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Pancreatic insufficiency If the pancreas doesn't secrete enough enzymes, it cannot break down the R-binder-B12 complex, preventing B12 from binding to intrinsic factor

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doi:10.2337/dc17-0280 Boscari F, Vettoretti M, Cavallin F, et al

17 Compounding the issue is the fact that various professional organizations and grading references (the American Academy of Pediatrics, American Family Practice, Scottish Intercollegiate Guidelines Network, and many others) have different letter assignments and cutoffs for the use of non-RCT-containing literature, creating confusion about the meaning of an A, B, or C to denote the quality of literature used for evidence