Biochemical Thiamine Deficiency in Exclusively Breastfed Infants from an Endemic Region in Northern India: A Population-Based Cross Sectional Study

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Additionally, few cultural dietary practices among lactating women further predispose them to this deficiency. This population based Cross-Sectional study was conducted to estimate the prevalence of biochemical thiamine deficiency among exclusively breastfed infants whose mothers were on customary dietary restrictions compared to age-matched controls. Methods The study participants consisted of two groups namely “Exposure group” and “Control group”. The desired demographic, socioeconomic, dietary and clinical information were noted. The thiamine status was assessed using blood thiamine diphosphate (TDP) estimation. Results Exposure group and control group comprised of 335 and 293 exclusively breastfed infants and their mothers, respectively. Exposure group mothers significantly belonged to lower socioeconomic classes and had lower education levels. The mean TDP level in infants was significantly lower in the Exposure group (99.3 ± 33 nmol/L) compared to the Control group (119 ± 35 nmol/L). At a cut-off value of 90 nmol/L, the prevalence of thiamine deficiency in the Exposure group infants was 35.8% (120/335) and 18.8% (55/293) in the control group infants. Conclusion We found Customary dietary restrictions commonly associated with lower socioeconomic status and lower maternal education levels. Biochemical thiamine deficiency was high in both groups, it was significantly higher in the Exposure group infants compared to the Control group infants. Biological sciences/Biochemistry/Metabolomics Health sciences/Medical research/Epidemiology Thiamine deficiency Infants Beriberi Figures Figure 1 Figure 2 Figure 3 What is already known? Subclinical thiamine deficiency and clinical infantile beriberi are prevalent in Southeast Asian countries because of cultural dietary restrictions and the absence of food fortification programs. What does this study add? The study identified a significant correlation between maternal and infant thiamine status, revealing a higher risk among infants whose mothers followed cultural dietary restrictions and increased prevalence of subclinical thiamine deficiency in Kashmir. Introduction Thiamine (vitamin B1) is an essential micronutrient required for energy metabolism, with no endogenous synthesis and limited body stores because of its short half-life. [ 1 ] In high-income countries, routine food fortification of staple foods has largely prevented thiamine deficiency at the population level. However, in India, no such micronutrient fortification program is in practice, leaving a large section of the population vulnerable to this deficiency. The problem is further compounded by the widespread consumption of polished rice, which contains negligible amounts of thiamine. In addition, certain cultural dietary practices in communities such as those in Kashmir, where pregnant and lactating women are largely given a monotonous diet consisting of meat soup and polished rice, while restricting fresh food such as vegetables, fruits and beans further predispose women to severe deficiency. [ 2 ] Since the thiamine content of human milk is directly determined by maternal thiamine status, inadequate maternal levels can predispose breastfed infants to thiamine deficiency and its associated consequences. [ 3 ] Thiamine deficiency remains an important cause of morbidity and mortality among breastfed infants in Southeast Asia. Reports of acute fulminant beriberi in breastfed infants have also been reported from various regions of India, including Kashmir. [ 4 – 6 ] suggesting an underlying widespread deficiency among lactating women and their infants at the population level. However, reliable data on biochemical thiamine deficiency are lacking. This study aims to study the prevalence of biochemical thiamine deficiency among asymptomatic breastfed infants from this region, whose mothers are subjected to customary dietary restrictions, and comparing them with age-matched controls. Materials and Methods This community-based Cross-Sectional study was conducted from December 2021 to November 2024 on exclusively breastfed infants. The study infants and their mothers were enrolled from both rural and urban areas of the valley via multistage sampling. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Institutional Ethics Committee (SKIMS-IEC; ethics number; RP/02/2020). Written informed consent was obtained from either of the parents. The study participants consisted of two groups namely “Exposure group” and “Control group”. The Exposure group consisted of exclusively breastfed babies and their mothers who followed a certain customary dietary restrictions (a cultural practice in Kashmir where pregnant and lactating women are given predominantly rice with meat/chicken soups). The “Control group” consisted of exclusively breastfed babies and mothers who did not follow the aforementioned cultural practice and were consuming a diverse diet. This categorization was done with the help of predesigned and validated dietary intake questionnaire. The exclusion criteria included; babies on formula feeds, mother or baby on thiamine supplementation, any known illness in mother or her offspring at the time of enrolment. Study infants were selected from the immunization centers and /or well-baby clinics of the selected area. A total of 335 Exposure group subjects and 293 Controls were selected for the said study. Sample size was calculated using Sample size formula for qualitative variables. A case report form (CRF) was prepared to capture the requisite demographic, socioeconomic, and clinical information from the study population. This included demographic details like age of the child, gender, residence, feeding history, history of prior illness, maternal dietary history, socioeconomic history, type of diet consumed by mother, history of customary dietary restrictions in the mother, history of previous sib deaths, and socioeconomic status of family by modified Kuppuswami socioeconomic scale. Similarly, relevant clinical and anthropometric details were captured and entered in the CRFs of the study participants. 3 ml of venous blood was collected from the study infants and their mothers for whole blood thiamine-di-phosphate (TDP) estimation. The samples were transported to the laboratory in liquid nitrogen, where they were stored at -20 0 C until further analysis. Whole blood Thiamine diphosphate (TDP) was estimated using high performance liquid chromatography (HPLC) using a fluorescent detector (Arc HPLC System, Waters™ ) . We used the post-column derivatization method devised by Lu and frank et al. for whole blood TDP estimation. [ 7 ] Fig. 1 shows the chromatographic profiles of the calibration solution and whole blood extract. A level of 90 nmol/l was considered thiamine deficiency in our study. After the completion of blood TDP estimation, the mean TDP level and the number of children with level below 90 nmol/l in both groups were compared. In addition, a correlation coefficient was calculated between blood TDP levels of the mother and her offspring. The main outcome measure of our study was to determine the prevalence of subclinical thiamine deficiency among Exposure group infants compared to Controls. The other outcome measure was the mean blood TDP level in the Exposure and Control groups. Statistical analysis : Continuous variables are presented as mean ± SD or median and interquartile range. For distinct data, a simple frequency was calculated. The Student’s t-test and the chi-square test were applied. IBM SPSS® statistical software (Armonk, NY: IBM Corp) was used for data analysis. Results We enrolled 628 healthy breastfed infants and their mothers in our study, which included 335 participants in the Exposure group and 293 participants in the Control group. The total study duration was three years (December 2021 to November 2024). All infants were exclusively breastfed and were younger than six months, with a mean age (SD) of 95.6 ± 54.9 days in the Exposure group and 98.0 ± 59.7 days in the Control group (p = 0.6), indicating no significant age difference. Female infants comprised 52.5% in the Exposure group and 47.5% in the control group (p = 0.7). Majority of infants in both groups were delivered by lower-segment cesarean section (LSCS) (p = 0.1). Additionally, 324 infants in the Exposure group and 285 infants in the Control group were term born (p = 0.68). There was no significant difference with respect to history of previous abortions, stillbirths, or child deaths, weight, length, pulse rate, and respiratory rate (see Table 1 ), between the two groups. Table 1 Demographic and Clinical Profile of the Study Population Parameter Case (N = 335) Control (N = 293) P-value Age in days. Mean ± SD 95.6 ± 54.9 98.0 ± 59.7 0.60 Gender (female) No.(%) 155 (52.5) 140 (47.5) 0.70 Type of Delivery - LSCS 214 (63.9) 205 (70) 0.10 Weight in kg. Mean ± SD 5.0 ± 1.5 5.2 ± 3.7 0.13 Length in cm. Median (IQR) 54.9 ± 6.4 55.5 ± 7.4 0.37 Head Circumference. Mean ± SD 38.9 ± 3.1 39.3 ± 3.7 0.12 Gestation – Term. No.(%) 324 (96.7) 285 (97.2) 0.68 Pulse. Mean ± SD 101 ± 15.6 104 ± 61.4 0.38 RR Mean ± SD 33.8 ± 2.4 33.9 ± 2.7 0.6 Consanguineous Marriage. No.(%) 116 (34.6) 83 (28.3) 0.14 Socioeconomic and Educational Status; As shown in Fig. 2, Exposure group mothers more likely belonged to the lower socioeconomic class than the Control group mothers (p = 0.000). Figure 3 shows the educational level of the mother groups. Mothers who followed the customary dietary restrictions had significantly less years of formal education than the Control group mothers. (p = 0.00). Table 2 provides a comparison of TDP levels and the prevalence of thiamine deficiency between two groups. The mean (SD) TDP level in infants was significantly lower in the Exposure group (99.3 ± 33 nmol/L) than the control group (119 ± 35 nmol/L). Similarly, maternal TDP levels were lower in the Exposure group (148.5 ± 62.9 nmol/L) than the Control group (183.5 ± 76.1 nmol/L), with both differences reaching the statistical significance (p = 0.00). At cut-off value of 90 nmol/L, the prevalence of thiamine deficiency in the Exposure group infants was 35.8% (120/335) and 18.8% (55/293) in the control group infants, while as 39 (11.64%)of Exposure mothers and 10 (3.5%) of Control group mothers were found thiamine deficient Table 2 Mean Thiamine Diphosphate (TDP) Levels of the Study Population Parameter Study Group (N = 335) Control Group (N = 293) P-value TDP level of Babies (nmol/l). Mean ± SD 99.3 ± 33 119 ± 35 0.00 TDP level of Mothers (nmol/l). Mean ± SD 148.5 ± 62.9 183.5 ± 76.1 0.00 Thiamine Deficiency in Babies. No (%) 33 (9.9) 5 (1.7) 0.00 Thiamine Deficiency in Lactating Mothers. No (%) 39 (11.64%) 10 (3.5%) 0.00 Correlation between maternal and infant blood TDP levels. The Pearson correlation analysis revealed a correlation coefficient of 0.533 between maternal and infant blood TDP levels, which was highly significant (p < 0.001). Discussion In this population based cross sectional study, a total of 628 healthy breastfed infants and their mothers were enrolled from the community. Exposure group consisted of 335 participants and 293 participants belonged to the Control group. The key findings included a significant association of customary dietary restrictions with low socioeconomic status of the family as well as lower maternal educational level. The prevalence of thiamine deficiency in the Exposure group infants and Control group infants was 35.8% (120/335) and 18.8% (55/293) respectively. The mean thiamine level in the Exposure Group infants (99.3 ± 33 nmol/L) was significantly lower than that the Control Group infants (119 ± 35 nmol/L). Additionally, there was a strong correlation between maternal serum TDP levels and the TDP levels of offspring, with a correlation coefficient of 0.533, highlighting the close relationship between maternal and infant thiamine status. Thiamine serves as an essential cofactor in energy metabolism and the synthesis of nucleic acids, myelin, and neurotransmitters such as acetylcholine. [ 8 ] The body's thiamine stores are limited, and the turnover rate is high. Conditions which Increase metabolic demand, such as febrile illness, pregnancy, lactation, and infancy leads to rapid consumption of thiamine. [ 9 ] Therefore, severe thiamine deficiency can develop rapidly in pregnant and lactating women as well as their offspring, if dietary thiamine intake is limited. This risk is particularly relevant in populations with low thiamine intake, often due to the consumption of polished rice as a staple diet. [ 10 ] In India, a large section of the population consumes polished rice as a staple diet, therefore are at the risk of said deficiency. Our study is among the few global studies to assess the effect of dietary habits and taboos of lactating women on their thiamine status as well as their offspring. In addition, we investigated the factors that influence the adoption of customary dietary restrictions by women in this region. We found that cultural food practices during pregnancy and lactation were significantly associated with lower maternal education level and lower socioeconomic background of the family. Similar findings have been reported in many low- and middle-income countries (LMICs) where certain cultural practices in the marginalized class of the society often limit the intake of essential nutrients, including proteins, iron, and vitamins, thus negatively affecting maternal and infant health [ 10 , 11 ]. In contrast, higher education levels and higher-income households are associated with reduced adherence to traditional dietary restrictions. Azene et al. [ 12 ] found that literate women were 82% more likely to consume a diversified diet than illiterate women. Similarly, a study in Kenya reported that women from high-income households consumed a greater variety of foods. [ 13 ]. Pregnant and lactating women from lower socioeconomic and educational backgrounds are already at a higher risk of complications. [ 14 ] The adoption of a monotonous diet, devoid of essential nutrients including thiamine, further would predispose them and their offspring at risk of various complications. A study on beriberi infants by Coats et al. [ 15 ] in rural Cambodia, found that approximately 60% of the mothers followed postpartum dietary avoidance practices, the mean thiamine level of their infants was significantly lower compared to the American controls. We assessed the thiamine status of our study cohort, including both mothers and infants, by directly estimating thiamine diphosphate (TDP) levels in whole blood. This method was chosen over the traditional erythrocyte transketolase (ETK) enzyme activity coefficient assay, which is a functional assay for evaluating body thiamine levels. Although the ETK activity assay has been widely used, it is influenced by factors other than thiamine deficiency. Additionally, it has several limitations, including limited availability, non-standardized reference ranges, poor inter-assay reproducibility, rapid inactivation of the transketolase enzyme, and the absence of external quality assurance systems. [ 16 ] These limitations make the ETK assay less reliable than the direct estimation of whole blood TDP levels using high-performance liquid chromatography (HPLC). The primary drawback of direct TDP estimation is its highly unstable nature, with rapid degradation due to exposure to light and heat. To address this challenge, blood samples were collected using vacutainer wrapped in silver foil to shield them from light. The samples were then immediately transferred to liquid nitrogen at the collection site for transportation and subsequently stored at -20°C in the laboratory before final analysis. The mean TDP levels in both the Exposure and control groups infants and their mothers were lower than those reported in industrialized countries, such as Canada and the United States. [ 15 , 17 ] This discrepancy can be attributed to several factors. First, the control group also consumed polished rice, which is a staple food in the Kashmir Valley. Polished rice, which is typically washed multiple times before cooking, leads to substantial loss of thiamine. Second, India lacks routine thiamine fortification of staple foods, resulting in marginal thiamine intake at the community level. Furthermore, the carbohydrate-based nature of rice results in an increased rate of thiamine consumption, further depleting thiamine reserves in the body. Coats et al. [ 15 ] measured mean blood thiamine levels in Cambodian infants with and without beri beri symptoms and in their mothers and American controls. The mean TDP level in Cambodian cases, Cambodian controls and American controls were 48 mmol/l, 56 mmol/l, 132 mmol/l respectively. These findings suggested that populations relying predominantly on rice-based diets tend to have lower mean thiamine levels than populations consuming more diverse diets. This underscores the need for dietary diversification, and thiamine fortification programs in regions relying on polished rice as a staple food. In our study, the mean thiamine level was significantly lower in the Exposure group mothers and their infants compared to the control group. This difference was likely due to adaptation of customary dietary restrictions by the mothers in the Exposure group, who primarily consumed meat soups and rice, a very common cultural practice in this part of the world predisposing their breastfed babies to severe thiamine insufficiency. When TDP levels were analyzed as a dichotomous variable using a deficiency cutoff of 90 nmol/L, we found the prevalence of biochemical thiamine deficiency significantly high in the Exposure group infants (35.8%, 120) compared to the control group infants (18.8%, 55). Similarly 11.64% of Exposure mothers and 3.5% of Control group mothers were found thiamine deficient, These findings are consistent with studies from Southeast Asia, where thiamine deficiency is endemic, reflecting substantial burden of subclinical deficiency in studied population. [ 13 ] Multiple studies from Lao and other southeast Asian countries have shown that limited dietary diversity, consumption of low-thiamine staple crops (such as polished white rice), certain cooking practices (repetitive washing and soaking rice for many hours) and traditional postpartum restrictive diets, all place lactating women at high risk of thiamine deficiency.[ 15 , 18 , 19 ] Breast-milk thiamine concentration and infant thiamine status are strongly dependent on maternal thiamine intake and status, hence, maternal thiamine deficiency rapidly results in biochemical thiamine deficiency in their infants.[ 15 ] According to the WHO, infantile thiamine deficiency is the only serious form of malnutrition that occurs in adequately breastfed infants and most commonly occur when the mother herself is thiamine-deficient.[ 20 ] While the clinical implications of biochemical thiamine deficiency in asymptomatic breastfed infants cannot be directly inferred from our data, the high burden of clinical infantile beriberi in our region provides indirect evidence that the biochemical deficiency if not corrected may progress to overt fulminant beriberi in situations that lead to rapid thiamine depletion such as acute febrile illness, vaccination etc. There is ample evidence to support this hypothesis, multiple studies have been published from this region as well as other thiamine deficient endemic countries on acute infantile beriberi. The common feature in all studies were involvement of young breastfed infants, milled rice was a staple diet as well as practice of customary dietary restrictions among mothers of the affected infants. [ 10 ] There is ample evidence that thiamine deficiency endemic areas have high infant mortality which improve if thiamine supplementation is provided to pregnant and lactating women. [ 21 ] These findings reinforce our hypothesis that biochemical thiamine deficiency in infants can evolve into fulminant beriberi over time if left unaddressed. The strength of our study lies in its community-based design, with a sufficiently large sample size, recruited from well-baby clinics and immunization centers. However, the primary limitation of our study is the inability to establish a direct causal link between biochemical thiamine deficiency and the subsequent development of beriberi symptoms, as this would be an unethical practice not to treat the subclinical deficiency and to longitudinally follow these infants for the development of beriberi symptoms. Nevertheless, substantial epidemiological evidence indicates that places with high infantile and maternal beriberi cases have high prevalence of subclinical thiamine deficiency at population level as well as high infant mortality rates beyond one month of age, which is a surrogate marker of thiamine deficiency at community level. [ 20 ] Infantile beriberi represents the most critical outcome of thiamine deficiency, but marginal thiamine status in the broader population has been linked to symptoms such as fatigue, apathy, anorexia, and dizziness [ 22 ], which may lead to poor school performance and economic productivity. Furthermore, a study on Israeli children who consumed thiamine-deficient infant formula during infancy revealed delayed neurocognitive development at ages 5–7 years. [ 23 ] This underscores the crucial importance of ensuring adequate thiamine levels during early-life support healthy growth and development. To conclude, this community-based Cross-Sectional study among healthy breastfed infant’s highlights that customary dietary restrictions are significantly more prevalent in families with lower socioeconomic status and among women with lower education status and are associated with a higher prevalence of biochemical thiamine deficiency in both mothers and their infants. The mean TDP levels in both groups were lower than expected, with the Exposure Group exhibiting significantly lower levels than the Control Group. We notably observed a strong correlation between maternal blood TDP levels and those of their offspring, highlighting the close relationship between maternal and infant thiamine status. These findings emphasize the need for targeted nutritional interventions in vulnerable populations to mitigate the risk of subclinical thiamine deficiency. Abbreviations TDP: Thiamine diphosphate LMICs: Low- and middle-income countries CRF: Case report form HPLC: High performance liquid chromatography Declarations Funding : Indian Council of Medical Research. Acknowledgements, Aisha for helping in making various graphs Financial Support : This work was supported by the Indian Council of Medical Research (ICMR) Conflict of Interest: Nil Authorship: concept and design, JIB, paper writing, JIB, BAC; Review and editing, BAC, ZAS, project administration, ABB and ABP. All authors have read and agreed to the published version of the manuscript. 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Geneva: World Health Organization, 1999. https://iris.who.int/handle/10665/66139. Luxemburger C, White NJ, ter Kuile F, Singh HM, Allier-Frachon I, Ohn M, Chongsuphajaisiddhi T, Nosten F. Beri-beri: the major cause of infant mortality in Karen refugees. Trans R Soc Trop Med Hyg. 2003 Mar-Apr;97(2):251-5. Carpenter KJ. Beriberi, white rice, and vitamin B: a disease, a cause, a cure Berkley: University of Califormia Press; 2000. Mimouni-Bloch A, Goldberg-Stern H, Strausberg R, Brezner A, Heyman E, Inbar D, et al. Thiamine deficiency in infancy: long-term follow-up. Pediatr Neurol. Elsevier Inc; 2014;51 Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":73487,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"figure1modified.png","url":"https://assets-eu.researchsquare.com/files/rs-7558131/v1/2804ccdc0644a28bfd5dcdf5.png"},{"id":91954358,"identity":"e5856d1e-c405-4b6b-b14f-a75f6b13e164","added_by":"auto","created_at":"2025-09-23 07:07:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32839,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"MosaicPlotforSocioeconomicstatusmodified.png","url":"https://assets-eu.researchsquare.com/files/rs-7558131/v1/b9024082a5abbe81f947465a.png"},{"id":91956461,"identity":"4713af56-22b4-466e-8904-017f50e4c22e","added_by":"auto","created_at":"2025-09-23 07:15:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":22733,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"EducationalStatusmodified.png","url":"https://assets-eu.researchsquare.com/files/rs-7558131/v1/2dfaccffc8d21dac84ed03c5.png"},{"id":107706191,"identity":"8f072bed-37ea-48f1-826a-7fc900ee7422","added_by":"auto","created_at":"2026-04-24 09:17:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":337360,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7558131/v1/09a43796-5c02-412a-a563-96ce2d8b9bed.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Biochemical Thiamine Deficiency in Exclusively Breastfed Infants from an Endemic Region in Northern India: A Population-Based Cross Sectional Study","fulltext":[{"header":"What is already known?","content":"\u003cp\u003eSubclinical thiamine deficiency and clinical infantile beriberi are prevalent in Southeast Asian countries because of cultural dietary restrictions and the absence of food fortification programs.\u003c/p\u003e"},{"header":"What does this study add?","content":"\u003cp\u003eThe study identified a significant correlation between maternal and infant thiamine status, revealing a higher risk among infants whose mothers followed cultural dietary restrictions and increased prevalence of subclinical thiamine deficiency in Kashmir.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThiamine \u003cem\u003e(vitamin B1)\u003c/em\u003e is an essential micronutrient required for energy metabolism, with no endogenous synthesis and limited body stores because of its short half-life. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] In high-income countries, routine food fortification of staple foods has largely prevented thiamine deficiency at the population level. However, in India, no such micronutrient fortification program is in practice, leaving a large section of the population vulnerable to this deficiency. The problem is further compounded by the widespread consumption of polished rice, which contains negligible amounts of thiamine. In addition, certain cultural dietary practices in communities such as those in Kashmir, where pregnant and lactating women are largely given a monotonous diet consisting of meat soup and polished rice, while restricting fresh food such as vegetables, fruits and beans further predispose women to severe deficiency. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Since the thiamine content of human milk is directly determined by maternal thiamine status, inadequate maternal levels can predispose breastfed infants to thiamine deficiency and its associated consequences. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Thiamine deficiency remains an important cause of morbidity and mortality among breastfed infants in Southeast Asia. Reports of acute fulminant beriberi in breastfed infants have also been reported from various regions of India, including Kashmir. [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] suggesting an underlying widespread deficiency among lactating women and their infants at the population level. However, reliable data on biochemical thiamine deficiency are lacking. This study aims to study the prevalence of biochemical thiamine deficiency among asymptomatic breastfed infants from this region, whose mothers are subjected to customary dietary restrictions, and comparing them with age-matched controls.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis community-based Cross-Sectional study was conducted from December 2021 to November 2024 on exclusively breastfed infants. The study infants and their mothers were enrolled from both rural and urban areas of the valley via multistage sampling. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Institutional Ethics Committee (SKIMS-IEC; ethics number; RP/02/2020). Written informed consent was obtained from either of the parents. The study participants consisted of two groups namely \u0026ldquo;Exposure group\u0026rdquo; and \u0026ldquo;Control group\u0026rdquo;. The Exposure group consisted of exclusively breastfed babies and their mothers who followed a certain customary dietary restrictions (a cultural practice in Kashmir where pregnant and lactating women are given predominantly rice with meat/chicken soups). The \u0026ldquo;Control group\u0026rdquo; consisted of exclusively breastfed babies and mothers who did not follow the aforementioned cultural practice and were consuming a diverse diet. This categorization was done with the help of predesigned and validated dietary intake questionnaire. The exclusion criteria included; babies on formula feeds, mother or baby on thiamine supplementation, any known illness in mother or her offspring at the time of enrolment. Study infants were selected from the immunization centers and /or well-baby clinics of the selected area. A total of 335 Exposure group subjects and 293 Controls were selected for the said study. Sample size was calculated using Sample size formula for qualitative variables. A case report form (CRF) was prepared to capture the requisite demographic, socioeconomic, and clinical information from the study population. This included demographic details like age of the child, gender, residence, feeding history, history of prior illness, maternal dietary history, socioeconomic history, type of diet consumed by mother, history of customary dietary restrictions in the mother, history of previous sib deaths, and socioeconomic status of family by modified Kuppuswami socioeconomic scale. Similarly, relevant clinical and anthropometric details were captured and entered in the CRFs of the study participants. 3 ml of venous blood was collected from the study infants and their mothers for whole blood thiamine-di-phosphate (TDP) estimation. The samples were transported to the laboratory in liquid nitrogen, where they were stored at -20\u003csup\u003e0\u003c/sup\u003e C until further analysis. Whole blood Thiamine diphosphate (TDP) was estimated using high performance liquid chromatography (HPLC) using a fluorescent detector (Arc HPLC System, Waters\u0026trade;\u003csub\u003e)\u003c/sub\u003e. We used the post-column derivatization method devised by Lu and frank et al. for whole blood TDP estimation. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Fig.\u0026nbsp;1 shows the chromatographic profiles of the calibration solution and whole blood extract. A level of 90 nmol/l was considered thiamine deficiency in our study. After the completion of blood TDP estimation, the mean TDP level and the number of children with level below 90 nmol/l in both groups were compared. In addition, a correlation coefficient was calculated between blood TDP levels of the mother and her offspring. The main outcome measure of our study was to determine the prevalence of subclinical thiamine deficiency among Exposure group infants compared to Controls. The other outcome measure was the mean blood TDP level in the Exposure and Control groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatistical analysis\u003c/b\u003e: Continuous variables are presented as mean\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD or median and interquartile range. For distinct data, a simple frequency was calculated. The Student\u0026rsquo;s t-test and the chi-square test were applied. IBM SPSS\u0026reg; statistical software (Armonk, NY: IBM Corp) was used for data analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e We enrolled 628 healthy breastfed infants and their mothers in our study, which included 335 participants in the Exposure group and 293 participants in the Control group. The total study duration was three years (December 2021 to November 2024). All infants were exclusively breastfed and were younger than six months, with a mean age (SD) of 95.6\u0026thinsp;\u0026plusmn;\u0026thinsp;54.9 days in the Exposure group and 98.0\u0026thinsp;\u0026plusmn;\u0026thinsp;59.7 days in the Control group (p\u0026thinsp;=\u0026thinsp;0.6), indicating no significant age difference. Female infants comprised 52.5% in the Exposure group and 47.5% in the control group (p\u0026thinsp;=\u0026thinsp;0.7). Majority of infants in both groups were delivered by lower-segment cesarean section (LSCS) (p\u0026thinsp;=\u0026thinsp;0.1). Additionally, 324 infants in the Exposure group and 285 infants in the Control group were term born (p\u0026thinsp;=\u0026thinsp;0.68). There was no significant difference with respect to history of previous abortions, stillbirths, or child deaths, weight, length, pulse rate, and respiratory rate (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), between the two groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and Clinical Profile of the Study Population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase (N\u0026thinsp;=\u0026thinsp;335)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;293)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge in days. Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95.6\u0026thinsp;\u0026plusmn;\u0026thinsp;54.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98.0\u0026thinsp;\u0026plusmn;\u0026thinsp;59.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (female) No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e155 (52.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e140 (47.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of Delivery - LSCS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e214 (63.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e205 (70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight in kg. Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength in cm. Median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead Circumference. Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGestation \u0026ndash; Term. No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e324 (96.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e285 (97.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulse. Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e101\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104\u0026thinsp;\u0026plusmn;\u0026thinsp;61.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRR Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConsanguineous Marriage. No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116 (34.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83 (28.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSocioeconomic and Educational Status;\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;2, Exposure group mothers more likely belonged to the lower socioeconomic class than the Control group mothers (p\u0026thinsp;=\u0026thinsp;0.000). Figure\u0026nbsp;3 shows the educational level of the mother groups. Mothers who followed the customary dietary restrictions had significantly less years of formal education than the Control group mothers. (p\u0026thinsp;=\u0026thinsp;0.00).\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides a comparison of TDP levels and the prevalence of thiamine deficiency between two groups. The mean (SD) TDP level in infants was significantly lower in the Exposure group (99.3\u0026thinsp;\u0026plusmn;\u0026thinsp;33 nmol/L) than the control group (119\u0026thinsp;\u0026plusmn;\u0026thinsp;35 nmol/L). Similarly, maternal TDP levels were lower in the Exposure group (148.5\u0026thinsp;\u0026plusmn;\u0026thinsp;62.9 nmol/L) than the Control group (183.5\u0026thinsp;\u0026plusmn;\u0026thinsp;76.1 nmol/L), with both differences reaching the statistical significance (p\u0026thinsp;=\u0026thinsp;0.00). At cut-off value of 90 nmol/L, the prevalence of thiamine deficiency in the Exposure group infants was 35.8% (120/335) and 18.8% (55/293) in the control group infants, while as 39 (11.64%)of Exposure mothers and 10 (3.5%) of Control group mothers were found thiamine deficient\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean Thiamine Diphosphate (TDP) Levels of the Study Population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudy Group (N\u0026thinsp;=\u0026thinsp;335)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl Group (N\u0026thinsp;=\u0026thinsp;293)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTDP level of Babies (nmol/l). Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e99.3\u0026thinsp;\u0026plusmn;\u0026thinsp;33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e119\u0026thinsp;\u0026plusmn;\u0026thinsp;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTDP level of Mothers (nmol/l). Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e148.5\u0026thinsp;\u0026plusmn;\u0026thinsp;62.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e183.5\u0026thinsp;\u0026plusmn;\u0026thinsp;76.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThiamine Deficiency in Babies. No (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (1.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThiamine Deficiency in Lactating Mothers. No (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (11.64%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (3.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCorrelation between maternal and infant blood TDP levels.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Pearson correlation analysis revealed a correlation coefficient of 0.533 between maternal and infant blood TDP levels, which was highly significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this population based cross sectional study, a total of 628 healthy breastfed infants and their mothers were enrolled from the community. Exposure group consisted of 335 participants and 293 participants belonged to the Control group. The key findings included a significant association of customary dietary restrictions with low socioeconomic status of the family as well as lower maternal educational level. The prevalence of thiamine deficiency in the Exposure group infants and Control group infants was 35.8% (120/335) and 18.8% (55/293) respectively. The mean thiamine level in the Exposure Group infants (99.3\u0026thinsp;\u0026plusmn;\u0026thinsp;33 nmol/L) was significantly lower than that the Control Group infants (119\u0026thinsp;\u0026plusmn;\u0026thinsp;35 nmol/L). Additionally, there was a strong correlation between maternal serum TDP levels and the TDP levels of offspring, with a correlation coefficient of 0.533, highlighting the close relationship between maternal and infant thiamine status.\u003c/p\u003e\u003cp\u003eThiamine serves as an essential cofactor in energy metabolism and the synthesis of nucleic acids, myelin, and neurotransmitters such as acetylcholine. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] The body's thiamine stores are limited, and the turnover rate is high. Conditions which Increase metabolic demand, such as febrile illness, pregnancy, lactation, and infancy leads to rapid consumption of thiamine. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Therefore, severe thiamine deficiency can develop rapidly in pregnant and lactating women as well as their offspring, if dietary thiamine intake is limited. This risk is particularly relevant in populations with low thiamine intake, often due to the consumption of polished rice as a staple diet. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] In India, a large section of the population consumes polished rice as a staple diet, therefore are at the risk of said deficiency.\u003c/p\u003e\u003cp\u003eOur study is among the few global studies to assess the effect of dietary habits and taboos of lactating women on their thiamine status as well as their offspring. In addition, we investigated the factors that influence the adoption of customary dietary restrictions by women in this region. We found that cultural food practices during pregnancy and lactation were significantly associated with lower maternal education level and lower socioeconomic background of the family. Similar findings have been reported in many low- and middle-income countries (LMICs) where certain cultural practices in the marginalized class of the society often limit the intake of essential nutrients, including proteins, iron, and vitamins, thus negatively affecting maternal and infant health [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In contrast, higher education levels and higher-income households are associated with reduced adherence to traditional dietary restrictions. Azene et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] found that literate women were 82% more likely to consume a diversified diet than illiterate women. Similarly, a study in Kenya reported that women from high-income households consumed a greater variety of foods. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Pregnant and lactating women from lower socioeconomic and educational backgrounds are already at a higher risk of complications. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The adoption of a monotonous diet, devoid of essential nutrients including thiamine, further would predispose them and their offspring at risk of various complications. A study on beriberi infants by Coats et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] in rural Cambodia, found that approximately 60% of the mothers followed postpartum dietary avoidance practices, the mean thiamine level of their infants was significantly lower compared to the American controls.\u003c/p\u003e\u003cp\u003eWe assessed the thiamine status of our study cohort, including both mothers and infants, by directly estimating thiamine diphosphate (TDP) levels in whole blood. This method was chosen over the traditional erythrocyte transketolase (ETK) enzyme activity coefficient assay, which is a functional assay for evaluating body thiamine levels. Although the ETK activity assay has been widely used, it is influenced by factors other than thiamine deficiency. Additionally, it has several limitations, including limited availability, non-standardized reference ranges, poor inter-assay reproducibility, rapid inactivation of the transketolase enzyme, and the absence of external quality assurance systems. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] These limitations make the ETK assay less reliable than the direct estimation of whole blood TDP levels using high-performance liquid chromatography (HPLC). The primary drawback of direct TDP estimation is its highly unstable nature, with rapid degradation due to exposure to light and heat. To address this challenge, blood samples were collected using vacutainer wrapped in silver foil to shield them from light. The samples were then immediately transferred to liquid nitrogen at the collection site for transportation and subsequently stored at -20\u0026deg;C in the laboratory before final analysis.\u003c/p\u003e\u003cp\u003eThe mean TDP levels in both the Exposure and control groups infants and their mothers were lower than those reported in industrialized countries, such as Canada and the United States. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] This discrepancy can be attributed to several factors. First, the control group also consumed polished rice, which is a staple food in the Kashmir Valley. Polished rice, which is typically washed multiple times before cooking, leads to substantial loss of thiamine. Second, India lacks routine thiamine fortification of staple foods, resulting in marginal thiamine intake at the community level. Furthermore, the carbohydrate-based nature of rice results in an increased rate of thiamine consumption, further depleting thiamine reserves in the body. Coats et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] measured mean blood thiamine levels in Cambodian infants with and without beri beri symptoms and in their mothers and American controls. The mean TDP level in Cambodian cases, Cambodian controls and American controls were 48 mmol/l, 56 mmol/l, 132 mmol/l respectively. These findings suggested that populations relying predominantly on rice-based diets tend to have lower mean thiamine levels than populations consuming more diverse diets. This underscores the need for dietary diversification, and thiamine fortification programs in regions relying on polished rice as a staple food.\u003c/p\u003e\u003cp\u003eIn our study, the mean thiamine level was significantly lower in the Exposure group mothers and their infants compared to the control group. This difference was likely due to adaptation of customary dietary restrictions by the mothers in the Exposure group, who primarily consumed meat soups and rice, a very common cultural practice in this part of the world predisposing their breastfed babies to severe thiamine insufficiency. When TDP levels were analyzed as a dichotomous variable using a deficiency cutoff of 90 nmol/L, we found the prevalence of biochemical thiamine deficiency significantly high in the Exposure group infants (35.8%, 120) compared to the control group infants (18.8%, 55). Similarly 11.64% of Exposure mothers and 3.5% of Control group mothers were found thiamine deficient, These findings are consistent with studies from Southeast Asia, where thiamine deficiency is endemic, reflecting substantial burden of subclinical deficiency in studied population. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Multiple studies from Lao and other southeast Asian countries have shown that limited dietary diversity, consumption of low-thiamine staple crops (such as polished white rice), certain cooking practices (repetitive washing and soaking rice for many hours) and traditional postpartum restrictive diets, all place lactating women at high risk of thiamine deficiency.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Breast-milk thiamine concentration and infant thiamine status are strongly dependent on maternal thiamine intake and status, hence, maternal thiamine deficiency rapidly results in biochemical thiamine deficiency in their infants.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] According to the WHO, infantile thiamine deficiency is the only serious form of malnutrition that occurs in adequately breastfed infants and most commonly occur when the mother herself is thiamine-deficient.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eWhile the clinical implications of biochemical thiamine deficiency in asymptomatic breastfed infants cannot be directly inferred from our data, the high burden of clinical infantile beriberi in our region provides indirect evidence that the biochemical deficiency if not corrected may progress to overt fulminant beriberi in situations that lead to rapid thiamine depletion such as acute febrile illness, vaccination etc. There is ample evidence to support this hypothesis, multiple studies have been published from this region as well as other thiamine deficient endemic countries on acute infantile beriberi. The common feature in all studies were involvement of young breastfed infants, milled rice was a staple diet as well as practice of customary dietary restrictions among mothers of the affected infants. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] There is ample evidence that thiamine deficiency endemic areas have high infant mortality which improve if thiamine supplementation is provided to pregnant and lactating women. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] These findings reinforce our hypothesis that biochemical thiamine deficiency in infants can evolve into fulminant beriberi over time if left unaddressed.\u003c/p\u003e\u003cp\u003eThe strength of our study lies in its community-based design, with a sufficiently large sample size, recruited from well-baby clinics and immunization centers. However, the primary limitation of our study is the inability to establish a direct causal link between biochemical thiamine deficiency and the subsequent development of beriberi symptoms, as this would be an unethical practice not to treat the subclinical deficiency and to longitudinally follow these infants for the development of beriberi symptoms. Nevertheless, substantial epidemiological evidence indicates that places with high infantile and maternal beriberi cases have high prevalence of subclinical thiamine deficiency at population level as well as high infant mortality rates beyond one month of age, which is a surrogate marker of thiamine deficiency at community level. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Infantile beriberi represents the most critical outcome of thiamine deficiency, but marginal thiamine status in the broader population has been linked to symptoms such as fatigue, apathy, anorexia, and dizziness [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which may lead to poor school performance and economic productivity. Furthermore, a study on Israeli children who consumed thiamine-deficient infant formula during infancy revealed delayed neurocognitive development at ages 5\u0026ndash;7 years. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] This underscores the crucial importance of ensuring adequate thiamine levels during early-life support healthy growth and development.\u003c/p\u003e\u003cp\u003eTo conclude, this community-based Cross-Sectional study among healthy breastfed infant\u0026rsquo;s highlights that customary dietary restrictions are significantly more prevalent in families with lower socioeconomic status and among women with lower education status and are associated with a higher prevalence of biochemical thiamine deficiency in both mothers and their infants. The mean TDP levels in both groups were lower than expected, with the Exposure Group exhibiting significantly lower levels than the Control Group. We notably observed a strong correlation between maternal blood TDP levels and those of their offspring, highlighting the close relationship between maternal and infant thiamine status. These findings emphasize the need for targeted nutritional interventions in vulnerable populations to mitigate the risk of subclinical thiamine deficiency.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTDP: Thiamine diphosphate\u003c/p\u003e\n\u003cp\u003eLMICs: Low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eCRF: Case report form\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHPLC: High performance liquid chromatography\u0026nbsp;\u003c/p\u003e\n"},{"header":"Declarations","content":"\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Indian Council of Medical Research.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAcknowledgements,\u003c/strong\u003e Aisha for helping in making various graphs\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFinancial Support\u003c/strong\u003e:\u0026nbsp;This work was supported by the Indian Council of Medical Research (ICMR)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e Nil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship:\u003c/strong\u003e concept and design, JIB, paper writing, JIB, BAC; Review and editing, BAC, ZAS, project administration, ABB and ABP. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWhitfield KC, Bourassa MW, Adamolekun B, Bergeron G, Bettendorff L et al. Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs. Ann N Y Acad Sci. 2018 Oct;1430(1):3-43.\u003c/li\u003e\n\u003cli\u003eBhat JI, Rather HA, Ahangar AA, Qureshi UA, Dar P et al. Shoshin beriberi-thiamine responsive pulmonary hypertension in exclusively breastfed infants: A study from northern India. Indian Heart J. 2017 Jan-Feb;69(1):24-27. \u003c/li\u003e\n\u003cli\u003eAllen LH. B vitamins in breast milk: relative importance of maternal status and intake, and effects on infant status and function. Adv Nutr. 2012 May 1;3(3):362-9.\u003c/li\u003e\n\u003cli\u003eBhat JI, Rather HA, Ahangar AA, Qureshi UA, Dar P et al. Shoshin beriberi-thiamine responsive pulmonary hypertension in exclusively breastfed infants: A study from northern India. Indian Heart J. 2017 Jan-Feb;69(1):24-27. \u003c/li\u003e\n\u003cli\u003eBhat JI, Ahmed QI, Ahangar AA, Charoo BA, Sheikh MA, Syed WA. Wernicke\u0026apos;s encephalopathy in exclusive breastfed infants. World J Pediatr. 2017 Oct;13(5):485-488. \u003c/li\u003e\n\u003cli\u003ePanigrahy N, Chirla DK, Shetty R, Shaikh FAR, Kumar PP, et al. Thiamine-Responsive Acute Pulmonary Hypertension of Early Infancy (TRAPHEI)-A Case Series and Clinical Review. Children (Basel). 2020 Oct 28;7(11):199. \u003c/li\u003e\n\u003cli\u003eLu J, Frank EL. Rapid HPLC measurement of thiamine and its phosphate esters in whole blood. Clin Chem. 2008 May;54(5):901-6. doi: 10.1373/clinchem.2007.099077. \u003c/li\u003e\n\u003cli\u003eDhir S, Tarasenko M, Napoli E, Giulivi C. Neurological, Psychiatric, and Biochemical Aspects of Thiamine Deficiency in Children and Adults. Front Psychiatry. 2019 Apr 4;10:207. \u003c/li\u003e\n\u003cli\u003eHiffler L, Rakotoambinina B, Lafferty N, Martinez Garcia D. Thiamine Deficiency in Tropical Pediatrics: New Insights into a Neglected but Vital Metabolic Challenge. Front Nutr. 2016 Jun 14;3:16.\u003c/li\u003e\n\u003cli\u003eSoukaloun D, Kounnavong S, Pengdy B, Boupha B, Durondej S, Olness K, Newton PN, White NJ. Dietary and socioeconomicfactors associated with beriberi in breastfed Lao infants. Ann Trop Paediatr2003;23:181\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eAmare W, Tura AK, Semahegn A, Teji Roba K. Food taboos among pregnant women and associated factors in eastern Ethiopia: A community-based cross-sectional study. SAGE Open Med. 2022 Nov 19.\u003c/li\u003e\n\u003cli\u003eAzene AG, Aragaw AM, Wubetie HT, Wassie GT, Tsegaye GW, et al. Dietary diversity among pregnant women and associated factors in Ethiopia: Systematic review and meta-analysis. PLoS One. 2021 Jun 10;16(6). :e0251906.\u003c/li\u003e\n\u003cli\u003eKorir, L., Rizov, M. \u0026amp; Ruto, E. (2023) Diet diversity, malnutrition and health: Evidence from Kenya. Journal of Agricultural Economics, 74, 534\u0026ndash;550.\u003c/li\u003e\n\u003cli\u003eSouza JP, Day LT, Rezende-Gomes AC, Zhang J, Mori R, Baguiya A, Jayaratne K, Osoti A, Vogel JP, Campbell O, Mugerwa KY, Lumbiganon P, Tun\u0026ccedil;alp \u0026Ouml;, Cresswell J, Say L, Moran AC, Oladapo OT. A global analysis of the determinants of maternal health and transitions in maternal mortality. Lancet Glob Health. 2024 Feb;12(2):e306-e316.\u003c/li\u003e\n\u003cli\u003eCoats D, Shelton-Dodge K, Ou K, Khun V, Seab S, et al. Thiamine deficiency in Cambodian infants with and without beriberi. J Pediatr. 2012 Nov;161(5):843-7.\u003c/li\u003e\n\u003cli\u003eTaylor AJ, Talwar D, Lee SJ, Cox L, Mayxay M, et al. Comparison of Thiamin Diphosphate High-Performance Liquid Chromatography and Erythrocyte Transketolase Assays for Evaluating Thiamin Status in Malaria Patients without Beriberi. Am J Trop Med Hyg. 2020 Dec;103(6):2600-2604.\u003c/li\u003e\n\u003cli\u003eMcGready R, Simpson JA, Cho T, Dubowitz L, Changbumrung S, et al. Postpartum thiamine deficiency in a Karen displaced population. Am J Clin Nutr. 2001 Dec;74(6):808-13.\u003c/li\u003e\n\u003cli\u003eHolmes W, Hoy D, Lockley A, Thammavongxay K, Bounnaphol S, Xeuatvongsa A, Toole M. Influences on maternal and child nutrition in the highlands of the northern Lao PDR. Asia Pac J Clin Nutr. 2007;16(3):537-45.\u003c/li\u003e\n\u003cli\u003eBarennes H, Sengkhamyong K, Ren\u0026eacute; JP, Phimmasane M. Beriberi (thiamine deficiency) and high infant mortality in northern Laos. PLoS Negl Trop Dis. 2015 Mar 17;9(3):e0003581.\u003c/li\u003e\n\u003cli\u003e\u003ccite\u003eWorld Health Organization Thiamine deficiency and its prevention and control in major emergencies. Geneva: World Health Organization, 1999.\u003c/cite\u003ehttps://iris.who.int/handle/10665/66139.\u003c/li\u003e\n\u003cli\u003eLuxemburger C, White NJ, ter Kuile F, Singh HM, Allier-Frachon I, Ohn M, Chongsuphajaisiddhi T, Nosten F. Beri-beri: the major cause of infant mortality in Karen refugees. Trans R Soc Trop Med Hyg. 2003 Mar-Apr;97(2):251-5.\u003c/li\u003e\n\u003cli\u003eCarpenter KJ. Beriberi, white rice, and vitamin B: a disease, a cause, a cure Berkley: University of Califormia Press; 2000.\u003c/li\u003e\n\u003cli\u003eMimouni-Bloch A, Goldberg-Stern H, Strausberg R, Brezner A, Heyman E, Inbar D, et al. Thiamine deficiency in infancy: long-term follow-up. Pediatr Neurol. Elsevier Inc; 2014;51\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Thiamine deficiency, Infants, Beriberi","lastPublishedDoi":"10.21203/rs.3.rs-7558131/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7558131/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe widespread consumption of polished rice as a staple food in many parts of India increases the risk of thiamine deficiency. Additionally, few cultural dietary practices among lactating women further predispose them to this deficiency. This population based Cross-Sectional study was conducted to estimate the prevalence of biochemical thiamine deficiency among exclusively breastfed infants whose mothers were on customary dietary restrictions compared to age-matched controls.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study participants consisted of two groups namely \u0026ldquo;Exposure group\u0026rdquo; and \u0026ldquo;Control group\u0026rdquo;. The desired demographic, socioeconomic, dietary and clinical information were noted. The thiamine status was assessed using blood thiamine diphosphate (TDP) estimation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eExposure group and control group comprised of 335 and 293 exclusively breastfed infants and their mothers, respectively. Exposure group mothers significantly belonged to lower socioeconomic classes and had lower education levels. The mean TDP level in infants was significantly lower in the Exposure group (99.3\u0026thinsp;\u0026plusmn;\u0026thinsp;33 nmol/L) compared to the Control group (119\u0026thinsp;\u0026plusmn;\u0026thinsp;35 nmol/L). At a cut-off value of 90 nmol/L, the prevalence of thiamine deficiency in the Exposure group infants was 35.8% (120/335) and 18.8% (55/293) in the control group infants.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe found Customary dietary restrictions commonly associated with lower socioeconomic status and lower maternal education levels. Biochemical thiamine deficiency was high in both groups, it was significantly higher in the Exposure group infants compared to the Control group infants.\u003c/p\u003e","manuscriptTitle":"Biochemical Thiamine Deficiency in Exclusively Breastfed Infants from an Endemic Region in Northern India: A Population-Based Cross Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:07:14","doi":"10.21203/rs.3.rs-7558131/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2be7fce5-4638-4b15-ba74-d69766c60f89","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54679646,"name":"Biological sciences/Biochemistry/Metabolomics"},{"id":54679647,"name":"Health sciences/Medical research/Epidemiology"}],"tags":[],"updatedAt":"2026-04-22T10:01:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 07:07:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7558131","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7558131","identity":"rs-7558131","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}