Innspill til NNR-2022 kapittel om vitamin B12

Her er teksten vi har sendt til Nordic Nutritional Recommendations 2022. Dette, NNR 2022, er et forarbeid, eller vitenskapelig grunnlag, til fellesnordiske kostholdsråd.

Vitamin B12 deficiency is usual among a wide population. More research and food enrichment may be necessary

Severe vitamin B12 deficiency is rare, but internationally it is reported that up to 26% of the general population may have subclinical vitamin B12 deficiency. The occurrence of it has not been investigated widely and well enough in Norway (1,2,3).

Only animal or enriched foods contains vitamin B12.

At the same time, animal food is the biggest source of environmental toxins in the Norwegian diet. The recent report by the Science Committee for Food and Environment, VKM, says:

 «The Norwegian population is exposed on average to more dioxins and dioxin-like PCBs from food than the tolerance limit.» And «The food groups that contribute the most are fatty fish, milk and dairy products and meat.» (4)

In contrast to toxins, there are no disadvantages to fortification.

Report Development in Norwegian diet 2021 from the Directorate of Health, (5 – page 9, 40, 41) says that it is dairy (cheese, whole milk) and red meat that are the main sources of saturated fat. Saturated is the type of fat that 80% of Norwegians eat in harmful for health amounts, acc. to the Action plan for a better diet (6 – page 13 and 56). (5,6)

To hope that animal foods are a robust source of B12 for the general population may be not correct. This is:

1. Not safe (26% of population are estimated to have subclinical B12 deficiency, in addition to many pregnant and lactating women)

2. Not healthy (the main source of environmental toxins and high in saturated fat)

3. Not good for the environment or sustainable food production (The Norwegian Directorate of Agriculture’s concentrate feed statistics (Kraftfôrstatistikk) shows that huge amounts of food are used to feed livestock). (7)

A recent study on Norwegian vegans, on the other hand, shows that all of them have a good B12 status. (8)

This shows that 1) the use of fortified foods, 2) increased attention to possible B12 deficiency and 3) use of B12 as a dietary supplement are important not only for vegans but for the general population – on a broad basis.

Both vitamin D and iodine are difficult to get enough of without supplementation (see reports of The Norwegian Nutritional Council), and B12 should be considered as one of such «difficult» nutrients. (9,10).

Content of, among other things, vitamin B12 in various plant milks and meat substitutes, see Table 5 page 17. (11)  It is also listed in the official Norwegian matvaretabellen.no (12). The enrichment can therefore be extended to other foods.

Sources:

1.           Mouland G, Lie Berg C, Nouri Sharikabad M, Thode Sommerschild H. Fylkesforskjeller i utredning og behandling av vitamin B12-mangel. Tidsskr Nor Legeforen 2022 doi: 10.4045/tidsskr.21.0749

2.           Green R, Allen LH, Bjørke-Monsen AL et al. Vitamin B12 deficiency. Nat Rev Dis Primers 2017; 3: 17040.

3.           Carmel R. Prevalence of undiagnosed pernicious anemia in the elderly. Arch Intern Med 1996; 156: 1097–100.

4.           VKM. Dioksiner i maten til den norske befolkningen. Risk assessment of dioxins, furans, and dioxin-like PCBs in food in Norway

5.           Helsedirektoratet. Utviklingen i norsk kosthold. Oslo: Helsedirektoratet; 2021. P. 9,40,41

6.           Helse- og omsorgsdepartementet. Nasjonal handlingsplan for bedre kosthold (2017–2021). Oslo: Helsedirektoratet; 2017. S. 13 og 56

7.           Landbruksdirektoratet. Kraftfôrstatistikk

8.           Henjum, S. et al. (2022). Adequate vitamin B12 and folate status of Norwegian vegans and vegetarians. British Journal of Nutrition, 1-20. doi:10.1017/S0007114522002987

9.           Nasjonalt råd for ernæring, 2016. Risiko for jodmangel i Norge. Identifisering av et akutt behov for tiltak.

10.         Nasjonalt råd for ernæring. (2018). Vitamin D i Norge: Behov for tiltak for å sikre god vitamin D-status?.

11.         Rapport: Analyser av næringsstoffer og uønskede stoffer i plantebaserte middagsprodukter og drikker 2021. Havforskningsinstituttet.

12.         Mattilsynet, Helsedirektoratet, Universitetet i Oslo. Matvaretabellen 2019

Innspill 2:

Plant based diets, despite lower content of vitamin B12, are more healthy and sustainable than western diets (which means with our high consumption of meat and dairy that are good B12-sources).

Sources about diets and health and sustainability:

World Health Organization. Regional Office for Europe. (2021). Plant-based diets and their impact on health, sustainability and the environment: a review of the evidence: WHO European Office for the Prevention and Control of Noncommunicable Diseases. WHO. Regional Office for Europe. https://apps.who.int/iris/handle/10665/349086 License: CC BY-NC-SA

Willett W, Rockström J, Loken B, et al. Food in the Anthropocene: the EAT Lancet Commission on healthy diets from sustainable food systems [published correction appears in Lancet. 2019 Feb 9;393(10171):530] [published correction appears in Lancet. 2020 Feb 1;395(10221):338] [published correction appears in Lancet. 2020 Oct 3;396(10256):e56]. Lancet. 2019;393(10170):447-492. doi:10.1016/S0140-6736(18)31788-4

Altomkost.dk. Fødevarestyrelsen. De officielle Kostråd – godt for sundhed og klima. Spis mindre kød – vælg bælgfrugter og fisk. https://altomkost.dk/raad-og-anbefalinger/de-officielle-kostraad-godt-for-sundhedog-klima/spis-mindre-koed-vaelg-baelgfrugter-og-fisk/

USDA. Scientific Report of the 2020 Dietary Guidelines Advisory Committee. Advisory Report to the Secretary of Agriculture and Secretary of Health and Human Services. First Print: July 2020 https://www.dietaryguidelines.gov/2020-advisory-committee-report
Canada’s food guide. Healthy food choices https://foodguide.canada.ca/en/healthy-food-choices/

Food and Agriculture Organization of the United Nations Food-based dietary guidelines – Belgium https://www.fao.org/nutrition/education/food-based-dietaryguidelines/regions/countries/belgium/en/

Springmann M, Godfray HCJ, Rayner M, Scarborough P. Analysis and valuation of the health and climate change cobenefits of dietary change. Proc Natl Acad Sci U S A. Published online March 21, 2016.

Rinaldi S, Campbell EE, Fournier J, O’Connor C, Madill J. A Comprehensive Review of the Literature Supporting Recommendations From the Canadian Diabetes Association for the Use of a Plant-Based Diet for Management of Type 2 Diabetes. Canadian Journal of Diabetes. 2016.

Marteau, T. M., Chater, N., & Garnett, E. E. (2021). Changing behaviour for net zero 2050. BMJ (Clinical research ed.), 375, n2293. https://doi.org/10.1136/bmj.n2293

Martin C. Parlasca and Matin Qaim. Meat Consumption and Sustainability. Annual Review of Resource Economics. Annu. Rev. Resour. Econ. 2022. 14:6.1–6.25 https://doi.org/10.1146/annurev-resource-111820-032340

Norwegian sources:

Helsedirektoratet. Bærekraftig kosthold – vurdering av de norske kostrådene i et bærekraftperspektiv https://helsedirektoratet.no/publikasjoner/berekraftig-kostholdvurdering-av-de-norske-kostradene-i-et-berekraftperspektiv

Helsedirektoratet. Utviklingen i norsk kosthold. Oslo: Helsedirektoratet; 2021.

Helse- og omsorgsdepartementet. Nasjonal handlingsplan for bedre kosthold (2017–2021). Oslo: Helsedirektoratet; 2017
Kreftforeningen.no. Kosthold og kreft https://kreftforeningen.no/forebygging/kosthold-og-kreft/

Chapter 6, Vegans/Vegetarians

We (at Physicians Association for Nutrition Norway) suggest that the whole text changes to the following:

Vegan diets do not contain vitamin B12 except of fortified foods and supplementation. Vegetarian diets that contains dairy and eggs on regulary basics, may supply enough amounts of Vitamin B12. Vegan and vegetarian diets were (before 2000 – 2020) associated with an increased risk of vitamin B12 deficiency (22, 57-60). But a recent study on Norwegian vegetarians and vegans (Henjum 2022), on the opposite, shows that all of the study-participants have a good B12 status.

This shows that following:

1) appropriate information and communication (that Norwegian Directorate of Health did already from 2015 https://www.helsenorge.no/kosthold-og-ernaring/vegetarisk-kosthold/ )
2) the use of fortified foods,
3) awareness about possible B12 deficiency and
4) use of B12 as a dietary supplement

will give good results, when animal foods are excluded og reduced significantly in the amount.

Plant foods might contain trace amounts due to bacterial or soil contamination or as a result of fermentation. Green and purple lavers (Nori) may contain some vitamin B12 and can be used by humans, whereas blue-green algae or
cyanobacteria (Spirulina) contain biologically inactive B12 analogues (2, 61).
All these are not any good sources and should not be mentioned/discussed as reliable sources of vitamin B12.

Plant-based milks and other dairy substitutes are as a rule fortified/enriched with vitamin B12

(with exception of biologic/ecologically produced plant milks). These dairy substitutes may be a source of vitamin B12 in vegans, but because of varying absorption in the intestine they may be not enough to satisfy the requirements, especially at children, pregnant and lactating women. Therefore, vegans should get recommendation to take supplements of/with B12 vitamin in adequate doses.

Plant-based diets (which means considerably reduces intake of animal foods compared to Western (including Nordic) diets) are generally better for health and the environment. Public health strategies should therefore facilitate the transition to a balanced diet with more diverse nutrient-dense plant foods through consumer education, food fortification and possibly supplementation.

Animal foods are also the biggest source of environmental toxins in the Norwegian diet.

The recent (2022) report by the Science Committee for Food and Environment, VKM, says:

«The Norwegian population is exposed on average to more dioxins and dioxin-like PCBs from food than the tolerance limit.» And «The food groups that contribute the most are fatty fish, milk and dairy products and meat.»
In contrast to toxins, there are no disadvantages to fortification. Therefore supplementation should be considered as the best choice/source of vitamin B12.

Source: Henjum, S. et al. (2022). Adequate vitamin B12 and folate status of Norwegian vegans and vegetarians. British Journal of Nutrition, 1-20. doi:10.1017/S0007114522002987

Helsenorge.no Vegetarian Diet https://www.helsenorge.no/kosthold-og-ernaring/vegetarisk-kosthold/

Vegetarian and vegan diet – expert opinion from the National Council for Nutrition. Chapter 2. What kind of supplements should adults on a vegetarian or vegan diet take? https://www.helsedirektoratet.no/rapporter/vegetar-og-vegankost-ekspertuttalelse-fra-nasjonalt-rad-for-ernaering/hva-slags-kosttilskudd-bor-voksne-med-et-vegetarisk-eller-vegansk-kosthold-ta

VKM. Dioksiner i maten til den norske befolkningen. Risk assessment of dioxins, furans, and dioxin-like PCBs in food in Norway https://vkm.no/risikovurderinger/allevurderinger/dioksinerimatentildennorskebefolkningen.4.413ea92416707dc4375a0a18.html

Miljøgifter i norsk mat. Henrik S. Huitfeldt, Bjørn J. Bolann Tidsskr Nor Legeforen 2021 doi: 10.4045/tidsskr.21.0499
https://tidsskriftet.no/2021/07/debatt/miljogifter-i-norsk-mat