Newsletter Monday
Hello Reader,
I read a story recently that I haven't been able to stop thinking about.
Georgina Owen was 21, studying geography at Swansea University, on track for a first-class degree and extremely active. She was also vegan.
In the summer of 2019, her family began to notice subtle changes in her behaviour. She became unusually irritable and her thinking didn't seem quite right. Then her mental health deteriorated frighteningly quickly.
Within days she attempted to take her own life. Her father found her and resuscitated her, but tragically she died a few days later.
But it wasn't the tragedy itself that made this story stick with me. It was the conclusion of the coroner at the inquest this year.
Georgina had developed vitamin B12 deficiency as a result of her vegan diet. The coroner concluded that the deficiency had caused delusional beliefs which preceded her suicide.
Her father, Julian, is an orthopaedic surgeon. Her mother is a respiratory nurse. They knew vegans needed B12. Georgina knew too and had supplements, although she hadn't been taking them consistently.
Her father has since devoted considerable time to raising awareness of B12 deficiency and bringing clinicians and researchers together to improve our understanding of it. His message isn't that veganism killed his daughter. It's that even as a doctor who knew about B12 deficiency, he hadn't appreciated how serious its neurological and psychiatric consequences could be.
That was the bit I couldn't stop thinking about.
And before anyone starts sharpening their knives in anticipation of an anti-vegan rant, that's not where I'm going with this.
Is a vegan diet unhealthy?
No.
I've known people eating healthy vegan diets since long before veganism was fashionable, a social media identity or something people did because of climate change.
I'm also not entirely convinced by the argument that simply replacing animal foods with plant foods is the environmental solution. My own view of sustainability is considerably less exciting: we need to consume less of everything.
Fewer clothes we wear three times. Fewer plastic toys destined for landfill. Fewer gadgets. Less food bought and subsequently thrown in the bin. All food should be treated with considerably more respect than it is.
But whatever your reasons for eating a vegan diet, there is one nutritional issue you cannot wish away.
You need vitamin B12.
B12 is found predominantly in animal-derived foods: meat, fish and shellfish, eggs and dairy products. If you eat no animal products, you need to obtain it reliably from fortified foods or supplements.
This isn't anti-vegan propaganda. It's biochemistry.
B12 isn't a wellness accessory
B12 is essential for normal neurological function, DNA synthesis and red blood cell production.
Significant deficiency can cause neurological and psychiatric symptoms as well as anaemia.
Importantly, those symptoms can occur without anaemia, so if B12 deficiency is suspected, you need to measure B12 itself rather than assuming a normal blood count rules it out.
But sometimes, normal results get spun.
Measuring B12, finding it is within the normal range, and deciding it isn't quite "optimal" enough is a popular marketing angle.
This is exactly where the wellness industry has found an opportunity: persuading otherwise healthy people that a normal result is nevertheless something that needs fixing.
Someone messaged me recently, delighted with the results of private health testing.
She had discovered that her B12 was at the "low end of normal" and had been recommended a B12 spray, which she was told was a more absorbable form.
She started taking it, felt much better, and understandably regarded this as evidence that the testing had discovered something important.
Maybe it did.
But "low normal" isn't a diagnosis.
Depending on the actual result, symptoms and risk factors, a borderline result may warrant further investigation. But simply being towards the bottom of a reference range doesn't make you deficient.
And while she may genuinely feel better, taking something and subsequently feeling better doesn't establish that one caused the other.
As for needing a spray because it's "more absorbable", there isn't convincing evidence that B12 sprays provide an important clinical absorption advantage over an ordinary oral supplement.
So who actually needs B12?
If you eat a varied diet containing animal products and absorb B12 normally, you should ordinarily get enough from food: meat, fish and shellfish, eggs and dairy products.
If you're vegan, you need a reliable source from fortified foods and/or supplements. There is nothing wrong with doing this. It's simply part of making a vegan diet nutritionally adequate.
But if you're genuinely deficient despite consuming enough, we need to ask why.
Autoimmune gastritis — traditionally called pernicious anaemia — can prevent normal absorption.
So can surgery involving the stomach or terminal ileum and some conditions affecting the bowel.
Medications including metformin and long-term acid suppression can also contribute.
High-dose oral B12 can work even in some people with impaired absorption, but there are circumstances where intramuscular B12 is necessary and recommended.
And if someone has significant neurological symptoms from suspected B12 deficiency, this is absolutely not the moment to mess about ordering a premium wellness spray from the internet.
Which brings me back to Georgina
I think her story exposes an uncomfortable contradiction.
We measure vitamins in healthy people, talk about "optimal" rather than normal levels, and sell methylated versions, activated versions, sprays and formulations promising superior absorption.
And yet genuine vitamin deficiency still exists.
Sometimes it causes serious disease.
And occasionally, as Georgina's family discovered in the most appalling circumstances imaginable, the consequences can be catastrophic.
The lesson from her story isn't that veganism is dangerous.
Nor is it that everyone should start taking B12 "just in case".
It's that nutrition matters.
If you eat animal products and absorb nutrients normally, a varied diet remains a remarkably effective way of obtaining what you need.
If you choose not to eat foods containing an essential nutrient, you need to replace it.
And if you have a genuine deficiency despite apparently consuming enough, we need to ask why.
Sometimes food is the answer. Sometimes a cheap, boring tablet is the answer. And sometimes you need proper medical investigation and treatment.
Perhaps we could spend a little less time trying to optimise healthy people — and make sure we're better at recognising when someone is actually ill.
