Have you ever wondered why vitamin B12 is so important after bariatric surgery?  Check out our audio transcript to learn more.

Why is vitamin B12 so important after bariatric surgery?

Dawn (00:00):

Hello and welcome to the Gastric Health Show. My name is Dawn Boxell, a Registered Dietitian, and I am excited to talk to you today about why vitamin B 12 is so important after bariatric surgery. So we are going to dive into the importance of having adequate vitamin B 12, and I do feel like a lot of bariatric patients are aware of this, but I do see that over time a lot of patients gets taken off of their supplements for various reasons or quit taking them or have just not gotten a good routine of taking it consistently. And so here I want you to understand the why of its importance. I feel like when you know the why, it’s easier to do it. You prioritize the doing and because we all know that knowing and doing are two different things, but when you understand that it’s impacting your mood and it’s impacting your energy level, it’s easier to prioritize it because you know that you’re going to feel pretty crummy if you don’t.

How is vitamin B12 absorbed?

(01:14):

So let’s dig into B 12 so that you have a good understanding and you can support yourself well with understanding how this impacts your life overall. So vitamin B 12, or we also call it cobalamin. It is a water-soluble vitamin. And years ago we would really think not too much about the dosing of vitamin B 12 because it is water soluble and it was kind of believed that, hey, if you’re just going to pee out what you don’t need. But really essentially it does matter the dosing. So you don’t want to go too crazy, but there are a lot of factors that kind of determine the appropriate dose for you. So vitamin B 12 plays really a variety of roles in your body. It is mostly found in animal foods and can be found in lots of fortified foods as well. However, many people do not absorb vitamin B 12 properly due to really multiple factors like medications, disease, age, genetics, food choices, all of that plays a role in your ability to absorb. So just because you maybe take a supplement doesn’t mean that you’re absorbing all of it appropriately. So how is B 12 absorbed? I don’t want to get too technical, but really the foundation of it is the stomach acid and pepsin that breakdown food. It kind of breaks off the B 12 from the food. And then we have a protein, it’s a binder protein,

what interferes with the absorption of B 12?

(03:01):

And in the small intestines the pancreatic enzymes break down transcobalamine and freeze up B 12 again. So your stomach, it binds your small intestines, it gets broken off from that binding, and then from that release it gets bound with intrinsic factor, which is actually something that comes from your stomach into your small intestines. And then it is absorbed in the cells in your part of your intestines called the ilium. And then from there, that’s where it gets bound to transco ballin two, which is really what transports B 12 into the bloodstream and delivers it to your organs and your tissues. So that process, any glitch in any of those processes can impact your ability to have normal B 12 levels. So what interferes with the absorption of B 12? We can think of medications, disease, your diet, age and genetics, all of those play a role in your ability to actually absorb adequate amounts of vitamin B 12.

Medication

(04:24):

So medication metformin is one. This is a very popular diabetes medication, proton pump inhibitors, PPIs, and then also H two blockers. So those acid, think of all those acid blockers, acid reflux medications, they are widely used in bariatric surgery and it is something that you want to challenge your practitioners on in trying to get off of them and not maintaining on them long-term. Next is birth control pills. They are known to deplete vitamin B 12 or just interfere with that absorption of, so then you have lower levels of B 12 and then certain antibiotics and anti-convulsants, all of those impact how you can absorb vitamin B 12. The next is certain disease states. So anything that’s going to inflame or damage your stomach or intestinal lining would definitely be a risk factor for having low absorption of B 12. So think of things like gastritis, which is really just an inflammation of the stomach celiac disease, Crohn’s disease atrophic or atrophic gastritis or pernicious anemia, which is autoimmune disorders that destroy the stomach cells.

Diet

(05:55):

So those are things that in the big picture really do prevent you from having normal B 12 levels. Next is your diet. So if you consume a diet that is low in animal proteins, then you’re not going to be getting adequate amounts of B 12 in your diet. So think about vegans and vegetarians mostly in this case, or if you’re a bariatric patient that has a difficult time with solid dense meats that could contribute. But if you do well with eggs and cheese and dairy type stuff, that could make up for it. If you’re strong in those but maybe weaker in the solid dense meats, you might be fine potentially. It just really depends. You got to look at all these factors that’s going to interfere. So if you have some of those medications that you’re taking or maybe some of those disease states, you can’t just rely on that alone.

Genetics

(07:04):

You also have to think about your age as we age, we have less intrinsic factor and stomach acid, which that impairs your ability to actually absorb vitamin B 12. And then we have to think about genetics. So various gene variants can affect your ability to metabolize and transport vitamin B 12. For example, people with mutations in the gene that code for the transco ballin two, that protein that we talked about that actually gets it into your bloodstream, transports it into your bloodstream, that goes to your tissues and your organs and stuff. If there is a mutation in that gene or its receptors, you may have lower levels of circulating vitamin B 12. So it’s how you were made, it’s the genes you were given and it just is impacting your ability to have a normal B 12 level. So how can bariatric surgery impact B 12 absorption?

How can bariatric surgery affect vitamin B12 absorption?

(08:13):

So this is where you got to think a little critically on this because bariatric surgery reduces your stomach acid, it reduces intrinsic factor and it reduces the pancreatic enzymes in some cases. So if we talk about your stomach acid, this across the board, at least in all the research that I have dug into when it comes to bariatric surgery and especially with ruin white gastric bypass, but even with gastric sleeve, we see lower amounts of stomach acid and it can be tricky with a sleeve because some people with the sleeve have a lot of heartburn and reflux, which may be more from the pressure as opposed to just excess acid. And that pressure is creating that sphincter from that lower esophageal sphincter, the flap at the bottom of your esophagus to not be tight and sealed, but then also having adequate stomach acid plays a role in that too.

Reduced stomach acid

(09:32):

If you don’t have adequate stomach acid, it’s not going to have a tight seal. So it matters. Your stomach acid matters and you’ve got to have, whether you’ve had a sleeve or you’ve had a roid gastric bypass, the amount of stomach acid that you have is not appropriate. So supporting that, and that’s where the digestive enzymes really do help and help set you up for success in having adequate amounts of stomach acid and supporting it. And that’s why I really love our W L S formulated digestive enzymes. It really does support you in this way. The next one is the reduced intrinsic factor, and this is because of where intrinsic factor is made in your body and it is in the lower portion of your stomach, which is either removed with a gastric sleeve or it is stapled off with a ruin wide gastric bypass.

Reduced intrinsic factor

(10:33):

So you are reducing that availability of intrinsic factor and that’s what your body needs. Like we talked about, the intrinsic factor plays a role, it’s part of the process for you to absorb and it’s important to have adequate amounts. So you’re lacking that with bariatric surgery. And then pancreatic enzymes, and this isn’t for every person, but this is where the exocrine pancreatic insufficiency comes into play or E P i, certain people after bariatric surgery will develop E P I where you aren’t going to have enough pancreatic enzymes. And then you think about if an you’re having low levels of pancreatic enzymes released. That is, remember when we went through the process when those pancreatic enzymes are not sufficient, that’s what breaks that binding apart so that it can go to the next binder when we are going through the steps of absorption. So the pancreatic enzymes break down the transcobalamine and freeze up the B 12 again, and then now the B 12 gets bound to intrinsic factor.

Reduced pancreatic enzymes

(11:54):

So if you don’t have that adequate pancreatic enzymes to break down or break apart that transcobalamin and free up the B 12, then it’s not going to get attached or bound to that intrinsic factor. So that’s why it matters. That’s why you have to pay attention to all of these pieces. And are there signs that maybe you aren’t releasing enough of the pancreatic enzymes? Are there digestive issues? So again, working with someone is critical in making sure that you cover all of these pieces to really get down to what’s driving it. So how can vitamin B 12 deficiency be diagnosed? Personally, I still look at a serum B 12. Now this is definitely not a conclusive lab test, this is not your end all be all to determine adequacy of vitamin B 12 that you are adequately getting in enough B 12 and absorbing it.

How can vitamin B12 deficiency be diagnosed?

(13:10):

It is really showing you more of what you’re taking in with your food and your supplements as opposed to telling me what’s in the cell. What you need to determine if you have enough in the cell is methylmalonic acid or M M A. And this test measures a byproduct of the metabolic process that requires vitamin B 12 as a co-factor and the body accumulates M M A when vitamin B 12 levels are low. And so whenever your M M A is elevated, it means that you have a vitamin B 12 deficiency. So I like looking at both. Someone can give me their vitamin B 12 level if it’s within that normal, I like it above 600 if it’s a high or if it’s low, I really like to have an M M A as well. But if somebody within that reference range, it’s like 200 to 900 or a thousand depending on the lab.

Methylmalonic acid (MMA) test

(14:19):

If that serum B 12 is within those reference ranges, but it’s at least around 600 or a little more than 600, I’m probably not going to get too worried if I have an M M A to look at, unless the person is saying I’m tired, I have numbness and tingling, I have all these symptoms, then I’m going to want an M M A for sure. But again, it’s information. So if we need more data with the M M A, we need to do it. And then the last one is homocysteine. So homocysteine, this measures the amount of homocysteine, which is just an amino acid that kind of participates in that metabolic pathway requiring vitamin B 12 and folate. So it’s not a full picture of just B 12, but it’s what they do together. Folate and B 12 work together and homocysteine accumulates in the blood when vitamin B 12 or folate levels are low.

Homocysteine indicate vitamin B 12

(15:23):

So having a high level of homocysteine indicate vitamin B 12 or a folate deficiency and then to really determine if it’s B 12, you would need the M M A to really get to the full answer. I don’t know that a lot of surgery centers really do test for homocysteine. We did at the very, very beginning and then our doctors just feel uncomfortable with it because it’s also a cardiac marker. It’s utilized in that way as well. So when those levels are elevated, it can be saying, Hey, there’s maybe some cardiac issues. So again, that’s where some programs probably aren’t going to be testing that, but it is information if we need to dig deeper that a homocysteine could be drawn on. The last one is the holo TC or the holo transcobalamine test. This is not used often more in research as opposed to in a clinical setting, but it measures the level of the holo tc, which is the active form of B 12, bound to transcobalamine two, the transcobalamin two, and delivered to the tissues.

Why is vitamin B12 essential after bariatric surgery?

(16:48):

As a result, low levels of holo TC indicate vitamin B 12 deficiency. So again, probably not something that you are going to have drawn in a clinical setting per se, but if your doctor is aware of this test and wants to really doesn’t feel like he’s getting the data he needs with these other available tests, then he could totally do that. The next is why is vitamin B 12 so essential after bariatric surgery? So why would someone’s body need vitamin B 12? So one, it prevents anemia. Two, it supports nerve function. Three, it enhances your cognitive function. Four, it protects cardiovascular health. Five, it supports your metabolism. And six, it supports D N a synthesis. So when it comes to research has shown that vitamin B 12 is crucial for the production of red blood cells, which that’s what transport red blood cells are, what transport oxygen through the body.

Prevents anemia

(18:01):

An anemia can cause fatigue, weakness, shortness of breath, pale skin, and an increased heart rate. So if you have anemia and you have these symptoms, you feel tired all the time, but you’re also kind of short of breath walking up steps or not even going up and down steps, but maybe just walking two things, you are more tired and you feel like your heart rate can erasing a lot. Those could all be signs of anemia because you don’t have enough of the red blood cells to transport the oxygen through your body. So super important. But B 12 plays a role in this process, support your nerve function. So think of this as your ability to have healthy nerves. So you have myelin sheath that protect or encapsulate these nerve fibers and low levels of vitamin B 12 can damage myelin sheath or those protectors around the nerves and then end up causing nerve problems, which is the numbness, the tingling, burning or just pain in general.

Supports nerve function

(19:22):

And it can progress further if left undiagnosed going to the cognitive function. So B 12 plays a vital role in the cognitive function and plays a role in neurotransmitters such as serotonin and dopamine, which regulate your mood, your memory, your learning. And low B 12 levels really do contribute to depression and confusion and dementia and Alzheimer’s. All of those pieces is information. So if you’re really struggling with your brain, like your foggy thoughts and you just feel down all the time and confused, maybe part of this is your B 12 cardiovascular health.  B 12 regulates homocysteine, which we kind of talked about works with folate. So folate and B 12 work together to lower homocysteine levels and homocysteine can damage blood vessels and contribute to cardiovascular disease and stroke. Having a high level of homocysteine can inhibit the function of nitric oxide. And this nitric oxide is a molecule that relaxes and dilates the blood vessels to improve blood flow.

Enhances cognitive function

(20:55):

So this is a positive thing. We want adequate amounts of nitric oxide. So anything that can impair that from functioning appropriately or having adequate amounts is not a positive thing. And high levels of homocysteine will inhibit this nitric oxide function. So that’s where it can lead to damages with cardiovascular events. D N A, oh, let’s see here, support your metabolism. So vitamin B 12 is a co-factor in many enzymes involved in energy production and fat metabolism. When we say energy, we mean calories. So when vitamin B 12 levels are low carbs, fats and proteins are not properly converted into energy, which can result in weight gain, low energy and poor appetite. It’s part of the package deal. We need all of these things in your body working correctly for you to get the end result of a healthy metabolism. So you can’t ignore some of these and use a different pill to treat your or symptoms when it’s B 12.

DNA Synthesis

(22:24):

That’s the problem D N A synthesis. So vitamin B 12 facilitates D N A synthesis ensuring that your cells can replicate and grow properly. So our cells turnover and become new frequently. I think it’s like every seven years all of our cells throughout our body have been replated and restored and brand new. So it’s important to make sure that you think about B 12 because it’s a helper that ensures that our cells can make new D n a. So it’s part of how our body functions and grows. Now how much vitamin B 12 should bariatric patients take or how much do you need as a bariatric patient? How much vitamin B 12 do you need? Typically when it comes to supplements, you’re talking 500 to a thousand micrograms a day, and this is in the form of sublingual, which means underneath your tongue a nasal spray or an injection.

How much vitamin B12 do bariatric surgery patients need?

(23:37):

I would not recommend a swallowable B 12 pill because of all of the things we just talked about. We’re not going to have enough stomach acid to break that off so that you can utilize it efficiently. Food, you can get it from food like we’re talking about animal proteins have a good source of vitamin B 12. So think of clams, beef, liver, trout, salmon, tuna, milk, yogurt, cheese, eggs and chicken. All of those have a good quality of vitamin B 12 available that you can absorb and you can also get it from some fortified cereal. But remember that all of those fortified foods or those ultra processed foods are not going to be absorbed equally like an animal based B 12. So you get better absorption of the whole real food form compared to a synthetic fortified form from ultra processed foods. So hopefully that makes sense that you whole real food is really going to outperform an ultra processed food that has been fortified or refortified with vitamin B 12.

Managing Vitamin B12 Deficiency After Bariatric Surgery

(25:07):

So it’s important to get those animal sources in and make sure that you are getting it in consistently. So let’s wrap this up.  Bariatric surgery really does put a person in need of maintaining normal. Vitamin B 12 levels because we are altering how your body breaks down and absorbs nutrients. So bariatric surgery is all about malnutrition. So we are trying to prevent malnutrition, and that is where we have to make sure you’re absorbing adequately of these nutrients so that you don’t have problems and symptoms that you are thinking is something way completely different. Proper monitoring, at least annual labs, you should be getting a serum B 12 and methylmalonic acid or M M A drawn from either your bariatric team or whoever does your annual labs with all the nutrition indicators that is necessary. Also making sure that you’re supplementing. And I find frequently that a lot of bariatric patients will be taken off of B 12 supplements because their serum B 12 is elevated.

Supplementation

(26:37):

And remember how I said that serum B 12 is really just an indicator of what you’re taking in from your food. And your supplements and something I’ll be talking about next time on. I have another continued topic on B 12 where we’re dialing more of the genetics and. The gut microbiome because gut bacteria actually produce vitamin B 12. So you have to think about those pieces as well because it’s going to influence how your body is utilizing all of it. So it matters. And I want you to make sure that you are supplementing appropriately and. Not allowing a primary care provider to take you off because of an elevated serum B 12 that is sometimes dangerous. And I’ve seen it frequently that they’re like, yeah, my doctor said I don’t need to take that anymore. My level was good. Well, your level was good because you were taking it and you don’t have. Your surgery has created this environment that you are not going to have the ability to absorb enough from your diet.

Education and Support

(28:04):

So don’t go off of it and make sure that you are testing, you’re getting those labs test every year. And if they’re abnormal, then you test them every three months until you get ’em normal and. Making sure that you’re correcting those low levels. So it’s important to work with a provider like myself who is skilled in interpreting this data. Just gathering this data. I find it interesting that the lens in which we look through things. I find that an md, a pa, an np, an RN might look at it one way and say. Oh, that looks fine to me. But a dietician might look at it and say, oh no, that’s not high enough. If I have somebody that has a serum B 12 that’s 400, I want it higher, I want it above 600. If I have somebody that’s at 1200, I want a methylmalonic acid drawn. And if that is elevated, then I’m going to get concern or. I don’t want to say concerned, but I’m going to start digging a little deeper. I’m going to start thinking, Hey, what’s happening in their gut? Do we need to do some gut work? And that’s why, because their gut microbiome is now. Or those gut bacteria are now producing excessive amounts of vitamin B 12 that are not going to be utilize. And so it’s creating this wrong environment. So again, we’ll get in deeper with the gut microbiome and your genetics next

Conclusion

(29:41):

Time when I talk about B 12, so that you have that to process on as well. So I hope this has helped and I hope you guys have learned something and. Maybe this will make you be a little more efficient with taking your B 12 supplements. And making sure that you’re taking it regularly like you’re suppose to after bariatric surgery because it is super important. It is something that does matter and can impact how you feel. So you guys have a great week and we will see you next time. Bye-bye.

Listen, Learn, Enjoy…

1. Guéant, J. L., Guéant-Rodriguez, R. M., & Alpers, D. H. (2022). Vitamin B12 absorption and malabsorption. In Vitamins and hormones (Vol. 119, pp. 241-274). Academic Press.

2. Lurz, E., Horne, R. G., Määttänen, P., Wu, R. Y., Botts, S. R., Li, B., … & Sherman, P. M. (2020). Vitamin B12 deficiency alters the gut microbiota in a murine model of colitis. Frontiers in nutrition, 7, 83.

3. Kumar, R., Singh, U., Tiwari, A., Tiwari, P., Sahu, J. K., & Sharma, S. (2023). Vitamin B12: Strategies for enhanced production, fortified functional food products and health benefits. Process Biochemistry.

4. Pardo-Cabello, A., Manzano-Gamero, V., & Puche-Cañas, E. (2023). Vitamin B12: For more than just the treatment of megaloblastic anemia? Revista ClíNica Española (English Edition), 223(2), 114-119. 

5. Baltrusch, S. (2021). The role of neurotropic B vitamins in nerve regeneration. BioMed research international, 2021, 1-9.

6. Moore, E., Mander, A., Ames, D., Carne, R., Sanders, K., & Watters, D. (2012). Cognitive impairment and vitamin B12: a review. International psychogeriatrics, 24(4), 541-556.

7. Lauer, A. A., Grimm, H. S., Apel, B., Golobrodska, N., Kruse, L., Ratanski, E., … & Grimm, M. O. W. (2022). Mechanistic link between vitamin b12 and Alzheimer’s disease. Biomolecules, 12(1), 129.

8. Vidya, C. S., AHER, J., & Mysuru, S. N. Correlation of vitamin B12, folate, homocysteine with cognitive functions in Alzheimer’s disease: A review article. hippocampus, 4, 5.

9. Raza, M., & Khan, A. (2023). Recent Advances in Microbial Production of Vitamin B12: Review of Optimization Strategies and High-Yielding Strains.

10. Institute of Medicine (US). Food and Nutrition Board. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. (2000). Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline (pp. 306-56). Washington, DC: National Academy Press.

11. Mahawar, K. K., Reid, A., Graham, Y., Callejas-Diaz, L., Parmar, C., Carr, W. R., … & Small, P. K. (2018). Oral vitamin B 12 supplementation after Roux-en-Y gastric bypass: A systematic review. Obesity surgery, 28, 1916-1923.