Transcription
Imagine you're given the diagnosis of cancer or MS, dementia, depression, neuropathy, lupus, fibromyalgia, or heart failure. Imagine receiving treatments for these medical conditions only to later discover your body was missing a vitamin it needed to function.
That sounds extreme, but it's documented in the medical literature. Today we're talking about one of the most overlooked problems in modern medicine: nutrient deficiencies that mimic disease. If you're being treated for a diagnosed disease, you definitely don't want to miss this show.
Stay tuned. We'll be right back.
>> You unlock this door with the key of compassion. Beyond it is another world, a world of science, a world of common sense, [music] a world of sanity.
You're moving into a land of both empathy and ethics, of nutritional knowledge and empowerment. [music] You've just crossed over to Dr. Osborne's Zone.
>> Welcome to Dr. Osborne's Zone. Today I'm covering how a simple vitamin deficiency may have tricked your doctor and put you on the wrong path of taking medications and treatment that might not be necessary.
Maybe you're thinking that's not possible. Well, think again. You probably didn't know this, but most doctors don't study nutrition at all. Let's look at how nutrition gets covered in medical school.
And as always, if you want the show notes, type in "wrong diagnosis" below and I'll get you all the slides. Let's look at nutrition in medical school. So, this was a published paper in the journal Advances in Nutrition.
>> Okay, we can cut it.
>> Look at the first sentence here. The importance of nutrition in the development of disease and in the recovery from illness is among the most fundamental tenets in human biology and optimal health.
Now, that's the first sentence. And the authors later in the paper, they they put this direct translation from the Greek Hippocratic Oath. And what is that translation? The first do no harm oath. It states this: "I will apply dietetic." What does dietetic mean? Means nutrition. "I will apply dietetic and lifestyle measures to help the sick to my best ability and judgment. I will protect them from harm and injustice." That's the Hippocratic Oath.
Now, think about that for a minute. "I will apply nutrition."
Now, let's look at the nutritional training in in medical schools as we speak today. Recent data show that 75% of US medical schools have no required clinical nutrition classes. That's 3/4. 75% have no requirement whatsoever for nutritional training.
14% of residency programs have a required nutritional curriculum. So, if your doctor went on and specialized in something else, there's a 14% chance that maybe he got some nutrition. More troubling, only 14% of current healthcare providers feel comfortable discussing nutrition with their patients.
Now, when was this study done? When was this data pulled? This is 2024. So, this isn't old. This is still current.
75% of schools don't have training, 14% have some residency programs with some required training, and only 14% of doctors even have a level of comfort talking about this topic.
Nutrition was fundamental in many traditional forms of medicine until its role in medical care experienced a rapid decline over the last century. So, what we've had in the last century is pharmaceutical takeover of medical schools and a displacement of that curriculum with a replacement of curriculum focused on drugs and surgical treatment options, not nutritional options.
These authors believe a key cause of the decline in nutrition's essential role in health care and preventable medicine is the escalating crisis of inadequate nutrition education in medical training. It's a major problem.
Down here, the statement of significance. Currently, there is a crisis of inadequate nutrition education medical training with recent data showing 75% of US medical schools and 86% of residency programs have no required clinical nutrition training. More troubling, only 14% feel comfortable about talking about nutrition with their patients.
And this was another study here where they were comparing US medical school training with French medical school training. And so, just some some bullets here. In US, it's not taught in every school. As I just showed you, 75% of schools don't teach it.
There is no residency in nutrition. So, if you wanted to become an expert in nutrition as a medical doctor or an osteopath, there's no path to do that through a residency.
So, when you go to your doctor, let's set the the stage here. When you go to your doctor and they tell you nutrition's not important and they tell you how rare nutritional diseases, what they're really telling you is something they don't have the qualification to speak on. They're talking about something they're not an expert in.
Unfortunately, in the US, I don't know if this is true in every country, but in the US, the medical license gives doctors kind of a carte blanche to practice nutrition even though they don't have any training. But in most patients going to see your doctor, I mean, raise your hand if you're one of these patients. Did you think that your doctor had nutritional training? How many of you think your doctor had nutritional training before hearing what I've just told you? I'd love to see the answers down below.
But the reality is they can practice nutrition, but they don't train in nutrition. So, they're not qualified to make the statement that scurvy's rare. They're not qualified to make the statement that B vitamin deficiencies are rare. They're not qualified to make really any statements on nutrition unless they've done some more aggressive postgraduate training.
Like myself, I've got an extra 2 years of postgraduate training. I'm a diplomat with the American Clinical Board of Nutrition. So, I've gone on to study and to add a lot more detailed information to my knowledge base, plus I have 25 years of clinical experience working with patients.
So, again, most doctors don't practice nutrition. They don't study nutrition. And so, there's no experiential ability for them to make great judgment calls.
So, let's dive in now to how different vitamin deficiencies have actually been shown to mimic different diseases and end up in patients getting wrong diagnoses.
So, the first one that we're going to talk about is vitamin C. Now, just a little mini crash course on vitamin C. It's a water-soluble vitamin. And you get it predominantly from eating plant-based materials. Anything that has bright, vivid colors, you know, orange, green, red, yellow, blues. Those pigments in those foods are largely vitamin C-based pigments.
Vitamin C's primary role, or one of its primary roles, is in the formation of collagen. Now, collagen is the structural protein that makes up your skin, it makes up your hair, it makes up your bones, your tendons, your ligaments, your joints. It's very, very important as a structural element in the body.
And so, if you don't have adequate vitamin C, what ultimately happens is your collagen, which is a trihelix or a triple helix, kind of looks like this if you blow it up very close, and it has these little rungs in between it. Vitamin C, one of its jobs is to form that rung to make the collagen elastic and and tensile strength very, very strong. But, if you don't have vitamin C, these little cross-links don't form properly, and your collagen can rupture more prematurely. And this can lead to a lot of different types of symptoms, and it can lead to misdiagnoses.
Let's look at what some of these are. So, this first one is a report on scurvy. Vitamin C deficiency disease is called scurvy. So, if somebody's vitamin C levels are low enough, we call that scurvy.
If you remember, you know, the pirates, "you scurvy dog," this is where that term comes from. Those long sea voyages where sailors didn't have adequate ability to consume vitamin C, and so they developed scurvy, scurvy as a disease.
So, you see here, "Scurvy is a disease caused by chronic vitamin C deficiency. The greater prevalence was found in the pediatric population with neurodevelopmental disorders."
So, the thing about autistic kids and kids with other neurodevelopmental disorders is they have very, very meticulous eating patterns. They have texture issues, they have flavor and taste issues, and so they're very selective about what they eat. And this puts them at a much greater risk for developing vitamin C deficiency. A lot of them, I've known several that like they're very fond of things like chicken nuggets, they're very fond of of french, you know, fast foods that have the same type of fried like texture, and there's no vitamin C in those foods. And if their diets are predominantly that, it's a lot easier for them to develop vitamin C deficiency.
But in this case, you see here, our case reported a child with autism who presented with arthralgia, which is joint pain, and anemia. Systemic lupus was the first diagnostic impression. After the child was treated with ascorbic acid, however, the child's symptoms resolved.
So, what was happening is this child was being treated not with vitamin C, non-responsive. That led to further investigation where they identified the child was low in vitamin C and treated the child, and the symptoms recovered.
Furthermore, parents and physicians should be concerned about nutritional status. Now, how can physicians be concerned about nutritional status when they don't take nutritional training? Again, going back to the premise of what we talked about. Especially in children with restrictive dietary intake.
Here's the patient's perspective, right? "At first, I was afraid my daughter might have some severe illness. The doctor doesn't know anything about nutrition, he's diagnosing lupus." Lupus is a scary, scary disease. It can people, and it comes with a broad array of immune-suppressing treatments, very dangerous medications to be taking long-term, especially in a child. So, imagine being the parent of that child and getting that diagnosis, and that's what you're being told, and it's a simple vitamin C deficiency.
"So, in anyway, when the doctor said that my daughter had to be consulted with a pediatric neurologist, it made me feel nervous. After my daughter was consulted, she was pretty normal. My anxious feeling was relieved when we have known the exact cause of the illness. They finally figured out it was vitamin C. The doctor explained to me about the disease and treatments extensively."
Learning points: scurvy should be considered in a case presenting with musculoskeletal manifestations. Muscle pain, muscle aches, arthritis, joint pain, leg pain, limping gates, if children are limping, refusal to walk is also a sign because of the pain.
So, point being, lupus can be misdiagnosed. Vitamin C could be mimicking that condition. And if the doctor doesn't know to measure vitamin C or doesn't know to think about measuring vitamin C, we get prolonged treatments for disease that the child or the patient doesn't even have. And that has a profound impact not just from the patient's pure health perspective, but also from a cost perspective.
There's another study on scurvy masquerading as reactive arthritis. In this case, patient developed a rash and left ankle pain of 1 week's duration, as well as a fever after 3 weeks of a productive cough, sore throat, hoarse voice, and general malaise.
6 days prior to presentation had redness and swelling of the dorsal aspects of both hands with accompanying rash, and 2 days prior to presentation developed a similar rash on the legs with associated left ankle pain, redness, and swelling. Reported eye redness, pain, photophobia, or sensitivity to bright light, crusty eye discharge, and pins and needles sensation on the soles of both feet. Additionally, had noted difficulty with urination over several days.
These were the rashes that you can see. You can see the little petechial rashes sticking out on the skin. Patient was mildly low potassium and hypoalbuminemic, which means low protein. So, the patient had low protein, malnourished basically, low protein, low potassium, had slightly elevated international normalized ratio, which is a measure for clotting.
Further questioning revealed that his diet consisted mostly of soda and energy drinks. And the vitamin C level was subsequently checked and found to be zero, no vitamin C.
And I see this quite frequently. I'll see scurvy a couple times a week in my practice, in patients with musculoskeletal problems and neurological problems. And in this case, the vitamin C was measured, it was zero.
A diagnosis of scurvy was made, and his symptoms improved at the hospital while maintaining a diet with normal levels of vitamin C. His rash had markedly improved by hospital day two, joint swelling decreased, and the conjunctival injection and eye pain had resolved. Upon outpatient follow-up, his rash and joint swelling continued to improve, and he had not experienced any further hair loss. Because in this case, this gentleman also had hair loss that had stopped as a result of vitamin C.
Remember I told you vitamin C also it makes collagen, which is what your hair is made out of.
Here's another case. This is an interesting one reported. This is a 40-year-old male with Crohn's disease who was initially misdiagnosed with vasculitis, but was later shown to have scurvy, vitamin C deficiency.
The patient's diet was nearly exclusive, made up of highly processed fast food with no fresh fruits or vegetables. Well, folks, that's the vast majority of the population nowadays. Fast food diets with very few fruits and vegetables.
A mildly sensitive petechiae rash on his lower legs, mild gingival hemorrhage, and enlargement, and muscle soreness were among his symptoms. Anemia and undetectable vitamin C levels were discovered in lab studies. A misdiagnosis might result in unnecessary treatment.
So, ultimately, had this patient been, you know, if they had they continued to call his condition vasculitis, that was the misdiagnosis, the initial misdiagnosis, he would have gone through treatments and medical studies and everything else that weren't necessary. In this case, simple vitamin C led to resolution.
You can see here the rash that the patient showed up at the hospital with. You can see the the small red dots here. You can see the larger conglomeration, the erythematous patch, if you will, here and here where it's super red. Okay.
And then they also found corkscrew-like hairs. So, if you see little hairs that look like they're shaped like a corkscrew, that's your cue to think potential vitamin C deficiency. But this was at onset, and this was after treatment. So, you can see the legs completely cleared, the rash completely went away after vitamin C administration.
And it doesn't take a lot of vitamin C to correct these types of deficiencies. You know, 1,000-2,000 mg a day is generally enough, depending on the depth of deficiency and how long it's been there.
But remember, folks, scurvy can kill you. So, if the doctor misses the diagnosis, you might go on and have enough problems with it that it creates internal hemorrhaging. Because when you don't have enough vitamin C, your blood vessels break so easily, you can actually have internal hemorrhaging, which is basically you lose blood internally, inside.
Here's another one, scurvy masquerading as cellulitis. Scurvy continues to be found regularly in the elderly and those who abuse alcohol. Clinical findings result from decreased collagen production. That's what I was talking about earlier. Ascorbic acid is a necessary cofactor for proper collagen formation.
Clinical findings can vary from bleeding gums, hair abnormalities, poor wound healing. I mean, who would be a classic person that we might think about with poor wound healing? It would be a diabetic. And diabetics, in my experience, are very, very frequently low in vitamin C. But hemorrhage and sudden cardiac death. So, death.
Response is typically rapid and impressive with dietary replacement. So, vitamin C deficiency responds really well to supplementation.
In this case, 61-year-old Caucasian male presented to the ER with a 2-week history of asymptomatic lower extremity erythema, swelling, and subcutaneous nodules that had failed to respond to multiple courses of intramuscular and oral antibiotics. So, they were pumping this guy full of antibiotics, calling it an infection.
And this is what I'm talking about earlier with the lack of training. The guy shows up with a rash, it's automatically assumed the guy's got an infection, and what do they do? They proceed to use antibiotics. And look, antibiotics are not a benign treatment. Like antibiotics come at a cost.
So, they're pumping this guy full of antibiotics, and what does that do? Wipes out his microbiome, it can increase permeability of the gut, it can cause a host of other complications. In some cases, antibiotic use can drive tendinopathies and lead to major, major musculoskeletal pain problems that last for months to years. So, not a benign treatment.
In this case, vitamin C, again, was later found. So, the physical examination revealed a non-tender deeply erythematous plaque on bilateral lower legs. A targeted history, which is what should have happened at first, like that should have been the first thing that was done, is a targeted history, revealed poor nutritional status secondary to poor diet and dentition.
A diagnosis of scurvy was rendered, and the patient was started on oral vitamin C replacement. You see her 500 mg three times a day with meals. Lab evaluation for serum C revealed extremely low vitamin C levels less than 0.1 mg per deciliter. There was a rapid improvement with a decrease in the erythema and warmth over the next 4 days, and the patient was discharged from the hospital.
There's a saying that I was taught and most doctors are, and that is 80% of the diagnosis, it's actually been researched, is from a patient's history. When the doctor takes enough time, have a conversation with the patient, ask the right questions, typically 80% of the accuracy of the diagnosis is found within the context of having that conversation.
How many of you have gone to a doctor and maybe you got three to four, maybe five minutes with the doctor, maybe you spent more time with the nurse than the doctor, or maybe you spent more time with the med tech than the doctor, and the doctor just comes in and asks a couple questions, writes you a script, and walks out the room? How can you do a proper medical history in that short constraint of time frame? And especially if you're not trained in nutrition, how can you do an accurate medical history as it relates to nutrition?
This stuff makes me mad, and it should make you mad, too, because a lot of people are actually on medications or going through treatment because they're malnourished, and their doctors haven't been trained about it, and so they're just being misappropriated and mishandled. And it's not benign. Like I said, it's very much to their detriment.
Here's another one. Nutritional deficiency masquerading as neurological disorder: scurvy-induced paraparesis. This is a case, a 5-year-old child started having trouble walking and standing, and so quit walking, right?
So, you can see your 5-year-old child presented with an acute onset inability to stand for 3 months. She had tenderness on moving the knee and ankle. The neurological exam was normal.
And that's a really important clue because a lot of times with paraparesis or when somebody has like an ascending paralysis or neuropathy where they're losing nerve control over their muscles, that means that's why they can't walk. In this case, the nerve exam was normal, meaning this girl didn't have any neurological abnormalities that were driving that.
So, then they did dietary history and revealed food sensitivity or a food selectivity. So, this child was very picky on the diet. X-ray of the knee was suggestive of scurvy. There were certain findings in the X-ray, and the vitamin C level was low, so scurvy was considered.
She was treated with diet modification and vitamin C. She improved and began standing on the third day. That's how fast she reacted. Now, imagine if this diagnosis had held and they would have kept treating her in another way, and it was your, imagine your child having that. And then walking on the 10th day of vitamin C therapy.
Scurvy should be considered a differential diagnosis in children with acute or subacute pseudoparalysis of the lower limb. There are some examples of vitamin C scurvy being misdiagnosed as other conditions.
Let's talk a little bit about vitamin B1. Now, vitamin B1, also known as thiamine, is a very important B vitamin. One of its main roles is in the production of a compound called acetylcholine.
And acetylcholine is the primary nerve transmitter or neurochemical that drives the nervous system, specifically the parasympathetic nervous system. This is your part of your nervous system that helps you sleep and digest. You think of it as it calms everything down. It takes you out of fight or flight. Sleep, rest, digest, sexual intercourse, all part of parasympathetic nerve tone.
And you need vitamin B1 to make this substance. And without it, you can develop a lot of different types of problems. But let's talk about some of the diseases linked to vitamin B1 mimicry.
So, you see here, thiamine deficiency masquerading as GBS, Guillain-Barré syndrome. Now, if you don't know what Guillain-Barré syndrome is or GBS, it is an autoimmune ascending paralysis. So, it starts in the feet and it works its way up. And it can cause you to get, it can put you in a wheelchair. It's very, and it can be very, very quick onset as well.
And so, you see here, serious neurological manifestations. Besides this, which is Guillain-Barré, vitamin B1 deficiency can cause peripheral neuropathy, paralysis, confusion, paresthesia, pain, dysarthria, and nystagmus, which is an abnormal movement of the eyes.
Thiamine deficiency also develops at an increased frequency in patients who have gastric bypass. If you have a gastric bypass or if you know somebody's had a gastric bypass, you're at greater risk for vitamin B1 deficiency because you've bypassed your stomach, and there's an important role in digestion and absorption.
Prompt recognition of thiamine deficiency is important since it's readily treatable, and prompt treatment increases the likelihood of favorable outcomes. On the other hand, if the diagnosis is delayed, treatment of severe thiamine deficiency can lead to permanent neurological damage. In other words, if those nerves don't have adequate vitamin B1 for long enough period of time, you might have damage that doesn't recover.
Since clinicians often do not consider thiamine deficiency in patients without a history, and how can they? They don't train in nutrition. Especially if the patient doesn't have a history of alcohol, this diagnosis is often either delayed or missed altogether.
This case series presents four patients with acute neuropathy due to thiamine deficiency. So again, I won't go through each one of the cases, but I just want you to understand that these neurological conditions, Guillain-Barré syndrome, which is also linked to another treatment that are commonly given to children in pediatric office. I'll let you draw the line there. Because there's a known driver for that. But at any rate, vitamin B1 deficiency can mimic it.
Here's another case. Thiamine deficiency and heart failure. Over the next 3 months, the patient presented to the emergency room multiple times with acute heart failure exacerbations that were suspected to be secondary to medication non-compliance. On the third visit, he was admitted for further workup. So this is three times they've missed the diagnosis so far, three times.
He was admitted for further workup as he appeared confused. Neurologic testing revealed significant neurocognitive deficits as well as bilateral cranial nerve six palsies. Cranial nerve six, that's the abducens nerve. It's the nerve that takes your eyes and allows them to move laterally. And so when you have a palsy of that nerve, your eyes won't go laterally, and so they'll look, you know, they'll kind of look cross-eyed.
He was presumed to have Wernicke's encephalopathy caused by his history of alcohol abuse, although he denied recent alcohol use. Oral thiamine at 100 mg per day was started. After 16 days, he became progressively hypotensive, requiring discontinuation of all his cardiac medications.
That's an important note. Much of what cardiac patients have, a lot of them are put on diuretics, especially loop diuretics. And diuretics will cause vitamin B1 deficiencies. And so, if you add, you know, for example, high blood pressure, your doctor may put you on a diuretic, know that it's driving down your vitamin B1.
And vitamin B1 deficiency can cause congestive heart failure. That's part of the problem, and that's what was happening with this gentleman here, is that as he was taking the vitamin B1, he never needed any hypertensive drugs. The vitamin B1 deficiency was what was driving the problem, and so the medicines were not necessary, which is why he became hypotensive, and it required him to stop the medication.
A repeat test showed dramatic improvement in his left ventricular systolic function with ejection fraction of 55%. Moreover, the patient's cognitive status significantly improved with his cognitive assessment score improving as well. So, this patient improvement with thiamine, vitamin B1. And it took three trips to the ER to get it figured out.
In this case, thiamine supplementation in symptomatic chronic heart failure. This was a double-blind randomized placebo-controlled study. They did diuretic treatment for heart failure may lead to an increased urinary thiamine excretion. That's what I was just telling you. Diuretics deplete vitamin B1, which may further compromise cardiac function.
That's what the name of the disease associated with vitamin B1 deficiency is called beri-beri. And beri-beri, the wet form, there's a dry form which affects the nervous system, but the wet form affects heart function.
So, at any rate, when a doctor doesn't understand what beri-beri is or has never seen a case of beri-beri because he has never known how to look for it because he's not been trained in nutrition, he's looking at heart failure and he's just thinking this patient's maybe overweight and maybe this patient is just getting older, and they're putting them on diuretics and they're putting them on other medications to try to prolong their life without ever asking the question, is vitamin B1 driving the heart failure?
So, in this study, nine patients with diuretic treatment for symptomatic chronic heart failure and left ventricular ejection fraction of less than 40% were randomly assigned to receive thiamine at 300 mg a day or a placebo pill for 28 days. What happened?
The study suggests that thiamine supplementation has beneficial effects on cardiac function in patients with diuretic drugs for symptomatic chronic heart failure. Subclinical thiamine deficiency is probably an underestimated issue in these outpatients.
I'll say it's underestimated. Why is it underestimated? Because doctors don't train in nutrition. How many times am I going to say that today? I'm just going to keep saying it so that it sinks in.
Here is a diagram that I put together for you to kind of understand this a little bit better. When you're on a diuretic, it does several things. So, some studies have shown that certain diuretics will actually reduce thiamine uptake into heart cells. Other studies show that diuretics cause vitamin B1 loss through the kidneys, through the urine. So, you're excreting more of your vitamin B1 out.
But, at the end of the day, if you're on a diuretic, it's depleting your thiamine status. And when you deplete thiamine, as I mentioned earlier, you deplete your acetylcholine production. This is the primary neurochemical your brain uses it, your nervous system uses it, your heart needs it to function properly.
And so, you can develop memory loss, depression, irritability. You can develop nerve damage. You can develop edema and congestive heart failure.
What happens in each one of these situations? When you develop memory loss, depression, or irritability, what do doctors like to do? They put you on another medicine, SSRIs in this case, and SSRIs drive down folate. And there's some newer research talking about vitamin D deficiency, not B, my sorry, vitamin D deficiency with SSRIs. So, you end up taking a drug for vitamin deficiency and driving more vitamin deficiency as a result of being on the medication.
If you got nerve damage, phenytoin might be prescribed or other drugs like gabapentin. This is one of the more common drugs used today for neurological damage or nerve pain. And gabapentin shuts down your GI tract and causes malnutrition through the stoppage of peristalsis.
And then if you have the edema from the acetylcholine deficiency caused by the thiamine deficiency, then they put you on more diuretics. Or they change up your diuretics, which will just continue to drive your thiamine status lower.
Now, one other thing that can happen, and I say this because, you know, you may have neurological symptoms, but you may have muscular symptoms. You may end up with muscle pain and generalized fatigue kind of manifesting or feels like fibromyalgia or like chronic fatigue syndrome, because your blood lactate pyruvate levels are going up because you can't process this stuff out of your system without thiamine, and that leads to muscle pain fatigue, which is commonly treated in pain management clinics.
And a lot of people just pop over-the-counter ibuprofen or NSAIDs, you know, things like ibuprofen, NSAIDs, which deplete iron, and they can deplete vitamin C, and they can deplete folate. So, that's a bad idea, right?
And if you take other types of pain medications like opiates, then you run the problem with shutting your bowel down and addictive problems, and drugs are very, very dangerous. They're responsible for a lot of deaths every year. Not that NSAIDs aren't. NSAIDs kill about 13,000 people a year, just over-the-counter aspirin.
But anyway, if you're trying to treat the symptoms of a B1 deficiency, it's not going to work if you're using a drug because you're deficient in a vitamin. Remember, why are vitamins important? They're essential. Your body can't function without them. I mean, you have to eat these things in your diet, and you have to get these nutrients in because they are important for essential functions your body can't survive without. That's why treating symptoms of vitamin deficiency always leads to struggle. It never resolves the problem.
Okay. Let's move on to vitamin B12. Now, vitamin B12 has a few very important roles. One of its roles is in the nervous system, where it helps to produce myelin. Myelin sheath. Without vitamin B12, we can have a demyelination of the sheath.
Now, vitamin B12 also plays a role in methylation, which is a chemical process in your body that helps with detoxification. But importantly, there's a compound called homocysteine, which is a nerve toxin and a vascular toxin, and it's linked to cancer and stroke and heart attack and nerve damage. But you need vitamin B12 to control this natural byproduct of metabolism.
Now, vitamin B12 also is very, very important in stimulating the red blood cells to properly mature. So, your red blood cells require vitamin B12 so that they can mature. When your red blood cells are born, they're typically very, very large. As they mature, they get smaller, and they take on, ultimately, they take on a biconcave discoid-like shape. This is so they can carry oxygen.
And so, this is a multi-step process whereby the cell's born out of your bone marrow, it's very large, and as it matures under the influence of vitamin B12, it becomes normal shape so that it can deliver oxygen effectively. This is why vitamin B12 deficiencies are linked to what are called macrocytic anemias. Macro because the cell is macro, it's large. Cytic means cell. So, a macrocytic anemia would be caused by vitamin B12 deficiency because that red blood cell can't mature properly.
So, now you know a little bit basically about vitamin B12 and where we eat vitamin B12. Vitamin B12 is in meat. There's no, or not, there's no vitamin B12 to speak of of any significance in plant foods. So, you're not going to get this from eating fruits or vegetables. You have to get it from eating meat.
And I know many of you may be on plant-based diets. If you are, look, supplement with some vitamin B12. Get your vitamin B12 checked periodically just to make sure you don't end up in this situation. Let's talk about some of the disease mimics here.
Low vitamin B12 levels, an underestimated cause of cognitive impairment and dementia. And dementia, Alzheimer's, is becoming more and more of a problem. You see here, vitamin B12 deficiency linked to impaired cognition and memory along with sensation of tingling and numbness, an outcome of poor myelinization.
We conducted this study to determine the effect of vitamin B12 replacement therapy on B12 deficient patients with noted cognitive impairment. So these patients with dementia that they knew that had vitamin B12 deficiency, there were 202 patients in total. Of those, 171 of them, that's 84% of the patients, reported marked symptomatic improvement after B12 replacement. And their mental status evaluation scores improved in 78%.
So this many mental evaluations are tests that doctors give to determine cognitive function in patients. And so again, 84% reported improvement, 78% had medical testing that showed improvement. Of the remaining 44 patients who reported no symptomatic improvements, their MMSE scores improved in 26 of them, 18 patients showed no improvement. So that's pretty substantial, meaning that the vast majority of patients with B12 deficiency and cognitive dementia showed improvement by just taking in vitamin B12.
Now one of the reasons this can happen in the elderly, especially, is because of stomach acid. Many of the elderly, there's some research that shows that as we age, we make less stomach acid, although I don't know that that's 100% true. I don't think it's aging that causes reduction of acid production. I think it's damage accumulation to the GI tract over time that gets misdiagnosed as aging that drives down stomach acid.
And so, it's very common too for patients and for the elderly to be on antacids, which will block stomach acid. And so, what happens here is without stomach acid, you don't absorb B12 efficiently. So, it's much more common to be B12 deficient.
There are also many medications that can block vitamin B12 absorption beyond antacids, like metformin, the classic diabetes medication. Many diuretics deplete B vitamins, not just B1, but also B12. So, a lot of the elderly are taking five or more medications. And my experience clinically with this is that many of these people have basically, through drug-induced nutritional deficiencies, through physiological reduction of stomach acid, have a greater risk for developing these types of deficiencies.
Okay. This is an interesting case report. So, reversible dementia, psychotic symptoms, and epilepsy in a patient with vitamin B12 deficiency.
You see, B12 deficiency is common, typically associated with megaloblastic anemia or macrocytic anemia, glossitis, which is swollen tongue, and neuropsychiatric symptoms. Report the case of a patient presenting with progressive cognitive and functional deterioration, psychosis, and seizures, later found to be secondary to pernicious anemia.
Pernicious anemia is an autoimmune condition where the immune system is damaging the cells in the stomach lining that produce acid and predominantly intrinsic factor, which is the substance that attaches to B12 to help it become absorbed. The patient had a remarkable neuropsychiatric recovery after vitamin replacement. So, B12.
Now, if the doctors in this case weren't educated about B12, they may not have even looked. And again, that's the point.
This was a nice review of diseases that we know that vitamin B12 can contribute to because of its role in the nervous system. So, you see here, peripheral neuropathy, memory loss, ataxia. So, if you're losing your balance, you might think B12, impaired attention, reduced executive function, gait abnormalities, muscle weakness, tremors, numbness, spasticity of muscles.
So, if your muscles stay really tight, and psychiatric disturbances, hallucinations, visual impairments, cognitive decline, difficulty in decision-making, delayed reaction times can all be subsequent problems of vitamin B12 deficiencies.
And this again, this was a review of human studies where they actually did vitamin B12 interventions and found improvement in all of these different types of problems.
Keep in mind that most of the time when people get a diagnosis, neurological diagnosis of dementia and neuropathy, they're told it's idiopathic. They're told the doctors say, "We don't know why." And then they go on to give them some type of medication.
What I'm trying to show you is that vitamin B12 deficiency may be the reason you started to develop a neuropathy, may be the reason why you started to have cognitive decline, or balance issues, or your ability, your senses, your taste, your smell can deteriorate with vitamin B12 deficiency. So, if those things are happening to you, ask your doctor to measure your levels, or get a doctor who knows nutrition. Call my office.
Here's another one. Vitamin B12 deficiency masquerading as thrombocytic or thrombotic thrombocytopenic purpura, or TTP, which is a very dangerous disease, by the way. And so what happened, a workup and management of a 40-year-old man who presented with anemia, thrombocytopenia, and schistocytes on peripheral smear.
A schistocyte is just an abnormally shaped red blood cell. You can see that right there. It's kind of clefted off. A normal looking red blood cell is more like this. Although you, and then you can see this one here, this one with the red, that's a macrocytic cell. It's a large red blood cell without proper maturation.
And the reason why, you know, you want to think about vitamin B12. I said earlier that vitamin B12 helps red blood cells mature. Right? So they start out large and then they get smaller.
But one of the other things that is in your bone marrow are stem cells. These stem cells produce not just red blood cells. They also produce platelets. And they also produce white blood cells.
And so what can happen is when you're B12 deficient, you don't just necessarily have red blood cell abnormalities. You can have white blood cell abnormalities, as in this case here, hypersegmentation of these neutrophils, which are a type of white blood cell. And then an absence of platelets is really not very in this smear. You don't really see any platelets to speak of.
And so low platelets, thrombocytopenia, that's what that means. And in this case, vitamin B12 deficiency is not properly stimulating the bone marrow. So we're getting these blood abnormalities that look like a disease called. And good thing these doctors were smart enough to do some additional investigation.
They initially treated this patient with steroid therapy and plasmapheresis. But his hemolysis, hemolysis means red blood cells continuing to break, it continued to happen. So he continued to have hemolysis.
Further workup showed that he had megaloblastic anemia, severe vitamin B12 deficiency, high iron saturation, and absent reticulocytosis. Our patient similarly had significantly elevated serum homocysteine levels. Remember what I told you a minute ago? Homocysteine.
Okay, it's a simple blood test, by the way, that can be measured. Elevated homocysteine above nine is generally indicative of vitamin B12 deficiency. So the homocysteine elevation confirming the suspicion of B12 deficiency, vitamin B12 replacement led to normalization of the elevated levels of homocysteine, the disappearance of the schistocytes on the peripheral smear, and resolution of the microangiopathic hemolysis, thereby confirming the diagnosis.
So this patient could have gone on and stayed on some really bad care had these doctors not had the insight to search for vitamin B12 as, you know, as the differential in the diagnosis of this patient. So good doctoring in that case.
Here's another on vitamin B12 deficiency mimicking multiple sclerosis. This is a report of two cases, and I won't read the reports to you, but I'll just read the conclusion here.
However, clinical features and MRI findings. So if we look at, how do you diagnose MS? Multiple sclerosis is a diagnosis predominantly of exclusion. The patient has certain symptoms. They usually see a neurologist to get a neurological exam, and maybe they'll get an MRI. And the MRI will show demyelinating lesions.
And a lot of these demyelinating lesions can be autoimmune in nature, meaning that it could be an autoimmune attack on the nervous system, but it could also be vitamin B12 deficiency. So, when you're looking at an MRI, remember it's just a picture, and it might show lesions, but B12 deficiency can cause the same kinds of lesions, and B12 deficiency can cause the same types of neurological symptoms as MS.
And so, this is why if you've got a diagnosis of MS, you better ask your doctor to rule out whether or not you have a vitamin B12 deficiency. Clinical features and MRI findings closely resembled signs of MS. Low vitamin B12 levels and good response to B12 supplementation allowed them to establish the diagnosis of vitamin B12 deficiency.
And I've seen cases where people had started to lose their ability to walk, started to lose their ability to control their feet. And we get B12 in them, and that goes away. And they were really well on the path to a disease diagnosis of probably of MS, but we caught it. We caught the nutritional deficiency and, you know, and headed it off at the pass, so to speak.
Okay, vitamin D. Vitamin D is very, very critical for a lot of different functions. Some of its major roles include the absorption of calcium from your gut. So, vitamin D actually tells your gut cells to absorb calcium from the food that you eat.
This is one of the reasons why low vitamin D can contribute to diseases like rickets. Rickets is that childhood vitamin D deficiency disease that causes bow legs. You ever seen an adult with bow legs? It's because he was vitamin D deficient as a child.
So, calcium absorption is an important part of vitamin D. Insulin signaling is very important, so it helps regulate blood sugar. Vitamin D helps mature immune cells. This is one of its most important functions.
In the thymus, vitamin D regulates how your immune cells become appropriately. Let's just say it's like Goldilocks and the Three Bears. Your immune cells can behave too strongly, they can behave not strongly enough, or they can be like the porridge and be just right. And vitamin D helps make that decision because what it does is it teaches the body to kick out immune cells that are too strong and to get rid of immune cells that are too weak. So, what's left are the ones that are appropriately behaving.
And so, with that in mind, vitamin D deficiency can create or contribute to a lot of immune dysfunction. We've looked at many, many different forms of autoimmune disease. So, we know, for example, lupus, psoriatic arthritis, rheumatoid arthritis, uveitis, Hashimoto's hypothyroid, type 1 diabetes, those are all linked to vitamin D deficiency.
But in this case, we're talking about vitamin D deficiency masquerading as an occult malignancy, meaning a cancer.
And there was a woman in this case where she started to have severe pain, severe bone pain. And so, when she went in, let me see where these arrows are here. We can blow that up. You can see there's bone loss in that hip. There's also a little fracture right here. And then you can also see there's a lesion in the hip. It's what's called an osteolytic lesion in that hip.
And so, marked osteopenia, an expansile osteolytic lesion as seen by those arrows up here. And then she also had, like I said, she had some lack of mineralization in the actual hip itself. So, this was on admission. This was the original, let me say, the original image here. This was a follow-up image, and you can see the lesion here that was here is gone, and you can see the increased density of the bone.
And this was after many months of being treated with vitamin D. But in this case, what happened was vitamin D deficiency was driving down her ability to absorb calcium. And when you don't absorb enough calcium, your body makes more of a hormone called parathyroid hormone. And parathyroid hormone will suck calcium out of the bones. The blood doesn't do well when calcium levels drop, so parathyroid hormone will pull that calcium out of the bone, and that can create osteolytic-like lesions that can be sometimes confused with cancer.
Now in her case, she had elevated parathyroid. She had also had a chemical in her blood called ALP, alkaline phosphatase, that was elevated, and so these were some of the clues. When they treated this woman with vitamin D, her parathyroid hormone declined dramatically to within normal.
Additionally, her serum alkaline phosphatase, it took a little bit longer for that one to normalize, in this case it took about 5 months. But you can see these markers right here on this side. So, the green line is her at initial diagnosis. This is her alkaline phosphatase, it's very high, but over the course of several months it came down and normalized. We also can see here the blue line represents parathyroid hormones. You can see it started out extremely high, and then over the course of vitamin D supplementation it normalized very quickly within 3 months.
So again, this was a vitamin D deficiency masquerading as an occult type of cancer. And think about the consequences of being treated for cancer. In many cases, it's chemotherapeutic treatment, radiative treatment, depending on the type of cancer.
Here's another case of vitamin D deficiency masquerading as a metastatic cancer. Patients with vitamin D deficiency can present with non-specific bone pain as one of the symptoms and findings on radionuclide bone scanning that may suggest metastatic malignancy. If you've ever seen one of these radionuclide bone scans, it's basically just a scan, and it shows all these different hot spots that doctors speculate may be cancer. So, they're doing that scan to look for those types of hot spots, but vitamin D deficiency can cause a lot of those hot spots.
leading to kind of a false impression. In this report, we we present four such cases in which clinicians initially pursued the diagnosis of metastatic malignancy and did not consider vitamin D deficiency and osteomalacia, which is um the name of the disease state of vitamin D deficiency in adults, in the differential diagnosis. Eventual recognition of vitamin D deficiency and provision of supplementation resulted in prompt resolution of symptoms for each patient.
Uh cancer's a big deal. Um in that first case I showed you, that that person was treated for cancer and mistreated because you didn't actually need the treatment. And so, that treatment was very deteriorating to her health further and it wasn't until the second opinion doctor came in and said, "This isn't cancer. This is vitamin D deficiency that's mimicking cancer. We need to get this uh we need to get this treated uh [snorts] as soon as possible."
Now, I'm not telling any of you that are watching this that you should throw away your doctor's orders and throw away your treatments and throw away your medications and just go take some vitamins. What I'm trying to allude to for you is that vitamin deficiencies can mimic disease because doctors aren't trained in nutrition. They're not trained to look for the signs of nutrient deficiency. They don't even Many of them don't know what test to order. They don't know the difference between serum tests and intracellular tests and other specialized types of nutritional testing because the vast majority of them have received no training during their medical medical school curriculum.
So, there's a there's a gap between do you have a disease or do you really just have the symptoms of a nutritional deficiency or multiple nutritional deficiencies that are being misdiagnosed as disease? And that's the question and that's the thought process that I'm trying to impart to you to put in your mind and to think about. And if you doubt that you're on the right path, if you've been diagnosed with something and you're medicating and you're not getting better and you're just frustrated, you need to start thinking about vitamin deficiencies, mineral deficiencies. I only covered a handful of things today. We could talk literally for days about the different disease mimics that vitamin and mineral deficiencies can contribute to.
And I would even go a step further and say it's not even really disease mimics, it's just a misinformed medical community that has forgotten the historical past. They've forgotten their what their Hippocratic oath means, which is dietetic in nature, to study nutrition and to help patients with nutrition and lifestyle. Nutrition and lifestyle, not help patients with new drugs and third generation drugs and fourth generation drugs and all these other types of treatments that have taken the front stage. You know, we we live in a society where patients have unfortunately overestimated the intelligence and the capacity of their doctors to to understand why they're sick.
And now this is not a damning scathing report of all doctors. There's some wonderful, wonderful doctors out there. But when they're not training them in nutrition, they're missing diagnoses, and that means they're misdiagnosing, which means they're mistreating, which means patient can go on for years and years and years miserable, doing the wrong things, spending their money and losing their life and losing their quality of life as a result of the wrong diagnosis.
So, please, I urge you, if you learn anything from today's show, it's think nutrition and lifestyle intervention interventions first. Think medicines and medical procedures next. Primary care should be focused on nutrition first. And if you're doing nutrition first and you have an odd diagnosis or you have a diagnosis that requires medication, by all means, work with your doctor to figure that out. But, if you haven't even looked at nutrition, please, I encourage you all, go and do it. It might just save your life. It might just save somebody you care about's life.
Thanks so much for tuning in to Dr. Osborne's Zone. I'll be back on Thursday for a live Q&A. So, if you've got questions on nutrients mimicking disease, I'll be there to answer them. And like I said earlier, if you'd like to get the show notes, just comment below and I'll make sure I send them over to you. Have a great evening.