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What is Vitamin B12 Deficiency?

Vitamin B12 deficiency anemia is a lack of vitamin B12 that leads to insufficient healthy red blood cells. Vitamin B12 is necessary for producing red blood cells, which transport oxygen in the body. It can result from inadequate B12 in the diet or an inability to absorb B12 in the small intestine, also known as pernicious anemia.

Typical Symptoms of Vitamin B12 Deficiency

Diagnostic Questions for Vitamin B12 Deficiency

Your doctor may ask these questions to check for this disease:

  • Do you experience wheezing or whistling sounds when breathing?
  • Do you have pain all over your body?
  • Do you have trouble feeling pain?
  • Recently, are you more confused than before?
  • Do you feel dizzy?

Treatment of Vitamin B12 Deficiency

Treatment includes dietary modifications or vitamin B12 supplements in the form of oral medication or injections.

Reviewed By:

Scott Nass, MD, MPA, FAAFP, AAHIVS

Scott Nass, MD, MPA, FAAFP, AAHIVS (Primary Care)

Dr. Nass received dual medical degrees from the David Geffen School of Medicine at UCLA and Charles R. Drew University in Medicine and Science. He completed Family Medicine residency at Ventura County Medical Center with subsequent fellowships at Ventura, University of North Carolina-Chapel Hill, George Washington University, and University of California-Irvine. He holds faculty appointments at Keck School of Medicine of USC, Loma Linda University School of Medicine, and Western University of Health Sciences.

Yoshinori Abe, MD

Yoshinori Abe, MD (Internal Medicine)

Dr. Abe graduated from The University of Tokyo School of Medicine in 2015. He completed his residency at the Tokyo Metropolitan Health and Longevity Medical Center. He co-founded Ubie, Inc. in May 2017, where he currently serves as CEO & product owner at Ubie. Since December 2019, he has been a member of the Special Committee for Activation of Research in Emergency AI of the Japanese Association for Acute Medicine. | | Dr. Abe has been elected in the 2020 Forbes 30 Under 30 Asia Healthcare & Science category.

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Content updated on Feb 19, 2025

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Symptoms Related to Vitamin B12 Deficiency

Diseases Related to Vitamin B12 Deficiency

FAQs

Q.

Still Tired? Why Magnesium Supplements Are Key + Medical Next Steps

A.

Persistent fatigue often reflects low magnesium, which drives cellular energy, sleep quality, muscle function, and stress balance; many people feel better with a well absorbed form like magnesium glycinate, typically 200 to 400 mg daily after medical advice. If tiredness continues, other causes like iron or B12 deficiency, thyroid disease, sleep apnea, diabetes, or heart problems need evaluation with the specific labs and safety red flags outlined below. There are several factors to consider, and important details about supplement types, dosing, and when to seek care appear below.

References:

* pubmed.ncbi.nlm.nih.gov/34371982/

* pubmed.ncbi.nlm.nih.gov/29949869/

* pubmed.ncbi.nlm.nih.gov/35317769/

* pubmed.ncbi.nlm.nih.gov/27144078/

* pubmed.ncbi.nlm.nih.gov/38300898/

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Q.

Tingling? Why Your Nerves React to Vitamin B6 + Medically Approved Next Steps

A.

Vitamin B6 supports nerves, but excess from supplements can damage sensory nerves and trigger tingling, burning, or numbness, with risk rising at long-term doses around or above 50 to 100 mg per day or from stacked products; there are several factors to consider, see below to understand more. Next steps include reviewing all supplements and stopping high-dose B6 after medical advice, getting blood tests for B6, B12, blood sugar, and thyroid, monitoring symptoms, and ruling out other causes like B12 deficiency or diabetes, seeking urgent care if symptoms are severe or rapidly worsening; complete guidance and recovery timelines are detailed below.

References:

* Kapoor, A., & Gupta, D. (2020). Pyridoxine neuropathy: An update for clinicians. *Journal of Clinical Neuroscience*, *76*, 280-282.

* Parry, G. J., & Bredesen, D. E. (2018). Pyridoxine (Vitamin B6) Neurotoxicity: From Laboratory to Clinical Practice. *Seminars in Neurology*, *38*(5), 553-562.

* Mehndiratta, M. M., Garg, D., Kumar, M., & Pandey, S. (2014). Pyridoxine-induced peripheral neuropathy: a review of the literature. *International Journal of Neuroscience*, *124*(6), 406-412.

* Schaumburg, H. H., & Berger, A. R. (2017). Vitamin B6-induced neuropathy and vitamin B6 levels: a case series and review of the literature. *Journal of Clinical Neuromuscular Disease*, *19*(1), 16-24.

* Ryan-Harshman, M., & Bergman, J. N. (2015). Risk of sensory neuropathy with oral pyridoxine (vitamin B6) in women of reproductive age. *Journal of Clinical Pharmacy and Therapeutics*, *40*(2), 177-181.

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Q.

Always Tired? Why Your B12 Vitamin Is Low + Medically Approved Next Steps

A.

Low B12 vitamin levels are a common, treatable cause of constant tiredness, often due to low intake, absorption problems, age related changes, or medications, and can lead to anemia and nerve issues like tingling, balance problems, and memory changes. Medically approved next steps include getting blood tests, then addressing the cause with diet changes, oral B12 supplements or injections, and follow up monitoring, but there are several factors to consider. See below for important details that can affect which steps are right for you.

References:

* Langan RC, Goodbred EF. Vitamin B12 Deficiency: An Update on Diagnosis and Treatment. Am Fam Physician. 2017 Sep 15;96(8):546-548. PMID: 28925647.

* Green R, Datta P. Neurological manifestations of vitamin B12 deficiency: A comprehensive review. J Neurol Sci. 2021 Jul 15;426:117498. doi: 10.1016/j.jns.2021.117498. Epub 2021 Apr 28. PMID: 33924151.

* Gremel G, et al. Vitamin B12: an old vitamin in a new era. Eur J Clin Nutr. 2023 Dec;77(12):1121-1127. doi: 10.1038/s41430-023-01306-3. Epub 2023 Apr 5. PMID: 37021199.

* Stabler SP. Clinical practice. Vitamin B12 deficiency. N Engl J Med. 2013 Jan 10;368(2):149-61. doi: 10.1056/NEJMcp1113996. PMID: 23301726.

* Dali-Youcef N, et al. Pernicious anemia and vitamin B12 deficiency. Rev Med Interne. 2021 Oct;42(10):707-717. doi: 10.1016/j.revmed.2021.06.012. Epub 2021 Jul 15. PMID: 34293998.

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Q.

Always Tired? Why Pernicious Anemia Blocks Your B12 + Medically Approved Next Steps

A.

Pernicious anemia is an autoimmune condition in which the immune system attacks stomach cells that make intrinsic factor, blocking vitamin B12 absorption and causing relentless fatigue, brain fog, and tingling even if you eat well or take supplements; it is serious but highly treatable. There are several factors to consider, and early diagnosis helps prevent permanent nerve problems. Medically approved next steps include asking your clinician for a CBC, vitamin B12 and MMA levels, and intrinsic factor antibodies, then starting B12 replacement usually with lifelong injections, sometimes high dose oral under supervision, plus regular monitoring and awareness of urgent red flags, with full guidance below.

References:

* Ankar, A., & Ettinger, S. (2023). *Pernicious Anemia*. In *StatPearls*. StatPearls Publishing. PMID: 28722008

* Bizzaro, N., & Antico, A. (2014). Clinical and laboratory aspects of pernicious anemia. *Autoimmunity Reviews*, *13*(7), 746–751. PMID: 24713291

* Devalia, V., Hamilton, M. S., & Greenwood, D. (2014). Guidelines for the diagnosis and treatment of cobalamin and folate disorders. *British Journal of Haematology*, *166*(1), 1–29. PMID: 24806465

* Langan, R. C., & Goodbred, A. J. (2017). Vitamin B12 Deficiency: Recognition and Management. *American Family Physician*, *96*(6), 384–389. PMID: 28925642

* Stabler, S. P. (2013). Clinical practice. Vitamin B12 deficiency. *The New England Journal of Medicine*, *368*(2), 149–160. PMID: 23301742

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Q.

Always Tired? Why Your Nutrition Is Failing + Medical Next Steps

A.

There are several factors to consider. Always feeling tired is often tied to fixable nutrition issues like iron or vitamin B12 deficiency, low vitamin D, dehydration, skipped meals, and too many refined carbs with too little protein. If fatigue persists, ask your doctor about CBC, iron studies, B12, vitamin D, thyroid, and glucose testing, and seek urgent care for warning signs like chest pain or shortness of breath; key details that could change your next steps are explained below.

References:

* Lopresti, A. L. (2017). The Role of Nutritional Factors in the Etiology and Treatment of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis. *Advances in Nutrition*, *8*(5), 724-734.

* Pasricha, S. R., et al. (2021). Iron deficiency. *The Lancet*, *397*(10290), 2024-2037.

* Huang, W., et al. (2020). The Effect of Vitamin D Supplementation on Fatigue: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. *Nutrients*, *12*(4), 1146.

* Kennedy, D. O. (2016). B Vitamins and the Brain: Mechanisms, Dose and Efficacy—A Review. *Nutrients*, *8*(2), 68.

* Lim, M., et al. (2018). Management of chronic fatigue syndrome. *Australian Prescriber*, *41*(4), 112-115.

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Q.

Numb or Tingling? Why Your Nerves Are Failing From Nitrous Oxide + Medical Next Steps

A.

Numbness, tingling, weakness, or balance problems after nitrous oxide use often result from vitamin B12 being inactivated, causing nerve damage that can progress and sometimes become permanent without prompt treatment. Stop nitrous now and see a clinician quickly for B12-focused testing and injections, even if a basic B12 level is normal, and seek urgent care for trouble walking, bladder changes, or confusion; there are several factors that can change your next steps, so see the complete guidance below.

References:

* Hathout GM, et al. Nitrous oxide myeloneuropathy: a case report and review of the literature. J Med Case Rep. 2018 Dec 20;12(1):369. doi: 10.1186/s13256-018-1896-1. PMID: 30573038; PMCID: PMC6302488.

* Kitabata Y, et al. Nitrous oxide-induced peripheral neuropathy. BMJ Case Rep. 2021 Jan 18;14(1):e239063. doi: 10.1136/bcr-2020-239063. PMID: 33462100; PMCID: PMC7814983.

* Feng R, et al. Nitrous oxide abuse presenting with myeloneuropathy associated with vitamin B12 deficiency: a case series and literature review. BMC Neurol. 2020 Jan 22;20(1):28. doi: 10.1186/s12883-020-01602-5. PMID: 31969137; PMCID: PMC6975232.

* Alt RS, et al. The dangers of recreational nitrous oxide use: A literature review. Am J Emerg Med. 2021 Nov;49:283-289. doi: 10.1016/j.ajem.2021.06.015. Epub 2021 Jun 17. PMID: 34182410.

* Yu Y, et al. Comprehensive rehabilitation therapy and vitamin B12 for nitrous oxide-induced myeloneuropathy with severe ataxia: a case report. BMC Neurol. 2023 Feb 15;23(1):72. doi: 10.1186/s12883-023-03120-x. PMID: 36792945; PMCID: PMC9931327.

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Q.

Always Tired? Why Your B12 is Low & Medically Approved Next Steps

A.

Always tired even after good sleep? Low vitamin B12 is a common, underrecognized cause of fatigue, brain fog, anemia, and nerve symptoms, often from poor absorption, certain medicines, low intake, or age, and it is usually very treatable once properly tested. Medically approved next steps include targeted lab tests, high dose oral B12 or injections depending on the cause, and monitoring; there are several factors to consider, including other conditions that can mimic B12 issues, so see below for the complete guidance and urgent symptoms that may change your next steps.

References:

* Ankar A, Kumar A. Vitamin B12 Deficiency. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559124/

* Lederer H, et al. Vitamin B12 Deficiency: An Updated Review. Clin Med Res. 2021 Sep;19(3):121-130. doi: 10.3121/cmr.2021.1627. Epub 2021 Jun 25. PMID: 34172421; PMCID: PMC8492298.

* Wolters M, et al. Diagnosis and Treatment of Vitamin B12 Deficiency: A Systematic Review. Dtsch Med Wochenschr. 2021 Mar;146(6):384-391. doi: 10.1055/a-1317-1524. Epub 2021 Mar 17. PMID: 33730704.

* Green R. Vitamin B12 deficiency from the perspective of a practicing hematologist. Blood. 2017 Jul 27;130(4):450-456. doi: 10.1182/blood-2017-03-746092. PMID: 28751503; PMCID: PMC5557790.

* Langan RC, Goodbred EF. Vitamin B12 Deficiency: Recognition and Management. Am Fam Physician. 2017 Sep 15;96(6):384-389. PMID: 28925643.

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Q.

Always Tired? The Vitamin D Reality & Medically Approved Next Steps

A.

If you are always tired, vitamin D deficiency is a real possibility that affects energy, immunity, muscles, mood, and bones, but many other conditions can cause the same symptoms. Medically approved next steps include talking to a clinician, getting a 25-hydroxy vitamin D blood test, and using evidence-based vitamin D3 dosing if low, plus safe sun exposure and diet adjustments while evaluating other causes like anemia, thyroid disease, sleep apnea, or B12 deficiency. There are several factors to consider, including target ranges, dosing options, safety precautions, and urgent red flags, so see the complete guidance below.

References:

* Al-Ayadhi L, Al-Daghri N, Al-Attar S, Al-Fakhri M, Al-Saleh Y. Vitamin D Deficiency and Fatigue: An Updated Systematic Review and Meta-Analysis. Nutrients. 2023 Sep 8;15(18):3920. doi: 10.3390/nu15183920. PMID: 37704153.

* Huang W, Zhang J, Li N, Ma J, Wang J, Shi J, Yao Y, Feng X, Xia Y, Yu X. Effect of vitamin D supplementation on fatigue in healthy young adults: a randomized controlled trial. J Cachexia Sarcopenia Muscle. 2021 Apr;12(2):494-503. doi: 10.1002/jcsm.12674. PMID: 33580468.

* Amrein K, Scherkl M, Hoffmann M, Neuwersch-Sommerauer S, Kostenberger M, Wirnsberger G, Verheyen N. Vitamin D deficiency management: a comprehensive review of clinical guidelines. Eur J Endocrinol. 2020 Jul;183(1):F3-F25. doi: 10.1530/EJE-20-0226. PMID: 32486445.

* Saponaro F, Saponaro M, Mazzanti C, Caprio M, Gagliardi R. Vitamin D: new perspectives on the classical and non-classical health effects. Nutrients. 2022 Oct 25;14(21):4498. doi: 10.3390/nu14214498. PMID: 36294713.

* Valderas P, Estecha-Fernández MA, Alías J, Sempere-Martínez J, Meseguer M, Micol V, Galindo F. Chronic Fatigue Syndrome and Vitamin D: A Systematic Review. Nutrients. 2020 Jan 30;12(2):373. doi: 10.3390/nu12020373. PMID: 32014041.

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Q.

Feeling Weak? Why Your Blood Plasma Is Vital and Medically Approved Next Steps

A.

Weakness often relates to changes in your blood plasma, which keeps blood pressure steady, carries nutrients, balances electrolytes, and supports immunity; dehydration, blood loss, anemia, electrolyte or protein problems, and chronic illness are common culprits. There are several medically approved next steps, from rehydration and diet review to targeted blood tests and medication review, plus clear red flags that should prompt urgent care. See the complete guidance below to choose the safest next move for your situation.

References:

* Jankovic J, Jankovic M. Plasma proteins: an overview of functions and clinical applications. Exp Ther Med. 2017 Aug;14(2):1061-1064. doi: 10.3892/etm.2017.4660. Epub 2017 Jun 29. PMID: 28811800; PMCID: PMC5529944.

* Li S, Gu Z, Xie Y, Yu H, Wang K, Zheng B, Li M, Wu Y, Tang K. Hypoalbuminemia and muscle weakness: a systematic review. Nutr Metab (Lond). 2023 Jul 19;20(1):50. doi: 10.1186/s12986-023-00778-4. PMID: 37468826; PMCID: PMC10355415.

* Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schmitt M, Schmitz S, Weinstein R, Wu Y, Zantek ND, Dunbar NM. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Guidelines from the American Society for Apheresis (ASFA) 8th Edition. J Clin Apher. 2019 Jun;34(3):171-354. doi: 10.1002/jca.21700. Epub 2019 May 15. PMID: 31087452.

* Loar RK, DeMeo D. Intravenous immunoglobulin (IVIG) for chronic fatigue syndrome (CFS). J Clin Apher. 2015 Oct;30(5):267-73. doi: 10.1002/jca.21390. Epub 2014 Dec 11. PMID: 25492476.

* Geyer PE, Kulak NA, Schuetz T, Kussmann S, Strauss MT, Adamski J, Mann M. Plasma Proteome Profiling to Assess Human Health and Disease. Cell Syst. 2016 Feb 24;2(2):120-34. doi: 10.1016/j.cels.2016.02.005. PMID: 27136709.

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Q.

Always Tired? Why Your Vitamin B12 Is Low + Medical Next Steps

A.

Persistent tiredness can stem from low vitamin B12, a common and treatable problem caused by inadequate intake, poor absorption from issues like pernicious anemia or prior gastric surgery, long term acid reducers or metformin, and age related changes. There are several factors to consider. See below to understand more, including key symptoms to watch for, which blood tests confirm deficiency, and the right next steps such as high dose oral B12, injections, or urgent evaluation if severe neurologic or cardiopulmonary symptoms appear to prevent permanent nerve damage and other complications.

References:

* Ankar, I., & Kumar, A. (2023). Vitamin B12 Deficiency. In StatPearls. StatPearls Publishing.

* Pawlak, R., & Parrott, S. J. (2022). Vitamin B12 deficiency: a comprehensive review of diagnosis and treatment. Critical Reviews in Food Science and Nutrition.

* Langan, R. C., & Goodbred, A. J. (2021). Vitamin B12 deficiency: New Clinical Practice Guidelines. The Permanente Journal.

* Green, R., & Kinsella, L. J. (2020). Vitamin B12 deficiency in adults: a guide for general practice. BMJ.

* Dali-Youcef, N., & Andrès, E. (2018). Pernicious anemia and vitamin B12 deficiency: Management in clinical practice. The Journal of the American Medical Association.

See more on Doctor's Note

Q.

Brain Fog? Why Your Nervous System Is Starving + Medical Avocado Plan

A.

Brain fog often signals an undernourished nervous system that needs steady blood sugar, healthy fats, and key nutrients like B12, magnesium, folate, and iron; the Medical Avocado Plan helps by adding daily avocado for monounsaturated fats, fiber, potassium, and folate, especially when paired with protein for stable energy. There are several factors to consider. See below for step by step guidance, who should get B12 testing, sleep and circulation support, how to cut ultra processed foods, and urgent red flags that may need medical care so you can choose the right next steps.

References:

* Tvedt, L. S., et al. (2022). Nutritional Deficiencies and Cognitive Impairment: A Narrative Review. *Nutrients*, *14*(3), 660. doi: 10.3390/nu14030660.

* Larsson, S. C., et al. (2020). Dietary Fat and Brain Health: An Overview of the Importance of the Dietary Fatty Acid Composition. *Nutrients*, *12*(4), 1146. doi: 10.3390/nu12041146.

* Tan, M. M. S., et al. (2022). Avocado consumption and its impact on cognitive function and visual health in older adults: A systematic review. *International Journal of Environmental Research and Public Health*, *19*(11), 6428. doi: 10.3390/ijerph19116428.

* Baraboi, C. M., et al. (2022). Dietary Monounsaturated Fatty Acids and Cognitive Health. *Nutrients*, *14*(11), 2267. doi: 10.3390/nu14112267.

* Gibson, L. T., et al. (2021). The Role of Nutrition in Brain Health: A Systematic Review. *Nutrients*, *13*(9), 3048. doi: 10.3390/nu13093048.

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Q.

B12 Deficiency Insomnia: Why Women 40+ Can’t Sleep & Next Steps

A.

In women 40 and older, an often missed driver of new insomnia is vitamin B12 deficiency, which can disrupt melatonin and circadian rhythm, and becomes more likely with perimenopausal stomach acid changes, certain medications such as PPIs and metformin, and lower dietary intake. There are several factors to consider, including key symptoms, what labs to request, safe supplement options, other causes of poor sleep, and red flags that need prompt care. See below for the complete guidance and step by step next steps to discuss with your clinician.

References:

* Gupta, R., & Singh, A. (2021). Vitamin B12 and Sleep-Wake Regulation: A Comprehensive Review. *Journal of Clinical Sleep Medicine, 17*(7), 1431-1437.

* Almaghrabi, M. S., Althobaiti, A. A., Alhussaini, Y. A., Alzahrani, A. A., & Almalki, S. I. (2023). Cobalamin and Its Relationship with Insomnia and Sleep Disorders. *Cureus, 15*(6), e40589.

* Wang, W., Sun, M., Li, H., Zhang, J., & Li, Z. (2022). The relationship between vitamin B12 levels and sleep quality: a systematic review and meta-analysis. *Sleep Medicine, 100*, 380-388.

* Lederer, S., & Biedermann, B. (2020). Neurological manifestations of vitamin B12 deficiency: An update. *Clinical Neurology and Neurosurgery, 192*, 105741.

* Pawlak, R., & Smith, C. (2017). Diagnosis and treatment of vitamin B12 deficiency. *Medical Clinics of North America, 101*(2), 359-376.

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Q.

Vitamin B12 Deficiency Symptoms: Women 30-45 Guide & Next Steps

A.

Vitamin B12 deficiency in women 30 to 45 often presents with persistent fatigue, brain fog or memory issues, mood changes, numbness or tingling, pale or yellowish skin, palpitations or shortness of breath, and glossitis or mouth sores. There are several factors to consider, including higher needs in pregnancy and breastfeeding, vegetarian or vegan diets, absorption problems such as pernicious anemia or after gastric surgery, and medicines like metformin or acid reducers; see below for the exact tests to ask for, signs that require urgent care, and step by step treatment options, since untreated deficiency can cause anemia and nerve damage.

References:

* Vashisht, K., Sethi, N., & Gupta, A. (2020). Vitamin B12 Deficiency and Its Implications for Women's Health: A Review. *Journal of Women's Health*, *29*(8), 1028–1036.

* Green, R., & Dement, T. (2021). Vitamin B12 deficiency: a 21st century perspective. *Current Opinion in Gastroenterology*, *37*(4), 307–313.

* Kancherla, M., Miller, S., Patel, S., Nambur, S., Khan, A. S., Al-Othaimeen, F., Makkawi, N., Al-Naami, A., Algahtani, H., & Algahtani, R. (2023). Neurological Manifestations of Vitamin B12 Deficiency: A Systematic Review. *Nutrients*, *15*(3), 792.

* Langan, R. C., & Goodbred, A. J. (2018). Clinical and laboratory aspects of vitamin B12 deficiency. *Clinical Chemistry and Laboratory Medicine (CCLM)*, *57*(7), 909–917.

* Dharmarajan, T. S., & Nambiar, A. K. (2014). Vitamin B12 Deficiency: The Silent Epidemic. *American Journal of Lifestyle Medicine*, *8*(1), 38–43.

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