Vitamin B12 is one of the most widely prevalent nutritional deficiencies. According to a 2019 study published in the Indian Journal of Endocrinology and Metabolism, the prevalence of vitamin B12 deficiency is 47 percent in north Indian population.
Vitamin B12 plays a crucial role in various bodily function like DNA synthesis. It also helps in keeping blood and nerve cells healthy and prevents megaloblastic anemia.
Strict vegetarians and vegans are also at risk of B12 insufficiency because the vitamin is naturally found in animal-based diets, Dr. Suranjit Chatterjee, Senior Consultant, Internal Medicine, Indraprastha Apollo Hospital, New Delhi told Financial Express.com.
“Because their diets lack these animal products, individuals must rely on other forms of B12 supplementation or fortified foods, he said.
He also maintained that vitamin B12 deficiency is highly prevalent in India, with studies estimating over 70 percent of Indians have suboptimal levels. According to Dr. Chatterjee, the high rates in India are thought to be driven by the country’s large vegetarian population.
“Since vitamin B12 is primarily found in food from animal sources, those avoiding meat, fish, eggs and dairy are at a greater risk of deficiency. Compounding this issue is that even non-vegetarians in India consume relatively low amounts of animal products compared to Western diets. Milk products are a common part of Indian cuisine, yet the vitamin B12 supplied may not be adequate without supplementation from other complete animal protein sources. Genetic factors also influence B12 deficient prevalence in India,” he told Financial Express.com.
Many Indians have a mutation that lowers the production of a protein necessary for B12 absorption in the gut, he said.
Meanwhile, pernicious anemia and other disorders that impede with absorption are becoming more prevalent.
“Parasitic infections, long-term use of acid-reducing drugs, alcoholism, and digestive issues all contribute to the growing public health concern of B12 insufficiency. Addressing risk factors via targeted food fortification regulations and awareness efforts will be critical in combating high insufficiency rates,” he told Financial Express.com.
Given the serious consequences that can result from sustained low B12 status, focused public health initiatives on this topic are required, he added.
How vitamin B12 deficiency occurs?
Vitamin B12 Deficiency happens primarily due to poor lifestyle habits, dietary choices and medical conditions that hinder proper absorption and intake of this essential nutrient.
According to Sheetal Arora, CEO, Mankind Pharma, it is an essential vitamin with largely non-vegetarian source and possible causes of vitamin B12 deficiency are:
- Dietary Patterns: A shift towards more plant-based diets and a decrease in animal product consumption can lead to lower B12 intake. Vitamin B12 is primarily found in animal-derived foods like meat, fish, eggs, and dairy products. Vegan or vegetarian diets without sufficient supplementation or fortified foods may lack an adequate B12 supply, increasing the risk of deficiency.
- Ageing Population: As individuals age, the ability to absorb B12 from food diminishes. Older adults often experience decreased stomach acid production, which is essential for releasing B12 from food. This can lead to poor absorption of the vitamin, contributing to deficiency among the elderly population.
- Gastrointestinal Disorders: Certain gastrointestinal conditions, such as Crohn’s disease, Celiac disease and atrophic gastritis, can impair the body’s ability to absorb B12. These disorders affect the digestive tract, inhibiting the absorption of nutrients, including B12, leading to deficiencies even in individuals with sufficient dietary intake.
- Medications: Long-term use of certain medications, such as proton pump inhibitors (PPIs) used to treat acid reflux, and metformin, commonly prescribed for diabetes, can interfere with vitamin B12 absorption. PPIs reduce stomach acid production, which is necessary for releasing B12 from food, while metformin may affect B12 absorption in the intestines.
Meanwhile, Dr. Chatterjee maintained that vitamin B12 insufficiency can develop for a variety of reasons. One of the most frequent is pernicious anemia, an autoimmune disease in which the body targets stomach cells that create intrinsic factor.
“Intrinsic factor is required for vitamin B12 absorption, hence its absence leads to insufficiency over time. Vitamin B12 insufficiency can also occur in patients who have had gastrointestinal surgery, such as weight loss surgery or the removal of a portion of the stomach or small intestine. This operation can decrease the absorption of nutrients such as vitamin B12,” he told Financial Express.com.
Who is at more risk of developing vitamin B12 deficiency?
It is estimated that over 70 percent of adults in India have some form of Vitamin B12 deficiency. On the other hand, 80 percent of pre-school children in India have some form of Vitamin B12 deficiency.
According to Arora these group of people are more susceptible to develop vitamin B12 deficiency:
- People older than 75 years
- People following a vegan diet or strict vegetarians
- People on Alcohol abuse
- People who use these medications: Histamine H2 blocker (use>1 year), Proton pump inhibitor (use >1 year), Metformin (use >4 months)
What are the symptoms of vitamin B12 deficiency?
Some of the symptoms of vitamin b12 include:
- Pale skin: People with B12 deficiency will have a yellow tinge to skin and whites of the eyes, also known as jaundice. Vitamin B12 plays an important role as it helps in producing red blood cells, which makes the DNA. Without it, the cells are unable to divide, according to Healthline. It leads to the type of anaemia called megaloblastic anaemia.
- Weakness and Fatigue: Since your body is not getting enough B12 to make red blood cells transport oxygen throughout the body, it can make feel tired and weak.
- The sensation of Pins and needles: The most peculiar sign and symptom of B12 deficiency is nerve damage. Healthline report says as vitamin B12 is an important contributor to the metabolic pathway that produces the fatty substance myelin. Myelin surrounds your nerves as a form of protection and insulation. Without B12, myelin is produced differently, and your nervous system can’t function properly. But sensations of pins and needles are a common symptom which can happen due to many reasons, it’s better to consult a doctor.
- Memory Loss: Do you forget things easily? That can be a sign of B12 deficiency, patchy memory and forgetfulness can happen. According to the TOI report, B12 controls nerve function.
- Change to the way you walk: As deficiency of B12 can directly impact the nervous system, it can also change the way you walk or move. It can affect your overall balance and coordination.
- Dizziness: Vitamin B12 deficiency can cause dizziness and breathlessness as the body is unable to transport oxygen to all the cells. That’s not all, Vitamin B12 deficiency can lead to glossitis, a condition in which the tongue gets red and swollen, it can impact your vision, lead to anxiety, and more.
“People who have had gastrointestinal/weight loss surgery are additionally at risk since sections of the stomach and small intestine required for B12 absorption have been removed. Those who take heartburn drugs that lower stomach acid on a regular basis may have low B12 levels for the same reason,” Dr. Chatterjee told Financial Express.com.
As the deficit progresses, neurological symptoms such as numbness, tingling, and finally walking difficulties might develop as a result of nerve damage. The most advanced sign is pernicious anemia, which is distinguished by severe, massive red blood cell shortages as well as neurological impairment, he explained.
“Treatment is critical before the harm becomes permanent. Early detection of B12 insufficiency allows symptoms to be quickly cured before any severe consequences take hold with adequate dosage and dietary modifications,” Dr. Chatterjee told Financial Express.com.
Understanding vitamin B12 supplements
Usually vitamin B12 is treated with supplements. In India, pharmaceutical companies like Mankind Pharma played a crucial role in addressing the issue Vitamin B12 deficiency. In 2004, Mankind launched Nurokind which is a man-made form of Vitamin B12 which is important for nerve health, brain function, and red blood cell production. This medicine is mainly used to treat Vitamin B12 deficiency in people with anaemia and peripheral neuropathy (nerve pain in hands and feet).
According to a 2023 report by Anand Rathi, a brokerage firm, Nurokind is one of the top brands of Mankind and it clocked sales of Rs5.3bn in FY22. Brands sold under this group are Nurokind LC (treating chronic fatigue), Nurokind Gold and Nurokind Plus-RF (vitamin deficiency). In FY22, these three were ranked first in their combination molecule categories (domestic saleswise), enjoying ~51.6%, 14.8% and 10.4% market shares respectively.
“Nurokind is a brand of Active form of Vitamin B12 i.e. mecobalamin 1500 mcg sublingual tablet (Sublingual administration of drug refers to the placement of drug under the tongue), that bypasses the first-pass metabolism and hence facilitates rapid absorption of the drug that directly reaches the systemic circulation using blood vessels. Moreover, Nurokind Sublingual Tablets does not require the “intrinsic factor” for its absorption in the intestine, which lacks in patients either due to pernicious anemia or gastric bypass surgery, as traditional oral tablets of B12 would not be fully absorbed,” Arora told Financial Express.com.
He also informed that Nurokind plays an essential role in red blood cell formation, cell metabolism, nerve function and the production of DNA, the molecules inside cells that carry genetic information.
“A brand of Vitamin B12 & Combinations, Nurokind is worth 566 crores and has consistently maintained its No.1 ranking in the market,” he said.
According to Arora, in terms of sublingual spray, below are the advantages and disadvantages of the format:
Advantages:
- Rapid onset of action is achieved as compared to the oral route.
- Liver is bypassed and also drug is protected from metabolism due to digestive enzymes of the middle gastro intestinal tract
- Improved patient compliance due to the elimination of associated pain with injections;
- administration of drugs in unconscious or incapacitated patients; convenience of administration as compared to injections or oral medications.
- Low dosage gives high efficacy as hepatic first pass metabolism is avoided and also reduces the risk of side effects.
- The large contact surface of the oral cavity contributes to rapid and extensive drug absorption. Due to rapidity in action these sublingual dosage forms are widely used in emergency conditions e.g. asthma.
- Rapid absorption and higher blood levels due to high vascularization of the region and therefore particularly useful for administration of antianginal drugs.
- They also present the advantage of providing fast dissolution or disintegration in the oral cavity, without the need for water or chewing.
Disadvantages:
- Since sublingual administration of drugs interferes with eating, drinking, and talking, this route is generally considered unsuitable for prolonged administration.
- Although this site is not well suited to sustained‐delivery systems.
- Sublingual medication cannot be used when a patient is uncooperative.
- The patient should not smoke while taking sublingual medication, because smoking causes vasoconstriction of the vessels. This will decrease the absorption of the medication.
- Various types of sublingual dosage forms are available but tablets, films and sprays are in trends these days. For the preparation of these dosage forms different methods are described depends upon the feasibility and advantages over the others.
- One disadvantage, in any case, is tooth staining and brought about by long term utilization of this technique with acidic or generally burning medications and fillers.
Other than Mankind, several other pharmaceutical companies have products offering to treat vitamin B12 deficiency. Moreover, in the recent time, many neutraceuticals companies have also launched over-the-counter (OTC) supplements to deal with vitmain B12 deficiency. In 2022, Zydus Lifesciences got final approval from the USFDA to market cyanocobalamin injection. Cyanocobalamin injection is used to treat and prevent lack of vitamin B12 that may be caused due to pernicious anemia.
What more needs to be done to address the challenge of Vitamin B12 deficiency?
The growing incidence of vitamin D deficiency has become a cause of concern among experts. According to a 2022 study published in The Egyptian Journal of Internal Medicine, people on vegetarian diet, having dark complexion, below middle socio-economic class, or using R.O processed water should consume foods fortified with vitamin B12 or oral VitB12 supplements.
Arora suggests some strategies that can help to overcome this challenge:
- Dietary Modifications: Encouraging a well-balanced diet that includes B12-rich foods or fortified products can help prevent deficiencies, especially among individuals following vegetarian or vegan diets. Educating the public about food sources and the importance of adequate B12 intake is crucial.
- Supplementation: For individuals at risk of deficiency, including older adults, strict vegetarians/vegans and those with malabsorption issues, supplementation is recommended on a monitoring basis.
- Routine Screening and Testing: Healthcare providers should consider screening individuals at risk of vitamin B12 deficiency, such as older adults, individuals with gastrointestinal disorders or those on long-term medications affecting B12 absorption. Timely testing can facilitate early detection and appropriate intervention.
- Public Health Campaigns: Raising awareness about the symptoms, risk factors and consequences of B12 deficiency through public health campaigns can help promote early
- recognition and encourage proactive measures to prevent deficiency-related complications.
- Medical Education and Training: Healthcare professionals need continued education on recognising and managing B12 deficiency to facilitate timely diagnosis and appropriate treatment for affected individuals.
Meanwhile, Dr. Chatterjee highlighted that increased awareness and education are critical in addressing vitamin B12 insufficiency.
“People are frequently unaware of concerns with poor B12 consumption or conditions that impair absorption, putting them at danger. Better knowledge and awareness can help to detect and correct flaws early on, before they have long-term consequences. Additionally, targeted food fortification initiatives show promise for lowering deficiency rates. Given the specific dietary patterns involved, solutions that supply additional B12 by fortifying everyday foods such as cereal grains, milk, and milk replacements could have a major impact,” he told Financial Express.com.
He also informed that food fortification procedures that have been carefully applied have helped to combat various micronutrient deficits around the world.
“Along with food-based treatments, professional bodies might create guidelines advocating regular B12 monitoring in elderly and other high-risk populations. It is critical to detect defects early on, before they become irreparable,” he added.
‘Dietary security crucial’
With vitamin B12 insufficiency being such a common problem with serious health consequences, it warrants special consideration in health policy and planning, Dr Chatterjee emphasised.
Nutrition is sometimes overlooked in favor of medical therapies, despite the fact that deficiency prevention is an extremely cost-effective method of addressing a wide range of issues before they worsen. An encouraging move toward dietary security can yield many benefits across populations. A complex network of variables undoubtedly contributes to vitamin B12 insufficiency, but this should not be used as an excuse to do nothing. Rather, it requires applying strategic thinking from diverse experts to strengthen nutrition environments now and for future generations,” he told Financial Express.com.
Of course, medical perspectives are required to influence policy, and agricultural innovation plays an important role. However, social and behavioral science insights into habits and decision making are equally important in fostering long-term dietary change that reduces deficiencies, whether through supplements for known hazards or population shifts toward balanced whole food sources, he said.
We all deserve access to high-quality information and food supplies that promote appropriate vitamin B12 levels, allowing us to thrive throughout the lifespan. Science and society should work together to adopt smart solutions, both high-tech and simple, gradually creating a landscape in which defects that were formerly considered normal become relics of the past. A future substantially free of vitamin B12 deficiency is highly feasible if we have the will to prioritize change,” Dr. Chatterjee told Financial Express.com.
