There's evidence chiropractic may treat back and neck pain, but what about chiropractic treatment of phobias, addiction, ADHD and other psychiatric disorders?

Before engaging in any complementary medical technique, you should be aware that many of these techniques have not been evaluated in scientific studies. Often, only limited information is available about their safety and effectiveness. Each state and each discipline has its own rules about whether practitioners are required to be professionally licensed. If you plan to visit a practitioner, it is recommended that you choose one who is licensed by a recognized national organization and who abides by the organization's standards. It is always best to speak with your primary health care provider before starting any new therapeutic technique.

• Background
• Theory
• Evidence
• Unproven Uses
• Potential Dangers
• Summary
• Resources

Background

Chiropractic focuses on the relationship between musculoskeletal structure (primarily the spine) and bodily function (primarily nervous system function) and on how this relationship affects the maintenance or improvement of health. Chiropractors use multiple therapeutic techniques. Chiropractic encompasses spinal manipulative therapy, diet, exercise, X-rays, and other therapeutic techniques such as interferential and electrogalvanic muscle stimulation.

Spinal manipulative therapy (or spinal manipulation) — a method of adjusting the spinal cord using hand pressure, twists and turns — is broad and includes many types of techniques, including those used by chiropractors.

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History: Rotation or movement of the spine plays a role in many healing traditions. Records of the use of spinal manipulative therapy date to ancient Chinese and Greek medicine.

The principles of modern chiropractic stem from the work of David Daniel Palmer in the late 1800s. Palmer believed that abnormal nerve function can cause medical disorders. He theorized that adjustment of the spine can improve health. Initially, Palmer's principles were not well received in the medical community, and some early chiropractors were imprisoned (including Palmer himself). A divide between chiropractors and medical doctors culminated in a successful antitrust lawsuit against the American Medical Association for bias against the chiropractic profession (1977-1987). Divisions have also existed in the chiropractic community regarding the extent to which chiropractic should be integrated with other health care fields.

Medicare has reimbursed for chiropractic since 1972. The Council on Chiropractic Education (CCE) adopted national standards in 1974, which are now recognized by the U.S. Department of Education.

Since 1975, the CCE has accredited all U.S. chiropractic colleges. Currently, all 50 U.S. states have statutes recognizing and regulating the practice of chiropractic. There are more than 60,000 licensed chiropractors in the United States, a number expected to reach 100,000 by 2010.

Techniques: Most visits to chiropractors are for musculoskeletal complaints, and almost half are for back pain. Clients usually lie facedown on a Cox table, which is similar to a massage table with an open space in which to place your face. Visits may last 15 minutes to one hour depending on the technique used. Chiropractors may see clients up to three times per week at first, then less frequently over time.

There are more than 100 chiropractic and spinal manipulative adjusting techniques, and practitioners may vary in their approaches. Techniques taught widely in chiropractic schools include:

• Diversified
• Extremity adjusting
• Activator
• Gonstead
• Cox flexion-distraction
• Thompson

Other techniques are taught outside of the established curriculum.

Diagnostic procedures such as X-ray, computed tomography, magnetic resonance imaging and thermography may be used, followed by treatment with ice packs, heat packs, electrical current or ultrasound therapy. Dietary counseling and nutritional support, plus exercise recommendations, may be offered.

Spinal manipulative therapy uses various techniques to apply force to an area of the spine or to a joint. Massage or mobilization of soft tissue is used in techniques such as myofascial trigger point therapy, cross-friction massage, active release therapy, muscle stripping or Rolfing® structural integration. Mechanical traction or the use of external resistance on an area of the spine or on an extremity may be used in certain people.

Theory

There are a number of traditional and scientific theories about the mechanism of action and potential health benefits of chiropractic and spinal manipulative therapy. However, the underlying effects of these therapies on the body are largely unknown.

Traditional hypotheses suggest that changes in normal relationships between the bones of the spine (vertebral bodies) or joints can result in health problems and that manipulation of these areas may correct these changes and improve function. There are more recent theories that nerve damage or compression, muscle spasm, soft-tissue adhesions or release of toxic chemicals from damaged soft tissues can be caused by abnormal spine or joint positioning, which can be improved with manipulation. Scientific research is limited in these areas.

Scientific studies in animals and humans report that abnormal positioning of the spine can alter the function of nerves coming from the spine and may alter heart rate and blood pressure. It is controversial whether spinal manipulative therapy affects the release of chemicals that influence pain and pleasure sensations, such as substance P and endorphins.

 

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Evidence

Scientists have studied chiropractic and spinal manipulative therapy for the following health problems:  

Tension headache, migraine headache
There are several studies of chiropractic techniques or spinal manipulative therapy in humans for the relief of tension or migraine headache. Although most of this research is not well designed, overall the evidence does suggest some benefits for prevention of episodic tension headaches. Effects on migraine headaches have not been shown. Better-quality research is necessary to make a strong conclusion. Patients should be aware of the safety concerns about the use of cervical or neck manipulation before starting this type of therapy.

Low back pain
There are more than 400 published studies and case reports about the use of chiropractic manipulation in patients with low back pain. Results are variable, with some studies reporting benefits, and others suggesting no effects. Although most research is not well designed or reported, the available scientific evidence overall suggests improvements in pain in patients with subacute or chronic low back pain. However, it is not clear that there are any benefits in patients with acute low back pain. Better-quality research is necessary to make a definitive conclusion.

Lumbar disk herniation
Multiple studies have examined the effects of spinal manipulative therapy in patients with herniated lumbar disks. Results are variable, with some studies reporting benefits, and others finding no effects. Better-quality research is necessary to make a clear conclusion.

Neck pain
Multiple studies have examined the effects of spinal manipulative therapy in patients with acute or chronic neck pain. Overall, the quality of studies has been poor. Better-quality research is necessary to make a clear conclusion.

Asthma
There are several studies of the effects of chiropractic spinal manipulative therapy on breathing and quality of life in children and adults with asthma. However, because of weaknesses in this research, no clear conclusions can be drawn.

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Carpal tunnel syndrome
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with carpal tunnel syndrome.

Cervical disk herniation
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with cervical disk herniation.

Chronic obstructive lung disease
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with chronic obstructive lung disease.

Chronic pelvic pain
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with chronic pelvic pain. Duodenal ulcers Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with ulcers.

Dysmenorrhea (painful menstruation)
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with dysmenorrhea.

Fibromyalgia
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with fibromyalgia.

High blood pressure
The effects of spinal manipulative techniques on blood pressure are controversial. There are many published studies and reviews in this area. Overall, the existing research is unclear. Better research is necessary to draw a clear conclusion. However, patients with low blood pressure or taking medications that may lower blood pressure should use caution because of a risk of additional decreases in blood pressure with manipulative therapies.

HIV/AIDS
Because there are a limited number of studies in humans and weaknesses in existing research, the effects of chiropractic techniques on CD4 count or quality of life in patients with HIV/AIDS is unclear.

Colic
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in infants with colic.

Jet lag
Early research suggests that chiropractic manipulation may not be helpful for the prevention of jet lag. However, because there are a limited number of studies in humans and weaknesses in existing research, the effects of chiropractic are unclear.

Nocturnal enuresis (bed-wetting)
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people who experience nocturnal enuresis.

Otitis media
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in patients with otitis media.

Parkinson's disease
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with Parkinson's disease.

Phobias
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with phobias.

Pneumonia
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with pneumonia.

Premenstrual syndrome
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with premenstrual syndrome.

Respiratory tract infections
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with respiratory tract infections.

Seizure disorders
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people who experience seizures.

Shoulder pain
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with shoulder pain.

Sprained ankle
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with ankle sprains.

Temporomandibular joint disorders
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with temporomandibular joint disorders.

Visual field loss
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with visual field loss.

Whiplash injuries
Despite promising preliminary results, there is not enough reliable scientific evidence to draw firm conclusions about the effects of chiropractic techniques in patients with whiplash injuries.

Tennis elbow
Preliminary evidence suggests that manipulation of the wrist may be effective for the management of tennis elbow. Additional study is warranted before a conclusion can be made.

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Unproven Uses

Chiropractic and spinal manipulative therapy have been suggested for many other uses, based on tradition or on scientific theories. However, these uses have not been thoroughly studied in humans, and there is limited scientific evidence about safety or effectiveness. Some of these suggested uses are for conditions that are potentially life-threatening. Consult with a health care provider before using chiropractic or spinal manipulative therapy for any use.

Acute respiratory distress syndrome Addiction Anxiety Attention-deficit hyperactivity disorder Cancer pain Complex regional pain syndrome Constipation Craniofacial disorders Glaucoma Head trauma Hip pain Immune enhancement Multiple sclerosis

Optic nerve damage Optic nerve ischemia Osteoarthritis Pancreatitis Postoperative atelectasis (diminished lung volume) Postoperative recovery Post-traumatic concussion syndrome Scoliosis Scotoma (a visual problem) Spinal stenosis Thoracic spine pain Vision restoration after head trauma Visual perception deficit

Potential Dangers

The safety of chiropractic techniques and spinal manipulative therapy is controversial. The most common side effects are thought to be discomfort in the area of treatment, stiffness, headache, and fatigue. These symptoms may occur in more than half of people undergoing spinal manipulation.

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There is scientific evidence that cervical spine or neck manipulation increases the chances of having a stroke. There are numerous published cases of stroke associated with cervical spine manipulation, affecting people aged anywhere from 20 to 60 years old. Death is reported very rarely.

There are rare reports of bleeding and blood clots in the spine with manipulation of the neck and back. Patients with blood-clotting disorders and those taking anticoagulant (blood-thinning) drugs such as warfarin (Coumadin) are at increased risk of side effects such as spinal bleeding after manipulative therapy.

Fractures to bones in the spine and nerve damage after manipulation have been reported in patients with osteomyelitis (bone infection), cancer involving bone, prior vertebral fractures, severe degenerative joint disease (osteoarthritis), osteoporosis and ankylosing spondylitis. Muscle strains, sprains and spasm after chiropractic manipulation have been reported, although it is not clear if these problems were related to the therapy or were pre-existing.

The effects of spinal manipulative techniques on blood pressure are controversial. Some studies report decreases in blood pressure, but better research is necessary to make a firm conclusion. There is a report of a heart attack that occurred during cervical spine manipulation, but it is not clear if manipulation played a role in this event. People with heart disease should check with their doctor before beginning spinal manipulative therapy.

Use of spinal manipulative therapy should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss spinal manipulative therapy or chiropractic with their primary care provider before starting treatment.

Summary

Chiropractic techniques and manipulative therapies have been suggested and used for many conditions. Preliminary evidence suggests benefits in patients with tension headache or low back pain. Better research is needed to make a strong conclusion. No other conditions have been sufficiently tested scientifically, partially because of technical difficulties involved with conducting research in this area. Many severe complications have been reported, including stroke, spinal cord damage, nerve compression, spinal bleeding, fracture and, very rarely, death. Patients with certain underlying medical conditions may be at increased risk. Speak with your health care provider if you are considering treatment. If you decide to begin therapy, be sure to inform the practitioner if you have an underlying medical condition.

The information in this monograph was prepared by the professional staff at Natural Standard, based on thorough systematic review of scientific evidence. The material was reviewed by the Faculty of the Harvard Medical School with final editing approved by Natural Standard.

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Resources

1. Natural Standard: An organization that produces scientifically based reviews of complementary and alternative medicine (CAM) topics
2. National Center for Complementary and Alternative Medicine (NCCAM): A division of the U.S. Department of Health & Human Services dedicated to research

Selected Scientific Studies: Chiropractic, Spinal Manipulative Therapy, Spinal Manipulation

Natural Standard reviewed more than 1,440 articles to prepare the professional monograph from which this version was created.

Some of the more recent English-language studies are listed below:

1. Brealey S, Burton K, Coulton S, et al. UK Back pain Exercise And Manipulation (UK BEAM) trial: national randomized trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578].
2. BMC Health Serv Res 2003;3(1):16.
3. Bronfort G, Assendelft WJ, Evans R, et al. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther 2001;24(7):457-466.
4. Cagnie B, Vinck E, Beernaert A, Cambier D. How common are side effects of spinal manipulation and can these side effects be predicted? Man Ther 2004;9(3):151-156.
5. Cooper RA, McKee HJ. Chiropractic in the United States: trends and issues. Milbank Q 2003;81(1):107-138.

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1. Di Duro JO. Stroke in a chiropractic patient population. Cerebrovasc Dis 2003;15(1-2):156. Ernst E. Spinal manipulation: its safety is uncertain. CMAJ 2002;166(1):40-41.
2. Ernst E, Harkness E. Spinal manipulation: a systematic review of sham-controlled, double-blind, randomized clinical trials. J Pain Symptom Manage 2001;22(4):879-889.
3. Evans W. Chiropractic care: attempting a risk-benefit analysis. Am J Public Health 2003;93(4):522-523.
4. Evans R, Bronfort G, Nelson B, et al. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine 2002;27(21):2383-2389.
5. Ferreira ML, Ferreira PH, Latimer J, et al. Efficacy of spinal manipulative therapy for low back pain of less than three months' duration. J Manipulative Physiol Ther 2003;26(9):593-601.
6. Foster J, Gates T, Van Arsdel G. A randomized controlled trial of chiropractic spinal manipulative therapy for migraines. J Manipulative Physiol Ther 2001;24(2):143.
7. Giles LG, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine 2003;28(14):1490-1502.
8. Haas M, Groupp E, Kraemer DF. Dose-response for chiropractic care of chronic low back pain. Spin J 2004;4(5):574-583.
9. Haldeman S, Carey P, Townsend M, et al. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ 2001;165(7):905-906.
10. Hartvigsen J, Bolding-Jensen O, Hviid H, et al. Danish chiropractic patients then and now: a comparison between 1962 and 1999. J Manipulative Physiol Ther 2003;26(2):65-69.
11. Hayden JA, Mior SA, Verhoef MJ. Evaluation of chiropractic management of pediatric patients with low back pain: a prospective cohort study. J Manipulative Physiol Ther 2003;26(1):1-8.
12. Hertzman-Miller RP, Morgenstern H, Hurwitz EL, et al. Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA low-back pain study. Am J Public Health 2002;92(10):1628-1633.
13. Hestoek L, Leboeuf-Yde C. Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review. J Manipulative Physiol Ther 2000;23(4):258-275.
14. Hoiriis KT, Pfleger B, McDuffie FC, et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative Physiol Ther 2004;27(6):388-398.
15. Hurley DA, McDonough SM, Baxter GD, et al. A descriptive study of the usage of spinal manipulative therapy techniques within a randomized clinical trial in acute low back pain. Man Ther 2005;10(1):61-67.
16. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine 1996;21(15):1746-1760.
17. Hurwitz EL, Meeker WC, Smith M. Chiropractic care: a flawed risk-benefit analysis? Am J Public Health 2003;93(4):523-524.
18. Hurwitz EL, Morgenstern H, Harber P, et al. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Am J Public Health 2002;92(10):1634-1641.
19. Jeret JS, Bluth M. Stroke following chiropractic manipulation: report of 3 cases and review of the literature. Cerebrovasc Dis 2002;13(3):210-213.
20. Koes BW, Assendelft WJ, van der Heijden GJ, et al. Spinal manipulation for low back pain: an updated systematic review of randomized clinical trials. Spine 1996;21(24):2860-2871.
21. Licht PB, Christensen HW, Hoilund-Carlsen PF. Is cervical spinal manipulation dangerous? J Manipulative Physiol Ther 2003;26(1):48-52.
22. Nadgir RN, Loevner LA, Ahmed T, et al. Simultaneous bilateral internal carotid and vertebral artery dissection following chiropractic manipulation: case report and review of the literature. Neuroradiology 2003;45(5):311-314.
23. Plaugher G, Long CR, Alcantara J, et al. Practice-based randomized controlled-comparison clinical trial of chiropractic adjustments and brief massage treatment at sites of subluxation in subjects with essential hypertension: pilot study. J Manipulative Physiol Ther 2002;25(4):221-239.
24. Proctor ML, Hing W, Johnson TC, et al. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2004;(3):CD002119.
25. Schneider J, Vuckovic N, DeBar L. Willingness to participate in complementary and alternative medicine clinical trials among patients with craniofacial disorders. J Altern Complement Med 2003;9(3):389-401.
26. Shekelle PG, Coulter I. Cervical spine manipulation: summary report of a systematic review of the literature and a multidisciplinary expert panel. J Spinal Disord 1997;10(3):223-228.
27. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003;60(9):1424-1428.
28. Struijs PA, Damen PJ, Bakker EW, et al. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Phys Ther 2003;83(7):608-616.
29. Wenban AB. Is chiropractic evidence based? A pilot study. J Manipulative Physiol Ther 2003;26(1):47.
30. Williams LS, Biller J. Vertebrobasilar dissection and cervical spine manipulation: a complex pain in the neck. Neurology 2003;60(9):1408-1409.

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Details on tests doctors use to make a diagnosis of Alzheimer's disease.

Alzheimer's Diagnosis

There is no definitive test for Alzheimer's disease, and a true diagnosis of Alzheimer's can only be made after a person dies and an autopsy is performed on the brain. All individuals with Alzheimer's have an accumulation of abnormal deposits (called plaque) and tangled nerve cells in their brains. The physician will try to narrow down a diagnosis, however, by eliminating the possibility of other illnesses. He or she will ask the individual (or a close family member) to describe the primary symptoms, and how long they have been noticeable.

The following tests may also be used to aid in the diagnosis of Alzheimer's.

• Psychological tests - assess the individual's memory and attention span. They may also reveal difficulties in problem-solving, social, and language skills.
• Electroencephalograph (EEG)—traces brain-wave activity. This test sometimes reveals "slow waves" in people with AD. Although other diseases may reveal similar brain-wave activity, EEGs help distinguish a person with AD from a severely depressed person, whose brain waves are normal.
• Imaging tests (such as CT, MRI, or PET)—computerized tomography (CT) or magnetic resonance imaging (MRI) can detect the presence of stroke, blood clots, and tumors (problems that cause AD-like symptoms but are not themselves related to AD). MRI, positron emission tomography (PET) scans, and other advanced imaging techniques may eventually be able to diagnose AD by identifying altered blood flow patterns in the brain.
• Blood test for Apo E4—although the presence of Apo E4 gene in the blood may suggest AD, it does not always make an accurate diagnosis.

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next: Treatment of Alzheimer's Disease

Detailed information about vitamin B12, vitamin B12 deficiency and vitamin B12 supplement.

Dietary Supplement Fact Sheet: Vitamin B12

Table of Contents

• What is vitamin B12?
• What foods provide vitamin B12?
• What is the recommended dietary intake for vitamin B12?
• When is a deficiency of vitamin B12 likely to occur?
• Do pregnant and/or lactating women need extra Vitamin B12?
• Who else may need a vitamin B12 supplement to prevent a deficiency?
• Drug : Nutrient Interactions
• Caution: Folic Acid and vitamin B12 deficiency
• What is the relationship between vitamin B12 homocysteine, and cardiovascular disease?
• Do healthy young adults need a vitamin B12 supplement?
• What is the health risk of too much vitamin B12?
• Selecting a healthful diet
• References

What is vitamin B12?

Vitamin B12 is also called cobalamin because it contains the metal cobalt. This vitamin helps maintain healthy nerve cells and red blood cells [1-4]. It is also needed to help make DNA, the genetic material in all cells [1-4]. Vitamin B12 is bound to the protein in food. Hydrochloric acid in the stomach releases B12 from proteins in foods during digestion. Once released, vitamin B12 combines with a substance called gastric intrinsic factor (IF). This complex can then be absorbed by the intestinal tract.

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What foods provide vitamin B12?

Vitamin B12 is naturally found in animal foods including fish, meat, poultry, eggs, milk, and milk products. Fortified breakfast cereals are a particularly valuable source of vitamin B12 for vegetarians [5-7]. Table 1 lists a variety of food sources of vitamin B12.

Table 1: Selected food sources of vitamin B12 [5]

Food	Micrograms (μg) per serving	Percent DV*
Mollusks, clam, mixed species, cooked, 3 ounces	84.1	1400
Liver, beef, braised, 1 slice	47.9	780
Fortified breakfast cereals, (100%) fortified), ¾ cup	6.0	100
Trout, rainbow, wild, cooked, 3 ounces	5.4	90
Salmon, sockeye, cooked, 3 ounces	4.9	80
Trout, rainbow, farmed, cooked, 3 ounces	4.2	50
Beef, top sirloin, lean, choice, broiled, 3 ounces	2.4	40
Fast Food, Cheeseburger, regular, double patty & bun, 1 sandwich	1.9	30
Fast Food, Taco, 1 large	1.6	25
Fortified breakfast cereals (25% fortified), ¾ cup	1.5	25
Yogurt, plain, skim, with 13 grams protein per cup, 1 cup	1.4	25
Haddock, cooked, 3 ounces	1.2	20
Clams, breaded & fried, ¾ cup	1.1	20
Tuna, white, canned in water, drained solids, 3 ounces	1.0	15
Milk, 1 cup	0.9	15
Pork, cured, ham, lean only, canned, roasted, 3 ounces	0.6	10
Egg, whole, hard boiled, 1	0.6	10
American pasteurized cheese food, 1 ounces	0.3	6
Chicken, breast, meat only, roasted, ½ breast	0.3	6

*DV = Daily Value. DVs are reference numbers developed by the Food and Drug Administration (FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for vitamin B12 is 6.0 micrograms (μg). Most food labels do not list a food's vitamin B12 content. The percent DV (%DV) listed on the table indicates the percentage of the DV provided in one serving. A food providing 5% of the DV or less is a low source while a food that provides 10-19% of the DV is a good source. A food that provides 20% or more of the DV is high in that nutrient. It is important to remember that foods that provide lower percentages of the DV also contribute to a healthful diet. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient Database Web site: http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl.

References

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What is the recommended dietary intake for vitamin B12?

Recommendations for vitamin B12 are provided in the Dietary Reference Intakes (DRIs) developed by the Institute of Medicine of the National Academy of Sciences [7]. Dietary Reference Intakes is the general term for a set of reference values used for planning and assessing nutrient intake for healthy people. Three important types of reference values included in the DRIs are Recommended Dietary Allowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake Levels (UL). The RDA recommends the average daily intake that is sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals in each age and gender group [7]. An AI is set when there is insufficient scientific data available to establish a RDA. AIs meet or exceed the amount needed to maintain a nutritional state of adequacy in nearly all members of a specific age and gender group [7]. The UL, on the other hand, is the maximum daily intake unlikely to result in adverse health effects [7]. Table 2 lists the RDAs for vitamin B12, in micrograms (μg), for children and adults.

Table 2: Recommended Dietary Allowances (RDA) for vitamin B12 for children and adults [7]

Age (years)	Males and Females (μg/day)	Pregnancy (μg/day)	Lactation (μg/day)
1-3	0.9	N/A	N/A
4-8	1.2	N/A	N/A
9-13	1.8	N/A	N/A
14-18	2.4	2.6	2.8
19 and older	2.4	2.6	2.8

There is insufficient information on vitamin B12 to establish a RDA for infants. Therefore, an Adequate Intake (AI) has been established that is based on the amount of vitamin B12 consumed by healthy infants who are fed breast milk [7]. Table 3 lists the Adequate Intakes for vitamin B12, in micrograms (μg), for infants.

 

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Table 3: Adequate Intake for vitamin B12 for infants [7]

Age (years)	Males and Females (μg/day)	Pregnancy (μg/day)	Lactation (μg/day)
1-3	0.9	N/A	N/A
4-8	1.2	N/A	N/A
9-13	1.8	N/A	N/A
14-18	2.4	2.6	2.8
19 and older	2.4	2.6	2.8

When is a deficiency of vitamin B12 likely to occur?

Results of two national surveys, the National Health and Nutrition Examination Survey (NHANES III-1988-94) [8] and the Continuing Survey of Food Intakes by Individuals (CSFII 1994-96) found that most children and adults in the United States (U.S.) consume recommended amounts of vitamin B12 [6-8]. A deficiency may still occur as a result of an inability to absorb B12 from food and in strict vegetarians who do not consume any animal foods [9]. As a general rule, most individuals who develop a vitamin B12 deficiency have an underlying stomach or intestinal disorder that limits the absorption of vitamin B12 [10]. Sometimes the only symptom of these intestinal disorders is subtly reduced cognitive function resulting from early B12 deficiency. Anemia and dementia follow later [1,11].

Signs, symptoms, and health problems associated with vitamin B12 deficiency

• Characteristic signs, symptoms, and health problems associated with B12 deficiency include anemia, fatigue, weakness, constipation, loss of appetite, and weight loss [1,3,12].

• Deficiency also can lead to neurological changes such as numbness and tingling in the hands and feet [7,13].

• Additional symptoms of B12 deficiency are difficulty in maintaining balance, depression, confusion, dementia, poor memory, and soreness of the mouth or tongue [14].

• Signs of vitamin B12 deficiency in infancy include failure to thrive, movement disorders, delayed development, and megaloblastic anemia [15].

Many of these symptoms are very general and can result from a variety of medical conditions other than vitamin B12 deficiency. It is important to have a physician evaluate these symptoms so that appropriate medical care can be given.

References

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Do pregnant and/or lactating women need extra Vitamin B12?

During pregnancy, nutrients travel from mother to fetus through the placenta. Vitamin B12, like other nutrients, is transferred across the placenta during pregnancy. Breast-fed infants receive their nutrition, including vitamin B12, through breast milk. Vitamin B12 deficiency in infants is rare but can occur as a result of maternal insufficiency [15]. For example, breast-fed infants of women who follow strict vegetarian diets have very limited reserves of vitamin B12 and can develop a vitamin B12 deficiency within months of birth [7,16]. This is of particular concern because undetected and untreated vitamin B12 deficiency in infants can result in permanent neurologic damage. Consequences of such neurologic damage are severe and can be irreversible. Mothers who follow a strict vegetarian diet should consult with a pediatrician regarding appropriate vitamin B12 supplementation for their infants and children [7]. They should also discuss their own need for vitamin B12 supplementation with their personal physician.

Who else may need a vitamin B12 supplement to prevent a deficiency?

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  Individuals with pernicious anemia or with gastrointestinal disorders may benefit from or require a vitamin B12 supplement.

• Older adults and vegetarians may benefit from a vitamin B12 supplement or an increased intake of foods fortified with vitamin B12.

• Some medications may decrease absorption of vitamin B12. Chronic use of those medications may result in a need for supplemental B12.

Individuals with pernicious anemia
Anemia is a condition that occurs when there is insufficient hemoglobin in red blood cells to carry oxygen to cells and tissues. Common signs and symptoms of anemia include fatigue and weakness. Anemia can result from a variety of medical problems, including deficiencies of vitamin B12, vitamin B6, folate and iron. Pernicious anemia is the name given more than a century ago to describe the then-fatal vitamin B12 deficiency anemia that results from severe gastric atrophy, a condition that prevents gastric cells from secreting intrinsic factor. Intrinsic factor is a substance normally present in the stomach. Vitamin B12 must bind with intrinsic factor before it can be absorbed and used by your body [7,17-18]. An absence of intrinsic factor prevents normal absorption of B12 and results in pernicious anemia.

Most individuals with pernicious anemia need parenteral (deep subcutaneous) injections (shots) of vitamin B12 as initial therapy to replenish depleted body B12 stores. Body stores of vitamin B12 can then be managed by a daily oral supplement of B12. A physician will manage the treatment required to maintain the vitamin B12 status of individuals with pernicious anemia.

Individuals with gastrointestinal disorders
Individuals with stomach and small intestinal disorders may be unable to absorb enough vitamin B12 from food to maintain healthy body stores [19]. Intestinal disorders that may result in malabsorption of vitamin B12 include:

• Sprue, often referred to as Celiac Disease (CD), is a genetic disorder. People with CD are intolerant to a protein called gluten. In CD, gluten can trigger damage to the small intestines, where most nutrient absorption occurs. People with CD often experience nutrient malabsorption. They need to follow a gluten free diet to avoid malabsorption and other symptoms of CD.

• Crohn's Disease is an inflammatory bowel disease that affects the small intestines. People with Crohn's disease often experience diarrhea and nutrient malabsorption.

• Surgical procedures in the gastrointestinal tract, such as surgery to remove all or part of the stomach, often result in a loss of cells that secrete stomach acid and intrinsic factor [7,20-21]. Surgical removal of the distal ileum, a section of the intestines, also can result in the inability to absorb vitamin B12. Anyone who has had either of these surgeries usually requires lifelong supplemental B12 to prevent a deficiency. These individuals would be under the routine care of a physician, who would periodically evaluate vitamin B12 status and recommend appropriate treatment.

Older adults
Gastric acid helps release vitamin B12 from the protein in food. This must occur before B12 binds with intrinsic factor and is absorbed in your intestines. Atrophic gastritis, which is an inflammation of the stomach, decreases gastric secretion. Less gastric acid decreases the amount of B12 separated from proteins in foods and can result in poor absorption of vitamin B12 [10,22-26]. Decreased gastric secretion also results in overgrowth of normal bacterial flora in the small intestines. The bacteria may take up vitamin B12 for their own use, further contributing to a vitamin B12 deficiency [27].

Up to 30 percent of adults 50 years and older may have atrophic gastritis, an overgrowth of intestinal flora, and be unable to normally absorb vitamin B12 in food. They are, however, able to absorb the synthetic B12 added to fortified foods and dietary supplements. Vitamin supplements and fortified foods may be the best sources of vitamin B12 for adults over the age of 50 [7].

References

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Researchers have long been interested in the potential connection between vitamin B12 deficiency and dementia [28]. A recent review examined correlations between cognitive skills, homocysteine levels, and blood levels of folate, vitamin B12 and vitamin B6. The authors suggested that vitamin B12 deficiency may decrease levels of substances needed for the metabolism of neurotransmitters [29]. Neurotransmitters are chemicals that transmit nerve signals. Reduced levels of neurotransmitters may result in cognitive impairment. In 142 individuals considered at risk for dementia, researchers found that a daily supplement providing 2 milligrams (mg) folic acid and 1 mg B12, taken for 12 weeks, lowered homocysteine levels by 30%. They also demonstrated that cognitive impairment was significantly associated with elevated plasma total homocysteine. However, the decrease in homocysteine levels seen with vitamin supplementation did not improve cognition [30]. It is too soon to make any recommendations, but is an intriguing area of research.

Vegetarians
The popularity of vegetarian diets has risen along with an interest in avoiding meat and meat products for environmental, philosophical, and health reasons. However, the term vegetarianism is subject to a wide range of interpretations. Some people consider themselves to be vegetarian when they avoid red meat. Others believe that vegetarianism requires avoidance of all animal products, including meat, poultry, fish, eggs, and dairy foods. The most commonly described forms of vegetarianism include:

• "Lacto-ovo vegetarians", who avoid meat, poultry, and fish products but consume eggs and dairy foods

• "Strict vegetarians", who avoid meat, poultry, fish, eggs, and dairy foods

• "Vegans", who avoid meat, poultry, fish, eggs, and dairy foods but also do not use animal products such as honey, leather, fur, silk, and wool

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Strict vegetarians and vegans are at greater risk of developing vitamin B12 deficiency than lacto-ovo vegetarians and non-vegetarians because natural food sources of vitamin B12 are limited to animal foods [7]. Fortified cereals are one of the few sources of vitamin B12 from plants, and are an important dietary source of B12 for strict vegetarians and vegans. Strict vegetarians and vegans who do not consume plant foods fortified with vitamin B12 need to consider taking a dietary supplement that contains vitamin B12 and should discuss the need for B12 supplementation with their physician.

There is wide belief that vitamin B12 can be consistently obtained from nutritional yeasts. Consumers should be aware that these products may or may not contain added nutrients such as vitamin B12. Dietary supplements are regulated as foods rather than drugs, and companies that sell supplements such as nutritional yeasts fortified with vitamin B12 can legally change their formulation at any time. If you choose to supplement, select reliable sources of vitamin B12 and read product labels carefully.

When adults adopt a strict vegetarian diet, deficiency symptoms can be slow to appear. It may take years to deplete normal body stores of B12. However, breast-fed infants of women who follow strict vegetarian diets have very limited reserves of vitamin B12 and can develop a vitamin B12 deficiency within months [7]. This is of particular concern because undetected and untreated vitamin B12 deficiency in infants can result in permanent neurologic damage. Consequences of such neurologic damage are severe and can be irreversible. There are many case reports in the literature of infants and children who suffered consequences of vitamin B12 deficiency. It is very important for mothers who follow a strict vegetarian diet to consult with a pediatrician regarding appropriate vitamin B12 supplementation for their infants and children [7].

References

Drug : Nutrient Interactions

Table 4 summarizes several drugs that potentially influence vitamin B12 absorption.

Table 4: Important vitamin B12/drug interactions

Drug	Potential Interaction
Proton Pump Inhibitors (PPIs) are used to treat gastroesophageal reflux disease (GERD) and peptic ulcer disease. Examples of PPIs are Omeprazole (Prilosec©) and Lansoprazole (Prevacid©)	PPI medications can interfere with vitamin B12 absorption from food by slowing the release of gastric acid into the stomach [31-33]. This is a concern because acid is needed to release vitamin B12 from food prior to absorption. So far, however, there is no evidence that these medications promote vitamin B12 deficiency, even after long-term use [34].
H2 receptor antagonists are used to treat peptic ulcer disease. Examples are Tagament©, Pepsid©, and Zantac©	H2 receptor antagonists can interfere with vitamin B12 absorption from food by slowing the release of gastric acid into the stomach. This is a concern because acid is needed to release vitamin B12 from food prior to absorption. So far, however, there is no evidence that these medications promote vitamin B12 deficiency, even after long-term use [34].
Metformin© is a drug used to treat diabetes.	Metformin© may interfere with calcium metabolism [35]. This may indirectly reduce vitamin B12 absorption because vitamin B12 absorption requires calcium [35]. Surveys suggest that from 10% to 30% of patients taking Metformin© have evidence of reduced vitamin B12 absorption [35].

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In a study involving 21 subjects with type 2 diabetes, researchers found that 17 who were prescribed Metformin© experienced a decrease in vitamin B12 absorption. Researchers also found that supplementation with calcium carbonate (1200 milligrams per day) helped limit the effect of Metformin© on vitamin B12 absorption in these individuals [35].

Although these medications may interact with the absorption of vitamin B12, they are necessary to take for certain conditions. It is important to consult with a physician and registered dietitian to discuss the best way to maintain vitamin B12 status when taking these medications.

Caution: Folic Acid and vitamin B12 deficiency

Folic acid can correct the anemia that is caused by vitamin B12 deficiency. Unfortunately, folic acid will not correct the nerve damage also caused by B12 deficiency [1,36]. Permanent nerve damage can occur if vitamin B12 deficiency is not treated. Folic acid intake from food and supplements should not exceed 1,000 micrograms (μg) daily in healthy individuals because large amounts of folic acid can trigger the damaging effects of vitamin B12 deficiency [7]. Adults older than 50 years who take a folic acid supplement should ask their physician or qualified health care provider about their need for vitamin B12 supplementation.

What is the relationship between vitamin B12 homocysteine, and cardiovascular disease?

Cardiovascular disease involves any disorder of the heart and blood vessels that make up the cardiovascular system. Coronary heart disease occurs when blood vessels which supply the heart become clogged or blocked, increasing the risk of a heart attack. Vascular damage can also occur to blood vessels supplying the brain, and can result in a stroke.

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Cardiovascular disease is the most common cause of death in industrialized countries such as the U.S., and is on the rise in developing countries. The National Heart, Lung, and Blood Institute of the National Institutes of Health has identified many risk factors for cardiovascular disease, including an elevated LDL-cholesterol level, high blood pressure, a low HDL-cholesterol level, obesity, and diabetes [37]. In recent years, researchers have identified another risk factor for cardiovascular disease, an elevated homocysteine level. Homocysteine is an amino acid normally found in blood, but elevated levels have been linked with coronary heart disease and stroke [38-47]. Elevated homocysteine levels may impair endothelial vasomotor function, which determines how easily blood flows through blood vessels. High levels of homocysteine also may damage coronary arteries and make it easier for blood clotting cells called platelets to clump together a form a clot, which may lead to a heart attack [43].

Vitamin B12, folate, and vitamin B6 are involved in homocysteine metabolism. In fact, a deficiency of vitamin B12, folate, or vitamin B6 may increase blood levels of homocysteine. Recent studies found that supplemental vitamin B12 and folic acid decreased homocysteine levels in subjects with vascular disease and in young adult women. The most significant drop in homocysteine level was seen when folic acid was taken alone [48-49]. A significant decrease in homocysteine levels also occurred in older men and women who took a multivitamin/ multimineral supplement for 56 days [50]. The supplement taken provided 100% of Daily Values (DVs) for nutrients in the supplement.

Evidence supports a role for supplemental folic acid and vitamin B12 for lowering homocysteine levels, however this does not mean that these supplements will decrease the risk of cardiovascular disease. Clinical intervention trials are underway to determine whether supplementation with folic acid, vitamin B12, and vitamin B6 can lower risk of coronary heart disease. It is premature to recommend vitamin B12 supplements for the prevention of heart disease until results of ongoing randomized, controlled clinical trials positively link increased vitamin B12 intake from supplements with decreased homocysteine levels AND decreased risk of cardiovascular disease.

Do healthy young adults need a vitamin B12 supplement?

It is generally accepted that older adults are at greater risk of developing a vitamin B12 deficiency than younger adults. One study, however, suggests that the prevalence of B12 deficiency in young adults may be greater than previously thought. This study found that the percentage of subjects in three age groups (26 to 49y, 50 to 64y, and 65y and older) with deficient blood levels of vitamin B12 was similar across all age groups but that symptoms of B12 deficiency were not as apparent in younger adults. This study also suggested that those who did not take a supplement containing vitamin B12 were twice as likely to be B12 deficient as supplement users, regardless of age group. However, non-supplement users who consumed fortified cereal more than 4 times per week did appear to be protected from deficient blood levels of B12. Better tools and standards to diagnose B12 deficiencies are needed to make specific recommendations about the appropriateness of vitamin B12 supplements for younger adults [51].

References

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What is the health risk of too much vitamin B12?

The Institute of Medicine of the National Academy of Sciences did not establish a Tolerable Upper Intake Level for this vitamin because Vitamin B12 has a very low potential for toxicity. The Institute of Medicine states that "no adverse effects have been associated with excess vitamin B12 intake from food and supplements in healthy individuals" [7]. In fact, the Institute recommends that adults over 50 years of age get most of their vitamin B12 from vitamin supplements or fortified food because of the high incidence of impaired absorption of B12 from animal foods in this age group [7].

Selecting a healthful diet

As the 2000 Dietary Guidelines for Americans states, "Different foods contain different nutrients and other healthful substances. No single food can supply all the nutrients in the amounts you need" [52]. For more information about building a healthful diet, refer to the Dietary Guidelines for Americans http://www.usda.gov/cnpp/DietGd.pdf [52] and the US Department of Agriculture's Food Guide Pyramid http://www.nal.usda.gov/fnic/Fpyr/pyramid.html [53].

Source: Office of Dietary Supplements, National Institutes of Health

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References

• 1 Herbert V. Vitamin B12 in Present Knowledge in Nutrition. 17th ed. Washington, D.C.: International Life Sciences Institute Press, 1996.
• 2 Herbert V and Das K. Vitamin B12 in Modern Nutrition in health and disease. 8th ed. Baltimore: Williams & Wilkins, 1994.
• 3 Combs G. Vitamin B12 in The Vitamins. New York: Academic Press, Inc, 1992.

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• 4 Zittoun J and Zittoun R. Modern clinical testing strategies in cobalamin and folate deficiency. Sem Hematol 1999;36:35-46. [PubMed abstract]
• 5 U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl.
• 6 Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary sources of nutrients among US adults, 1989 to 1991. J Am Diet Assoc 1998;98:537-47. [PubMed abstract]
• 7 Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: Thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. National Academy Press. Washington, DC, 1998.
• 8 Bialostosky K, Wright JD, Kennedy-Stephenson J, McDowell M, Johnson CL. Dietary intake of macronutrients, micronutrients and other dietary constituents: United States 1988-94. Vital Heath Stat. 11(245) ed: National Center for Health Statistics , 2002.
• 9 Markle HV. Cobalamin. Crit Rev Clin Lab Sci 1996;33:247-356. [PubMed abstract]
• 10 Carmel R. Cobalamin, the stomach, and aging. Am J Clin Nutr 1997;66:750-9. [PubMed abstract]
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• 12 Bernard MA, Nakonezny PA, Kashner TM. The effect of vitamin B12 deficiency on older veterans and its relationship to health. J Am Geriatr Soc 1998;46:1199-206. [PubMed abstract]
• 13 Healton EB, Savage DG, Brust JC, Garrett TF, Lindenbaum J. Neurological aspects of cobalamin deficiency. Medicine 1991;70:229-244. [PubMed abstract]
• 14 Bottiglieri T. Folate, vitamin B12, and neuropsychiatric disorders. Nutr Rev 1996;54:382-90. [PubMed abstract]
• 15 Monsen ALB and Ueland PM. Homocysteine and methylmalonic acid in diagnosis and risk assessment from infancy to adolescent. American Journal of Clinical Nutrition 2003; 78:7-21.
• 16 von Schenck U, Bender-Gotze C, Koletzko B. Persistence of neurological damage induced by dietary vitamin B12 deficiency in infancy. Arch Dis Childhood 1997;77:137-9.
• 17 Gueant JL, Safi A, Aimone-Gastin I, Rabesona H, Bronowicki J P, Plenat F, Bigard MA, Heartle T. Autoantibodies in pernicious anemia type I patients recognize sequence 251-256 in human intrinsic factor. Proc Assoc Am Physicians 1997;109:462-9. [PubMed abstract]
• 18 Kapadia CR. Vitamin B12 in health and disease: part I--inherited disorders of function, absorption, and transport. Gastroenterologist 1995;3:329-44. [PubMed abstract]
• 19 Carmel R. Malabsorption of food cobalamin. Baillieres Clin Haematol 1995;8:639-55. [PubMed abstract]
• 20 Sumner AE, Chin MM, Abraham JL, Gerry GT, Allen RH, Stabler SP. Elevated methylmalonic acid and total homocysteine levels show high prevalence of vitamin B12 deficiency after gastric surgery. Ann Intern Med 1996;124:469-76. [PubMed abstract]
• 21 Brolin RE, Gorman JH, Gorman RC, Petschenik A J, Bradley L J, Kenler H A, Cody R P. Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass? J Gastrointest Surg 1998;2:436-42. [PubMed abstract]
• 22 Huritz A, Brady DA, Schaal SE, Samloff IM, Dedon J, Ruhl CE. Gastric acidity in older adults. J Am Med Assoc 1997;278:659-62. [PubMed abstract]
• 23 Andrews GR, Haneman B, Arnold BJ, Booth JC, Taylor K. Atrophic gastritis in the aged. Australas Ann Med 1967;16:230-5. [PubMed abstract]
• 24 Johnsen R, Bernersen B, Straume B, Forder OH, Bostad L, Burhol PG. Prevalence of endoscopic and histological findings in subjects with and without dyspepsia. Br Med J 1991;302:749-52. [PubMed abstract]
• 25 Krasinski SD, Russell R, Samloff IM, Jacob RA, Dalal GE, McGandy RB, Hartz SC. Fundic atrophic gastritis in an elderly population: Effect on hemoglobin and several serum nutritional indicators. J Am Geriatr Soc 1986;34:800-6. [PubMed abstract]
• 26 Carmel R. Prevalence of undiagnosed pernicious anemia in the elderly. Arch Intern Med 1996;156:1097-100. [PubMed abstract]
• 27 Suter PM, Golner BB, Goldin BR, Morrow FD, Russel RM. Reversal of protein-bound vitamin B12 malabsorption with antibiotics in atrophic gastritis. Gastroenterology 1991; 101:1039-45.
• 28 Carmel R. Megaloblastic anemias. Curr Opin Hematol 1994;1:107-12. [PubMed abstract]
• 29 Hutto BR. Folate and cobalamin in psychiatric illness. Comprehensive Psychiatry 1997;38:305-14.
• 30 Vital Trial Collaborative Group. Effect of vitamins and aspirin on markers of platelet activation, oxidative stress and homocysteine in people at high risk of dementia. Journal of Internal Medicine 2003; 254:67-75.
• 31 Bradford GS and Taylor CT. Omeprazole and vitamin B12 deficiency. Annals of Pharmacotherapy 1999;33:641-3
• 32 Kasper H. Vitamin absorption in the elderly. International Journal of Vitamin and Nutrition Research 1999;69:169-72.
• 33 Howden CW. Vitamin B12 levels during prolonged treatment with proton pump inhibitors. J Clin Gastroenterol 2000;30:29-33.
• 34 Termanini B, Gibril F, Sutliff VE, Yu F, Venzon DJ, Jensen RT. Effect of Long-Term Gastric Acid Suppressive Therapy on Serum Vitamin B12 Levels in Patients with Zollinger-Ellison Syndrome. American Journal of Medicine 1998; 104: 422-30.
• 35 Bauman WA, Shaw S, Jayatilleke K, Spungen AM, Herbert V. Increased intake of calcium reverses the B12 malabsorption induced by metformin. Diabetes Care 2000;23:1227-31.
• 36 Chanarin I. Adverse effects of increased dietary folate. Relation to measures to reduce the incidence of neural tube defects. Clin Invest Med 1994;17:244-52.
• 37 Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). National Cholesterol Education Program, NationalHeart, Lung, and Blood Institute, National Institues of Health, September 2002. NIH Publication No. 02-5215.
• 38 Selhub J, Jacques PF, Bostom AG, D'Agostino RB, Wilson PW, Belanger AJ, O'Leary DH, Wolf PA, Scaefer EJ, Rosenberg IH. Association between plasma homocysteine concentrations and extracranial carotid-artery stenosis. N Engl J Med 1995;332:286-91. [PubMed abstract]
• 39 Rimm EB, Willett WC, Hu FB, Sampson L, Colditz G A, Manson J E, Hennekens C, Stampfer M J. Folate and vitamin B6 from diet and supplements in relation to risk of coronary heart disease among women. J Am Med Assoc 1998;279:359-64. [PubMed abstract]
• 40 Refsum H, Ueland PM, Nygard O, Vollset SE. Homocysteine and cardiovascular disease. Annu Rev Med 1998;49:31-62. [PubMed abstract]
• 41 Boers GH. Hyperhomocysteinemia: A newly recognized risk factor for vascular disease. Neth J Med 1994;45:34-41. [PubMed abstract]
• 42 Selhub J, Jacques PF, Wilson PF, Rush D, Rosenberg IH. Vitamin status and intake as primary determinants of homocysteinemia in an elderly population. J Am Med Assoc 1993;270:2693-8. [PubMed abstract]
• 43 Malinow MR. Plasma homocyst(e)ine and arterial occlusive diseases: A mini-review. Clin Chem 1995;41:173-6. [PubMed abstract]
• 44 Flynn MA, Herbert V, Nolph GB, Krause G. Atherogenesis and the homocysteine-folate-cobalamin triad: do we need standardized analyses? J Am Coll Nutr 1997;16:258-67. [PubMed abstract]
• 45 Fortin LJ, Genest J, Jr. Measurement of homocyst(e)ine in the prediction of arteriosclerosis. Clin Biochem 1995;28:155-62. [PubMed abstract]
• 46 Siri PW, Verhoef P, Kok FJ. Vitamins B6, B12, and folate: Association with plasma total homocysteine and risk of coronary atherosclerosis. J Am Coll Nutr 1998;17:435-41. [PubMed abstract]
• 47 Ubbink JB, van der Merwe A, Delport R, Allen R H, Stabler S P, Riezler R, Vermaak WJ. The effect of a subnormal vitamin B6 status on homocysteine metabolism. J Clin Invest 1996;98:177-84. [PubMed abstract]
• 48 Bronstrup A, Hages M, Prinz-Langenohl R, Pietrzik K. Effects of folic acid and combinations of folic acid and vitamin B12 on plasma homocysteine concentrations in healthy, young women. Am J Clin Nutr 1998;68:1104-10.
• 49 Clarke R. Lowering blood homocysteine with folic acid based supplements. Brit Med Journal 1998:316: 894-8.
• 50 McKay DL, Perrone G, Rasmussen H, Dallal G, Blumberg JB. Multivitamin/Mineral Supplementation Improves Plasma B-Vitamin Status and Homocysteine Concentration in Healthy Older Adults Consuming a Folate-Fortified Diet. Journal of Nutrition 2000;130:3090-6.
• 51 Tucker KL, Rich S, Rosenberg I, Jacques P, Dallal G, Wilson WF, Selhub. J. Plasma vitamin B12 concentrations relate to intake source in the Framingham Offspring Study. Am J Clin Nutr 2000;71:514-22.
• 52 Dietary Guidelines Advisory Committee, Agricultural Research Service, United States Department of Agriculture (USDA). HG Bulletin No. 232, 2000. http://www.usda.gov/cnpp/DietGd.pdf .
• 53 Center for Nutrition Policy and Promotion, United Stated Department of Agriculture. Food Guide Pyramid, 1992 (slightly revised 1996). http://www.nal.usda.gov/fnic/Fpyr/pyramid.html.

Disclaimer

Reasonable care has been taken in preparing this document and the information provided herein is believed to be accurate. However, this information is not intended to constitute an "authoritative statement" under Food and Drug Administration rules and regulations.

General Safety Advisory

Health professionals and consumers need credible information to make thoughtful decisions about eating a healthful diet and using vitamin and mineral supplements. To help guide those decisions, registered dietitians at the NIH Clinical Center developed a series of Fact Sheets in conjunction with ODS. These Fact Sheets provide responsible information about the role of vitamins and minerals in health and disease. Each Fact Sheet in this series received extensive review by recognized experts from the academic and research communities.

The information is not intended to be a substitute for professional medical advice. It is important to seek the advice of a physician about any medical condition or symptom. It is also important to seek the advice of a physician, registered dietitian, pharmacist, or other qualified health professional about the appropriateness of taking dietary supplements and their potential interactions with medications.

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• Watch the video on Pathological Narcissistic Space

Question:

The behaviour of narcissists is very inconsistent. It is as though two distinct personalities occupy the same body simultaneously. How could this be explained?

Answer:

The narcissist is chronically depressed and anhedonic (finds no pleasure in life). Unable to love and, in the long run (as a result), unloved, the narcissist is ever in the pursuit of excitement and drama intended to alleviate his all-pervasive boredom and melancholy. The narcissist is a drama queen.

Needless to say that both the pursuit itself and its goals must conform to the grandiose vision that the narcissist has of his (False) Self. They must be commensurate with his view of his own uniqueness and entitlement.

The process of seeking excitement and drama cannot be deemed by the narcissist or by others to be humiliating, belittling or common. The excitement and drama generated must be truly unique, ground breaking, breathtaking, overwhelming, unprecedented, and, under no circumstances, routine.

Actually, the very act of dramatisation is intended to secure ego-syntony. "Surely, the dramatic is special, meaningful, eternal, and memorable" - says the narcissist to himself - "Just like me. I, myself, am dramatic (therefore I exist)." The narcissist - always a pathological liar and the chief victim of his own stratagems and deceit - can (and does) convince himself that his antics and exploits are significant.

Thus, existential boredom, self-directed aggression (depression), and the compulsive quest for excitement and titillating drama lead to the relentless pursuit of Narcissistic Supply (NS).

The processes of obtaining, preserving, accumulating and recalling Narcissistic Supply take place in the Pathological Narcissistic Space (PNS). This is an imaginary environment, a comfort zone, invented by the narcissist. It has clear geographical and physical boundaries: a home, a neighbourhood, a city, a country.

The narcissist strives to maximise the amount of Narcissistic Supply that he derives from people within the PNS. There, he seeks admiration, adoration, approval, applause, or, as a minimum: attention. If not fame - then notoriety. If not real achievements - then contrived or imagined ones. If not real distinction - then concocted and forced "uniqueness".

Narcissistic Supply substitutes for having a real vocation or avocation and actual achievements. It displaces the emotional rewards of intimacy in mature relationships. The narcissist is ruefully aware of this substitutive nature, of his inability to have a go at "the real thing". His permanent existence in fantasyland - intended to shield him from his self-destructive urges - paradoxically only enhances them.

This state of things makes him feel sad, enraged at his helplessness in the face of his disorder, and at the discrepancy between his delusions of grandeur and reality (the Grandiosity Gap). It is the engine of his growing disappointment and disillusionment, his anhedonia and impotence, his degeneration and ultimate ugly decadence.

 

 

The narcissist ages disgracefully, ungraciously. He is not a becoming sight as his defences crumble and harsh reality intrudes: the reality of his self-imposed mediocrity and wasted life. These flickers of sanity, these reminders of his downhill path get more ubiquitous with every day of confabulated existence.

The more fiercely the narcissist fights this painfully realistic appraisal of himself - the more apparent its veracity. Infiltrated by the Trojan Horse of his intelligence, the narcissist's defences are overwhelmed and this is followed by either spontaneous healing or a complete meltdown.

The narcissist's PNS incorporates people whose role is to applaud, admire, adore, approve and attend to the narcissist. Extracting Narcissistic Supply from them calls for emotional and cognitive investments, stability, perseverance, long-term presence, attachment, collaboration, emotional agility, people skills and so on.

But all this inevitable toil contradicts the deeply ingrained conviction of the narcissist that he is entitled to special and immediate preferential treatment. The narcissist expects to be instantaneously recognised as outstanding, talented, and unique. He does not see why this recognition should depend on his achievements and efforts. He feels that he is unique by virtue of his sheer existence. He feels that his very life is meaningful, that it encapsulates some cosmic message, mission, or process.

Narcissistic Supply obtained through the investment of efforts and resources, such as time, money and energy is to be expected, routine, mundane. In short: it is useless. Useful Narcissistic Supply is obtained miraculously, dramatically, excitingly, surprisingly, shockingly, unexpectedly and simply by virtue of the narcissist being there. No action is called for, as far as the narcissist is concerned. Cajoling, requesting, initiating, convincing, demonstrating, and begging for supply are all acts which starkly contrast with the grandiose delusions of the narcissist.

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Additionally, the narcissist is simply unable to behave in certain ways, even if he wanted to. He cannot get attached, be intimate, persevere, be stable, predictable, or reliable because such conduct contradicts the Emotional Involvement Prevention Measures (EIPM). This is a group of destabilising behaviours intended to forestall future emotional pain inflicted on the narcissist when he is abandoned or when he fails.

If the narcissist does not get attached - he cannot be hurt. If not intimate - he cannot be emotionally (or otherwise) blackmailed. If he does not persevere - he has nothing to lose. If he does not stay put - he cannot be expelled. If he rejects or abandons - he cannot be rejected or abandoned.

The narcissist anticipates the inevitable schisms and emotional abysses in a life fraught with gross dishonesty. He shoots first. Indeed, it is only when he is physically mobile and besieged by problems that the narcissist has a respite from his maddeningly nagging addiction to Narcissistic Supply.

This is the basic conflict of the narcissist. The two mechanisms underlying his distorted personality are incompatible. One calls for the establishment of a PNS and for the continuous gratification. The other urges the narcissist not to embark on any long-term project, to move, to disconnect, to dissociate.

Only others can provide the narcissist with his badly needed doses of Narcissistic Supply. But he is loath to communicate and to associate with them in an emotionally meaningful way. The narcissist lacks the basic skills required in order to obtain his drug. The very people who are supposed to sustain his grandiose fantasies through their adoration and attention - mostly find him too repulsive, eccentric (weird) or dangerous to interact with. This predicament can be aptly called The Narcissistic Condition

 

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next:   The Double Reflection Narcissistic Couples and Narcissistic Types

Question:

How to recognise a narcissist before it is "too late"?

Answer:

Many of my correspondents complain of the incredible deceptive powers of the narcissist. They found themselves involved with narcissists (emotionally, in business, or otherwise) before they had a chance to discover his true character. Shocked by the later revelation, they mourn their inabilities: their current inability to separate from him and their past inability to see through him. Narcissists are perceived as such only post facto and when it is too late.

There is no need to rehash the classic symptoms of the narcissistic personality.

These are enumerated in the DSM-IV-TR and are studied at length in this book. We are interested in for the more subtle, almost subliminal, signals that a narcissist emits. The psychotherapist would be looking for the "presenting symptoms".

Both should look for the following:

"Haughty" body language - A physical posture implying and exuding an air of superiority, seniority, hidden powers, mysteriousness, amused indifference, etc. The narcissist engages in sustained and piercing eye contact and normally refrains from bodily contact, physical proximity, or from entering in a discussion unless from a state of condescension, superiority and faked "magnanimity and largesse". He rarely mingles socially and prefers to adopt the stance of the "observer" or the "lone wolf".

Entitlement markers - The narcissist immediately asks for "special treatment" of some kind. Not to wait his turn, to have a longer or a shorter therapeutic session, to talk directly to authority figures (and not to their assistants or secretaries), to have special payment terms, custom tailored arrangements, inorddinate attention by the head waiter in a restaurant and so on. He reacts with rage and indignantly if denied his wishes.

Idealisation or devaluation - The narcissist instantly idealises or devalues, depending on his appraisal of the potential one has as a Narcissistic Supply Source. He IMMEDIATELY flatters, adores, admires and applauds the "target" in an embarrassingly exaggerated and profuse manner - or sulk, abuse and humiliate. In the second case (devaluation) he may force himself to be polite (because of the presence of a potential Supply Source). But this is bound to be a barbed sort of politeness, which rapidly deteriorates and degenerates into verbal or other violent displays of abuse, rage attacks, or cold detachment, totally out of the control of the narcissist.

The "membership" posture - The narcissist always tries to "belong". Yet, at the very same time, he maintains his stance as an outsider. The narcissist seeks to be admired for his ability to integrate and ingratiate himself without the efforts commensurate with such an undertaking. For instance: if he talks to a psychologist, the narcissist makes clear that he never studied psychology and then proceeds to use the most obscure professional jargon, in an effort to prove that he mastered the discipline all the same and thus that he is exceptionally intelligent or introspective. In general, the narcissist always prefers show-off to substance. One of the most effective methods of exposing a narcissist is by trying to go deeper and discuss matters substantially. The narcissist is shallow, a pond pretending to be an ocean. He likes to think of himself as a Renaissance man, a Jack of all trades. A narcissist never admits to ignorance IN ANY FIELD!

Bragging and false autobiography - The narcissist brags. His speech is peppered with "I", "my", "myself", "mine" and other appropriating linguistic structures. He describes himself as intelligent, or rich, or modest, or intuitive, or creative - but always excessively and extraordinarily so. One is almost tempted to say, inhumanly so. His biography sounds implausibly rich and complex. His achievements - incommensurate with his age, education, or renown. His actual state always appears evidently and demonstrably incompatible with his claims. Very often, the narcissist lies or fantasises in a manner very easy to discern. He always name-drops.

Emotion-free language - The narcissist likes to talk about himself and only about himself. He is not interested in what others have to tell him about themselves. He might pretend to be interested - but this is only with a potential Source of Supply and in order to obtain said supply. He acts bored, disdainful, even angry, if he feels an intrusion and abuse of his precious time. In general, the narcissist is a very impatient person, easily bored, with strong attention deficits - unless and until he is the topic of discussion. One can discuss all aspects of the intimate life of a narcissist, providing the discourse is not "emotionally tinted". If asked to relate directly to his emotions, he intellectualises, rationalises, speaks about himself in the third person and in a detached "scientific" tone or writes a short story with a fictitious character in it, suspiciously autobiographical.

Seriousness and sense of intrusion and coercion - The narcissist is dead serious about himself. He may possess a fabulous sense of humour, scathing and cynical. But he never appreciates it when this weapon is directed at him. The narcissist regards himself as being on a constant mission, whose importance is cosmic and whose consequences are global. If a scientist - he is always in the throes of revolutionising science. If a journalist - he is in the middle of the greatest story ever. This self-misperception is not amenable to light-headedness or self-deprecation. The narcissist is easily hurt and insulted (narcissistic injury). Even the most innocuous remarks or acts are interpreted by him as belittling, intruding, or coercive. His time is more valuable than others' - therefore, it cannot be wasted on unimportant matters such as social intercourse. Any suggestion to help, any advice or concerned inquiry are immediately interpreted as coercion and humiliation, implying that the narcissist is in need of help and advice and, thus, imperfect. Any attempt to set an agenda - as an intimidating act of enslavement. In this sense, the narcissist is both schizoid and paranoid.

These - the lack of empathy, the aloofness, the disdain and sense of entitlement, the restricted application of his sense of humour, the unequal treatment and the paranoia - make the narcissist a social misfit. The narcissist is able to provoke in his social milieu, in his casual acquaintances, even in his psychotherapist, the strongest, most avid and furious hatred and revulsion. He provokes violence, often not knowing why. He is perceived to be asocial at best (often - antisocial). This, perhaps, is the strongest presenting symptom. One feels ill at ease in the presence of a narcissist - and rarely knows why. No matter how charming, intelligent, thought provoking, outgoing, easy going and social the narcissist is - he forever fails to secure the sympathy of his fellow humans, a sympathy he is never ready, willing, or able to grant them in the first place.

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next: The Narcissistic Pendulum And the Pathological Narcissistic Space

• Watch the video on The Narcissist is Surprised when He's Accused

Question:

Do narcissists feel guilty and if so, do they ever repent?

Answer:

The narcissist has no criminal intent ("mens rea"), though he may commit criminal acts ("acti rei"). He does not victimise, plunder, terrorise and abuse others in a cold, calculating manner. He does so offhandedly, as a manifestation of his genuine character. To be morally repugnant, one needs to be purposeful, to deliberate and contemplate the options and then to prefer evil to good, wrong over right. No ethical or moral judgement is possible without an act of choice.

The narcissist's perception of his life and his existence is discontinuous. The narcissist is a walking compilation of "personalities", each with its own personal history. The narcissist does not feel that he is, in any way, related to his former "selves". He, therefore, does not understand why he has to be punished for "someone else's" actions or inaction.

This "injustice" surprises, hurts, and enrages him.

The narcissist is taken aback by society's insistence that he should be held accountable and punished for his transgressions. He feels wronged, hurt, the victim of pettiness, bigotry, bias, discrimination and injustice. He rebels and rages. Unable to link his act (perpetrated, as far as he is concerned, by a previous phase of his self, alien to his "current" self) to its outcomes - the narcissist is constantly baffled. Depending upon how pervasive his magical thinking is, the narcissist may develop persecutory delusions making him the quarry of powers cosmic and intrinsically ominous. He may develop compulsive rites to fend off this impending threat.

The narcissist is an assemblage. He plays host to many personas. One of the personas is always in the "limelight". This is the persona, which interfaces with the outside world, and which guarantees an optimal inflow of Narcissistic Supply. This is the persona which minimises friction and resistance in the narcissist's daily dealings and, thus, the energy which the narcissist needs to expend in the process of obtaining his supply.

The "limelight persona" is surrounded by "shade personas". The latter are potential personas, ready to surface as soon as needed by the narcissist. Their emergence depends on their usefulness.

 

An old persona might be rendered useless or less useful by a confluence of events. The narcissist is in the habit of constantly and erratically changing his circumstances. He switches between vocations, marriages, "friendships", countries, residences, lovers, and even enemies with startling and dazzling swiftness. He is a machine whose sole aim is to optimise its input, rather than its output - the input of Narcissistic Supply.

To achieve its goal, this machine stops at nothing, and does not hesitate to alter itself beyond recognition. The narcissist is the true shape-shifter. To achieve ego-syntony (to feel good despite all these upheavals), the narcissist uses the twin mechanisms of idealisation and devaluation. The first is intended to help him to tenaciously attach to his newfound Source of Supply - the second to detach from it, once its usefulness has been exhausted.

This is why and how the narcissist is able to pick up where he left off so easily. It is common for a narcissist returns to haunt an old or defunct PNS (Pathological Narcissistic Space, the hunting grounds of the narcissist). This happens when a narcissist can no longer occupy - physically or emotionally - his current PNS.

Consider a narcissist who is imprisoned or exiled, divorced or fired. He can no longer obtain Narcissistic Supply from his old sources. He has to reinvent and reshape a new PNS. In his new settings (new family, new country, different city, new neighbourhood, new workplace) he tries out a few personas until he strikes gold and finds the one that provides him with the best results - Narcissistic Supply aplenty.

But if the narcissist is forced to return to his previous PNS, he has no difficulty adjusting. He immediately assumes his old persona and begins to extract Narcissistic Supply from his old sources. The personas of the narcissist, in other words, bond with his respective PNS's. These couplets are both interchangeable and inseparable in the narcissist's mind. Every time he moves, the narcissist changes the narcissistic couplet: his PNS and the persona attached thereto.

Thus, the narcissist is spatially and temporally discontinuous. His different personas are mostly in "cold storage". He does not feel that they are part of his current identity. They are "stored" or repressed, rigidly attached to four-dimensional PNS's. We say "four dimensional" because, to a narcissist, a PNS is "frozen" both in space and in time.

This slicing of the narcissist's life is what stands behind the narcissist's apparent inability to predict the inevitable outcomes of his actions. Coupled with his inability to empathise, it renders him amoral and resilient - in short: a "survivor". His daredevil approach to life, his callousness, his ruthlessness, his maverick-ness, and, above all, his shock at being held accountable - are all partly the results of his uncanny ability to reinvent himself so completely.

 

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next: How to Recognise a Narcissist

Thoughtful quotes about wholeness, achieving wholeness and feeling whole.

Words of Wisdom

 

"There is an Indian proverb or axiom that says that everyone is a house with four rooms, a physical, a mental, an emotional and a spiritual. Most of us tend to live in one room most of the time, but unless we go into every room every day, even if only to keep it aired, we are not a complete person." (Rumer Godden)

"According to ancient Chinese and Indian wisdom, small minds perceive the separateness of things but great minds perceive the unity of all." (N.S. Xavier)

"A person cannot do right in one department whilst attempting to do wrong in another department. Life is one indivisible whole." (Mahatma Gandhi)

"Creativity is the urge to wholeness, the urge to individuation or to the becoming of what one truly is. And in that becoming we bring the cosmos into form." (Jean Houston)

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next:Wisdom

Relax, parents. Adolescents who eschew meat are becoming more common

If the teenager in your family has decided to go meat-free, you're not alone. In a recent national survey, 8 per cent of 15- to 18-year-olds reported being vegetarian. Vegetarianism covers a wide range of eating styles. Semi-vegetarians avoid only red meat; they eat poultry, fish, eggs and dairy products. Lacto-vegetarians eat dairy products, but avoid meat, poultry, fish, and eggs. Lacto-ovo-vegetarians include dairy and eggs, but no meat, poultry, or fish. Pesco-vegetarians eat fish, dairy products and eggs, but avoid meat and poultry. Vegans are the strictest. They eat only plant foods and shun all animal products.

Many parents worry their vegetarian teen won't get all the nutrients necessary for good health. Depending on the type of vegetarian diet your child follows, there may be cause for concern. A number of studies show that vegetarian teens don't meet daily targets for calories, protein, calcium, iron, and zinc.

It's important to keep a watchful eye on your teen's diet . The growing teenage body demands more energy, iron, zinc and calcium than at any other age. And vegetarianism in girls can sometimes be the first sign of an eating disorder. Research has shown that some girls use a vegetarian diet as a way to hide an eating disorder.

Here's the good news. If they are properly planned, vegetarian diets can provide all the nutrients adolescents need . A plant-based diet might also protect your teen's future health. Large studies suggest that, compared to their meat-eating peers, vegetarians have a lower risk of type 2 diabetes, heart attack, high blood pressure, gallstones and certain cancers.

The keys to a nutritionally complete vegetarian diet are planning and variety.

Protein

It's needed to build and repair all body tissues, including muscles, bones and skin. Vegetarians get protein from four main sources: dairy and eggs; beans, peas, lentils and soy meats; nuts and seeds; grains and cereals. As long as a variety of protein foods is eaten over the course of a day, there's no need to worry about combining different protein foods at every meal.

Calcium

It's vital for building strong bones and teeth. Because most peak bone mass is achieved by age 18, teenagers have high daily calcium requirements (1,300 milligrams). Getting too little calcium during the teen years can increase the risk for osteoporosis later in life.

Lacto- and lacto-ovo vegetarians can meet daily calcium needs by including low-fat milk, yogurt and cheese in their daily diet. Additional calcium sources, which vegans rely on, include fortified soy or rice beverages, fortified juice, almonds, soybeans, bok choy, broccoli, kale and figs.

Vegetarian teens need at least eight servings from the calcium-rich food group daily. Servings from this group also count toward servings from other food groups.

Vitamin D

It helps the body absorb more calcium from foods and deposit it in bones. Oily fish, egg yolks and butter contain vitamin D. Foods fortified with the nutrient include milk, soy and rice beverages, and margarine. Vegans must get adequate vitamin D from daily sun exposure (unlikely in Canada), fortified foods, or a multivitamin.

Iron

It's needed to maintain the supply of hemoglobin in the blood, which carries oxygen to all body tissues. Iron is especially important for teen girls, due to menstruation.

Since vegetarian iron sources are not as easily absorbed as animal sources, vegetarians have higher daily iron requirements than meat-eaters. Food sources include beans, lentils, nuts, leafy green vegetables, whole grains, breakfast cereals, and dried fruit.

Iron absorption can be increased by eating iron-rich foods with vitamin C-rich foods. For example, eating dried apricots with a glass of orange juice will boost iron intake.

Zinc

It's essential for growth, sexual maturation, wound healing and a healthy immune system. Vegans get zinc from nuts, legumes, whole grains, breakfast cereals, tofu, and soy-based meat analogs. Lacto-ovo vegetarians get additional zinc from milk, yogurt, cheese and eggs.

Vitamin B12

B12 plays a role in cell division, the nervous system and the production of red blood cells. Vegetarians need to include three sources in their daily diet: fortified soy or rice beverage (125 ml), nutritional yeast (15 ml), fortified breakfast cereal (30 grams), or fortified soy analog (42 grams), milk (125 ml), yogurt (175 ml), or one large egg.

Omega-3 fats

These special fats may protect us from heart disease and possibly aid in weight control. Vegetarians who don't eat fish need to get small amounts from plant sources such as walnuts, ground flaxseed, canola and flaxseed oils.

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Supplements

I strongly recommend that vegetarian teens take a daily multivitamin and mineral supplement to help them meet the daily allowances for most nutrients. Choose one that supplies five to 10 micrograms of vitamin B12.

However, a multivitamin won't provide all the iron and calcium teenagers need, and many won't provide a full day's zinc. Thoughtful food choices remain essential. Teens who don't eat enough calcium-rich foods should take a separate calcium supplement.

Encourage your teen to learn more about vegetarianism. Have them share some of the responsibility for their new diet. Take them grocery shopping, read vegetarian cookbooks together, and get them to participate in cooking. Have your teen plan and prepare a weekly vegetarian dinner for the whole family.

Variety, planning and support at home will help your teenager embark on a healthy vegetarian diet -- and pave the way for lifelong healthy eating habits.

Vegetarian food guide

Daily suggested food-intake needs:

6 servings of grains

1 slice of bread

½ cup (125 ml) cooked grain or cereal

1 oz. (28g) ready-to-eat cereal

5 servings of protein

½ cup (125 ml) cooked beans, peas or lentils

½ cup (125ml) tofu or tempeh

2 tbsp. (30ml) nut or seed butter

½ cup (60ml) nuts

1 oz. (28g) soy-based substitute, e.g. veggie burger

1 egg

½ cup (125ml) cow's milk or yogurt or fortified soymilk*

½ oz (14g) cheese*

½ cup (125ml) tempeh or calcium-set tofu*

¼ cup (60ml) almonds*

2 tbsp. (30ml) almond butter or sesame tahini*

½ cup(125ml) cooked soybeans*

¼ cup (60ml) soynuts*

4 servings of vegetables

½ cup (125ml) cooked vegetables

1 cup (250ml) raw vegetables

¼ cup (60ml) vegetable juice

1 cup* (250ml cooked) or 2 cups* (500ml raw): bok choy, broccoli, collards, Chinese cabbage, kale, justard greens or okra

½ cup (125ml) fortified tomato juice*

2 servings of fruits

1 medium fruit

½ cup (125ml) cut up or cooked fruit

½ cup (125ml) fruit juice

¼ cup (60ml) dried fruit

½ cup (125ml) fortified fruit juice*

5 figs*

2 servings of fats

1 tsp. (5ml) oil, mayonnaise, or soft margarine

-*Calcium-rich foods

Source: Dietitians of Canada and the American Dietetic Association

Leslie Beck, a Toronto-based dietitian at the Medcan Clinic, is on CTV's Canada AM every Wednesday. Visit her website at lesliebeck.com.

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There are various approaches to eating disorders treatment. It is important to find an option that is most effective for your needs.

There are many differing approaches to the treatment of eating disorders. No one approach is considered superior for everyone, however, it is important to find an option that is most effective for your needs. The following is a list of questions you might want to ask when contacting eating disorder support services. These questions apply to an individual therapist, treatment eating disorder facility, other eating disorder support services, or any combination of treatment options.

1. How long have you been treating eating disorders?
2. How are you licensed? What are your training credentials?
3. What is your treatment style? Please note that there are many different types of treatment styles available. Different approaches to treatment may be more or less appropriate for you dependent upon your individual situation and needs.
4. What kind of evaluation process will be used in recommending a treatment plan?
5. What kind of medical information do you need? Will I need a medical evaluation before entering the program?
6. What is your appointment availability? Do you offer after-work or early morning appointments? How long do the appointments last? How often will we meet?
7. How long will the treatment process take? When will we know it's time to stop treatment?
8. Are you reimbursable by my insurance? What if I don't have insurance or mental health benefits under my health care plan? It is important for you to research your insurance coverage policy and what treatment alternatives are available in order for you and your treatment provider to design a treatment plan that suits your coverage.
9. Ask the facility to send information brochures, treatment plans, treatment prices, etc. The more information the facility is able to send in writing, the better informed you will be.

With a careful search, the provider you select will be helpful. But, if the first time you meet with him or her is awkward, don't be discouraged. The first few appointments with any treatment provider are often challenging. It takes time to build up trust in someone with whom you are sharing highly personal information. If you continue to feel that you need a different therapeutic environment, you may need to consider other providers.

next: Questions to Ask Your Eating Disorder Treatment Provider
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Once you have chosen a treatment provider, you may want to consider asking these questions in your first meeting.

Remember that at any time during eating disorders treatment, you can raise questions and consult your treatment provider regarding areas of concern.

Questions for Treatment Providers:

1. What is the diagnosis? See eating disorder symptoms.
2. What treatment plan do you recommend?
3. Will you or someone else conduct the treatment? If someone else, does that person work for you or would this be a referral? Will you supervise the treatment?
4. What are the alternative treatments?
5. What are the benefits and the risks associated with the recommended treatment? With the alternative treatments?
6. What role will family members or friends play in treatment?

Questions for Parents:

1. How can I help to support my child during treatment? What is my role within the treatment?
2. How often will you talk to me about my child's progress?
3. What if my child doesn't want to participate in eating disorder therapy?

next: How Do I Begin Recovering from My Eating Disorder
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