Precautions When Using Alcohol after Bariatric Surgery?

Cynthia Buffington, Ph.D.

Beyond Change, July 2003

A 36-year old female gastric bypass patient left a party after having only two alcoholic beverages, drove her car into oncoming traffic, causing the death of a
12-year old child*.  Her blood alcohol level was above the legal limit for the operation of a motor vehicle and was far higher than would have been expected from the two alcoholic beverages she claimed to have consumed. Was the patient telling the truth about the amount of alcohol she drank at the party or did her surgery affect the way her body absorbed or metabolized the alcohol? 

A recent study reported in the British Journal of Clinical Pharmacology found that the gastric bypass procedure significantly affects alcohol absorption and its inebriating influence. According to the study protocol, a group of gastric bypass patients, three years post-surgery, and their non-surgical controls consumed an alcoholic drink containing 20% v/v alcohol (95% ethanol), and blood alcohol levels were examined over a period of time. The data showed that blood alcohol levels of the gastric bypass patients were far higher and required much less time to peak than those of the non-surgical controls. 

The more rapid absorption of alcohol and heightened blood alcohol levels would cause the bariatric patient to have a more pronounced feeling of inebriation during and shortly after drinking. And, such effects could have serious ramifications with regard to driving an automobile or performing other skilled tasks such as operating heavy machinery, piloting a plane or any other task that may influence the safety of the individual or that of others.

Why would alcohol absorption be higher for someone who has had gastric bypass (or any other surgical procedure that reduces the size of the stomach and bypasses the upper portion of the gut)? With the gastric bypass procedure, 95% of the stomach and the upper gut (duodenum and a portion of the jejunum) are bypassed.  Alcohol passes directly from the stomach pouch, usually without restriction, into the second portion of the gut, known as the jejunum. This portion of the gut has a large surface area and readily and rapidly absorbs the alcohol.

In addition to anatomical changes in GI tract that influence alcohol absorption, the gastric bypass patient (or patient having had any bariatric procedure), may also be more sensitive to the intoxicating effects of alcohol because of the reduced calorie intake caused by the surgery. A number of studies have found that alcohol absorption is far higher if fasting or when consumed on an empty stomach than if provided with a meal or drank soon thereafter. 

During the first several months following gastric bypass or any other bariatric surgical procedure, total daily calorie intake is quite low. Drinking alcohol, even small amounts, at this time, would increase significantly an individual’s risk for intoxication.

In the rapid weight loss period following bariatric surgery, alcohol consumption could have far more serious consequences than inebriation, namely brain damage, coma and death. How is this possible?

Muscle, heart, liver and other tissues use fat and sugar (glucose) for fuel. The brain, however, requires sugar (glucose) to function. To avoid low sugar, the body stores sugar in the form of glycogen. However, glycogen stores can be depleted in a short period of time with prolonged work or exercise, starvation or a diet low in carbohydrate. When this happens, the body has two back-ups mechanisms that help to provide the brain and nervous system the sugar required to function.

One of the mechanisms whereby sugar is produced is a process called gluconeogenesis, a chemical pathway that converts certain components of protein, lactic acid and other substances into sugar. Fat cannot be converted into sugar.  However, the production of sugar by gluconeogenesis is run by energy produced by the incomplete breakdown of fat into ketone bodies via a process known as ketosis. 

Ketone bodies can be used by all tissues, including the brain, for fuel. And, ketones can also be converted into sugar via gluconeogenesis. In this way, the brain and nervous system can function normally, even during times of low calorie intake, such as during the rapid weight loss period following bariatric surgery.

The production of ketones is what causes the sweet or distinct smell in the urine and on the breaths of bariatric patients during the rapid weight loss period after surgery. And, during this time, it is extremely important that alcohol NOT be consumed. Why?

Alcohol inhibits gluconeogenesis and ketosis. This means the brain and nerves are depleted of the fuel needed to function. The consequences of such fuel depletion initially are disorientation, confusion, semi-consciousness, coma and, ultimately, death. The detrimental effects of alcohol on the brain’s fuel supply can also cause accidents, such as the hypothetical situation described below. 

A bariatric patient, four weeks after surgery, had a couple of drinks and drove to the post office. But, instead of walking into the post office to get her mail, she drove her car through the front window. She claimed to have ‘blacked out’ before the accident and had no memory of the event. People standing by said she was disoriented and, presumably, intoxicated. Fortunately, someone provided her a beverage containing sugar that helped her to regain full consciousness, preventing coma or even death, as well as an evening in jail.

Drinking alcohol in the early postoperative period may have other adverse effects on health. Frequent vomiting, low calorie intake, not taking multivitamins and malabsorption may cause a number of vitamin and mineral deficits, including thiamin. Alcohol further reduces the absorption of thiamin, causing severe deficits and a condition known as Beriberi (see May 2003 issue of Beyond Change). Beriberi, in turn, may cause congestive heart failure, nerve damage, muscle cramping and pain, crippling, brain damage, a loss of memory and inability to learn, confusion, disorientation, coma and death. 

Addiction transfer is yet another precaution to be considered with regard to alcohol. The prevalence of food addiction and associated eating abnormalities, i.e. binge eating, carbohydrate cravings, are high among individuals with morbid obesity. With bariatric surgery, the addictive tendencies for food and aberrant eating behavior are considerably improved. However, individuals with addictions often transfer their addiction to yet another substance, such as alcohol. According to the findings of one study, addiction transfer may occur in up to 25% of
bariatric patients.

Drinking alcohol after surgery may also reduce maximal weight loss success. Alcohol has no nutrient benefits and contains high numbers of calories that may cause weight gain or prevent weight loss. One 12-ounce can of beer, for instance, contains 150 calories; 3.5 ounces of wine contains 70 calories; 1.5 ounces of gin, rum, vodka or whiskey contains between 97 and 124 calories; and 1.5 ounces of liquor contains 160 calories. 

Based on all the information provided above, should the bariatric patient abstain from alcohol totally? The bariatric patient should absolutely NOT drink alcohol during the rapid weight loss period and definitely not if consuming no or low carbohydrates, not taking vitamin and mineral supplements, vomiting frequently, or not able to keep their food down. However, with time, there is no reason an individual should not be able to enjoy an occasional drink, provided they are aware that it only takes a small amount of alcohol to produce an inebriating effect. With such knowledge, appropriate precautions should be taken, such as waiting a sufficient length of time after drinking to drive or perform other skilled tasks.

*the age of the individuals involved in the accident described and some details have been changed so that those involved may remain anonymous