The Wernicke-Korsakoff Problem jordanmarsh6, May 23, 2021April 5, 2023 Have you ever heard of something called Wernicke-Korsakoff syndrome? I had never heard of it until medical school. Of course I have been taught what it is and how to notice it in a patient, but recently I have learned some interesting history about it that I want to dive into here. At its most basic level, Wernicke-Korsakoff is a vitamin B1 (aka thiamine) deficiency. Patients largely have neurological problems: confabulations, memory loss, and gait abnormalities. What is a confabulation? It’s when patients will fill in gaps in their memory with made-up stories. The neurologist that taught our neuro block told us that when he enters a room of a patient with Wernicke-Korsakoff, he will act as if he knew them back in high school. He said without failure, his patients will respond as if they know him and start making up stories about the times they had in high school. It’s sad because these symptoms, along with memory loss and gait problems, will be permanent if not treated quickly. So a natural question then becomes: who is at most risk for a thiamine deficiency? Well, alcoholics are. There are many things that can cause thiamine deficiency, but the most common one by far is excessive alcohol consumption. This week I heard an idea that is not totally uncommon: why don’t we fortify alcohol with thiamine? Public health efforts to reduce vitamin deficiencies have been doing this for years. Once we realized neural tube defects like spina bifida are highly associated with vitamin B9 (aka folate or folic acid) deficiency in the pregnant mother, we began fortifying our food with folate. This has led to a dramatic drop in the rate of neural tube defects. There are many other examples. Many medications I have learned about in school so far will result in various vitamin deficiencies, and this is clearly a problem for the patient; thus, the medication must be paired with the use of that vitamin. Why on earth then don’t we add thiamine in alcohol? There is a clear correlation with Wernicke-Korsakoff and thiamine deficiency, and basically all the people walking into ERs with Wernicke-Korsakoff are alcoholics. Well, there is a fascinating article in the New York Times about this very thing, all the way back in 1979. Here is the link. You obviously can read the article for yourself, but the basic idea is what I have been describing. What it does say though about why this problem still existed (even in 1979!) is my point in all of this. Thiamine for the first time could be synthesized in 1936. Alcohol manufacturers started to experiment with thiamine as early as 1940. But then they ran into a problem that I want to particularly highlight: by law the government required manufacturers to put all ingredients on the label, but the government also didn’t want to give off the impression that alcohol was healthy by fortifying it with vitamins. Interest in fortifying alcohol with thiamine cooled, and here we sit almost a century later with Wernicke-Korsakoff still a large problem among alcoholics. The context is particularly fascinating. The U.S. had just failed a bold social experiment in 1933: prohibition. While folks still may have realized that alcohol use was inevitable whether it was illegal or not, that didn’t mean they wanted to start letting companies promote alcohol like it was vitamin water. I can see why regulators were hesitant. It raises an interesting question for me: how many things can be avoided by completely cutting them out of our life (prohibition), and how many things can be avoided by responsibly using them (adding thiamine to alcohol!). Rates of Wernicke-Korsakoff would drop under both scenarios. In fact, the article I linked previously claims that rates of Wernicke-Korsakoff dropped by nearly 90% (!) during prohibition. I bet you can just feel how eager I am to tell you why this question applies to so many areas of our life. I definitely am! But rather than do that, let’s just sit on this central question for a bit: to change my habits, do I need to completely cut out the bad habit or can I reduce the negative consequences of the bad habit a different way? You’ll hear more from me on this, I promise. 😉 Self Improvement