Vitamin B12 is one of the most commonly asked about vitamins. It is also one of the most misunderstood vitamins. B12 has some unique aspects that make it different than most other vitamins and minerals. In this week’s article we will look at determining if a person needs to supplement with B12 and what that right dose of B12 would be.
Vitamin B12 has many roles in the body. It’s most well-known roles are in the production of energy, blood cell generation, functioning of the brain, and as a methyl donator in the nervous system. B12 deficiency puts a person at risk of a variety of symptoms affecting the neurological system, blood cell formation, and energy production. The most well-known disease of B12 deficiency is pernicious anemia. This is where there’s a problem in the stomach, resulting in the inability to absorb enough B12.
Identifying overt vitamin B12 deficiency usually is straight forward. However, identifying sub-optimal or sub-clinical B12 deficiency can be controversial and difficult. For the most part, I utilize three types of tests to determine if someone has a B12 problem. None of the measures is exact, but I believe they are useful in identifying a problem.
The first two tests I look at can be run as part of your basic blood work. A marker called Vitamin B12 Status can be run to tell you how much B12 was available in the blood sample. This test picks up major deficiencies but may not pick up sub-clinical problems. One problem with this test is that the normal range in BC is likely set too low, which can make it look like a person does not have a B12 deficiency. I always get suspicious is the B12 Status is below 300-450.
The second test I look at is almost always part of your basic blood work. It’s called MCH, which stands for mean corpuscular haemoglobin. This test essentially looks at the red blood cells to see if they are enlarging in a suspicious way. When B12 is deficient, our red blood cells have difficulty maintaining their proper size and physical characteristics. Instead of getting smaller, like in iron deficiency, the RBCs get larger and lighter. I get suspicious anytime MCH gets about 31.
The third test I look at is a test by trial. This is where we give a patient 1-3 B12 shots to see how they respond. If they feel better with B12 shots, it’s likely they had a sub-clinical deficiency. I meet many patients who have figured out previously that they simply function better when they get regular B12 shots.
Not all B12 is equal. There are three major types of B12 you can purchase in supplement or injectable form. The three types are hydroxycobalamin, cyanocobalamin, and methylcobalamin. For the most part, I believe methylcobalamin to be the best because the methyl component plays a major role in neurological function.
B12 supplementation in pill form is not overly useful. Many people deficient in B12 also have problems absorbing B12 from their GI tract. This problem is not just for people with pernicious anemia, poor absorption seems to be a larger problem than that. In the past, a person who had difficulty absorbing B12 needed to have B12 shots or IVs. However, in the last 10 years the need for B12 shots has lessened as sublingual B12 supplements emerged. I still find that some people respond significantly better to B12 shots or IVs. However, most people can now get their B12 from a sublingual pill. The most common dose is 1000mcg of sublingual methylcobalamin per day. Since B12 is water soluble it’s best to have a moderately sized dose like this on a daily basis as opposed to larger doses you can’t handle.
If you have any questions about vitamin B12 or naturopathic medicine please contact Dr. Barlow at [email protected] or at his office at 250-448-5610.
In last week’s article we discussed how the desired effect of a medication or supplement can dictate how it is dosed. We used the example of hormone replacement therapy to illustrate how certain dosages are for replacement while other dosages may be for replenishment. In this week’s article, we will discuss how botanical remedies are dosed.
Many people think that botanical remedies are natural and thus don’t have potential to do harm or have side effects. Many people also think that they are taking the right dose of a botanical remedy because of what the label suggests. I run into these myths almost every day in practice. The reason these are important to talk about is because you may be taking the right remedy for your needs but not taking the right dose.
Botanical remedies can be tricky to identify the right dose because of how they are labeled. When a patient asks how many milligrams of a medication, vitamin, mineral, or amino acid they should take the answer is usually straight forward. “Your dose to start is 25mg and we can adjust from there based on your reaction.” However, with botanical remedies the number of milligrams is only one factor. The more important factor is how potent is the extract.
The active ingredients in a botanical remedy must be extracted from the plant. When they are extracted they are combined with inactive ingredients. The ratio of the active ingredient to the inactive ingredient determines the potency. When you look at the details on the label of an herbal product you should see a ratio. If you don’t, you should question the product. If the ratio is 1:1 it means that for every unit of active nutrient there is the same amount of inactive nutrients. If the ratio is 5:1 it means that for every 5 units of active nutrient there is only one unit of inactive nutrients. As you can see, a 5:1 ratio is 5 times more potent that a 1:1 ratio.
If you are comparing two botanical remedies for a nutrient like milk thistle and they appear to have the same amount of milligrams contained within, you may be surprised to see that one actually has 5 times more of the active nutrient. This basic but profound difference can dictate how effective or how safe a botanical remedy is for the patient.
In last week’s column we began a discussion about how dosages for medications and supplements are recommended. We learned that many meds/sups have recommended dosage ranges. However, most don’t have specific information to help guide decisions based on age, sex, metabolic rate, or other individual factors. This puts physicians in the position of needing to recommend a specific dosage for their patients. In this week’s column we will discuss how the intended use of a medication or supplement can greatly affect the dosage recommended.
The term “lowest effective dose” was discussed last week. In general, this means using the least amount of a med/sup to get the desired effect. Today we will talk more about the desired effect. A common part of my practice revolves around supporting healthy hormone production with both natural and prescription items. The dose of a medication, hormone, or supplement can vary greatly depending on the intended outcome. To illustrate this, let’s take a look at a common example from my practice.
When a patient visits their doctor to treat hot flashes and night sweats they may receive a prescription for some combination of hormone replacement therapy. Testing may or may not be involved depending on the physician’s mode of practice. A common prescription for hot flashes and night sweats usually involves estrogen and/or progesterone. In many cases, the symptoms will improve over the course of a few weeks or so. The conclusion many people would come to is that the therapy was successful. However, when you look deeper and ask the questions that inevitably get asked (usually after the fact) you can see more to the story.
When this patient comes into my office we always have a discussion about the short-term, intermediate-term, and long-term goals they have. I try my best to find out why the hot flashes and night sweats are happening. I usually recommend saliva hormone testing on at least three days to evaluate their production of DHEA, estradiol, estrone, progesterone, testosterone, and cortisol. There’s quite a detailed process in order to give us the best chance to achieve the goals they identified.
Most patients I work with put a high priority on doing things right over the long-term vs. a short-term intervention that may put you behind the 8-ball later on. My recommendations typically have a timeline associated with them for types of treatments, dosages, and re-testing. Depending on the patients goals I may be prescribing HRT prescriptions, botanicals, vitamins, minerals, intravenous infusions, or other therapies. If the patient chooses prescriptions to be part of the treatment plan it is likely that we are using different dosages than they may have used with another physician who recommended them for the treatment of the symptoms.
I hope the above example helps illustrate how the goals of the patient and the intended use by the doctor may alter the dosage of a medication or supplement.
The dose of a medication or supplement can be as important as or more important than the actual ingredients. However, in both conventional and integrative healthcare, dosing far too often is an afterthought. There are many factors that play a role in deciding on what dose to recommend to a patient. Some of these factors are evidence-based and most doctors stay close to the evidence. But, many factors are actually based on judgement and experience because of a lack of evidence-based information. In this week’s article we will discuss some of the factors that help guide doctors to answer the question, “What’s my dose”?
The majority of the most common medications and supplements have published guidelines for recommended dosage range. The average person likely thinks these ranges are specific for certain demographics and purposes of usage. However, most medications don’t have guidelines based on sex, age, ethnicity, metabolic rate, or any other individual factor. This lack of detailed information leaves the decision of dosage in the hands of the doctors making the recommendation.
The new buzz term for dosage recommendations in healthcare is “lowest effective dose”. I am a big fan of this term. This term acknowledges that people have individual characteristics that can affect the way they process and utilize medications and supplements. It also acknowledges the risks of using a dose higher than is really needed. It’s easy to overlook these risks but they are real and meaningful. These risks include increased side effects, dependency, the need for other medications, and the potential for the medication to eventually stop working as intended.
I see at least a few patients each week (if not each day) who are taking dosages that prove to be too high or even unnecessary. There is sometimes a question of whether they ever needed to medication to begin with. However, often it’s more of a problem of continuing longer than needed at a dose that was initially appropriate but has lost its effectiveness. I spend a lot of time every day in practice helping patients figure out what meds or supplements are actually needed and what their lowest effective dose is.
Last year 60 Minutes did a very interesting segment on dosage discrepancies with the most commonly prescribed sleep medication in the United States. The research they highlighted has shown a 40% difference between men and women in how they metabolize this class of sleep medication. This means that a female who is taking the same milligrams of the medication could actually be receiving 40% more than the doctor intended.
In next week’s column, we will continue our discussion on the factors that come into play when trying to find the right dose for medication and supplements.
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