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One of the most upsetting illnesses any psychiatrist encounters is Wernicke-Korsakoff Syndrome (WKS). Caused by a deficiency of thiamine (vitamin B1), it results in devastating impairment of muscle control and memory. Able-bodied men and women develop a severe and irreversible amnesia that wipes clean their pasts and prevents them from forming new memories. Those who survive — and many patients don’t — are often relegated to nursing homes. Yet the neurological damage WKS causes is only part of what makes it so upsetting to emergency room psychiatrists; after all, many neurological and psychiatric illnesses inflict irreversible cognitive harm. The tragedy of WKS is that, with appropriate public health measures, it could be easily prevented.
Historically, thiamine deficiency afflicted the indigent, prisoners of war, and societies with rice-based diets. Its most serious chronic manifestation, beriberi, can present in a “wet” form that results in cardiac overload and massive edema, or in a “dry” variant — of which WKS is a subset — that affects the peripheral nervous system, the brain, or both. In addition to amnesia, victims of WKS often display striking degrees of spontaneous confabulation, in which they volunteer personal stories that they believe to be true but are not. Prevalence rates for WKS at autopsy have been found to run as high as 2.8 percent in Australia, and between 0.1 to 2.2 percent in the U.S.
Among Americans, WKS is overwhelmingly a consequence of severe alcoholism. Although thiamine deficiency is sometimes caused by rare genetic conditions or advanced-stage eating disorders, nearly all WKS patients seen in emergencies rooms are chronic, heavy drinkers who are undernourished and nutrient-deprived. The vast majority of those cases could be prevented with one relatively simple and painless policy measure: fortifying alcohol products with thiamine.
Nutritional fortification stands out as one of the unequivocal public health triumphs of the modern era. Iodine-enriched salt has largely eliminated endemic goiters causes by thyroid malfunction. Bread supplemented with niacin has eradicated the scourge of pellagra. And folic acid supplements in flour have prevented countless birth defects. In 1940, the National Academy of Sciences’ Committee on Food and Nutrition, the precursor to the National Research Council’s Food and Nutrition Board, recommended that flour also be fortified with thiamine. Since 1941, the U.S. Food and Drug Administration has included such a standard in its definition of “enriched” flour. As a result, thiamine deficiency-induced amnesia is now extremely rare among non-alcoholics. A basic diet that includes bread products or breakfast cereals is usually enough to ward off the condition.
In contrast, alcoholic beverages are generally not nutritionally supplemented in the U.S. They are among the most widely consumed ingestible products that remain unfortified. Alcohol also impairs the absorption of thiamine in the gut, exacerbating the odds of developing WKS.
More than 40 years ago, Brandon Centerwall and Michael Criqui published a study in the New England Journal of Medicine arguing for the fortification of alcoholic beverages with thiamine. According to Centerwall and Criqui, every dollar invested in thiamine fortification saved approximately $7 in nursing home costs. Centerwall later reported that trials by Seagram & Sons, Anheuser-Busch, and the California Wine Institute during the 1930s found thiamine to be stable in whiskey, wine, and beer. And at the levels needed to prevent WKS, thiamine would have no impact on the safety of alcoholic beverages.
While taste tests have shown that thiamine fortification has limited effects on beer, subjects appear divided on whether or not they like the subtle flavor changes. A study by Peter Nixon and colleagues found that “subjects asked to discriminate between the bouquet and flavor of wine without added thiamine and that of wine with added thiamine expressed a ‘no preference’ result.” While no one has yet conducted taste tests on hypothetical samples of fortified Courvoisier or Dom Perignon, adding vitamins to top shelf products is not necessary. Fortifying packaged beers, table wines, and low-cost liquors alone would likely significantly reduce cases of WKS.
Over the past 15 years, several niche companies have attempted to market vitamin-enhanced alcohol products, including Stampede Beer, which was introduced in 2005 and advertised by American singer Jessica Simpson. However, efforts by private beer boutiques and microbreweries are no substitute for large-scale government action.
Scotland and Australia both explored the possibility of fortifying beer in the recent past. The Australian National Health and Medical Research Council even endorsed such a proposal, but opposition from an unlikely coalition of manufacturers and anti-alcohol activists prevented legislative action.
Addiction experts have often opposed the nutritional fortification of alcohol, fearing that it will convey the message that imbibing is healthful. The American Medical Association has objected to nutritional wines on similar grounds. This policy stance flies in the face of evolving medical attitudes toward harm reduction — attitudes embodied in such endeavors as clean needle exchanges and supervised injection sites. Of course, treating and even curing alcoholism should be a long-term goal. But one ought not mount that revolution, so to speak, on the backs of today’s chronic drinkers.
The enrichment of alcoholic beverages with thiamine — and possibly other vitamins from which alcoholics suffer deficiencies — need not pit public health activists against industry. Instead, authorities would be wise to make manufacturers their allies in the cause of fortification. By offering brewers and distillers tax incentives amounting to a portion of the projected health care savings, a system of fortification could actually prove profitable for these companies. In addition, allowing manufacturers to label their products as “thiamine-enriched” might further their marketing goals.
No one is going to drink vodka for the vitamins, and an enlightened society certainly should not encourage heavy alcohol consumption. Yet people do drink — often too much and at great costs. One of those costs need not be their memories.
Jacob Appel, MD, JD, MPH, is the Director of Ethics Education in Psychiatry at the Icahn School of Medicine at Mount Sinai in New York City and an emergency room psychiatrist in the Mount Sinai Healthcare System.