Are You Getting These Nutrients? - Part 11

Vegetarians: Naturally, the whole picture shifts for vegetarian and vegan low-carbers, who are limiting their diets even more. In addition to the nutrients in the previous blogs, watch intake of vitamin B12, choline, niacin, vitamin A, and zinc.

For vitamin B12, I have listed several of the blogs I have written for you to examine.

Vitamin B12

http://bobsdiabetes.blogspot.com/2015/09/b12-deficiency-silent-epidemic-part-1.html

http://bobsdiabetes.blogspot.com/2015/09/b12-deficiency-silent-epidemic-part-2.html

http://bobsdiabetes.blogspot.com/2014/12/more-on-importance-of-vitamins-b12-and.html

http://bobsdiabetes.blogspot.com/2012/12/nutrients-vitamin-b12.html

http://bobsdiabetes.blogspot.com/2011/12/risks-of-excess-vitamins-and-other.html

http://bobsdiabetes.blogspot.com/2014/01/joint-january-meeting.html

http://bobsdiabetes.blogspot.com/2015/01/two-topics-for-our-january-meeting-part_12.html

Vitamin B12, also called cobalamin, is one of eight B vitamins. All B vitamins help the body convert food (carbohydrates) into fuel (glucose), which is used to produce energy. These B vitamins often referred to as B complex vitamins, also help the body use fats and protein. B complex vitamins are needed for healthy skin, hair, eyes, and liver. They also help the nervous system function properly. All B vitamins are water soluble, meaning that the body does not store them.

Vitamin B12 is an especially important vitamin for maintaining healthy nerve cells, and it helps in the production of DNA and RNA, the body's genetic material. Vitamin B12 works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body. Folate and B12 work together to produce S-adenosylmethionine (SAMe), a compound involved in immune function and mood.

Vitamins B12, B6, and B9 work together to control blood levels of the amino acid homocysteine. High levels of homocysteine are associated with heart disease. However, researchers are not sure whether homocysteine is a cause of heart disease or just a marker that indicates someone may have heart disease.

It is rare for young people to be deficient in vitamin B12, but it is not uncommon for older people to be mildly deficient. This may be because their diets are not as healthy, or because they have less stomach acid, which the body needs to absorb B12. Low levels of B12 can cause a range of symptoms including – fatigue, shortness of breath, diarrhea, nervousness, numbness, and tingling sensation in the fingers and toes.

Severe deficiency of B12 causes nerve damage.

Others at risk for B12 deficiency include:

• Vegans and vegetarians who do not eat dairy or eggs, since vitamin B12 is found only in animal products
• People with problems absorbing nutrients due to Crohn's disease, pancreatic disease, weight loss surgery, or medications
• People who are infected with Helicobacter pylori, an organism in the intestines that can cause an ulcer. H. Pylori damages stomach cells that make intrinsic factor, a substance the body needs to absorb B12
• People with an eating disorder
• People with HIV
• People with diabetes
• The elderly

Folic acid (vitamin B9), especially when taken in high doses, can mask the symptoms of a vitamin B12 deficiency. The danger is that without symptoms, someone with a vitamin B12 deficiency may not know it, and could run the risk of developing nerve damage. You should talk to your doctor first if you plan to take more than 800 mcg of folic acid, to make sure you do not have a B12 deficiency.

Other good information can be found in this blog of mine:

http://bobsdiabetes.blogspot.com/2012/12/nutrients-vitamin-b12.html

Metformin Has Link to Neuropathy, B12 Deficiency

Called me puzzled! I have never understood why the American Diabetes Association had never called for testing of vitamin B12 deficiency for people taking metformin for any length of time. Even this article shows a lack of this testing and only calls for more research. This is why I am reversing the situation and listing what Diabetes-in-Control lists as practice pearls first.

Practice Pearls:

1. Metformin has been linked with vitamin B12 deficiency.
2. A randomized placebo-controlled trial showed that metformin use is associated with an increase in neuropathy scores for patients.
3. Current guidelines do not offer specific instructions on metformin and B12 deficiency, but future research is warranted.

Yes, one of the most common and beneficial T2DM drugs may contribute to neuropathy and vitamin deficiency – metformin.

The link between metformin and vitamin B12 lowering is well-known and mentioned in American Diabetes Association guidelines as a disadvantage of the drug. However, the ADA gives no recommendations for monitoring and prevention of vitamin B12 deficiency for patients taking metformin. Vitamin B12 deficiency is associated with adverse effects such as anemia, fatigue, mental status changes, and neuropathy. Given the prevalence of neuropathy in diabetic patients, metformin-induced vitamin B12 deficiency is clinically relevant.

The relationship between vitamin B12 deficiency and metformin was studied in a recent randomized placebo-controlled trial. The trial lasted 52 months and included 390 type 2 diabetes patients. They were treated with 850 mg metformin at doses up to three times a day or a placebo. Patients with baseline vitamin B12 deficiency or patients taking vitamin B12 supplements were excluded from the trial.

Metformin is prescribed around the world, so this relationship warrants more investigation according to the study authors. Future studies may clarify the relationship and will help the authors of guidelines decide whether to recommend testing or supplementation.

More on Importance of Vitamins B12 and D3

This topic is still being debated and I have had several of our new members on metformin say they don't believe they have a vitamin B12 problem. Of the seven new members that are using the VA, only two are on metformin and the rest are using insulin. On Thursday of last week, two members, Julie and Earl received their lab results and both were prescribed vitamin B12. Both have been on metformin for almost seven years. This was the reason for a few of us meeting at the restaurant to discuss what they had learned. Brenda, Allen, and I were there plus the two mentioned above.

When asked, Julie said her results were severe and she had received a shot and needed to see her primary care doctor for a second shot. Earl said he was low and the VA doctor had advised him to start on vitamin B12 immediately. Allen asked Julie if she was experiencing pain in her in her feet. She would not answer and Brenda told her that she could not hide this as Allen had been through this and we know what happens with severe vitamin B12 deficiency. She finally admitted that she was having pain in her feet and Allen said it was diabetic neuropathy. Earl said he was beginning to have minor pain in a couple of toes. Allen said that the quicker he worked to maximize his blood glucose management, the quicker the pain would possibly go away, and taking vitamin B12 is part of his diabetes management.

Brenda said this would be added to the program for January 10. Allen said good, as too many have been saying that they are having pain and will not let the doctor test them for vitamin B12 deficiency. Brenda said she has been hearing the same and she has been wondering why people will not do what is right.

Brenda then asked Allen and me if it would be correct to ask for a show of hands on how many had been tested for vitamin B12. I said the question needs to be asked and the other question that should be asked first is if anyone has a burning sensation in their feet or something that feels like a thousand pins sticking them. Allen agreed and said to ask the second question first and many will not associate their neuropathy with vitamin B12 deficiency. Then we will know who needs to be tested.

I then asked both Julie and Earl what their vitamin D results were. Both answered within the range, but at the low end of the range and that their doctor had advised taking a vitamin D3 supplement. I turned to Brenda and said this is another problem area everyone needs to be aware of and consider taking vitamin D3, not vitamin D2. Brenda said I remember you blogging about this and if you would send me the URL, I will review it and decide if we should use a slide.

Allen said that he was planning to present this to Brenda, but now that we had another experience with a member and she was in on it, she knew what needed to be included. Brenda said it would be nice to have Dr. Tom available, but she understood his needing to spend less time with our group. Allen said this may be a good thing and cause us to think more for ourselves as we did before.

We agreed and said things were right for the interventions and a few other things when we needed Dr. Tom, but now we needed to be on our own and work to help our members.

Joint January Meeting

Our January meeting started with Dr. Tom (previously shown as our local doctor) addressing both groups. First, he thanked our group for the impromptu meeting earlier and expressed his thanks to Sue for bringing her relative to be tested and having her depression brought under control without the need for depression drugs. He then turned to his group and told them that thanks to this group including you, many of you will now be tested for different vitamin and mineral deficiencies that would not otherwise be considered deficient.

Next, he explained that the last few months had been intensive and he thanked us for the research we do and to his group, he asked if any of them might be interested in research. Only one person expressed any desire and he was asked to meet with us after the meeting was over.

Tim had been setting up the projector for this Oregon State University website. Dr. Tom said he wanted to start with vitamin B12 and the foods area first within B12. When Tim scrolled to Food Sources, Dr. Tom took time to read it aloud and then emphasized how important the last sentence in the first paragraph should be to everyone. It says, “Individuals over the age of 50 should obtain their vitamin B12 in supplements or fortified foods like fortified cereal because of the increased likelihood of food-bound vitamin B12 malabsorption.”

Then Tim brought up the University of Maryland Medical Center website and scrolled down to the Dietary Sources, which reads, “Vitamin B12 is found only in animal foods. Good dietary sources include fish, shellfish, dairy products, organ meats -- particularly liver and kidney-- eggs, beef, and pork.” Dr. Tom said he understands people that do not like organ meats, as they are not his favorites either. He thanked Tim for doing this as he felt both sources were important. Tim stated that both URLs would be included in the email sent about the meeting.

Dr. Tom then explained that for anyone over the age of 50 that might have fatigue or other problems discussed on either site should not be afraid to ask for the test to determine if they might have a deficiency. He would do the test and felt it was important for people to consider before doing anything about supplements. Then he emphasized that this was important for their doctor to know because of the medication conflicts between vitamin B12 and certain prescription medications, as shown at the bottom of my blog..

After some discussion, Dr. Tom called attention to the Age-Related Macular Degeneration section and told people to read this on both sites. Then he introduced the ophthalmologist and said he would talk about vision and some of the common problems for people with diabetes.

The eye doctor thanked Dr. Tom and then thanked me for inviting him to speak about problems for diabetes affecting eyesight. He explained that I had provided him with my blog on vision and the related websites and this helped explain much of what he would be covering. Next he asked if everyone had diabetes or pre-diabetes. All hands went up and he asked how many had their eyes checked within the last year. Only 16 kept their hands up. He asked if there were some that had eye exam in the last two years – only two.

Then he addressed the seven that had not raised their hands asking how many of them were on Medicare and four raised their hand. He then stated that the American Diabetes Association guidelines stated that two years was now the recommended time between appointments. He said this is not good and you should see your eye doctor for a dilated eye examination at least annually if you are over 50 years of age and annually if certain conditions exist before age 50. With some eye problems, an exam every six months is recommended.

He then asked Tim to start the slides, which showed the eye, and he pointed out what he would be able to see in a dilated eye exam. Some of the slides showed what age-related macular degeneration (AMD) looked like. Then he moved on to cataracts and had several slides showing different aspects of their development. Then he had slides showing what glaucoma looked like. He then concluded with retinopathy and how this looked in the eye exam.

He concluded that of those present, that were his patients, none had retinopathy, several had early stages of cataracts, two were being treated for AMD, and only one had early glaucoma. He then had Tim show the last three slides, which showed advanced glaucoma, cataracts, and AMD. Anyone with these stages can be diagnosed as legally blind. The good news is by discovering them early; treatment can prevent this from happening or delay the serious problem of blindness.

He concluded by saying everyone over the age of 50 should have a dilated eye exam on an annual basis if they have diabetes. Medicare does cover most of the cost and will pay for most treatments. He finished that his office will work with people that are not covered by insurance and do their best for them in getting them help. Discussion and questions followed and he took a few people aside to talk privately with them. The meeting ended and the Dr. Tom asked several of us to talk with the one interested in doing research.

The eye doctor asked if I would be writing more blogs on the eye diseases and I said I was thinking seriously about this. Since he has my address and email address he asked which format I would prefer. I said email if he didn't mind. He indicated that he had several URLs that he would send me and if I could use them he would send several images as well. We agreed and the meeting was over.

Being Asked to Speak to Another Group

The weekend after our meeting with the doctor, a group from another town about 20 miles distant, asked Tim and I to speak to them on insulin. Because of the doctor involved, we decided not to accept. We had a suspicion of what may have been behind this and as such, I was thankful I already had another commitment. Tim said he agreed with me and agreed we should not become involved in this since this doctor had the reputation of not wanting his patients on oral medications to test.

Tim sent the regrets explaining that I had a commitment and he would not do this by himself. Tim called me the next day saying something that was a total surprise. This doctor was asking for our help on insulin and testing for all patients with diabetes. He was realizing that he was in the wrong and felt that since our group was having so much success and had in fact converted several of his patients to testing, that he needed to learn about us and to get his patients started in testing. Tim added that he felt we should accept the challenge. I stated that I was committed to my meeting and that he should talk to the local doctor and maybe he could attend with him. I said that maybe Allen should go as well.

The following day, Tim called again to say the local doctor had called this doctor and said that he could come if allowed along with Allen and Tim. Tim said the doctor was happy with this and that yes, he wanted this very much. I said this was great. I then explained my commitment of a late afternoon medical appointment and a speaking engagement in the same town to a diabetes group that had been scheduled a month ago. Tim said this sounds good as three of us were involved in spreading the word. I suggested to Tim that Allen should raise the issue of vitamin and mineral testing on their way there so that if necessary, they could sound out the doctor before the meeting about raising this in the meeting as well. Tim said they would be traveling in the same car and he felt this was worth exploring. I said good, and that we should have a meeting the day following to cover both meetings and learn from each other. Tim agreed and asked about including the doctor and I thought why not and told Tim to explore this.

So the day following our meetings, we met after hours at the doctor's office and had a good discussion. This doctor had forgot there were three groups in our town and the size of the groups. The third group was now at six members and hoping to add more members. The group the local doctor led was now at 10 members and he felt that would be more in the coming months. The group that I had spoken to was 18 members attending and they were hoping to grow. The two doctors leading this group were confident the number would grow. Tim stated that the group they had met with was 9 members and that they were shocked that there were so many groups. The doctor commented that this doctor realized that his diabetes patients were being spread out in different groups and knew he was being called out about not testing. He just did not have the knowledge he should about diabetes. At first, he was angry at what was happening. Then he realized that it was him causing his own problem and he needed to learn.

The doctor from our town said this was good for several reasons. He continued that we were being asked to speak for the next several months and now that this doctor was aware of my blog, he wanted me to speak about that. Allen said he had been asked by several of the people there if I was for real and a few had read some of my blogs, but wanted to know if I meant what I was saying. Allen was happy to say that he was the one I had written about in the testing for B12 and Vitamin D and yes, I was interested in people and helping to educate people about diabetes.

The doctor had discussed vitamin and mineral testing with this doctor before hand and had given Allen permission to bring up the topic. He knew there were tests, but had not taken them seriously, so he would also need to learn more about them. The doctor with us said he will be working with this doctor over the next few months until he can get to some continuing education courses and felt that this was a step in the right direction. We all agreed and Tim said he was surprised that this doctor was actually transferring a few patients to our town that needed insulin. The local doctor confirmed this and said there was too much for him to learn for the patients he had and had asked if this would be possible.

This was why the doctor wanted us back for more talks to his group since we knew insulin and this might help make the transition for these patients easier. I commented that none of us were patients of his.  Our local doctor admitted to having only a couple type 2 patients on insulin, but he would look to us for assistance. I suggested that since the three of us all were at the same diabetes clinic, maybe he could talk to them as well. I pulled out the card I had and photocopied it for him. He looked at it and said thank you, as he was not aware of the clinic being so close. He knew of the one in another larger city south of us, but not this one. He then said that he recognized the doctor's name, but did not realize where he was practicing.

He said he had the permission to refer the patients to our group for education if we were willing. After a short discussion about location, he said he would rather use video and have them learn this mode so they could email us when they had questions and use video if needed at any time. We agreed that would work for us and I explained I was already doing this for several doctors in other states. The doctor wanted to learn more and asked if I would email the contact information so that he could check how this was working. When I said yes, he handed me a card of his with an email address on it. He explained that was the office email address and for this purpose only. Then he added his home email address and said this was the one Tim had. I said I also do some peer-to-peer work for the doctor on the card and he said good. That would give him a good reason to call him and asked other questions.

Then he surprised all three of us and thanked us for our being up front in our recent conversation. He had approached us with other motives and when we had been up front with him, he realized that we were more interested in education than taking patients from doctors. He as very appreciative in being asked to go to the other doctor and felt this was a real help in getting this doctor on the right path. He said this proved to him that we wanted to help more that hurt those doctors that were not as knowledgeable about diabetes. He said that talking about the diversity of topics that Allen and Tim had covered during the meeting even showed that doctor you were more interested in education than pushing patients away from him.

Allen then asked if he knew the doctor he named. He said yes and was there a problem. Allen said this was the doctor he had left because he would not test him for vitamin and mineral shortages. That if it had not been for Tim and I taking him to see their doctor and the tests proving he needed shots and vitamin and mineral supplements, he might not be alive today. The doctor said he would get this corrected if possible, but it may not be easy. He asked us if this is what we do when a doctor does not step up when asked. Allen said yes, and he had not planned to leave this doctor, but when the test were done and he was asked to surrender his license because he was severely deficient in Vitamin B12 and D, he knew that it was severe. He had not liked having his license taken, but after considering the alternative of having to surrender it to the state, and then having so much on record, he said that that made him feel better. He stated that when his levels were normal they had given his license back and that made him feel even better about it. Allen said that our aggressive nature after the doctor refused to do the tests probably saved his life and for that, he was grateful.

The doctor looked at us and said that you normally give the doctor the opportunity to make the mistake first. I said that the doctor they were now working with had a reputation and it was the pharmacist that sent them to another doctor. He said either way, we are not trying to divert patients away without cause, and we all said yes. He then said we could consult any time with him and if we had a doctor that refused to step up, to bring the patient to him and he would see that they were taken care of and what needed to be done. If we were correct in our thinking like we seemed to be, then he would attempt to get the situation corrected. He said even if this meant loosing a friend and colleague which he then told Allen that the doctor was that he had left. He said that yes, he was aware of his position on vitamins and minerals, but for him to let someone on metformin become that deficient was inexcusable and he agreed with our actions.

We concluded and went our way home. Yes, several emails followed, but we wanted to think more about what had transpired.

Nutrients - Vitamin B12

Vitamin B12

Overview

All B vitamins are water-soluble, meaning that the body does not store them. Vitamin B12, also called cobalamin, is one of 8 B vitamins. It is important to know that all B vitamins help the body convert food (carbohydrates) into fuel (glucose), which is used to produce energy. These B vitamins, commonly referred to as B complex vitamins, also help the body use fats and protein. B complex vitamins are also used for healthy skin, hair, eyes, and liver. They help the nervous system function properly.

Vitamin B12 is an especially important vitamin for maintaining healthy nerve cells, and it helps in the production of DNA and RNA, the body's genetic material. Vitamin B12 also works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body. Folate and B12 work together to produce S-adenosylmethionine (SAMe), a compound involved in immune function and mood.

Vitamins B12, B6, and B9 work together to control blood levels of the amino acid homocysteine. High levels of homocysteine are associated with heart disease. However, researchers aren't sure whether homocysteine is a cause of heart disease or just a marker that indicates someone may have heart disease.

It' s rare for young people to be deficient in vitamin B12, but it' s not uncommon for older people to be mildly deficient. That may be because their diets are not as healthy or because they have less stomach acid, which the body needs to absorb B12. Low levels of B12 can cause a range of symptoms including fatigue, shortness of breath, diarrhea, nervousness, numbness, or tingling sensation in the fingers and toes. Severe deficiency of B12 causes nerve damage.

Others at risk for B12 deficiency include:

1. Vegans, vegetarians who also don't eat dairy or eggs -- vitamin B12 is found only in animal products

2. People with problems absorbing nutrients, due to conditions such as Crohn's disease, pancreatic disease, and people who have had weight loss surgery

3. People who are infected with Helicobacter pylori, an organism in the intestines that can cause an ulcer. H. pylori damages stomach cells that make intrinsic factor, a substance the body needs to absorb B12

4. People with an eating disorder

5. People with HIV

6. The elderly

Folic acid (vitamin B9), especially when taken in high doses, can mask the symptoms of a vitamin B12 deficiency. The danger is that without symptoms, someone with a vitamin B12 deficiency may not know it, and could run the risk of developing nerve damage. Anyone planning to take more than 800 mcg of folic acid should talk to their doctor first, to make sure they do not have a B12 deficiency.

Vitamin B12
Vitamin B12 is bound to protein in food. The activity of hydrochloric acid and gastric protease in the stomach releases vitamin B12 from its protein.  Once it is released, vitamin B12 begins to work quickly. It is important for the formation of red blood cells, neurological function, and DNA synthesis. It also supports the digestive system in keeping glucose levels stable.

A simple blood test can determine the level of B12 in the body. Adults who have a value below 170 to 250 pg/ml are considered deficient in the vitamin. An elevated blood homocysteine level or elevated methylmalconic acid level may also suggest a B12 deficiency.

Tests

Vitamin B12 and folate are ordered to detect deficiencies and to help diagnose the cause of certain anemias. One type of associated anemia is pernicious anemia, an autoimmune disease that affects the absorption of B12. This megaloblastic anemia occurs when the body produces antibodies against the gastric parietal cells or the intrinsic factor, resulting in B12 malabsorption.

Folate, B12, and an assortment of other tests may be ordered to help evaluate the general health and nutritional status of a person with signs of significant malnutrition or dietary malabsorption. This may include people with alcoholism, other liver diseases, gastric cancer, and those with malabsorption conditions such as celiac disease, tropical sprue, Crohn’s disease, inflammatory bowel disease, and cystic fibrosis.

B12 and folate may also be ordered to aid in diagnosis when an individual presents with an altered mental state or other behavioral changes, especially in the elderly. B12 may be ordered with folate, by itself, or with other screening laboratory tests (antinuclear antibody, CRP, rheumatoid factor, CBC and chemistry blood tests) to help establish reasons why a person shows symptoms of neuropathy.

In those treated for known B12 and folate deficiencies, these tests will be ordered occasionally to monitor the effectiveness of treatment. This is especially true in those who cannot properly absorb B12 and/or folate and must have lifelong treatment.

Recommended Daily Allowance

If you are considering taking a B12 supplement, ask your health care provider to help you determine the right dose for you.

Daily recommendations for dietary vitamin B12 are listed below.

Pediatric

 Newborns - 6 months: 0.4 mcg (adequate intake)

 Infants 6 months - 1 year: 0.5 mcg (adequate intake)

 Children 1 - 3 years: 0.9 mcg (RDA)

 Children 4 - 8 years: 1.2 mcg (RDA)

 Children 9 - 13 years: 1.8 mcg (RDA)

 Teens 14 - 18 years: 2.4 mcg (RDA)

Adult

 19 years and older: 2.4 mcg (RDA)*

 Pregnant women: 2.6 mcg (RDA)

 Breastfeeding women: 2.8 mcg (RDA)

*Because 10 - 30% of older people may not absorb B12 from food very well, people over 50 should meet their daily requirement through either foods fortified with vitamin B12 or a supplement containing B12.

Cautions

If the B12 deficiency is not remedied, permanent nerve damage can occur. Neuropathy is a common problem for people with diabetes, who experience pain, tingling, and numbness in their arms, hands, legs, and feet, resulting in sores.

Vitamin B12 is an especially important vitamin for maintaining healthy nerve cells, and it helps in the production of DNA and RNA, the body's genetic material. Vitamin B12 also works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body.

Food Sources

Vitamin B12 is found only in animal foods. Liver, sardines, and salmon rank highest, with liver running away with it. Kidney, eggs, beef, and pork are also good sources. There are no vegetarian sources. Supplements include - Methylcobalamin is probably the best.

Precautions

One large study found that women who took 1,000 mcg of vitamin B12 along with 2500 mcg of folic acid and 500 mg of vitamin B6 daily reduced their risk of developing AMD, an eye disease that can cause loss of vision.

Fatigue is one of the symptoms of a vitamin B12 deficiency. One preliminary study indicated that people with chronic fatigue syndrome might benefit from B12 injections, although more research is needed to know for sure.

Although there is no evidence that vitamin B12 alone reduces the risk of breast cancer, population studies have shown that women who get more folate in their diet have lower risk of breast cancer. Vitamin B12 works with folate in the body, so it may help contribute to a lesser risk. Another preliminary study suggested that postmenopausal women who had the lowest amounts of B12 in their diet had an increased risk for breast cancer.

Studies suggest that vitamin B12 supplements may improve sperm counts and sperm mobility. However, the studies were of poor quality. Better studies are needed to see whether B12 has any real effect.

Possible Interactions

If you are currently being treated with any of the following medications, you should not use vitamin B12 supplements without first talking to your health care provider.

Medications that reduce levels of B12 in the body include:

Anti-seizure medications -- including phenytoin (Dilantin), phenobarbital, primidone (Mysoline)

Chemotherapy medications -- particularly methotrexate

Colchicine -- used to treat gout

Bile acid sequestrants -- used to lower cholesterol; include colestipol (Colestid), cholestyramine (Questran), and colsevelam (Welchol)

H2 blockers -- used to reduce stomach acid; include cimetidine (Tagamet), famotidine (Pepcid AC), ranitidine (Zantac)

Metformin (Glucophage) -- medication taken for diabetes

Proton pump inhibitors -- used to reduce stomach acid; include esomeprazole (Nexium), lansprazole (Prevacid), omeprazole (Prilosec), and rabeprazole (Aciphex)

Antibiotics, Tetracycline -- Vitamin B12 should not be taken at the same time as tetracycline because it interferes with the absorption and effectiveness of this medication. Vitamin B12 should be taken at different times of the day from tetracycline. All vitamin B complex supplements act in this way and should be taken at different times from tetracycline. In addition, long-term use of antibiotics can lower vitamin B levels in the body, particularly B2, B9, B12, and vitamin H (biotin), which is considered part of the B complex vitamins.

Introduction to Series on Vitamins and Minerals

Many of us are deficient in certain nutrients and our doctors do not or will not test us for deficiencies as we age. Some of us do have sufficient quantities in our diets and then take supplements, which may give us an oversupply. I will give the name of the test when it is available. Your doctor should test for all of these (that have testing available) before you run out and buy supplements. You may not need them because you are already obtaining sufficient intake from your diet. If you have a doctor that will not test because you should be eating foods with sufficient nutrients, then you will have a decision to make about retaining your current doctor.

I realize that many of you may be aware of them, but it never hurts to review them. In the coming blogs I will cover iodine, selenium, choline, manganese, magnesium, potassium, Vitamin D, Vitamin K, and Vitamin B12. These may not be what you would think is needed for those of us with diabetes; however, they are still important. If you would like more detailed information, please read the links supplied with each blog as there may be several links. Some are water-soluble and others are fat-soluble. Vitamin D is neither as it is correctly a hormone. This will not change because of acceptance.

I would be remiss if I did not give you a warning about not overcompensating and ingesting too much of some of these nutrients as there are some medical concerns with toxicity and conflicts with certain prescription medications. More is often not better and can be fatal with some supplements. I will give warnings where they apply.

When there is a list of foods that may give you sufficient supply of a nutrient, they will be listed.

Since most of these vitamins and minerals have recommended daily allowances (RDAs) that vary by age, the entire table will be given. Some sources list only the adult RDAs and I prefer to give you the full list.

Please refer back to this blog if you question something and I will update this blog with each blog as I publish it. Some of my blogs will refer to my other blogs, as the nutrients can be essential for the same thing. Example - iodine and selenium both are essential for the thyroid gland to work properly. There may be others, but as of yet, I am not into research for each of them. I had intended to put two or three nutrients in a single blog, but with all that I am discovering, this would make the blog too long and essential points less obvious.

Iodine

Selenium

Choline

Manganese

Magnesium

Potassium

Vitamin D

Vitamin K

Vitamin B12

Metformin and B12 Deficiency

This is something my endocrinologist tests for and tells patients taking Metformin to take a Vitamin B12 supplement. Yet there are many doctors that do not tell their patients to add Vitamin B12 to their supplement regimen. One of the members of our group (Allen) is taking Metformin and was surprised when we told him to take Vitamin B12. After his last appointment, he said his doctor told him not to be taking supplements and said there was no reason to be on supplements if he was eating the right foods.

We decided to use this blog to discuss this with Allen. After reading this and following the links, he was still hesitant to go against his doctor. We did take time to explain that doctor or not, Metformin would cause the Vitamin B12 deficiency and that he should add this to his regimen. He did state that he had been on Metformin for almost eight years and we suggested strongly that he have the test to determine the level of B12. A call to his regular doctor confirmed that they would not do the test. We then suggested he go to the doctor that I see and he agreed

I was able to get him in the following day and went with him. After a quick talk with the doctor, he wanted to do several tests that his doctor was not doing. We waited for the lab to be available and he had a blood draw. Next, we sat for about 20 minutes and Allen asked if they will have the results that quickly. I said this was normal and depending on the tests ordered, he should receive most of them in another 10 to 15 minutes. He did ask me to accompany him when he saw the doctor and I agreed.

After updating and reviewing his medications, the nurse left and the doctor came in. He sat down, asked a couple of questions about allergies, and said he was going to get two shots. The first shot would be a Vitamin B12 injection. Then he surprised both of us by saying he would also have a large dose injection of Vitamin D. I stepped out for a few minutes and then was invited back in.

Allen was asking why the two shots. The doctor said that his Vitamin B12 was very low and required another test already ordered from the blood sample. The Vitamin D level was below minimum guidelines and he was given the shot just to prevent something that the doctor feared might happen. He did not say what it was, but for three days, Allen would need to return for the two shots. Or he said he could be admitted to the hospital. Allen said he could drive back and forth and the doctor said no driving until after two weeks or the tests were at or above minimum guidelines.

Then the doctor said he was also prescribing both B12 and D3 for him to start on the fifth day. He was to return in seven days for another round to tests and then in 14 days for repeat of tests to see if he could then drive. We asked why and he would only say that he was the first person they had seen with deficiencies that low and he and the head of the department did not want him to drive. He then asked for his license stating he could surrender it temporarily to them, or possibly a lot longer to the highway patrol. Allen looked at me and gave it up.

The doctor did say that the remainder of the tests would be available the next day and the head of the department was requesting two additional tests that would also be available. On the way home with me driving, Allen was somewhat surprised at the thoroughness and was wondering if he should consider changing doctors. I did suggest that he wait until the two weeks were done and see what he thought then. He agreed, but commented this had raised some serious issues in his mind and I had to agree.

Allen wanted to meet with Tim when we returned so he called him and Tim was there when we arrived. Tim was surprised at what had transpired, but agreed with the tests and asked if he was needed to drive. I said yes, to get me home, and for at least one or two trips. Allen asked about their taking his drivers license, and Tim said no, it was probably not legal, but that it was preferable to giving it up to the highway patrol where it would become part of his records, and that they could enforce it longer. Tim asked about which doctor he would keep and I said that Allen should not make a decision until at least this was done. Tim said that was probably best, but should be seriously considered. I agreed and said this should be discussed along with other possibilities.

Allen did want some reading and Tim said he would stop back after he took me home. We did discuss some reading and search words for him to leave Allen. Tim said he would take Allen the next day and we could alternate. I said that would work, but we should let Allen decide if he had preferences. Tim said he would, but that he could not go every time.

The next day, Allen asked me to come by when he returned home. So with Tim and me present, Allen asked what was he to do. He had all the test results now and he was really frightened. All the tests had been out of range on the low to extreme low side and the doctor had suggested he see another doctor for more tests. I agreed with Tim when he said that he should see the second doctor and get his health checked out. Tim did state that it was time to decide on making a change in doctors. He said he felt from what had been discussed today, that Allen was being given a second chance and he should take full advantage of it by switching doctors now and having his records transferred.

I could see some fear in Allen, so I asked him when his VA appointment would be. He said in about five months and I said that would be good. Therefore, if he ended up with some expensive medications and the VA had them or ones in the same drug family, the doctors would synchronize with the VA and he would be ready. I could see Allen relax visibly and he asked if the doctors would work with the VA? I said not the way he was thinking, but that he would give the doctors the name of his VA doctor and they would send a fax or call them with what they were suggesting for medications and see if the VA could get them started coming to him. The doctors would also forward copies of the tests and the reasons for the drug request.

Tim did say that the doctor had suggested that with his A1c and creatinine level that Allen should consider changing oral medications or start on insulin. He also said he would make a referral to the endocrinologist. Allen did say he would like to stay on oral medications if possible, but he was going to pay more attention to our discussions about insulins and not leave it as a medication of last resort. We said that was okay. I suggested that he should ask for the test for determining how much insulin he was still producing before he made that decision. Tim said that was another test they had done and his own insulin production was still okay, but on the low side. He said to Allen that just the fact he wanted to learn about insulin was a good sign and would make him ready when the change was right.

The following two days I drove Allen and we had some interesting discussions about the different oral medications and insulin. He did say that since the doctor had given him some time to read about the different oral medications and their side effects, he was thinking seriously about insulin. I did suggest that he ask which oral medications they would be recommending and Allen said that would give him a better idea instead of learning about all the oral medications.

One the fourth day, Allen said doctor (after conferring with the endocrinologist) would have a recommendation for him when he came in for the blood draw the following Tuesday, and that he should seriously consider insulin. So we asked several others to meet with us on Saturday and we would research and discuss oral medications in more detail and insulin. Even Brenda asked to be included so we would be only short one person as Sue had another commitment.