Case 1 - Fatigue (contd.)

  1. The most obvious diagnosis would be some form of anemia, however, her physician did order an iron test and was stuck on the fact that her iron levels were well within normal limits.

  2. The gold standard to rule out or rule in iron deficiency anemia is Ferritin. The second test I ordered was a urine methylmalonic acid test. This is a highly sensitive test for B-12 deficiency. (read peer reviewed paper supporting this test) See below

Judy's ferritin was 55 and her urine methylmalonic acid test was 3.2 (normal value is 0.4-2.5 µmol/mmol crt). High levels of methylmalonic acid test are indicative of B-12 deficiency.


In the event you see low normal serum B-12 values, consider ordering a urine methylmalonic acid

Our working diagnosis was B-12 anemia.

Vitamin B12 anemia is the result of an impaired ability of the digestive tract to absorb the B12 that is a normal part of the diet. B12 is essential for the production of red blood cells, as well as the maintenance of the nervous system, and is found in food of animal origin such as meat, fish and dairy products. There are four (4) causes.

  1. Failure of the stomach lining to produce intrinsic factor. Intrinsic factor is a chemical produced by the stomach lining and combined with vitamin B12 in the small intestine. Due to an autoimmune disorder (a disorder caused by a person's own immune system attacking the body's organs and tissues), the production of intrinsic factor is blocked.

  2. Removal of small intestine where vitamin B12 is absorbed

  3. Crohn’s disease - a chronic inflammatory disease that affects any part of the gastrointestinal tract

  4. Eating a vegan diet which excludes eggs, diary products, meat and fish

Based on this information, I decided to begin a trial of sub-lingual B-12 supplementation.

Within seven days, Judy's fatigue lifted and she commented that she felt like dancing.

How's that for a quick turn-around?

Our Comments:

As physicians and healthcare practitioners we have the unique ability to see "outside" the box. We simply are more keen to wanting to identify the cause of health problems. Unfortunately few traditional medical physicians have this same ability and tend to focus on suppressing symptoms.

With Functional Diagnostic Medicine you will soon see that you have the opportunity to help a ton of patients with a variety of hard to treat (and diagnose.. by most traditional MDs) conditions.

If you are like us, you will find it hard to contain yourself as you learn this new form of medicine.

Additional Comment: 

This case although appearing to be simplistic did involve some additional detective work to determine why Judy was low in B-12. Our goal is to present "real" cases that we can help with. We want to present the basics of the cases and encourage each one of you to consider adding this missing piece of the health equation. Believe me, your practice will never ever be the same once you begin to see how many different health conditions you can turn around.


  1. Norman EJ.New urinary methylmalonic acid test is a sensitive indicator of cobalamin (vitamin B12) deficiency: a solution for a major unrecognized medical problem.
    J Lab Clin Med. 1987 Sep;110(3):369-70.

  2. Norman EJ, Martelo OJ, Denton MD. Cobalamin (vitamin B12) deficiency detection by urinary methylmalonic acid quantitation.Blood. 1982 Jun;59(6):1128-31.

  3. Here is an eye-opening paper published in the 2003 American Academy of Family Physicians. This paper supports the superiority of using methylmalonic acid test over the serum B-12. Although the paper uses a serum methylmalonic acid test, the literature supports the testing of urine methylmalonic acid test.


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