to hold much sway as the organisation finalises its first ever formal guidance on diagnosing and treating vitamin B12 deficiency. Put simply, B12 deficiency is both common and underdiagnosed and the new Nice guidelines (which are still in draft form) are likely to lead to far more people being tested and treated for the condition. Might you be one of them?
B12 is essential for the production of red blood cells and normal functioning of the brain and nervous system. Deficiency can cause numerous symptoms (see more below) ranging from lack of energy, memory issues, a sore tongue, weakness and pins and needles, to anaemia, breathlessness, confusion and, rarely, even paralysis and death. It is easily missed because it tends to develop slowly over a few years, and the signs may not show up in routine blood tests which don’t check levels of the vitamin unless specifically requested.
B12 occurs naturally in animal products such as meat, fish, milk and eggs but isn’t easily absorbed. You need a good balanced diet, a healthy bowel, plenty of stomach acid and the presence of a special protein called intrinsic factor (IF) to have a good chance of maintaining optimum levels. And millions of people in the UK struggle with one or more of these, putting them at risk.
Deficiency is more common in older people but can occur at any age. Nice highlights a dearth of comprehensive data from the UK but points to international studies (from the US and Netherlands) suggesting that about 1 in 30 young adults may be affected, rising to 1 in 25 in middle age, and as many as 1 in 5 in people over 80.
Certain groups are at particular risk (see sidebar). At least one in ten vegans is thought to be deficient and it is vital that all vegans take supplements and/or regularly consume B12 fortified foods such as some plant-based milks, soy products and cereals. If you are a vegetarian, or a member of your family is, then it is important you know about B12 requirements. Visit vegansociety.com for more detailed information.
In other groups, particularly those with autoimmune conditions such as thyroid disease, vitiligo (depigmentation of the skin) or a family history of B12 deficiency, intrinsic factor can stop working as they get older, reducing absorption even if they have a good diet or take supplements. And in many others, widely prescribed medicines such as the “antacids” omeprazole and lansoprazole, or the type 2 diabetes drug metformin, can interfere with absorption. And then there are those who don’t absorb nutrients well because of bowel problems such as coeliac disease (gluten sensitivity).
The key to diagnosing B12 deficiency is to have a high index of suspicion. The NHS does not, and cannot, routinely screen the population using regular blood tests, so diagnosis depends on spotting the symptoms and/or adding in the test when monitoring others at higher risk because of underlying health conditions.
That said, diagnosis isn’t always straightforward. A detailed explanation of what level is optimum, the different types of test available and various ways to treat deficiency is beyond the scope of this column. Suffice to say that there is an ongoing debate about who should be given what — eg injections versus tablets — and how often. However, for most people a standard NHS B12 blood test will clinch the diagnosis, with pathways (Nice may alter these) advocating either B12 injections or high-dose (1,000mcg) tablets, depending on the individual’s circumstances, symptoms and blood results.
One word of caution. A course of high-dose supplements given for at least three months will resolve many deficiencies but, unless diets/medication/underlying conditions change the problem is likely to recur. Many people will require lifelong supplements or, at the very least, future testing to check they are maintaining good levels.
Due to changes in NHS prescribing, some people with low B12 levels will be advised to buy their own over-the-counter supplements, rather than be offered them on prescription. If this applies to you then I would opt for sublingual supplements designed to melt under your tongue (or in your cheek) as these may help absorption if you are on an antacid, have low IF activity or an underlying bowel problem.
However, whatever pathway you end up on for your deficiency, the journey will only start if you, or your doctor, requests a blood test. So who should be tested? I have summarised Nice’s suggestions below, and you can read the full draft guideline at nice.org.uk.
B12 deficiency
The draft guidance from Nice advises offering a B12 blood test to people who have at least one symptom and at least one risk factor.
Symptoms/signs include:
● Abnormal findings on a blood count, such as anaemia
● Cognitive difficulties, including memory problems and other symptoms of dementia
● A sore/inflamed tongue
● Unexplained eyesight changes, including blurred vision
● Mental health problems, such as anxiety and depression
● Neurological symptoms, including impaired balance, weakness, pins and needles or numbness
● Unexplained fatigue.
And risk factors include:
● Age over 65
● A diet low in B12 (eg vegan)
● A family history of vitamin B12 deficiency or an autoimmune/underlying health condition such as coeliac disease, thyroid problems and type 1 diabetes
● Taking some types of medication, including anti-seizure medicines pregabalin, primidone and topiramate, the gout pill colchicine, “antacids” such as omeprazole, and metformin for type 2 diabetes
● Previous abdominal or pelvic radiotherapy, or gastric/bowel surgery
● And, while unlikely to apply to many Times readers, for completeness: recreational nitrous oxide use.
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