Vitamin B12 – Medical science, Mrs White and the Church

1
Vitamin B12 Medical science, Mrs White and the
Church

• Dr Bevan Hokin BSc MAppSc PhD
• Director of Pathology
• SYDNEY ADVENTIST HOSPITAL

2
Programme.

• Vegetarianism and vitamin B12 the scientific
  basis
• Questions
• Break
• The Bible, Mrs White, The Church and vitamin B12
• Questions
• Treatment of vitamin B12 deficiency

3
Vegetarianism, with particular reference to
vitamin B12
4
Vegetarianism

• It is the position of the American Dietetic
  Association and Dietitians of Canada that
  appropriately planned vegetarian diets are
  healthful, nutritionally adequate and provide
  health benefits in the prevention and treatment
  of certain diseases.
• JADA June 2003 Volume 103 Number 6

5
Proven benefits

• Reduction in incidence of
• Obesity
• Cardiovascular disease
• Hypertension
• Diabetes (Type II)
• Cancer
• Osteoporosis
• Renal disease
• Dementia

6
ADA Statement qualifier

• Vegetarian diets must be appropriately planned

7
Nutrients for which planning is required in
vegetarian diets

• Protein RDA 40-50 gm
• Iron 12-15 mg
• Calcium 1200 mg
• Vitamin D 400 IU
• Vitamin B12 2.4 ug
• Iodine 150 ug
• Omega three fatty acids 2-4 gm

8
Types of vegetarian diets

• Vegan
• Vegetarian
• Lacto-vegetarian
• Lacto-ovo-vegetarian
• Semi vegetarian
• Occasional or moderate use of fish or chicken

9
Vegan

• Must pay strict attention to
• Calcium
• Can obtain sufficient from plant sources
• Vitamin B12
• MUST supplement

10
Vegetarians (Lacto- and lacto-ovo-)

• Less of an issue (compared with veganism) but
  still important to consider
• Calcium (as dairy products are included)
• Vitamin B12 (as eggs and dairy products (low fat)
  are included

11
Vitamin B12 the scientific and medical position
12
Vitamin B12 what is it?

• Water soluble
• Burgundy coloured crystals
• Molecular weight 1355.4
• Formula C65H38O14N14PCo
• Analogues
• hydroxyl-, hydroxo-, aquo-, nitrito-, methyl-,
  5-desoxy-, adenosyl-, cyano-, sulphuryl-.

13
(No Transcript)
14
Vitamin B12 Reference Ranges

• Published 171-850 pmol/L
• Victor Herbert gt221 pmol/L
• Clinical symptoms reported with vitamin B12 of
  258 pmol/L

15
What does vitamin B12 do?

• Essential for all cell division hence
  implications with growth, repair and reproduction
• Maintenance of the integrity of myelin (the
  insulation that surrounds most nerves)

16
Consequences of B12 deficiency

• Tired, heavy feeling
• Numb lips or nose
• Macrocytic anaemia
• Nerve (myelin sheath) damage
• Spinal cord degeneration
• Dementia
• Death

17
Symptoms of vitamin B12 deficiency

• Neurological Haematological Other
• Paraesthesia Shortness of breath
  Sore tongue/mouth
• Unsteadiness Anaemia Weight loss
• Leg weakness Macrocytosis
  Loss of appetite
• Muscle tenderness Hypersegmentation
  Tiredness
• Memory loss - General
  weakness
• Psychiatric changes Hair loss
• Dementia
• Death

18
How is vitamin B12 absorbed?

• Role of stomach
• Parietal cells
• Acid
• Role of terminal ileum for absorption
• Problems malabsorption
• Aging, some drugs and acid production
• Autoimmune
• anti parietal cell antibodies
• Anti intrinsic factor antibodies

19
Causes of vitamin B12 deficiency

• Inadequate intake (dietary deficiency)
• Impaired absorption (IF or ileum related)
• Inadequate utilisation (transport proteins)
• Increased requirement (pregnancy)
• Increased excretion (enterohepatic circulation)
• Increased destruction (NO anaesthesia, excessive
  vitamin C)

20
Vitamin B12 - Dietary Sources

• Egg (one Medium) 0.5 ug
• Fortified Soy Milk (So Good) 4.0 ug/L
• Milk 3.0 ug/L
• Cheese (50 gm) 1.0 ug
• Meat analogues (one serving) 0.6-0.8 ug
• Yoghurt (150 gm) 0.3 ug
• Marmite (5 gm serving) 0.5 ug
• Exercise caution with USA food tables (Yeast and
  cereals)

21
Vitamin B12 Other sources
22
Myths surrounding vitamin B12

• Is there useable vitamin B12 in
• Spinach
• Aloe Vera juice
• Mushrooms
• Spirulina
• Tempeh
• Yeast

23
Vitamin B12 - facts

• There is NO useable vitamin B12 in
• Spinach
• Aloe Vera juice
• Mushrooms (10 kg fresh to achieve the RDA)
• Spirulina
• Tempeh
• Yeast unless a fortified product
• There may be some useable vitamin B12 in the
  seaweeds Nori and/or Chlorella

24
Myths surrounding vitamin B12

• Vitamin B12 comes from animals
• The vitamin B12 used to fortify foods is
  extracted from animal sources
• ALL vitamin B12 from ALL sources comes from
  bacteria. Animals concentrate it in their tissue.
• Vitamin B12 used to fortify food is manufactured
  in vats by Proprionobacterium species of bacteria
  (and others) and purified.

25
Myths surrounding vitamin B12

• What about Dr Mervyn Hardinges 1977 report of
  vitamin B12 produced in the mouth by oral
  bacteria?
• Repeated his study
• Some people produce up to 10 of RDI
• Some people produce zero
• Why the difference needs further research

26
Why is vitamin B12 so important?
27
Implications of vitamin B12 deficiency

• Reversibility of vitamin B12 deficiency-induced
  dementia if treated within 1-2 years of onset.
  (Ho 1999, Bopp-Kistler 1999)
• B12 deficiency and short-term memory loss- New
  brain cells are made daily for that days
  short-term memory. Dependent on adequate vitamin
  B12 reserves. (Herbert 2002)

28
More implications of vitamin B12 deficiency

• Increased risk of breast tumours in post
  menopausal women who were deficient in vitamin
  B12 during their teens.
• Link between low maternal vitamin B12 during
  pregnancy and an increased incidence of brain
  tumours in their children when they reach puberty.

29
Incidence of vitamin B12 deficiency (B12 lt 220
pmol/L)

• Among
• Lacto-ovo-vegetarians 73
• Vegans (depends on duration) 90
• The elderly in assisted care 65

30
Why were the lacto-ovo-vegetarians vitamin B12
deficient?

• Cholesterol and saturated fats lead to heat
  disease. (Health message of the mid 1970s)
• From 1976 to 2002, consumption of both eggs and
  milk reduced, and vitamin B12 deficiency
  increased proportionally.
• Low vitamin B12 leads to an elevation in
  homocysteine which is linked to increased risk of
  heart disease

31
At-risk groups for vitamin B12 deficiency

• Vegetarians (consuming less than 20 servings of
  vitamin B12 containing foods/week).
• Vegans (MUST take supplements)
• The elderly (reduced absorption after age about
  55-60 years)
• In pregnancy (if commence with low body reserves
  or suffer severe or prolonged morning sickness)

32
Diagnosis of vitamin B12 deficiency

• Symptoms
• History (vegetarianism or near vegetarianism)
• Veganism
• Age (assisted care facilities)
• Blood tests

33
Diagnosis of vitamin B12 deficiency

• BLOOD TESTS
• Serum vitamin B12,
• homocysteine, MMA
• anti-IF antibodies,
• anti-parietal cell antibodies

34
HOMOCYSTEINE and B12

• Body stores vitamin B12 in liver 3 - 5 years
  reserves
• As vitamin B12 reserves fall, homocysteine
  increases
• Homocysteine is an excellent marker of low body
  vitamin B12 reserves
• Reference range for good reserves of
• Homocysteine lt 10 nmol/L

35
Treatment of vitamin B12 deficiency

• Severe IM injection at once, then assess
• Less severe and after initial treatment
• Dietary deficiency Diet advice, supplements,
  follow-up in 3-6 months
• IF Malabsorption IM Injections 4-6 weekly as
  needed

36
Treatment of vitamin B12 deficiency

• For those with a dietary deficiency normal
• absorption
• Food supplements (E.g. vitamin B12 fortified soy
  milk) are effective in increasing serum B12 and
  decreasing homocysteine.
• Small frequent doses (2ug) 6-8 hourly, are more
  efficacious than infrequent large doses
• Law of mass action in malabsorbers

37
How not to treat B12 deficiency

• Spirulina
• Case study
• Schillings test was normal, therefore probably
  inadequate intake
• Suggested 3 month trial of vitamin B12
  supplement 2 ug B12 three times/day
• Retested after 2-4 week equilibration period
• B12 fell from 117 to 87 pmol/L

38
Conclusions I

• Vitamin B12 deficiency is common
• At-risk groups include vegetarians and elderly
  non-vegetarians
• Reference ranges quoted by many laboratories are
  too low and fail to alert clinicians of
  deficiency risk
• Mis-diagnosis of deficiency may be serious

39
Conclusions II

• A metabolic marker of vitamin B12 (e.g.
  homocysteine) should be used along with serum
  levels
• Supplementary tests are available to diagnose the
  cause of deficiency
• Food supplements are efficacious in treating
  dietary deficiency
• Treatment with IM injections or tablets is
  effective in long-term management.

40
Conclusions III

• The vegetarian diet is a healthy one.
• All essential nutrients (except vitamin B12 in
  the Vegan diet) are able to be obtained from a
  well planned vegetarian diet. (Vegans MUST
  supplement with vitamin B12)
• The lacto-ovo-vegetarian diet is the least
  complicated form of vegetarianism as there is
  sound provision of calcium and vitamin B12, and
  it retains the health benefits of vegetarianism.

41
QUESTION TIME
42
Vitamin B12 the Bible, Mrs White and the Church
43
The Bible

• Mans diet history
• Original
• I have given you every herb bearing seed which
  is upon the face of all the earth, and every
  tree, in which is the fruit of a tree yielding
  seed to you it shall be for meat.
• Gen 129

44
The Bible

• Mans diet history
• Original
• Source of vitamin B12 ???

45
Possible sources of vitamin B12 ORIGINAL DIET

• Produced by bacteria
• Intestinal tract colonisation / symbiosis
• Modern man disrupted
• Antibiotics
• Diet change
• Preservatives
• Speculative more research needed
• Being undertaken in collaboration with University
  of Newcastle and the ARI

46
The Bible

• Mans diet history
• After the fall
• Fruits, grains, nuts and vegetables.
• Gen 318-19
• Source of vitamin B12 ???

47
Possible sources of vitamin B12 ORIGINAL DIET

• Produced by bacteria
• Intestinal tract colonisation / symbiosis
• Modern man disrupted
• Antibiotics
• Diet change
• Preservatives
• Speculative more research needed
• Being undertaken in collaboration with University
  of Newcastle and the ARI

48
The Bible

• Mans diet history
• After the flood
• Every moving thing that liveth shall be meat for
  you even as the green herb have I given you all
  things But flesh with the life thereof, which
  is the blood thereof, shall ye not eat.
• Gen 9 3,4
• Vitamin B12 source Flesh foods

49
The Bible

• Mans diet history
• Patriarchs and Christ
• Abraham Gen 18 7,8 Calf
• Isaac Gen 27 4 Kid
• Christ Luke 24 42,43 Fish
• Luke 22 15 Lamb
• Vitamin B12 source Flesh foods

50
Mrs White

• Strong advocate for vegetarianism
• Flesh was never the best food MH 313
• Many die of disease caused wholly by
• meat-eating SG 147
• Those who eat flesh are but eating grains
• and vegetables at second hand.How
• much better to get it direct, by eating food
  that
• God provided for our use. MH 313

51
Mrs White

• Strong advocate for vegetarianism
• Cancers, tumours and inflammatory diseases are
  largely caused by meat eating. CDF 385
• Animals are becoming more and more diseased, and
  it will not be long until animal food will be
  discarded by many beside Seventh-day Adventists.
  Foods that are healthful and life sustaining are
  to be prepared, so that men and women will not
  need to eat meat. CDF 202

52
Mrs White

• Strong advocate for vegetarianism
• Flesh foods are injurious to the physical
  well-being, and we should learn to do without
  them. CDF 403
• Grains, fruits, nuts and vegetablesprepared in
  as simple and natural a manner as possible, are
  the most healthful and nourishing. CDF 313

53
Mrs White

• Strong advocate for vegetarianism
• So where can vegetarian Adventists obtain vitamin
  B12?
• From a lacto-ovo-vegetarian diet.
• But doesnt Mrs White condemn eggs and dairy?

54
Mrs White

• Strong advocate for vegetarianism
• Position on Dairy products and eggs
• WARNING
• Cheese is wholly unfit for food MH 302
• I wish to say that when the time comes that it
  is no longer safe to use milk, cream, butter and
  eggs, God will reveal this. CDF 206

55
Mrs White

• Strong advocate for vegetarianism
• Position on Dairy products and eggs
• Cheese
• Made with arsenic
• No pasteurisation
• No refrigeration
• Overall poor hygiene
• Moderated her position to include some cheese in
  her diet. (Counsel and reproof Letter 1873)

56
Mrs White

• Strong advocate for vegetarianism
• Position on Dairy products and eggs
• We use no lard,but in its place, milk,cream MH
  302
• We have always used a little milkThis we have
  never denounced, either in our writings or in our
  preachings. 1873 letter
• Milkshould not be classed with flesh meat.. The
  time has not come to say that the use of
  milkshould be wholly discarded. T7 p134

57
Mrs White

• Strong advocate for vegetarianism
• Position on Dairy products and eggs
• Great care should be takento obtain eggs from
  healthy fowls MH 320
• ..eggs should not be classed with flesh meat. In
  some cases the use of eggs is beneficial. T7 134
  

58
Mrs White

• Strong advocate for vegetarianism
• Position on Dairy products and eggs
• Fruits, grains and vegetables, prepared in a
  simple way, free from spice and grease (animal
  fat) of all kinds, make with milk or cream, the
  most healthful diet. CDF 202

59
Mrs White

• Strong advocate for vegetarianism
• Position on Dairy products and eggs
• The time will come when (for health reasons) we
  may have to discard some of the articles of diet
  we now use, such as milk and cream and eggs but
  my message is that you must not bring yourself to
  a time of trouble beforehand, and thus afflict
  yourself with death . CDF 358

60
CASE STUDY Dr Kress

• In an interesting case, a Unites States trained,
  Adventist physician, Dr Kress, while working in
  Australia in the early 1900s, became obsessed
  with the health benefits of the soybean,
  virtually eating nothing else. Over time he
  developed symptoms consistent with vitamin B12
  deficiency, coming close to death. Ellen White
  wrote to him, instructing him to consume

61
Dr Kress 2

• raw eggs from healthy fowls, mixed with good
  quality unfermented grape juice. This will supply
  that which is necessary to your system.
• We appreciate your experience as a physician,
  and yet I say that milk and eggs should be
  included in your diet The doctrine of dispensing
  with them should not be taught. CDF 202

62
Dr Kress 3

• Current knowledge of nutrition, reveals that the
  remedy prescribed included both an excellent
  source of vitamin B12 and also of iron. This
  patient recovered and lived normally for many
  years. While a scientific and medical
  understanding of the role and importance of
  vitamin B12 did not occur until 1948, the
  Seventh-day Adventist church, while advocating
  vegetarianism on health grounds, unwittingly
  protected its adherents from vitamin B12
  deficiency by insisting that the healthiest diet
  was the lacto-ovo- form of vegetarianism.

63
The Churchs position SPD

•  Dairy foods (preferably low fat varieties for
  adults) such as milk, cheese and yoghurt and/or
  soy alternatives fortified with calcium and
  vitamin B12 such as Sanitarium So Good soymilk.
  Adults should aim for 2 serves of these foods
  daily (1 serve 250ml milk/soymilk, 40g cheese,
  200g yoghurt). (SPD Web page)

64
The Churchs position SPD

• In addition to 2 serves of dairy and calcium
  enriched soy foods, vegetarian adults should aim
  to include 2 serves of protein foods each day,
  selecting from the following foods
• o        eggs omega-3 enriched eggs or free
  range eggs are preferable as vegetarian diets
  tend to be high in omega-6 fats. (1 serve 2
  eggs)
• o        pre-prepared vegetarian foods such as
  tofu, tempeh, textured vegetable protein, soy
  burgers/sausages/luncheon slices. Look for
  products that are fortified with iron and vitamin
  B12, where possible. (1 serve 100g tofu)
• o        legumes
• o        nuts and seeds,

65
The Churchs position SHF

• Including vitamin B12 in the diet -
• Consume milk (and other dairy products) or a
  vitamin B12 fortified soymilk daily. Two cups of
  Sanitarium So Good soymilk provides the daily
  B12 requirement for an adult.
• Include other plant foods fortified with vitamin
  B12 such as some soy burgers/sausages/luncheon
  slices and Sanitarium Marmite.
• Eggs supply vitamin B12 for lacto-ovo
  vegetarians.
• Take a daily vitamin B12 supplement if you are
  pregnant, breastfeeding, travelling or dont
  include a regular supply of B12 containing foods
  in your diet.
• Despite the claims, mushrooms, tempeh, miso,
  seaweed, spirulina and sauerkraut are not
  reliable sources of vitamin B12.

66
The Churchs position GC

• Health reform and the teaching of health and
  temperance are inseparable parts of the Advent
  message. Instruction came to us through the
  Lord's chosen messenger "that those who are
  keeping His commandments must be brought into
  sacred relationship to Himself, and that by
  temperance in eating and drinking they must keep
  mind and body in the most favourable condition
  for service.'' - Counsels on Health, pp. 132,
  133. Also, "it is the Lord's design that the
  restoring influence of health reform shall be a
  part of the last great effort to proclaim the
  gospel message." - Medical Ministry, p. 259.

67
The Churchs position GC

• We belong to God, body, soul, and spirit. It is
  therefore our religious duty to observe the laws
  of health, both for our own well-being and
  happiness and for more efficient service to God
  and our fellow men. The appetite must be kept
  under control. Health is promoted by an
  intelligent observance of the hygienic principles
  having to do with pure air, ventilation, suitable
  clothing, cleanliness, proper exercise and
  recreation, adequate sleep and rest, and an
  adequate, wholesome diet. God has furnished man
  with a liberal variety of foods sufficient to
  satisfy every dietary need. Fruits, grains, nuts,
  and vegetables prepared in simple ways "make,
  with milk or cream, the most healthful diet." -
  Christian Temperance and Bible Hygiene, p. 47.

68
Independent assessment of lacto-ovo vegetarianism

• While the SDA church has historically promoted a
  vegetarian diet, independent studies have
  highlighted its health benefit. The incidence of
  certain cancers is less in those who use some
  milk. The US Committee on Diet, Nutrition and
  Cancer, reports that dairy milk consumption was
  protective of stomach cancer, oesophageal cancer,
  colorectal cancer and bladder cancer (CDNC 1982).

69
Lacto-ovo-vegetarian diet

• The Church maintains it strong position on Diet
  and Health, continuing to promote a
  lacto-ovo-vegetarian diet (Fraser 1995). The
  Sanitarium Health food Company manufactures
  vegetarian products suitable for both vegetarians
  and vegans that are fortified with vitamin B12
  (Radd 1999). A dairy milk alternative, So Good
  contains similar amounts of vitamin B12 as does
  milk. One serving of any of the meat analogues
  manufactured, contains 25 of the RDI for vitamin
  B12.
•  

70
Vitamin B12 sources for Adventists

•  Lacto-ovo-vegetarians. Consume at least 20
  servings of vitamin B12 containing foods each
  week
• Vegans. Consume at least 20 servings of So Good,
  Soy healthy and Marmite each week
• AND/OR
• Take a vitamin B12 supplement regularly

71
Conclusions 1

• While there may come a time when eggs and milk
  become unsafe
• We will know when
• We should not prematurely discard them
• Vitamin B12 is a critical issue that must be
  taken seriously
• The Church recommends a lacto-ovo-vegetarian diet.

72
Conclusions 2

• At least 20 servings/week of vitamin B12
  containing foods are required
• Low fat dairy and So Good are good sources of
  vitamin B12
• If you choose to be vegan, or do not consume at
  least 20 servings/week, take a supplement
• Regardless of diet preference, those over age 60
  should ask their doctor to monitor their vitamin
  B12 levels, and seek supplementation if low.

73
QUESTIONS

• And if there is time after, a research report on
  the most effective B12 treatment methods.

74
Efficacy of treatment methods in vitamin B12
deficiency
75
Research Method

• Initial blood tests (MBA, FBC, B12, Folic acid,
  Homocysteine)
• Initial life-style and well-being questionnaires
• Monthly B12 and Homocysteine (3 months)
• Final blood tests (MBA, FBC, B12, Folic acid,
  Homocysteine)
• Final well-being questionnaire

76
Treatment Groups

• Controls
• So Good (2, 250mL/day, 2ug vitamin B12)
• Meat Analogues (1 serving/day, Today's Gourmet
  Range, 0.6-0.8 ug vitamin B12)

77
Treatment Groups

• High dose tablets (50 ug, one/week)
• Low dose tablets (2 ug, one/day)
• IM injection (100ug, one/month)

78
Control
79
Meat Analogues
80
High Dose Tablet
81
Injection IM
82
Low Dose Tablet
83
So Good
84
Wellbeing Scores

• Statistical analysis of pre- and post treatment
  Wellbeing scores revealed that subjects felt
  better after treatment.
• p0.0006

85
Conclusion

• Low serum levels of vitamin B12 are common
  (vegetarians and the elderly)
• Dietary inadequacy is the most common cause.
• Serious health risks are associated with low
  levels of vitamin B12
• Food supplements are useful in prevention and
  treatment of vitamin B12 deficiencies.

86
Conclusion

• Vitamin B12 Fortified Soy Milk is effective in
  the treatment of vitamin B12 deficiency
• Daily Low dose tablet supplements are more
  effective than weekly High doses.
• There is an inverse relationship between serum
  B12 and homocysteine (body reserves)
• People feel better after treatment

87
(No Transcript)