Original Paper Ann Nutr Metab 2000;44:229–234 Received: February 24, 2000 Accepted: August 7, 2000 Metabolic Vitamin B12 Status on a Mostly Raw Vegan Diet with Follow-Up Using Tablets, Nutritional Yeast, or Probiotic Supplements Michael S. Donaldson Hallelujah Acres Foundation, Shelby, N.C., USA Key Words The urinary MMA assay is effective for identifying early Vegan W Vegetarianism W Raw food W Cobalamin W Vitamin metabolic cobalamin deficiency. People following the B12 W Methylmalonic acid W Probiotic supplements W Hallelujah diet and other raw-food vegetarian diets Nutritional yeast should regularly monitor their urinary MMA levels, con- sume a sublingual cobalamin supplement, or consume cobalamin in their food. Abstract Copyright © 2000 S. Karger AG, Basel Background: Pure vegetarian diets might cause cobal- amin deficiency due to lack of dietary intake. It was hypothesized that a population following a vegan diet Introduction consuming mostly raw fruits and vegetables, carrot juice, and dehydrated barley grass juice would be able to The vitamin B12 status of people who avoid eating all avoid vitamin B12 deficiency naturally. Methods: Sub- animal products remains an important scientific ques- jects were recruited at a health ministers’ reunion based tion. Vitamin B12 is important in DNA synthesis, erythro- on adherence to the Hallelujah diet for at least 2 years. poiesis, and development and maintenance of the myelin Serum cobalamin and urinary methylmalonic acid sheath of nerves. Deficiency of vitamin B12 leads to perni- (MMA) assays were performed. Follow-up with sublin- cious anemia, gastrointestinal disorders, and neurological gual tablets, nutritional yeast, or probiotic supplements damage. Generous folate intake by health-conscious veg- was carried out on subjects with abnormal MMA results. ans prevents easy detection of pernicious anemia, with Results: 49 subjects were tested. Most subjects (10th to the first signs of vitamin B12 deficiency being neurological 90th percentile) had followed this diet 23–49 months. 6 [1]. Symptoms of neurological damage due to poor vita- subjects had serum B12 concentrations !147 pmol/l min B12 status include numbness and/or tingling in outer (200 pg/ml). 37 subjects (76%) had serum B12 concentra- extremities, decreased vibration sense and/or position tions !221 pmol/l (300 pg/ml). 23 subjects (47%) had sense, decreased visual acuity, unsteadiness, poor muscu- abnormal urinary MMA concentrations above or equal to lar coordination with ataxia, moodiness, mental slowness, 4.0 Ìg/mg creatinine. Sublingual cyanocobalamin and poor memory, confusion, agitation, depression, delusions, nutritional yeast, but not probiotic supplements, signifi- hallucinations, and even overt psychosis [1]. There is sig- cantly reduced group mean MMA concentrations (tablet nificant overlap in the symptom picture with Alzheimer- p ! 0.01; yeast p ! 0.05, probiotic 1 0.20). Conclusions: type dementia [2]. © 2000 S. Karger AG, Basel Michael S. Donaldson, PhD ABC 0250–6807/00/0446–0229$17.50/0 Hallelujah Acres Foundation Fax + 41 61 306 12 34 PO Box 2388 E-Mail [email protected] Accessible online at: Shelby, NC 28152 (USA) www.karger.com www.karger.com/journals/anm Tel. +1 704 481 1700, Fax +1 704 481 0345, E-Mail [email protected] Fig. 1. Initial vitamin B12 status. The graph is divided into four quadrants (I–IV), based on the normal ranges for serum B12 and urinary methylcobalamin. P = Subjects with elevated concentrations; j = subjects with normal MMA concentrations. Since true cobalamin is not found in any appreciable The main selection criterion for this study was adherence for at amount in plant foods [3], it would be expected that all least 2 years, preferably over 3 years, to a diet popularly referred to as the Hallelujah diet. A second citerion was that the subjects not be people avoiding animal products would eventually devel- consumers of vitamin B supplements. The Hallelujah diet is a pure op symptoms of vitamin B12 deficiency. However, it has vegetarian diet based on consumption of raw vegetables and fruit, been reported that vitamin B12 can be synthesized by bac- carrot juice, dehydrated juice from young barley plants, raw nuts and teria residing in the small intestine [4]. Furthermore, seeds, and limited amounts of cooked tubers and whole-grain prod- dehydrated cereal grasses have been reported to contain a ucts [5]. Two years was chosen as the minimal time to see vitamin B12 deficiency based on previous reports [6; see figure 1 in 7]. small amount of vitamin B12. Therefore, it was hypothe- A short food frequency questionnaire was used to test for correla- sized that a group of people following a pure vegetarian tions between food consumption and B12 status. This questionnaire diet consuming mostly raw fruits and vegetables, carrot included questions on frequency and amounts of foods suspected to juice, and dehydrated barley grass juice would be able to be sources of vitamin B12 (dehydrated juice from young barley plants, seaweed, nutritional yeast, fortified vegetarian foods) as well as ques- avoid vitamin B12 deficiency through natural means with- tions regarding animal product consumption and vitamin and miner- out the use of supplementary vitamin B12. al supplements. Adherence to the Hallelujah diet was also assessed using this questionnaire. Exposure to chlorine through municipal water supplies and swimming pools was also assessed. Subjects and Methods Blood samples were drawn and processed in accordance with lab- oratory guidelines. Serum vitamin B12 concentrations were assayed The subjects were recruited at an annual meeting of health minis- using an immunochemiluminometric method (Labcorp, Charlotte, ters, sponsored by Hallelujah Acres. The meeting was a health educa- N.C., USA). A spot urine sample was also collected from each sub- tion seminar open to people who had previously attended a seminar ject. Urine samples were analyzed by stable isotope dilution gas chro- on implementing the Hallelujah diet. Most of the attendees were matography mass spectrometry for the methylmalonic acid (MMA) active in promoting the Hallelujah diet in their communities. concentration, on the basis of creatinine content (Norman Clinical 230 Ann Nutr Metab 2000;44:229–234 Donaldson Laboratories, Cincinnati, Ohio, USA). The usefulness of serum co- In the initial screening, it was found that 2 men and balamin levels for diagnosing vitamin B deficiency has been ques- 12 4 women had serum B12 concentrations !147 pmol/l (200 tioned due to the low specificity of the cobalamin assay; the preferred pg/ml). All concentrations were 1118 pmol/l (160 pg/ml). test for diagnosis is the MMA assay [2, 8–12]. In a study of hospital ! patients [9], the urinary MMA assay was 100% sensitive and 99% 37 and 44 subjects had serum B12 concentrations 221 specific in identifying patients who were clinically vitamin B12 defi- and 257 pmol/l, respectively. cient. 8 men and 15 women had urinary MMA concentra- Subjects who had elevated urinary MMA concentrations were tions above or equal to 4.0 Ìg/mg creatinine (fig. 1). 16 asked to participate in a follow-up of this initial screening. Subjects subjects had urinary MMA concentrations equal to or were randomly assigned to three treatment groups. Men and women Ì were randomized separately to evenly divide each sex into the three above 5.0 g/mg creatinine. 2 subjects had serum B12 con- groups. The first group consumed a sublingual cyanocobalamin tab- centrations !147 pmol/l, but had normal urinary MMA let (500 Ìg; Twinlabs, Minneapolis, Minn., USA) for 3 days a week. concentrations. Only 4 individuals had a combination of Sublingual tablets have been shown to be very effective in improving elevated MMA concentrations and low serum B12 concen- vitamin B12 status [6, 13]. The second group daily consumed 1 table- trations. There was no correlation between MMA and spoon of nutritional yeast (Red Star Vegetarian Support Formula; Universal Foods, Milwaukee, Wisc., USA). This was an attempt to intake of vitamin B12 from foods, length of time following identify an acceptable food that would supply vitamin B12. One a meatless diet, length of time following the Hallelujah tablespoon contained about 5 Ìg of cyanocobalamin. The third group diet, or exposure to chlorinated water. daily consumed 2 capsules of one of two selected probiotic supple- Subjects who had elevated urinary MMA concentra- ments: Probiotic Formula (Natural Choice Products, Frenchtown, tions were asked to participate in a follow-up of this initial Mont., USA) and Flora Food (AIM International, Nampa, Idaho, USA). The Probiotic Formula contains the five bacteria Lactobacil- screening. 24 subjects (23 subjects with elevated MMA lus plantarum, Lactobacillus salivarius, Lactobacillus acidophilus, Bi- concentrations, and 1 subject with MMA equal to 3.9 Ìg/ fidobacterium bifidus and Bacillus subtilis. Flora Food contains L. mg) were randomly assigned to three treatment groups. salivarius and L. plantarum variant OM. The probiotics were used to Men and women were randomized separately to evenly test whether the bowel flora could be modified to produce vitamin divide each sex into the three groups as detailed above. B12 at physiologically relevant amounts. It was estimated that 3 months would be sufficient time to see a significant effect of the pro- After 3 months of follow-up, the subjects submitted a biotic supplements. Compliance was checked by self-report at the urine sample for MMA determination. As shown in fig- end of the follow-up period. After 3 months of follow-up, the subjects ure 2, sublingual cyanocobalamin and nutritional yeast submitted a urine sample for another MMA determination. significantly reduced all MMA concentrations (tablet p = An informed consent document explaining the study and the 0.01; yeast p = 0.05). 7 of 8 subjects’ MMA concentrations risks and benefits of participation was given to each volunteer before sampling. Written consent was obtained from subjects before partici- normalized using the sublingual tablet; one was slightly pation.