Thiamin deficiency in low- and middle-income countries: Disorders,prevalences,previous interventions and current recommendations

Abstract

Background:

Thiamin deficiency is a major public health concern in several low- and middle-income countries (LMICs)—current attention to the problem is lacking.

Aim:

This review discusses prevalence of thiamin insufficiency and thiamin-deficiency disorders (TDDs) in LMICs, outlines programmatic experience with thiamin interventions, and offers recommendations to improve public-health and research attention to thiamin in LMICs.

Discussion:

Thiamin insufficiency, i.e. low-blood-thiamin status, is endemic among several Southeast Asian countries: Cambodia (70–100% of infants and 27–100% of reproductive-age women); Laos (13% of hospitalized infants); Thailand (16–25% of children and 30% of elderly adults). Thiamin deficiency accounts for up to 45% of under-5 deaths in Cambodia, 34% of infant deaths in Laos, and 17% of infant deaths in Myanmar. Deficiency also exists in Africa, Asia, and the Americas, but these instances have typically been isolated. Exclusively breastfed infants of thiamin-deficient mothers are at highest risk for TDD and related death. Intervention strategies that have been employed to combat thiamin deficiency include food processing, fortification, supplementation, dietary diversification, and dietary behaviors, all of which have shown varying levels of effectiveness.

Conclusions:

We recommend universal thiamin-fortification of context-specific staple-foods in LMICs as a promising solution, as well as thiamin supplementation, particularly for pregnant and lactating women. Food processing regulations, dietary diversification, and modification of dietary behaviors to increase consumption of thiamin-rich foods may provide benefits in some circumstances, especially in countries without universal fortification programs or in populations dependent on food aid.

Keywords

Thiamin thiamin deficiency low- and middle-income countries beriberi public health micronutrient malnutrition fortification supplementation

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References

Adamolekun

(2010) Etiology of Konzo, epidemic spastic paraparesis associated with cyanogenic glycosides in cassava: role of thiamine deficiency? Journal of the Neurological Sciences 296: 30–33.

Adamolekun

McCandless

Butterworth

(1997) Epidemic of seasonal ataxia in Nigeria following ingestion of the African silkworm Anaphe venata: role of thiamine deficiency? Metabolic Brain Disease 12: 251–258.

Ahoua

Etienne

Fermon

. (2007) Outbreak of beriberi in a prison in Côte d’Ivoire. Food and Nutrition Bulletin 28: 283–290.

Akerele

(2015) Household food expenditure patterns, food nutrient consumption and nutritional vulnerability in Nigeria: Implications for policy. Ecology of Food and Nutrition 54: 546–571.

Allen

De Benoist

Dary

. (2006) Guidelines on food fortification with micronutrients. World Health Organization, Geneva, Switzerland and the Food and Agriculture Organization of the United Nations, Rome, Italy.

Arnold

(2010) British India and the “beriberi problem”, 1798–1942. Medical History 54: 295–314.

Assantachai

Lekhakula

(2007) Epidemiological survey of vitamin deficiencies in older Thai adults: Implications for national policy planning. Public Health Nutrition 10: 65–70.

Aykroyd

(1932) The effect of parboiling and milling on the antineuritic vitamin (B₁) and phosphate content of rice. Epidemiology & Infection 32: 184–192.

Aykroyd

Jolliffe

Lowry

. (1949) Medical resurvey of nutrition in Newfoundland 1948. The Canadian Medical Association Journal 60: 329–352.

10.

Barennes

Sengkhamyong

René

. (2015) Beriberi (thiamine deficiency) and high infant mortality in northern laos. PLoS Neglected Tropical Diseases 9: e0003581.

11.

Barennes

Simmala

Odermatt

. (2009) Postpartum traditions and nutrition practices among urban Lao women and their infants in Vientiane, Lao PDR. European Journal of Clinical Nutrition 63: 323–331.

12.

Beal

Massiot

Arsenault

. (2017) Global trends in dietary micronutrient supplies and estimated prevalence of inadequate intakes. PloS One 12: e0175554.

13.

Bhat

Rather

Ahangar

. (2017) Shoshin beriberi-thiamine responsive pulmonary hypertension in exclusively breastfed infants: A study from northern India. Indian Heart Journal 69: 24–27.

14.

Butterworth

Gaudreau

Vincelette

. (1991) Thiamine deficiency in AIDS. The Lancet 338: 1086.

15.

Cerroni

Barrado

Nobrega

. (2010) Outbreak of beriberi in an Indian population of the upper Amazon region, Roraima State, Brazil, 2008. The American Journal of Tropical Medicine and Hygiene 83: 1093–1097.

16.

Chen

. (2008) Effects of vitamin A, vitamin A plus iron and multiple micronutrient-fortified seasoning powder on preschool children in a suburb of Chongqing, China. Journal of Nutritional Science and Vitaminology (Tokyo) 54: 440–447.

17.

Chen

Liu

(1984) Studies on beriberi and its prevention. Journal of Applied Nutrition 36: 20–26.

18.

Coats

Frank

Reid

. (2013) Thiamine pharmacokinetics in Cambodian mothers and their breastfed infants. The American Journal of Clinical Nutrition 98: 839–844.

19.

Coats

Shelton-Dodge

. (2012) Thiamine deficiency in Cambodian infants with and without beriberi. The Journal of Pediatrics 161: 843–847.

20.

Combs

Jr McClung

(2016) The vitamins: fundamental aspects in nutrition and health. San Diego: Academic Press.

21.

Darcel

Roussin

Vallat

. (2009) Polyneuropathies par hypovitaminose B1 aux iles de la Reunion et de Mayotte: a propos de 70 cas d’origine mahoraise et comorienne. Bulletin de la Societe de Pathologie Exotique 102: 167.

22.

Darnton-Hill

Nalubola

(2002) Fortification strategies to meet micronutrient needs: Successes and failures. Proceedings of the Nutrition Society 61: 231–241.

23.

De Wardener

Lennox

(1947) Cerebral beriberi (Wernicke’s encephalopathy). Review of 52 cases in a Singapore prisoner-of-war hospital. The Lancet 252: 11–17.

24.

Della Lucia

Rodrigues

. (2016) Diet quality and adequacy of nutrients in preschool children: should rice fortified with micronutrients be included in school meals? Nutrients 8: 296.

25.

Donnino

Andersen

Chase

. (2016) Randomized, double-blind, placebo-controlled trial of thiamine as a metabolic resuscitator in septic shock: a pilot study. Critical Care Medicine 44: 360.

26.

Doung-Ngern

Kesornsukhon

Kanlayanaphotporn

. (2007) Beriberi outbreak among commercial fishermen, Thailand 2005. Southeast Asian Journal of Tropical Medicine and Public Health 38: 130.

27.

Duce

Escriba

Masuet

. (2003) Suspected thiamine deficiency in Angola. Field Exchange 20: 26–28.

28.

Dzed

Dorji

Pelzom

. (2017) Status of Thiamin deficiency in boarding school children from seven districts in Bhutan with previous history of peripheral neuropathy outbreaks: a cohort study. Bhutan Health Journal 1: 49–56.

29.

Eijkman

(1897a) Ein Versuch zur Bekämpfung der Beri-Beri. Archiv für Pathologische Anatomie und Physiologie und für Klinische Medicin 149: 187–194.

30.

Eijkman

(1897b) Eine Beri Beri-Ähnliche Krankheit der Hühner. Archiv für Pathologische Anatomie und Physiologie und für Klinische Medicin 148: 523–532.

31.

Ershoff

(1978) Food fortification in the prevention and treatment of malnutrition in the urban areas of developing countries. Journal of Applied Nutrition 30: 114–126.

32.

Fattal-Valevski

(2011) Thiamine (vitamin B1). Journal of Evidence-Based Integrative Medicine 16: 12–20.

33.

Fattal-Valevski

Bloch-Mimouni

Kivity

. (2009) Epilepsy in children with infantile thiamine deficiency. Neurology 73: 828–833.

34.

Galpin

Thakwalakwa

Phuka

. (2007) Breast milk intake is not reduced more by the introduction of energy dense complementary food than by typical infant porridge. The Journal of Nutrition 137: 1828–1833.

35.

Gibson

Cavalli-Sforza

(2012) Using reference nutrient density goals with food balance sheet data to identify likely micronutrient deficits for fortification planning in countries in the Western Pacific region. Food and Nutrition Bulletin 33: S214–220.

36.

Gollobin

Marcus

(2002) Bariatric beriberi. Obesity Surgery 12: 309–311.

37.

Harper

(2006) Thiamine (vitamin B1) deficiency and associated brain damage is still common throughout the world and prevention is simple and safe! European Journal of Neurology 13: 1078–1082.

38.

Hiffler

Rakotoambinina

Lafferty

. (2016) Thiamine deficiency in tropical pediatrics: new insights into a neglected but vital metabolic challenge. Frontiers in Nutrition 3: 16.

39.

Hlaing

Fahmida

Htet

. (2016) Local food-based complementary feeding recommendations developed by the linear programming approach to improve the intake of problem nutrients among 12–23-month-old Myanmar children. British Journal of Nutrition 116: S16–S26.

40.

Höller

Bakker

Düsterloh

. (2018) Micronutrient status assessment in humans: Current methods of analysis and future trends. TrAC Trends in Analytical Chemistry 102: 110–122.

41.

Holliday

(1986) Body composition and energy needs during growth. In: Falkner

Tanner

, eds. Postnatal Growth Neurobiology. Boston, MA: Springer, Chapter 12.

42.

Hund

Northrop-Clewes

Nazario

. (2013) A novel approach to evaluating the iron and folate status of women of reproductive age in Uzbekistan after 3 years of flour fortification with micronutrients. PloS one 8: e79726.

43.

Institute of Medicine (1998) Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Washington DC: National Academies Press.

44.

Isabelle

Chan

Wijaya

(2011) Report on regulatory status of micronutrient fortification in Southeast Asia. The International Life Sciences Institute, Washington, DC, USA.

45.

Itokawa

(1976) Kanehiro Takaki (1849–1920) A biographical sketch. The Journal of Nutrition 106: 581–588.

46.

Jelliffe

(1956) Infantile beriberi as a public health problem. Journal of Tropical Pediatrics (London, England: 1955) 2: 49–50.

47.

Kauffman

Coats

Seab

. (2011) Thiamine deficiency in ill children. The American Journal of Clinical Nutrition 94: 616–617.

48.

Keating

Nget

Kea

. (2015) Thiamine deficiency in tachypnoeic Cambodian infants. Paediatrics and International Child Health 35: 312–318.

49.

Khampitak

Knowles

Yongvanit

. (2006) Thiamine deficiency and parasitic infection in rural Thai children. The Southeast Asian Journal of Tropical Medicine and public health 37: 441–445

50.

Khounnorath

Chamberlain

Taylor

. (2011) Clinically unapparent infantile thiamin deficiency in Vientiane, Laos. PLoS Neglected Tropical Diseases 5: e969.

51.

Krishna

Taylor

Supanaranond

. (1999) Thiamine deficiency and malaria in adults from southeast Asia. The Lancet 353: 546–549.

52.

Layrisse

Chaves

Mendez

. (1996) Early response to the effect of iron fortification in the Venezuelan population. The American Journal of Clinical Nutrition 64: 903–907.

53.

Hotta

Shi

. (2007) Malnutrition improvement for infants under 18 months old of Dai minority in Luxi, China. Pediatrics International 49: 273–279.

54.

Lima

LFPd

Leite

Taddei

JAdA

(2010) Low blood thiamine concentrations in children upon admission to the intensive care unit: risk factors and prognostic significance. The American Journal of Clinical Nutrition 93: 57–61.

55.

Liu

Zhang

K-n

Riley

(1994) Thiamine deficiency is associated with ethnicity in a subtropical area of China. Asia Pacific Journal of Clinical Nutrition 3: 217–222.

56.

Lonsdale

(2006) A review of the biochemistry, metabolism and clinical benefits of thiamin (e) and its derivatives. Evidence-Based Complementary and Alternative Medicine 3: 49–59.

57.

Lopriore

Guidoum

Briend

. (2004) Spread fortified with vitamins and minerals induces catch-up growth and eradicates severe anemia in stunted refugee children aged 3–6 y. The American Journal of Clinical Nutrition 80: 973–981.

58.

Luxemburger

White

ter Kuile

. (2003) Beri-beri: the major cause of infant mortality in Karen refugees. Transactions of the Royal Society of Tropical Medicine and Hygiene 97: 251–255.

59.

Macias-Matos

Rodriguez-Ojea

Chi

. (1996) Biochemical evidence of thiamine depletion during the Cuban neuropathy epidemic, 1992–1993. The American Journal of Clinical Nutrition 64: 347–353.

60.

Maleta

Kuittinen

Duggan

. (2004) Supplementary feeding of underweight, stunted Malawian children with a ready-to-use food. Journal of Pediatric Gastroenterology and Nutrition 38: 152–158.

61.

Map: Nutrient Levels in Fortification Standards (mid-range or average). Global Fortification Data Exchange. http://www.fortificationdata.org (accessed 19 September 2018).

62.

Mark

Houghton

Gibson

. (2016) Estimating dietary micronutrient supply and the prevalence of inadequate intakes from national Food Balance Sheets in the South Asia regiona. Asia Pacific Journal of Clinical Nutrition 25: 368–376.

63.

Mas

Pelegrino

Guzman

. (1997) Viral isolation from cases of epidemic neuropathy in Cuba. Archives of Pathology & Laboratory Medicine 121: 825.

64.

Mayxay

Taylor

Khanthavong

. (2007) Thiamin deficiency and uncomplicated falciparum malaria in Laos. Tropical Medicine & International Health 12: 363–369.

65.

McGready

Simpson

Cho

. (2001) Postpartum thiamine deficiency in a Karen displaced population. The American Journal of Clinical Nutrition 74: 808–813.

66.

Mimouni-Bloch

Goldberg-Stern

Strausberg

. (2014) Thiamine deficiency in infancy: long-term follow-up. Pediatric Neurology 51: 311–316.

67.

Monekosso

Annan

Ashby

(1964) Therapeutic effect of vitamin B complex on an ataxic syndrome in western Nigeria. Transactions of the Royal Society of Tropical Medicine and Hygiene 58: 432–436.

68.

Mosnier

Niemetzky

Stroot

. (2017) A large outbreak of thiamine deficiency among illegal gold miners in French Guiana. The American Journal of Tropical Medicine and Hygiene 96: 1248–1252.

69.

Nadel

Burger

(1976) Wernicke encephalopathy following prolonged intravenous therapy. JAMA 235: 2403–2405.

70.

Nesamvuni

Vorster

Margetts

. (2005) Fortification of maize meal improved the nutritional status of 1-3-year-old African children. Public Health Nutrition 8: 461–467.

71.

Nilles

Manaia

Ruaia

. (2018) Re-emergence of thiamine deficiency disease in the Pacific islands (2014–15): A case-control study. PloS one, 13: e0198590.

72.

Oelofse

Van Raaij

Benade

. (2003) The effect of a micronutrient-fortified complementary food on micronutrient status, growth and development of 6-to 12-month-old disadvantaged urban South African infants. International Journal of Food Sciences and Nutrition 54: 399–407.

73.

Ogunlesi

(2004) Thiamine deficiency: a cause of childhood ataxia not to be ignored. Annals of Tropical Paediatrics 24: 357–360.

74.

Okeke

Eneobong

Uzuegbunam

. (2009) Nutrient composition of traditional foods and their contribution to energy and nutrient intakes of children and women in rural households in Igbo culture area. Pakistan Journal of Nutrition 8: 304–312.

75.

Osei

Rosenberg

Houser

. (2010) Community-level micronutrient fortification of school lunch meals improved vitamin A, folate, and iron status of schoolchildren in Himalayan villages of India–3. The Journal of Nutrition 140: 1146–1154.

76.

Padilha

Fujimori

Borges

ALV

. (2011) Perfil epidemiológico do beribéri notificado de 2006 a 2008 no Estado do Maranhão, Brasil. Cadernos de Saúde Pública 27: 449–459.

77.

Parker

Mosites

Reider

. (2015) A blinded, cluster-randomized, placebo-controlled school feedingtrial in Burundi using rice fortified with iron, zinc, thiamine, and folic acid. Food and Nutrition Bulletin 36: 481–492.

78.

Porter

Coats

Fischer

. (2014) Thiamine deficiency and cardiac dysfunction in Cambodian infants. The Journal of Pediatrics 164: 1456–1461.

79.

Prinzo

(1999) Thiamine deficiency and its prevention and control in major emergencies. Micronutrient Series. World Health Organization (WHO). Department of Nutrition for Health and Development; Office of the United Nations High Commissioner for Refugees (UNHCR).

80.

Qureshi

Sami

Altaf

. (2016) Thiamine responsive acute life threatening metabolic acidosis in exclusively breast-fed infants. Nutrition 32: 213–216.

81.

Qureshi

Wani

Ahmad

. (2015) Infantile Wernicke’s encephalopathy. Archives of Disease in Childhood 100: 648.

82.

Rao

Chandak

(2010) Cardiac beriberi: often a missed diagnosis. Journal of Tropical Pediatrics 56: 284–285.

83.

Republic of the Union of Myanmar Ministry of Health and UNICEF (2014) Study on cause of under-five mortality. https://www.unicef.org/myanmar/COD_body.pdf.

84.

Reuler

Girard

Cooney

(1985) Wernicke’s encephalopathy. New England Journal of Medicine 312: 1035–1039.

85.

Rolfe

Walker

Samba

. (1993) Urban beri-beri in the Gambia, West Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene 87: 114–115.

86.

Ruel

Menon

Habicht

J-P

. (2008) Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial. The Lancet 371: 588–595.

87.

Saya

Baikunje

Prakash

. (2012) Clinical correlates and outcome of shoshin beriberi. North American Journal of Medical Sciences 4: 503.

88.

Sechi

Serra

(2007) Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. The Lancet Neurology 6: 442–455.

89.

Soukaloun

Kounnavong

Pengdy

. (2003) Dietary and socio-economic factors associated with beriberi in breastfed Lao infants. Annals of Tropical Paediatrics: International Child Health 23: 181–186.

90.

Soukaloun

Lee

Chamberlain

. (2011) Erythrocyte transketolase activity, markers of cardiac dysfunction and the diagnosis of infantile beriberi. PLoS Neglected Tropical Diseases 22: e971.

91.

Stevens

Araru

Dragudi

(2001) Outbreak of micronutrient deficiency disease: did we respond appropriately? Field Exchange 15–17.

92.

Stuetz

Carrara

McGready

. (2012) Micronutrient status in lactating mothers before and after introduction of fortified flour: cross-sectional surveys in Maela refugee camp. European Journal of Nutrition 51: 425–434.

93.

Tallaksen

Sande

Bøhmer

. (1993) Kinetics of thiamin and thiamin phosphate esters in human blood, plasma and urine after 50 mg intravenously or orally. European Journal of Clinical Pharmacology 44: 73–78.

94.

Tazhibayev

Dolmatova

Ganiyeva

. (2008) Evaluation of the potential effectiveness of wheat flour and salt fortification programs in five Central Asian countries and Mongolia, 2002–2007. Food and Nutrition Bulletin 29: 255–265.

95.

Team

CNFI

(1995) Epidemic optic neuropathy in Cuba—clinical characterization and risk factors. New England Journal of Medicine 333: 1176–1182.

96.

Thanangkul

Whitaker

(1966) Childhood thiamine deficiency in northern Thailand. American Journal of Clinical Nutrition 18: 275–277.

97.

Thankachan

Rah

Thomas

. (2012) Multiple micronutrient-fortified rice affects physical performance and plasma vitamin B-12 and homocysteine concentrations of Indian school children–4. The Journal of Nutrition 142: 846–852.

98.

US Department of Agriculture (USDA), Agricultural Research Service, Nutrient Data Laboratory. USDA National Nutrient Database for Standard Reference, Legacy. Version Current: April 2018. Internet: http://www.ars.usda.gov/nutrientdata

99.

Upadhyay

(1998) Persistent micronutrient problems among refugees in Nepal. Field Exchange 5: 4–5.

100.

Vedder

(1938) The pathology of beriberi. Journal of the American Medical Association 110: 893–896.

101.

Vimokesant

Kunjara

Rungruangsak

. (1982) Beriberi caused by antithiamin factors in food and its prevention. Annals of the New York Academy of Sciences 378: 123–136.

102.

Vimokesant

Nakornchai

Rungruangsak

. (1976) Food habits causing thiamine deficiency in humans. Journal of Nutritional Science and Vitaminology (Tokyo) 22: 1–2.

103.

Wani

Qureshi

Ahmad

. (2016a) Cranial ultrasonography in infantile encephalitic beriberi: A useful first-line imaging tool for screening and diagnosis in suspected cases. American Journal of Neuroradiology 37: 1535–1540.

104.

Wani

Qureshi

Jehangir

. (2016b) Infantile encephalitic beriberi: magnetic resonance imaging findings. Pediatric Radiology 46: 96–103.

105.

Watson

El Bushra

Lebo

. (2011) Outbreak of beriberi among African Union troops in Mogadishu, Somalia. PloS One 6: e28345.

106.

Whitfield

Bourassa

Adamolekun

. (2018) Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs. Annals of the New York Academy of Sciences 1430: 3–43.

107.

Whitfield

Karakochuk

Kroeun

. (2016) Perinatal Consumption of Thiamine-Fortified Fish Sauce in Rural Cambodia: A Randomized Clinical Trial. JAMA Pediatrics: e162065–e162065.

108.

Whitfield

Karakochuk

Kroeun

. (2017a) Household consumption of thiamin-fortified fish sauce increases erythrocyte thiamin concentrations among rural Cambodian women and their children younger than 5 years of age: a randomized controlled efficacy trial. The Journal of Pediatrics 181: 242–247. e242.

109.

Whitfield

Karakochuk

Liu

. (2015) Poor thiamin and riboflavin status is common among women of childbearing age in rural and urban Cambodia. The Journal of Nutrition 145: 628–633.

110.

Whitfield

Smith

Chamnan

. (2017b) High prevalence of thiamine (vitamin B1) deficiency in early childhood among a nationally representative sample of Cambodian women of childbearing age and their children. PLoS Neglected Tropical Diseases 11: e0005814.