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The phenotypic outcome is a shift toward higher energy expenditure and improved adipose/lipid profiles without the catabolic loss of lean tissue commonly seen with severe caloric restriction

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22,23 In patients with a normal or low-normal serum vitamin B 12 level, complete blood count results demonstrating macrocytosis, or suspected clinical manifestations, a serum methylmalonic acid level is an appropriate next step 1,2,6,18 and is a more direct measure of vitamin B 12 's physiologic activity