ARTICLES 

The 'Resurrection' of Beriberi

Cynthia Buffington, Ph.D.

Beyond Change, May 2003

During the early postoperative period, did you have problems keeping your food down? Or, because you were not hungry, did you often skip meals? Did you forget to take your post-surgery vitamin supplements?

For bariatric surgery patients who vomit frequently and those who have difficulty eating and do not take vitamin supplements, there is the rare but occasional risk of thiamin deficiency. Thiamin is one of the B-complex vitamins, known as Vitamin B1, and is important to help convert carbohydrate and fat to energy necessary for all body functions.

The disease caused by a thiamin deficiency is known as beriberi.  Beriberi is also called ‘the disease of lameness’ because individuals with the condition often lose the ability to walk and can even suffer from permanent brain damage or develop congestive heart failure and die.

There are two major forms of beriberi, ‘wet’ and ‘dry’.  ‘Dry Beriberi’ is the form of the disease that affects the nervous system, often causing pain in the legs (and sometimes the arms), muscular cramping in arms and legs and paralysis of the lower extremities. Later stages of the ‘Dry’ form of the disease can result in confusion, disorientation, memory loss, coma, and death, a condition known as Wernicke/Korsacoff Syndrome.

 ‘Wet Beriberi’ occurs when the deficiency in thiamin affects the heart and circulatory system, causing an enlargement of the heart, a very rapid heart rate, congestion and difficulty breathing, swelling in the legs and feet, and congestive heart failure. This form of the disease is extremely dangerous and is the major cause for death for individuals with thiamin deficits.

 Physicians sometimes fail to diagnose beriberi.  This is because thiamin is now added to cereals, breads, milled rice and other food products to prevent its occurrence. Therefore, the disease, today, in industrialized countries, such as the U.S., is quite rare, and many physicians have never seen a case of beriberi.

Beriberi didn’t used to be rare. In fact, the disease was extremely common among Asians for centuries.  A description of the condition was first recorded as early as 2695 B.C. but was not determined to be caused by something lacking in the diet until the early 1900’s when it was recognized that individuals with the disease consumed a diet that primarily consisted of milled rice.

Thiamin is contained in the outer coat of rice and when it is milled to produce ‘white’ rice, the outer coat is destroyed. Today, white rice is usually enriched with thiamin and other B-complex vitamins in countries, such as Japan and China, where rice is a dietary staple. Still, there are remote, low-income areas of Indonesia where beriberi remains common, with prevalence rates as high as 65% of the population.

In America and Europe, deficits in thiamin most often result from chronic alcoholism. Frequent use of alcohol reduces absorption of major B-complex vitamins, including thiamin. Other conditions that cause thiamin deficiencies include a diet high in sugar and refined carbohydrates, regular use of diuretics, hospital infusion drips that contain sugar without thiamin or other vitamins, nutrient malabsorption, chronic vomiting, or extremely low calorie intake.

Low calorie intake, nutritional deficiencies, and malabsorption may occur with bariatric surgery, causing thiamin deficits and beriberi. Thiamin is absorbed in the second portion of the small intestines, known as the jejunum. With certain surgical procedures, such as the gastric bypass, biliopancreatic diversion, and duodenal switch, a part of or, in some instances, most of the jejunum is bypassed which can cause, in the absence of vitamin supplementation, deficiencies in thiamin and other B-complex vitamins.

There are several published case reports of a severe stage of beriberi affecting the nervous system (Dry Beriberi), known as Wernicke/Korsacoff’s Syndrome, in patients who have had gastric bypass or biliopancreatic diversion. In addition, there are a number of reports of Wenicke/Korsacoff’s Syndrome following vertical banded gastroplasty and a few reports with the gastric band and gastric balloon procedures. There are also numerous ‘word-of-mouth’ incidents of thiamin deficits, or the symptoms thereof, among bariatric patients.

Wernicke/Korsacoff’s Syndrome, as mentioned previously, is the most severe form of neurological damage caused by thiamin deficiencies.  The brain uses sugar (glucose) to produce energy to function and thiamin deficits impair the ability of tissue to convert sugar into energy. Without energy, brain tissue may lose its ability to function normally or die. Furthermore, thiamin deficits also cause leaks in vessels that supply nutrients and oxygen to brain tissue causing bleeding, swelling and inflammation, a condition known as Wernicke’s Syndrome.

Wernicke’s Syndrome leads to the more chronic stage of beriberi, known as Korsacoff’s Psychosis.  This condition is characterized by memory gaps, short-term memory loss, defects in the ability to learn, apathy and a loss of motivation.  Wernicke/Korsacoff’s Syndrome is reversible if the condition is recognized and treated early but, if the thiamin deficiency remains untreated for too long a period of time, permanent brain damage may occur, as well as coma and death.

Thiamin deficiencies following bariatric surgery have been found to occur most often following an episode of frequent vomiting and, therefore, a period of extremely low nutrient intake. The condition, however, may also occur among individuals who refrain from eating in order to enhance their rate of weight loss and those who fail to take post-surgical vitamin supplements.

 ‘Bariatric beriberi’ (as it was recently titled in an article published in the journal, Obesity Surgery) generally occurs in early postoperative months and when calorie intake is at its lowest. However, there are published and ‘word-of-mouth’ reports of the disease in patients who have been out from surgery for a year or more.

How can this serious and potentially life-threatening condition be treated or avoided? First, it is important to take a daily vitamin/mineral supplement after surgery that contains at least 100% the RDI for thiamin and other major B-complex vitamins, and preferably higher amounts. Secondly, any episode of vomiting should be reported to clinic staff and immediate steps taken to resolve the condition. Third, every attempt should be made to eat three meals a day, even if hunger is not an issue. Finally, it is important to know the signs and symptoms (early and late) of  ‘bariatric beriberi’.

Early symptoms of thiamin deficiencies may include weakness, numbness or tingling in the extremities, particularly the legs. Without thiamin replacement, there may be further damage to nerves in the legs (and, sometimes, the arms) causing muscular atrophy (muscle breakdown) and even some paralysis. At night, in particular, the feet may feel as though they are burning.  Muscle cramps are not uncommon, nor is muscular soreness or pain.  And, there may be difficulty getting up from a squat position or unsteadiness while walking.

More serious forms of nervous system damage involve dizziness, disorientation and confusion about time or place. Short-term memory loss may occur, along with confabulation (making up stories because of memory loss). As previously mentioned, this condition, known as Wernicke/Korsacoff’s Syndrome, if not treated early, can cause irreversible brain damage and even death. 

Heart failure is the most common reason for death in individuals with beriberi.  Symptoms of ‘Wet Beriberi’, i.e. the form of beriberi that affects the heart and circulatory system, include a racing heart, lung congestion, difficulty breathing (particularly upon exertion), and swelling in the legs and feet.

Beriberi is treated through replacement of the thiamin deficit. Mild to moderate cases of ‘Dry Beriberi’ or nervous system defects are generally treated with high amounts of supplemental thiamin (10 to 30 mg daily), along with other B-vitamins, until symptoms disappear. Supplements are followed by, or included along with, a diet high in thiamin. 

Foods high in thiamin include lean pork, liver, oysters, beef, lima beans, peas, whole grains or enriched breads and pasta, brown rice, wheat germ and oats. Alcohol interferes with the absorption of thiamin and should be avoided, as should sugar and processed grains that are not enriched with B-vitamins.

Central nervous system damage (Wernicke/Korsakoff’s Syndrome) and cardiovascular problems or ‘Wet Beriberi’ are treated by injections of large doses (100 mg) of thiamin into the veins or muscles.  These injections are generally followed by thiamin and other B-vitamin supplements and by a diet high in thiamin.

Symptoms of thiamin deficiency generally take from a few weeks up to a year or more to disappear, depending upon the severity of the condition. Sometimes, an individual may require physical therapy to overcome nerve damage and develop muscular strength. Some individuals may even have to self-inject thiamin for life in order to prevent the reoccurrence of neurological symptoms. And, there are a small percentage of patients with irreversible brain damage who will never totally recover, having permanent memory loss and difficulty learning new information or tasks.

As is apparent from the above discussion, beriberi is serious and even life-threatening condition. Severe nutrient reduction with vomiting or extreme calorie restriction following bariatric surgery can cause deficits in thiamin responsible for the disease.  Taking a multivitamin and eating foods high in thiamin can help to prevent the occurrence of this disease, as can knowledge of its symptoms.   If such symptoms occur, see your bariatric surgeon or physician immediately.