Thiamine Deficiency After Bariatric Surgery

Thiamine (also thiamin or vitamin B-1) is part of the B complex vitamins. It was the very first compound identified as a vitamin, and thus retains its historical numerical place in the B vitamin family. Thiamine is found in a broad range of foods from grains and nuts to pork and beans. It is thought to be easily absorbed by the body, except in special cases such as surgical bypass of the upper small intestine and excess ingestion of ethanol. In the former case, some of the primary absorption sites for thiamine are missed, and in the latter ethanol actually blocks transport of thiamine from the gut into the body.

The body does not store much thiamine, thus it can be rapidly depleted. Individuals deprived of thiamine will begin to express deficiency symptoms in about a week. Because of the wide-spread presence of thiamine in a varied diet and its general high bioavailability, deficiency — called Beriberi — is rare in the general population. Inadequate intake is typically only seen in underdeveloped countries or areas of famine. In countries where there is endemic malaria, there is some evidence that malarial infection may increase thiamine demand to a great enough degree for deficiency to manifest. Some foods are known to contain anti-thiamine factors (ATFs). These include coffee, black tea, betel nuts, blueberries, cabbage and Brussels sprouts. Rarely are people able to ingest enough ATFs to induce thiamine deficiency. However, if there is high ingestions of ATFs coupled with low food intake or overall low nutrition intake, this has been known to occur.

Alcoholism is the primary cause of thiamine deficiency in the developed world. This is both due to the ability of the ethanol to block thiamine uptake as well as the high correlation of alcoholism with poor nutrient intake. It may also be associated with eating disorders such as anorexia or bulimia nervosa, fad diets, and peritoneal dialysis.

The growing popularity of weight loss surgery has created a new axis for thiamine deficiency. While there are few reports in medical literature, thiamine has become a topic of increased interest and suspicion. In the case of weight loss surgery, especially gastric bypass, there may be more than one factor that plays into thiamine deficiency. The greatest risk appears to be in patients who develop vomiting or are unable to consume adequate amounts of food in the early weeks or months following surgery. This is compounded by a generally increased body demand for thiamine with any surgery, decreased food intake, and bypassing of key areas of vitamin uptake. Patients who undergo more rapid or greater than expected weight loss may also be at increased risk. There are reports of chronic deficiency as well, associated with alcohol intake, lack of supplementation and onset of poor eating habits . Subsequent development of anorexia or bulimia following weight loss surgery, would be a significant risk for thiamine deficiency, and has been reported in literature .

Thiamine has many important functions in the body but is especially critical for energy production and nerve transmission. For this reason Beriberi reflects problems related to high-energy need systems (the heart and brain) as well as nerve function. There are three classes of Beriberi: dry, wet and cerebral (Wernicke-Korsakoff Syndrome). Very mild deficiency presents with vague symptoms such as fatigue, weakness, and difficulty concentrating. With dry Beriberi (which is most common), patients may complain of vomiting, loss of appetite, weakness, sleepiness, burning feet, calf and leg pain, abdominal pain, constipation, headache and cramping. Peripherial polyneuropathy is also common, and this is one reason that a presumptive diagnosis of B12 deficiency should not be made in a gastric bypass patient in the absence of supportive lab data. The neuropathy on thiamine deficiency begins with fatigue and loss of sensation, pain, and “heaviness” in the legs. Then pretibial edema develops, along with glove-and-stocking paresthesias and difficulty with tasks such as climbing stairs and standing on one leg . If there is involvement of the brain, mental confusion can be a prominent symptom. While this can be severe enough to include symptoms of delusion, hallucination, or psychosis, more mild symptoms are confabulation, memory impairment, eye dysfunction such as double vision (due to optic neuropathy), inability to walk or stand, or waddling gait. Wet Beriberi presents with symptoms of congestive heart failure. This would be less expected in post-operative weight loss surgery patients as it most often results from excessive over eating of carbohydrate.

Laboratory evaluation of thiamine status should be considered in patients with any suspect axis of deficiency (vomiting, anorexia, etc) or in those presenting with symptoms. Serum thiamin will find moderate to severe deficiency, but is not appropriate to follow treatment as it responds too rapidly to supplementation and will correct before the deficiency itself is corrected. Erythrocyte or whole blood transketolase activity is the most accurate assessment of both deficiency and progress, but may be hard to obtain through some labs. Urinary excretion appears to be relative accurate. Pyruvate levels below 1mg/dL is also considered to be reliable . One may also want to check TSH (to rule out hyperthyroidism as a cause of thiamine deficiency), serum folate (low folate is an indirect cause of thiamine deficiency) and liver enzymes (to rule out occult alcohol abuse).

Generally, thiamine will replete rapidly. Case reports with gastric bypass patients have demonstrated that doses of 100mg IV or IM thiamine for one week, or alternately 100mg tid of an oral thiamine for 2 weeks, together with a multivitamin containing B-complex can correct deficiency . Patients should then be able to maintain with a B-complex or B-complex containing multivitamin assuming that the cause of the deficiency has been addressed.

Bariatric Advantage is pleased to introduce our new 100mg Thiamine capsule. This product is in a small, easy to swallow and digest two-piece capsule (which could also be emptied into liquid or soft foods). All of our Multivitamins contain comprehensive B-complex with 6 mg of thiamine (400% of the RDA)in our chewables and 10mg (667% of the RDA) in our capsules.

Grace DM, Alfieri MA, Leung FY. Alcohol and poor compliance as factors in Wernicke’s encephalopathy diagnosed 13 years after gastric bypass. Can J Surg. 1998 Oct;41(5):389-92.

Bonne OB, Bashi R, Berry EM. Anorexia nervosa following gastroplasty in the male: two cases. Int J Eat Disord. 1996 Jan;19(1):105-8.

Sewell AR, Recht, LD. Nutritional Neuropathy. http://www.emedicine.com/med/topic221.htm, accessed 25 May 2005.

ibid.

Towbin A, Inge TH, Garcia VF, Roehrig HR, Clements RH, Harmon CM, Daniels SR. Beriberi after gastric bypass surgery in adolescence. J Pediatr. 2004 Aug;145(2):263-7.

All About Thiamine
by Jacqueline Jacques, ND
November 14, 2005

Related Posts

• Terry One Year After Gastric Bypass Surgery
• Importance of Protein in Diet
• Hitting Bottom – What Helped Guide Me Toward Gastric Bypass Surgery
• Acid Reflux Disease Before and After Gastric Bypass Surgery
• Gastric Bypass Surgery for Weight Loss