Vitamin B12 deficiency – still a serious threat

Even if an individual eats a well-balanced diet, a vitamin B12 deficiency can occur and cause serious damage before a lack of this nutrient is even suspected. It’s estimated that some 6% of the population under age 60 has a lack of vitamin B12, and about 20% of people 60 and older. Of those 85 and older, 23% are deficient. Deficiency can impact everyone, from an embryo to the very old, in some of the following ways:

  • It can cause infertility, miscarriage, and premature birth
  • Like a folate deficiency, a lack of B12 can lead to spinal abnormalities
  • Babies lacking B12 may have problems with sucking and with swallowing
  • Adults with a B12 deficit may experience numbness and tingling of the hands and feet, weakness, fatigue, decreased appetite, constipation, and weight loss
  • A type of anemia called macrocytic anemia can develop but this doesn’t always occur
  • Neurological and psychological problems may be present even when the blood B12 level is normal or only slightly below normal.
  • Problems with memory and reasoning – because of this, it is often confused with dementia, especially in older individuals – a group at high risk of having a B12 deficiency
  • Difficulty walking and with balance or fine motor tasks like using silverware or scissors

Who is at risk for a B12 deficiency?

Anyone over age 50 is more prone to atrophic gastritis with a decrease in gastric acid and thus less able to release B12 from animal protein – a very common cause of deficiency

Strict vegetarians (vegans) – because the main source of B12 is meat, eggs, dairy products and other sources of animal protein

Those with celiac disease, Crohn’s disease, and those who had weight loss surgery

Individuals who are H. pylori positive (this is specialized testing usually done when someone develops an ulcer since the bacteria cause ulcers too) – the bacteria devour B12 in the gut

Some medications can interfere with B12 absorption – proton pump inhibitors, H-2 receptor blockers (both of these are used to prevent and treat ulcers and GERD), the type 2 diabetes drug metformin (Glucophage), some antibiotics and certain medication to prevent seizures

The best test for a vitamin B12 deficiency isn’t a B12 level. Either a total homocysteine or MMA level may be superior. These chemicals accumulate when there is insufficient B12, so elevated levels indicate a deficiency.

Crystalline vitamin B12 is a synthetic form of the vitamin. It is in the free form so it doesn’t require the usual high level of stomach acid for it to be made available for absorption. This makes it effective for prevention and treatment of a vitamin B12 deficiency.



  1. O’Leary, et al “Vitamin B12 status, dietary protein intake and proton pump inhibitors use in geriatric rehabilitation subjects.” Nutrition and Dietetics, 2011: 68, 109-114.

Mary Cadogan, “Functional Implications of Vitamin B12 Deficiency,” Journal of Gerontological Nursing, Vol. 36, no. 6, 2010.

Samantha Nash, “Vitamin B12 deficiency,” British Journal of Midwifery, Nov. 2016, Vol. 24, #11


Radon, is it really a serious threat to health?

Radon, is it really a serious threat to health?

Yes, radon is a serious health hazard. It is a radioactive substance that comes from uranium and thorium in the rocks and soil of the earth. It leaks from the ground and into the air at the soil-air junction such as in basements. Radon quickly breaks down and attaches to air and water particles, making it easy to inhale. These particles, radon progeny, stay in the lung, emitting radiation and causing damage that can lead to cancer (from “Radon Action Month:  Why Nurses Should care about Radon Exposure,” by P. Allen, et al, Tar Heel Nurse, Winter, 2015).

Because radon primarily gets into the body through inhalation, it isn’t surprising that lung cancer is the main disease it has been linked to and is the only one officially identified by the CDC (EPA, 2015). Because it is naturally occurring, odorless, and colorless, people rarely suspect its presence. An estimated 15% of lung cancer deaths are believed to be caused by it and it is the number one cause of lung cancer in non-smokers. It is the leading preventable cause of death and decreasing it in buildings could save more lives than efforts to eliminate home fires, fall prevention and drownings, not to take away from these important measures (from J. Worrell, et al, “Radon Exposure:  Using the Spectrum of Prevention Framework to Increase Health Care Provider Awareness,” in Clinical Journal of Oncology Nursing, Dec. 2016).

Kits to measure radon levels are available at home improvement stores but in some areas, kits are offered at reduced cost through the state’s radon detection program or health departments. The kits should be placed at the lowest level where people live. For a reading of 4.0 pCi/L or greater, a mitigation system can be installed to vent the radon to outdoor air, where it is quickly diluted and no threat. Radon should be measured every few years if the level is above two or if a mitigation system is installed (American Family Physician, Audio Digest for December, 2017).

Radon can be found all over the world. In the U.S., parts of the Midwest have high rates, as does Kentucky, and the northeast. Portions of the West near fault lines may have radon problems too. The only way to really know is to use a kit to measure it. There is great variability even from one house to the next due to difference in building materials, environment, etc. Also, the U.S. population is quite mobile so current exposure doesn’t indicate lifetime risk.

Smoking is still the number one risk for lung cancer in smokers and even thought radon is the main cause in non-smokers, it is important to understand that there is a ten to twenty-fold greater risk of lung cancer from radon for smokers compared to non-smokers (Worrell, et al, 2016). To put it another way, the EPA estimates that 86% of radon-induced lung cancer deaths are found among current and former smokers (from Editorial Letters in the American Journal of Public Health, Sept. 2013, Volume 103, #9.

Good Egg, Bad Egg

Good Egg, Bad Egg

Eggs are an amazing food, packed with many nutrients, usually inexpensive, and readily available. They are an exceptional source of several B vitamins, the micronutrients iron, iodine, and selenium, as well as potassium and phosphorus, and one of only several natural sources of vitamin D. Egg white (also called albumen) is the most excellent protein thus far identified. The choline in eggs is another strengths. This nutrient is important for nerve and artery health and is necessary for many metabolic processes. Developing fetuses in particular need it. Nine years ago, the Institute of Medicine added choline to their list of recommended nutrients.1 The American Medical Association recommended adding it to prenatal vitamins.2

Because eggs are nutrient-dense, those that are malnourished or at high risk of it stand to benefit the most from eggs. Some over age 65 are at high risk of sarcopenia, a decrease in muscle mass. This disorder increases the chances of a person falling and of developing osteoporosis, so increasing intake of protein, especially one that contains the easily digested protein such as that found in eggs, is a priority. Eggs are a good source of the vital amino acid leucine, adding to their value.3

In research done in Ecuador, babies ages six to nine months were fed one egg a day. This produced a drop in stunting by 47% and a 74% decrease in underweight. Older children that are malnourished can also benefit from eating eggs daily. But USDA data revealed that eggs made up only 1% of food expenses even though they are low cost. In the same survey, soft drinks comprised more than 9% of household food expenses. Access to fresh eggs and a lack of cooking facilities may contribute to that problem. 2

But not all the egg news is good news. Eggs were attacked for their high cholesterol level for many years. The high cholesterol content of eggs has not been found to increase significantly the blood cholesterol level (saturated fat, however, does). Still, some studies found that those with type 2 diabetes, especially men, who ate at least one egg a day were more likely to develop heart disease. Since 10% of Americans have type 2 diabetes and 30% have pre-diabetes, this isn’t a miscellaneous detail. Eating five or more eggs a week may also increase the risk of developing type 2 diabetes. Higher egg consumption could also increase the risk for aggressive prostate cancer. The authors of this article recommend that the well-nourished limit their egg consumption to four per week.4

     Labels  on egg cartons can be misleading. Cage-free is good for the hens but not necessarily for humans eating their eggs. Stating eggs are “hormone free” is also meaningless since all eggs are hormone-free. But the “USDA Organic” label is important. It indicates that the hens are fed an organic, vegetarian diet that is without antibiotics or pesticides.4 Eating raw eggs offers no advantages but does pose risks.Try to buy eggs produced locally as time and travel can lead to a decrease in some nutrients. Eggs high in omega-3 fatty acids are also a very good thing.5



Reinhard, Tonia. Super Foods the Healthiest Foods on the Planet. Buffalo, New York:  Firefly Books, Inc., 2014.

Rains, Tia, PhD. “Eggs for the Nutritionally Vulnerable,” in Nutrition Close-up, Summer, 2017.

Smith, A. and Gray, J. “Considering the benefits of egg consumption for older people at risk of Sarcopenia,” in British Journal of Community Nursing, June, 2016, vol. 21, #6.

Liebman, Bonnie, “Unscrambling Eggs Health food or bad yolk,” in Nutrition Action Healthletter, June, 2015.

Guarneri, Mimi, M.D. The Science of Natural Healing. Chantilly, VA:  The Teaching Company, 2012.

Diseases, Drugs and Vitamin D deficiency

Vitamin D Deficiency, diseases and drugs

Vitamin D is needed by almost every tissue in the body, so the harm from deficiency isn’t surprising. The majority of research on vitamin D deficiency and depression found a correlation between the two, but a few studies didn’t. In one such study, “Low vitamin D status is associated with more depressive symptoms in Dutch older adults,” (E.M. Brouwer-Brolsma, et al, in European Journal of Nutrition, 2016, 55:1525-1534) supplementing those with depression with vitamin D for two years didn’t lead to any improvement. Is there some other benefit from sun exposure apart from vitamin D synthesis that improves mood?

Vitamin D is needed to absorb calcium. It also helps regulate this mineral in the body. So, it isn’t surprising that vitamin D deficiency is associated with weak even deformed bones in children. A lack of this vitamin can also lead to seizures and heart failure. In adults, vitamin D deficiency can lead to hypertension, coronary artery disease, and heart failure. In one study of patients with heart failure, 87% were found to be significantly deficient in vitamin D. Muscle weakness is common with a shortfall of the vitamin, so it isn’t surprising that falls and fractures are more common in those with a lack of it.

It has long been known that vitamin D is needed by many of the immune system cells and those that are deficient in t have a much higher risk of developing autoimmune disorders such as type 1 (juvenile) diabetes as well as multiple sclerosis. A country in northern Europe started giving infants vitamin D every day for their first year and after twenty years of this practice, the rates of type 1 diabetes fell by over 80%! Resent research shows a link between a lack of vitamin D and type 2 (adult onset) diabetes. The immune system is more able to fight infections if the blood level of vitamin D are normal.

Vitamin D appears to boost the body’s cancer-fighting ability. Those with metastatic colon cancer may have a longer life expectancy if they maintain adequate levels of it. This isn’t surprising given the way it supports immune system functioning.

Some medications have been found to be linked to vitamin D deficiency. This information comes from “Vitamin D deficiency as adverse drug reaction? A cross sectional study in Dutch geriatric outpatients.” (A.C.B. van Orten-Luiten, et al, in European Journal of Clinical Pharmacology, 2016, 72:605-614). The following are those uncovered thus far:

  • metformin for type 2 diabetes
  • loop diuretics such as furosemide and potassium-sparing diuretics like spironolactone
  • digoxin used for heart failure and atrial fibrillation
  • warfarin, a medication that decreases blood clot formation
  • ACE inhibitors such as lisinopril and
  • SSRI antidepressants such as sertraline.

See your health care provider if you are taking one of these medications and ask if a vitamin D supplement may be recommended. Those needed to avoid sun exposure may want to ask about this as well.

  Heartburn and GERD

Heartburn and GERD

Heartburn or acid indigestion, is a burning sensation caused by irritation of the esophagus, the hollow, muscular tube that carries food and fluids from the mouth to the stomach. If it occurs 2 or more times a week, and/or is associated with complications, it is diagnosed as Gastroesophageal Reflux Disease (GERD). The esophagus becomes irritated when food and fluids mixed with acid in the stomach, backs up into the esophagus. The stomach can tolerate the acidic blend but the esophagus doesn’t have the same protective mechanisms, so stomach contents can injure it.

Normally, stomach contents are brought to the small intestines, but a backward flow of stomach contents can occur if the valve between the esophagus and stomach becomes displaced upward and loses its support from the surrounding diaphragm. This displacement of the valve, – a hiatal hernia, is caused by excess pressure in the abdomen from pregnancy or abdominal obesity. The unsupported valve allows reflux to easily occur, especially with lying down after eating.

Overeating can also physically push food back through the valve. Bending over after eating can also have this effect. Some medications and foods can weaken the valve and allow stomach contents to back up into the esophagus and irritate the tissues. Medications that can weaken the valve include aspirin, ibuprofen, the high blood pressure and heart drugs calcium channel blockers and beta blockers, the asthma medication theophylline, nitrates and nitroglycerin used for angina, and anticholinergics like medications for incontinence.

Foods and fluids that can have this effect on the valve include spicy foods, and acidic foods such as tomatoes, grapefruit and other citrus fruits. Other foods or fluids that can worsen reflux: chocolate, coffee, tea, carbonated drinks, peppermint, garlic, and yellow onions. Fatty foods delay stomach emptying and thus worsen heartburn. Drinking alcohol also can result in reflux. Smoking stimulates the release of stomach acid and the nicotine in it weakens the valves.

Heartburn can be prevented and the frequency of it decreased by avoiding eating for three hours before going to bed, eating smaller meals, and raising the head of the bed 8 to 10 cm with blocks so that gravity prevents food from backing up. If you need to lie down after eating, try lying on your left side so your stomach is lower than your esophagus, making reflux less likely. Avoid wearing constrictive clothing. Also, cut back on fatty, spicy or acidic foods – especially later in the day. If you are taking a medication that can cause heartburn, discuss this with you doctor.

Although antacids can give relief from heartburn, they contain ingredients that can cause problems for those with high blood pressure, heart arrhythmias, kidney disease, certain intestinal problems, chronic heartburn or appendicitis. Those pregnant and breast feeding also should discuss heartburn treatment with their doctor. Occasional heartburn is uncomfortable, but frequent heartburn can be dangerous. Over time, repeated episodes of reflux can cause bleeding of the esophagus or tissue changes that can lead to cancer. Chest or upper abdominal pain may be from a heart attack. If the pain radiates to your arms or shoulders, this is more likely to be from a heart attack. A heart attack needs immediate attention and anyone possibly having a heart attack must be brought to an emergency room by ambulance.

Reference:  “Gastroesophageal Reflux,” by J. Pilgrim and J. Parks-Chapman in Nursing Course, 1/12/2018.

Vitamin D:  How much do we need? Where does it come from?

Vitamin D:  How much do we need? Where does it come from?

Vitamin D has been in the news a lot lately. There are many articles about it in medical journals as well, and most of those articles confirm numerous health benefits from it. This critical element is needed by virtually every tissue of the body, so it’s not surprising that there is a large number of health problems caused by a deficiency. This is particularly concerning because almost half of all Americans are low on vitamin D. Those with darker skin color are at especially high risk because it takes more sun exposure to make vitamin D.

80% to 90% of the body’s vitamin D comes from sun exposure. Sun exposure needs to be when the sun is high in the sky, and shouldn’t be enough to cause a sun burn. About 40% of skin needs to be exposed. Sun passing through glass and light from tanning beds don’t stimulate vitamin D production. Use of sun block lotions and clothing that covers most of the skin makes it harder to get enough exposure to the needed ultra violet B (UBV) rays.

For adequate production, people need 6 to 8 minutes a day of sun exposure in summer, and 24 to 97 minutes in winter; the time of day and latitude are significant variables. A light-skinned individual in a swimsuit lying in the midday sun for 30 minutes will create about 50,000 IU of vitamin D in the following 24 hours, but someone tanned or naturally dark-skinned will only produce 20,000 to 30,000 IU after the same exposure. Someone very dark-skinned would produce a mere 8,000 to 10,000 IU in such a situation since melanin decreases UVB effects.

The remaining amount of the vitamin has to come from food but there are only a few foods high in it. The best sources are oily fish like salmon and mackerel, and the yolks of eggs. Fortified cereal and milk as well as red meat are other sources of vitamin D.

Supplements can help, but sun exposure and foods are ideal sources. Fortified cereal and milk as well as red meat are other sources of vitamin D.

Since vitamin D is a fat-soluble vitamin, it is difficult for the body to get rid of excess vitamin D. The recommended intake for adults up to age 71 is 600 IU/day, and for those 71 and older its 800 IU/day. The upper limit is 4,000 IU/day. See your health care provider regarding the dose of vitamin D supplement that is right for you. When people are severely deficient, it is not uncommon for a large weekly dose to be prescribed.


Editorial, “Vitamin D:  Way more important in Critical Care than we may have Realized.” In Critical Care Nurse, June, 2017, Vol. 37, #3.

Joel Kreisberg, DC, “Preparing Patients for Proper Sun Exposure.” Integrative Medicine, Vol. 8, #4, August/September 2009

Fiona Hermann, “Vitamin D supplementation, sun exposure for Pregnant and breast-feeding women and their infants.” Midwifery News, September, 2011.

Diseases, Drugs and Nutritional Deficiencies that increase Depression risk

   Diseases, Drugs and Nutritional Deficiencies that increase Depression risk

     Although depression is a complex disease, research and other methods of learning about it have uncovered some things that can increase the chances of developing it. This is crucial information to aid people in preventing it or helping to lessen it. Depression can worsen the outcomes of some diseases such as heart attacks, and impact the quality of life.

The following disorders can cause or contribute to depression:

  • Parkinson’s disease, stroke, normal pressure hydrocephalus, dementia
  • Coronary artery disease, heart failure, TB, viral pneumonia, a high calcium level, low sodium or low potassium level
  • Diabetes, hypothyroidism, hyperthyroidism, cancer – especially GI or pancreatic
  • Hypoglycemia, hyperglycemia, liver or kidney disease, adrenal disorders
  • Rheumatoid arthritis, hip fracture, hepatitis, urinary tract infections
  • Chronic pain – and depression can increase pain
  • Stressors alone don’t contribute to the risk for depression but combined with a lack of social support can contribute to it.

There are also some medications that can cause depression or at least increase the risk of it developing. Those taking such medications should consult their health care provider if they suspect they have depression. Here are some of the medications that have been linked to depression:

Opioids and opiates including hydrocodone, barbiturates, benzodiazepines for anxiety

Indomethacin, beta blockers, digitalis, methyldopa, levodopa for Parkinson’s disease

Alcohol – those over age 65 are particularly sensitive to the adverse effects of alcohol including depression because of decreased breakdown of it

Cimetidine (for ulcers), estrogen, some chemotherapy agents, and corticosteroids such as prednisone

A lack of certain nutrients has also been associated with an increased risk of depression. Folate – a B vitamin, vitamin B12, iron, and vitamin D deficiencies have all been found to increase the risk of depression. And those with depression are more apt to not eat properly including not getting all the nutrients they need.