Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature

A Corrigendum to this article was published on 06 July 2016

Abstract

Individuals following vegetarian diets are at risk for developing vitamin B12 deficiency owing to suboptimal intake. As vitamin B12 is essential for the synthesis of nucleic acids, erythrocytes and in the maintenance of myelin, deficiency may result in a variety of symptoms. Some of these symptoms may be severe while others may be irreversible. The objective of this review was to assess vitamin B12 deficiency, based on reported serum vitamin B12, among individuals adhering to different types of vegetarian diets. A systematic literature search was carried out using multiple search engines including PubMed, Medline, CINAHL plus, ERIC, Nursing and Allied Health Collection and Nursing/Academic Edition. The inclusion criteria consisted of original studies that assessed serum vitamin B12, studies written in English, non-case studies and studies that reported actual percentages of vitamin B12 deficiency. Forty research studies were included. The deficiency prevalence among infants reached 45%. The deficiency among the children and adolescents ranged from 0 to 33.3%. Deficiency among pregnant women ranged from 17 to 39%, dependent on the trimester. Adults and elderly individuals had a deficiency range of 0–86.5%. Higher deficiency prevalence was reported in vegans than in other vegetarians. Thus, with few exceptions, the reviewed studies documented relatively high deficiency prevalence among vegetarians. Vegans who do not ingest vitamin B12 supplements were found to be at especially high risk. Vegetarians, especially vegans, should give strong consideration to the use of vitamin B12 supplements to ensure adequate vitamin B12 intake. Vegetarians, regardless of the type of vegetarian diet they adhere to, should be screened for vitamin B12 deficiency.

This is a preview of subscription content

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

All prices are NET prices.

References

  1. National Institute of Health NIH Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin B12. Available at: http://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/. Accessed on 15 November 2013.

  2. Institute of Medicine. Food and Nutrition Board Dietary Reference Intakes: Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC, USA: National Academy Press, 1998.

  3. Craig WJ . Nutrition concerns and health effects of vegetarian diets. Nutr Clin Pract 2010; 25: 613–620.

    Article  Google Scholar 

  4. Elmadfa I, Singer I . Vitamin B-12 and homocysteine statues among vegetarians: a global perspective. Am J Clin Nutr 2009; 89: 1693s–1698s.

    CAS  Article  Google Scholar 

  5. Herrmann W, Obeid R . Causes and early diagnosis of vitamin B12 deficiency. Dtsch Arztebl Int 2008; 105: 680–685.

    PubMed  PubMed Central  Google Scholar 

  6. Escott-Stump S . Nutrition and Diagnosis-Related Care. Baltimore, MD, USA: Lippincott Williams & Wilkins, 2008.

    Google Scholar 

  7. Pawlak R, James PS, Raj S, Cullum-Dugan D, Lucus D . How prevalent is vitamin B12 deficiency among vegetarians? Nutr Rev 2013; 71: 110–117.

    Article  Google Scholar 

  8. Gammon CS, vonHurst PR, Coad J, Kruger R, Stonehouse W . Vegetarianism, vitamin B12 status, and insulin resistance in a group of predominately overweight/obese South Asian women. Nutr 2012; 28: 20–24.

    CAS  Article  Google Scholar 

  9. Gilsing AMJ, Crowe FL, Lloyd-Wright Z, Sanders TA, Appleby PN, Allen NE et al. Serum concentrations of vitamin B12 and folate in British male omnivores, vegetarians, and vegans: results from a cross-sectional analysis of the EPIC-Oxford cohort study. Eur J Clin Nutr 2010; 64: 933–939.

    CAS  Article  Google Scholar 

  10. 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: 229–234.

    CAS  Article  Google Scholar 

  11. Lowik MRH, Schrijver J, Odink J, van den Berg H, Wedel M . Long-term effects of a vegetarian diet on the nutritional status of elderly people (Dutch Nutrition Surveillance System). J Am Coll Nutr 1990; 9: 600–609.

    CAS  Article  Google Scholar 

  12. Bar-Sella P, Rakover Y, Ratner D . Vitamin B12 and folate levels in long-term vegans. Isr J Med Sci 1990; 26: 309–312.

    CAS  PubMed  Google Scholar 

  13. Pongstaporn W, Bunyaratavej A . Hematological parameters, ferritin and vitamin B12 in vegetarians. J Med Assoc Thai 1999; 82: 304–310.

    CAS  PubMed  Google Scholar 

  14. Leung SSF, Lee RHY, Sung RYT, Luo HY, Kam CW, Yuen MP et al. Growth and nutrition of Chinese vegetarian children in Hong Kong. J Paediatr 2001; 37: 247–253.

    CAS  Google Scholar 

  15. Gupta AK, Damji A, Uppaluri A . Vitamin B12 deficiency—prevalence among South Asians at a Toronto clinic. Can Fam Physician 2004; 50: 743–747.

    PubMed  PubMed Central  Google Scholar 

  16. Barghouti FF, Younes NA, Halaseh LJ, Said TT, Ghraiz SM . High frequency of low serum levels of vitamin B12 among patients attending Jordan University Hospital. East Mediterr Health J 2009; 15: 853–860.

    CAS  Article  Google Scholar 

  17. Krajcovicova-Kudlackova M, Blazicek P, Mislanova C et al. Nutritional determinants of plasma homocysteine. Bratisl Lek Listy 2007; 108: 510–515.

    CAS  PubMed  Google Scholar 

  18. Yajnik CS, Deshpande SS, Lubree HG, Naik SS, Bhat DS, Uradey BS et al. Vitamin B12 deficiency and hyperhomocysteinemia in rural and urban Indians. J Assoc Physicians India 2006; 54: 775–782.

    CAS  PubMed  Google Scholar 

  19. Morad M, Gringols M, Kandel I, Valachovicova M, Paukova V, Spustova V . Vitamin B12 deficiency in persons with intellectual disability in a vegetarian residential care community. Scientific World J. 2005; 5: 58–61.

    Article  Google Scholar 

  20. Madry E, Lisowska A, Grebowiec P, Walkowiak J . The impact of vegan diet on B-12 status in healthy omnivores: five-year prospective study. Acta Sci Pol Technol Aliment 2012; 11: 209–213.

    PubMed  Google Scholar 

  21. Lee Y, Krawinkel M . The nutritional status of iron, folate, and vitamin B-12 of Buddhist vegetarians. Asia Pac J Clin Nutr 2011; 20: 42–49.

    CAS  PubMed  Google Scholar 

  22. Yen CE, Yen CH, Cheng CH, Huang YC . Vitamin B-12 status is not associated with plasma homocysteine in parents and their preschool children: lacto-ovo, lacto, and ovo vegetarians and omnivores. J Am Coll Nutr 2010; 29: 7–13.

    CAS  Article  Google Scholar 

  23. Majchrzak D, Singer I, Manner M, Rust P, Genser D, Wagner KH et al. B-vitamin status and concentrations of homocysteine in Austrian omnivores, vegetarians and vegans. Ann Nutr Metab 2006; 50: 485–491.

    CAS  Article  Google Scholar 

  24. Karabudak E, Kiziltan G, Cigerim N . A comparison of some of the cardiovascular risk factor in vegetarian and omnivorous Turkish females. J Hum Nutr Diet 2008; 21: 13–22.

    CAS  Article  Google Scholar 

  25. Rush EC, Chhichha P, Hinckon E, Nabiryo C . Dietary patterns and vitamin B12 status of migrant Indian preadolescent girls. Eur J Clin Nutr 2009; 63: 585–587.

    CAS  Article  Google Scholar 

  26. Waldmann A, Koschizke JW, Leitzmann C, Hahn A . German vegan study: diet, life-style factors, and cardiovascular risk profile. Ann Nutr Metab 2005; 49: 366–372.

    CAS  Article  Google Scholar 

  27. Koebnick C, Hoffmann I, Dagnelie PC, Heins UA, Wickramasinghe SN, Ratnayaka ID et al. Long-term ovo-lacto vegetarian diet impairs vitamin B-12 status in pregnant women. J Nutr 2004; 134: 3319–3326.

    CAS  Article  Google Scholar 

  28. Waldmann A, Koschizke JW, Leitzman C, Hahn A . Homocysteine and cobalamin status in German vegans. Public Health Nutr 2004; 7: 467–472.

    Article  Google Scholar 

  29. Herrmann W, Schorr H, Obeid R, Geisel J . Vitamin B-12 status, particularly holotranscobalamin II and methylmalonic acid concentrations, and hyperhomocysteinemia in vegetarians. Am J Clin Nutr 2003; 78: 131–136.

    CAS  Article  Google Scholar 

  30. Carmel R, Mallidi PV, Vinarskiy S, Brar S, Frouhar Z . Hyperhomocysteinemia and cobalamin deficiency in young Asian Indians in the United States. Am J Hematol 2002; 70: 107–114.

    CAS  Article  Google Scholar 

  31. Larsson C, Johansson G . Dietary intake and nutritional status of young vegans and omnivores in Sweden. Am J Clin Nutr 2002; 76: 100–106.

    CAS  Article  Google Scholar 

  32. Bissoli L, Di Francesco V, Ballarin A, Mandragona R, Trespidi R, Brocco G et al. Effect of vegetarian diet on homocysteine levels. Ann Nutr Metab 2002; 46: 73–79.

    CAS  Article  Google Scholar 

  33. Hung CJ, Huang PC, Lu SC, Li YH, Huang HB, Lin BF et al. Plasma homocysteine levels in Taiwanese vegetarians are higher than those of omnivores. J Nutr 2002; 132: 152–158.

    CAS  Article  Google Scholar 

  34. Refsum H, Yajnik CS, Gadkari M, Schneede J, Vollset SE, Orning L et al. Hyperhomocysteinemia and elevated methylmalonic acid indicate a high prevalence of cobalamin deficiency in Asian Indians. Am J Clin Nutr 2001; 74: 233–241.

    CAS  Article  Google Scholar 

  35. Herrmann W, Schorr H, Purschwitz K, Rassoui F, Richter V . Total homocysteine, vitamin B12, and total antioxidant status in vegetarians. Clinical Chemistry. 2001; 47, 1094–1101.

    CAS  PubMed  Google Scholar 

  36. Krajcovicova-Kudlackova M, Blazicek P, Kopcova J, Bederova A, Babinska K . Homocysteine levels in vegetarians versus omnivores. Ann Nutr Metab 2000; 44: 135–138.

    CAS  Article  Google Scholar 

  37. Haddad EH, Berk LS, Kettering JD, Hubbard RW, Peters WR . Dietary intake and biochemical, hematologic, and immune status of vegans compared with nonvegetarians. Am J Clin Nutr 1999; 70: 586S–593S.

    CAS  Article  Google Scholar 

  38. Hokin BD, Butler T . Cyanocobalamin (vitamin B-12) status in Seventh-day Adventist ministers in Australia. Am J Clin Nutr 1999; 70: 576S–578S.

    CAS  Article  Google Scholar 

  39. Alexander D, Ball MJ, Mann J . Nutrient intake and haematological status of vegetarians and age-sex matched omnivores. Eu J Clin Nutr 1994; 48: 538–546.

    CAS  Google Scholar 

  40. Woo J, Kwok T, Ho SC, Sham A, Lau E . Nutritional status of elderly Chinese vegetarians. Age and Aging 1998; 27: 455–461.

    CAS  Article  Google Scholar 

  41. Krivosikova Z, Krajcovicova-Kudlackova M, Spustova V et al. The association between high plasma homocysteine levels and lower bone mineral density in Slovak women: the impact of vegetarian diet. Eur J Nutr 2010; 49: 147–153.

    CAS  Article  Google Scholar 

  42. Ingenbleek Y, McCully KS . Vegetarian produces subclinical malnutrition, hyperhomocysteinemia, and atherogenesis. Nutr 2012; 28: 148–153.

    CAS  Article  Google Scholar 

  43. Rauma AL, Torronen R, Hanninen O, Mykkanen H . Vitamin B-12 status of long-term adherents of a strict uncooked vegan diet (‘living food diet’) is compromised. J Nutr 1995; 125: 2511–2515.

    CAS  PubMed  Google Scholar 

  44. Miller DR, Specker BL, Ho ML, Norman EJ . Vitamin B-12 status in a macrobiotic community. Am J Clin Nutr 1991; 53: 524–529.

    CAS  Article  Google Scholar 

  45. Specker BL, Miller D, Norman EJ, Greene H, Hayes KC . Increased urinary methylmalonic acid excretion in breast-fed infants of vegetarian mother and identification of an acceptable dietary source of vitamin B-12. Am J Clin Nutr 1988; 47: 89–92.

    CAS  Article  Google Scholar 

  46. Crane M, Sample C . Vitamin B12 studies in total vegetarians (vegans). J Nutr Med 1994; 4: 419–430.

    Google Scholar 

  47. Dagnelie PC, van Staveren WA, Vergote FJVRA, Dingjan PG, van den Berg H, Hautvast JGAJ . Increased risk of vitamin B-12 and iron deficiency in infants on macrobiotic diets. Am J Clin Nutr 1989; 50: 818–824.

    CAS  Article  Google Scholar 

  48. Rowlett R University of North Carolina at Chapel Hill SI units for clinical data. How many? A dictionary of units of measurement. Available at: http://www.unc.edu/~rowlett/units/scales/clinical_data.html (last accessed 13 June 2001).

  49. Grace ND . Effect of ingestion of soil on the iodine, copper, cobalt (vitamin B12) and selenium status of grazing sheep. NZ Vet J 2006; 54: 44–47.

    CAS  Article  Google Scholar 

  50. Hytten F . Blood volume changes in normal pregnancy. Clin Haematol 1985; 14: 601–612.

    CAS  PubMed  Google Scholar 

  51. Dror DK, Allen LH . Effect of vitamin B12 deficiency on neurodevelopment in infants: current knowledge and possible mechanisms. Nutr Rev 2008; 66: 250–255.

    Article  Google Scholar 

  52. Pawlak R, Parrott SJ, Raj. S, Cullum-Dugan D, Lucus D . Understanding vitamin B12. Am J Lifestyle Med 2012; 7: 59–65.

    Google Scholar 

  53. The Academy of Nutrition and Dietetics (formerly the American Dietetic Association). Position of the American Dietetic Association: vegetarian diets. J Am Diet Assoc 2009; 109: 1266–1282.

    Article  Google Scholar 

  54. Herbert V . Staging vitamin B-12 (cobalamin) status in vegetarians. Am J Clin Nutr 1994; 59: 1213S–1222S.

    CAS  Article  Google Scholar 

Download references

Acknowledgements

The authors did not receive any financial compensation for creating this manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to R Pawlak.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Pawlak, R., Lester, S. & Babatunde, T. The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature. Eur J Clin Nutr 68, 541–548 (2014). https://doi.org/10.1038/ejcn.2014.46

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ejcn.2014.46

Further reading

Search

Quick links