Purpose: The purpose of this study is to define the prevalence of vitamin B 12 deficiency in a type 2 diabetic population within a primary care practice. Metformin use and advanced age are associated with vitamin B 12 deficiency and often present in type 2 diabetic patients, yet the prevalence of vitamin B 12 deficiency in the diabetic population is unknown.Methods: We conducted a cross-sectional study of 203 outpatient type 2 diabetic patients at a large military primary care clinic. Patients completed a survey and had B 12 levels measured. Patients with borderline B 12 levels also had methylmalonic acid and homocysteine levels drawn. Serum B 12 levels <100 pg/mL or serum B 12 levels of 100 to 350 pg/mL with elevation of serum methylmalonic acid >243 nmol/L or homocysteine >11.9 nmol/L defined B 12 deficiency. Descriptive statistics described frequency and means.2 and student's t tests were used to analyze associations between categorical and continuous variables, respectively. Multivariate logistical regression identified covariates independently associated with B 12 deficiency.Results: Twenty-two percent (n ‫؍‬ 44) of diabetic patients had metabolically confirmed B 12 deficiency. Patients on metformin had lower serum B 12 levels (425.99 pg/mL vs 527.49 pg/mL; P ‫؍‬ .012) and were at increased risk for B 12 deficiency (P ‫؍‬ .04), as defined by a serum B 12 level <350 pg/mL. Prevalence of B 12 deficiency was significantly lower for patients using a multivitamin (odds ratio, 0.31; 95% CI, 0.15-0.63).Conclusions :

Those in medical education have a responsibility to prepare a physician workforce that can serve increasingly diverse communities, encourage healthy changes in patients, and advocate for the social changes needed to advance the health of all. The authors of this Perspective discuss many of the likely causes of the observed differences in mean Medical College Admission Test (MCAT) scores between students from groups well represented in medicine and those from groups underrepresented in medicine. The lower mean MCAT scores of underrepresented groups can present challenges to diversifying the physician workforce if medical schools only admit those applicants with the highest MCAT scores. The authors review the psychometric literature, which showed no evidence of bias in the exam, and note that the differences in mean MCAT scores between racial and ethnic groups are similar to those in other measures of academic achievement and performance on high-stakes tests. The authors then describe the ways in which structural racism in the United States has contributed to differences in achievement for underrepresented students compared with well-represented students. These differences are not due to differences in aptitude but to differences in opportunities. The authors describe the widespread consequences of structural racism on economic success, educational opportunity, and bias in the educational environment. They close with 3 recommendations for medical schools that may mitigate the consequences of structural racism while maintaining academic standards and admitting students likely to succeed. Adopting these recommendations may help the medical profession build the diverse physician workforce needed to serve communities today.