Improving Bariatric Patient Aftercare Outcome by Improved Detection of a Functional Vitamin B12 Deficiency

A new perspective on vitamin B12 deficiency in rheumatology: a case-based review

Vitamin B12 (cobalamin) deficiency is common in patients with rheumatic diseases. Pernicious anemia is a well-known cause, but recent reports suggest that autoimmune-derived deficiency may not be limited to this cause alone. Symptoms of low vitamin B12 concentration are often deceptive, mimicking and overlapping with symptoms of other conditions. Neuropsychiatric manifestations, anemia, and fatigue are frequently attributed to a rheumatic disease without further evaluation. In this study, we present three cases of patients with neuropathic pain, depression, fatigue, and muscle weakness, initially attributed to a rheumatic disease, which almost completely resolved after implementing vitamin B12 supplementation. Furthermore, we provide an overview of current scientific reports regarding the potential use of cobalamin in rheumatology. Treatment of pain and neuropathy, often very challenging in long-lasting rheumatic diseases, can be more effective after a course of vitamin B12, even when no apparent deficiency is detected in laboratory tests. Considering recent research demonstrating vitamin B12's nerve-protecting properties, we recommend that physicians should assess vitamin B12 levels early in the diagnostic process of rheumatic diseases. In specific cases, physicians should consider cobalamin supplementation regardless of vitamin B12 serum concentration.

An unusual case of subacute combined degeneration due to nitrous oxide abuse, which relapsed after bariatric surgery: A case report

RATIONALE

Several studies have reported subacute combined degeneration (SCD) induced by nitrous oxide (N2O) abuse. However, few studies have reported that N2O-induced SCD recurred because of sleeve gastrectomy after neurological symptoms improved.

PATIENT CONCERNS

We report the case of an 18-year-old woman who developed paresthesia, weakness in 4 limbs, and an unstable gait after frequent, excessive N2O inhalation.

DIAGNOSIS

The patient was diagnosed as having SCD.

INTERVENTIONS AND OUTCOMES

Nineteen days after intravenous mecobalamin and supplementation with other kinds of vitamin B, her weakness and paresthesia resolved. However, 7 months after discharge, the patient experienced recurrence following sleeve gastrectomy. Blood biochemistry revealed low vitamin B12 levels. After a 22-day treatment, similar to the first hospitalization, her residual numbness and unsteady gait improved.

LESSONS

This case highlights that patients, especially those at high risk of vitamin B12 deficiency, undergoing sleeve gastrectomy require careful nutritional follow-up and routine monitoring of micronutrients such as vitamin B12 and homocysteine. Continuous vigilance is essential for patients with common and rare neurological complications.

Is Inflammation Status in Postbariatric Patients Predictive for Their Response to Vitamin B12 Supplementation Therapy?

Background

Several studies indicate that there is a relationship between vitamin B12 levels and inflammatory status. Some studies showed a significantly correlation between vitamin B12 status and inflammation. The aim of this study is to investigate the influence of inflammatory status on the effect of different vitamin B12 supplementation regimes.

Methods

We selected patients with a vitamin B12 deficiency based on methylmalonic acid (MMA) levels. A moderate vitamin B12 deficiency was defined as an MMA blood level between ≥300 and 430 nmol/L. In included patients, C-reactive protein (CRP), leukocytes, serum vitamin B12, and MMA levels were measured at baseline and after 6 months of follow-up.

Results

A total of 63 patients were included, treated with 3, 6, or no intramuscular vitamin B12 injections. In the 6 intramuscular injections group, the presupplementation CRP levels significantly predicted the response in terms of vitamin B12 increase (P = 0.015). Also, there was a significant reduction in CRP levels (P = 0.03) after 6 injections. There was a significant correlation between presupplementation MMA and presupplementation CRP (r = 0.127, P = 0.049).

Conclusion

This study showed that presupplementation CRP levels significantly predicted the response on 6 intramuscular vitamin B12 injections in patients after bariatric surgery. Second, the 6 intramuscular injection regimen showed a significant reduction in CRP levels. Third, there was a significant correlation between MMA and presupplementation CRP. This might indicate that there is interplay between the vitamin B12 supplementation and inflammatory levels in patients after bariatric surgery.

The Effects of Bariatric Surgery on Vitamin B Status and Mental Health

Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.

British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update

Bariatric surgery is recognized as the most clinically and cost-effective treatment for people with severe and complex obesity. Many people presenting for surgery have pre-existing low vitamin and mineral concentrations. The incidence of these may increase after bariatric surgery as all procedures potentially cause clinically significant micronutrient deficiencies. Therefore, preparation for surgery and long-term nutritional monitoring and follow-up are essential components of bariatric surgical care. These guidelines update the 2014 British Obesity and Metabolic Surgery Society nutritional guidelines. Since the 2014 guidelines, the working group has been expanded to include healthcare professionals working in specialist and non-specialist care as well as patient representatives. In addition, in these updated guidelines, the current evidence has been systematically reviewed for adults and adolescents undergoing the following procedures: adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch. Using methods based on Scottish Intercollegiate Guidelines Network methodology, the levels of evidence and recommendations have been graded. These guidelines are comprehensive, encompassing preoperative and postoperative biochemical monitoring, vitamin and mineral supplementation and correction of nutrition deficiencies before, and following bariatric surgery, and make recommendations for safe clinical practice in the U.K. setting.

The Many Faces of Cobalamin (Vitamin B12) Deficiency

Although cobalamin (vitamin B₁₂) deficiency was described over a century ago, it is still difficult to establish the correct diagnosis and prescribe the right treatment. Symptoms related to vitamin B₁₂ deficiency may be diverse and vary from neurologic to psychiatric. A number of individuals with vitamin B₁₂ deficiency may present with the classic megaloblastic anemia.

In clinical practice, many cases of vitamin B₁₂ deficiency are overlooked or sometimes even misdiagnosed. In this review, we describe the heterogeneous disease spectrum of patients with vitamin B₁₂ deficiency in whom the diagnosis was either based on low serum B₁₂ levels, elevated biomarkers like methylmalonic acid and/or homocysteine, or the improvement of clinical symptoms after the institution of parenteral vitamin B₁₂ therapy. We discuss the possible clinical signs and symptoms of patients with B₁₂ deficiency and the various pitfalls of diagnosis and treatment.

Improved testing for vitamin B12 deficiency: correcting MMA for eGFR reduces the number of patients classified as vitamin B12 deficient

Background Methylmalonic acid (MMA) can detect functional vitamin B₁₂ deficiencies as it accumulates early when intracellular deficits arise. However, impaired clearance of MMA from blood due to decreased glomerular filtration rate (eGFR) also results in elevated plasma MMA concentrations. Alternative to clinical trials, a data mining approach was chosen to quantify and compensate for the effect of decreased eGFR on MMA concentration. Methods Comprehensive data on patient's vitamin B₁₂, eGFR and MMA concentrations were collected ( n = 2906). The relationship between vitamin B₁₂, renal function (eGFR) and MMA was modelled using weighted multiple linear regression. The obtained model was used to estimate the influence of decreased eGFR on MMA. Clinical impact was examined by comparing the number of patients labelled vitamin B₁₂ deficient with and without adjustment in MMA. Results Adjusting measured MMA concentrations for eGFR in the group of patients with low-normal vitamin B₁₂ concentrations (90-300 pmol/L) showed that the use of unadjusted MMA concentrations overestimates vitamin B₁₂ deficiency by 40%. Conclusions Through a data mining approach, the influence of eGFR on the relation between MMA and vitamin B₁₂ can be quantified and used to correct the measured MMA concentration for decreased eGFR. Especially in the elderly, eGFR-based correction of MMA may prevent over-diagnosis of vitamin B₁₂ deficiency and corresponding treatment.

Comparison Between Different Intramuscular Vitamin B12 Supplementation Regimes: a Retrospective Matched Cohort Study

BACKGROUND

The incidence of vitamin B₁₂ deficiency after bariatric surgery can range from 26 to 70 %. There is no consensus on optimal vitamin B₁₂ supplementation in postbariatric patients. The objective of this study was to compare three different regimes.

METHODS

In this retrospective matched cohort study, we included 63 patients with methylmalonic acid (MMA) levels ≥300 nmol/L. Group A (n = 21) received 6 intramuscular (im) vitamin B₁₂ injections including a loading dose, group B (n = 21) received 3 im vitamin B₁₂ injections without loading dose and group C (n = 21) received no im vitamin B₁₂ injections.

RESULTS

The total post-bariatric patient population consisted of 14 males (22.2 %) and 49 women (77.8 %) with a mean current body mass index of 30.6 ± 8.0 kg/m². There was no significant difference in vitamin B₁₂ and MMA levels between 3 groups at baseline. There was a significant difference in follow-up vitamin B₁₂ levels of group A compared to group B (p = 0.02) and group A compared to group C (p = 0.03). In the follow-up results, there is also a significant decrease in MMA levels of group A compared to group B (p = 0.02), group A compared to group C (p < 0.001), and group B compared to group C (p < 0.01).

CONCLUSIONS

In this study, a shorter injection regime is probably not sufficient to treat a vitamin B₁₂ deficiency. An injection regime with 6 injections recovered all vitamin B₁₂ deficiencies biochemically. MMA levels cannot recover spontaneously over time without additional im injection regime.