Let’s all thank the Brits for the trifle, which we are going to take full advantage of here to turn leftover cake into breakfast. Breakfast trifle will make you look like the Patron Saint of Brunch (or hey, just a cool mom) and it’s easy, pretty, and delicious.
So what is a breakfast trifle, you ask? It has layers of tangy yogurt, studded with ripe blueberries and candied ginger, all sandwiched between vanilla cake and granola. Sounds like a real treat, right? That’s because it is!
Chris Kresser: Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. This week, we have a question from Kristin. Let’s give it a listen.
Kristin: Hey, Chris, my name is Kristin. I have a question for you in regards to vitamin B12 and deficiency in it. I was doing some research on vitamin B12 a while back because I have severe anxiety and panic attacks, and I noticed that sometimes people that have symptoms like that have B12 deficiency. But I also came across some articles in regards to our fingernails and how the half moons will be gone if we have vitamin B12 deficiency. I don’t know if that’s something that is common in functional medicine to look at, is the fingernails, or stuff like that. But that’s really been interesting to me lately and I would just really love to know your opinion on that. Thanks.
Chris: That’s a great question. I often get questions like this related to the fingernails as markers of nutritional deficiency, and there is some limited data on nutritional deficiency showing up in the fingernails. It can be one of the many diagnostic criteria for nutritional deficiencies, but in some cases, the data is stronger than they are in other cases, and I wouldn’t use fingernails as the sole way of diagnosing a nutritional deficiency. I would think about it as one sign that could point us toward doing further diagnostic workup for nutritional deficiencies that would include lab testing, blood testing in most cases, sometimes urine testing. But I would never make a definitive diagnosis of a nutritional deficiency just based on the fingernails alone.
Why you should have your vitamin B12 tested—and the right way to test it
Let’s talk a little bit more about B12 and diagnosing the B12 deficiency because it’s really, really important. B12 deficiency turns out to be much more common than statistics indicate, and it can have really devastating consequences. B12 deficiency has been associated with or can actually cause premature aging or logical disorders that are similar in presentation to MS or even Parkinson’s, brain fog, memory problems, cognitive decline; stroke, heart disease, and other vascular problems, primarily due to elevated homocysteine levels—B12 is required to convert homocysteine back into methionine; developmental or learning disabilities in children; impaired immune function, autoimmune disease, and cancer; male and female infertility; and numerous other symptoms because B12 plays a very, very important role in the body. As you can see, when you don’t have enough B12, it can affect virtually every system and tissue in the body.
The problem with conventional B12 serum testing
Now, one of the biggest issues with diagnosing B12 deficiency is that the conventional serum B12 test that most doctors use only picks up a small fraction of people who are actually B12 deficient. I mean, that’s a big enough problem on its own. I suppose we could say an even bigger problem is that very few doctors even use that conventional serum B12 test. I’ve had so many patients that I have diagnosed with B12 deficiency in their 40s, 50s, even 60s or older who have never once in their entire life been tested for B12, which is just crazy to me given how important it is, given how easy it is to test for B12 and how cheap that serum B12 test is. That’s a big problem. A lot of doctors aren’t including serum B12 in their workup.
But as I just said, even if they are including it, chances are they’re missing a lot of people with B12 deficiency because the serum B12 test measures a total amount of B12 in the blood, but it doesn’t rule out functional B12 deficiency.
There are more sensitive markers for B12 deficiency that are now available including methylmalonic acid (MMA), which can be measured both in the serum or the urine. And not so much in the US but in Europe and other parts of the world, there’s another marker called holotranscobalamin II, or holoTC. That’s in fact the most sensitive marker for B12 deficiency. It is capable of detecting B12 deficiency at the earliest stage, stage one. These markers are much more sensitive to B12 deficiency than serum B12, which means they’ll go out of range at an earlier stage of B12 deficiency.
Then we also have homocysteine, which is a marker of B12 deficiency, although it’s not exclusively related to B12. Homocysteine can be high in cases of folate deficiency or even B6 deficiency as well. Homocysteine is more sensitive than serum B12, but it doesn’t only reflect B12 deficiency. If you see it high, that tells you that either B12, folate, or B6 is low, and you need to do some additional testing with these other markers to determine whether the cause of the elevated homocysteine is related to B12 or if it’s related to folate or B6.
Those are the additional markers you can use. Serum B12 is still a useful test and can still detect deficiency in some patients, but those people are people that are in stage three or four of 12 deficiency. There are four stages: One, two, three, and four—and serum B12 doesn’t typically go out of range until stage three or four, so you’re missing people in stage one or two if that’s the only marker that’s used. Homocysteine and methylmalonic acid can detect people in stage two deficiency. Holotranscobalamin or holoTC is the only marker, unfortunately, that they can detect people in stage one deficiency. It’s a mystery to me why it’s not available in the US. It is in a few teaching hospitals—I think Mayo Clinic, maybe Cleveland Clinic and a few other places around the country offer it—but you can’t get it drawn at your typical lab. I’ve been hoping that that will change for years, but unfortunately, it hasn’t yet.
The prevalence of B12 deficiency
We talked a little bit about the important roles of B12 and why you should get tested, but I want to mention a little bit more about the prevalence of B12 deficiency because there is an incorrect notion in the medical world that B12 deficiency is rare and it only really affects people on a plant-based diet like vegans and vegetarians. There is even a bigger myth in the vegan and vegetarian world that B12 deficiency is not common in those worlds.
The problem is, those ideas are based in using only serum B12 as a marker for B12 deficiency. If you use serum B12 as the only marker for B12 deficiency rather than some of these newer tests, the statistics suggest that only 7 percent of vegetarians are B12 deficient. Interestingly enough, they still show that 52 percent of vegans are deficient. Even using a relatively insensitive marker like serum B12, you still see over 50 percent of vegans deficient in it, 7 percent of vegetarians. But in a more recent study, using the more sensitive markers that I just talked about that are capable of detecting B12 deficiency at an earlier stage, a whopping 83 percent of vegans were B12 deficient and 68 percent of vegetarians were B12 deficient. Now remember, only 7 percent were deficient using serum B12, but 68 percent were deficient using these more accurate and sensitive markers.
Why even omnivores may be deficient
Now in terms of omnivores, only 5 percent were deficient. But I can tell you having worked with patients for a very long time—most of whom are on a Paleo type of diet or a nutrient-dense diet where they’re consuming animal products—I see B2 deficiency fairly regularly. One of the reasons for that is that deficiency of a certain nutrient doesn’t just come down to how much of that nutrient you’re getting from your diet. It comes down to how well you are absorbing that nutrient in the gut and also what the demand for that nutrient is because of certain physiological processes in the body. It also comes down to whether you have genetic polymorphisms that affect your utilization of that nutrient.
Let’s use folate as an example—well, let’s use B12 as an example since that’s what we’re talking about here. There are some polymorphisms that affect B12 metabolism and the use of B12 in the body. MTRR and MTR are both genes that are connected to B12 metabolism. If you have single nucleotide polymorphisms or SNPs in those genes, MTRR and MTR, that can be measured with a test like 23andMe, those can impact B12 metabolism and they may indicate a greater need for B12 than you would have if you didn’t have polymorphisms in those genes.
And then there are conditions like SIBO, bacterial overgrowth in the small intestine, that have been shown to decrease absorption of B vitamins like B12 in the small intestine because the bacteria in the small intestine can actually utilize B vitamins as well. They’ll take them for themselves and you will get less of them. Hypochlorhydria, or low stomach acid, which, as I’ve written and spoken about elsewhere, I think is a major cause of reflux in people and a very common condition that can also decrease the absorption of B12. Even if someone is consuming enough B12, if they have low stomach acid, they have SIBO or they have genetic polymorphisms that affect their ability to absorb and then utilize B12, then these people can also be deficient even though they’re not vegetarian or vegan and so that’s really important to understand.
The serious consequences of B12 deficiency going undiagnosed
Another crucial concept to get is that B12 depletion can take years to become clinically evident. I mentioned that there are four stages of B12 deficiency. In stage one and two, there will be no observable … usually no signs or symptoms of B12 deficiency. In other words, it’s not measurable using any other markers. It doesn’t start to cause anemia at that level and it’s not going to show up in other markers and it may even be completely asymptomatic. In fact, B12 deficiency doesn’t cause macrocytic anemia until stage 4, so that’s in the very last stage of B12 deficiency.
Unfortunately, some of the more serious effects of B12 deficiency such as nerve damage are irreversible. We have this really tricky situation where B12 deficiency is underdiagnosed because it’s not being adequately tested for. The symptoms and clinical signs can take years to become evident, but some of the more serious effects of B12 deficiency can actually be irreversible if the B12 deficiency has progressed to an advanced stage and has gone on for long enough.
I think it’s a major issue. This is why I’ve written two really detailed articles about the important effects of B12 and the problems with diagnosis and how to accurately diagnose it. We’ll definitely include a link to those articles in the show notes for the show. There are actually books that have been written about B12 deficiency. Sally Pacholok and Jeffrey Stuart have a book, Could It Be B12?: An Epidemic of Misdiagnoses, that covers this topic in great detail and goes into even some of the history and all of the conditions that can be caused by B12 deficiency and more background on what we’ve been talking about in this podcast.
Lab results: what to look for
I would encourage everybody to, at the very least, have their serum B12 measured. But as I have mentioned, that’s in many cases inadequate to detect stage one and stage two deficiency. Homocysteine is a marker that you shouldn’t have any trouble getting your primary care practitioner to order. It’s well known. It’s recognized as a marker for cardiovascular disease, and it’s pretty cheap. They should at least be familiar with that, and if you request a serum homocysteine, that’s probably a good starting place. Remember though, if it comes back high, it doesn’t guarantee you a B12 deficiency. It could also be folate or B6, but that might be enough ammunition to then get your clinician to order some of the more advanced tests for detecting B12 deficiency like serum or urinemethylmalonic acid. I personally have found that urine methylmalonic acid is superior to serum, possibly because it’s more concentrated in urine than in the blood. I’ve just seen it be more sensitive and more consistent with the other markers of B12 deficiency then than serum methylmalonic acid. If you live in Europe or outside of the United States, you also might be able to get a holotranscobalamin, or a holoTC, which is again, the most sensitive marker for B12 deficiency.
If you can’t get your doctor to order those tests, you can order some of these tests perhaps through companies like DirectLabs.com, although there is quite a bit of nuance to interpreting these tests. It’s really helpful to have somebody who is experienced in interpreting these tests.
Another thing I want to say about these labs, if you’ve been listening to my work for any length of time, you may be aware that the conventional lab ranges that are used for these markers and many other lab markers are often not accurate. Conventional ranges are typically designed to detect frank disease rather than an optimal level, and serum B12 and even homocysteine are no exception. Most labs define B12 deficiency at less than 200 pg/mL, but it is well documented in the scientific literature that many people experience signs and symptoms of B12 deficiency at levels between 200 and 350. In Japan and Europe, I believe the lower end of the range is 400 and up or even 500 and up in either Japan or Europe. I can’t recall.
And so, if you get the B12 tests back and the level is 300, it’s going to be marked as normal, but at that level there’s a really good chance that you are in the earlier stages of B12 deficiency, and then if you were to measure homocysteine or MMA, that those would be out of range as well. With homocysteine, the range typically goes up to 13, 14, or even 15 in some labs, but I’ve seen lots of research suggesting that with B12 or folate deficiency, that can show up on homocysteine levels, start getting higher than eight. Homocysteine level above eight doesn’t necessarily reflect B12 deficiency, but it would be cause in my mind for doing further testing. Keep in mind that homocysteine is an inverse marker, which means when it’s high, that suggests B12 is low, and both serum and urine methylmalonic acid are also inverse markers, so when they’re high, that suggests that B12 is low.
Be aware that high serum B12 does not necessarily rule out functional B12 deficiency. This is what I was referring to when I said there’s some nuance on how to interpret these markers. In fact, I have come to view a high serum B12 when the patient is not supplementing or not eating really extreme amounts of B12 foods like liver as a potential red flag for active B12 deficiency.
Nutrients rich in vitamin B12
If you do actually have B12 deficiency, then there is much bigger discussion about how to address that. Eating B12-rich foods in my opinion is the best way. If you do eat animal products, B12 is richest in liver, clams, oysters, organ meats, and shellfish—once again, top of the list in terms of the most nutrient-dense foods. If you just ate a serving of liver and a serving of clams, oysters, or mussels each once a week, you would probably be able to meet your needs for B12 for the entire week. Other seafood like fish eggs, octopus, crab, and lobster are good sources for B12. Beef, lamb, even cheese and eggs are good sources of B12 as well, but they pale in comparison to the organ meats and shellfish in terms of the amount of B12 per serving.
A common myth amongst vegetarians and vegans is that it’s possible to get B12 from plant sources like seaweed, fermented soy, spirulina, brewer’s yeast, etc., but many of those plant foods actually contain B12 analogues called cobamides that block the intake of and increase the need for true B12. My intention here is not to bash vegetarian and vegan diets. As many of you know, I was a macrobiotic vegan myself at one point, but just helping to educate people about how to make wise choices. If you are on a vegetarian or vegan diet, you should be definitely getting your B12 levels measured with the more sensitive markers that I have mentioned, and then if your levels are low, you should be supplementing with B12, which is really quite easy to do.
We won’t go into a lot of detail on supplementation because I’ve written about that before, and I will just provide a link to the articles, which have some recommendations there.
Okay. Thanks again, Kristen, for sending in your question, and please do continue to send in your questions, everybody, to chriskresser.com/podcastquestion. Thanks for listening. Talk to you next time.
Barely there frosting was once only seen by bakers between as a crumb coat before the final layer of frosting was added, but now naked cakes have moved from verified trend to bakery staple. These cakes, easily recognized by their exposed layers and minimal garnishes, have become a staple style for everything from homemade birthday cakes to multi-tiered wedding cakes. More than just a cake with less frosting, here’s everything you need to know about the naked-cake trend and why you might actually want to try it at home.
If you were put on the spot and had to guess the most popular item so far for 2017 on the wedding registry website Zola, could you guess it? You’d probably get it right and guess a KitchenAid stand mixer, yeah? And not because we told you in the title of this post! You just know it’s a safe bet.
“You cannot go wrong gifting a couple a KitchenAid stand mixer. It remains one of the most popular items on registries year after year — and with good reason, it’s a kitchen staple!” says Zola’s Newlywed-at-Large and Director of Brand, Jennifer Spector.
To put you on the spot again: Can you name the second most popular registry item for 2017? Is it a Le Creuset Dutch oven? Rose gold flatware? A waffle maker? A Lodge cast iron skillet?
It’s Friday, everyone! And that means another Primal Blueprint Real Life Story from a Mark’s Daily Apple reader. If you have your own success story and would like to share it with me and the Mark’s Daily Apple community please contact me here. I’ll continue to publish these each Friday as long as they keep coming in. Thank you for reading!
I first wrote to Mark in September of 2015 after transitioning to a primal lifestyle in 2014. As a quick review I was coming off six or seven years of living in a post college frat house devouring IPAs, nachos, and pizza; spending late nights at bars, and running four or five miles four or five times a week in the name of staying healthy. I look back on my twenties with fondness and nostalgia, but I have no desire to go back to those dive bars that I used to frequent with such ferocious regularity.
When I last wrote I had a 4-month-old son who was born a month early and only screamed during times when he was not sleeping (so that was awesome), was beginning graduate school, was a week into a new administrative job, and was transitioning to a suburban lifestyle. Stressful times! Now I find myself with a thriving but demanding two-year-old son, a two-month-old daughter who only screams about a quarter as much as our son did (still awesome), three months from finishing graduate school, and about to successfully finish the second year at my new job. Still stressful times!
During the hardest moments of the past couple of years, I have again and again found myself grateful for the primal lifestyle and way of eating. I have taken a great deal of comfort from knowing that I am nourishing myself and giving myself the best chance to be more patient, loving, and fun for my family and everyone in my community.
I have had some revelations in terms of food and movement since I last wrote, and I’ll get into those in a moment. However, as I examine my life I am more and more aware of the acute importance of self-care and the incredibly powerful ways that living primally allows for that. I am not proud to admit this, but being a dad was (and, at times, still is) really difficult for me. There are some moments that feel really dark, trying, and interminable. Amidst a storming sea of violent diaper explosions, tantrums about which shoe my son should put on first, and orange slices being thrown all over the dining room, the primal lifestyle has been my anchor.
On the good days I feel like I don’t need a trip to a spa, a slow, romantic dinner at a restaurant, or even half an hour alone to recharge my battery. I don’t desire those things because the food I am putting into my body and the choices I’m making around sleep and wellness feel like a luxury in and of themselves.
I don’t want to paint too rosy a picture, and I almost made myself cry writing that sentence about a slow, romantic dinner. However, I am also consistently reminded that, as Mark says, my wife and I are investing in our family and ourselves with the nutritional and lifestyle choices we are making on a daily basis. During the moments when I can project past getting thrown up on or hearing the first dreaded thump in the crib at 5:45 a.m., I am at peace knowing that our priorities and choices are exactly where I want them to be. The primal life is a bit of a compass with which I can navigate the confusing map of parenting young ones while trying to maintain some contact with my wife and myself as well.
In terms of nutrition and body composition, I have found a way to eat a bit less than I was before. First of all, I am using a compressed eating window by skipping breakfast every day, and I am thriving with this change. Though not starving, I am genuinely hungry by lunchtime, and I enjoy a giant salad with sauerkraut, a fried egg, a small piece of protein, and any veggies I can get my hands on bathed in some homemade dressing. Mercifully, my work has a salad bar and I can get healthful food (thanks to a chef who let’s us know what is Whole30 compliant) even in the middle of a busy workday. Dinner is some form of a few veggies and a good piece of protein.
In terms of macros, I am really enjoying experimenting with the minimum effective dose of protein. At around 180 pounds and between 13 and 14 percent body fat, I am trying to nourish around 155-160 pounds of lean mass. Over the past couple of months I’ve been getting by on around 70-80 grams of protein a day. There’s a chance I could put on a few pounds of muscle if I ate some more, but I am sleeping well, my energy is good, and my mind is sharp. That seems like more than a fair trade for slightly stronger boobs. I’ve read mixed things about the conversion of excess protein to glucose, but ingesting less feels healthy and sustainable to me.
Fat is a mainstay as I stay in ketosis almost all of the time. After winning the Grok Pose contest two years ago, the family is making its way through $1,000 of Primal Kitchen Mayo one gallon at a time. When I’m hungry, I go grab a broccoli floret or twenty and get a heaping bowl of mayo to dip until I’m satisfied. It beats a bowl of ice cream any day. Okay, that might be a stretch, but no one ever hated himself for snacking on broccoli.
In terms of exercise, I am lifting quite heavy (for me) twice a week, sprinting once a week (possibly twice if I play basketball), doing a bunch of push-ups, pull-ups, air squats, planks, and belly flexes whenever the spirit moves me. One of my lifting sessions is pushing and pulling (failing around four or five reps once I am warm), and the next one is very heavy lifting with my legs along with some core work. I focus on my hamstrings every week to keep them healthy for sprinting and play. My performance in the weight room is slowly improving (like I said, maybe not as quickly as it might if I were to eat some more protein), and I’m not consistently sore or lethargic.
On the lifestyle side of things, I have recently reconnected with meditation, and that has been incredibly powerful. Like I said, there are some moments where I am not sure that parenting tiny people is something I’ll be able to keep doing, and the meditation has allowed me to be better for my kids by highlighting that, just like everything, it is temporary. Similar to my relationship with food, I am realizing that I cannot compromise meditating and live the life that I want to live. It has been costing me forty-five minutes of sleep every morning and a little time in the evenings with my wife, but if I wasn’t meditating she wouldn’t want to hang out with me anyway…I don’t even want to hang out with me when I don’t meditate.
In terms of struggles, my biggest one has been the unadulterated joy that I get from food. My favorite thing to do is experiment with cuts of meat from Wild Harmony Farm, and roast some veggies doused in homemade melted lard. My cooking is getting better and better, and I’ve created some truly wonderful meals. On the hard parenting days, it can be the only positive stimulation I get, and it is easy to overdo it when there are three pounds of juicy pulled pork shoulder braised in coconut milk and curry with some cauliflower rice on the counter just waiting to be devoured. I’ve been working hard to increase the positive feelings I get outside of food with meditation and connecting with friends more regularly, and that has reduced the need to have fifths seconds of whatever I am eating.
Reading over my last “success story,” I still have the feeling that the more good choices I make, the more good choices I will make. It’s amazing that this journey started with the goal of LGN, and has ended up being a really steadying force in a tumultuous time in my life – though I still wouldn’t mind LGN. I feel a sense of purpose and forward momentum associated with these choices, and it allows me to improve just a little bit. The lifestyle feeds on itself, and I love how empowered I feel to make knowledgeable, healthy decisions as I commence my life as a parent of two.
When it comes to throwing a bridal shower, whether it’s for your sister or your BFF, picking the favors for guests can be one of the hardest decisions. You want the favors to be cute, not cheesy, and something guests will actually use (read: you don’t want to give everyone another cheap-o wooden cheeseboard emblazoned with the couple’s monogram).
Keep calm: We’ve rounded up 10 bridal shower favor ideas that definitely won’t be left behind. Carry on.
Next time you wander through the produce section to pick up some dates (yes, that is the best place to find them at the grocery store!), you might want to grab a few extra. This fruit has a deep, caramel-like flavor that makes everything from smoothies and energy bars to salads and cookies even sweeter. Here are 20 recipes that show you how to harness the sweetness of dates in almost any kind of dish.
Yogurt with fruit and granola is a pretty common breakfast dish, but sometimes all it takes is one clever tweak to transform the everyday combination into something whimsical and fun. In this case, I’m talking about making ice pops!
For now classes are 6pm and 640pm at 2840 Wildwood st in the Boise Cloggers studio.
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In terms of nutrition and body composition, I have found a way to eat a bit less than I was before. First of all, I am using a compressed eating window by skipping breakfast every day, and I am thriving with this change. Though not starving, I am genuinely hungry by lunchtime, and I enjoy a giant salad with sauerkraut, a fried egg, a small piece of protein, and any veggies I can get my hands on bathed in some homemade dressing. Mercifully, my work has a salad bar and I can get healthful food (thanks to a chef who let’s us know what is Whole30 compliant) even in the middle of a busy workday. Dinner is some form of a few veggies and a good piece of protein.
On the lifestyle side of things, I have recently reconnected with meditation, and that has been incredibly powerful. Like I said, there are some moments where I am not sure that parenting tiny people is something I’ll be able to keep doing, and the meditation has allowed me to be better for my kids by highlighting that, just like everything, it is temporary. Similar to my relationship with food, I am realizing that I cannot compromise meditating and live the life that I want to live. It has been costing me forty-five minutes of sleep every morning and a little time in the evenings with my wife, but if I wasn’t meditating she wouldn’t want to hang out with me anyway…I don’t even want to hang out with me when I don’t meditate.
For now classes are 6pm and 640pm at 2840 Wildwood st in the Boise Cloggers studio.
Book your class NOW!
click this ==>
