DOI: https://doi.org/10.

2298/SARH210929019B
UDC: 616.356:577.164.1 233

REVIEW ARTICLE / ПРЕГЛЕД ЛИТЕРАТУРЕ

Vitamin B1, eye and brain

Marija M. Božić1,2, Marija Milenković1,3, Dragan M. Pavlović4, Miroslav Stamenković4,5,
Aleksandra M. Pavlović1,6
1
University of Belgrade, Faculty of Medicine, Belgrade, Serbia;
2
University Clinical Center of Serbia, University Eye Hospital, Belgrade, Serbia;
3
University Clinical Center of Serbia, Emergency Center, Department for Anesthesiology, Belgrade, Serbia;
4
University of Belgrade, Faculty for Special Education and Rehabilitation, Belgrade, Serbia;
5
Zvezdara University Clinical Centre, Belgrade, Serbia;
6
University Clinical Center of Serbia, Neurology Clinic, Belgrade, Serbia

SUMMARY
Vitamin B1 (aneurin, thiamine) is a water-soluble vitamin necessary for the normal function of the nervous
system, visual system and heart and is part of important enzymes in the body. Thiamine enables the nor-
mal use of glucose, other carbohydrates and proteins, and enables the supply of energy to the organism.
The main sources of thiamine are exogenous and small amounts are synthesized by microorganisms of
the human intestinal microbiome.
Vitamin B1 cannot accumulate in the body, so signs of deficiency are quickly manifested. Hypovitaminosis
B1 is seen in chronic ethyl abuse, persistent vomiting (as in some pregnant women) or after bariatric
surgical procedures, but in a mild form it is present in the general population.
Normal daily needs for vitamin B1 depend on calorie intake, and 0.4 mg should be ingested for every
1000 kcal.
Keywords: vitamin B1; eye, brain

INTRODUCTION PHYSIOLOGY

Although importance of vitamins for visual Vitamin B1 is necessary for normal function
function is well known, the importance of all of the nervous system, visual system and heart,
of them is not yet elucidated [1]. Vitamin B1 and is part of important enzymes in the body.
(aneurin, thiamine) is a water-soluble vitamin Thiamine enables the normal use of glucose,
that is crucial for glucose metabolism and is other carbohydrates and proteins, and en-
necessary for normal growth and development ables the supply of energy to the organism.
of the organism. Thiamine is essential for func- Thiamine-dependent enzymes use thiamine
tioning of both central and peripheral nervous diphosphate (ThDP) as a coenzyme. These
systems, visual, digestive and cardiovascular enzymes are also called ThDP-dependent en-
systems [2]. zymes. Other thiamine derivatives are thiamine
The main sources of thiamine are exog- triphosphate and thiamine adenylate, which
enous, with food, and small amounts are syn- participate in homeostasis that is the non-en-
thesized by microorganisms of the human zymatic activity of vitamin B1 [6].
intestinal microbiome [3]. Most thiamine is
found naturally in pork and other meats, germ
grains, liver, eggs, fish, beans, peas, nuts and DEFICIENCY
whole grains. The recommended daily intake
is 0.4 mg per 1000 kcal. Significant amounts Historically, hypovitaminosis B1 – beriberi,
of vitamin B1 are lost during heat treatment was first described in Japan, several centuries Received • Примљено:
September 29, 2021
of food. The polyphenols in coffee and tea can ago, and in the 19th century, Wernicke’s en-
Revised • Ревизија:
inactivate thiamine. The recommended daily cephalopathy and Korsakoff ’s syndrome [3]. January 24, 2022
intake of thiamine is 2 mg [2]. Even today, B1 hypovitaminosis is more com- Accepted • Прихваћено:
Vitamin B1 cannot accumulate in the body, mon than previously thought, primarily due to February 3, 2022
so signs of deficiency are quickly manifested the discrepancy between high intake of pure Online first: February 10, 2022
[2]. Thiamine stores in the body are only calories and low intake of vitamins, with the
about 30 mg, with a half-life of 10–18 days [4]. situation being exacerbated by the fact that
Hypovitaminosis B1 is seen in chronic ethyl this vitamin deficiency is a major imitator [7].
abuse, persistent vomiting (as in some pregnant The modern way of eating “fast” food favors Correspondence to:
women) or after bariatric surgical procedures, the development of the withdrawal period of Marija M. BOŽIĆ
but in a mild form it is present in the general vitamin B1. The aggravating factor is the lack Pasterova 2
Belgrade
population [5]. of pathognomonic signs and reliable laboratory Serbia
diagnostics. A study conducted by Williams in ammilovic@gmail.com
234 Božić M. M. et al.

the United States in 1943 showed a significant prevalence (“socks” and “gloves” type) and the vibrational sensibility
of vitamin B1 deficiency in the general population [8]. also suffer. When the process spreads to shorter fibers,
The most commonly affected systems in thiamine defi- the abdomen is also affected, with a vague border of loss.
ciency are the heart, blood vessels, nervous system, eyes, and Paresthesia also occurs. Later, the fibers for pain are also
gastrointestinal system [9]. Periventricular gray matter neu- affected. Loss of sensibility is in most cases symmetrical,
rons are particularly sensitive to thiamine deficiency [10]. but the dominant extremities are usually affected first.
Damage to the nuclei of the vestibular and abducens nerves Nystagmus and decreased visual acuity may be ob-
may precede B1 encephalopathy with mild ophthalmopare- served in the eyes, followed by narrowing of the visual
sis and bilateral vestibular damage. Aneurin deficiency leads field. Eventually, optic neuritis may develop with papil-
to pseudohypoxia at the cellular level, and later to dysau- lary edema and then temporal pallor, similar to multiple
tonomy in various tissues [7]. In deficiency states, lactates, sclerosis [3, 14]. Blurred vision and blindness are possible
pyruvate and other substances increase. Thiamine deficiency with severe neuropathy.
disrupts the function of nitric oxide which is an important Patients experience stomach pain and constipation, and
transmitter, especially in the vascular system. Vitamin B1 in more severe forms anorexia, thirst, nausea and vomit-
deficiency has been found to correlate with degeneration ing [15]. There is a disorder in the secretion of the saliva,
of ganglion cells of the brain and spinal cord and reduced gastric, and intestinal juices, usually a decrease, due to dys-
retinal ganglion cell layer thickness in animal models [11]. autonomia. Lymphocytosis, neutropenia and eosinophilia
can be seen in the blood count. Erythrocyte sedimentation
Beriberi rate is also often elevated. In advanced cases, normoblasts
are seen in the peripheral blood.
Vitamin B1 deficiency causes beriberi with: weight loss,
emotional disorders, changes in perception, weakness of Wernicke/Korsakoff syndrome
the extremities, irregular heartbeat and tissue edema. Heart
failure can be fatal. No sign of beriberi is pathognomonic, Wernicke’s encephalopathy and Korsakoff ’s dementia/psy-
and the clinical picture is very variable [7]. There is a divi- chosis are often interrelated phenomena caused by vitamin
sion into dry beriberi (neurological) where polyneuropa- B1 deficiency. Both disorders require urgent treatment,
thy predominates and wet beriberi (cardiological) where but the diagnosis is often made late or not at all. Autopsy
cardiomyopathy with peripheral edema predominates, shows pathological findings characteristic of these diseases
although they are often associated [9]. Disorders of the significantly more common than is the prevalence in both
gastrointestinal system are also present. the general population and the ethyl abuse individuals [16].
Beriberi was first described in Japan in people who used Korsakoff ’s psychosis is a severe acute dementia with the
glazed rice. Thus, food contained high levels of calories impossibility of remembering new information, that is,
with a lack of other essential nutrients called high-calorie anterograde amnesia and confabulations and is difficult
malnutrition [12]. Today, high-calorie malnutrition is not to treat [9].
uncommon in the West in obese people, where thiamine Wernicke’s encephalopathy manifests itself as global con-
deficiency is present in as many as 15–29% of people with fusion, oculomotor disorder (nystagmus, ophthalmoplegia)
mild and nonspecific symptoms [13]. Beriberi can be di- and gait ataxia, which is a classic triad that is seen in only
vided into alcohol-induced and non-alcoholic. At risk are 16–20% of cases, so the diagnosis is often wrong [16]. It is
people who use diuretics, e.g., furosemide that enhance especially difficult to diagnose Wernicke’s encephalopathy
vitamin B1 secretion [4]. during a drunken state, other causes of confusion, the use of
As a rule, patients with beriberi are pale. Slightly elevat- benzodiazepines, sepsis, hypoxia, hepatic encephalopathy,
ed body temperature is due to dysautonomia. At the begin- delirium tremens and head injuries. Untreated Wernicke’s
ning of the disease, palpitations can occur in exertion or encephalopathy is fatal in about 20% of cases [17].
stress, while later they might also occur at rest [7]. Edema Wernicke’s encephalopathy and/or Korsakoff ’s demen-
may only be mild pretibial with sensitivity to palpation. tia most often occur in chronic alcoholics, followed by a
The heart is enlarged, especially the right side. Diastolic decreasing incidence in cancer, gastrointestinal surgery,
pressure is below 60 mm/Hg, and sometimes even drops Hyperemesis gravidarum, starvation, fasting, gastrointesti-
to zero, especially in children. nal diseases, AIDS, resorption disorders, dialysis and kid-
Oxygen saturation becomes low in arterial and high ney disease, parenteral nutrition, vomiting, psychiatric dis-
in venous blood, which indicates the role of thiamine in eases with eating disorders and schizophrenia, infections,
oxygen transport. In the initial stages, the vagal tone is in- intoxication, thyroid disorders, iatrogenic, poor nutrition,
creased, and in the advanced stages, the sympathetic tone. hypoxic encephalopathy, diarrhea, magnesium deficiency,
Thus, bradycardia can sometimes be found, and sometimes some congenital conditions and other [16].
tachycardia. Changes in the electrocardiogram are seen
only in the later stages. Marginal thiamine deficiency
The neurological findings are dominated by signs of
damage to peripheral nerves, autonomic, sensory and mo- Mild forms of thiamine deficiency are common because
tor neuropathy [9]. Initially the loss of superficial sensibil- depos are scarce (liver, muscle) and can occur as early as
ity for touch can be found due to damage to long fibers 2–3 weeks after thiamine-deficient nutrition [9]. Alcohol,

DOI: https://doi.org/10.2298/SARH210929019B Srp Arh Celok Lek. 2022 Mar-Apr;150(3-4):233-237

Vitamin B1, eye and brain 235

tea and coffee lower thiamine levels as well as higher vibrational sensitivity is improved. Usually, 150 mg twice
amounts of carbohydrates. Also at risk are people with a day or 300 mg twice a day of benfotiamine is given with
increased thiamine needs such as pregnant and lactating food. In some cases of Korsakoff ’s psychosis, long-term
women, people exposed to heavy physical exertion, people administration of benfotiamine is required with gradual
with cancer, liver, infections and hyperthyroidism, patients reduction of doses to maintenance doses with excellent
undergoing surgical procedures, as well as thiamine re- results. Benfotiamine can be given up to 600 mg daily.
sorption disorders (excess alcohol intake, gastrointestinal
diseases, vomiting, diarrhea). Sulbutiamine
Thiamine deficiency can manifest as anorexia, malaise,
burning in the extremities distally, irritability and depres- Another synthetic derivate of vitamin B1, with beneficial
sion, while later, after 2–3 months, insomnia, cough, emo- effects in treatment of Alzheimer’s disease. Sulbutiamine
tional lability, panic attacks, pain in the joints, muscles or enhances cholinergic and glutamanergic transmis-
extremities may occur. It also increased need for sugar, sion, mainly by hippocampus and prefrontal cortex.
gastro-esophageal reflux, abdominal pain with constipa- Sulbutiamine has proven neuroprotective effect on reti-
tion and diarrhea, daily headaches or migraines, edema of nal ganglion cells [25]. This is a highly lipid soluble syn-
the nasal mucosa, dyspnea, polyneuropathy with numb- thetic analogue of vitamin B1, clinically used for asthenia
ness, paresthesia, cold extremities, palpitations, also chest treatment. When tested on retinal ganglion cells in vitro,
pain, intolerance to ambient temperature as well as recur- it showed effects of preventing trophic factor induced
rent nausea and vomiting [9, 7]. apoptotic cell death. Sulbutiamine is lipophilic and easily
Chronic vitamin B1 deficiency significantly contrib- crosses the brain blood barrier. Numerous studies showed
utes to the development of neurodegenerative diseases that this agent stimulates reticular activating system, po-
[2]. Thiamine is associated with Alzheimer’s disease, tentiates cholinergic activity in hippocampus and glutama-
Parkinson’s disease, Huntington’s disease, and Wernicke- tergic activity in the prefrontal cortex [26, 27].
Korsakoff syndrome. Thiamine administration not only
has a neuroprotective effect but also has a beneficial effect Diagnosis of vitamin B1 deficiency
even in advanced neurodegenerative diseases.
Thiamine deficiency in children should be suspected in The diagnosis of vitamin B1 deficiency requires, above
a whole range of non-specific symptoms such as: emotions, all, a high degree of suspicion of these disorders in all
behavior and attention disorders, learning disabilities, red- increased risk conditions because the clinical picture is
ness of the cheeks, pale eyes, blood pressure disorders, highly variable [28]. A detailed anamnesis regarding the
muscle reflex disorders, dermographism and others [7]. consumption of food, alcohol, vomiting, digestion, etc.,
is also necessary, as well as a careful clinical examination.
Benfotiamine Vitamin B1 testing is based on measuring concentrations:
thiamine pyrophosphate or transketolase (thiamine-de-
Benfotiamine is a synthetic vitamin B1 that is liposoluble pendent enzyme) activity in erythrocytes [5].
and passes many times better into the brain and periph- Well-documented cases of Wernicke’s encephalopathy
eral nerves, which makes it suitable in the treatment of with normal or even elevated thiamine levels have also
nervous diseases [18]. Comparative studies have shown been described [28]. This is probably due to the discrep-
that lipophilic thiamine derivatives are significantly better ancy of levels in serum and tissues, as is the case with
resorbed than hydrophilic thiamine [19]. Benfotiamine is vitamin B12 and magnesium [7, 9, 29]. Normal serum
a liposoluble precursor of thiamine that can be converted thiamine values are 70–180 nmol/L, and deficits indicate
to thiamine in tissues and then metabolized to thiamine values less than 70 nmol/L.
monophosphate and thiamine diphosphate [20].
The effects of benfotiamine are mild inhibition of cho-
linesterase, reduction of amyloid plaque production and THERAPY
hyperphosphorylated tau [21, 22]. It also accelerates the
recovery of peripheral nerves after various injuries. In an Normal daily needs for vitamin B1 depend on calorie in-
animal model, administration of benfotiamine improved take: 0.4 mg should be ingested for every 1000 kcal [9].
spatial memory in a dose-dependent manner and reduced This would mean e.g., that an adult man who ingests 3200
in Alzheimer’s disease model both amyloid beta plaques kcal per day should take 1.3 mg of thiamine per day, and a
and hyperphosphorylated tau levels, with other forms woman who ingests 2300 kcal to take 0.9 mg of thiamine.
of thiamine not being effective. Long-term use of ben- Slightly different is the recommendation of the National
fotiamine in a small study in patients with Alzheimer’s Research Council from the United States, which states the
disease improved cognitive status [23]. required intake of 0.5 mg per 1000 kcal, with the proviso
Benfotiamine has been used successfully in diabetic that the daily intake should not be less than 1.0 mg regard-
polyneuropathy [24]. The greatest effect was achieved after less of calorie intake.
3–6 weeks of administration with large doses of benfo- National Research Council states that due to the addi-
tiamine of 320 mg/day, but smaller doses were also effec- tional caloric needs of the fetus, pregnant women should
tive (150 mg/day). The feeling of pain is reduced and the take an additional 0.4 mg per day of thiamine at the

Srp Arh Celok Lek. 2022 Mar-Apr;150(3-4):233-237 www.srpskiarhiv.rs

236 Božić M. M. et al.

appropriate daily intake, and during lactation, the infant slowly intravenously, then daily 10 mg intramuscularly
needs another 0.5 mg per day for their own needs [30, 31]. for one week and then 3–5 mg daily orally for at least six
Infants should take 0.17 mg of thiamine daily. The recom- weeks [9].
mendation of the World Health Organization (WHO) is
0.3 mg/L or 0.4 mg/1000 kcal. Children and adolescents
have the same needs as adults, i.e., 0.4 mg / 1000 kcal and SAFETY
0.5 mg/1000 kcal [31].
Excess thiamine is excreted by the kidneys [9]. Isolated
cases of adverse reactions have been reported with intra-
THERAPEUTIC APPLICATION venous administration in doses of 5–100 mg, and very
rarely an allergic reaction may occur with extremely high
Thiamine has been used in patients with: anxiety disorders, oral doses of 5–10 g [32]. Also, it has been proven that
chronic fatigue, sleep disorders, anorexia, nausea, indiges- long term use of thiamine supplements (along with other
tion, chest and abdominal pain, depression, aggression, B group vitamins and vitamin A) is associated with re-
headaches, etc. Some studies have shown a beneficial effect duced prevalence of nuclear and cortical cataract [33, 34].
of vitamin B1 in people with neurodegenerative diseases In this study a supplement user was defined as a subject
[6]. The benefit of thiamine therapy in Wernicke-Korsakoff who consumed vitamin supplements for at least four days
syndrome, beriberi and other deficiencies is unequivo- per week, with variable dosage 0.8–1 mg/day.
cal. Prompt thiamine replacement is necessary to prevent
irreversible changes [16]. Due to urgency, vitamin B1 is
usually applied empirically, especially since the level of CONCLUSION
B1 in the blood is not a reliable measure of deficiency.
Benfotiamine is also used. Thiamine, or Vitamin B1, is an essential nutrient with
There are no generally accepted guidelines for the use many health benefits, especially protecting the brain and
of thiamine. There are schemes with the administration heart [33, 34, 35]. Time will tell whether vitamin supple-
of thiamine for prophylactic purposes in persons at risk mentation, especially thiamine, has an impact on winning
with 100 mg intramuscularly three times a day for 3–5 days the covid pandemic [36]. This is an opportunity for medi-
or 250 mg intramuscularly for 3–5 days, as well as many cal workers and ordinary people, to be reminded of its im-
other schemes [16]. In the case of diagnosed Wernicke and/ portance, natural sources and possible supplementation.
or Korsakoff syndrome, thiamine is administered intrave-
nously in doses of 100–500 mg for at least five days, and
then in smaller doses, e.g., 250 mg intramuscularly until im- ACKNOWLEDGMENT
provement occurs. Prolonged oral administration is usually
required to achieve better effects. Giving doses of ≥ 500 mg This article is partially financed by the Ministry of Science,
intravenously daily is safe [31]. According to recommenda- Republic of Serbia, Project No. 175033 and 175022.
tions, in mild deficits, 100 mg should be given orally daily.
In children with vitamin B1 deficiency and heart failure,
convulsions or coma, 25–50 mg of thiamine is given very Conflict of interest: None declared.

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Витамин B1, око и мозак

Марија М. Божић1,2, Марија Миленковић1,3, Драган М. Павловић4, Мирослав Стаменковић4,5, Александра М. Павловић1,6
1
Универзитет у Београду, Медицински факултет, Београд, Србија;
2
Универзитетски клинички центар Србије, Клиника за очне болести, Београд, Србија;
3
Универзитетски клинички центар Србије, Ургентни центар, Центар за анестезију, Београд, Србија;
4
Универзитет у Београду, Факултет за специјалну едукацију и рехабилитацију, Београд, Србија;
5
Клиничко-болнички центар Звездара, Београд, Србија;
6
Универзитетски клинички центар Србије, Клиника за неурологију, Београд, Србија
САЖЕТАК код хроничне злоупотребе алкохола, упорног повраћања
Витамин B1 (анеурин, тиамин) растворљив је у води, неопхо- (као код неких трудница) или после баријатријских хирур-
дан је за нормално функционисање нервног система, органа шких процедура, али у благом облику је присутна и у општој
вида и срца и део је важних ензима у телу. Тиамин омогућава популацији.
нормалну употребу глукозе, других угљених хидрата и про- Нормалне дневне потребе за витамином B1 зависе од уноса
теина и снабдевање организма енергијом. калорија, па на сваких 1000 kcal треба унетити 0,4 mg овог
Главни извори тиамина су егзогени и мале количине синте- витамина.
тишу микроорганизми људског цревног микробиома.
Витамин B1 се не може накупљати у телу, па се знакови не-
достатка брзо манифестују. Хиповитаминоза B1 се опажа Кључне речи: витамин B1; око; мозак

Srp Arh Celok Lek. 2022 Mar-Apr;150(3-4):233-237 www.srpskiarhiv.rs