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Approximately one year later, he experienced a severe worsening of his previously very mild neuropathy, and lab evaluation yielded a serum B12 of 220 pmol/l (which is normal, remember!?), but an elevated serum MMA of 1300 nmol/l, supporting the existence of true B12 deficiency

Pernicious Anaemia Society Extreme tiredness after B12 injection

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It can also be depleted by chronic stress, alcohol, smoking, digestive issues, cardiovascular disease, illness, and aging because stomach acid production decreases with age, reducing B12 absorption significantly

Another major constraint arises from the immature market architecture surrounding the commercialization of recovered resources