Vitamin B12 & folate in IBD
What is vitamin B12 and folate?
Vitamin B12 (aka Cyanocobalamin) is one of the B vitamins and has many roles in our bodies. Deficiency symptoms include fatigue, pale or slightly yellowing skin, shortness of breath, palpitations, diarrhoea, tingling in fingers and toes, and lack of coordination. We get vitamin B12 from the food we eat - it can be found in meat (esp organ meat - liver), fish, shellfish, dairy products, eggs, some fortified breakfast cereals, and fermented foods. Vitamin B12 is absorbed in our ileum so those with ileocolitis (Crohns in the ileum) and anyone who has had ileal resection is at greater risk of B12 deficiency. Also, anyone following a vegan diet is more at risk as B12 is mainly found in animal sources of food. Vitamin B12 injections are common in Crohns Disease and where people have had an ileum resection. However, studies have shown that oral B12 (cyanocobalamin) supplementation provides effective acute and maintenance treatment for vitamin B12 deficiency caused by Crohns Disease with or without ileum resection. This is because even without an ileum, it is estimated that 1% of total absorption of vitamin B12 is by passive diffusion throughout the small intestine. Therefore, higher doses of oral vitamin B12 can still be used in these patients to ensure normal levels of B12. There still may be cases though where B12 injections are needed.
What is folate?
Folate (aka folic acid/vitamin B9 NB: Folic acid is the synthetic form of B9, found in supplements and fortified foods; Folate occurs naturally in foods) works closely with B12 and also had many roles in our bodies. Symptoms of folate deficiency include poor growth, tongue inflammation, gingivitis, loss of appetite, shortness of breath, diarrhoea, irritability, forgetfulness, and mental sluggishness. Like vitamin B12, we also get folate from the food we eat – it can be found in dark leafy green vegetables - broccoli, brussels sprouts, spinach, asparagus, peas, chickpeas, liver, and fortified breakfast cereals. Folate is also absorbed in our ileum so those with ileocolitis (Crohns in the ileum) and anyone who has had ileal resection is at greater risk of folate deficiency.
Prevalence of deficiency in IBD
Frequency of B12 deficiency in CD and UC is 48% and 5% respectively. Frequency of folate deficiency 54% and 36% respectively.
Genetic variations
What complicates things a little more is that some people have a genetic variation (methylenetetrahydrofolate (MTHFR) C677T SNP) which inhibits the way the body processes folic acid and other important B vitamins. Studies have shown an increased prevalence of this gene variant in patients with inflammatory bowel disease compared to the normal population. In this group of people, the type of vitamin B supplement given is important and a supplement with active forms of folate and B12 should be used (L-methlyfolate (5-MTHF) and methylcobalamin).
What can we do?
Test B12 and folate levels – this is a simple blood test that can be done with your GP.
Support levels of B12 and folate by consuming foods that contain these vitamins (see above)
Supplementation or injections (for B12) may be required – if you have a deficiency supplementation may be suggested. The British Society of Gastroenterology guidelines suggest B12 replacement for all patients with ileal resection greater than 20 cm and yearly monitoring of B12 levels for patients with ileal resection below 20 cm. Important note: long term supplementation of a single B vitamin can lead to an imbalance of other B vitamins so a vitamin B complex if supplementing can be a better option.
Read more here:
Pan, Y., Liu, Y., Guo, H., Jabir, M. S., Liu, X., Cui, W., & Li, D. (2017). Associations between Folate and Vitamin B12 Levels and Inflammatory Bowel Disease: A Meta-Analysis. Nutrients, 9(4), 382. https://doi.org/10.3390/nu9040382
Gomollón, F., Gargallo, C. J., Muñoz, J. F., Vicente, R., Lue, A., Mir, A., García-Alvarado, M., Gracia, M., & García-López, S. (2017). Oral Cyanocobalamin is Effective in the Treatment of Vitamin B12 Deficiency in Crohn's Disease. Nutrients, 9(3), 308. https://doi.org/10.3390/nu9030308
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