Vitamin B12 is an essential nutrient that your body needs for processes, like DNA synthesis, energy production, and central nervous system function.
Even though the vitamin is found in many foods, B12 insufficiency and deficiency are relatively common. This is often due to limited dietary intake, malabsorption, certain medical conditions, or the use of B12-depleting medications.
Studies suggest that up to 20% of people over the age of 60 in the United States and the United Kingdom are deficient in vitamin B12.
For reference, B12 levels above 300 pg/mL are considered normal, levels of 200–300 pg/mL are considered borderline, and levels below 200 pg/mL are considered deficient.
Because the ability to absorb B12 from food declines with age, deficiency is more common in older adults. Still, that doesn’t mean children and younger adults, including those who are pregnant and breastfeeding, can’t develop B12 deficiency.
Unfortunately, B12 deficiency is often overlooked and misdiagnosed. Oftentimes, this is due to inadequate laboratory testing or because the symptoms are not specific to vitamin B12 deficiency alone.
If you suspect you might have a B12 deficiency, it’s important to visit a healthcare professional to discuss your symptoms and undergo appropriate testing.
This article covers nine of the most commonly reported symptoms related to B12 deficiency and how this deficiency is diagnosed and treated.
If you’re low in B12, you’ll likely feel fatigued.
Your body’s cells need B12 to function properly. As such, having inadequate B12 levels can decrease normal red blood cell production, which can impair oxygen delivery.
Specifically, a deficiency in B12 or folate can cause megaloblastic anemia. This condition leads to the formation of large, abnormal, and immature red blood cells and impaired DNA synthesis.
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When your body doesn’t have enough healthy red blood cells to carry oxygen to tissues, you’ll likely feel weak and tired.
It’s important to know that you can develop fatigue and other symptoms related to B12 deficiency, even when your B12 levels are considered within range or only borderline low.
2. Pale or yellow skin
Another sign that can indicate B12 deficiency is pale or yellow skin.
Like the condition called iron deficiency anemia, anemia related to B12 deficiency may make your skin pale due to a lack of fully-matured, healthy red blood cells in the body.
B12 deficiency can also cause a condition called jaundice, which makes your skin and the whites of your eyes take on a yellowish color.
The color is caused by high levels of bilirubin, a waste product created when your body breaks down red blood cells.
B12 insufficiency and deficiency can lead to neurological side effects, including headaches.
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Headaches are amongst the most commonly reported symptoms related to B12 deficiency in both adults and kids.
Some studies have shown that people who frequently experience certain types of headaches are more likely to have low B12 levels.
A 2019 study with 140 people, half of whom experienced migraines, found that blood levels of B12 were significantly lower in the participants with migraines compared with the participants with no migraine history.
The study also found that those with the highest B12 levels were 80% less likely to have migraines compared with participants with the lowest B12 levels.
Research continues to investigate if treatment with B12 may improve migraine headache symptoms in some people.
4. Depressive symptoms
B12 is essential to the proper functioning of your central nervous system, and a deficiency in this nutrient can impact your mental health.
Specifically, B12 deficiency is associated with a greater risk of developing depression.
Having low levels of B12 can cause elevated levels of a sulfur-containing amino acid called homocysteine. In turn, this may contribute to the development of depression by increasing oxidative stress, DNA damage, and cell death in the body.
A 2020 study with 132 children and teens, 89 with and 43 without depression, found that the participants with depression had lower B12 levels and higher levels of homocysteine compared with those without depression.
In addition to depressive symptoms, low B12 levels may lead to other mental conditions, including psychosis and mood disorders.
5. Gastrointestinal issues
A B12 deficiency may also cause diarrhea, nausea, constipation, bloating, gas, and other gastrointestinal symptoms.
These issues can affect both adults and children.
Keep in mind, though, that many of these symptoms are non-specific and could be caused by other factors. For example, food intolerances, medications, and infections could all lead to diarrhea.
6. Difficulty concentrating and mental impairment
Because a deficiency in B12 negatively impacts the central nervous system, people with low B12 levels may feel foggy-headed and have difficulty concentrating and completing tasks.
Older adults are especially at risk for these side effects because the risk of B12 deficiency increases with age.
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Many studies have associated low B12 levels with worsened mental function in older adults.
Fortunately, studies show that mental impairment related to low B12 levels can improve with B12 treatment.
For example, a 2020 study gave 202 people with mild mental impairment and low or low-normal B12 levels and elevated homocysteine levels B12 replacement therapy for 3 months.
After the treatment, 84% of the participants reported significant improvements in symptoms, like poor focus, memory decline, and forgetfulness.
7. Pain and inflammation of the mouth and tongue
Glossitis is a medical term that refers to an inflamed, red, and painful tongue. It can be caused by a B12 deficiency.
In people with this deficiency, glossitis can appear alongside stomatitis, which is characterized by sores and inflammation in the mouth.
Even though glossitis and stomatitis are common in people with B12 deficiency-related anemia, they can also occur without anemia and can be a sign of an early B12 deficiency.
That being said, glossitis can also be caused by deficiencies in other nutrients, like folate, riboflavin (B2), and niacin (B3).
8. Paresthesia in hands and feet
Paresthesia is a medical term that refers to a burning or pins-and-needles sensation in certain areas of the body, like the hands and feet.
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Many adults and kids who have B12 deficiency report experiencing paresthesia.
Unfortunately, this symptom of B12 deficiency overlaps with symptoms related to diabetic neuropathy — nerve damage caused by high blood sugar that can cause pain and numbness in the extremities.
People with diabetes taking metformin are at a higher risk of developing B12 deficiency because this medication can reduce vitamin B12 absorption in the body.
So, a B12 deficiency could be misdiagnosed as peripheral neuropathy in people with diabetes.
As a result, many experts recommend that people taking metformin regularly get screened for vitamin B12 deficiency.
9. Other signs and symptoms of B12 deficiency
In addition to the symptoms above, B12 deficiency may lead to the following:
- Muscle cramps and muscle weakness. B12 deficiency negatively impacts motor and sensory nerve function, which can cause muscle cramps and weakness.
- Impaired coordination. Ataxia, or impaired balance and coordination, is a neurological symptom that can be caused by B12 deficiency. As such, a person with B12 deficiency may have difficulty walking and balancing.
- Erectile dysfunction. Men with B12 deficiency may experience erectile dysfunction as a result of increased levels of homocysteine in the body.
- Vision disturbances. B12 deficiency may cause vision disturbances, possibly due to damage to the optic nerve.
How is B12 deficiency detected and treated?
Because vitamin B12 deficiency symptoms aren’t specific to the condition, it may go undetected or get misdiagnosed.
If you’re experiencing any of the symptoms listed above, it’s important to discuss them with a healthcare professional.
This is especially relevant if you:
- follow a restrictive diet, like a vegan diet
- are over the age of 60
- are pregnant or breastfeeding
- have a medical condition that can deplete B12 levels
- take a B12-depleting medication, like metformin or proton pump inhibitors
In addition to learning about your symptoms and giving you a physical exam, a healthcare professional can rule out a B12 deficiency by ordering blood tests.
These tests can include:
- B12 levels
- folate levels
- a complete blood count (CBC) with a peripheral smear
- methylmalonic acid (MMA) levels
- homocysteine levels
If you’re diagnosed with too low B12 levels, your healthcare professional will recommend the most appropriate treatment. It may include B12 injections, oral B12 supplements, or addressing an underlying health condition that could be causing the deficiency.
B12 injections are generally recommended for people who can’t properly absorb B12 from food or supplements, like those who’ve undergone gastric bypass surgery or people with certain autoimmune diseases.
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B12 supplements and injections are considered safe and well-tolerated, even in large doses.
Summary: If your healthcare professional thinks you may be low in B12, they’ll order appropriate blood tests to assess your B12 levels. Treatment of B12 deficiency typically includes oral supplements or injections.
B12 deficiency can cause a variety of symptoms, including fatigue, headaches, depression, pale or yellow skin, mental impairment, and pain and inflammation in the mouth and tongue.
Many of the symptoms caused by low B12 levels are not specific to B12 deficiency, which can cause the condition to go undetected.
If you’re experiencing any of the symptoms listed above, it’s important to visit a healthcare professional to undergo appropriate testing and get the right treatment.
If you’re low in B12, your healthcare professional will likely recommend an oral supplement or injections.
Additionally, if low dietary intake is the cause, increasing your intake of B12-rich foods, like fish and shellfish, organ meats, and eggs, is a good idea.
If you follow a vegan or vegetarian diet, enjoying B12 fortified foods, like nutritional yeast and plant milk, and taking a B12 supplement can help you maintain optimal levels.
Suggested read: Zinc: Benefits, deficiency, food sources and side effectsLast updated on January 10, 2022, and last reviewed by an expert on January 2, 2022.