Neurological disorders as a result of micronutrient deficiencies

Bariatric surgery has undoubtedly improved the health and quality of life of millions of people around the world. As estimated, in 2014, about 150,000 such surgeries were done in the US alone.[1] These types of surgeries are considered safe, however, they still pose certain risks associated with postoperative macro- and micronutrient deficiencies, especially if the preoperative nutritional status was inadequate.

One of such risks is neurological disorders resulting from malnutrition. These diseases affect the nervous system potentially impacting organ function. They may include a variety of symptoms and are caused by deficiencies of various vitamins and minerals, such as: [2-6]
Thiamine, Vitamins B12, B6 and E, Folate (folic acid), Copper

Studies confirm that in patients undergoing bariatric surgery, neurological disorders are mainly the result of vitamin and mineral deficiency, [3.4] and timely diagnosis and complete deficit filling are critical to preventing long-term, irreversible damage. [1] Neurological complications can arise from vitamin and mineral deficiencies a few weeks, months or years after any of the bariatric surgeries and can negatively affect the quality and longevity of life.
What exactly are these violations?

In recent years a new disease has emerged - "bariatric BeryBery". It is the result of low levels of thiamine and can lead to such devastating effects as muscle paralysis and heart failure. A low level of thiamine can lead to death. Other neurological diseases that may occur as a result of nutrient deficiencies include Wernicke's encephalopathy and Korsakov's syndrome. Wernicke’s encephalopathy is a neuropsychic condition caused by the depletion of thiamine stocks in brain cells, and Korsakov’s is a chronic memory disorder caused by thiamine deficiency. [8]
Myth: Neurological disorders due to nutrient deficiencies are only common in malabsorption procedures
Gastric bypass, which is restrictive and malabsorptive at the same time, is the procedure most associated with micronutrient deficiencies (particularly folate, B12, and thiamine) [5] resulting in neurological complications. However, it is not safe to assume that restrictive procedures as they have no risk of nutritional deficiencies. Eventually, they can lead to detrimental neurological complications. In fact, according to the latest data, one in three patients undergoing bariatric procedures is deficient in thiamine before surgery. [1] The best way to avoid thiamine deficiency is to consistently take appropriate foods (wheat wholemeal bread, soy, beans, peas, spinach, liver, kidney, brain, pork, beef, yeast) and nutritional supplements, as well as to secure frequent monitoring of the nutritional status using laboratory tests conducted by a physician.
When do these conditions after bariatric surgery occur?
Researchers and clinicians have recognized that each condition tends to be associated with unique nutrients at certain stages of the postoperative period:

  • Wernicke's encephalopathy (due to thiamine deficiency) is one of the most common early complications.

  • Myelopathy and myeloneuropathy (due to vitamin B12 or copper deficiency) [4] are considered late complications.

  • Polyneuropathy is associated with B12, B6 and vitamin E deficiencies and is usually a late complication.
Similarly, it is generally recognized that:
  • Thiamine deficiency may develop in the first weeks or months after surgery.

  • B12 deficiency may develop several years or many years after surgery.

  • Copper deficiency is usually a late complication (several to many years after surgery). [3,7]
As with health in general, prevention is the key factor. And for neurological disorders resulting from nutritional deficiencies, prevention means ensuring an adequate micronutrient status for the best condition of the nervous system. Knowing the preoperative micronutrient status and following the schedule for postoperative laboratory testing to assess sufficiency are important steps in taking the necessary precautions to prevent one of these potentially irreversible conditions.

Consistency is another important aspect. Most patients have good intentions, however many of them stop taking vitamin and mineral supplements recommended by the surgeon after they have normal test results for many years as they believe that there are no risks anymore. However, reducing recommended doses and/or discontinuation of supplements may lead to adverse implications. Therefore, maintaining a regular supplementation regimen is an important step in reducing the risk of neurological complications that can occur long after the procedure.
  1. Berger JR & Singhal D. The neurologic complications of bariatric surgery. Handb Clin Neurol. 2014;120:587-94.
  2. Clinical pharmacology and rational pharmacotherapy for practitioners: textbook / M.L. Maksimov, R.A. Bontsevich, I.S. Burashnikova [et al.]; ed. Prof. M.L. Maksimov. – Kazan: Publishing house "MedDoc", 2021. - p. 948 ISBN 978-5-6045764-9-6;
  3. Malykhina A.I., Yashkov Yu.I., Maksimov M.L. Unresolved issues of vitamin and mineral support for patients undergoing bariatric surgery. - Obesity and metabolism. 2019. Vol. 16. No. 4. p. 31-36.
  4. Kumar N. Neurologic complications of bariatric surgery. Continuum (Minneap Minn). 2014 Jun;20(3 Neurology of Systemic Disease):580-97
  5. Saab R, El Khoury M, & Farhat S. Wernicke's encephalopathy three weeks after sleeve gastrectomy. Surg Obes Relat Dis.2014 Sep-Oct;10(5):992-4.
  6. Dudorova EY, Damulin IV, Khatkov IE. [Neurological complications due to vitamin deficiencies after bariatric surgery]. Ter Arkh.2015;87(12):117-121.
  7. Rudnicki SA. Prevention and treatment of peripheral neuropathy after bariatric surgery. Curr Treat Options Neurol. 2010 Jan;12(1):29-36.
  8. Alzheimer's Association. Korsakoff Syndrome. Alzheimer's Association,
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