Food Fighting and Disease Series: Beriberi

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Advancing the Integration of Food as Medicine in Modern Healthcare Using Proof from the Past

What is Beriberi?

Beriberi is a disease caused by not consuming enough thiamine (vitamin B1).¹ The role of thiamine (vitamin B1) in the body is metabolism – it helps cells grow and function.¹ When the body does not get enough thiamine through diet or does not absorb thiamine (due to conditions like bariatric surgery,  chronic alcoholism, or inability to absorb thiamine) it causes neuropathy (nerve damage that results in pain, weakness, and burning in extremities)² and wasting.¹ There are two main types of Beriberi – wet and dry. Wet Beriberi is characterized by increased heart rate, swollen legs, and shortness of breath while dry Beriberi is characterized by difficulty walking and paralysis of lower limbs, confusion, pain, nausea, and vomiting.¹ Widespread fortification of foods, often grains and cereals, with thiamine (vitamin b1) as well as increased variety of foods available, contributes to incredibly low incidences of Beriberi, especially in developed countries.¹ Foods with high levels of naturally occurring thiamine include pork, nuts, seeds, yogurt, peas, and beans. Fortification of grains and foods people are already eating with thiamine ensures that even if an individual is not varying their diet as much as they should or does not enjoy consuming foods with naturally occurring thiamine, they will still have thiamine in their diet, and thus won’t fall subject to Beriberi.

“Beriberi is a disease in which the body does not get enough thiamine (Vitamin B1).”³

“Beriberi is a deficiency of thiamine, more commonly known as vitamin B1. Your body needs thiamine to break down and digest the foods you eat, keep your metabolism going, and help your muscles and nervous system do their jobs effectively. Beriberi can affect the cardiovascular system or central nervous system.”⁴

“Thiamine deficiency, or beriberi, refers to a lack of thiamine pyrophosphate, the biologically active form of the vitamin known as thiamine (also spelled thiamin), or vitamin B-1.”⁵

There are two kinds of Beriberi: 

Wet Beriberi

Wet beriberi is characterized by cardiac symptoms including a fast heart rate as well as high blood pressure, swelling, and difficulty breathing.⁶

Dry Beriberi

Dry beriberi occurs more often than wet beriberi. Symptoms are neurological, including weakness in extremities (especially the legs), muscle pain, and in extreme cases, paralysis.⁶

Cerebral Beriberi

“Cerebral beriberi is a special form of dry beriberi that is more severe. Neurological changes are more pronounced. In severe stages, coma is possible.”⁶

History 

Beriberi caused the most problems in Asia, where white, polished rice was a dietary standard.¹⁰ Beriberi accounts can be found dating back to 1798 and impacted areas of Asia – including Indonesia, China, and Japan.¹⁰ It especially impacted Asian sailors and explorers, where cases were seen to be the most severe.¹⁰ Early European accounts of Beriberi mention Asian sea explorers and how emaciated and lacking in lower limb muscles these individuals were.¹⁰ 

Beriberi wreaked havoc among the Japanese in the late 1800s – it was so widespread due to the common diet among the wealthy of eating polished rice, that people thought it was contagious.¹¹ Beriberi first mainly impacted the wealthy of Japan, since they were eating the most polished rice.¹¹ It reached commoners more during the war, when in 1904-1905, the Japanese navy were fed unlimited white polished rice, and over 27,000 deaths were caused from thiamine deficiency alone, prompting navy officials to experiment with soldiers’ diets.¹¹ 

Early Observations

The Japanese were convinced Beriberi was contagious, yet in the 1904-1905, thousands of soldiers were still losing their lives to disease, prompting further experimentation.¹¹ Different ships set out with the intentions of testing the progression of Beriberi in these sailors, since it was becoming quite prevalent.¹² 

Some ships went farther west than others, to places where they were not as abundant in polished white rice and thus had to feed on brown, unrefined grains.¹²  Other ships had so little money that they were forced to bring meat and vegetables in order to supplement the polished rice.¹²  To navy officials’ surprise, the experiments did not work on ships where they had brown rice or brought vegetables and meat, since those individuals were not developing symptoms associated with Beriberi.¹²  

Furthermore, when the wealthy Japanese (who lived close to the capital) came down with Beriberi and got quite sick, they were transported far West as quickly as possible in an effort to find a remedy.¹²  To their surprise, when traveling West and eating foods besides polished white rice, they started to show a reversal in their condition quickly.¹²  It took a while to pinpoint that the problem could be polished white rice, since it was considered such a delicacy.¹²  

When was Beriberi discovered? 

1897

Who is attributed with connecting the disease or deficiency to food as medicine?

Christiann Eijkman¹³ 

Food as Medicine – Historical approaches to treating the disease 

Beriberi hit the wealthy in Asia – where polished, white rice was considered a delicacy, it was also contributing to a high death toll.¹¹ In Japan, when an official got really sick with Beriberi, it was common practice to travel out to the West to seek medical care.¹¹ During the journey to the West, travelers would start eating a more varied diet and would start to find themselves feeling better before event itching their destination.¹¹ This phenomenon was not understood at the time, as it was believed that individuals were just getting better from the travel West rather than what they were actually consuming on the journey.¹¹

Beriberi was plaguing the Japanese soldiers during the Russo-Japanese War in 1904-1905.¹¹  211,600 soldiers came down with Beriberi, 27,000 of whom died from the condition.¹¹ Considering that 47,000 Japanese soldier deaths occurred in combat during this time, an extremely high proportion were getting sick from Beriberi and no doubt this affected their health on the battlefield.¹¹ Although sailors were being given ample amounts of polished white rice, they were still getting sick – from malnourishment.¹¹ 

Japanese doctors started to get involved after seeing how many soldiers were suffering from Beriberi – the accepted theory at the time was that Beriberi was infectious and contagious from person to person, yet astute medical students noticed Westerners as well as wealthier soldiers were not getting sick.¹¹ To test the theory, military officials were given more varied foods to give their soldiers – including root vegetables, barley, and inexpensive meats – a diet Westerners were following.¹¹ 

In the West, Eijkman was discovering his own solution to Beriberi.¹⁴ Eijkman was a doctor called in to help with members of the military who had been suffering from Beriberi back in 1897, and he made the important discovery that chickens nearby the prisoner of war camp he was working at were suffering from seemingly similar symptoms – weak legs.¹⁴ When the feed for these chickens (polished rice at the time) was switched out for lower quality, less refined food, then the chickens started recovering and showing reversal of their weak legs.¹⁴ Still, Eijkman thought the chickens were catching a contagious disease and tried infecting well chickens with sick chickens, but had no success.¹⁴ In fact, when the sick chickens were brought into the pens with the well chickens, they started getting better since they started feeding on the food that the well chickens were eating, which was unrefined food.¹⁴

Public Health Interventions

The prevention of Beriberi is quite simple in modern society – incidences in Asia have gone down incredibly due to a more balanced diet and better distribution of fortified foods.² In Asia, there has been a growing acceptance of rice that has not been completely fortified or polished, leading to a healthier diet for people at all levels of wealth.² In Europe, the only cases of Beriberi tend to be caused by chronic alcoholism or following bariatric surgery or frequent use of diuretics, since the body cannot absorb the thiamine it is ingesting.²

Thiamine (Vitamin B1) Fortification Programs

Thiamine (vitamin B)1 is most readily absorbed by the body in its raw form.⁷ When cooked, thiamine-containing foods can lose some or all of their thiamine.⁷ For this reason, thiamine-fortified cereals and grains are extremely popular in Western culture as well as throughout the rest of the world.⁷

Certain foods block the ability of the body to absorb thiamine since they contain enzymes called thiaminases.⁷ Tea, raw fish, and clams are some examples.⁷ However, it is extremely rare that an individual would consume enough of these foods to cancel out all of the thiamine they are absorbing.⁷

Anecdote – Curry Rice Becomes the National Dish of Japan!

The Japanese were reluctant to believe that Beriberi could be caused by a dietary deficiency rather than by a virus or by bacteria, which led to them acknowledging the cure nearly 20 years after it was already discovered by Dutch scientists.¹⁹

From 1904-1905, Japanese soldiers were promised unlimited polished white rice when joining the navy.¹⁹ While this was alluring, sailors started getting sick from malnutrition due to eating only white rice.¹⁹ Officials soon discovered they had to mix in flour and meat with the rice in order to supplement it enough to prevent Beriberi, of which the cause was still mysterious at the time.¹⁹ This mixture of flour and meat, which was cooked together and poured over the rice, was known as curry, and had a thick, gravy-like texture.²⁰ Curry is quite rich in thiamine due to the flour, root vegetables vegetables, and meat it contains.²⁰

Curry over rice gained such popularity that Japanese soldiers were promised it upon enlisting, and it was used as an incentive to get men to join the navy.²⁰ This cheap dish was healthy and helped prevent disease.²⁰ It was novel and unlike Indian curry – it gained so much traction that it is now known as the official dish of Japan!²⁰

Role of Thiamine (Vitamin B1)

“Vitamin B1, also called thiamine or thiamin, is one of 8 B vitamins. All B vitamins help the body convert food (carbohydrates) into fuel (glucose), which the body uses to produce energy. These B vitamins, often referred to as B-complex vitamins, also help the body metabolize fats and protein.”⁷

“Thiamine (vitamin B1) helps the body’s cells change carbohydrates into energy. The main role of carbohydrates is to provide energy for the body, especially the brain and nervous system. Thiamine also plays a role in muscle contraction and conduction of nerve signals. Thiamine is essential for the metabolism of pyruvate, which is an important molecule in several chemical reactions in the body.”³

Recommended Dietary Allowance of Thiamine (Vitamin B1)

According to the USDA, most people in first world countries get more than enough thiamine just through consuming fortified foods.² The Recommended Dietary Allowance (RDA) for thiamine for adult men is 1.2 mg daily, and 1.1 mg daily for adult women.² Pregnant or lactating women should have 1.4 mg daily.² For the average American, half of their thiamine intake comes from foods containing naturally occurring thiamine while the other half comes from thiamine-fortified foods where the thiamine has been added.²

Causes & Risk Factors 

“Lack of thiamine, or vitamin B1, in the diet will lead to beriberi, no matter where you live in the world. You need a daily intake of thiamine-rich foods, which can be easily accomplished with a varied diet. While your body stores thiamine in the liver, it doesn’t hold enough to prevent a deficiency.”⁸

According to the NIH, Beriberi incidences are very rare in developed countries but the following traits put individuals at high risk:¹ 

• Alcohol abuse
• Dialysis
• Taking high doses of diuretics or having prolonged diarrhea
• Bariatric surgery
• AIDS
• Malnutrition and other conditions that cause wasting
• Diabetes
• Hyperthyroidism
• Genetic inability to absorb thiamine (very rare), known as Genetic Beriberi

Beriberi is very rarely inherited genetically, and is observed more frequently as isolated cases in non-related individuals.¹ 

Symptoms 

“Wet Beriberi:

• Increased heart rate
• Shortness of breath 
• Swelling of the lower legs

Dry Beriberi: 

• Difficulty walking
• Loss of feeling in hands and/or feet
• Paralysis of the lower legs
• Mental confusion 
• Speech difficulty
• Pain
• Vomiting”⁹

Food as Medicine – Natural Sources of Thiamine (Not Enriched)

Food	Serving Size	Amount (mg) of Thiamine (Vitamin B)	Percent Daily Value
Pork	3.5 oz.	1 mg	82%
Tofu	1 cup	0.41 mg	36%
Beans (black)	1 cup	0.42 mg	35%
Sunflower seeds	¼ cup	0.4 mg	33%
Green peas	1 cup	0.4 mg	33%
Brown rice	1 cup	0.345 mg	29%
Lentils	1 cup	0.3 mg	28%
Mussels	3 oz.	0.3 mg	25%
Asparagus	1 cup	0.3 mg	25%
Fish – salmon	3 oz.	0.289 mg	18%
Flax seeds	1 Tbsp.	0.17 mg	14%
Acorn squash	1 cup	0.16 mg	13%
Yogurt	1 cup	0.1 mg	8%

This chart, which lists the top naturally occurring thiamine-rich foods, is made with data from the USDA.¹⁰

Discovery of its Connection to Nutrition 

“The first breakthrough in the study of thiamine deficiency came in the late 1880s, when two Dutch scientists Eijkman and Grojn, through a series of experiments with chickens, discovered that the absence of a substance from natural foods caused serious damage to the peripheral nervous system. The significance of their work led to expanded interest in the study of thiamine deficiency in subsequent decades.”¹¹

Eijkman realized that chickens living next to humans suffering from Beriberi were exhibiting similar symptoms – lower body weakness and eventual paralysis, which autopsies later revealed to be severe nervous system damage.¹² When Eijkman tried infecting well chickens with chickens who had been infected with Beriberi, he found that Beriberi was not contagious.¹² In fact, Eijkman found that when he moved sick chickens into the pens with well chickens, they were actually getting better – which was because the sick chickens were able to eat the food that the well chickens were eating.¹² The well chickens had been eating brown rice which was not refined, unlike the polished, white rice, which was making both chickens as well as prisoners at a nearby penitentiary, exhibit symptoms of Beriberi.¹² 

Contemporary Understanding 

The contemporary understanding of Beriberi came in 1929 when Christiaan Eijkman was awarded the Nobel Prize in Medicine for discovering that a lack of thiamine (vitamin B) causes Beriberi, and thus that providing thiamine could prevent Beriberi.¹² Scientists were reluctant to abandon ideas that Beriberi could be spread by a virus or bacteria, but malnutrition alone was defined as the cause.¹²

Wernicke’s Encephalopathy – Another Thiamine Deficiency

Thiamine deficiency can also cause Wenicke’s Encephalopathy, which is characterized by symptoms including confusion, difficulty walking, and low blood pressure.¹³ It can occur in patients with chronic malnutrition caused by not eating enough, getting gastric bypass surgery, or consuming excessive amounts of alcohol for a prolonged period of time.¹³ This condition can be reversed if caught quickly by thiamine injections which increase the levels of thiamine throughout the body and especially in the brain.¹³

Modern Medical Intervention

If a patient is diagnosed with Beriberi, the standard is that they should follow a course of thiamine shots or a series of pills.¹⁴  In very severe cases, patients will receive an intramuscular shot of thiamine.¹⁴  Then, the patient is assessed over the next few weeks via blood tests to ensure that they are absorbing the thiamine.¹⁴  Beriberi is a reversible condition with early intervention.¹⁴ There is no upper limit (UL), or maximum amount that should not be exceeded, for thiamine consumption.²

Beriberi Today 

“Beriberi is rare in the United States. This is because most foods are now vitamin enriched. If you eat a normal, healthy diet, you should get enough thiamine. Today, beriberi occurs mostly in people who abuse alcohol. Drinking heavily can lead to poor nutrition. Excess alcohol makes it harder for the body to absorb and store vitamin B1.”³ Beriberi can occasionally occur in people with the inability to absorb thiamine – this is a genetic deficiency and extremely rare.⁸ 

Thiamine (Vitamin B1) was first added to flour in the United States in 1940, following the identification of Beriberi in the American population starting in the 1930s.¹⁵ Across the world, over 85 countries have mandatory thiamine fortification programs, mostly consisting of the mandatory addition of thiamine (vitamin B1) to wheat flour.¹⁶ The majority of these 85 countries with thiamine fortification programs are developed countries where thiamine deficiencies are already rare, while places at the highest risk (South and Southeast Asia) still do not have programs in place. Some reasons why the highest risk countries do not have programs regulating thiamine consumption include that thiamine deficiencies have not been identified as a public health risk in that country, or that the populations suffering from lack of thiamine do not consume enriched foods (they are eating rice, not wheat flour, which is consumed by upper class individuals in their country who are already not subject to Beriberi due to their varied diets).¹⁶ South and Southeast Asia as well as sub-Saharan Africa have high rates of thiamine deficiency in lower and middle class populations due to monotonous diets of mostly polished white rice.¹⁷ There is a lack of legislation about fortifying foods as well as limited access to a varied diet, causing malnourished mothers who do not have enough thiamine to give birth to babies who are equally malnourished and lacking thiamine as well.¹⁸ 

Databases

• Thamin: Fact Sheet for Health Professionals (National Institutes of Health, 2023)
• Beriberi – Disease at a Glance (National Institutes of Health, 2013) 
• Thamin Contributed from Major Foods Groups (US Department of Agriculture, 2014) 
• Thiamin Deficiency, Beriberi, and Maternal and Child Health: Why Pharmacokinetics Matter (Centers for Disease Control, 2013) 

Research Studies 

• Clinical Profile of Patients Presenting with Thiamine-Responsive Upper-Gastrointestinal Upset: A Pointer Toward Gastric Beriberi (ScienceDirect, 2022) 
• Shoshin Beriberi and Thiamine-Responsive Right Heart Failure: A Case Report in Mayotte Recognition and Management of Infant Shoshin Beriberi (ScienceDirect, 2022) 
• Pathophysiology, prevention, and treatment of beriberi after gastric surgery (Nutrition Reviews, 2020) 
• Dry Beriberi Due to Thiamine Deficiency Associated with Peripheral Neuropathy and Wernicke’s Encephalopathy Mimicking Guillain-Barré Syndrome: A Case Report and Review of Literature (NIH, 2019)
• Thiamine and Heart Failure: Challenging Cases of Modern-Day Cardiac Beriberi (ScienceDirect, 2019)
• Thiamine and Cardiovascular Disease: A Literature Review (ScienceDirect, 2018)
• Wet beriberi with multiple organ failure remarkably reversed by thiamine administration (PubMed, 2018)
• Shoshin Beriberi- Thiamine Responsive Pulmonary Hypertension in Exclusively Breastfed Infants: A Study from Northern India (Indian Heart Journal, 2017) 
• Do not forget to give thiamine to your septic shock patient! (NIH, 2016)
• Infantile encephalitic beriberi: magnetic resonance imaging findings (Pediatric Radiology, 2016)
• Beriberi (Thiamine Deficiency) and High Infant Mortality in Northern Laos (PLOS Neglected Tropical Diseases, 2015) 
• Shoshin Beriberi with Low Cardiac Output and Hemodynamic Deterioration Treated Dynamically by Thiamine Administration (International Heart Journal, 2015)
• Shoshin Beriberi in Critically-Ill patients: case series (Nutrition Journal, 2015)
• Beriberi, a Severe Complication after Metabolic Surgery – Review of the Literature (Obesity facts, 2014)
• Shoshin Beriberi Induced by Long-term Administration of Diuretics: A Case Report (Case Reports in Cardiology, 2014)

News and Media 

• Thiamine responsive high output heart failure of adults: an unrecognized entity (European Journal of Clinical Nutrition, 2023) 
• “Bariatric Beriberi”: A Rare Case of Wernicke Encephalopathy Two Weeks After Laparoscopic sleeve Gastrectomy (Cureus, 2023)  
• Kare Raisu: How Curry and Rice Saved Japan’s Navy and Gave it a National Dish (Slurrp Editorial, 2023) 
• The Causes and Treatment of Beriberi (VeryWell Health, 2022) 
• Beriberi: A Reversible Cause of Acute Severe Pulmonary Hypertension (Cureus, 2022) 
• Thiamine: Uses, Benefits, Dosage, Side Effects, Precautions (VeryWell Health, 2022) 
• Study recommends thiamine supplements for breastfeeding mothers (Kuensel, 2021) 
• Beriberi in Brazil: A Disease that Affects Indigenous People (Sage Journals, 2021) 
• Alcohol and Thiamine (Alcohol and Drug Foundation, 2021) 
• Health benefits of Vitamin B1: How much thiamine do you need? (Times Now, 2020)
• Infantile Cardiac Beriberi in Rural North East India (Indian Pediatrics, 2020)  
• Control and Prevention of Thiamine Deficiency Disorders (The New York Academy of Sciences, 2019) 
• Everything you need to know about beriberi (Medical News Today, 2019)
• Meet The Dutch Army Doctor Who Discovered Vitamin B And Cured A Deadly Disease (Forbes, 2018) 
• Beriberi: Overview, Causes, and Symptoms (Healthline, 2018) 
• Doctor’s Guide to Unexplained Illness Points to B1 Deficiency (PRWeb, 2018)
• A Beri beri bad problem! (Hans India, 2017) 
• What is thiamin, or vitamin B1? (Medical News Today, 2017) 
• What you need to know about Beriberi and Wernicke’s encephalopathy (EMS, 2017) 
• Nigerian rice brings health, foreign rice brings death (The Nation, 2017) 
• Thiamine-rich Foods to Treat Beriberi (Boldsky, 2016)
• Halifax researcher enriches fish sauce to save infant lives (CBC News, 2016) 
• Beri-beri Found in scottish Beer Drinkers (The Guardian, 2015) 
• Beriberi in Cambodia (Pediatrics and International Child Health, 2015) 

Key Words

Searched on Google, Google News,  Google Scholar, and PubMed, with search terms:

Beriberi (Google Scholar, Filter 2014-2023)

Beriberi (Google News) 

Beriberi (PubMed, Filter 2014-2023) 

Thiamine +  Deficiency (Google Scholar, Filter 2014-2023)

Thiamine-containing foods (Google Scholar, Filter 2014-2023)

Beriberi + News (Google Scholar, Filter 2014-2023)

Beriberi + History (Google Scholar, Filter 2014-2023)

Beriberi + Treatment (Google Scholar, Filter 2014-2023)

Beriberi + Symptoms (Google Scholar, Filter 2014-2023)

Beriberi + Trial (Google Scholar, Filter 2014-2023)

Christiaan Eijkman (Google Scholar, Filter 2014-2023)

Historical Treatment of Beriberi (Google Scholar, Filter 2014-2023)

Beriberi + Thiamine (Google Scholar, Filter 2014-2023)

Beriberi + Today (Google Scholar, Filter 2014-2023)

Beriberi + Developing countries (Google Scholar, Filter 2014-2023)

Beriberi + Developed countries (Google Scholar, Filter 2014-2023)

References 

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