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This is why supplementation is often recommended

First, routine screening for vitamin B12 deficiency should be incorporated into primary care for high-risk populations such as older adults, women of reproductive age, vegetarians, and patients with diabetes or chronic use of metformin or proton pump inhibitors

The American Academy of Family Physicians and NIH identify the following clinical manifestations: Fatigue and generalized weakness Megaloblastic anemia (abnormally large, immature red blood cells) Tingling or numbness in the hands and feet (peripheral neuropathy) Difficulty walking and balance problems Cognitive disturbances including memory difficulty and confusion Mood changes, including depression and irritability Glossitis (swollen, inflamed tongue) Early symptoms such as fatigue and mild tingling are often attributed to stress, aging, or other conditions

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To prevent pernicious anemia, it is important to avoid foods that can interfere with the absorption of vitamin B12