Vegetarian Nutrition

VN: Vitamin B-12 (2011)

Vitamin B-12 and Vegetarian Nutrition

See evidence analysis questions below diagram.

• Assessment
  What is the vitamin B-12 status of children of vegetarians, as measured by methylmalonic acid (MMA)?

  • Conclusion

    Based on data from two studies, there is limited, though consistent, evidence that small children of parents who follow very restrictive vegetarian diets are likely to be deficient in vitamin B-12 as measured by MMA. The proportion of these children who were vitamin B-12 deficient ranged from 55% to 85%.

  • Grade: III
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the vitamin B-12 status among vegetarians, as measured by methylmalonic acid (MMA) across the lifespan?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Dhonukshe-Rutten RA, van Dusseldorp M, Schneede J, de Groot LC, van Staveren WA. Low bone mineral density and bone mineral content are associated with low cobalamin status in adolescents. Eur J Nutr. 2005 Sep; 44 (6): 341-347. Epub 2004 Aug 30.
      • Donaldson MS. Metabolic vitamin B12 status on a mostly raw vegan diet with follow-up using tablets, nutritional yeast, or probiotic supplements. Ann Nutr Metab. 2000; 44(5-6): 229-234.
      • Geisel J, Hübner U, Bodis M, Schorr H, Knapp JP, Obeid R, Herrmann W. The role of genetic factors in the development of hyperhomocysteinemia. Clin Chem Lab Med. 2003 Nov; 41 (11): 1,427-1,434.
      • Geisel J, Schorr H, Bodis M, Isber S, Hübner U, Knapp JP, Obeid R, Herrmann W. The vegetarian lifestyle and DNA methylation. Clin Chem Lab Med. 2005; 43(10): 1164-1169.
      • Gibson RS, Abebe Y, Stabler S, Allen RH, Westcott JE, Stoecker BJ, Krebs NF, Hambidge KM. Zinc, gravida, infection, and iron, but not vitamin B-12 or folate status, predict hemoglobin during pregnancy in Southern Ethiopia. J Nutr. 2008 Mar; 138(3): 581-586.
      • Herrmann W, Obeid R, Schorr H, Geisel, J. Functional vitamin B12 deficiency and determination of holotranscobalamin in populations at risk. Clin Chem Lab Med. 2003; 41(11): 1,478-1,488.
      • Herrmann W, Obeid R, Schorr H, Hübner U, Geisel J, Sand-Hill M, Ali N, Herrmann M. Enhanced bone metabolism in vegetarians: The role of vitamin B12 deficiency. Clin Chem Lab Med. 2009; 47 (11): 1,381-1,387.
      • Herrmann W, Schorr H, Purschwitz K, Rassoul F, Richter V. Total homocysteine, vitamin B(12), and total antioxidant status in vegetarians. Clin Chem. 2001 Jun; 47 (6): 1,094-1,101.
      •  Herrmann W, Schorr H, Obeid R, Geisel J. Vitamin B12 status, particularly holotranscobalamin II and methylmalonic acid concentrations, and hyperhomocysteinemia in vegetarians. Am J Clin Nutr. 2003 Jul; 78(1): 131-136.
      • Kwok T, Cheng G, Lai WK, Poon P, Woo J, Pang CP. Use of fasting urinary methylmalonic acid to screen for metabolic vitamin B12 deficiency in older persons. Nutrition. 2004 Sep; 20(9): 764-768.
      • Kwok T, Cheng G, Woo J, Lai WK, Pang CP. Independent effect of vitamin B12 deficiency on hematological status in older Chinese vegetarian women. Am J Hematol. 2002 Jul; 70(3): 186-190.
      • Miller DR, Specker BL, Ho ML, Norman EJ. Vitamin B-12 status in a macrobiotic community. Am J Clin Nutr. 1991; 53: 524-529.
      • Mørkbak AL, Hvas AM, Lloyd-Wright Z, Sanders TA, Bleie O, Refsum H, Nygaard OK, Nexø E. Effect of vitamin B12 treatment on haptocorrin.Clin Chem. 2006 Jun; 52 (6): 1,104-1,111. Epub 2006 Apr 13.
      • Obeid R, Geisel J, Schorr H, Hubner U, Herrmann W. The impact of vegetarianism on some haematological parameters. Eur J Haematol. 2002; 69: 275-279.
      • Refsum H, Yajnik CS, Gadkari M, Schneede J, Vollset SE, Orning L, Guttormsen AB, Joglekar A, Sayyad MG, Ulvik A, Ueland PM. Hyperhomocysteinemia and elevated methylmalonic acid indicate a high prevalence of cobalamin deficiency in Asian Indians. Am J Clin Nutr. 2001 Aug; 74(2): 233-241.
      • Schneede J, Dagnelie PC, van Staveren WA, Vollset SE, Refsum H, Ueland PM. Methylmalonic acid and homocysteine in plasma as indicators of functional cobalamin deficiency in infants on macrobiotic diets. Pediatr Res. 1994 Aug; 36 (2): 194-201.
      • van Dusseldorp M, Schneede J, Refsum H, Ueland PM, Thomas CM, de Boer E, van Staveren WA. Risk of persistent cobalamin deficiency in adolescents fed a macrobiotic diet in early life. Am J Clin Nutr. 1999 Apr; 69(4): 664-671.
  • Search Plan and Results: VN: Vegetarianism and Vitamin B12 Status - 2010
     
  What is the vitamin B-12 status among adolescent vegetarians, as measured by methylmalonic acid (MMA)?

  • Conclusion

    Adolescent vegetarians who followed restrictive diets in childhood may be at risk for vitamin B-12 deficiency. Based on two studies of the same group of subjects, vegetarian (LOV/LV) or omnivorous adolescents who had followed a very restrictive (macrobiotic) vegetarian diet early in life were likely to be vitamin B-12 deficient. Forty-one percent of adolescents had MMA >290nmol/L and 21% had MMA >410nmol/L.

  • Grade: III
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the vitamin B-12 status among vegetarians, as measured by methylmalonic acid (MMA) across the lifespan?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Dhonukshe-Rutten RA, van Dusseldorp M, Schneede J, de Groot LC, van Staveren WA. Low bone mineral density and bone mineral content are associated with low cobalamin status in adolescents. Eur J Nutr. 2005 Sep; 44 (6): 341-347. Epub 2004 Aug 30.
      • Donaldson MS. Metabolic vitamin B12 status on a mostly raw vegan diet with follow-up using tablets, nutritional yeast, or probiotic supplements. Ann Nutr Metab. 2000; 44(5-6): 229-234.
      • Geisel J, Hübner U, Bodis M, Schorr H, Knapp JP, Obeid R, Herrmann W. The role of genetic factors in the development of hyperhomocysteinemia. Clin Chem Lab Med. 2003 Nov; 41 (11): 1,427-1,434.
      • Geisel J, Schorr H, Bodis M, Isber S, Hübner U, Knapp JP, Obeid R, Herrmann W. The vegetarian lifestyle and DNA methylation. Clin Chem Lab Med. 2005; 43(10): 1164-1169.
      • Gibson RS, Abebe Y, Stabler S, Allen RH, Westcott JE, Stoecker BJ, Krebs NF, Hambidge KM. Zinc, gravida, infection, and iron, but not vitamin B-12 or folate status, predict hemoglobin during pregnancy in Southern Ethiopia. J Nutr. 2008 Mar; 138(3): 581-586.
      • Herrmann W, Obeid R, Schorr H, Geisel, J. Functional vitamin B12 deficiency and determination of holotranscobalamin in populations at risk. Clin Chem Lab Med. 2003; 41(11): 1,478-1,488.
      • Herrmann W, Obeid R, Schorr H, Hübner U, Geisel J, Sand-Hill M, Ali N, Herrmann M. Enhanced bone metabolism in vegetarians: The role of vitamin B12 deficiency. Clin Chem Lab Med. 2009; 47 (11): 1,381-1,387.
      • Herrmann W, Schorr H, Purschwitz K, Rassoul F, Richter V. Total homocysteine, vitamin B(12), and total antioxidant status in vegetarians. Clin Chem. 2001 Jun; 47 (6): 1,094-1,101.
      •  Herrmann W, Schorr H, Obeid R, Geisel J. Vitamin B12 status, particularly holotranscobalamin II and methylmalonic acid concentrations, and hyperhomocysteinemia in vegetarians. Am J Clin Nutr. 2003 Jul; 78(1): 131-136.
      • Kwok T, Cheng G, Lai WK, Poon P, Woo J, Pang CP. Use of fasting urinary methylmalonic acid to screen for metabolic vitamin B12 deficiency in older persons. Nutrition. 2004 Sep; 20(9): 764-768.
      • Kwok T, Cheng G, Woo J, Lai WK, Pang CP. Independent effect of vitamin B12 deficiency on hematological status in older Chinese vegetarian women. Am J Hematol. 2002 Jul; 70(3): 186-190.
      • Miller DR, Specker BL, Ho ML, Norman EJ. Vitamin B-12 status in a macrobiotic community. Am J Clin Nutr. 1991; 53: 524-529.
      • Mørkbak AL, Hvas AM, Lloyd-Wright Z, Sanders TA, Bleie O, Refsum H, Nygaard OK, Nexø E. Effect of vitamin B12 treatment on haptocorrin.Clin Chem. 2006 Jun; 52 (6): 1,104-1,111. Epub 2006 Apr 13.
      • Obeid R, Geisel J, Schorr H, Hubner U, Herrmann W. The impact of vegetarianism on some haematological parameters. Eur J Haematol. 2002; 69: 275-279.
      • Refsum H, Yajnik CS, Gadkari M, Schneede J, Vollset SE, Orning L, Guttormsen AB, Joglekar A, Sayyad MG, Ulvik A, Ueland PM. Hyperhomocysteinemia and elevated methylmalonic acid indicate a high prevalence of cobalamin deficiency in Asian Indians. Am J Clin Nutr. 2001 Aug; 74(2): 233-241.
      • Schneede J, Dagnelie PC, van Staveren WA, Vollset SE, Refsum H, Ueland PM. Methylmalonic acid and homocysteine in plasma as indicators of functional cobalamin deficiency in infants on macrobiotic diets. Pediatr Res. 1994 Aug; 36 (2): 194-201.
      • van Dusseldorp M, Schneede J, Refsum H, Ueland PM, Thomas CM, de Boer E, van Staveren WA. Risk of persistent cobalamin deficiency in adolescents fed a macrobiotic diet in early life. Am J Clin Nutr. 1999 Apr; 69(4): 664-671.
  • Search Plan and Results: VN: Vegetarianism and Vitamin B12 Status - 2010
     
  What is the vitamin B12 status among adult vegetarians, as measured by methylmalonic acid (MMA)?

  • Conclusion

    Among healthy adults, vegetarians consistently had a significantly higher prevalence of vitamin B-12 deficiency (as measured by elevated MMA levels) than omnivores. Depending on the criteria used to define vitamin B-12 deficiency and sample differences, prevalence of B-12 deficiency among adult vegetarians ranged from 30% to 86%. When vegans and LOV/LV vegetarians were analyzed separately, vegans had even higher proportions of vitamin B-12 deficiency (43% to 88%).

  • Grade: I
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the vitamin B-12 status among vegetarians, as measured by methylmalonic acid (MMA) across the lifespan?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Dhonukshe-Rutten RA, van Dusseldorp M, Schneede J, de Groot LC, van Staveren WA. Low bone mineral density and bone mineral content are associated with low cobalamin status in adolescents. Eur J Nutr. 2005 Sep; 44 (6): 341-347. Epub 2004 Aug 30.
      • Donaldson MS. Metabolic vitamin B12 status on a mostly raw vegan diet with follow-up using tablets, nutritional yeast, or probiotic supplements. Ann Nutr Metab. 2000; 44(5-6): 229-234.
      • Geisel J, Hübner U, Bodis M, Schorr H, Knapp JP, Obeid R, Herrmann W. The role of genetic factors in the development of hyperhomocysteinemia. Clin Chem Lab Med. 2003 Nov; 41 (11): 1,427-1,434.
      • Geisel J, Schorr H, Bodis M, Isber S, Hübner U, Knapp JP, Obeid R, Herrmann W. The vegetarian lifestyle and DNA methylation. Clin Chem Lab Med. 2005; 43(10): 1164-1169.
      • Gibson RS, Abebe Y, Stabler S, Allen RH, Westcott JE, Stoecker BJ, Krebs NF, Hambidge KM. Zinc, gravida, infection, and iron, but not vitamin B-12 or folate status, predict hemoglobin during pregnancy in Southern Ethiopia. J Nutr. 2008 Mar; 138(3): 581-586.
      • Herrmann W, Obeid R, Schorr H, Geisel, J. Functional vitamin B12 deficiency and determination of holotranscobalamin in populations at risk. Clin Chem Lab Med. 2003; 41(11): 1,478-1,488.
      • Herrmann W, Obeid R, Schorr H, Hübner U, Geisel J, Sand-Hill M, Ali N, Herrmann M. Enhanced bone metabolism in vegetarians: The role of vitamin B12 deficiency. Clin Chem Lab Med. 2009; 47 (11): 1,381-1,387.
      • Herrmann W, Schorr H, Purschwitz K, Rassoul F, Richter V. Total homocysteine, vitamin B(12), and total antioxidant status in vegetarians. Clin Chem. 2001 Jun; 47 (6): 1,094-1,101.
      •  Herrmann W, Schorr H, Obeid R, Geisel J. Vitamin B12 status, particularly holotranscobalamin II and methylmalonic acid concentrations, and hyperhomocysteinemia in vegetarians. Am J Clin Nutr. 2003 Jul; 78(1): 131-136.
      • Kwok T, Cheng G, Lai WK, Poon P, Woo J, Pang CP. Use of fasting urinary methylmalonic acid to screen for metabolic vitamin B12 deficiency in older persons. Nutrition. 2004 Sep; 20(9): 764-768.
      • Kwok T, Cheng G, Woo J, Lai WK, Pang CP. Independent effect of vitamin B12 deficiency on hematological status in older Chinese vegetarian women. Am J Hematol. 2002 Jul; 70(3): 186-190.
      • Miller DR, Specker BL, Ho ML, Norman EJ. Vitamin B-12 status in a macrobiotic community. Am J Clin Nutr. 1991; 53: 524-529.
      • Mørkbak AL, Hvas AM, Lloyd-Wright Z, Sanders TA, Bleie O, Refsum H, Nygaard OK, Nexø E. Effect of vitamin B12 treatment on haptocorrin.Clin Chem. 2006 Jun; 52 (6): 1,104-1,111. Epub 2006 Apr 13.
      • Obeid R, Geisel J, Schorr H, Hubner U, Herrmann W. The impact of vegetarianism on some haematological parameters. Eur J Haematol. 2002; 69: 275-279.
      • Refsum H, Yajnik CS, Gadkari M, Schneede J, Vollset SE, Orning L, Guttormsen AB, Joglekar A, Sayyad MG, Ulvik A, Ueland PM. Hyperhomocysteinemia and elevated methylmalonic acid indicate a high prevalence of cobalamin deficiency in Asian Indians. Am J Clin Nutr. 2001 Aug; 74(2): 233-241.
      • Schneede J, Dagnelie PC, van Staveren WA, Vollset SE, Refsum H, Ueland PM. Methylmalonic acid and homocysteine in plasma as indicators of functional cobalamin deficiency in infants on macrobiotic diets. Pediatr Res. 1994 Aug; 36 (2): 194-201.
      • van Dusseldorp M, Schneede J, Refsum H, Ueland PM, Thomas CM, de Boer E, van Staveren WA. Risk of persistent cobalamin deficiency in adolescents fed a macrobiotic diet in early life. Am J Clin Nutr. 1999 Apr; 69(4): 664-671.
  • Search Plan and Results: VN: Vegetarianism and Vitamin B12 Status - 2010
     
  What is the vitamin B-12 status among vegetarian older adults (>55 years) as measured by methylmalonic acid (MMA)?

  • Conclusion

    Research on the vitamin B-12 status among vegetarians older than 55 years is limited to only two neutral quality studies of Chinese women. Based on these studies, the proportion of older adult vegetarians who are vitamin B-12 deficient ranges from 46.9% to 68%.

  • Grade: III
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the vitamin B-12 status among vegetarians, as measured by methylmalonic acid (MMA) across the lifespan?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Dhonukshe-Rutten RA, van Dusseldorp M, Schneede J, de Groot LC, van Staveren WA. Low bone mineral density and bone mineral content are associated with low cobalamin status in adolescents. Eur J Nutr. 2005 Sep; 44 (6): 341-347. Epub 2004 Aug 30.
      • Donaldson MS. Metabolic vitamin B12 status on a mostly raw vegan diet with follow-up using tablets, nutritional yeast, or probiotic supplements. Ann Nutr Metab. 2000; 44(5-6): 229-234.
      • Geisel J, Hübner U, Bodis M, Schorr H, Knapp JP, Obeid R, Herrmann W. The role of genetic factors in the development of hyperhomocysteinemia. Clin Chem Lab Med. 2003 Nov; 41 (11): 1,427-1,434.
      • Geisel J, Schorr H, Bodis M, Isber S, Hübner U, Knapp JP, Obeid R, Herrmann W. The vegetarian lifestyle and DNA methylation. Clin Chem Lab Med. 2005; 43(10): 1164-1169.
      • Gibson RS, Abebe Y, Stabler S, Allen RH, Westcott JE, Stoecker BJ, Krebs NF, Hambidge KM. Zinc, gravida, infection, and iron, but not vitamin B-12 or folate status, predict hemoglobin during pregnancy in Southern Ethiopia. J Nutr. 2008 Mar; 138(3): 581-586.
      • Herrmann W, Obeid R, Schorr H, Geisel, J. Functional vitamin B12 deficiency and determination of holotranscobalamin in populations at risk. Clin Chem Lab Med. 2003; 41(11): 1,478-1,488.
      • Herrmann W, Obeid R, Schorr H, Hübner U, Geisel J, Sand-Hill M, Ali N, Herrmann M. Enhanced bone metabolism in vegetarians: The role of vitamin B12 deficiency. Clin Chem Lab Med. 2009; 47 (11): 1,381-1,387.
      • Herrmann W, Schorr H, Purschwitz K, Rassoul F, Richter V. Total homocysteine, vitamin B(12), and total antioxidant status in vegetarians. Clin Chem. 2001 Jun; 47 (6): 1,094-1,101.
      •  Herrmann W, Schorr H, Obeid R, Geisel J. Vitamin B12 status, particularly holotranscobalamin II and methylmalonic acid concentrations, and hyperhomocysteinemia in vegetarians. Am J Clin Nutr. 2003 Jul; 78(1): 131-136.
      • Kwok T, Cheng G, Lai WK, Poon P, Woo J, Pang CP. Use of fasting urinary methylmalonic acid to screen for metabolic vitamin B12 deficiency in older persons. Nutrition. 2004 Sep; 20(9): 764-768.
      • Kwok T, Cheng G, Woo J, Lai WK, Pang CP. Independent effect of vitamin B12 deficiency on hematological status in older Chinese vegetarian women. Am J Hematol. 2002 Jul; 70(3): 186-190.
      • Miller DR, Specker BL, Ho ML, Norman EJ. Vitamin B-12 status in a macrobiotic community. Am J Clin Nutr. 1991; 53: 524-529.
      • Mørkbak AL, Hvas AM, Lloyd-Wright Z, Sanders TA, Bleie O, Refsum H, Nygaard OK, Nexø E. Effect of vitamin B12 treatment on haptocorrin.Clin Chem. 2006 Jun; 52 (6): 1,104-1,111. Epub 2006 Apr 13.
      • Obeid R, Geisel J, Schorr H, Hubner U, Herrmann W. The impact of vegetarianism on some haematological parameters. Eur J Haematol. 2002; 69: 275-279.
      • Refsum H, Yajnik CS, Gadkari M, Schneede J, Vollset SE, Orning L, Guttormsen AB, Joglekar A, Sayyad MG, Ulvik A, Ueland PM. Hyperhomocysteinemia and elevated methylmalonic acid indicate a high prevalence of cobalamin deficiency in Asian Indians. Am J Clin Nutr. 2001 Aug; 74(2): 233-241.
      • Schneede J, Dagnelie PC, van Staveren WA, Vollset SE, Refsum H, Ueland PM. Methylmalonic acid and homocysteine in plasma as indicators of functional cobalamin deficiency in infants on macrobiotic diets. Pediatr Res. 1994 Aug; 36 (2): 194-201.
      • van Dusseldorp M, Schneede J, Refsum H, Ueland PM, Thomas CM, de Boer E, van Staveren WA. Risk of persistent cobalamin deficiency in adolescents fed a macrobiotic diet in early life. Am J Clin Nutr. 1999 Apr; 69(4): 664-671.
  • Search Plan and Results: VN: Vegetarianism and Vitamin B12 Status - 2010