B12 Deficiency and Weight Loss Surgery: Solving the Energy Crisis with Beet Juice?

Photo by M Clock

I remember well the cute old ladies that would come into the Family Practice I used to work in and request their monthly dose of "Beet Juice" to pep them up and help keep them active and sassy.

If it worked anecdotally, that was fine with me, as B12 was relatively cheap and seemed to make a positive difference in their reported energy level and their health in general. I used to check labs to see if they were anemic,  check their MCV to see if they were macrocytic, or check and see if they had prior gastric surgery or chronic PPI usage, or a past history of an issue with their intrinsic factor. Usually not on all accounts.  But they still wanted it...

I checked for my own interest, as well as the insurance companies who did not want to pay for a regular dose of B12 for fatigue or malaise (code 780.79).  You know how that is.

With my setting now in Bariatric Surgery, it is a little different story.  Risk factors abound in our patients, and often lead to B12 deficiencies that CAN be detected in labwork.  Our patients obviously have a history of past Gastric Bypass or Sleeve Gastrectomy, or they may have the history of poor compliance with the lifelong vitamin regimen that is heavy in B vitamins (B12 1,000 mcg per day, and B Complex one daily).

The recommended dosing is generally one B12 tablet daily, but can be given IM once per month, sublingually, or even intranasally (Nascobal) as well.

We do tend to have patients on PPIs for 3 mos after surgery to allow for staple lines to heal satisfactorily, and patients may use them prn after that.  Obviously, with a  much smaller stomach with the Bypass more than the Sleeve, and less exposure of food / vitamin nutrients in the pouch to acid and intrinsic factor, substantially less B12 will be absorbed.  We describe this side effect of surgery to patients to encourage compliance with their vitamin regimen, but occasionally they fall short of regular dosing.

With B12 deficiency, we will often see neurological complaints such as depression, memory issues, or symmetrically peripheral neuropathies of tingling / burning / and numbness in the hands or feet or upper extremities.  Fatigue and malaise may also be reported, but is usually multifactorial and not B12 specific.

Having them restart their B12, or getting them off to a better start with an IM injection in the office usually makes a difference in no time, which becomes reassuring.  These neurological complaints may become permanent if long lived, or severe in nature.

Catching B12 issues early, as with most nutritional issues, with regular lab work and a detailed history on our follow up visits (especially in the first year) definitely makes a difference. Another reason why follow up is so important.