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For several months during the summer of 2022, my dog Scout vomited at 3 a.m. nearly every day. If you have a dog, you know the sound. And each time, she gobbled up her mess before I could get to it, making diagnosis of the cause difficult.The vet and I eventually settled on my hydrangeas as the source of the problem – but keeping Scout away from them didn’t work. She started to seem tired all the time – highly concerning in a typically hyper yellow Lab puppy. Then one day Scout vomited up a hairball – but not just any hairball. In dogs, hair normally passes easily through the digestive system, but this hairball was wrapped around a brillo pad that was too big to move through. Once this foreign object was removed, the overnight vomiting ended. Scout still needed treatment, though, for a different and surprising reason: The object had inhibited a step in her body’s absorption of vitamin B12. B12 is an essential nutrient involved in proper functioning of blood cells, nerves and many other critical processes in the body. I’m a registered dietitian, and I teach nutrition and food science to college students, but still I missed the B12 deficiency that was causing my puppy’s fatigue. Doctors can just as easily be blind to it in people – even though B12 deficiency is a common health problem that affects an estimated 6% to 20% of the U.S. population. B12 is scarce in the diet, and it is found only in foods from animal sources. Fortunately, humans need only 2.4 micrograms of B12 daily, which is equivalent to one ten-millionth of an ounce – a very, very small amount. Without adequate B12 in the body, overall health and quality of life are negatively affected. Signs and symptoms One primary symptom of B12 deficiency is fatigue – a level of tiredness or exhaustion so deep that it affects daily life activities. Other symptoms are neurological and may include tingling in the extremities, confusion, memory loss, depression and difficulty maintaining balance. Some of these can be permanent if the vitamin deficiency is not addressed. However, since there can be so many causes for these symptoms, health care providers may overlook the possibility of a B12 deficiency and fail to screen for it. Further, having a healthy diet may seem to rule out any vitamin deficiency. Case in point: Because I knew Scout’s diet was sound, I didn’t consider a B12 deficiency as the source of her problems. How B12 is absorbed Research is clear that people who consume plant-based diets must take B12 supplements in amounts typically provided by standard multivitamins. However, hundreds of millions of Americans who do consume B12 may also be at risk because of conditions that could be hampering their body’s absorption of B12. B12 absorption is a complex multistep process that begins in the mouth and ends at the far end of the small intestine. When we chew, our food gets mixed with saliva. When the food is swallowed, a substance in saliva called R-protein – a protein that protects B12 from being destroyed by stomach acid – travels to the stomach along with the food. Specific cells in the stomach lining, called parietal cells, secrete two substances that are important to B12 absorption. One is stomach acid – it splits food and B12 apart, allowing the vitamin to bind to the saliva’s R-protein. The other substance, called intrinsic factor, mixes with the stomach’s contents and travels with them into the first part of the small intestine – the duodenum. Once in the duodenum, pancreatic juices release B12 from R-protein and hand it to intrinsic factor. This pairing allows B12 to be absorbed into cells, where it can then help maintain nerve cells and form healthy red blood cells. A B12 deficiency typically involves a breakdown at one or more of these points on the way to absorption.