What is the main cause of low B12?

Diet. Some people can develop a vitamin B12 deficiency as a result of not getting enough vitamin B12 from their diet. A diet that includes meat, fish and dairy products usually provides enough vitamin B12, but people who do not regularly eat these foods can become deficient.

nhs.uk - Vitamin B12 or folate deficiency anaemia - Causes - NHS

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A vitamin B12 or folate deficiency can be the result of a variety of problems. Red blood cells carry oxygen around the body. Most people with vitamin B12 or folate deficiency anaemia have underdeveloped red blood cells that are larger than normal. The medical term for this is megaloblastic anaemia. Vitamin B12 or folate deficiency anaemia occurs when a lack of either of these vitamins affects the body's ability to produce fully functioning red blood cells.

Causes of vitamin B12 deficiency

Pernicious anaemia

Pernicious anaemia is the most common cause of vitamin B12 deficiency in the UK.

Pernicious anaemia is an autoimmune condition that affects your stomach.

An autoimmune condition means your immune system, the body's natural defence system that protects against illness and infection, attacks your body's healthy cells. Vitamin B12 is combined with a protein called intrinsic factor in your stomach. This mix of vitamin B12 and intrinsic factor is then absorbed into the body in part of the gut called the distal ileum. Pernicious anaemia causes your immune system to attack the cells in your stomach that produce the intrinsic factor, which means your body is unable to absorb vitamin B12.

Diet

Some people can develop a vitamin B12 deficiency as a result of not getting enough vitamin B12 from their diet. A diet that includes meat, fish and dairy products usually provides enough vitamin B12, but people who do not regularly eat these foods can become deficient. People who eat a vegan diet and do not take vitamin B12 supplements or eat foods fortified with vitamin B12, are also at risk. Stores of vitamin B12 in the body can last around 2 to 4 years without being replenished, so it can take a long time for any problems to develop after a dietary change.

Conditions affecting the stomach

Some stomach conditions or stomach operations can prevent the absorption of enough vitamin B12. For example, a gastrectomy, a surgical procedure where part of your stomach is removed, increases your risk of developing a vitamin B12 deficiency.

Conditions affecting the intestines

Some conditions that affect your intestines can also stop you absorbing the necessary amount of vitamin B12. For example, Crohn's disease, a long-term condition that causes inflammation of the lining of the digestive system, can sometimes mean your body does not get enough vitamin B12.

Medicines

Some types of medicine can lead to a reduction in the amount of vitamin B12 in your body. For example, proton pump inhibitors (PPIs), a medicine sometimes used to treat indigestion, can make a vitamin B12 deficiency worse. PPIs inhibit the production of stomach acid, which is needed to release vitamin B12 from the food you eat. Your GP will be aware of medicines that can affect your vitamin B12 levels and will monitor you if necessary.

Functional vitamin B12 deficiency

Some people can experience problems related to a vitamin B12 deficiency, despite appearing to have normal levels of vitamin B12 in their blood. This can happen as the result of a problem known as functional vitamin B12 deficiency, where there's a problem with the proteins that help transport vitamin B12 between cells.

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