Vitamin B12 Deficiency

Vitamin B₁₂ deficiency a complication following Bariatric Surgery

It has recently been shown that vitamin B12 deficiency is an unforeseen complication of Bariatric surgery. There are significant stores of vitamin B₁₂ in the liver, and so onset of symptoms following Bariatric surgery may take several years. Whilst some of the symptoms/consequences of vitamin B₁₂ deficiency may be reversible, some are not. Studies have shown that serum vitamin B₁₂ deficiency had developed in 33.3% of patients at 2 years post surgery. In a 2-year follow-up study, 46.6% of the patients had already developed anemia which increased to 63.6% at 3 years. Hence it is recommended that high dose supplementation with  vitamin B₁₂ be initiated as soon as possible after surgery. Procedures that have definitely been shown to cause deficiency include Roux-en-Y gastric by-pass and biliopancreatic diversion with duodenal switch, and potentially Laparoscopic sleeve gastrectomies (LSG) (Sherf-Dagan et al,  2017; Ponsky et al, 2005; Avarez-Leitte, 2004; Sally and Stabler, 2013; Smelt et al, 2015). An additional complication is often iron and magnesium deficiencies. Vitamin B12 supplementation in such individuals generally requires either frequent injections, of application of topical B12 - see below. Accompanying the deficiency in vitamin B12, an additional deficiency in iron routinely occurs (Crusell etal, 2016). Both vitamin B12 and iron deficiency become more pronounced the longer it is after surgery.

Vitamin B₁₂ deficiency a complication following Pancreaticoduodenectomy

It has been known for over 40 years that vitamin B12 deficiency is also common in procedures such as pancreticoduodenectomy for pancreatic cancer, or chronic pancreatitis where procedures such as the Whi;;le procedure can be used. Depending upon the extent of intestinal and stomach removal uptake of vitamin B12 from the intestine can be reduced to only 1% of normal. Similar reductions are also seen in iron uptake (Traverso and Longmire, 1980). Unfortunately the majority of persons undergoing the surgeon are not made aware of these complications (personal communications).

Vitamin B₁₂ deficiency due to altered absorption

The absorption of vitamin B12 requires binding to Intrinsic Factor that is released from gastric parietal cells, low gastric pH to help in the release of vitamin B12 from food, and absorption in the ileum. Any or all of these factors can be disrupted after bariatric surgery..

Vitamin B₁₂ deficiency leads to Neurological complications                

While it is well known that anaemia is a direct consequence of very low levels of vitamin B₁₂ earlier, during the development of vitamin B₁₂ deficiency It has been shown that early in vitamin B₁₂ deficiency demyelination of the autonomic nervous system may occur.  Vitamin B₁₂ has a vital role in neuronal development, particularly in myelinogenesis. Neurologic symptoms commonly seen with B₁₂ deficiency include paresthesias, weakness, decreased reflexes, spasticity, ataxia, position and vibratory sense loss, incontinence, loss of vision from optic nerve injury, macular degeneration, dementia, psychosis, and altered mood. Severe autonomic symptoms may also sometimes occur. More recently there have been examples of vitamin B₁₂-deficiency following bariatric surgery causing optic neuropathy and associated loss of visual acuity (Sawica-Pierko et al, 2014).

Other Deficiencies

Apart from vitamin B12 deficiency, deficiencies in vitamin D, magnesium, phosphate, iron and vitamin A are common following bariatric surgery (Lefebvre etal, 2014), as too are folic acid, copper and zinc (de Luis etal, 2013; Sanchez etal, 2016).

Vitamin B₁₂ Supplementation

It is very important that  Vitamin B₁₂supplementation is started before any of the potential symptoms develop. Due to the compromised nature of the intestine of the Bariatric surgery patient, normal multi-vitamin supplements have little effect and so high dose supplementation is required. Normal vitamin supplements do NOT provide sufficient vitamin B₁₂ to over-come loss following surgery. Supplementation with folate, thiamine, vitamin D, vitamin E and copper may also be required.

Vitamin B₁₂ in Supplements

The use of vitamin B₁₂ in supplements for treatment of deficiency is controversial with many studies showing no benefit being obtained from standard supplements as the amount of vitamin B₁₂ in the standard supplements is too low and because the normal intrinsic factor-mediated uptake system is compromised., Furthermore, studies with high dose oral supplements with cyanocobalamin were not effective in restoring normal levels of homocysteine, in reversing clinical signs of deficiency, or in maintaining normal levels of serum vitamin B₁₂ once supplements were ceased. Furthermore studies have shown that  oral supplements given to VB12 deficient vegan mothers who have undergone bariatric surgery were NOT effective in restoring VB12 levels in new born babies. It is recommended that those who have had bariatric surgery take a daily dose of at least 500 ug of vitamin B12 (Sherf-Dagan et al, 2017)

Vitamin B₁₂ Injections

Vitamin B₁₂ injections can be administered in cases of insufficiency if it is diagnosed, however they are generally not administered post-partum to women who have had Bariatric surgery, nor are they regularly administered to most people who have had Bariatric surgery, until there is a problem.

Topical Vitamin B₁₂

A topical form of vitamin B₁₂ has recently been developed which  is easy to administer, contains the natural form of the vitamin and has the added advantage of providing a prolonged release of the vitamin over several days.  This topical formulation is able to provide a much higher dose of vitamin B₁₂ than oral supplements and is ideally suited for people who have undergone bariatric surgery.

Further information on Vitamin B₁₂supplementation

Sawicka et al. Nutritional optic neuropathy following bariatric surgery. Wideochir Inne Tech Maloinwazyine 2014 9: 662-6

Sherf-Dagan et al. Health and nutritional status of vegetarian candidates for Bariatric surgery and practical recommendations. Obes Surg 2017

Ponsy et al. Alterations in gastrointestinal physiology after Roux-en-Y gastric surgery. J Am Coll Surg 2005 201:125-31

Alvarex-Leitte Nutrient deficiencies secondary to bariatric surgery Curr Opin Clin Nutr Metab Care 2004 7:569-75

Salle And Stable Vitamin B12 deficiency - clinical practice N Eng J Med 2013 368: 149-60

Smelt et al Improving Bariatric patient aftercare outcome by improved detection of a functional vitamin B12 deficiency Obes Surg 2015

Crusell etal, A Time Interval of More Than 18 Months Between a Pregnancy and a Roux-en-Y Gastric Bypass Increases the Risk of Iron Deficiency and Anaemia in Pregnancy. Obes Surg. 2016 Oct;26(10):2457-62. doi: 10.1007/s11695-016-2130-3.

Traverso and Longmire. Preservation of the pylorus in pancreaticodouodenectomy.Ann, Surg, 1980 192: 306-309

Lefebvre et al. Nutrient deficiencies in patients with obesity considering bariatric surgery... Surg Obese Relat Dis 2014 10:540-6

deLuis et al. Micronutrient status in morbidly obese women before bariatric surgery. Surg Obese Relat Dis 2013 9:323-7

Sanchez et al. Micronutrient deficiencies in morbidly obese women prior to bariatric surgery. Obese Surg. 2016 26:361-8

Further information on vitamin B12 and deficiency states, as well as potential use of vitamin B₁₂ can be found by following the following links: