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Nutritional deficiency is caused by a lack of the vitamin in the diet, whereas acquired deficiency occurs when the intestinal absorption of the vitamin is interfered with by diseases and conditions such as pernicious anemia (an autoimmune disorder affecting intrinsic factor protein produced by gastric parietal cells), chronic atrophic gastritis, Crohn's and celiac diseases, gastric bypass surgery, and medications such as metformin, gastric acid secretion blockers (i.e., proton-pump inhibitors and H2-receptor antagonists), and others (2, 3)