Thiamine (vitamin B1) is an essential micronutrient responsible for key reactions involved in the conversion of the foods we consume into the chemical energy substrate requisite for cellular function, adenosine triphosphate (ATP). Absent sufficient ATP, all sorts of metabolic functions become disordered leading to the disease processes that dominate western medicine. Chronic inflammation, altered immune function, hormone dysregulation, cognitive and mood disorders, and dysautonomias, all can be traced back to insufficient thiamine > inefficient mitochondrial function, reduced ATP, and the compensatory reactions that ensue.
Among the most common but least well-recognized contributors to thiamine deficiency is the regular consumption of a high carbohydrate/highly processed food diet. Although most of these foods are enriched or fortified with thiamine, perhaps staving off more severe deficiencies, the density of sugars overwhelms mitochondrial capacity to process these foods, both the thiamine and any other potential nutrients are excreted, while the carbohydrates themselves are stored as fat for future use. High-calorie malnutrition is a common contributor to thiamine deficiency in obesity but also may develop in presumed healthy athletes whose diets focus heavily on high carbohydrate intake.
Thiamine, along with other B vitamins is often deficient in vegetarian and vegan diets as well. Not only do fruits, vegetables, and carbohydrates contain minimal, if any, thiamine, but some have anti-thiamine factors and are high in what are called oxalates. Anti-thiamine factors found in some fruits and vegetables interfere with the absorption or digestion of thiamine. Oxalates are mineralized crystals of sorts that tend to build up and store in places like the kidneys (kidney stones), but also may store and cause problems anywhere in the body like bones, arteries, eyes, heart, and nerves. Effective oxalate metabolism and clearance requires thiamine. Since vegetarian and vegan diets are also carbohydrate intensive, thiamine deficiency and oxalate issues may be compounded. Thus, a number of common diets not only contain reduced thiamine content but cause an increased need for thiamine by at least three mechanisms; higher carbohydrate consumption overwhelming capacity, which is then magnified by poor carbohydrate and oxalate processing.
Add daily coffee, tea, and/or alcohol consumption to any diet, and whatever thiamine that is consumed is either inactivated by enzymes before being used or is unabsorbable. Add a medication or four and thiamine availability will tank simultaneously with an increased need. Medications both block nutrient uptake and/or increase the need for nutrients by inducing mitochondrial damage. Given that 70% percent of the US population takes at least one medication regularly, while 20% take four or more, it is safe to say, that a good percentage of the population is consuming insufficient thiamine to maintain mitochondrial function and health.
Are We Really Thiamine Deficient?
As an essential nutrient, thiamine must be consumed regularly to maintain sufficient concentrations. The question is how much thiamine is sufficient to maintain health? Current RDA values for daily thiamine intake suggest a little over a milligram per day is adequate for most adults. If this is true, then the minimum value can be attained through just about any diet including those dominant in highly processed, carbohydrate-dense foods, which are commonly either enriched or fortified with thiamine. Everything from bread to cereals and even junk food like Oreos have thiamine. Per the RDA values, none of us ought to be thiamine deficient and none of us ought to require thiamine supplementation, and yet, many of us are and do. Indeed, several studies, across disparate populations show that even by this minimum standard, deficiency is a serious health problem. From our book:
- 76% of diabetics (type 1 and type 2)
- 29% of obese patients, 49% of post-bariatric surgery
- 40% of community-dwelling elderly, 48% of elderly patients in acute care
- 55% of cancer patients
- 20% ER patients (random sample, UK)
- 33% of congestive heart failure patients
- 38% of pregnant women, more with hyperemesis
- 30% of psychiatric patients
It takes approximately 18 days to completely abolish endogenous thiamine stores in a diet that is completely devoid of thiamine. Except under total starvation, medical or industrial food production mishaps, and experimentally contrived situations, thiamine consumption is never completely abolished. It waxes and wanes by dietary choices and life stressors. According to rodent studies, it takes a reduction of greater than 80% of thiamine stores before the more severe neurological symptoms are recognizable. In humans, these symptoms include those associated with Wernicke’s encephalopathy, the various forms of beriberi, and dysautonomic function. These include but are not limited to: ataxia, changes in mental status, optic neuritis, ocular nerve abnormalities, diminished visual acuity, high-output cardiac failure with or without edema, high pulse pressure, polyneuropathy (sensorimotor), enteritis, esophagitis, gastroparesis, nausea and vomiting, constipation, hyper- or hypo-stomach acidity, sympathetic/parasympathetic imbalance, postural orthostatic tachycardia syndrome (POTS), cerebral salt wasting syndrome, vasomotor dysfunction, respiratory distress, reduced vital capacity, and/or low arterial O2, high venous O2.
With a less severe thiamine deficiency, symptoms are rarely recognized as such and often attributed to psychological manifestations. A not entirely ethical study done in 1942 involving 11 women on a low thiamine diet over a period of ~3-6.5 months found striking symptoms.
- During this time all subjects showed definite changes in personality.
- They became irritable, depressed, quarrelsome, and uncooperative.
- Two threatened suicide. All became inefficient in their work, forgetful, and lost manual dexterity.
- Their hands and feet frequently felt numb.
- Headaches, backaches, sleeplessness, and sensitivity to noises were noted.
- The subjects fatigued easily and were not able to vigorous exertion.
- Constipation was the rule, but no impairment, of gastrointestinal motility, could be demonstrated fluoroscopically.
- Anorexia, nausea, vomiting, and epigastric distress were frequently observed.
- Low blood pressure and vasomotor instability were present in all patients.
- At rest, pulse rates were low (55 to 60 per minute) but tachycardia followed moderate exertion. Sinus arrhythmia was marked.
- Macrocytic, hypochromic anemia of moderate severity (3.0 to 3.5 million red cells) developed in 5 cases.
- A decrease in serum protein concentration occurred in 8 subjects.
- Basal metabolic rates were lowered by 10 to 33 points.
- Fasting blood sugar was often abnormally high.
The study above demonstrated a rapid and dramatic onset of symptoms relative to a diet with limited thiamine. Depending upon caloric intake, the amount of thiamine allowed was approximately 1/3 to 1/5 of the amount recommended by the RDA. Admittedly, the RDA for thiamine is low, to begin with, but even so, this was not a complete absence of thiamine. Since the study took place in the early 1940s, it is difficult to ascertain the specifics of the diet. Nevertheless, it demonstrates a clear association between general health and one’s ability to function, and thiamine insufficiency.
High Carbohydrate Diets Equal Lower Thiamine
More recently, a short and very small study (12 days and 12 participants) of active young men and women (ages 25-30) investigated the relationship between carbohydrate intake and thiamine status. Thiamine was measured in blood, plasma, urine (creatinine), and feces at four time points: at baseline, before the study began, during an adaptation phase where carbohydrate intake represented 55% of the total caloric intake, and during the two subsequent intervention phases, where carbohydrate intake was increased to 65% and 75% of the total caloric intake, respectively. Both caloric and thiamine intake was held constant throughout the study despite the increased intake of carbohydrates. Activity levels were also held constant. Across this short-term study, as carbohydrate intake increased, plasma, and urinary thiamine decreased. Excretion through feces remained unchanged. Transketolase enzyme activity was also measured but remained unchanged. Given the short-term nature of this study, the fact that transketolase remained unchanged is unexpected. In addition to the decreasing thiamine values, there were several changes in lipid profile as well. Despite the short duration of this study, however, the results show a clear relationship between carbohydrate intake and thiamine status; one that would likely be magnified over time and certainly if other life stressors and medical and environmental toxicants were added to the mix.
It is important to note current dietary guidelines suggest carbohydrate consumption should fall between 45-65% of total calories, percentages which, per this study would decrease thiamine availability significantly. From the baseline diet to the 55% adaptation phase, thiamine dropped precipitously, only to drop even further at the 65% phase. A recent study surveying macronutrient consumption showed that average carbohydrate consumption across the US population represented approximately 50% of total caloric intake. Importantly though, the study found that 42% of the carbohydrate consumption came in the form of what researchers termed ‘low-quality carbs’ e.g. sugary processed foods with no nutritional value. Thiamine is only found in pork, beef, wheat germ and whole grains, organ meats, eggs, fish, legumes, and nuts. It is not present in fats/oils, polished rice, or simple sugars, nor are dairy products or many fruits and vegetables a good source. Indeed as mentioned previously, some fruits and vegetables may contain anti-thiamine factors. A diet that is 42% empty calories, that contains limited to no nutritive value, save except what has been added post hoc via enrichment, begs for mitochondrial damage and the illnesses that ensue. And yet, that is precisely the nutritional landscape in which most of us exist.
Admittedly, both studies were very small, but the research connecting thiamine deficiency to ill-health and carbohydrate consumption to thiamine loss is clear. Given the dominance of ultra-processed carbohydrate-dense foods in the modern diet, is likely that high-calorie malnutrition underlies much of the chronic illness that plagues western medicine. To learn more about thiamine deficiency and the havoc it wreaks on health: Thiamine Deficiency Disease, Dysautonomia, and High Calorie Malnutrition.
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This article was published originally on September 2, 2020.
Just want to add another question – Is 500mg too high for a fat soluble molecule like Benfotiamine? I’m aware that high doses of the water soluble method are safe, but I haven’t yet found common dosages for thiamine therapy with a fat soluble molecule.
24 year old male here. All blood tests and MRIs are completely healthy (except pending thiamine, which could be flakey).
Recently diagnosed with POTS 4 months ago and have had a number of troubling symptoms: chronic fatigue, sleep issues, increased anxiety, poor muscle recovery after workouts and feeling like my body/muscles are burning (in one case it was mild rhabdomyolysis, but more recently my CPK level was fine). My guess is this is the lactic acid production due to thiamine deficiency. My POTS doesn’t have a clear cause – not hypotensive or hyperadrenergic, which makes me think something is just up with my vagus nerve. Been eating relatively well with good sleep hygiene since this all started. Have a very, very poor history with sugar: used to drink sugary drinks several times a day (sometimes a gallon of orange juice with cookies), a period of time where I drank 200-600mg of caffeine per day (this lasted a few months this year), and I never really cooked or ate super well (lots of chicken and turkey, sometimes beef, fast food, never green leafy stuff or anything high in thiamine). As a kid I drank 1-3 cokes a day, ate junk food snacks, etc.
Recently, after taking 500-750mg of Benfotiamine per day for the last few days, I’ve noticed a few things: in one instance, my heart rate, instead of going to the 130s upon standing, stayed under 100 for the entire 10 minutes I stood up, and usually hovered in the 80s. Last night, slept mostly through the night with 1-2 wakeups, which never happens. I usually wake up 10+ times throughout the night, and have had several instances of 2-3 days of no sleep. My muscles are unusually weak (used to lift and play sports before this happened). My appetite has been poor since the start of this all, quite nauseated when I’m hungry and nothing ever sounds good.
Question for you: Is this a sign that something is working? I do notice pretty extreme fatigue after taking the Benfotiamine, along with brain fog that I never had before, but things that have not happened in a long time have happened since I started supplementing and I’m afraid to get my hopes up. Can you give thoughts on the increase in fatigue? I know there can be initial paradox reactions, but what explains this one?
Do you have any updates? Im interested in starting benfotiamine cause of POTS too.Thanks
Can Dr. Marrs or Dr. Lonsdale share more information about what a healthy thiamine-rich and thiamine-optimizing diet would look like, considering the information that oxalates in many fruits and vegetables are counterproductive?
I consume a diet following the work of Dr. Terry Wahls, a previous multiple sclerosis sufferer who reversed her disease through a whole food, nutritionally dense, ketogenic diet consisting heavily of a variety of brightly colored vegetables and leafy greens (many of which are very high oxalate content), organ meats, grass fed meat, wild-caught fish and seafood, seeds and nuts, berries, and coconut milk. My average daily food intake consists of large amounts of leafy greens, avocados, beets, peppers, broccoli, asparagus, cabbage, Brussels sprouts, onions, garlic, and a variety of other vegetables, as well as three servings of beef, bison, pork, lamb, or fish, coconut milk, berries, and seeds. I also supplement with nutritional yeast, spirulina, a food based multivitamin and b complex, fish oil, CoQ10, probiotics, magnesium, and 600 mg allithiamine. I began the allithiamine on November 13, 2020, after having a massive resurgence of symptoms that I believe were thiamine deficiency driven.
Prior to June 2020, I would have considered myself a very healthy adult, with many of my health problems a thing of the past since quitting alcohol six years ago in 2014. I followed a paleo diet until I became sick and then embarked on the Wahls paleo plus diet to enhance my nutrition. I was diagnosed with POTS by the medical system but always felt there was an underlying cause and wanted to know that cause so I could correct the problems that completely robbed me of quality of life.
In June 2020, I began experiencing the following symptoms in rapid succession:
Feeling of poor circulation/lack of blood flow throughout entire body and brain
Constant feeling of brain asphyxiation/hypoxia
Poor memory, slowed cognition, and difficulty concentrating
Numbness, pins and needles, tingling, and deep aching pains in arms and legs
Sharp, electrical storm-like nerve pain in joints, spine, and cranium
Muscular pain, spasticity, and cramping despite adequate hydration and use of electrolytes and minerals
Relentless eyelid twitching
Burning sensation in feet
Syncope, near syncope, and tachycardia upon standing
Heart palpitations & pounding
Feels like heart is overworked
Shortness of breath
Shivering and sweating more easily with temperature change
Difficulty staying warm
Increase in viral and bacterial illnesses that last weeks longer than in the past
Constant sore throat & cough
Constant dry mouth & thirst
Symptoms of cerebral salt wasting
Loss of appetite
Sensitivity to light
High FBG (110-130)
Chronically low RBC count
*Symptoms improved somewhat with B12 and B1 injections, oral B complex, multivitamin/mineral complex, 2-3 teaspoons of daily salt, and strict adherence to Wahls paleo plus ketogenic diet.
*Symptoms grew much worse with use of Lipoic acid supplements. Lipoic acid depletes Thiamine.
*Former heavy binge drinker- began drinking age 14, stopped drinking age 33
*Consumed extreme amounts of candy from ages 7-11.
*Was prescribed antibiotics at least 75 times from age 5-33 for chronic UTIs and bronchitis
*Prior health problems in life have been chronic urinary tract and kidney infections, chronic bronchitis, viral and bacterial pneumonia, sinus infections, Candida overgrowth, digestive problems, anxiety, depression, and depersonalization disorder.
From all I’ve read on your site and in your most recent book, my symptoms are classic beriberi. The risk factors are there, although I’m perplexed that such a high nutrient diet could be lacking in adequate thiamine. Should I cut out high oxalate vegetables and leafy greens? Is there something I’m not consuming that I should be? How did I end up in such thiamine deficit when, for the last six years, I’ve adopted a lifestyle of healthful behaviors and nutrient density?
My hypothesis is that I have digestive malabsorption and possible mitochondrial damage from previous lifestyle factors (sugar, alcohol, antibiotic use). Still, it’s the assertion of Terry Wahls that mitochondrial damage can be healed through lifestyle and diet. Any guidance, suggestions, or thoughts would be most welcomed. Thank you.
You should be commended on such a radical change in diet. Often folks are reticent to change diet. Given your history, however, and the severity of your symptoms, I would suspect that food alone will not resolve the longstanding thiamine issues. It is likely that the thiamine transporters in the gut are impaired and you absorb more poorly than others and/or the enzymes that metabolize thiamine and other nutrients are not as active as they need to be. In either case, higher dosages of thiamine than can be garnered from food alone will be required. You mentioned that you felt better on the few occasions that you were given IV. That would support absorption and metabolism issues. Not to worry though, with supplementation you will likely be able to override those issues. You mentioned beginning allithiamine recently. What is the dose and what has been your response thus far?
Regarding the oxalate issues – if you are low on thiamine, eating foods high in oxalate will not only induce secondary hyperoxaluria, but deplete thiamine (because more is required), alter B6 and deplete glutathione (because thiamine is required for the metabolism of B6, which is required for glutathione). So while these foods may be healthy for some folks, against the background of insufficient thiamine, they become problematic. You might want to reduce your intake of high oxalate foods for a period of time while you get your thiamine issues resolved.
Finally, despite marketing, no one protocol works for everyone. Each of us carries a unique constellation of genetics and exposures that mix together to create health or illness. While I agree with Dr. Wahls that mitochondrial damage can be healed with lifestyle and diet, which lifestyle and diet is always going to be a factor. There is no one-size-fits-all and some folks need additional help in the form of supplements.
Thank you very much for your in depth response. I will change my diet to include low oxalate vegetables. Would it be prudent to take glutathione or NAC? There is so much to know about the intricacies of our systems and how diet and supplementation affect them, it feels quite overwhelming, especially from the standpoint of a sick person who isn’t functioning at a level to do all the research.
To answer your questions about about my dose of allithiamine and experience so far, I started high, contradicting the advice of “low and slow,” because I was heading downhill fast after experimenting with R-Lipoic acid (a stronger form of ALA), which unbeknownst to me at the time, depletes thiamine. After taking two 100 mg capsules of R-Lipoic acid, my nervous system lit up like an electric grid. My heart rate shot up, my muscles felt like they were seizing from the extreme cramping, I became very dehydrated, began vomiting, and I felt like I was going into a state of lactic acidosis. I was very sick, and over the course of the next few days, I began to experience symptoms of Wernicke’s encephalopathy – difficulty walking and thinking. I felt like I had a severe head injury and was in a state of extreme fight or flight panic. My vision was blurry. I could barely function. It was a harrowing experience.
I had thiamine HCL 500 mg capsules and began taking them the first day all of this started, finally putting together the pieces of what had been going on the past six months after I googled “alpha lipoic acid” contraindications and saw it shouldn’t be taken with a thiamine deficiency as it depletes thiamine. I took 500 mg of HCL three to four times daily along with some benfotiamine I had on hand. I also was able to get IV fluids with thiamine HCL from my primary care, as well as two B complex injections from a local naturopath. None of this was enough, and I continued to worsen until I began the high dose allithiamine, which finally came in the mail on November 13th. From the first dose, it helped significantly with WE symptoms.
All the medical literature online states that for WE, treatment must begin as quickly as possible and in high amounts at least three times daily, so that was my reasoning in forgoing “low and slow.” The first day I received the Allithiamine in the mail, I immediately took 300 mg and repeated this dose twice more that day. I did this for five consecutive days, then dropped down to 300 mg twice daily for three days, intending to stay at that dose; however, I developed a worsening of the tachycardia and heavy pounding heart two days ago, which was already quite bad at the onset of WE symptoms, so today I am cutting down to one dose of 50 mg and intend to go “low and slow” in finding an optimal long-term dose. Do you think 50 mg will be enough for the time being? I certainly don’t wish to decline again.
One more question – with my resting heart rate now sitting between 70-80 and the heavy pounding heart, should I be concerned about high output heart failure, a condition that can come with thiamine depletion? I don’t have any edema, but my heart is definitely working very hard. It’s impossible to relax or sleep much because of the heavy pounding. Would hawthorn be a prudent supplement to try? Any other ideas to try or avoid?
Are you taking magnesium as well?
Yes, I am taking magnesium. I’ve done my best to read through your site and purchased your book as well to ensure I’m learning all I can.
I recognized very quickly yesterday that 50 mg allithiamine was severely inadequate. Even 600 mg allithiamine isn’t covering symptom return – circulation/blood flow dropping from my brain and extremities, causing me to become ataxic and feel like I have a brain injury, numbness, neuropathy, pain in muscles, joints, and bones, tachycardia and pounding heart. It’s like my body has forgotten how to properly circulate blood.
I’m taking 1000 mg allithiamine as of yesterday and today. From an article of yours I just read, you state that a 6% increase in thiamine levels from the point of WE development should reverse symptoms. I’m concerned that symptoms are being held barely at bay, with some debilitating breakthroughs, even at very high dosage for many days now. Have you ever heard of cases where people no longer respond to thiamine treatment or require enormous doses for extended periods or permanently?
I wish so much I had a qualified doctor in my community to shepherd me through this process. I have gone into the ER asking for IV thiamine, and I was given a single dose thiamine pill and sent home. There is simply no comprehension of this condition among the medical providers I’ve encountered.
Any guidance you can offer would be deeply valued.
The the study involved rats and very basic measures of symptoms. Nevertheless, some of the more ‘gross’ symptoms do seem to resolve relatively quickly. The more complex and entrenched ones, however, take more time. Going up that quickly, to that high of a dose of TTFD can be problematic, especially for someone who has longstanding deficiency. TTFD is more readily absorbed but its molecular configuration requires a different metabolic pathway and so it can tax the glutathione system in folks who have been chronically deficient. You might be consider tapering down and using a combination of allithiamine and thiamine HCL so that the glutathione pathways are not overly taxed. Additionally, it will take time to resolve this. It is not immediate. As far as how long one has to supplement – it is often indefinitely and the dose will increase and decrease over time relative to additional stressors. Unfortunately, there are few physicians who understand this, hence the book. You will have to become an expert in your own recovery. You will have to learn how much your body needs and when. This knowledge has to be accumulated over time. There is no easy, one size, one answer. I am sorry I am concerned that maybe you went to high too quickly, though. We have a private FB group called Understanding Mitochondrial Nutrients, where a lot of folks have gone through what you are going through. You might join there to get some additional support. Be advised, there are folks with entirely different solutions and so you have to wade through some of that and again, figure out what works best for you. Having said all of that, be confident that you will recover. It will be a difficult road, but you will get there. Here is the link for the group: https://www.facebook.com/groups/mitochondrialnutrients
Thank you so much for your reassurance and taking the time to write. I will check out the Facebook group and continue on with this journey using your guidance. This site and your work are an invaluable source of information. I believe the contents of this site saved my life. As a single mother of five children, ages 16 to 20 months, my health and recovery is critical for all of us. Thank you for the work you are gifting to the world.
Hi Therese Turner,
Hope you are okay and in better health.
If you do not mind I have some questions as I have been thru a lot similar to yours but more extreme.
Did you ever had feeling of paralysis/numbness/heaviness in one side of your body ?
Do you feel your body is not very symmetric and is getting worse ?
Do you have regular swelling in one side of body after some physical exercise ?
Do you feel that some part of your head/brain and neck is numb and have no feeling ?
Do you have constant/regular inflammation in one side of your body ?
Hi Dr. Marrs,
I am 51 years old and have a decades-long history of SIBO, fructose malabsorption and steatorrhea. After years of unsuccessful treatment by orthodox physicians and alternative practitioners I decided to take matters into my own hands (especially since no one here in Germany knows about thiamine deficiency). A few weeks ago I started taking Sulbuthiamine (400 mg a day) plus magnesium and a multivitamin complex. After a few days of paradox I felt some improvement, but every time I eat some carbs (it doesn’t matter which kind of carbs, even vegetables with a higher amount of carbs) I feel like I’m back where I started, back to point zero – my symptoms become worse (brain fog, anxiety, memory problems, digestive problems, shallow breathing, heavy legs). I am pretty sure that this is no paradox, but due to the consumption of carbs, because when I leave them out I don’t feel this way. Is there anything I can do about it? Any recommendations?
Hi Dr Marrs,
I am currently on a carnivore diet to help with health issues and I am finding great success with this, especially with my mental health and energy levels (along with thiamine supplementation)
Would you agree that this diet is safe and quite helpful for a lifelong thiamine deficient person, such as myself?
not in my experience. you will eventually crash due to running on stress hormones. when you restrict carbohydrates in primates, cortisol levels rise too high, thus degenerating the body quicker. Cortisol might ‘feel good’ in order to keep you alive, but you will eventually crash. Look into Ray Peat, after you crash.
Thank god for gluconeogenesis, the body fabricates glucose from fat and protein in the absence of exogenous carbs. If not, zero carb eaters will be going down like flies all around the world.
I was a very low then eventually Zero Carb eater for well over 8 years & I eventually went down like a fly. My digestion, which had always struggled a bit through the Keto process anyway, regardless of what I tried, eventually threw in the towel & ground to a halt. Gradually too, my insulin resistance had been worsening to the point that not even injected insulin was barely working. I had had to keep increasing it but still was running very high numbers. Rather than losing like some manage to, I had also GAINED an additional 30+ lbs & was still struggling with fatigue. It was a very scary time.
Defeated, and though it was counterintuitive, I changed to a whole food plant based diet. I juiced for the first month to give my poor beleaguered digestion a break. To my utter amazement, By the end of the month my blood sugar dropped, my insulin sensitivity returned and I had to radically cut my insulin intake by more than half, from 50+ units per day to just 20-25 or less.
By the time I had come off the Low/no carb diet my adrenals were shot to pieces. Even using the landline phone set me shaking. So I can very much understand the cortisol issue & the crash.