When we hear B-vitamins, we often think of vitamin B12 and rightfully so, because this is an essential B vitamin for many functions in our body - see Part 1 for some more details and fun facts on vitamin B12 deficiency. However, there are 8 vitamins that make up the complex - these are essential for our cellular, nerve, cognitive, mood, immune health and resiliency! Also, recently I've seen many patients taking high doses of active B-vitamins, this can be problematic - more details to follow.

Folate (aka Vitamin B9): Folate is essential for healthy tissues as it is required in the synthesis of DNA and nerve formation. Deficiency is associated with neural tube and other birth defects in newborns. In the past several years genetics has been found to be a significant factor in human folate levels. There are many genetic variants or mutations that increase need for active or methylfolate in the body. There are common variants, however, some people have a number of these that can lead to a function deficiency of this important B vitamin. However, the solution is not always to supplement with loads of it either. While we need active folate for DNA repair, cellular healing, and detoxification, too much of it can promote pathways of growth that can promote cancer. Both deficiency of folate and excessive supplementation can promote cancer. The same goes for vitamin B12 and excessive supplementation with vitamin B12 as methylcobalamine. One of the most common genetic variants that involves folate is methylenetetrahydrofolate reductase (or MTHFR, and my patients have a few other nicknames for this). MTHFR is a common genetic variant, with at least 50% of the population having at least one genetic variant. When there are two or more variants the risk for issues including elevated homocysteine (which can lead to cardiovascular disease) increase as well as mental health concerns of anxiety, depression, and even schizophrenia. Just because one has a variant or even two of MTHFR does not mean that they need to supplement with methylfolate. It is important to look at the totality of variants related to methylation and to also consider clinical signs and symptoms. Small amounts of active or methylfolate as in a multivitamin or prenatal vitamin are likely safe, but amounts over 1 gram I have not seen to be clinically useful or helpful for the majority of my patients. On multiple occasions I've seen higher doses cause aggravations of anxiety and a few occasions I've even seen the amount in a multivitamin be aggravating. Rarely, there are patients whose genetic need does require a higher dose of supplementation. The bottom line is that it is important to consider genetic methylations in totality, rather than just looking at a single variant to inform possible supplementation and work with a provider who has some training around this. Additionally, lifestyle, including a wholefoods diet, adequate sleep, positive outlook, and exercise all have positive impacts on genetic function, and should be the foundational approach to wellness generally. Folate takes its name form foliage, and green leafy vegetables, along with asparagus, broccoli, and brussels sprouts are all great sources of folate along with legumes. Heating foods does cause significant looses of folate. 

Thiamin (aka Vitamin B1): Thiamin is extremely important for blood sugar regulation in the body and a healthy nervous system. Thiamin is require for formation of its coenzyme, thiamin pyrophosphate (TPP), which helps to convert sugars and ketones into energy. I have seen this to be consistently deficient in patients with Type I diabetes, and in many patients with Type 2 and pre-diabetes. I have additionally seen deficiencies in those who consume alcohol daily or regularly. Patients on dialysis, tube feeding, and those with chronic infections are also at risk for deficiency. The main food sources of thiamin are unrefined grains, meats, nuts, and legumes. Deficiency, as I've seen it clinically, typically presents with cognitive deficits (brain fog, memory loss, easily confused) and neuropathy in the hands or feet. Cardiovascular symptoms such as edema or swelling and rapid heart rate can also occur with deficiency. When the blood sugar is elevated we can end up with neurologic issues from cellular damage - thiamin is an important, but often under-considered B vitamin in blood sugar management and amid such symptoms. As with many of our B vitamins genetics can play a role in how well we bind TPP - so some folks who are at high risk for deficiency due to genetics will be at even higher risk for deficiency and related neurologic deficits with regular alcohol consumption.

Niacin (aka Vitamin B3): is essential for the synthesis of coenzymes required for the energy production cycle. Simply stated, without this we cannot produce energy. Thankfully, I rarely see deficiency of this in practice, as it is widely available from common meat, fish, poultry, vegetable (tomatoes, mushroom, corn, and potatoes), grain (wheat, barley, rice) sources and peanuts. Because of the importance of niacin, along with riboflavin, niacin and iron and the fact that the milling of grains results in a loss of it, in the early 1940s the US government established enrichment standards for processed grain products such as bread, pasta and cereals. I recommend wholefoods as the primary source of food, then loss of nutrients at least through processing, is not such a concern.

Riboflavin (aka Vitamin B2): Like niacin, riboflavin is essential for the synthesis of coenzymes required for the energy production cycle. I rarely see severe deficiency of riboflavin in practice. Common food sources are dairy products, enriched grains, meat and eggs, with smaller amounts in some vegetables (spinach, mushrooms, soybeans). Those on vegan diets are more at risk.

I will write more about one of my favorite B vitamins, pyridoxine (vitamin B6), and another favorite pantothenic acid (vitamin B5), as well as biotin (vitamin B7), in my next blog.

I highly recommend working with a provider who is specifically trained in nutrition, including nutritional supplementation. While it may seem harmless to take an over-the-counter, generic vitamin supplement, nothing beats sage advice from a skilled provider. Naturopathic doctors are the only healthcare providers specifically trained in drug-herb and drug-nutrient interactions.

Sarah Giardenelli is a naturopathic doctor and acupuncturist with over 10 years of experience. She enjoys working with patients to solve their complex health concerns. She is a considers the whole picture, recommends the least invasive, natural approaches first and considers lifestyle approaches as foundational for health for her patients at Collective Health Center.

While most of my patients are aware of the importance of various B-vitamins for immune health – few are aware of how essential the complex of B vitamins are for cellular, nerve, cognitive, mood, immune health and resiliency!

Amid the global pandemic and subsequent social challenges there has been a significant uptick of Americans struggling with mental health. An estimated 1/3 of Americans are struggling with depression, which is a 50% increase from prior to the pandemic. The complex of B vitamins are essential for good health, including for our behavioral health, particularly vitamin B12. Vitamin B12 deficiency is a direct cause of psychological challenges, including depression and anxiety. Approximately 6% of Americans ≥ 60 years old are vitamin B12 deficient (plasma vitamin B12 < 148 pmol/ L) with close to 20% having borderline deficiencies.

Vitamin B12 Deficiency

Vitamin B12 deficiency is quite common among my patients. Many report having struggled with symptoms, like fatigue, for years with levels never having been checked previously or report having been told that their borderline low levels are unremarkable. In my experience, I have seen that it is not uncommon for patients to exhibit signs of deficiency with levels below 400 pmol/L. Common symptoms of vitamin B12 deficiency include:

• Fatigue
• Weakness
• Memory loss or forgetfulness
• Dizziness or lightheadedness
• Ringing in the ears
• Tingling in hands or feet
• Poor coordination
• Nausea
• Diarrhea
• Red and glazed appearing tongue

While it is fairly common knowledge that without adequate supplementation, vegetarian and vegan diets can lead to vitamin B12 deficiencies, a diet low in vitamin B12 isn’t the only cause of deficiency. The prevalence of deficiency increases with age, often due to the ‘tea and toast’ diets of many seniors, but also due to the fact that the acidity levels in our stomach decline with age; adequate stomach acidity is required for absorption of many B vitamins, including B12 and folate. There are many factors that influence need for B vitamins, and our genes also impact how some of us absorb our vitamin B12.

Genetic Variants

It is said that variety is the spice of life and the same holds true for our genes. There are a multitude of different genes that control processes in our bodies that are dependent on various B vitamins (and other vitamin/ nutrient cofactors) to function. The differences or variants between people can mean low, normal, or even high B vitamin levels for different patients. Medicine is ever evolving and changing, and one of the things I love about my vocation of naturopathic medicine, is that naturopathic doctors are called to stay current and adapt our practice upon new information. One such gene that affects B12 status is FUT2. There are plenty of interesting details surrounding the effect of FUT2 gene – however – the essence of whether one is a secretor of type 1-H antigens in the gut or not both affects the diversity of the gut microbiome and one’s ability to absorb vitamin B12. With non-secretors a lower risk for vitamin B12 deficiency, as well as less risk for symptomatic norovirus infection and less diversity of the gut microbiotia, while secretors have a great risk for vitamin B12 deficiency, increased risk for norovirus, but also a healthier gut micobiome. Our gut bacteria are significantly impacted by FUT2 secretor status. A multitude of other genes, the methylation genes for example, influence enzyme processes that that require various B-vitamins as cofactors to function. Several of my patients are already familiar with the MTHFR gene, however, MTHFR represent just two of over a hundred genes that influence hundreds of B-vitamin dependent enzyme processes. Considering MTHFR only, is shortsighted. Additionally, there four forms of vitamin B12 (methylcobalamine, adenosylcobalamin, hydroxycobalmin, and cyanocoblamin) and genetics impact which of each form an individual might benefit from. The whole picture must always be considered.

The Strange, Rare, and Peculiar

I often am referred patients who have not been able to get help elsewhere. Because of this I have seen patients who have with strange, rare and peculiar signs and symptoms where the root cause was related to vitamin B12 – including pernicious anemia and vitamin B12 binding deficiency. Pernicious anemia is a rare autoimmune condition that leads to malabsorption of vitamin B12 and vitamin B12 binding deficiency is a genetic condition that makes utilization of vitamin B12 extremely challenging for patients. One thing that I think is important to point out, is that in each of these conditions serum B12 levels DO NOT correspond with functional needs. Unfortunately, this is not well understood by some health care providers, which can delay appropriate care for patients who are most in need of vitamin B12. Because this is so essential to understand, I am reiterating, adequate serum vitamin B12 levels DOES NOT always reflect functional need. In other words, just because your serum levels are ‘normal’ does not mean you are not functionally deficiency or needing additional support from vitamin B12. Outside of the box healthcare is vital in these cases. Aside from serum vitamin B12 testing, intracellular tests of micronutrient levels inside of the white or red blood cells can be helpful in exploring patterns of deficiency that can point towards possible underlying causes. Vitamins deficiencies often occur synonymously, so considering a pattern of deficiencies can be quite helpful.

Part 2

Stay tuned for Part 2 of this article will discuss how other B vitamins (vitamins B1, B2, B3, B6, and B9) are essential for our immune health and resiliency. Also, I will discuss how too much of a good thing – including certain B vitamins can be problematic for some people. Because of the wide variety of factors that influence individual need for B-vitamins – including specific forms of the vitamins, I highly recommend working with a provider who is specifically trained in nutrition, including nutritional supplementation. While it may seem harmless to take an over-the-counter, generic vitamin supplement, nothing beats sage advice from a skilled provider. Naturopathic doctors are the only healthcare providers specifically trained in drug-herb and drug-nutrient interactions.

Sarah Giardenelli is a naturopathic doctor and acupuncturist with over 10 years of experience. She appreciates working with patients who have what appear to be complex health issues and exploring underlying root causes with them. She is a believer in holistic and outside of the box thinking and brings this passion to every patient in her practice at Collective Health Center.