J. Nutr. Sci. Vitaminol., 22 (Suppl)., 29-32, 1976
EARLY
SIGNS
OF
THIAMINE
DEFICIENCY
J. C. Somogyi Institute for Nutrition Research, Ruschlikon-Zurich, Switzerland
While thiamine deficiency in industrialized countries is rather rare, slight deficiencies with subclinical symptoms in certain groups of the population can still be observed. Since these minor vitamin deficiencies show no or only very slight symptoms their diagnosis was for a long time rather difficult. Mainly in the last 10 years biochemical tests were developed, some of which are useful in the detection of early signs of thiamine deficiency. The determination of blood pyruvate concen tration may be not practicable to detect marginal deficiencies of thiamine, since blood pyruvate levels are influenced by many factors and the assay is not sensitive and accurate enough as it follows from several investigations, e.g., Buckle (1,2). As a useful method for measurement of thiamine status the estimation of thiamine in the urine was proposed by several authors. A close relation between the development of thiamine deficiency and decreasing urinary ex cretion of thiamine per g creatinine has been established. Also the surveys conducted in 18 countries by the Interdepartmental Com mittee on Nutrition for National Defense (ICNND) show a close correlation between thiamine intake and urinary excretion of thiamine (Fig. 1). While Bamji (3) found no correlation be tween urinary excretion and red blood cell transketolase activity in a cross sectional survey of 65 Indian volunteers, according to Sauber lich (4) and other authors (e.g., ICNND (5)), a statistically significant relationship exists between the TPP effect and the thiamine content of urine (Fig. 2). This finding was recently confirmed by investigations of Bru bacher et al. (6) with 45 Swiss students.
Fig.
1.
Relationship
between
thiamine
intake
and
thiamine urinary excretion in adults as observed in nutrition surveys conducted in 18 countries.
Fig. 2. Relationship of erythrocyte transketolase ac tivity to urinary excretion of thiamine in adult male subjects during controlled intakes of thiamine. Another possibility for the detection thiamine deficiency in its early stage would
of be
the
of
measurement
of the thiamine
content
30
J. C. SOMOGYI
blood, mainly by microbiological assay. The limitations of this procedure and its possible application in relation with the determination of the transketolase activity and the TPP effect respectively will be discussed in con nection with our experiments. It was supposed that the assay of red blood cell transketolase activity per se is a sensitive measure of the thiamine status in man as well as in experimental animals and very slight deficiency states can be detected by this method. Further investigations, however, have shown that the in vitro TPP effect, i.e., the extent of the increase of transketolase activity after in vitro addition of thiamine pyrophosphate to the hemolized blood, gives better information. In many cases this may be true, but as our experiments have shown the determination of the TPP effect before and after oral thiamine administration is a more specific test. In the following I shall summarize our investigations with chronic alcoholics, healthy persons and former alcoholics which show the advantages of the proposed method in the detection of thiamine deficiencies. As it is known chronic alcoholism causes vitamin deficiencies. The main reasons for these deficiencies are the following: a) reduced food intake, b) decreased intestinal absorption, c) reduced storage capacity. The principal storage place of vitamins is the liver, the organ which is mostly affected in chronic alcoholics. d) Also the conversion of vitamins into their metabolically active forms-and this may be the most important point-is markedly reduced, e.g., it is known that the formation of thiamine pyrophosphate is decreased. No doubt, thiamine deficiency is the most common and probably the most important vitamin deficiency seen in chronic alcoholics. Several investigations have been carried out on the changes of the thiamine status of alcoholics. These are partly contradictory mainly because of the diversity of the methods employed. As an example may I mention the determination of the transketolase activity in the blood. We determined the changes of transketolase
activity before and after oral administration of thiamine to alcoholics, former alcoholics and healthy persons. The dose of vitamin Pl was varied and the smallest quantity causing a decrease of the TPP erect was used. The investigations were carried out with 51 chronic alcoholics, with 52 healthy persons, inmates of the State Prison of Canton, Zurich, and with 30 former alcoholics. The first group of chronic alcoholics consisted of free living persons (14), the second group of inhabitants of a so-called open home (11), and the third group of patients of the Psychiatric Clinic of the University of Zurich (26) (Somogyi and Kopp (7)). For the determination of the transketolase activity, a modified version of the method by Schouten et al. (8), was used. In the greater part of our experiments the thiamine content of blood was determined microbiologically with the method of Sarett and Cheldelin (9). Oral administration of 10mg thiamine daily during 7 days did not cause any decrease of the TPP effect in chronic alcoholics and 20mg did so only in a few cases. A reduction of the TPP effect has been observed only after increas ing the dose at least to 50mg thiamine per day and person (Table 1). The mean value of Table 1. Thiaminestatus of alcoholicsbefore and after thiamineadministration (freelivingpersons).
the TPP effect is high. After oral admini stration of 50mg thiamine during 14 days a marked decrease of the TPP effect occurred. After a further 7 days the initial values were nearly reached again. Similar results have second
group,
been achieved
inhabitants
of an
with
open
the
home
THIAMINE
Table 2. Thiamine status of alcoholics before and after thiamine administration (inhabitants of an open home).
Table 3. Thiamine status of alcoholics before and after thiamine administration (patients of a psychiatric clinic).
SYMPOSIUM
31
(Table 3). As we mentioned previously the thiamine content of the blood was determined micro biologically and the results of these assays have been compared with the TPP effect of the same person. A typical experiment is shown in Fig. 3. The correlation is very good: an increase of the thiamine content of blood runs parallel with a reduction of the TPP effect. However, in many cases the changes of the thiamine content of blood are smaller than those of the TPP effect. The increase of the transketolase activity Table
4.
Thiamine
status
and after thiamine
of healthy
persons
before
administration.
Fig. 3. Changesof the TPP effectand thiaminecon tent in the blood of alcoholicsbefore and after thiamineadministration. Fig.
(Table 2) and with the third one, patients of the Psychiatric Clinic of the University of Zurich
4.
Changes
of the TPP effect
tent in the blood of healthy after thiamine administration.
and thiamine persons
before
con and
32
J. C. SOMOGYI
after in vitro addition of TPP in healthy persons is lower than in alcoholics. Doses of 10mg thiamine per person and day given during 7 days and 14 days respectively caused a marked reduction (Table 4). A good relation ship occurred in most cases between thiamine content of the blood and the TPP effect in healthy persons (Fig. 4). We were further interested to find out whether there are any changes in these para meters of former alcoholics who had abstained from drinking alcohol for at least 4-10 months. The average TPP effect in this group shows an increase of 15%, a borderline case of a bio Table5. Thiaminestatusof formeralcoholicsbefore and after thiamineadministration.
chemical vitamin B1 deficiency state-a value which we found also with healthy persons however similarly to healthy persons the TPP effect could be reduced by oral administration of 10mg thiamine daily during 14 days(Table 5) Also in this case a good correlation between the vitamin B1 content of the blood and the TPP effect has been observed (Fig. 5). From this part of our investigation follows that the thiamine status of former alcoholics has improved in a short time. This result is surprising since there were chronic alcoholics amongst the investigated persons of whom certain damages, e.g., of the intestinal mucosa or liver cannot be excluded. We can conclude that the TPP effect in chronic alcoholics was high in about 80% of the investigated cases. A significant decrease of the TPP effect could be achieved only with doses of 50 mg thiamine or more given orally during 7-14 days. This finding was confirmed by an Australian group (Penington (10)). In contrast to this the TPP effect in healthy persons and former alcoholics was lower and already 10mg thiamine per person and day caused a reduction of the TPP effect. The described method allows a more reliable and accurate assessment of thiamine status and early detection of thiamine deficiency than former procedures. REFERENCES 1) 2) 3) 4) 5) 6) 7) 8)
Fig.
5.
Changes
of
the
TPP
effect
content in the blood of former and after thiamine administration.
and
alcoholics
thiamine
9)
before
10)
Buckle,R. M., Clin.Sc., 25, 207(1963). Buckle,R. M., Metabolism,15, 141(1965). Bamji,M. S., Am.J. Clin.Nutr., 23, 52 (1972). Sauberlich,H. E., Am. J. Clin. Nutr., 20, 528 (1967). Sauberlich,H. E., Dowdy,R. P., and Skala,J. H., Grit.Rev. Clin.Lab. Sc., 236(1973). Brubacher,G., Haenel,A., and Ritzel,G., Int. Z. Vitamin-Nahrungsforsch., 42,190 (1972). Somogyi,J. C. and Kopp, P. M., Proc. 9th Int. Congr. Nutrition, Mexico 1972, Vol. 1, p. 212 (1975). Schouten,H., van Eps,L. W., andBoudier,A. M., Clin.Chim.Acta, 10, 474(1964). Sarett,H. P. and Cheldelin,V.H., J Biol.Chem., 155, 153(1944). Penington,D. G.,personalcommunication (1972).
EARLY
SIGNS
OF
THIAMINE
DEFICIENCY
J. C. Somogyi Institute for Nutrition Research, Ruschlikon-Zurich, Switzerland
While thiamine deficiency in industrialized countries is rather rare, slight deficiencies with subclinical symptoms in certain groups of the population can still be observed. Since these minor vitamin deficiencies show no or only very slight symptoms their diagnosis was for a long time rather difficult. Mainly in the last 10 years biochemical tests were developed, some of which are useful in the detection of early signs of thiamine deficiency. The determination of blood pyruvate concen tration may be not practicable to detect marginal deficiencies of thiamine, since blood pyruvate levels are influenced by many factors and the assay is not sensitive and accurate enough as it follows from several investigations, e.g., Buckle (1,2). As a useful method for measurement of thiamine status the estimation of thiamine in the urine was proposed by several authors. A close relation between the development of thiamine deficiency and decreasing urinary ex cretion of thiamine per g creatinine has been established. Also the surveys conducted in 18 countries by the Interdepartmental Com mittee on Nutrition for National Defense (ICNND) show a close correlation between thiamine intake and urinary excretion of thiamine (Fig. 1). While Bamji (3) found no correlation be tween urinary excretion and red blood cell transketolase activity in a cross sectional survey of 65 Indian volunteers, according to Sauber lich (4) and other authors (e.g., ICNND (5)), a statistically significant relationship exists between the TPP effect and the thiamine content of urine (Fig. 2). This finding was recently confirmed by investigations of Bru bacher et al. (6) with 45 Swiss students.
Fig.
1.
Relationship
between
thiamine
intake
and
thiamine urinary excretion in adults as observed in nutrition surveys conducted in 18 countries.
Fig. 2. Relationship of erythrocyte transketolase ac tivity to urinary excretion of thiamine in adult male subjects during controlled intakes of thiamine. Another possibility for the detection thiamine deficiency in its early stage would
of be
the
of
measurement
of the thiamine
content
30
J. C. SOMOGYI
blood, mainly by microbiological assay. The limitations of this procedure and its possible application in relation with the determination of the transketolase activity and the TPP effect respectively will be discussed in con nection with our experiments. It was supposed that the assay of red blood cell transketolase activity per se is a sensitive measure of the thiamine status in man as well as in experimental animals and very slight deficiency states can be detected by this method. Further investigations, however, have shown that the in vitro TPP effect, i.e., the extent of the increase of transketolase activity after in vitro addition of thiamine pyrophosphate to the hemolized blood, gives better information. In many cases this may be true, but as our experiments have shown the determination of the TPP effect before and after oral thiamine administration is a more specific test. In the following I shall summarize our investigations with chronic alcoholics, healthy persons and former alcoholics which show the advantages of the proposed method in the detection of thiamine deficiencies. As it is known chronic alcoholism causes vitamin deficiencies. The main reasons for these deficiencies are the following: a) reduced food intake, b) decreased intestinal absorption, c) reduced storage capacity. The principal storage place of vitamins is the liver, the organ which is mostly affected in chronic alcoholics. d) Also the conversion of vitamins into their metabolically active forms-and this may be the most important point-is markedly reduced, e.g., it is known that the formation of thiamine pyrophosphate is decreased. No doubt, thiamine deficiency is the most common and probably the most important vitamin deficiency seen in chronic alcoholics. Several investigations have been carried out on the changes of the thiamine status of alcoholics. These are partly contradictory mainly because of the diversity of the methods employed. As an example may I mention the determination of the transketolase activity in the blood. We determined the changes of transketolase
activity before and after oral administration of thiamine to alcoholics, former alcoholics and healthy persons. The dose of vitamin Pl was varied and the smallest quantity causing a decrease of the TPP erect was used. The investigations were carried out with 51 chronic alcoholics, with 52 healthy persons, inmates of the State Prison of Canton, Zurich, and with 30 former alcoholics. The first group of chronic alcoholics consisted of free living persons (14), the second group of inhabitants of a so-called open home (11), and the third group of patients of the Psychiatric Clinic of the University of Zurich (26) (Somogyi and Kopp (7)). For the determination of the transketolase activity, a modified version of the method by Schouten et al. (8), was used. In the greater part of our experiments the thiamine content of blood was determined microbiologically with the method of Sarett and Cheldelin (9). Oral administration of 10mg thiamine daily during 7 days did not cause any decrease of the TPP effect in chronic alcoholics and 20mg did so only in a few cases. A reduction of the TPP effect has been observed only after increas ing the dose at least to 50mg thiamine per day and person (Table 1). The mean value of Table 1. Thiaminestatus of alcoholicsbefore and after thiamineadministration (freelivingpersons).
the TPP effect is high. After oral admini stration of 50mg thiamine during 14 days a marked decrease of the TPP effect occurred. After a further 7 days the initial values were nearly reached again. Similar results have second
group,
been achieved
inhabitants
of an
with
open
the
home
THIAMINE
Table 2. Thiamine status of alcoholics before and after thiamine administration (inhabitants of an open home).
Table 3. Thiamine status of alcoholics before and after thiamine administration (patients of a psychiatric clinic).
SYMPOSIUM
31
(Table 3). As we mentioned previously the thiamine content of the blood was determined micro biologically and the results of these assays have been compared with the TPP effect of the same person. A typical experiment is shown in Fig. 3. The correlation is very good: an increase of the thiamine content of blood runs parallel with a reduction of the TPP effect. However, in many cases the changes of the thiamine content of blood are smaller than those of the TPP effect. The increase of the transketolase activity Table
4.
Thiamine
status
and after thiamine
of healthy
persons
before
administration.
Fig. 3. Changesof the TPP effectand thiaminecon tent in the blood of alcoholicsbefore and after thiamineadministration. Fig.
(Table 2) and with the third one, patients of the Psychiatric Clinic of the University of Zurich
4.
Changes
of the TPP effect
tent in the blood of healthy after thiamine administration.
and thiamine persons
before
con and
32
J. C. SOMOGYI
after in vitro addition of TPP in healthy persons is lower than in alcoholics. Doses of 10mg thiamine per person and day given during 7 days and 14 days respectively caused a marked reduction (Table 4). A good relation ship occurred in most cases between thiamine content of the blood and the TPP effect in healthy persons (Fig. 4). We were further interested to find out whether there are any changes in these para meters of former alcoholics who had abstained from drinking alcohol for at least 4-10 months. The average TPP effect in this group shows an increase of 15%, a borderline case of a bio Table5. Thiaminestatusof formeralcoholicsbefore and after thiamineadministration.
chemical vitamin B1 deficiency state-a value which we found also with healthy persons however similarly to healthy persons the TPP effect could be reduced by oral administration of 10mg thiamine daily during 14 days(Table 5) Also in this case a good correlation between the vitamin B1 content of the blood and the TPP effect has been observed (Fig. 5). From this part of our investigation follows that the thiamine status of former alcoholics has improved in a short time. This result is surprising since there were chronic alcoholics amongst the investigated persons of whom certain damages, e.g., of the intestinal mucosa or liver cannot be excluded. We can conclude that the TPP effect in chronic alcoholics was high in about 80% of the investigated cases. A significant decrease of the TPP effect could be achieved only with doses of 50 mg thiamine or more given orally during 7-14 days. This finding was confirmed by an Australian group (Penington (10)). In contrast to this the TPP effect in healthy persons and former alcoholics was lower and already 10mg thiamine per person and day caused a reduction of the TPP effect. The described method allows a more reliable and accurate assessment of thiamine status and early detection of thiamine deficiency than former procedures. REFERENCES 1) 2) 3) 4) 5) 6) 7) 8)
Fig.
5.
Changes
of
the
TPP
effect
content in the blood of former and after thiamine administration.
and
alcoholics
thiamine
9)
before
10)
Buckle,R. M., Clin.Sc., 25, 207(1963). Buckle,R. M., Metabolism,15, 141(1965). Bamji,M. S., Am.J. Clin.Nutr., 23, 52 (1972). Sauberlich,H. E., Am. J. Clin. Nutr., 20, 528 (1967). Sauberlich,H. E., Dowdy,R. P., and Skala,J. H., Grit.Rev. Clin.Lab. Sc., 236(1973). Brubacher,G., Haenel,A., and Ritzel,G., Int. Z. Vitamin-Nahrungsforsch., 42,190 (1972). Somogyi,J. C. and Kopp, P. M., Proc. 9th Int. Congr. Nutrition, Mexico 1972, Vol. 1, p. 212 (1975). Schouten,H., van Eps,L. W., andBoudier,A. M., Clin.Chim.Acta, 10, 474(1964). Sarett,H. P. and Cheldelin,V.H., J Biol.Chem., 155, 153(1944). Penington,D. G.,personalcommunication (1972).
