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Decreased stomach acid Atrophic gastritis Autoimmune pernicious anaemia Helicobacter pylori Gastrectomy, partial or complete Gastric bypass surgery (weight loss) Intestinal resection Partial or complete ileectomy Gastrointestinal neoplasms Malnutrition Eating disorders anorexia bulimia Inadequate diet Vegetarianism / veganism Malabsorption syndromes Alcoholism Crohns disease Coeliac disease (gluten enteropathy) Dipphyllobothrium infection blind loop syndrome diverticulosis inflammatory bowel disease small bowel overgrowth tropical sprue gastric irradiation ileal irradiation (bladder,cervix, uterus,prostate) Inborn errors of B12 metabolism Transcobalamin II deficiency Pancreatic exocrine insufficiency & Chronic pancreatitis Imerslund Gresbeck syndrome Zollinger Ellison Syndrome Bacterial overgrowth (small bowel) Fish tapeworm Advanced liver disease Drug induced causes Please note

The cells also become more resistant to lipolysis, the breakdown of stored fat for energy

10.1136/bmjopen-2019-033687 49 SaraswathyA

Digestive issues may further reduce the effectiveness

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