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1.  Prevalence of Goitre in Isfahan, Iran, Fifteen Years After Initiation of Universal Salt Iodization 
This cross-sectional study investigated the prevalence of goitre in Isfahan, a centrally-located city in Iran, 15 years after the initiation of universal salt iodization. In total, 2,523 Isfahani adults (1,275 males, 1,248 females) aged >20 years were selected by multi-stage cluster-sampling method. Goitre rate, serum thyroid-stimulating hormone (TSH), thyroxine (T4), thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TgAb), and urinary iodine concentration (UIC) were measured and compared between the goitrous (n=478) and the non-goitrous (n=2,045) participants. The total goitre rate was 19% (n=478) of the 2,523 adults. The rate of Grade I and II goitre was 12.4% (n=312) and 6.6% (n=166) respectively. The total goitre rate, Grade I and II goitre were more prevalent among women than among men. Hypothyroidism was observed in 6.4% (130/2,045) and 18.6% (89/478) of the non-goitrous and goitrous participants respectively [odds ratio (OR)=3.6, 95% confidence interval (CI) 2.7-4.9, p=0.001]. Hyperthyroidism was present in 0.8% (17/2,045) and 5.2% (29/478) of the non-goitrous and goitrous adults respectively (OR=9.0, 95% CI 4.9-16.6, p=0.001). Hypothyroidism was more prevalent in Grade II than in Grade I goitre and among those without goitre (31.3%, 14.1%, and 6.4% respectively) (p=0.001). Positive TPOAb was observed in 24% (n=50) of the non-goitrous and 33.5% (n=84) of the goitrous subjects (p=0.03). Positive TPOAb was observed in 24.6% (35 of 142) of the Grade I and 45% (49 of 109) of the Grade II goitrous adults (p=0.001). Positive TgAb was observed in 21.6% (n=45) of the non-goitrous and 35.9% (n=90) of the goitrous adults (p=0.001). Positive TgAb was observed in 30.3% (43 of 142) of the Grade I and 43.1% (47 of 109) of the Grade II goitrous adults (p=0.04). The median UIC was 18 μg/dL (range 1-80 μg/dL). It was 17.9 μg/dL and 19 μg/dL in the non-goitrous and goitrous adults respectively. After 15 years of successful universal salt iodization in Isfahan, goitre is still endemic, which may be due to thyroid autoimmunity. However, other environmental or genetic factors may have a role.
PMCID: PMC2965326  PMID: 20824978
Autoimmunity; Cross-sectional studies; Goitre; Hypothyroidism; Hyperthyroidism; Impact studies; Iodine; Iodine deficiency; Iran
2.  Persistence of goitre in the post-iodization phase: micronutrient deficiency or thyroid autoimmunity? 
Background & objectives:
Despite years of salt iodization, goitre continues to be a major public health problem worldwide. We examined the prevalence of goitre in the post-iodization phase and the relationship of goitre with micronutrient status and thyroid autoimmunity in school children of Chandigarh, north India.
Methods:
Two phase study; in the first phase, 2148 children of 6 to 16 yr were screened for goitre by two independent observers as per the WHO grading system. In the second phase, a case-control study, 191 children with goitre and 165 children without goitre were compared with respect to urinary iodine, iodine content of salt, serum levels of T3, T4, TSH, anti-TPO (thyroid peroxidase) antibody, haemoglobin, ferritin and selenium.
Results:
Prevalence of goitre in the studied subjects was 15.1 per cent (13.9% in 6 to 12 yr and 17.7% in 13 to 16 yr age group, P= 0.03). Median urinary iodine excretion in both the groups was sufficient and comparable (137 and 130 µg/l). 3.2 per cent children with goitre and 2.4 per cent without goitre had hypothyroidism (subclinical and clinical) and only one child with goitre had subclinical hyperthyroidism. Nine (4.9%) children in the goitre group and 3 (1.9%) in control group had anti-TPO antibody positivity. The median serum selenium levels were not different in both the groups (181.9 and 193.5 µg/l). Seventy one (37.4%) of the goitrous children had anaemia (haemoglobin <12 g/dl) as compared to 41 (24.8%) of the control group (P <0.01). More number of goitrous children (39, 20.6%) were depleted of tissue iron stores (serum ferritin <12 µg/l) as compared to controls (11, 6.4%; P<0.001). Serum ferritin level negatively correlated with the presence of goitre (r = - 0.22, P =0.008) and had an OR of 2.8 (CI 1.20 - 6.37, P =0.017).
Interpretation & conclusions:
There was a high prevalence of goitre in young children despite iodine repletion and low thyroid autoimmunity. The concurrent iron deficiency correlated with the presence of goiter. However, the cause and effect relationship between iron deficiency state and goitre requires further elucidation.
PMCID: PMC3100137  PMID: 21321427
Goitre; iodine deficiency; iron deficiency; selenium; thyroid autoimmunity
3.  Iodine nutritional status and risk factors for goitre among schoolchildren in South Tajikistan 
Background
Iodine deficiency affects nearly 1.9 billion people worldwide, but it can be prevented by salt iodization. This cross-sectional survey assessed current iodine status, iodized salt coverage and risk factors for goitre among schoolchildren in South Tajikistan.
Methods
Ten primary schools in four districts in South Tajikistan were randomly selected. In schoolchildren aged 7 to 11 years, a spot urine sample was collected for measurement of urinary iodine, dried blood spots were collected for measurement of thyroglobulin, and goitre was assessed by palpation. Iodine content of salt samples and local selling points was determined by coloration using rapid test kits and titration method.
Results
Of 623 schoolchildren enrolled, complete data was obtained from 589. The overall median urinary iodine concentration (UIC) was 51.2 μg/L indicating mild-to-moderate iodine deficiency. Among all children, 46.6% (95% Confidence Interval (CI) = 42.4%-50.6%) of children were found to be goitrous (grade 1 goitre: 30.6%, 95% CI = 26.9%-34.5%; grade 2 goitre: 16.0%, 95% CI = 13.1%-19.2%). The risk factor for goitre remaining significant in the multivariable logistic regression model was 'buying salt once a month’ (OR = 2.89, 95% CI = 1.01-8.22) and 'buying salt once every six months’ (OR = 2.26, 95% CI = 1.01-5.04) compared to 'buying salt every one or two weeks’. The overall median thyroglobulin concentration was elevated at 13.9 μg/L. Of the salt samples from households and selling points, one third were adequately iodised, one third insufficiently and one third were not iodised.
Conclusion
Iodine deficiency remains a serious health issue among children in southern Tajikistan. There is a persisting high prevalence of goitre, elevated thyroglobulin and low UIC despite interventions implemented by Tajikistan and international partners. Quality control of salt iodine content needs to be improved. Continued efforts to raise awareness of the health effects of iodine deficiency are needed to increase consumer demand for iodised salt.
doi:10.1186/1472-6823-13-50
PMCID: PMC4175091  PMID: 24180470
Iodine status; Goitre; Risk factors for goitre; Urinary iodine concentration; Thyroglobulin concentration; Salt iodization; Schoolchildren; Tajikistan
4.  New Zealand Views on Goitre 
Simple goitre is highly prevalent in New Zealand, and there is considerable incidence of toxic goitre. The ætiology of simple goitre seems fairly well established, and an attempt is being made to apply the data from simple goitre to the problems of toxic goitre.
Endemic goitre is of great antiquity among the Maoris, and has been described among Europeans for about fifty years. It occurs in both men and animals. At five years its incidence is similar in boys and girls, later it decreases in boys but increases greatly in girls. It is often hereditary, and many children are born goitrous. In children it is generally small, but may enlarge and cause pressure, myxœdema and toxicity. Its incidence varies greatly in different districts.
The only cause found consistent with this variation in distribution is lack of iodine in the soil. An inverse ratio has been demonstrated between the iodine content of the soil and the incidence of goitre in school children in thirty-three districts. The iodine content of the soil is reflected in the food raised upon it.
The daily iodine intake was estimated at 35 microgrammes in a non-goitrous, and at 20 microgrammes in a goitrous district.
The amount of iodine involved is infinitesimal, and its intake can be ensured by the use of salt for ordinary consumption, which contains four parts per million of potassium iodide.
Toxic goitre is also frequent: in this connexion, the influence of iodine on the thyroid has been investigated. If starved of iodine the thyroid adapts itself either by increasing its colloid or by a diffuse hyperplasia, both may occur in different parts of the same gland. Simple goitre is the response of the healthy thyroid to iodine deficiency, the responding areas may be diffuse or adenomatous, and degenerations may occur. Such goitres may be treated with iodine, in children re-adjustment to the increased intake is readily made, but in adults long accustomed to a low intake, excess often causes too great hormone production, with toxic symptoms, hence the minimal dose alone is permissible in iodized salt.
Goitre stored with iodine at low pressures may become toxic under stress, and this may be precipitated by iodine. The prevalence of toxic goitre may be partly due to the prescription of iodides in therapeutic doses for common ailments.
Diffuse colloid goitre may subside under physiological iodine, the adenomatous is more prone to toxic symptoms and may go on to secondary Graves' disease or to myxœdema. Diffuse hyperplasia is a possible manifestation of iodine deficiency as primary Graves' disease. Lugol's solution probably allows of a temporary storage in this condition. Iodine has certainly some bearing on the problems of toxic goitre.
PMCID: PMC2102294  PMID: 19986504
5.  Zinc status in goitrous school children of Semirom, Iran 
BACKGROUND:
Iodine deficiency produces the spectrum of iodine deficiency disorders (IDDs) including endemic goiter, hypothyroidism, cretinism and congenital anomalies. Other factors, including goitrogens and micronutrient deficiencies may influence the prevalence and severity of IDDs and response to iodine supplementation. An association between zinc and goiter has previously been reported.
METHODS:
A cross sectional study investigating an association between goiter and serum zinc status was performed in 2003 in a mountainous region of Iran. One thousand eight hundred twenty-eight children were selected by multistage cluster sampling. Goiter staging was performed by inspection and palpation. Serum zinc, total thyroxine, thyroid stimulating hormone and urinary iodine concentration were measured in a group of these children.
RESULTS:
Thirty six and seven tenth percent of subjects were classified as goitrous. Serum zinc level in goitrous and nongoitrous children was 82.80 ± 17.85 and 83.38 ± 16.25 μg/dl, respectively (p = 0.81). The prevalence of zinc deficiency (serum zinc ≤65 μg/dl) in goitrous and nongoitrous children did not differ significantly (9.3 % vs. 10.8%, p = 0.70).
CONCLUSIONS:
Goiter is still a public health problem in Semirom. According to the present study zinc status may not play a role in the etiology of goiter in Semirom school children. However, the role of other goitrogens or micronutrient deficiencies should be investigated in this region.
PMCID: PMC3129056  PMID: 21772878
Goiter; Iodine Deficiency; Zinc Deficiency; Child
6.  Protein-energy Malnutrition in Goitrous Schoolchildren of Isfahan, Iran 
Background:
Some studies have shown the possible role of protein-energy malnutrition (PEM) in persistence of endemic goiter in iodine replenished areas. The present study was conducted to assess the association between PEM and goiter in schoolchildren of Isfahan, Iran.
Methods:
In a cross-sectional study using multistage cluster random-sampling, 2331 schoolchildren with age ranged from 6-13 years old with a female to male ratio of 1.60 were enrolled. Thyroid size was examined by two endocrinologists for goiter detection. Children were considered goitrous if they had palpable or visible goiters according to World Health Organization (WHO)/United Nations children's Fund/International Council for the Control of Iodine Deficiency criteria. Weight and standing height were measured using the standard tools and anthropometric indices were calculated using the WHO AnthroPlus software developed by the World Health Organization. Height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ) and body mass index (BMI) for age were calculated for each child. Children with a HAZ, WAZ or BMI-for-age of Z-score < –2.0 were classified as stunted, underweight or thin, respectively. Blood samples were drowned to measure serum thyroid hormones.
Results:
Overall, 32.9% of subjects were classified as goitrous. Weight, height, BMI, WAZ and BMI-for-age Z-score were significantly lower in children with goiter than in children who did not have goiter (P < 0.05). The prevalence of goiter in thin children was higher than that in non-thin ones (48.4 vs. 31.6%, odds ratio [OR]: 2.02, 95% confidence interval [CI]: 1.52-2.69, P < 0.001). Although 33.4% of non-stunted children were goitrous, 31% of stunted ones had goiter (P = 0.5). According to the logistic regression model taking sex and age as covariates, the only significant parameter affecting palpable goiter detection was thinness (OR = 2.13, 95% CI: 1.22-3.69, P < 0.001).
Conclusions:
In the present study, we found a high prevalence of goiter in children who were malnourished. It seems that PEM may play a role in the still high prevalence of goiter in this region.
PMCID: PMC4050673  PMID: 24932384
Body mass index-for-age Z-score; goiter; height-for-age Z-score; Iran; protein-energy malnutrition; weight-for-age Z-score
7.  The Association between Cobalt Deficiency and Endemic Goiter in School-Aged Children 
Endocrinology and Metabolism  2014;29(3):307-311.
Background
In Iran, an iodine deficiency control program was initiated in 1989 by iodizing salt. Despite this program, goiters have remained an endemic condition in most parts of Iran. Thus, it is possible that other factors aside from iodine deficiency may contribute to endemic goiter. The aim of this study was to investigate the association between cobalt deficiency and endemic goiter in a region of Iran with a high prevalence of goiter.
Methods
A cross-sectional study was conducted among school children aged 9 to 11 years in the city of Kerman, Iran. In the first phase of the study, a multistage, proportional-to-size, cluster sampling method was used to screen 5,380 out of 29,787 students. After the screening phase, 170 students (130 goitrous and 40 nongoitrous) were randomly selected, and serum and urine specimens were obtained. We measured thyroid function, serum cobalt level, and urinary iodine excretion. Univariate and multiple logistic regression analyses were performed.
Results
The prevalence of grade 2 goiters was 34.8% (95% confidence interval [CI], 31.5 to 42.5), with both sexes being equally affected. The weight and body mass index of goitrous subjects was significantly lower (P<0.001) than those of nongoitrous subjects. The serum cobalt levels were lower in goitrous subjects than in nongoitrous subjects (4.4±2.9 µg/L vs. 6.4±2.7 µg/L). The urinary iodine levels were also lower in goitrous subjects than in nongoitrous subjects (198.3±108.3 µg/L vs. 270.2±91.1 µg/L). Multiple regression analysis showed that only cobalt deficiency, not iodine deficiency, significantly contributed to the presence of goiter (odds ratio, 0.78; 95% CI, 0.61 to 0.99; P=0.042).
Conclusion
Cobalt deficiency may be an important independent predicator for goiter in endemic regions, especially areas in which goiters persist despite salt iodization programs.
doi:10.3803/EnM.2014.29.3.307
PMCID: PMC4192825  PMID: 25309789
Goiter; Cobalt; Iodine deficiency; Urine Iodine; Thyroid
8.  Iodine deficiency, hypothyroidism, and endemic goitre in southern Tanzania. A survey showing the positive effects of iodised oil injections by TSH determination in dried blood spots. 
The Ukinga and Uwanji regions, located in the southern highlands of Tanzania, were studied for the degree of iodine deficiency and the incidence of goitre and hypothyroidism, respectively. A urinary iodine excretion as low as 17.6 +/- 9.3 micrograms/g creatinine was observed in Wangama village. The mean goitre prevalence in 27 villages in Uwanji ranged between 65 and 96% (n = 3031 schoolchildren). Of 681 pregnant women from Ukinga 79.6% had goitre. The prevalence of cretinism as estimated on clinical criteria was 3% in Magoye (Uwanji). A normal serum TSH (below 2.1 mU/l) was observed in only 12 out of 66 school children before iodine prophylaxis, whereas the T4/TBG ratio was decreased in 36 of 63 cases. Blood spot TSH levels in newborn infants (n = 219) from mothers without iodine supplementation were above 12 mU/l in 45%. In contrast, only 20.3% of the newborn (n = 118) had elevated blood spot TSH (p less than 0.002) when the mothers had received an iodised oil injection during pregnancy. Most of the newborn (n = 18; 75%) of the latter group with elevated TSH (n = 24) came from mothers who had received the iodine injection only 1-25 days before delivery. Maternal iodine prophylaxis in late pregnancy does not increase the rate of neonatal hypothyroidism. Conclusions: It has been confirmed that severe iodine deficiency resulting in endemic goitre, cretinism, and hypothyroidism is prevalent in the regions studied. Dried blood spot TSH determinations may serve as an index for the efficiency of iodine prophylaxis programmes. Such a programme was carried out with relatively little expenditure and effort on a large scale basis.
PMCID: PMC1052447  PMID: 2995534
9.  The goitre rate, its association with reproductive failure, and the knowledge of iodine deficiency disorders (IDD) among women in Ethiopia: Cross-section community based study 
BMC Public Health  2007;7:316.
Background
Iodine deficiency is severe public health problem in Ethiopia. Although urinary iodine excretion level (UIE) is a better indicator for IDD the goitre rate is commonly used to mark the public health significance. The range of ill effect of IDD is however beyond goitre in Ethiopia. In this study the prevalence of goitre and its association with reproductive failure, and the knowledge of women on Iodine Deficiency were investigated.
Methods
A cross-section community based study was conducted during February to May 2005 in 10998 women in child bearing age of 15 to 49 years. To assess the state of iodine deficiency in Ethiopia, a multistage "Proportional to Population Size" (PPS) sampling methods was used, and WHO/UNICEF/ICCIDD recommended method for goitre classification.
Results
Total goitre prevalence (weighted) was 35.8% (95% CI 34.5–37.1), 24.3% palpable and 11.5% visible goitre. This demonstrates that more than 6 million women were affected by goitre.
Goitre prevalence in four regional states namely Southern Nation Nationalities and People (SNNP), Oromia, Bebshandul-Gumuz and Tigray was greater than 30%, an indication of severe iodine deficiency. In the rest of the regions except Gambella, the IDD situation was mild to moderate. According to WHO/UNICEF/ICCIDD this is a lucid indication that IDD is a major public health problem in Ethiopia. Women with goitre experience more pregnancy failure (X2 = 16.5, p < 0.001; OR = 1.26, 1.12 < OR < 1.41) than non goitrous women. Similarly reproductive failure in high goitre endemic areas was significantly higher (X2 = 67.52; p < 0.001) than in low. More than 90% of child bearing age women didn't know the cause of iodine deficiency and the importance of iodated salt.
Conclusion
Ethiopia is at risk of iodine deficiency disorders. The findings presented in this report emphasis on a sustainable iodine intervention program targeted at population particularly reproductive age women. Nutrition education along with Universal Salt Iodization program and iodized oil capsule distribution in some peripheries where iodine deficiency is severe is urgently required.
doi:10.1186/1471-2458-7-316
PMCID: PMC2194698  PMID: 17996043
10.  Iodine Status and Prevalence of Goitre in School Going Children in Rural Area 
Introduction: Iodine deficiency disorder (IDD) is one of the preventable major public health problems in India. It has been always thought that goitre was only found in the Himalayan goitre belt. Recent surveys outside the conventional goitre belt have identified foci of iodine deficiency in other parts of India.
Aim: 1) To assess the prevalence of goitre among school-going children in the age group of 6-15 years. 2) To find out the relationship of goitre prevalence with the salt intake and urinary iodine excretion. 3) To unfold the iodine nutritional status of the study population.
Material and Methods: The study was conducted from January 2005 to July 2006 in school children of 6-15 years of age, attending the 55 schools of Bellur hobli in the southern part of India. The clinical examination of all the 1600 children of the selected schools was done to detect and grade goitre. Urine and salt samples were collected from sub-samples (n = 400) to estimate the urinary iodine excretion level and iodine content in the salt respectively.
Results: The goitre prevalence in the study population was found to be 0.125%. Urinary iodine excretion (UIE) level of ≥ 100 mcg / l was found in 361 children (90.25%) and < 100 mcg/ l in 39 children (9.75%). Estimation of iodine content of the salt samples revealed that 363 (90.75%) consumed adequately iodised salt (> 15ppm) and 37 (9.25%) consumed inadequately iodised salt (< 15ppm).
Conclusion: Bellur Hobli is not an endemic area for goitre and there is no biochemical iodine deficiency in this population due to effective implementation of Universal iodization programme (UIP). It is reasonable to conclude that by achieving the universal iodisation of salt, IDD can be successfully eliminated from the community.
doi:10.7860/JCDR/2013/6311.4732
PMCID: PMC4190768  PMID: 25302243
Goitre; Iodine deficiency; Iodised salt; Urinary iodine excretion
11.  Prevalence of Goitre in School Children of Chamarajanagar District, Karnataka, India 
Introduction: Iodine is an essential micronutrient. A daily consumption of 100-150 micrograms of iodine is recommended for normal human growth and development.
Rationale: Iodine Deficiency Disorders (IDD) can be easily prevented. Simplest, most effective and inexpensive preventive method is consumption of iodated salt.
Objectives: To find out the prevalence of Goitre among school children in Chamarajanagar district, India, and to estimate iodine in salt samples.
Methodology: A cross-sectional study in the age group of 6-12 years using PPS systematic sampling method. A total of 3757 children were selected for the study. Clinical examination of the thyroid was done and salt samples were collected for Iodine estimation. Data was analyzed by using appropriate statistical tests.
Results: The overall prevalence of Goitre was found to be 7.74% in Chamarajanagar district, India. It was higher in female children compared to male children. The difference was more evident in Grade II cases where 64.47% cases were females and 35.53% cases were males and it showed an increasing trend with age (Class1-4.8%, Class 6-10.9%, Class 7–17.6%).
Conclusion: It was observed that IDD is endemic in the district with a prevalence of 7.74% among children of 6-12 years. Analysis of salt samples suggested that 28.42% samples had Iodine less than 15ppm.
doi:10.7860/JCDR/2013/6878.3702
PMCID: PMC3919349  PMID: 24551643
Goitre prevalence; School children; Chamarajanagar; Dot plot analysis
12.  Drifting continents and endemic goitre in northern Pakistan. 
BMJ : British Medical Journal  1990;300(6738):1507-1512.
Although Baltistan, north east Pakistan, is in a region of iodine deficiency disorders, the distribution of goitre within the district, according to age and sex, has not been clearly defined. To establish the prevalence of the condition and to measure the reported difference in prevalence in the north and south of the district thyroid size was assessed in new patients attending the Aman clinic, Khapalu, and outlying areas between April and September from 1981 to 1986. Samples of potable water collected from villages were analysed for iodine (as iodide) concentrations in Britain. Population weighted prevalences were: in the north in males 20.4%, in females 28.1% and in the south in males 13.9%, in females 21.2%. There was an overall deficiency of iodine in the water (mean iodine (as iodide) concentrations (north) 11.0 nmol/l (1.4 micrograms/l), (south) 11.8 nmol/l (1.5 micrograms/l) (95% confidence interval -0.7 to 0.9). The differences followed the Main Karakoram Thrust, suggesting a geological goitrogen in the north, which might be minerals containing ions such as BF4- and SO3F-, and molybdenite and calcium, which are present in rocks in Baltistan. A new hypothesis for the genesis of endemic goitre is proposed--that is, that continents on crustal plates drift across the earth and collide, one plate sliding under the other and melting, giving rise to characteristic mineral assemblages in the overlying rocks. As the minerals weather out they enter the diet of the local population, where in the presence of iodine deficiency they produce or enhance iodine deficiency disorders. Despite the current iodised oil campaign by the Pakistani government with Unicef a long term working iodisation programme is still urgently needed.
PMCID: PMC1663226  PMID: 2372605
13.  Prevalence of goitre and hypothyroidism in Southern Tanzania: effect of iodised oil on thyroid hormone deficiency. 
In the Southern Highlands of Tanzania the prevalence of endemic goitre due to iodine deficiency is in the range of 90% and hypothyroidism in the range of 50% of schoolchildren. The present study confirms these data and documents the beneficial effect of Lipiodol injections on thyroid function in children around the age of puberty compared with untreated children from the same villages. On the other hand, a decrease in the prevalence of goitre could not be shown. A beneficial effect is shown for infants of mothers who received iodine during pregnancy. It seems that this form of supplementation is sufficient for breast fed children for more than three years, even when a second child has been delivered in the meantime. In contrast, older siblings of these babies may become hypothyroid when breast feeding is stopped. The determination of thyroid autoantibodies in iodine treated and untreated children and in young adults showed no increasing prevalence of positive findings thus excluding iodine induced chronic thyroiditis at least in the young target population.
PMCID: PMC1052495  PMID: 3011945
14.  Current iodine nutrition status and progress toward elimination of iodine deficiency disorders in Jazan, Saudi Arabia 
BMC Public Health  2012;12:1006.
Background
The term iodine deficiency disorders (IDD) refers to all the effects of iodine deficiency on growth and development in human and animal populations that can be prevented by correction of the iodine deficiency. The objective of this paper was to determine the iodine nutrition status among schoolchildren in the Jazan Region of the Kingdom of Saudi Arabia (KSA), by measuring urinary iodine concentrations and by clinical assessments of goiter rate.
Methods
A school-based cross-sectional survey was conducted in the Jazan region of southwestern KSA from May to November 2010. A total of 311 children, aged 6–13 years, drawn from 12 schools, were selected by a three-stage cluster random sampling method. Data on sociodemographic characteristics were collected using a structured questionnaire. Urine samples were collected and physical examinations were conducted to determine the presence or absence of goiter. Data were analyzed using SPSS version 17.0. Chi square and independent t-tests were used for proportions and mean comparisons between groups.
Results
Out of 360 selected children, 311 were examined. There were 131 males (42%) and 180 females (58%). The median urinary iodine concentration (UIC) of the study group was 421 μg/L. The study population proportion with UIC > 300 μg/L was 74% with a higher proportion among males and urban populations. The proportion of children with UIC of 100–300 μg/L was only 21% and was significantly higher among females compared with males (p < 0.001). Only about 3% of the children had a median UIC less than 50 μg/L. The prevalence of total goiter rate (TGR) among the sample of schoolchildren in Jazan was 11%, with significant variations between rural and urban populations and by gender.
Conclusions
The present study demonstrates a remarkable achievement in Universal Salt Iodization (USI) and IDD elimination goals in the Jazan area. However, UIC levels reflect excessive iodine intake and may put the population at risk of adverse health consequences like iodine-induced hyperthyroidism and autoimmune thyroid diseases.
doi:10.1186/1471-2458-12-1006
PMCID: PMC3533993  PMID: 23167286
Iodine nutrition; Saudi Arabia; Jazan; USI
15.  Evaluation of efficacy of iodine prophylaxis in Poland based on the examination of schoolchildren living in Opoczno Town (Lodz Voivodship) 
Thyroid Research  2012;5:23.
Background
In 1997 a currently obligatory model of iodine prophylaxis, based on mandatory iodization of household salt with 30 mg KI/kg, was introduced. The aim of our study was to assess the iodine intake among school-age children living in Opoczno in 3 subsequent time points – in 1994, before establishment of currently operating model of iodine prophylaxis, in 1999 – 2 years after implementation of iodine prophylaxis and in 2010, – 14 years after its implementation.
Methods
We assessed goitre incidence and urine iodine concentration (UIC) in 104 children in 1994, 207 children in 1999 and 174 children in 2012. Age of examined children ranged from 6 to 15 years. The thyroid volumes evaluated by ultrasound were compared to reference values for thyroid volume proposed by Zimmermann at al. Moreover, we have introduced a new index – V/BSA ratio (comparison of thyroid volume to the body surface area), which to our belief allows for more accurate assessment of thyroid volume.
Results
The median of UICs was 45.5 μg/L (1994), 101.1 μg/L (1999) and 100.6 μg/L (2010). The distribution of obtained results has changed as well – iodine concentrations below 50 μg/L were present in 59.1% children in 1994, in 12.6% children – in 1999 and in 7.1% children – in 2010.
Although a significant decrease in goitre incidence with regard to age – 92.6% (1994) vs 18.5% (1999) and 15.8% (2010), as well as with regard to BSA – 95.4% (1994) vs 15.2% (1999) and 11.6% (2010) was observed, it still points to the iodine deficiency, which is in contradiction with UICs as they are within normal limits. V/BSA ratio avoids such discrepancy. The values of ratio V/BSA were higher in 1994 (7.079 ± 2.775) than in 1999 (2.935 ± 1.112) (p<0.05) and in 2010 (2.846 ± 1.029) (p<0.05).
Conclusions
Hitherto model of iodine prophylaxis has proved to be effective in eliminating the iodine deficiency. The iodine intake is now more even, homogenous, which translates into smaller scatter of UICs and less percentage of children, in whom UIC is less than 50 μg/L. However, the iodine intake only slightly exceeds the recommended values, so median of UICs oscillates around the lower limit of references values.
doi:10.1186/1756-6614-5-23
PMCID: PMC3544695  PMID: 23259538
Iodine prophylaxis; Goitre; Schoolchildren; Urine iodine concentration
16.  Thyroid volume, goiter prevalence, and selenium levels in an iodine-sufficient area: a cross-sectional study 
BMC Public Health  2013;13:1153.
Background
Selenium (Se) is a necessary element for the biosynthesis of thyroid hormones. We investigated the relationship between selenium status, thyroid volume, and goiter in a cross-sectional study in an iodine-sufficient area.
Methods
We selected residents of Chengdu (over 18 years old and living in the city for more than 5 years) using a stratified cluster sampling technique. Fifteen hundred subjects were selected for the study, which involved a questionnaire survey, physical examination, thyroid ultrasound, serum thyroid function test, and determination of serum selenium level. Thyroid volume was calculated from the thickness, width, length, and a corrective factor for each lobe. Ultimately, 1,205 subjects completed the investigation and were included in our study. Additionally, 80 school-age children were selected to provide urine samples for urinary iodine analysis. We analyzed the data using appropriate nonparametric and parametric statistical tests.
Results
The median urinary iodine value was 184 μg/L in school-age children, indicating iodine sufficiency. The median serum selenium level of the 1,205 subjects was 52.63 (interquartile range [IQR] : 40.40-67.00) μg/L. The median thyroid volume was 9.93 (IQR: 7.71-12.57) mL; both log-transformed serum selenium and log-transformed thyroid volume were Gaussian distributions (P = .638 and P = .046, respectively). The prevalences of goiter and thyroid nodules were 8.8% and 18.6%. The prevalences of positive thyroid autoantibodies, thyroperoxidase autoantibodies and thyroglobulin autoantibodies were 16.7%, 12.0%, and 11.1%, respectively. In the general linear regression model, there were positive associations between serum selenium and age, and body mass index. We found no association between serum selenium and thyroid-stimulating hormone. In simple linear regression analyses, we found no association between thyroid volume and serum selenium. There were no significant differences in serum selenium between persons with or without goiter. Serum selenium was not a risk factor for goiter.
Conclusion
In our study population, serum selenium was neither associated with thyroid volume nor with goiter in an iodine-sufficient area. More studies should be conducted by following non-goitrous persons over time and monitoring their selenium status.
doi:10.1186/1471-2458-13-1153
PMCID: PMC3878896  PMID: 24321191
Iodine; Selenium; Thyroid hormones; Thyroid volume; Thyroid goiter; Thyroid disease; Cross-sectional study
17.  Iodine Nutrition and the Prevalence of Thyroid Disease after Salt Iodization: A Cross-Sectional Survey in Shanghai, a Coastal Area in China 
PLoS ONE  2012;7(7):e40718.
Background
Both insufficient and excess iodine may produce thyroid disease. After salt iodization in China, the median urine iodine concentration (UIC) of children aged 8–10 years appeared adequate. However, it is unknown whether dietary changes due to rapid economic development in Shanghai have affected whole population iodine nutrition.
Objective
To assess dietary iodine intake, UIC and the prevalence of thyroid disease in the general population of Shanghai.
Design
A cross-sectional survey was conducted with general participants aged 5–69 years (n = 7,904) plus pregnant and lactating women (n = 380 each) selected by stratified multistage sampling. The iodine concentrations in their salt, drinking water and urine were measured. Daily iodine intake was estimated using the total diet study approach. Serum thyroid hormone concentrations and thyroid-related antibodies were measured and thyroid ultrasonography was performed.
Results
The median iodine concentration in salt was 29.5 mg/kg, and 12.8 µg/L in drinking water. Iodized salt, used by 95.3% of participants, contributed 63.5% of total dietary iodine. Estimated daily iodine intake was 225.96 µg. The median UIC of general participants was 146.7 µg/L; UIC <100 µg/L (iodine insufficiency) was seen in 28.6%; UIC >300 µg/L (iodine excess) in 10.1%. Pregnant women had a median UIC of 135.9 µg/L, with UIC <150 µg/L in 55.4%. Thyroid nodules and subclinical hypothyroidism were found in 27.44% and 9.17%, respectively.
Conclusions
According to published criteria, the current dietary iodine intake in Shanghai was generally sufficient and safe, but insufficient in pregnant women. Thyroid nodules and subclinical hypothyroidism were the commonest thyroid diseases identified.
doi:10.1371/journal.pone.0040718
PMCID: PMC3414375  PMID: 22911705
18.  Maternal urinary iodine concentration in pregnancy and children's cognition: results from a population-based birth cohort in an iodine-sufficient area 
BMJ Open  2014;4(6):e005520.
Objective
Reports from populations with an insufficient iodine intake suggest that children of mothers with mild iodine deficiency during pregnancy are at risk for cognitive impairments. However, it is unknown whether, even in iodine-sufficient areas, low levels of iodine intake occur that influence cognitive development in the offspring. This study investigated the association between maternal low urinary iodine concentration (UIC) in pregnancy and children's cognition in a population-based sample from a country with an optimal iodine status (the Netherlands).
Setting and participants
In 1525 mother–child pairs in a Dutch multiethnic birth cohort, we investigated the relation between maternal UIC<150 μg/g creatinine, assessed <18 weeks gestation and children's cognition.
Outcomes measures
Non-verbal IQ and language comprehension were assessed during a visit to the research centre using Dutch test batteries when the children were 6 years.
Results
In total, 188 (12.3%) pregnant women had UIC<150 μg/g creatinine, with a median UIC equal to 119.3 μg/g creatinine. The median UIC in the group with UIC>150 μg/g creatinine was 322.9 μg/g and in the whole sample 296.5 μg/g creatinine. There was a univariate association between maternal low UIC and children's suboptimum non-verbal IQ (unadjusted OR=1.44, 95% CI 1.02 to 2.02). However, after adjustment for confounders, maternal low UIC was not associated with children's non-verbal IQ (adjusted OR=1.33, 95% CI 0.92 to 1.93). There was no relation between maternal UIC in early pregnancy and children's language comprehension at 6 years.
Conclusions
The lack of a clear association between maternal low UIC and children's cognition probably reflects that low levels of iodine were not frequent and severe enough to affect neurodevelopment. This may result from the Dutch iodine fortification policy, which allows iodised salt to be added to almost all processed food and emphasises the monitoring of iodine intake in the population.
doi:10.1136/bmjopen-2014-005520
PMCID: PMC4067856  PMID: 24928597
EPIDEMIOLOGY
19.  A comprehensive assessment of urinary iodine concentration and thyroid hormones in New Zealand schoolchildren: a cross-sectional study 
Nutrition Journal  2012;11:31.
Background
Insufficient iodine in children’s diets is of concern because thyroid hormones are needed for normal growth and development, particularly of the brain. This study aimed to carry out a comprehensive assessment of the iodine status of New Zealand schoolchildren using a range of biochemical indices suitable for populations (i.e. urinary iodine concentration) and individuals (i.e. thyroid hormones).
Methods
The New Zealand National Children’s Nutrition Survey was a cross­‒sectional survey of a representative sample of schoolchildren aged 5­‒14 years. Children were asked to provide a casual urine sample for the determination of urinary iodine concentration (UIC) and a blood sample for the determination of thyroglobulin (Tg), Thyroid Stimulating Hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3).
Results
The median UIC was 68 μg/L (n = 1153), which falls between 50­‒99 μg/L indicative of mild iodine deficiency. Furthermore, 29% of children had an UIC <50 μg/L and 82% had an UIC <100 μg/L. The median Tg concentration was 12.9 μg/L, which also falls between 10.0­‒19.9 μg/L indicative of mild iodine deficiency. The Tg concentration of children with an UIC <100 μg/L was 13.9 μg/L, higher than the 10.3 μg/L in children with an UIC >100 μg/L (P = 0.001). The mean TSH (1.7 mU/L), fT4 (14.9 pmol/L), and fT3 (6.0 pmol/L) concentrations for these mildly iodine deficient New Zealand children fell within normal reference ranges.
Conclusions
The UIC and Tg concentration indicate that New Zealand schoolchildren were mildly iodine deficient according to WHO/UNICEF/ICCIDD, and both are suitable indices to assess iodine status in populations or groups. The normal concentrations of TSH, fT4 and fT3 of these children suggest that these thyroid hormones are not useful indices of mild iodine deficiency.
doi:10.1186/1475-2891-11-31
PMCID: PMC3422176  PMID: 22569210
Iodine; Iodine deficiency; Urinary iodine concentration; Children; Thyroid hormones
20.  Evolution of hypothyroidism in familial goitre due to deiodinase deficiency: report of a family and review of the literature. 
Postgraduate Medical Journal  1986;62(728):477-480.
We studied two sisters who developed large non-toxic goitres in adolescence. Deiodinase deficiency was diagnosed by a rapid thyroid uptake of radioactive iodine (RAI) at 2 hours associated with a marked fall in thyroidal 131I by 24 hours. Serial RAI scans in the second patient documented evolution of the iodine-deficient state. Conservation of intra-thyroidal iodine stores was maintained by avid iodine uptake and failure to release organified 131I. With progressive loss of inorganic iodine, hypothyroidism developed, associated with a rise in serum TSH which further exacerbated the loss of iodine. Treatment with L-thyroxine resulted in an improvement of thyroid function, but normalization was achieved only after small doses of Lugol's iodine were administered. These studies illustrate the variable nature and late onset of an inborn error of thyroid metabolism. This family supports an autosomal recessive mode of inheritance for deiodinase deficiency. We have documented progression from a euthyroid to hypothyroid state resulting from decompensation of iodine conservation mechanisms.
PMCID: PMC2418798  PMID: 3774680
21.  Stunting, Poor Iron Status and Parasite Infection Are Significant Risk Factors for Lower Cognitive Performance in Cambodian School-Aged Children 
PLoS ONE  2014;9(11):e112605.
Background
Nutrition is one of many factors affecting the cognitive development of children. In Cambodia, 55% of children <5 y were anemic and 40% stunted in 2010. Currently, no data exists on the nutritional status of Cambodian school-aged children, or on how malnutrition potentially affects their cognitive development.
Objective
To assess the anthropometric and micronutrient status (iron, vitamin A, zinc, iodine) of Cambodian schoolchildren and their associations with cognitive performance.
Methods
School children aged 6–16 y (n = 2443) from 20 primary schools in Cambodia were recruited. Anthropometry, hemoglobin, serum ferritin, transferrin receptors, retinol-binding protein and zinc concentrations, inflammation status, urinary iodine concentration and parasite infection were measured. Socio-economic data were collected in a sub-group of children (n = 616). Cognitive performance was assessed using Raven’s Colored Progressive Matrices (RCPM) and block design and picture completion, two standardized tests from the Wechsler Intelligence Scale for Children (WISC-III).
Results
The prevalence of anemia, iron, zinc, iodine and vitamin A deficiency were 15.7%; 51.2%, 92.8%, 17.3% and 0.7% respectively. The prevalence of stunting was 40.0%, including 10.9% of severe stunting. Stunted children scored significantly lower than non-stunted children on all tests. In RCPM test, boys with iron-deficiency anemia had lower scores than boys with normal iron status (−1.46, p<0.05). In picture completion test, children with normal iron status tended to score higher than iron-deficient children with anemia (−0.81; p = 0.067) or without anemia (−0.49; p = 0.064). Parasite infection was associated with an increase in risk of scoring below the median value in block design test (OR = 1.62; p<0.05), and with lower scores in other tests, for girls only (both p<0.05).
Conclusion
Poor cognitive performance of Cambodian school-children was multifactorial and significantly associated with long-term (stunting) and current nutritional status indicators (iron status), as well as parasite infection. A life-cycle approach with programs to improve nutrition in early life and at school-age could contribute to optimal cognitive performance.
doi:10.1371/journal.pone.0112605
PMCID: PMC4236074  PMID: 25405764
22.  Iodine Intake in Somalia Is Excessive and Associated with the Source of Household Drinking Water123 
The Journal of Nutrition  2014;144(3):375-381.
Few data on iodine status in Somalia are available, but it is assumed that deficiency is a public health problem due to the limited access to iodized salt. We aimed to describe the iodine status of the population of Somalia and to investigate possible determinants of iodine status. A national 2-stage, stratified household cluster survey was conducted in 2009 in the Northwest, Northeast, and South Central Zones of Somalia. Urinary iodine concentration (UIC) was determined in samples from women (aged 15–45 y) and children (aged 6–11 y), and examination for visible goiter was performed in the Northwest and South Central strata. A 24-h household food-frequency questionnaire was conducted, and salt samples were tested for iodization. The median UICs for nonpregnant women and children were 329 and 416 μg/L, respectively, indicating excessive iodine intake (>300 μg/L). The prevalence of visible goiter was <4%. The coverage of salt iodization was low, with a national average of 7.7% (95% CI: 3.2%, 17.4%). Spatial analysis revealed localized areas of relatively high and low iodine status. Variations could not be explained by food consumption or salt iodization but were associated with the main source of household drinking water, with consumers of borehole water having a higher UIC (569 vs. 385 μg/L; P < 0.001). Iodine intake in Somalia is among the highest in the world and excessive according to WHO criteria. Further work is required to investigate the geochemistry and safety of groundwater sources in Somalia and the impact on human nutrition and health.
doi:10.3945/jn.113.176693
PMCID: PMC3927550  PMID: 24500936
23.  Data quality and practical challenges of thyroid volume assessment by ultrasound under field conditions - observer errors may affect prevalence estimates of goitre 
Nutrition Journal  2010;9:66.
Background
The ultrasonographic estimation of thyroid size has been advocated as being more precise than palpation to diagnose goitre. However, ultrasound also requires technical proficiency. This study was conducted among Saharawi refugees, where goitre is highly prevalent. The objectives were to assess the overall data quality of ultrasound measurements of thyroid volume (Tvol), including the intra- and inter-observer agreement, under field conditions, and to describe some of the practical challenges encountered.
Methods
In 2007 a cross-sectional study of 419 children (6-14 years old) and 405 women (15-45 years old) was performed on a population of Saharawi refugees with prevalent goitre, who reside in the Algerian desert. Tvol was measured by two trained fieldworkers using portable ultrasound equipment (examiner 1 measured 406 individuals, and examiner 2, 418 individuals). Intra- and inter-observer agreement was estimated in 12 children selected from the study population but not part of the main study. In the main study, an observer error was found in one examiner whose ultrasound images were corrected by linear regression after printing and remeasuring a sample of 272 images.
Results
The intra-observer agreement in Tvol was higher in examiner 1, with an intraclass correlation coefficient (ICC) of 0.97 (95% CI: 0.91, 0.99) compared to 0.86 (95% CI: 0.60, 0.96) in examiner 2. The ICC for inter-observer agreement in Tvol was 0.38 (95% CI: -0.20, 0.77). Linear regression coefficients indicated a significant scaling bias in the original measurements of the AP and ML diameter and a systematic underestimation of Tvol (a product of AP, ML, CC and a constant). The agreement between re-measured and original Tvol measured by ICC (95% CI) was 0.76 (0.71, 0.81). The agreement between re-measured and corrected Tvol measured by ICC (95% CI) was 0.97 (0.96, 0.97).
Conclusions
An important challenge when using ultrasound to assess thyroid volume under field conditions is to recruit and train qualified personnel to perform the measurements. Methodological studies are important to assess data quality and can facilitate statistical corrections and improved estimates.
doi:10.1186/1475-2891-9-66
PMCID: PMC3018367  PMID: 21156073
24.  Tanzania national survey on iodine deficiency: impact after twelve years of salt iodation 
BMC Public Health  2009;9:319.
Background
In many low-income countries, children are at high risk of iodine deficiency disorders, including brain damage. In the early 1990s, Tanzania, a country that previously suffered from moderate to severe iodine deficiency, adopted universal salt iodation (USI) as an intervention strategy, but its impact remained unknown.
Methods
We report on the first national survey in mainland Tanzania, conducted in 2004 to assess the extent to which iodated salt was used and its apparent impact on the total goitre prevalence (TGP) and urinary iodine concentrations (UIC) among the schoolchildren after USI was initiated. In 2004, a cross-sectional goitre survey was conducted; covering 140,758 schoolchildren aged 6 - 18 years were graded for goitre according to new WHO goitre classification system. Comparisons were made with district surveys conducted throughout most of the country during the 1980s and 90s. 131,941 salt samples from households were tested for iodine using rapid field test kits. UIC was determined spectrophotometrically using the ammonium persulfate digestion method in 4523 sub-sampled children.
Results
83.6% (95% CI: 83.4 - 83.8) of salt samples tested positive for iodine. Whereas the TGP was about 25% on average in the earlier surveys, it was 6.9% (95%CI: 6.8-7.0) in 2004. The TGP for the younger children, 6-9 years old, was 4.2% (95%CI: 4.0-4.4), n = 41,965. In the 27 goitre-endemic districts, TGP decreased from 61% (1980s) to 12.3% (2004). The median UIC was 204 (95% CF: 192-215) μg/L. Only 25% of children had UIC <100 μg/L and 35% were ≥ 300 μg/L, indicating low and excess iodine intake, respectively.
Conclusion
Our study demonstrates a marked improvement in iodine nutrition in Tanzania, twelve years after the initiation of salt iodation programme. The challenge in sustaining IDD elimination in Tanzania is now two-fold: to better reach the areas with low coverage of iodated salt, and to reduce iodine intake in areas where it is excessive. Particular attention is needed in improving quality control at production level and perhaps the national salt iodation regulations may need to be reviewed.
doi:10.1186/1471-2458-9-319
PMCID: PMC2749826  PMID: 19728863
25.  Ten-year follow-up of thyroid epidemiology in Slovenia after increase in salt iodization 
Croatian Medical Journal  2011;52(5):615-621.
Aim
To assess iodine supply and follow thyroid epidemiology for ten years after an iodine increase from 10 to 25 mg of potassium iodide per kilogram of salt in 1999.
Methods
In 2002 and 2003, we determined the thyroid size by palpation and ultrasound and measured urinary iodine concentration (UIC) in 676 schoolchildren from 34 schools throughout Slovenia. From 1999 to 2009, we followed the incidence of diffuse and nodular goiter, thyroid autonomy, Graves’ disease, and Hashimoto’s thyroiditis among adults in the stable catchment area of the University Medical Centre Ljubljana with 1 000 000 inhabitants.
Results
In children, only 1% had a goiter grade 2 (visible and palpable thyroid gland), median thyroid volume was 5.8 mL, and median UIC was 148 µg/L. In adults, the incidence of diffuse goiter and thyroid autonomy decreased significantly (2009 vs 1999, rate ratio [RR], 0.16; 95% confidence interval [CI], 0.12-0.21 and RR, 0.73; 95% CI, 0.62-0.86, respectively), with a lower incidence in younger participants in 2009 (P < 0.001). The incidence of multinodular goiter and solitary nodule increased (2009 vs 1999, RR, 1.55; 95% CI, 1.35-1.79 and RR, 1.72; 95% CI, 1.49-1.99, respectively). No long-term changes were observed for Graves’ disease (2009 vs 1999, RR, 0.95; 95% CI, 0.81-1.13), while the incidence of Hashimoto’s thyroiditis increased strongly (2009 vs 1999, RR, 1.86; 95% CI, 1.64-2.12).
Conclusions
The change from mildly deficient to sufficient iodine supply was associated with a marked change in the incidence of thyroid epidemiology – a significant decline in the incidence of diffuse goiter and thyroid autonomy and a marked increase in the incidence of Hashimoto’s thyroiditis.
doi:10.3325/cmj.2011.52.615
PMCID: PMC3195970  PMID: 21990079

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