### instruction:
If you are a doctor, please answer the medical questions based on the patient's description.

### input:
I have been having a difficult time losing weight for the past 3 years. I have Hasimotos disease. I eat well and take many different supplements. In spite of that I havemild osteoporosis, a B12 deficiency and a vitamin D deficiency even though I take 4,000 units of late. I was recently diagnosed accidentally with a high homcystine level which make me concerned that all I do is not being absorbed. Could I have a digestice enzyme deficiency and a betaine deficiency. If so, what test should I have my doctor do.

### output:

Hi, One of the causes of a raised homocysteine level is Vitamin B12 deficiency. Raised homocysteine levels are also a risk factor for diseases such as heart attack (medically called myocardial infarction), stroke etc. In fact a rise in homocysteine levels detects even early phases of Vitamin B12 deficiency. As you have been diagnosed with Hashimoto disease which is an immune mediated disease you may be prone to develop immune mediated diseases in other organs as well. An immune mediated disease is one where certain molecules called autoantibodies attacks its own cells and tissues. There is a possibility that you may have a condition called PERNICIOUS ANEMIA which is known to occur in some patients with Hashimoto. Pernicious anemia is a common cause of B12 deficiency. A protein called intrinsic factor, made by parietal cells that line the stomach, is needed for B12 absorption. In pernicious anemia, inflammation damages the parietal cells, leading to little or no intrinsic factor, thus preventing the intestines from absorbing B12. I would advise you to do the following tests Intrinsic factor antibody testParietal cell antibody testify any of these tests are positive then there is the possibility that you also have PERNICIOUS ANEMIA. In addition to this please also do a Fasting blood sugar and Post radial blood sugar test to detect Diabetes mellitus which may be associated with your condition. All of the above contribute to loss of weight and a feeling of exhaustion. You should also recheck your THYROID FUNCTION TESTS (TSH, T3 and T4). I presume that you may be taking medication for Hashimoto. You should take lifelong Vitamin B12 if you have Pernicious anemia. To correct the Vitamin B12 deficiency due to Pernicious anemia one of the methods is to take 1000 mcg I'm/SC injections once daily for 7 days, then weekly for 1 month, then monthly. There is also a nasal spray option:Nasal spray: 500 mcg (1 spray in 1 nostril) weekly.