Case study: B12 deficiency, rapid weight loss, protein in the urine, osteoarthritis, elevated vitamin D

Just last week, a friend of mine wrote me this:

My mom has not been well.  Not eating well, massive head ache, lost a lot of weight.  Blood test results yesterday showed that she’s B12 deficient;  urine, however, has too much protein.  Any idea why?

I suppose, since he asked me, it most likely meant her MD didn’t offer an explanation for the test results.  One this is sure, neither she nor he knew what to do.  My feeling is that he asked just in case I knew anything that could help. And I did. So, I did.

Let’s go through the analysis together:


Is it normal to have protein in the urine?  What is supposed to be excreted in the urine?  What organ regulates what goes and what doesn’t go into the urine?  Under what circumstances would protein end up in the urine?

From a biological standpoint protein is precious.  From an evolutionary standpoint protein is hard to come by and hence relatively rare.  Therefore, the body has evolved to use and keep as much protein as it can.  The urine is intended to excrete uric acid, which is the main acid produced by metabolic processes.  Urine is excreted through the urethra, it is stored in the bladder, and it is produced by the kidneys, which filter the acids out of the blood.  The kidneys try to prevent large molecules like amino acids and glucose from going through into the urine.  The solids in the blood are separated from the water, the acid is filtered out of it, and depending on the state of hydration, more or less water is used to make urine or returned back to the blood.  The only circumstances under which protein would end up in the urine are 1) that the kidneys are not working properly, and unable to filter the protein out of the blood, 2) that there is a serious excess of protein in the blood, or 3) that there is both kidney dysfunction and excess amino acids in the blood.  We’ve explored kidney function in great detail before in The kidney: evolutionary marvel, and this understanding comes from there.

This means we already know that his mom either has kidney disease, that there is too much protein in the blood, or both.  But he wrote that she had lost a lot of weight.  Losing weight can be due to fat loss, muscle loss, or both.  Usually, very rapid weight loss in the elderly is not voluntary, and almost always means rapid loss of fat and muscle.  Therefore, for sure, the protein in the urine was the result of a the fast weight loss with rapid breakdown of muscle tissue.

But why?  Why would she all of a sudden start losing weight so fast?  What could have happened or triggered this?

Well, he also wrote that she was found to be B12 deficient.  And if this was recognized by the conventional MD who ordered the tests, you can be sure B12 levels were very low: surely below 200 pg/ml.

Do we become B12 deficient all of a sudden?  Or do B12 levels decrease slowly and gradually over the years?  Can we even become B12 deficient all of a sudden?  Why do we become B12 deficient in the first place?  And why is B12 important and relevant in this case?

It is possible to become B12 deficient all of a sudden.  This happens when our levels are marginally acceptable to start, and we receive a large dose of an anesthetic, before a surgery, for example.  Anaesthetic drugs deplete B12; and the larger the dose, the more severe the depletion.  But this is certainly not the majority of cases.

Most of the time, B12 levels decrease slowly and gradually over the years,  either from inadequate intake, or from compromised digestion.  In the younger population, it is usually from inadequate intake—as is the case for vegans and vegetarians.  In older adults, it is usually from compromised digestion—as is the case from the middle aged to the elderly, generally from a damaged gut and stomach cells that do not produce enough hydrochloric acid needed to break down the protein we eat.

As some of you will remember, we’ve also explored the importance and functions of vitamin B12 in B12: your life depends on it and more recently in Case Study: Homocysteine, B12, and folate.  Vitamin B12 is most important for its role in the nervous system: for healthy nerves and proper brain function.  But it is also an important anabolic nutrient essential in building and preserving muscle tissue.  Bodybuilders everywhere have been taking B12 supplements for at least 4 decades, exactly because it’s a potent natural anabolic.

Therefore, here is where our analysis leads us:

The most probable explanation is that his mother has been growing more and more deficient over the years, a B12 deficiency developed over several decades that just recently reached critically low levels. This triggered rapid weight loss that caused both the loss of body fat stores and the breakdown of muscle tissue.  The fat loss released streams of toxins that have been accumulating in the fat cells over years and years, and which caused the massive head aches from which she was complaining.  The muscle loss, the rapid breakdown of muscle tissue due to the extreme B12 deficiency, caused the kidneys to be overwhelmed and become unable to keep all these amino acids in circulation, and the protein therefore spilled into the urine.

My recommendation: B12 shots of 1 mg once a week for 10 weeks, and then of 5 mg once a month for the rest of her life.


The story doesn’t end here.  It turns out that she has osteoarthritis and she’s in pain.  Some time ago some friends of hers recommended taking vitamin D supplements, and so she did.  When she got her blood test done, her 25-OH-D was through the roof at 127 ng/ml.  If you’ve read our last post on vitamin K2 you will know that this is possibly the worst thing that someone with arthritis can do: high levels of D without correspondingly high levels of K2 will accelerate soft tissue calcification.  And since osteoarthritis is a disease of calcification, it will make everything much worse than it already is.  Naturally, I immediately recommend she stop taking vitamin D and start taking large doses of vitamin K2 as soon as possible, before something more serious like a stroke or a heart attack happens.

He sent me the blood tests, which I examined to get a better picture.  Interestingly, few markers were out of the reference ranges.  This is probably why nobody said anything other than to point out the obvious abnormalities: low B12, high D, and protein in the urine.

But in addition, what could be seen was that both urea and creatinine were near the top of their range, which is expected from rapid weight (muscle) loss, and the eGFR (the estimated glomerular filtration rate) was at the low end of the reference range, which is expected from compromised kidney function given the protein in the urine.  C-reactive protein was high but not super high.  This signals system inflammation, and is naturally excepted for someone with arthritis, as we also have seen together in the past (  Lastly, calcium was also high, but nevertheless within the reference range, something we would expected for someone with high D and not enough K2.


I asked if she was taking medications, and she was.  Several different drugs among which were a statin drug to lower cholesterol, a malaria drug used to treat symptoms of arthritis, and a couple of high blood pressure drugs one that is a diuretic and forces the kidneys to excrete more water, and the other that is an angiotensin antagonist that blocks the hormone which tells the kidneys to retain water when hydration is inadequate.  I replayed my view that drugs typically always attempt to block some pathway, and prevent the body from doing something that it naturally does to protect itself.  And in this case, she should wean herself off all of these over a few weeks.

I also explained that one of the most serious side effects of statin drugs is that they cause muscle wasting, promoting muscle tissue breakdown.  Statins do this in everyone, but in the elderly who already have accelerated muscle breakdown, it can be very serious.

My final recommendations, beside coming off the various drugs gradually to avoid a shock to the body, were as simple as possible for an old woman to follow: high dose B12 shots, high dose K2 pills, and high dose Mg as L-threonate, plenty of water and salt each day, a low carb diet rich in animal fats and green veggies, and sodium bicarbonate in water first thing in the morning on an empty stomach.  We’ll see what happens.


Blood tests can be used very effectively as a window onto the inner environment of the body.  MDs tend to only pay attention to the markers outside the reference range that appear in bold on the print outs.  But the reference range is derived from the blood tests of the whole population, and the population is far from being optimally healthy, that’s for sure.  What we need are not reference ranges derived from a sickly population, but an understanding of how the body works, what its organs and systems are trying to do, and with that understanding, of what our blood markers should be … ideally. What they should be in the best possible case.

That’s what we have to aim for.  And that’s what we have to learn to do, because we certainly can’t rely on your average MD to help us in this.  If you are an MD, and you are reading this, you already know that you are not your average MD, and I’m pretty confident you also know that your patients are lucky to have you.

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