Thorne B-Complex #6, Pure Encapsulations O.N.E. Multivitamin Zinc 15–25 mg (with food)
separately:
Hemaplex
| What we suspected (from angular cheilitis history) | What the blood test shows | Assessment | |
|---|---|---|---|
| Iron deficiency — rapid response to iron/folate/B12 suggested this was a key driver | Ferritin: 16 ng/mL (ref 22–291) — LOW. HGB 12.9, HCT 40.7, MCV 88 are normal. | Confirms iron deficiency without anemia (low iron stores, but red blood cells still normal size and count). This is exactly the stage where symptoms like angular cheilitis, fatigue, and poor wound healing appear before full anemia develops. | |
| B12 deficiency — high-dose B12 produced dramatic improvement | B12 serum: 978 pg/mL (ref ≥301) — normal/high. | Inconclusive while supplementing. Serum B12 can look normal or high even when tissue levels are inadequate. The rapid symptom response to B12 is still clinically meaningful. We need MMA and homocysteine to assess true functional status. | |
| Folate deficiency — folic acid was part of the initial recovery combo | Not tested. | Gap in the panel. RBC folate should be added. | |
| Riboflavin (B2) deficiency — never directly supplemented; classic cause of angular cheilitis | Not tested. | Still pending. This is a critical missing piece. | |
| Vitamin D insufficiency — common in vegans, especially with limited sun | Vitamin D 25-OH: 26 ng/mL (ref 20–99) — low-normal. | Not frank deficiency, but suboptimal. Immune function, barrier repair, and mood all benefit from levels closer to 40–60 ng/mL. | |
| Zinc deficiency — impaired mucosal healing, immune function | Zinc: 54.0 ug/dL (ref 60–120) — LOW. | Confirmed low. Directly relevant to why the corners heal slowly and relapse quickly. | |
| --- |
Symptoms to watch for: - Fatigue, reduced exercise tolerance, difficulty concentrating - Pale skin or conjunctiva - Brittle nails, hair loss or thinning - Restless legs, especially at night - Cold hands and feet - Dizziness or headaches - Angular cheilitis, glossitis (smooth/sore tongue), and brittle nails — these are the mucocutaneous signs that often appear before anemia
Vegan foods with absorbable iron (no fortified foods): - Legumes: Lentils, chickpeas, black beans, tofu, tempeh — high in iron but phytates reduce absorption; pair with vitamin C - Seeds: Pumpkin seeds, sesame seeds (tahini), hemp seeds — good iron density - Dark leafy greens: Spinach, Swiss chard, kale — iron plus some vitamin C - Whole grains: Quinoa, amaranth, teff — moderate iron, better absorbed than wheat - Blackstrap molasses: Very high iron; small amounts go a long way - Dried fruit: Apricots, raisins, prunes — modest iron, but the vitamin C in a meal helps absorption
Absorption tip: Non-heme iron (plant iron) absorption is 2–20% depending on the meal. Pair every iron-rich plant food with vitamin C (citrus, bell peppers, strawberries, tomatoes, broccoli). Avoid tea, coffee, or calcium-rich foods at the same meal — they inhibit absorption.
Symptoms to watch for: - Delayed wound healing and poor skin repair (directly relevant to the recurring mouth-corner lesions) - Frequent infections or slow recovery from illness - Loss of appetite, altered taste or smell - Hair thinning or brittle nails - Brain fog or difficulty concentrating - Skin rashes, especially around eyes, nose, and mouth
Vegan foods with absorbable zinc (no fortified foods): - Pumpkin seeds — among the best vegan zinc sources; soaking or roasting improves availability - Hemp seeds — high zinc, also good protein and iron - Sesame seeds / tahini — good zinc density - Cashews, pine nuts — decent zinc; soak to reduce phytates - Legumes: Chickpeas, lentils, beans — zinc is present but phytates bind it; soaking, sprouting, or fermenting (e.g., tempeh) dramatically improves absorption - Whole grains: Oats, quinoa, brown rice — moderate zinc; soaking improves bioavailability - Nutritional yeast — often fortified, so excluded here, but unfortified varieties exist and are decent
Absorption tip: Phytates in whole plant foods strongly bind zinc. Soaking, sprouting, fermenting, or leavening (sourdough) increases absorbable zinc. If Stella eats a lot of whole grains and legumes (healthy, but high-phytate), her zinc requirement may be higher than omnivores.
Symptoms to watch for: - Frequent colds or infections (D regulates immune function) - Low mood, seasonal sluggishness - Muscle aches or weakness - Slower bone healing or growing pains - Poor sleep quality
Vegan food sources of vitamin D (naturally occurring, no fortified foods): - UV-exposed mushrooms — the only meaningful natural vegan source. Mushrooms exposed to sunlight or UV light during growth contain vitamin D2. Dried shiitake, maitake, and portobello exposed to UV are the best. - Sunlight — not a food, but the primary natural source. 10–30 minutes of midday sun on arms and legs, several times per week, depending on skin tone and latitude. San Francisco spring/summer sun is adequate if she gets regular outdoor time without sunscreen for that window.
Reality check: It is extremely difficult to maintain adequate vitamin D on a vegan diet without fortified foods, UV mushrooms, or supplements. Sunlight helps but is unreliable. This is the most justifiable ongoing supplement for a vegan in a temperate climate.
Current regimen: - Heme iron every other day - Thorne B-Complex #6 every day - Ritual multivitamin on alternate days
Issues with the current regimen: 1. Ferritin is still low despite heme iron every other day. Either the dose is too low, she hasn't been on it long enough (ferritin rises slowly — 4–8 weeks minimum), or absorption is impaired. 2. Zinc is low. Ritual contains some zinc, but on alternate days plus competition from iron may not be enough. 3. Vitamin D is suboptimal. Ritual contains some D, but alternate-day dosing plus the amount in Ritual is clearly insufficient to move her into the optimal range. 4. Iron and zinc compete for absorption if taken together. Same with iron and calcium. 5. Stella dislikes Ritual (flavor issue) and won't switch to the citrus version.
Proposed adjustments:
| Supplement | Current | Proposed | Rationale |
|---|---|---|---|
| Iron | Heme iron every other day | Continue every other day if she has been on it <8 weeks. If ≥8 weeks and ferritin still 16, increase the dose or switch to daily (heme iron is well-tolerated and absorbs regardless of the hepcidin cycle, but daily may be needed if stores are severely depleted). | Every-other-day dosing is evidence-based for non-heme iron to bypass hepcidin, but heme iron absorbs via a different pathway and may benefit from daily dosing when stores are this low. |
| B-Complex | Thorne B-Complex #6 daily | Continue daily. | Still warranted. Riboflavin, B6, methylfolate, and methylcobalamin are all relevant. Do not exceed label dose due to the 100 mg B6 content. |
| Multivitamin | Ritual alternate days | Discontinue Ritual. Replace with Pure Encapsulations O.N.E. Multivitamin daily, or Thorne Basic Nutrients 2/Day (1 capsule daily instead of 2). | Both are unflavored capsules, vegan, similar or higher quality than Ritual, and provide broader coverage without the flavor issue. See options below. |
| Zinc | None separate | Add 15–25 mg elemental zinc daily, taken at a different time than iron (e.g., zinc with lunch, iron with dinner). | Corrects confirmed deficiency. Take away from iron and calcium to avoid competition. |
| Vitamin D | None separate / Ritual only | Add 1,000–2,000 IU vegan D3 (lichen-derived) daily, or 5,000 IU every other day. Recheck in 8–12 weeks. | 26 ng/mL needs a meaningful push. Ritual's amount on alternate days is insufficient. |
| Vitamin C | None specified | Add 100–250 mg vitamin C with the iron dose (or ensure the iron meal is rich in C). | Doubles non-heme iron absorption. Even with heme iron, vitamin C helps overall iron trafficking. |
Highest priority: 1. Iron panel (serum iron, TIBC, transferrin saturation) 2. RBC folate 3. MMA (methylmalonic acid) 4. Homocysteine 5. Riboflavin status (plasma B2 or EGRAC)
Strongly consider: 6. Celiac screen (tTG-IgA + total IgA) 7. RBC magnesium
| Test | Why order |
|---|---|
| Serum iron | See if ferritin low is reflected in circulating iron |
| TIBC / UIBC | Transferrin capacity rises in iron deficiency |
| Transferrin saturation | <20% supports iron deficiency; most sensitive combined with ferritin |
| Reticulocyte count | Check if bone marrow is responding to low iron |
Without serum iron + transferrin saturation, ferritin alone doesn't distinguish deficiency from inflammation. Given she is symptomatic and has low ferritin, the full panel is warranted.
| Test | Why order |
|---|---|
| RBC folate | Better marker of tissue folate stores than serum folate; less affected by recent intake |
| Serum folate | Quick screen; can be falsely normal if she took folic acid recently |
She took iron + folic acid during her initial improvement. We need to know if folate deficiency was part of the picture. RBC folate is preferred if available.
| Test | Why order |
|---|---|
| Homocysteine | Elevated in B12, folate, or B6 deficiency. Functional marker even when serum B12 is normal/high |
| Methylmalonic acid (MMA) | Most sensitive marker for functional B12 deficiency at the cellular level. Can be elevated even with normal/high serum B12 |
Serum B12 of 978 pg/mL does NOT rule out functional B12 deficiency, especially given recent 2000 mcg cyanocobalamin use. MMA is the gold standard for tissue-level B12 adequacy.
| Test | Why order |
|---|---|
| Riboflavin (plasma or whole blood) | Direct assessment; no routine standard but can be ordered via specialty labs |
| EGRAC (Erythrocyte Glutathione Reductase Activation Coefficient) | Functional riboflavin status — the classic biochemical marker for B2 deficiency |
Angular cheilitis is a hallmark of riboflavin deficiency. She was not supplementing B2 during her initial rapid recovery (only iron, folate, B12), which makes B2 a strong suspect for the recurrence pattern. This is the biggest gap in the current workup.
| Test | Why order |
|---|---|
| Tissue transglutaminase IgA (tTG-IgA) | Celiac screen — celiac causes iron, B-vitamin, zinc, and D deficiency |
| Total IgA | Required to rule out IgA deficiency causing false-negative celiac screen |
Celiac disease or non-celiac gluten sensitivity can drive this pattern even without GI symptoms.
These are the shortest practical windows to stop each supplement before a blood draw and still get meaningful baseline data. Longer discontinuation gives a truer deficiency picture, but these windows balance usefulness with not keeping her off repletion for too long.
| Supplement | Stop Before Draw | Rationale |
|---|---|---|
| Iron | 3–5 days | Serum iron and ferritin normalize quickly after a dose. 3 days minimum; 5 days better for ferritin. |
| Vitamin B12 | 3–5 days | Serum B12 can spike for 24–72 hours after a dose. 3 days clears the acute spike; 5 days is safer. |
| Folate / folic acid | 3–5 days | Serum folate reflects recent intake strongly. RBC folate is more stable but still best without recent loading. |
| Riboflavin (B2) | 3–5 days | Plasma riboflavin drops within days. EGRAC (if ordered) is less affected by acute intake but still best without recent megadoses. |
| B-Complex (Thorne #6 or similar) | 3–5 days | Contains B2, B6, B12, folate — same logic as above. Stop the whole complex together. |
| Vitamin D | 1–2 weeks | Fat-soluble; serum 25-OH changes slowly. 1 week is the absolute minimum to see any downward shift; 2 weeks gives a clearer picture. Short discontinuation will NOT fully reveal baseline deficiency. |
| Zinc | 24–48 hours | Serum zinc drops rapidly after stopping. 24 hours is usually enough; 48 hours is conservative. |
If you want one blood draw with the most informative results and minimal time off supplements:
Total time off repletion: 3–5 days.