What is the Vitamin B12 Status Among Adult Vegans and Vegetarians

as Measured by Methylmalonic Acid (MMA)?

Conclusion Statement:
In a population of healthy vegetarian and vegan adults, recent research shows inconsistent results
of vitamin B12 status as measured by MMA. Using MMA as the outcome measure, the rate of
B12 deficiency in three of the studies ranges from 10-55%, and one study shows no change in
B12 status.

Purpose of the Evidence Appraisal Process:

Original Question: What is the Vitamin B12 Status Among Adult Vegans and Vegetarians
as Measured by Methylmalonic Acid (MMA)?

In 2010, the Academy of Nutrition and Dietetics Evidence Analysis Library (EAL) reviewed
research on the vitamin B12 status among vegetarians across the lifespan, as measured by
methylmalonic acid (MMA). At that time, the EAL indicated that the available research was
Grade I (strong), concluding that among healthy vegetarian adults, there was a significantly
increased prevalence of vitamin B12 deficiency as determined by high MMA levels. Due to the
increase in popularity of vegan and vegetarian diets, it is important to examine updated research
on vitamin B12 status based on various indicators. The purpose of this evidence analysis
investigation is to examine the most recent literature to determine vitamin B12 status, as
measured by MMA, among vegetarians and vegans.

Conclusion:
Out of the four studies, three indicated deficiency in vitamin B12 in vegetarians and/or vegans as
measured by MMA, while the one remaining study’s participants exhibited vitamin B12
deficiency via holo-TC measurements alone. Looking at the four studies reviewed, MMA has
shown to be one of the necessary measures used to monitor vitamin B12 among vegan and
vegetarian populations. Among total study participants who are clinically deficient in vitamin
B12, as shown by their high MMA level, serum vitamin B12 levels were within normal limits or
relatively low. In one short-term intervention study, however, the designated population
consuming a 4-week vegan diet had no changes to either MMA or serum vitamin B12. It is well
understood that it takes between 2-5 years to show vitamin B12 deficiency, so these results were
expected. Furthermore, the limitations to the selected studies include potential participant error in
reporting, inadequate sample size and study duration, lack of follow-up reporting in three of the
studies, and interventional approach in only one of the studies. It is also significant to note that of
the four articles, only one was grade A; the remaining three articles were grade D, which further
limits the research quality. The outcomes from these studies indicate that larger, long-term
studies within this area of research are warranted. This research must utilize MMA as a primary
outcome, as it is a direct measurement of functional B12 status.

Grade: III

Implications for Clinical Practice: ​In clinical settings, it is important for vegans and
vegetarians to have a standardized MMA test. From these studies, it has been shown that those
with high MMA might not necessarily have signs of clinical deficiency, as measured by serum
vitamin B12 alone. By having vegans and vegetarians complete regular MMA screenings in
conjunction with serum vitamin B12, they might be able to combat vitamin B12 deficiency
before the physical signs of deficiency become present.

Table 1: Key Findings

Study Key Findings

Gallego-Narbon A, Zapatera B, Alvarez I, et >70% consumed B12 supplements.

al.
Non-users of supplements exhibited lower
values of vitamin B12 and higher MMA.

There was not a significant difference in

serum vitamin B12 or MMA levels between
vegetarians or vegan who did not use
supplements.

Consuming dairy and eggs (lacto-ovo

vegetarians) did not affect vitamin B12 or
MMA levels

11 volunteers (6 vegetarians and 5 vegans)

had values of MMA higher than the MMA
cutoff level of 271 nmol/L. Ten of these
volunteers had serum vitamin B12 levels that
were above the 150 pmol/L cutoff (normal).

Gilsing AMG, Crowe FL, Lloyd-Wright Z, et The mean serum vitamin B12 concentration in
al. vegans was 33% lower than in vegetarians
and 57% lower than in omnivores, and was
35% lower in vegetarians compared with
omnivores.

Lederer A-K, Hannibal L, Hettich M, et al.
Shobha V, Tarey SD, Singh RD, et al.
The mean concentration of serum folate in
vegans was 34% higher than in vegetarians
and 88% higher than in omnivores.
52% of vegans and 7% of vegetarians had
B12 concentrations below the point of
deficiency.
21% of vegans, 17% vegetarians, and 1% of
omnivores had B12 levels indicative of
depletion.
Of the follow-up data round, 1/3 were
considered deficient and 8% were
depleted, and there was a strong positive
association with serum B12 and holoTC
and inverse relationship with serum B12 and
MMA.
This study showed that short-term reduced
intake of vitamin B12 does lead to rapid
decrease of serum holo-transcobalamin
(holo-TC).
MMA and Hcy remained within normal
reference ranges and showed no clinical signs
of vitamin B12 deficiency.
Revealed low plasma vitamin B12 levels and
high MMA levels within the elderly
population, indicated a negative correlation
between the two. Concluded that there was no
significant correlation between plasma
vitamin B12, MMA, homocysteine, and red
cell folate levels and cognitive function based
on the results from neurologic testing
Found that of the subjects 57% of the
population were consuming a vegetarian diet
and 31% of the vegetarian group consumed a
multivitamin supplement. Subjects who
consumed a multivitamin supplement had a
significantly higher plasma vitamin B12 and
lower MMA.