Thiamine Deficiency in the Bariatric Surgery Patient—a Multidisciplinary Challenge in the Clinic and the Community

This column is dedicated to covering a variety of topics relevant to the multidisciplinary care of the bariatric surgical patient.

by Barbara Hodges Klick, RD, MPH

Barbara Hodges Klick, RD, MPH, is Program Manager, Bariatric Surgery, at the University Hospital Case Medical Center, Cleveland, Ohio, and University Hospital Geauga Medical Center in Chardon, Ohio.

Funding: No funding was provided in the preparation of this manuscript.

Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(1):20–21.

Abstract
Thiamine deficiency in the bariatric patient is a complication that can result in serious and permanent side effects. Educating community healthcare providers on the higher likelihood of thiamine deficiency in the bariatric patient, as well as the causes, symptoms and treatment of this deficiency can significantly impact the health and overall wellbeing of the bariatric patient.

Introduction
Thiamine (i.e., vitamin B1) deficiency is considered uncommon in the general population; therefore, its diagnosis is easily delayed or missed by community healthcare providers or providers not familiar with the bariatric surgery patient. Thiamine deficiency in the bariatric surgery patient is a complication that can present quickly and cause serious side effects if left unreported or misdiagnosed. Bariatric experts are likely familiar with the presentation and treatment of this deficiency; however, sharing this knowledge and educating community providers who also treat bariatric patients are essential to avoiding the potentially permanent and devastating results of undiagnosed thiamine deficiency.

Community physicians, emergency personnel, advanced practice providers, physical therapists, nurses, and dietitians are all involved in the care of the bariatric patient. Each one of these providers plays an integral role in the diagnosis and/or management of vitamin deficiencies, including thiamine deficiency. This article will discuss symptoms and treatment of thiamine deficiency, which can be used as a springboard for educating community healthcare providers.

Bariatric Surgery Patients and Thiamine Deficiency
A variety of situations place the bariatric surgery patient at increased risk for thiamine deficiency after surgery. These include the following:
1.    Nausea and vomiting are common occurrences after bariatric surgery. This side effect may be related to a variety of factors including patient eating behaviors or surgery-related complications, such as stenosis and/or bowel obstruction.[1] Bariatric surgery patients are at an increased risk of developing thiamine deficiency, particularly after an episode of intractable vomiting.[2]
2.    Bariatric surgery results in a drastic restriction in energy intake, which requires additional vitamin and mineral supplementation. Nonadherence to a multivitamin regimen puts patients at risk for a variety of deficiencies, including that of thiamine.
3.    Thiamine deficiency is also observed in patients with periods of high carbohydrate intake, such as nasogastric feeding, total parenteral nutrition, or intravenous hyperalimentation.[3]

The Symptoms of Thiamine Deficiency
Thiamine deficiency is typically characterized with cardiac as well as neruologic signs.4
Early deficiency. The early stages of thiamine deficiency may present with anorexia, indigestion, constipation, malaise, heaviness and weakness of the legs, tender calf muscles, numbness in the legs, and an increased pulse rate.[4]

Severe thiamine deficiency. Syndromes caused by frank thiamine deficiency, including beriberi, Wernicke’s encephalopathy (WE), and Korsakoff syndrome, commonly present with a classic triad of symptoms including ocular abnormalities, gait ataxia, and mental status changes.3 It is important to note that all three components of the triad may not be present at time of diagnosis; hence providers should not rely on all three components presenting at one time in order to make a definitive diagnosis.[3]

Laboratory Testing to Detect Thiamine Deficiency
Utilizing the correct laboratory test is essential in determining the presence of thiamine deficiency. Thiamine diphosphate (TDP) is the active form of thiamine and should be measured in whole blood to accurately assess body stores of thiamine.[3,5] Plasma thiamine concentration should not be relied upon as it only reflects recent thiamine intake rather than tissue concentrations.[3]

Important information for the Emergency Response team
Patients presenting to the emergency department with thiamine deficiency may mistakenly be diagnosed with dehydration or even hypoglycemia. Thiamine is absorbed mainly in the jejunum and ileum and plays an essential role in the metabolism of carbohydrates.[6] For this reason, the administration of glucose and other carbohydrates (often used in the treatment of dehydration), without the addition of thiamine, can be dangerous in patients with acute thiamine deficiency.
Thiamine requirements are highest during periods of high metabolic demand or high glucose intake[.1,3] Since glucose oxidation is a thiamine-dependent process, it may cause the utilization of the reserves of circulating thiamine, thus exacerbating the deficiency.[1]

Treatment of Thiamine Deficiency
Thiamine deficiency, once identified, may require long-term attention to prevent recurrence of the deficiency.

For significant thiamine deficiency, data from randomized trials suggesting optimal thiamine dose, frequency, route, or duration of treatment are lacking.[7,8] When WE is of concern, the minimum treatment recommendation is 200mg of parenteral thiamine per day for two days.[8]
Patients who have experienced a thiamine deficiency may require a daily oral thiamine supplement to prevent a re-occurrence.[2,8] The recommended dosage for oral supplementation varies, but generally falls between 20 and 100mg/d.[2,3]

What the Bariatric Patient Needs to Know
Many vitamin and mineral deficiencies develop slowly and often go unnoticed until the deficiency is quite severe.

Prior to surgery, patients should to be advised on the importance of regular medical follow-up visits after bariatric surgery.

Patients should be educated that they are at risk for a plethora of vitamin and mineral deficiencies, including thiamine deficiency, whose side effects may be permanent if left untreated or inadequately treated.

Educating our Community
The bariatric healthcare community can help to increase education and awareness of thiamine deficiency among their patients and other healthcare providers. The following are some options one might consider:
1.    Provide patients with a wallet-sized card highlighting the medically important details of their particular surgery, including the possibility of thiamine deficiency. The patient can present this card to healthcare providers who may not be familiar with bariatric surgery and its risks.
2.    Send a courtesy letter to the patient’s primary care providers highlighting the possible long-term complications and standard laboratory panels used in postoperative bariatric surgery patients. This is especially important for patients who live a long distance from the bariatric practice or choose to follow up at their personal physician’s office.
3.    Provide inservice education to local emergency departments on the presentation of bariatric complications; including first responders (e.g., paramedics and emergency medical technicians) is highly recommended. The American Society for Metabolic and Bariatric Surgery (ASMBS) offers free downloadable copies of the handout titled “Clinical Pearls for Emergency Care of the Bariatric Patient.” This can be distributed as part of an inservice that includes education on thiamine deficiency.
4.    Combine your practice marketing efforts with education. When visiting a referring physician’s office, offer to schedule an educational session for the staff on the long-term needs of the bariatric patient.
5.    If the bariatric practice publishes a bariatric newsletter, include information on the signs and symptoms of vitamin deficiency, including thiamine deficiency.
6.    Present at local, state, or national professional conferences. This will reach a variety of healthcare providers who may not regularly treat the bariatric patient.

Thiamine deficiency can be a dangerous complication after bariatric surgery. Educating our healthcare partners in both the hospital and community settings can prevent serious long-term side effects of thiamine deficiency.

References
1.    Ianelli A, Addeo P, Novellas S, Gugenheim J. Wernicke’s Encephalopathy after laparoscopic Roux-en-Y gastric bypass: A misdiagnosed complication. Obes Surg. 2010;20:1594–1596.
2.    Ails L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4(5 Suppl):S73–108.
3.    Kumar N. Neurologic Presentations of nutritional deficiencies. Neurol Clin. 2010;28(1):107–170.
4.    Mahan L, Escott-Stump S, Raymond J. Krause’s Food and the Nutrition Care Process. 13th Edition. Elsevier Saunders; St Louis, Missouri: 2012.
5.    Mayo Clinic Thiamin (Vitamin B1), Whole Blood. Accessed September 9, 2012. www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/85753
6.    Malinowski S. Nutritional and netabolic complications of bariatric surgery. Am J Med Sci. 2006;331(4):219–225.
7.    Aasheim ET. Wernicke Encephalopathy after bariatric surgery: A systematic review. Ann Surg. 2008;248(5):714–720.
8.    Merola J, Ghoroghchian P, Samuels M, Levy B, Loscalzo J. Clinical problem-solving. At a loss. N Engl J Med. 2012;367(1):67–72.

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