Vitamin B12 Shots 101

Vitamin B12 Shots 101

I'm excited to announce that I will now be offering methylcobalamin injections (Vitamin B12 shots) at my Bracebridge office location, Rooted in Counselling. The cost is $20 per injection, billed as a Naturopathic 10min Service (covered by health insurance plans) and are available only to my existing patients, or from those who have a referral from their Naturopathic Doctor, Medical Doctor, or Nurse Practitioner. Unfortunately I cannot provide B12 shots to patients I haven't worked with before as an assessment is required.

Vitamin B12 shots offer a double whammy in terms of health benefits - by one, increasing Vitamin B12 status but also from the 'methyl' group that plays a role in methylation reactions in the body aka a signal that is capable of turning on/off gene expression. Be sure to read Part 2 to learn more about the importance of methylation.

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Part 1: Vitamin B12

Functions of Vitamin B12 in the Body:

-Neurotransmitter production (mood, memory, sleep, cognitive function)

-Detoxification

-Energy Levels

-Immunity

-Red Blood Cell Production

-Metabolizing carbohydrates and protein

-Nerve Function

-Cardiovascular Health

Signs of Deficiency or Sub-Optimal Status:

-Low mood or depression

-Trouble falling asleep or sleep disruption

-Cognitive difficulties: memory, recall, processing speed

-Numbness or tingling

-Fatigue or weakness

-Chronic pain

-Anemia

-Tinnitus or ringing in the ears

The Vitamin B12 Reference Range Debate:

What's optimal status? In North America, deficiency is considered only when status falls below 220pmol/L on blood work.

In Europe and Japan, their standard is higher and will consider levels below 370-407pmol/L to be likely deficiency. This isn't even considering what the 'optimal' level is, just trying to avoid deficiency.  This creates some controversy and explains why some practitioners have targets for optimal status that aren't flagged by conventional practitioners. I like to see levels at least 400pmol/L in my practice.

I'm going to make it more complicated and throw in another variable - the blood test for Vitamin B12 status only measures levels floating around in our blood, but more advanced studies in neurology that test Vitamin B12 levels in cerebral spinal fluid (CSF) in the brain have found that these levels can be completely different. CSF levels of Vitamin B12 can be more specific to mood and brain function. This can be why some patients have so much symptomatic relief after having Vitamin B12 injections or supplementing with Vitamin B12 despite normal blood status- beyond 'placebo' effect.

Who is at Greatest Risk of B12 Deficiency?:

1. Vegans and vegetarians or those who consume very little red meat, animal protein, or eggs. Nutritional yeast doesn't tend to cut it.
2. Those on antacid medications like PPIs - by suppressing stomach acid, which is required to extract Vitamin B12 from food, this increases the risk of deficiency (in addition to other vitamins and minerals!)
3. Those taking metformin - a known side effect is Vitamin B12 depletion.
4. Older adults (>age 65) - stomach acid production is decreased over time so ability to extract Vitamin B12 from food is compromised.
5. Those with gastrointestinal conditions where absorption is impacted - ex. Celiac disease or Crohn's Disease
6. Inflammatory factors impacting absorption: food sensitivity, SIBO, dybsiosis
7. Those with genetic defects in Vitamin B12 impacting the absorption, transport, or use of B12 by tissues. Over 59 genes have been identified in this process.  
8. Those with chronic stress - depletes stomach acid production to impair absorption
9. Autoimmune condition: antibodies against parietal cells or intrinsic factor (these antibodies can be tested on bloodwork !)

Oral vs. Injection:

I want to be totally clear - if Vitamin B12 status is low or suboptimal, the majority of people can increase their status effectively by taking an oral methylcobalamin supplement. When a high dose (1000mcg) of Vitamin B12 is taken orally in supplement form, the need for intrinsic factor and an acidic stomach environment isn't required.

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Note: approx. 1% of a 1000mcg oral dose is absorbed via GI tract compared to the absorption rate of 15-97% of a 1000mcg Vitamin B12 injection. You can see why 1x/monthly injections can replace daily oral supplementation.

Reasons to choose injection over oral:

-Risk factors #5-7 (above) are present so direct absorption into body is more effective than relying on compromised absorption in gastrointestinal tract.

-Cost savings if injections are covered by drug plan or extended health insurance vs. paying for supplement.

-Forget to take daily oral supplement so easier to get injection 1x/month.

-Feel more of a surge in energy following injection vs. oral.

-Methylation factors are also present (see below)

-Local delivery to a specific tissue. Ex. studies have shown efficacy of methylcobalamin injections for chronic back pain, shingles or herpetic neuropathy, and peripheral neuropathy - likely due to high dose B12 being used to facilitate nerve healing and function. (Vitamin B12 is critical for supporting myelin sheath, the conductive 'coating' around a nerve.) In this scenario, a B12 shot would be offering a triple whammy of benefits for someone - nerve support, methylation support and increasing Vitamin B12 status.

This is why we follow up with testing once someone has begun Vitamin B12 oral supplementation or injections -to ensure the status is going up!

Forms of Vitamin B12:

There are 3 naturally occurring forms of Vitamin B12: methylcobalamin, adenosylcobalamin, and hydroxycobalamin.

Cyanocobalamin is a synthetic version of B12 that's isn't naturally found in food, nature or our bodies and cyanide is a byproduct of its breakdown. There are concerns around cyanide accumulation in the tissues with long-term cyanocobalamin supplementation (no thanks!) It's also the form of Vitamin B12 that is used in food fortification. The reason this form is used and often found in most supplements is that it's cheaper! However, it is comparable in its ability to raise blood levels of B12  to other natural forms. BUT how the body uses it is where the difference lies because there is: 1. 3x more urinary loss of cobalamin (B12) with this cyano form compared to methyl 2. Lower tissue retention of cyano form compared to others and 3. Cyano form had 13% less storage in liver. In other words - lower bioavailability. It's in our blood, but our cells don't use it as well. And makes sense, because it's a human invention - manmade.

There are also concerns that some individuals lack the genes to breakdown cyanocobalamin into a useable form, so this reaction can vary from being less efficient, to severely compromised.

Bottom line: Just go with the methylcobalamin form if feasible - both with injections and oral supplementation. 

Part 2: Benefits of 'Methyl' Group

What is "Methylation"

This refers to a reaction where a methyl group is transferred to genetic material aka our DNA which acts as a signal to turn that particular gene off. If you're familiar with the term 'epigenetics' - the concept that we can modify our genetic expression based on our environment and lifestyle choices, methylation is one way we can do this.

Dysregulated methylation has been linked to chromosomal instability and DNA aging. So in the era of anti-aging medicine, measures of methylation have actually been used as a biomarker of aging and can help predict someone's biological age vs. their chronological age.

Methylation is also linked with cell growth. Since methylation turns off cell functioning, it makes sense that studies are finding associations between defects in methylation and uncontrolled cell growth...aka cancer risk and conditions like uterine fibroids or endometriosis.

Methylation also needs to be considered in the context of neurotransmitter and hormone production/ breakdown. These steps in producing and breaking down hormones rely on dozens of genes. So wheren certain ones get turned off, this is where you can see influence on mood, energy, behaviour, cognition, digestion - etc.!

Methylation is actually a very complicated process and I'm not going to pretend I'm an expert in it. :)

Conditions Associated with "Defects" in Methylation

1. Autism and ADHD - the most research has been done with these conditions and explains why Vitamin B12 injections are part of many treatment plans for these individuals. Read more here.
2. SLE and other autoimmune conditions.
3. Neurological conditions like Alzheimer's Disease, Parkinson's Disease, ALS, MS, etc.
4. Metabolic conditions like Type 2 Diabetes and Dyslipidemia.
5. Cancer - notably breast cancer
6. Hormone conditions - like endometriosis and uterine fibroids

**this list is not all encompassing

Reminder: health is complex and multiple factors go into disease risk. Methylation is just one.

Questions? Click the button below to get in touch.

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Resources:

1. Mohn ES, Kern HJ, Saltzman E, Mitmesser SH, McKay DL. Evidence of Drug–Nutrient Interactions with Chronic Use of Commonly Prescribed Medications: An Update. Pharmaceutics. 2018 Mar 20;10(1):36.

2. Green R. Vitamin B12 deficiency from the perspective of a practicing hematologist. Blood. 2017 Jan 1:blood-2016.

3. Prousky JE. Understanding the serum vitamin level and its implications for treating neuropsychiatrie conditions: an orthomolecular perspective. J Orthomolecular Med. 2010;25.

4. Skerrett PJ. Vitamin B12 deficiency can be sneaky, harmful. Harvard Health Blog. 2013.

5. Issac TG, Soundararajan Soundarya RC, Chandra SR. Vitamin B12 deficiency: an important reversible co-morbidity in neuropsychiatric manifestations. Indian journal of psychological medicine. 2015 Jan;37(1):26.

6. https://pubmed.ncbi.nlm.nih.gov/31566312/

7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5312744/

8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6147084/

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