Vitamin B12 aka cobalamin: Essential for mood, nervous system

[Dylanmatthew]

I'll check it out after work. What do they say about lunch meat and chicken breasts

[Songbird]

If you are vegetarian (not vegan) you can get vitamin B12 from milk, yoghurt, cheese and eggs.

[Kittygiggles]

Talking about diet online is emotive and controversial. I hate mentioning what I eat but I have done so on my thread only because I felt it was necessary. My extensive research as a lay person, my own positive personal results, as well as impressive results from advising family and friends, has led me to conclude that:

 

Whole plants are healthy

 

Processed (oils, extracts, juices, dairy etc) foods, some grains, and meat can cause problems

 

I wish I knew more but no matter who you consult, the majority seem convinced by their claims, despite very convincing evidence to the contrary. It seems that diets that sustained previous generations through millennia were very healthy and they were devoid of processed foods and modern eating patterns. I think there is wisdom in that and therein lies the answer to appropriate diets: how did those groups who consistently lived the longest and healthiest eat? Diet could also be very individualized, so that each person must tailor diets for optimal health. 

It seems most people advocate a diet they consume and their bias is entrenched. Modern life it seems is at the heart of dietary issues. Also, many of us who devote time to researching what foods to eat are already suffering in some way: one could argue that we aren't the best advocates of a particular way of eating due to our health issues. I'd say it's a valid point; my health is obviously not great due to an autoimmune condition and withdrawal syndrome. How much of that is due to distant past or present dietary choices is unknown. I have some excellent health markers under many different tests that were improved with a change in diet.

 

As for B12: whether people eat animal products or not, they can run into deficiency but of course, it is more common with vegans. I have seen some convincing evidence that suggests we could get B12 from non-animal sources but that kind of environment is not really feasible in the modern day. My conclusion is that I think B12 should be tested for routinely. Although the standard test isn't detailed, it is cheap (I think) and it can give a good indication as to whether further investigation or intervention is necessary.

 

Just my 2 cents.

[bubbles]

7 hours ago, papaloapan said:

Watch the documentary I posted, it has interviews with physicians and nutritionists

There are also some "debunkings" around, which are very enlightening.

 

As a society, we eat less and less meat, and less and less animal fats, compared to previous generations, and we seem to have more and more poor mental health. (I am talking about good quality meat, a good grass fed steak or a healthy free range chicken. This is the sort of meat we get here in Australia - I'm not sure how that is in other countries.)

 

I'm yet to see any convincing evidence that humans can be really healthy on a vegetarian diet. India, which has the lowest meat intake in the world (or did a few years ago) has appalling diabetes rates. I'm also yet to see any convincing evidence that we can get B12 from anything but animal foods. (There seems to be some thought that if we didn't wash our foods then we could get some B12 from - presumably - the manure that adheres to it. That sounds risky to me.)

 

I also know that we are different. I have had to greatly increase my meat intake in order to get my ferritin up to an adequate level - it could go higher, but it's okay now. I have a friend with hemachromatosis who has to give blood monthly in order to prevent ferritin from becoming toxic! So we're quite different. If I became vegetarian, I'd be okay for a while until I depleted that ferritin, and then I'd be very unwell.

 

For me, greatly increasing my meat and my animal fats has significantly improved my mood - to the point where, even withdrawing, I am better emotionally than I ever was fully medicated with this SSRI. This is hugely enlightening to me - my mental health problems date from when a dietitian told me to reduce my meat and my fat intake. (Also, from thyroid - I saw a dietitian because I'd gained weight, which realistically was my thyroid. Low thyroid is known to cause mood issues too.)

 

Diet is such an emotive subject, and I'm impressed at how polite everyone is in this thread. Hope you're all well and that your choices work for you.

 

 

[bubbles]

43 minutes ago, Kittygiggles said:

I wish I knew more but no matter who you consult, the majority seem convinced by their claims, despite very convincing evidence to the contrary. It seems that diets that sustained previous generations through millennia were very healthy and they were devoid of processed foods and modern eating patterns. I think there is wisdom in that and therein lies the answer to appropriate diets: how did those groups who consistently lived the longest and healthiest eat?

 

I keep coming back to eating what my great grandparents ate. Nothing processed, lots of vegetables, meat with the fat on, butter (not "spreads"), and fewer grains and much less sugar. If great granny wouldn't recognize it, I try not to eat it. Though we do occasionally have a pizza on a Friday night, and great granny most certainly wouldn't recognize that, but the principle is there!!

 

[Kittygiggles]

10 minutes ago, bubbles said:

 

I keep coming back to eating what my great grandparents ate. Nothing processed, lots of vegetables, meat with the fat on, butter (not "spreads"), and fewer grains and much less sugar. If great granny wouldn't recognize it, I try not to eat it. Though we do occasionally have a pizza on a Friday night, and great granny most certainly wouldn't recognize that, but the principle is there!!

 

 

It makes sense to me. I take comfort in your example and when I think of our ancestors. If they were doing something dietary as wrong as some modern advocates claim, why did they exhibit such good health at such an advanced age?

 

"If great granny wouldn't recognize it, I try not to eat it."

 

I love that! 

 

I see from your signature that you're on NDT. I am planning to move over to it (from levothyroxine) as soon as I can get a good supplier here. Do you supplement B12 as well? I had to when I had a test done and I was around 250. Hypothyroidism is likely the cause. I take methylcobalamin orally and it does raise my serum level impressively (currently at the top of the range) but I have to keep it way above that I suspect and I think I wasn't taking enough in recent months. I'm exploring whether my recent megadoses of B12 helped with my palpitations. 

[bubbles]

28 minutes ago, Kittygiggles said:

 

I see from your signature that you're on NDT. I am planning to move over to it (from levothyroxine) as soon as I can get a good supplier here. Do you supplement B12 as well? I had to when I had a test done and I was around 250. Hypothyroidism is likely the cause. I take methylcobalamin orally and it does raise my serum level impressively (currently at the top of the range) but I have to keep it way above that I suspect and I think I wasn't taking enough in recent months. I'm exploring whether my recent megadoses of B12 helped with my palpitations. 

 

 

I don't supplement B12, though perhaps next time I get a blood test it is worth testing. I've never been worried about it because (due to the iron issues) I eat lots of animal foods, so my dietary intake of B12 is good. I've read that hypothyroidism is associated with a few nutrient deficiencies, but I didn't know it was associated with B12 deficiency so that's good to know.

 

Yes, I've taken NDT for a long time. At present I'm working on getting my thyroid hormones as optimal as I can for overall health reasons. I know NDT is available in some European countries, though I've never had to get it there. (Also, we have a thyroid thread here at SA: https://www.survivingantidepressants.org/topic/1593-thyroid-symptoms-hypothyroid-hashimotos/?tab=comments#comment-15040. Not sure if you've seen it.)

[bubbles]

@Kittygiggles oops I see you've already seen that thread.

[Kittygiggles]

7 hours ago, bubbles said:

I don't supplement B12, though perhaps next time I get a blood test it is worth testing. I've never been worried about it because (due to the iron issues) I eat lots of animal foods, so my dietary intake of B12 is good. I've read that hypothyroidism is associated with a few nutrient deficiencies, but I didn't know it was associated with B12 deficiency so that's good to know.

 

Yes, unfortunately it's just one other thing to have to deal with when one has thyroid disease. I ate fish, almost every single day for close to 15 years. Fish, as far as I have read, have the highest concentration of vitamin B12 of any meat. I had a blood test without supplementing and I was around 250picograms per milliliter (I think that's the unit), the reference range was around 200 to 900. However, Japan have defined a minimum of 500 as being close to deficient. Based on my diet, I was shocked at how low it was. A percentage that could be half of that number is what is actually usable by the body I think. 

 

I am fairly new to learning about it but as it is so cheap to buy and supplement, I just started taking it before reading more about it. I got my levels over the upper range fairly quickly with methylcobalamin (I took 5000micrograms per day for about two weeks then maintained at about 1000micrograms a day but your numbers and requirements may vary, if you have to supplement).

 

So, if you test low and you have a B12-rich diet, you could have a thyroid issue that results in hypochlorhydria, reducing your absorption of B12 from food. I think there are other ways hypothyroidism affects B12, I can't recall, sorry. In addition, many people have that problem without thyroid disease. Also, you may have an MTHFR gene problem, which means you cannot convert B12 into a usable form properly. 

 

I didn't test for the MTHFR gene as I doubt they do it here. In any case, I just thought I'd supplement and get my levels up, accepting I may need to supplement for life and getting on with the myriad other health issues hypothyroidism and SSRIs cause!

 

So don't worry (if you were) because it's easily fixed if you respond to oral treatment and if you need injections, well that's pretty straight forward too. Sadly, people who eat lots of B12-rich food aren't always safe

 

[bubbles]

Thanks @Kittygiggles, that's good to know.

 

I have no B12 deficient symptoms, and no real reason to think I'm deficient, but I'll do some investigating and work out what I need to ask the doctor to test for - if they're drawing blood it might as well have some other useful stuff in there. I keep toying with that gene test, but not sure it would give me enough information to make the cost worthwhile.

 

Cheers!

[ChessieCat]

From Post #1 of this topic regarding subclinical B12 deficiency:

 

On 11/3/2011 at 9:12 AM, Altostrata said:

 

There are other factors that might cause B12 levels to be low, but show up as normal on regular blood tests -- that's why it's called subclinical B12 deficiency.

 

Subclinical B12 deficiency may cause low mood for which many people might seek an antidepressant. Many psychiatric symptoms may very well be just low B12.

 

Over the long run, subclinical B12 deficiency can be as destructive as frank B12 deficiency.

 

 

[Happy2Heal]

21 hours ago, bubbles said:

 

As a society, we eat less and less meat, and less and less animal fats, compared to previous generations, and we seem to have more and more poor mental health.

this is not true of the USA

we are eating an enormous amnt of meat, esp chicken here in the USA

 

[papaloapan]

In the documentary "What the health" physicians mention that humans closest relatives are chimps, they share 96% of our DNA.

Chimps get 97% of their calories from plants and their remaining 3% mostly of insects and they don't die at young age of heart disease, diabetes or cancer like humans. 

This short video has good info about vegan diet from a physician, cardiothoracic surgeon, practiced surgery until he was 95

 

 

[papaloapan]

 

Another physician by the way and with historical facts of how diet has been since many years ago and how was the health of humans over the years with those diets

[Wellbutrinsucks]

Is it common for B12 to make you worse before getting better? I had one a fewdays ago and my symptoms are now worse.

[papaloapan]

On 12/20/2018 at 11:42 AM, Dylanmatthew said:

So the lunch meat I get that says no nitrates or nitrites is terrible for me? And the fresh chicken breasts and steaks I buy are bad too? I seriously don't even know what to eat anymore. It all causes me anxiety that I am harming my body

 

Don't worry. Remember the mind is very powerful. If placebo means that you can take any psychiatric or medical drug, and if you believe that it is good for you, even though it is toxic for your body, it helps you/enhances your health. My theory is that this should also apply to food, meaning that even though any food is toxic, lets say an animal based food, and you believe it is good for you, it will enhance your health. 

Also a nutritionist told me, because I am vegetarian and I have a very strict and healthy diet, that once a week I should have a non healthy animal food meal. This is because if I have the strict healthy vegetarian dieat every single day and in every single meal, the day I'll have an animal based non healthy food, my body will feel terrible.

So you can have a mixed diet, lets say 70% healthy and 30% unhealthy, or the way you wish to distribute this percentage

[bubbles]

On 1/13/2019 at 4:16 PM, papaloapan said:

This is because if I have the strict healthy vegetarian dieat every single day and in every single meal, the day I'll have an animal based non healthy food, my body will feel terrible.

So you can have a mixed diet, lets say 70% healthy and 30% unhealthy, or the way you wish to distribute this percentage

 

That’s because animal foods contain crucial nutrition. 

[papaloapan]

5 hours ago, bubbles said:

 

That’s because animal foods contain crucial nutrition. 

False. Watch the last 2 videos I posted. It is because of this: " the day I'll have an animal based non healthy food, my body will feel terrible." Because by having every day a healthy vegetarian diet, my body gets used to it.

[papaloapan]

On 1/13/2019 at 3:16 PM, papaloapan said:

So you can have a mixed diet, lets say 70% healthy and 30% unhealthy, or the way you wish to distribute this percentage

I wish I could delete this. I wrote that without really thinking it through.

[papaloapan]

Another reason for which people might feel bad when switching from an animal based diet to a plant based diet (vegetarian), is because their bodies got used to eating meat and animal based food for a long time, and if suddenly they switch cold-turkey to a vegetarian or vegan diet, that's why they feel bad. They have to do the switch gradually.

[bubbles]

We may have to agree to disagree on this one.

[papaloapan]

On 1/13/2019 at 3:16 PM, papaloapan said:

Also a nutritionist told me, because I am vegetarian and I have a very strict and healthy diet, that once a week I should have a non healthy animal food meal. 

Animal food = unhealthy food

[Altostrata]

Vegetarian or vegan, you need vitamin B12. If you're not getting it from animal-sourced foods, you need to take a supplement. End of story.

 

On 1/12/2019 at 11:34 AM, Wellbutrinsucks said:

Is it common for B12 to make you worse before getting better? I had one a fewdays ago and my symptoms are now worse.

 

Please read this topic from the beginning. Like other B vitamins, vitamin B12 can be activating (make you jumpy, nervous, anxious, or unable to sleep).

 

If you need B12 supplementation but react poorly to it, ramp up your dosage by taking a tiny amount -- a crumb of a tablet -- first and gradually increase the amount.

[Wellbutrinsucks]

I don’t think I need B12 supplementation as I’m not a vegetarian or a vegan. I’ve had B12 tests before but they came back normal. When I went to the doctor last week, they did a bunch of blood work but didn’t test me for B12 deficiency; they prescribed it for the muscle twitching, but obviously that didn’t work.

[papaloapan]

Folic acid and B12 supplementation was associated with a 21% increased risk for cancer, a 38% increased risk for dying from the disease, and an 18% increase in deaths from all causes. (Source_ https://www.webmd.com/cancer/news/20091117/folic-acid-b12-may-increase-cancer-risk

 

Solution: get it from natural sources

[Kittygiggles]

4 hours ago, papaloapan said:

Folic acid and B12 supplementation was associated with a 21% increased risk for cancer, a 38% increased risk for dying from the disease, and an 18% increase in deaths from all causes. (Source_ https://www.webmd.com/cancer/news/20091117/folic-acid-b12-may-increase-cancer-risk

 

Solution: get it from natural sources

 

Natural sources of vitamin B12 are always better but that option doesn't work for some. For those wanting to reach the study directly, here's the link: Cancer Incidence and Mortality After Treatment With Folic Acid and Vitamin B12; Marta Ebbing, MD; Kaare Harald Bønaa, MD, PhD; et al; JAMA. 2009;302(19):2119-2126. doi:10.1001/jama.2009.1622. Your own interpretation may vary; mine did as the study did not consider vitamin B12 monotherapy.

 

A study that may be of interest in those wondering about the safety of vitamin B12 with B6 is this one: Long-Term, Supplemental, One-Carbon Metabolism–Related Vitamin B Use in Relation to Lung Cancer Risk in the Vitamins and Lifestyle (VITAL) Cohort; Theodore M. Brasky, Emily White, and Chi-Ling Chen, Journal of Clinical Oncology 2017 35:30, 3440-3448. 

 

My concern is still the tendency for some people to supplement blindly and broadly, which can lead to adverse consequences. Having read both studies, my opinion regarding vitamin B12 monotherapy remains unchanged.

[Songbird]

On 4/18/2019 at 5:54 AM, papaloapan said:

Folic acid and B12 supplementation was associated with a 21% increased risk for cancer, a 38% increased risk for dying from the disease, and an 18% increase in deaths from all causes. (Source_ https://www.webmd.com/cancer/news/20091117/folic-acid-b12-may-increase-cancer-risk

 

Solution: get it from natural sources

 

It says "Study Shows Slight Increase in Cancer Risk From Large Doses of Supplements" - the risk increased from 8.4% to 10% - the study participants were all heart patients who were mostly smokers or ex-smokers.  We need to be careful about how we interpret the results of studies.

[trenace]

I have a question. My b12 is high and my ND says its because its not being processed. My folate is low and my iron is also low. I take a supplement before working out which contains b12 cyanocobalamin and the injections are hydroxocobalimin. After my second b12 shot my nervous system went into overdrive rendering me disabled for two days with terror. I then continued taking my workout supplement with little issues. I then built up my injections by only injecting a third every other day. After the third injection I had the same reaction which hadn't let up for almost a week now. I've continued to take my preworkout supplement. Is there a chance that I'm now reacting bad to my workout supplement due to overdoing various forms of the b12? The only other supplement I take is taurine which I'm also planning on stopping because these reactions are setting me back quite a bit. 

[Kittygiggles]

4 hours ago, trenace said:

I have a question. My b12 is high and my ND says its because its not being processed. My folate is low and my iron is also low. I take a supplement before working out which contains b12 cyanocobalamin and the injections are hydroxocobalimin...The only other supplement I take is taurine which I'm also planning on stopping because these reactions are setting me back quite a bit. 

 

I am not a doctor nor medically trained but I wanted to just share the following:

Do you have megaloblastic anemia, is that why you cannot process B12? I would expect your doctor to have checked your red blood cells. How did he or she arrive at the conclusion that you cannot process it? One hypothesis is that some people benefit more from methylcobalamin. I take it and it is about the same price as cyanocobalamin. It can be taken sublingually as well. 

 

However, you may be allergic or sensitive to cobalt/cobalamin, which could explain your reactions. Can you ask your doctor (or get a second opinion) about your red blood cells, iron, folate, and B12 levels?

 

Taurine on its own I've heard is pretty safe up to certain amounts. I think problems start when it is used with caffeine. 

 

I asked my doctor about low iron and ferritin within range, she said that as long as my hemoglobin production is good (can be checked with a blood test), which it is, she wouldn't supplement. Again, I'd ask your doctor before supplementing with iron because it can build up to dangerous levels without supervision.

[trenace]

I dont think my doc (she) has checked my red blood cells but I don't know yet. I was improving up until last month quite a bit tbh being able to socialise a lot more and laugh and joke and tolerate various supplements and caffiene. I was then thrown off for a couple weeks due to a course of penicillin and recently some b12 injections and have now been hit with inner restlessness and anxiety which is very severe. It doesn't feel like a wave though if that makes sense? It feels like Ive become sensitive to supplements and caffiene and even food to some extent. Is it possible to be setback in terms of nervous system hypersensitivity? If that's the case I'm going to lay off anything artificial for a while because I've been struggling more in the last week than I have since January. I feel its incredibly Important to remain positive though and pray this reaction calms down. 

[trenace]

18 minutes ago, Kittygiggles said:

 

I am not a doctor nor medically trained but I wanted to just share the following:

Do you have megaloblastic anemia, is that why you cannot process B12? I would expect your doctor to have checked your red blood cells. How did he or she arrive at the conclusion that you cannot process it? One hypothesis is that some people benefit more from methylcobalamin. I take it and it is about the same price as cyanocobalamin. It can be taken sublingually as well. 

 

However, you may be allergic or sensitive to cobalt/cobalamin, which could explain your reactions. Can you ask your doctor (or get a second opinion) about your red blood cells, iron, folate, and B12 levels?

 

Taurine on its own I've heard is pretty safe up to certain amounts. I think problems start when it is used with caffeine. 

 

I asked my doctor about low iron and ferritin within range, she said that as long as my hemoglobin production is good (can be checked with a blood test), which it is, she wouldn't supplement. Again, I'd ask your doctor before supplementing with iron because it can build up to dangerous levels without supervision.

 

[trenace]

I was supposed to quote you in my previous comment lol. Guess it's because I've been off the site for a while

[Kittygiggles]

28 minutes ago, trenace said:

I was then thrown off for a couple weeks due to a course of penicillin and recently some b12 injections and have now been hit with inner restlessness and anxiety which is very severe. It doesn't feel like a wave though if that makes sense? It feels like Ive become sensitive to supplements and caffiene and even food to some extent. Is it possible to be setback in terms of nervous system hypersensitivity? If that's the case I'm going to lay off anything artificial for a while because I've been struggling more in the last week than I have since January. I feel its incredibly Important to remain positive though and pray this reaction calms down. 

Yes, stay positive and take a break from worrying about all this! Nothing you've written is alarming. It's horrible for you but I think it is likely benign in origin and should resolve easily. I am just curious about that diagnosis of not being able to process B12; I wanted to know more about the underlying issue. Usually and ironically, I think the treatment for that is B12. However, if you have a problem with processing B12 I think it is often linked to your red blood cells; they need the right amount of B12 and time to get used to it again before everything starts functioning normally once more. So it could be just too much B12 (or the wrong kind) too frequently. There is also a link with folate and iron, as you pointed out, which I don't know the answer to either, sorry.

 

I could be completely wrong but I think it would be best to talk to your doctor about that side of things, trying oral methylcobalamin as an option and possibly reducing or stopping the injections for a short while to give you a rest. I know little to nothing about all this but as I have a B12 issue I wanted to give my two cents. I sometimes go through periods where I too think it is best to just stop supplements for a while before restarting them. Do you consume caffeine much? I get pretty agitated and anxious with caffeine so I haven't had any in almost a decade!

 

I think once you've been through SSRI withdrawal, you're probably much more likely to be sensitive to things, whether that's psychological in origin or not, I don't know. I don't think it's necessarily a bad thing nor an indication of a serious problem. One hypothesis I am pondering is whether those susceptible to SSRI withdrawal are already a little more sensitive anyway, so this process just increases that somewhat. Again, what I said could all be wrong and I haven't done enough reading about the subject but I understand how you feel. 

 

I now think twice about any supplement I take and research it beforehand; beyond that, I avoid all drugs (including caffeine) like the plague!

[trenace]

17 minutes ago, Kittygiggles said:

Yes, stay positive and take a break from worrying about all this! Nothing you've written is alarming. It's horrible for you but I think it is likely benign in origin and should resolve easily. I am just curious about that diagnosis of not being able to process B12; I wanted to know more about the underlying issue. Usually and ironically, I think the treatment for that is B12. However, if you have a problem with processing B12 I think it is often linked to your red blood cells; they need the right amount of B12 and time to get used to it again before everything starts functioning normally once more. So it could be just too much B12 (or the wrong kind) too frequently. There is also a link with folate and iron, as you pointed out, which I don't know the answer to either, sorry.

 

I could be completely wrong but I think it would be best to talk to your doctor about that side of things, trying oral methylcobalamin as an option and possibly reducing or stopping the injections for a short while to give you a rest. I know little to nothing about all this but as I have a B12 issue I wanted to give my two cents. I sometimes go through periods where I too think it is best to just stop supplements for a while before restarting them. Do you consume caffeine much? I get pretty agitated and anxious with caffeine so I haven't had any in almost a decade!

 

I think once you've been through SSRI withdrawal, you're probably much more likely to be sensitive to things, whether that's psychological in origin or not, I don't know. I don't think it's necessarily a bad thing nor an indication of a serious problem. One hypothesis I am pondering is whether those susceptible to SSRI withdrawal are already a little more sensitive anyway, so this process just increases that somewhat. Again, what I said could all be wrong and I haven't done enough reading about the subject but I understand how you feel. 

 

I now think twice about any supplement I take and research it beforehand; beyond that, I avoid all drugs (including caffeine) like the plague!

Well basically my results are like this, iron is all normal except my transferrin saturation which is low. My active b12 is high whereas my total b12 is normal. My folate is deficient and vitamin d is very very low. She has said in her comments that my active b12 is high because there's an issue with processing maybe due to low folate which I'm aware is crucial for proper functioning of b12. I will only know more after a follow up app. She isn't aware of hypersensitivity though and believes I have sibo which I definitley agree with and has given me a list of supplements to take as long as my arm lmao. I'm going to back off all supps now though because I've become sensitive to everything! I'll keep you updated. It may help you. 

[Kittygiggles]

Ah okay, she sounds like she's considering things in detail. Perhaps the issue lies in balancing your folate. I have no idea I guess but I would like to know more when you do, because you're right, it could help me Today I actually backed off all supplements too. I will try to do this for up to a week to see which ones seem unnecessary. 

 

Good luck!

[Songbird]

15 hours ago, trenace said:

I was then thrown off for a couple weeks due to a course of penicillin and recently some b12 injections and have now been hit with inner restlessness and anxiety which is very severe. It doesn't feel like a wave though if that makes sense? It feels like Ive become sensitive to supplements and caffiene and even food to some extent. Is it possible to be setback in terms of nervous system hypersensitivity?

 

Yes.  I've found that when my system is already sensitive, I'm then more sensitive to other things as well - it can be a nasty spiral.  The antibiotics could have started it, making your system more sensitive so it reacted to the b12 injections.  I've had this happen with steroid injections (for my shoulder injury) - when I was unstable I had a bad reaction to the steroid, but when I was stable the steroid injection wasn't a problem.  It's wise to be very cautious during any period of instability.