Vitamins, Obesity and Weight Loss Surgery

Obese patients who undergo weight-loss surgery may risk a rare but serious brain condition if they do not take the recommended vitamin supplements, a new review reports.

Authors of the systematic review conducted literature searches of MEDLINE, Embase, Ovid, SCI (Science Citation Index) and Google Scholar, for case reports, case series or cohort studies of Wernicke encephalopathy after bariatric surgery. Wernicke encephalopathy is a neurological syndrome that causes memory loss, vision changes, loss of motor control, vomiting, confusion and hallucinations. The researchers sought to characterize the clinical features, risk factors, radiographic findings and prognosis of Wernicke encephalopathy after bariatric surgery.

Researchers from Wake Forest University Health Sciences, Johns Hopkins University and the University of Iowa explained that taking the suggested dose of supplements after surgery may prevent Wernicke encephalopathy, which is caused by an inadequate intake or absorption of thiamine (vitamin B1) coupled with continued carbohydrate ingestion.

Researchers analyzed 32 cases of Wernicke encephalopathy after obesity surgery. The 32 patients had various types of obesity surgery, but the most common type was Roux-en-Y gastric bypass, in which some of the stomach and small intestine is bypassed.

The study reported that most cases of Wernicke encephalopathy occurred between four and 12 weeks after the surgery, and that one case developed 18 months later. A majority of the patients (27) were women. Researchers found that the complication usually occurs in women younger than 55 years old, one to three months after surgery.

Less than half of the patients (13 of the 32) made full recoveries after treatment with vitamin B1, while others continued to have problems. One patient died while hospitalized from septic shock, reported the study.

Vomiting was the most common risk factor (25 patients), which presented with the triad of Wernicke encephalopathy (confusion, ataxia and nystagmus) in 21 patients. Optic neuropathy, papilledema (swelling/bruising of the optic nerve), deafness, seizures, asterixis (involuntary, jerking or flapping movements), weakness and sensory and motor neuropathy were also reported.

Researchers concluded that Wernicke encephalopathy after bariatric surgery usually occurs between four and 12 weeks postoperatively, especially in young women with vomiting. Atypical neurological features are common. The diagnosis is mainly clinical because radiographic findings are normal in some patients. Prospective studies to determine the prevalence of this problem and protocols for preventive thiamine supplementation need evaluation.

For more information about vitamin supplementation, please visit Natural Standard's Herbs & Supplements Database.

Comments

[J.Kathryn Bryan]

It's sad to hear that patients who undergo such an extreme weight-loss procedure also have an increased risk of developing a brain disease. I think that the factors that put these patients at risk for obesity are perhaps related to the presentation of their symptoms post-surgery.

I think it’s important for doctors to carefully discuss the risks of the procedure with their patients prior to surgery. It's also important that doctors help patients recognize symptoms before they become critical. Doctors should structure meetings with their patients more like a conversation, rather than a question and answer session. I think this would put patients at ease and possibly increase their compliance with treatment protocols. Most importantly, such rapport would help patients who are not in the medical field feel less intimidated when communicating with their doctors.

Developing such a rapport would take time, which is something physicians do not have a lot of. If doctors take the time to respectfully educate their patients about the importance of a healthy lifestyle, perhaps fewer patients would need weight-loss surgery. Also, if patients had a sense that their physicians cared about them before and after surgery, they might feel more motivated to follow post-op protocols.

[thrasher543]

Reading this article, I am profoundly saddened by the number of patients turning to extremes like bariatric surgery as a "fix" for their internalized fatphobia. Is a larger body really so horrible that people prefer to risk *brain disease* ? It's time for patients and doctors to embrace the philosophy of Health at Every Size! "First, Do No Harm"

[James Hegarty]

The researchers looked at 32 cases of Wernicke encephalopathy after obesity surgery, but out of how many obesity surgeries altogether? What is the incidence rate of this condition among obesity surgery patients compared to the general population? Obviously, it must be higher, or the study would not have been warranted, but what is the difference? Did these patients also have beri-beri, which, I would think would have presented first, before brain complications became involved? Maybe a study should be done to evaluate the presentation of early signs of beri-beri (prickling or burning sensation in the toes or feet, muscle atrophy, tachycardia or warm moist skin). Looking for these may head off the later stages leading to Wernicke.

[Emily]

Thirty-two case reports of Wernicke’s encephalopathy is an alarming number for a procedure like bariatric surgery, which is relatively uncommon. Physiologically, the development of this syndrome following weight-loss surgery does make sense, as transit time of food through the gastrointestinal tract is shortened and the exposed surface area is not as large – each leading to decreased total absorption of thiamine. The discovery of this relationship between bariatric surgery and Wernicke’s encephalopathy will hopefully lead to standardized procedures for supplementation and monitoring in this patient population, as well as minimizing the risk of developing this neurological syndrome and lowering the associated mortality rates.

[J. Kathryn Bryan]

I’d agree that societal standards inevitable influence concepts of what designates good health and good care. Indeed, nobody lives in a vacuum. It is impossible for culture not to influence a diagnosis. For instance, the extent to which a health condition or set of symptoms interferes with daily life (often the threshold for prescribing medications, conducting investigative tests to form a diagnosis, etc) is in part determined by the patient’s perceived role of what they should reasonably be able to do (cooking, laying bricks, working 40 hours a week). Obviously, these perceptions also filter down to what the body should look like. Acne (a non-life threatening or even life-interfering condition) doesn’t usually become a problem or diagnosis till the patient voices to the health professional that they are bothered by it.

We live in an environment where patients are increasingly viewing health care practitioners as service providers. In an environment where patients are taking a more active role towards health care decisions, it makes sense that doctors might accept input from patients and create protocol that the doctor may not consider ideal. For instance, it is a patient’s right to accept or refuse chemotherapy. It is a patient’s right to accept or refuse wart cryotherapy (freezing). And it is a patient’s right to accept or refuse weight loss procedures.

One person’s decision to have a weight loss procedure such as the one described in this blog may not necessarily reflect internalized fatphobia. But I’d agree that the overall trend (that is, the many individual decisions to have this surgery, and doctors signing the forms to make an appointment for this surgery) may reflect our country’s current obsession with body size.

[Dexter Otis Grenne]

In response to the first comment, it does seem like most doctors should take a more personal interest in their patients at an individual level. It seems like they care for the health of their patients collectively but not necessarily individually. I find they are often too blunt and too by-the-book, instead of looking at the patient's specific situation and needs. This, of course, does not apply to all doctors but to enough where I think it's an issue.

[Anonymous]

The number of people who undergo bariatric surgery in the United States is growing exponentially. But the I feel chronic alcoholics have equal risks of potentially developing Wernicke's. They generally consume a lot of carbohydrates, and at times they vomit. As they vomit, they throw their bodies' electrolytes off, as well as their nutrients, and they also become dehydrated. Any suggestions on this?

[D Meyer]

Re: Dexter Otis Greene's question: Alcoholics are probably the highest risk population for Wernicke's out there. This has less to do with eating carbohydrates than it does the chronic vitamin B depletion that occurs in heavy drinkers. Apparently, this can also happen in people who have had gastric bypass because this can significantly interfere with absorption of B and other vitamins. What's concerning to me is that people who are having this procedure are evidently not being educated on self care and the very real risk of vitamin deficiency post-surgery. With no effective treatments for very obese people who simply cannot lose weight, I suppose gastric bypass is a last resort that can have life-altering and perhaps life-saving results. However, patients should be made fully aware of the risks and what they need to do to avoid them. They should also be made aware that this is not a panacea or cure for everyone and that it can be dangerous. I personally knew one woman who lost 60 pounds after her surgery, and over the next year she gained back every pound and then some by grazing on small amounts of high-calorie treats all day long. I also knew of a young man whose surgical band broke while he was asleep, causing him to vomit and choke, which resulted in his death.

For those who are truly obese and do not respond to diets, let us hope a more effective and safer way to lose excess weight comes along.

[Cady]

Wernicke's is not the only complication associated with surgeries of this type. Patients can ultimately starve themselves because they cannot consume the proper amount of calories that their bodies need to function effectively. It is important for every patient undergoing a surgery such as this one (or any of the other gastric operations), to follow the aftercare instructions carefully, including taking any necessary vitamins.

[Rachelle Provost]

I heard that they are coming up with a new pill to replace surgeries like gastric bypass. While I agree with thrasher543's point, I also think that it's not always possible to be healthy at any weight. There are serious health concerns that are correlated with obesity. I think though, rather than having all of these extreme surgeries, we should focus on prevention. You don't have to be a perfect size 6 or even 10, but you should incorporate nutritious foods and exercise into your daily living to keep your heart (and brain) healthy.

[Woods]

The TLC channel has two new shows about morbidly obese patients. One is about an obesity clinic that tries to help patients learn how to eat healthier and exercise, while the other one features patients who are getting weight loss surgery.

I've seen a few episodes of both of these shows, and although parts can be hard to watch, I find them interesting. The experts on these shows say that some morbidly obese people are actually addicted to food, the same way people are addicted to drugs.

One expert was saying that when we eat food, it triggers neurons in our brains to release endorphins. These endorphins make us feel good. Studies have shown that some obese people do not have as many of these neurons as non-obese people. Therefore, they have to eat more food in order to feel the same positive effects. Also, studies show that the more you stuff yourself, the less sensitive these neurons become. If this is true, it sounds like a vicious cycle.

As obesity continues to be a growing problem in our country, I think it's important that we really try to figure out how to treat the underlying problems that lead to obesity. In order to properly treat obese patients, we need to figure out what drives them to overeat.

[Emily P.]

I would agree with Woods' comment. It is not uncommon for one to turn to food while going through a period of stress or sadness. This is due to the positive feelings you do get after eating. I think it would be worth investigating ways to cut off over eating right off the bat, rather than remedying the problem once it becomes so severe. This would include researching alternative ways to stimulate the production endorphins.

[MV]

With the popularity of bariatric surgery and its success stories in the media, I never really thought about the side effects mentioned in this research. The symptoms of Wernicke encephalopathy sound serious, and I would not associate them with weight loss surgery. I personally wouldn’t think to ask my doctor about these things. In the past I have found that if I don’t ask, the doctors won’t always go right ahead and tell me. I think people need to research their options and understand that this surgery is not a quick fix.

[Paul]

Add this to the list of very serious problems associated with gastric bypass. It would be great to know the incidence rate of this adverse event, but even without that information, this is something that should be discussed with every patient. For people that become so severely obese that this is the last option, one has to wonder what their ability to follow strict post-operative guidelines are? Except for those with some biological reason, these are people who have not been able to follow basic life skills of eating and exercise throughout life, and now they are being asked to follow a very specific regimen. It seems like they are being set up for failure. After watching the TLC show mentioned above, I am really curious how the obesity clinic will do long term. Hopefully it will be a model for future therapy and fewer gastric surgeries will be considered.

[Lola]

Has anyone seen the TV show where they use a computer program to show parents what their overweight/obese children will look like when they are adults? The idea is to shock the parents and make them realize how serious the problem is. If bad eating habits begin during childhood, they usually continue into adulthood.

I think that instead of cutting physical education in schools and performing gastric bypass surgery, we should try to instill good eating and exercise habits in children.

[Jessica]

I haven't seen the show that Lola is talking about, but I have seen Shaq's show. He is helping a small group of obese children learn how to eat healthfully and exercise regularly. The ultimate goal is to raise awareness about the growing problem of obesity. I definitely agree with Lola. I think it's probably a lot easier to maintain a healthful lifestyle if it' adopted at a young age.