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1.  Association between Serum Ferritin and Goitre in Iranian School Children 
Despite long-standing supplementation of iodine in Iran, the prevalence of goitre among general people remains high in some regions. The study investigated the role of iron status in the aetiology of goitre in school children in Isfahan, Iran. Two thousand three hundred and thirty-one school children were selected by multi-stage random sampling. Thyroid size was estimated by inspection and palpation. Urinary iodine concentration (UIC) and serum ferritin (SF) were measured. Overall, 32.9% of the children had goitre. The median UIC was 195.5 μg/L. The mean±SD of SF in the goitrous and non-goitrous children was 47.65±42.51 and 44.55±37.07 μg/L respectively (p=0.52). The prevalence of iron deficiency in goitrous and non-goitrous children was 9.6% and 3.1% respectively (p=0.007). Goitre is still prevalent in school children of Isfahan. However, their median UIC was well in the accepted range. Iron deficiency is associated with goitre in a small group of goitrous children. The role of goitrogens should also be investigated in this region.
PMCID: PMC2980875  PMID: 20411676
Cross-sectional studies; Goitre; Iodine; Iron deficiency; Serum ferritin; Iran
2.  Protein-energy Malnutrition in Goitrous Schoolchildren of Isfahan, Iran 
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.
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.
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).
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
3.  Iodine Deficiency Disorders in the Iodine-Replete Environment 
Iodine deficiency disorders (IDD) constitute significant public health problems in parts of the world with poor iodine nutrition, but have been eradicated in North America and other regions. We herein report three cases of iodine deficiency disorders (IDD) which occurred in women living in iodine-replete environments.
The clinical presentation, biochemical findings, and radiological features of the patients were analyzed and presented in three case reports. The radiological features are illustrated in sonographic and scintigraphic images. A literature review and discussion which highlight the risk factors, pathogenesis, ancillary investigations and rational treatment of iodine deficiency goiter and hypothyroidism are provided.
All of our three patients were young females, aged 24–38 years, who had goiter. Two of them presented with goitrous hypothyroidism. Radioactive iodine scintigraphy showed a characteristic finding of diffusely increased uptake (in the absence of clinical and biochemical evidence of hyperthyroidism). This scintigraphic pattern was found to be pathognomonic. Dietary iodine supplementation alone resulted in complete remission of IDD in the subjects, including the two patients with hypothyroidism.
IDD can occur in iodine replete-environments. A high index of suspicion is needed to recognize these cases. It is pertinent that the correct diagnosis be made to avoid unwarranted life-long thyroxine therapy in patients presenting with goiter and hypothyroidism, which is easily treatable with iodized salt. These cases underscore the need for considering iodine deficiency in the etiologic diagnosis of goiter and hypothyroidism, even in iodine sufficient regions.
PMCID: PMC2634852  PMID: 19155752
Iodine deficiency; Goiter; Hypothyroidism; Urinary iodine
4.  Thyromegaly and iodine nutritional status in a tertiary care hospital in South India 
Aim and Objectives:
1. To assess the iodine nutritional status in patients with goiter by measuring urinary iodine excretion. 2. To compare the iodine nutritional status with the thyroid function and correlate with the type of thyroid disease.
Study Design:
Case control study.
Materials and Methods:
Three hundred patients with goiter and one hundred euthyroid healthy non-goitrous volunteers were included in this study.
Results and Conclusions:
All patients had elevated urinary iodine suggesting excess iodine intake and absence of iodine deficiency. Complications known to be associated with excess iodine, viz., benign goiter (35%), iodine-induced hyperthyroidism or thyrotoxicosis (34%), thyroiditis (16%) and cancer of thyroid (15%) have been observed in this study. Therefore, continued supplementation of edible salt fortified with iodine should be monitored carefully, and supplementation programs should be tailored to the particular region.
PMCID: PMC3683201  PMID: 23776899
Goiter; iodine-induced hyperthyroidism; thyroiditis; thyrotoxicosis; urinary iodine
5.  Influence of dietary iodine deficiency on the thyroid gland in Slc26a4-null mutant mice 
Thyroid Research  2011;4:10.
Pendred syndrome (PDS) is an autosomal recessive disorder characterized by sensorineural hearing impairment and variable degree of goitrous enlargement of the thyroid gland with a partial defect in iodine organification. The thyroid function phenotype can range from normal function to overt hypothyroidism. It is caused by loss-of-function mutations in the SLC26A4 (PDS) gene. The severity of the goiter has been postulated to depend on the amount of dietary iodine intake. However, direct evidence has not been shown to support this hypothesis. Because Slc26a4-null mice have deafness but do not develop goiter, we fed the mutant mice a control diet or an iodine-deficient diet to evaluate whether iodine deficiency is a causative environmental factor for goiter development in PDS.
We evaluated the thyroid volume in histological sections with the use of three-dimensional reconstitution software, we measured serum levels of total tri-iodothyronine (TT3) and total thyroxine (TT4) levels, and we studied the thyroid gland morphology by transmission electron microscopy.
TT4 levels became low but TT3 levels did not change significantly after eight weeks of an iodine-deficient diet compared to levels in the control diet animals. Even in Slc26a4-null mice fed an iodine-deficient diet, the volume of the thyroid gland did not increase although the size of each epithelial cell increased with a concomitant decrease of thyroid colloidal area.
An iodine-deficient diet did not induce goiter in Slc26a4-null mice, suggesting that other environmental, epigenetic or genetic factors are involved in goiter development in PDS.
PMCID: PMC3141755  PMID: 21689387
6.  Current iodine nutrition status and progress toward elimination of iodine deficiency disorders in Jazan, Saudi Arabia 
BMC Public Health  2012;12:1006.
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.
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.
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.
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.
PMCID: PMC3533993  PMID: 23167286
Iodine nutrition; Saudi Arabia; Jazan; USI
7.  Kashin-Beck disease and iodine deficiency in Tibet 
International Orthopaedics  2001;25(3):164-166.
We evaluated iodine and selenium status in 575 children between 5 and 15 years with Kashin-Beck disease from endemic and non-endemic areas. Of these 267 (46%) children had goiter. The proportion of subjects with goiter was higher in the villages with Kashin-Beck disease than in the control village. In the villages with Kashin-Beck disease, 105 (23%) of the subjects had a serum thyrotropin greater than 10 mU/l as compared with 3 (4%) in the control village. The percentages of low serum thyroxine values and low serum tri-iodothyronine were greater in the villages where Kashin-Beck disease was endemic than in the control village. The percentages of low urinary iodine concentration were significantly greater in the subjects with Kashin-Beck disease. The results suggest that in areas where severe selenium deficiency is endemic, iodine deficiency is a risk factor for Kashin-Beck disease.
PMCID: PMC3620653  PMID: 11482533
Journal of Clinical Investigation  1973;52(1):116-125.
Butanol-insoluble iodinated compounds in the urine of patients with congenital goiters have been generally regarded as iodopeptides. Monoiodohistidine (MIH) and diiodohistidine (DIH) were identified from the urine of four patients with congenital goitrous hypothyroidism. From radioiodine studies, 40-70% of the urinary radioactivity was in the iodide-free fraction from which about 40% was identified as MIH and DIH by crystallizations to a constant specific activity.
Iodotyrosines were simultaneously identified in the urine. However the presence of an iodotyrosine-deiodinase activity was demonstrated in the two removed goiters with a normal Km for MIT. In vivo iodotyrosine deiodination was normal for hypothyroid subjects.
No thyroglobulin was identified in the thyroids from these patients. The major iodoprotein was iodoalbumin which, after in vivo labeling, contained 84-89% of the total soluble protein radioactivity. The thyroxine content of the goiter iodoalbumins and other iodoproteins was extremely low.
Iodohistidines were identified in comparable proportions in the iodoalbumin and in the other iodoproteins isolated from each goiter. The average iodohistidine content of these proteins as crystallizable MIH and DIH was in the individual cases 15 and 4% of the in vivo incorporated radioiodine. DIH was identified in all iodoprotein fractions. The mean DIH/MIH ratios from the individual cases were 1.16 and 0.35. The corresponding DIT/MIT ratios were 3.19 and 1.45, respectively.
The major consequence of this thyroglobulin defect is the iodination of inappropriate proteins (mainly albumin) resulting in low yields of thyroxine and high yields of iodohistidines. Iodohistidines from the goiter iodoproteins were not deiodinated and, at least for MIH, were quantitatively excreted in the urine of these patients. From the MIH iodoalbumin content and the MIH urinary excretion, goiter iodoalbumin turnover estimates were made and, although elevated, could not maintain a normal thyroxine secretion.
The urinary excretion of iodohistidines easily demonstrated by column chromatography is offered as a test for detecting this variety of congenital goiter.
PMCID: PMC302233  PMID: 4629905
9.  Do Thyroxine and Thyroid-Stimulating Hormone Levels Reflect Urinary Iodine Concentrations? 
Therapeutic drug monitoring  2005;27(2):178-185.
The toxicity of environmental chemicals such as nitrates, thiocynates, and perchlorates, some therapeutics, and dietary goitrogens can lower thyroidal iodine uptake and result in hypothyroidism and goiter. Iodine sufficiency, essential for normal thyroid hormone synthesis, is critical during gestation to assure that sufficient thyroxine (T4) and iodine reach the developing fetus. Spot urinary iodide (UI) measurements are used globally to indicate and monitor iodine sufficiency of populations. In individuals, however, UI are not routinely measured; instead, normal serum thyroid-stimulating hormone (TSH) and T4 concentrations serve as surrogate indicators of iodine sufficiency as well as thyroidal health. Our objective was to examine the relationship between UI concentrations and serum T4 and TSH concentrations in individuals in an ‘‘iodine-sufficient population.’’ Using a cross-sectional sample of the US population (n = 7628) from the National Health and Nutrition Examination Survey (NHANES III; 1988–1994) database, we examined the relationship among UI, T4, and TSH in pregnant and nonpregnant women and in men (15–44 years). There was a lack of relationship between UI (or UI/Cr) concentrations and serum T4 or TSH concentrations. Therefore, TSH and T4 are not appropriate markers of UI concentrations in this population. Monitoring the status of iodine nutrition of individuals in the United States may be important because serum TSH and T4 concentrations do not indicate low iodine status.
PMCID: PMC3666343  PMID: 15795649
urinary iodine measurements; maternal thyroxine T4 monitoring; TSH; pregnancy; iodine deficiency; prevention of neurological damage; NHANES
10.  Tracking Progress Toward Elimination of Iodine Deficiency Disorders in Jharkhand, India 
Research question:
What is the current status of Iodine Deficiency Disorders (IDD) in the state of Jharkhand?
(1) To determine the status of iodine deficiency in the state. (2) To determine the availability and cost of adequately iodized salt at the retail shops. (3) To study the perceptions of the community regarding iodine deficiency, salt and iodized salt.
A cross-sectional community-based survey.
Study setting:
Thirty clusters selected through the probability proportion to size (PPS) sampling in the state of Jharkhand.
Study participants:
Children aged 6-12 years, households, retail shopkeepers and opinion leaders.
Study tool:
Quantitative and qualitative methodology using a pretested questionnaire and focus group discussion used to carry out the community-based survey.
Total goiter rate (TGR) was 0.9%. Median urinary iodine level was 173.2 µg/L. The proportion of individuals with urinary iodine levels less than 100 and 50 µg/L were 26.4% and 10%, respectively. Slightly less than two-thirds (64.2%) of the households were found to be consuming adequately iodized salt as measured by titration (greater than 15 ppm). Iodized salt was available across the state and the cost varied between Re. 1 and Rs. 8 per kilogram. A common belief among the community was that iodized salt is equivalent to refined packet salt that is further equivalent to expensive salt.
The results of the present survey show that the iodine nutrition in the state of Jharkhand is optimal. Considering that the consumption of adequately iodized salt should increase from 64.2% to the goal of more than 90%, sustained efforts are required in this place to consolidate the current coverage of adequately iodized salt and increase it to greater than 90%.
PMCID: PMC2763680  PMID: 19876480
Goiter; iodine deficiency disorders; Jharkhand
11.  Status of iodine deficiency disorder in district Udham Singh Nagar, Uttarakhand state India 
Iodine deficiency disorder (IDD) is a public health problem in Uttarakhand state.
The present study was conducted in district Udham Singh Nagar, Uttarakhand state with an objective to assess the status of iodine deficiency amongst school age children (6-12 years).
Materials and Methods:
Thirty clusters were selected by utilizing the population proportionate to size (PPS) cluster sampling methodology. A total of 1807 children in the age group of 6-12 years were included. The clinical examination of the thyroid of each child was conducted. Urine and Salt samples were collected from children.
The Total Goiter Rate (TGR) was found to be 13.2%. The proportion of children with Urinary Iodine Excretion (UIE) level <20, 20-49, 50-99, 100-199 and ≥200 μg/l was found to be nil, 6.0, 21.2, 34.2 and 38.5 percent, respectively. The median UIE level was 150 μg/l. Only 46.7% of the salt samples had stipulated level of iodine of 15 ppm and more.
The study population had mild degree of public health problem of iodine deficiency.
PMCID: PMC4056146  PMID: 24944942
Excretion levels; goiter; iodine; iodised salt; thyroid
12.  Prevalence of Goiter and Urinary Iodine Status in Six-Twelve-Year-Old Rural Primary School Children of Bharuch District, Gujarat, India 
Iodine deficiency disorder (IDD) creates major public health problems in India, including Gujarat. The Bharuch district is a known iodine deficiency endemic area. This study was conducted to estimate the prevalence of goiter in primary school children; to determine the median urinary iodine concentration; to assess the level of iodine in salt samples at the household and retail shop levels; and to study the profile of salt sold at retail shops.
This study was carried out by using the 30-cluster survey method in the primary schools of the rural areas in Bharuch district. A total of 70 students, including five boys and five girls from the first to seventh classes, who were present in class on the day of the visit were selected randomly for goiter examination from each village. Urine samples were collected from one boy and one girl from each class in each cluster. From each community, a maximum of two boys and two girls from each standard in the same age group were examined and also salt samples were tested from their households. From each village, one retail shop was visited and the salt purchased from those shops was immediately tested for iodine with spot kits.
We found a goiter prevalence of 23.2% (grade 1 – 17.4% and grade 2 – 5.8%). As the age increased, the goiter prevalence decreased except in nine-year-olds. The median urinary iodine excretion level was 110 μg/L. An Iodine level > 15 ppm was found in 93% of the salt samples tested at the household level.
The present study showed moderate goiter prevalence in primary school children in the Bharuch district of Gujarat and an inadequate iodine content of salt at some household levels.
PMCID: PMC3278870  PMID: 22355478
Goitre survey; IDD; prevalence; primary school children; household level
California Medicine  1959;90(1):32-36.
Five to 10 per cent of cretinism in the United States is due to some congenital enzymatic defect in thyroid hormone synthesis. The clinical signs of hypothyroidism appear in early infancy. Differentiation from athyreotic cretinism is important because the metabolic defect tends to be familial and its presence in the patient's infant relatives should be diagnosed as early as possible. The differentiation is easily made if a goiter is discernible, but if it is not, radioiodine uptake should be measured, for in this condition the uptake is normal or greater. Thyroid replacement is the treatment in either the athyreotic state or the metabolic deficiency.
The three known defects in thyroid hormone synthesis are (1) failure to oxidize iodine to elemental iodine resulting in failure of all subsequent processes; (2) failure to deiodinate free iodotyrosine, and (3) failure to form iodothyronine although the previous steps are accomplished.
PMCID: PMC1577531  PMID: 13618742
14.  Prevalence and associated factors of goiter among rural children aged 6-12 years old in Northwest Ethiopia, cross -sectional study 
BMC Public Health  2014;14:130.
Goiter, an indicator of chronic iodine deficiency, is a major public health problem for populations living with iodine deficient environment, particularly for young children. It is a threat to the social and economic development of many developing countries including Ethiopia. The aim of the study was to assess the prevalence and associated factors of goiter among rural children aged 6-12 years, Northwest Ethiopia.
A community based cross-sectional study was employed from July to December 2012 in Lay Armachiho district. A total of 698 children aged 6-12 years were included in the study. Multistage sampling was used. Children were examined for the presence/absence of goiter using a criterion set by World Health Organization. The level of Iodine of the salt was estimated by using spot testing kits. Descriptive and summary statistics were employed. Bivariate and multivariate logistic regressions were used to identify associated factors. The degree of association was assessed by using Odds ratio with 95% confidence interval were computed to see the presence and strength of association.
Totally 694 children were included in the analysis. The prevalence of goiter was found to be 37.6%. Goiter of grade 1 was 28.5% and that of grade 2 was 9.1%. 29.7% of the samples had adequate iodine content. The age of child (AOR: 1.24,95% CI: 1.12, 1.36), being female (AOR = 1.98, 95% CI: 1.38-2.85), salt iodine level (AOR = 0.44, 95% CI: 0.27, 0.71), family history of goiter (AOR = 3.18, 95% CI: 2.08, 4.858), fish consumption (AOR = 0.42, 95% CI; 0.22, 0.80) were factors associated with goiter.
Chronic iodine deficiency was a severe public health problem in the study communities. Ensuring the consumption of iodized salt and promotion of fish intake at the household level are highly recommended.
PMCID: PMC3996147  PMID: 24502377
Goiter; Iodine deficiency; Children; Ethiopia
15.  Lithium therapy: an unusual cause of elevated and diffuse radioactive iodine uptake 
Lithium carbonate, a widely used treatment for bipolar disorders, is associated with goiter, hypothyroidism and thyrotoxicosis. However, the effect of lithium to increase radioactive iodine uptake has received little attention, thus, making Lithium a confounding factor in the interpretation of thyroid radionuclide studies. We herein report a case of misinterpreted high radioactive iodine uptake in a euthyroid, lithium-treated goitrous patient. We conclude that lithium therapy should be considered in the etiologic diagnoses of patients with goiter and homogenously elevated radioiodine uptake. It is pertinent to recognize this phenomenon in order to prevent unwarranted treatment with radioactive iodine or thionamides.
PMCID: PMC3303237  PMID: 22470595
16.  Study on Prevalence of lodine Deficiency Disorder and Salt Consumption Patterns in Jammu Region 
Research Question:
What is the situation of iodine deficiency disorder (IDD) and salt consumption in Jammu region?
The prevalence of IDD has decreased markedly as a result of medical as well as socio-economic factors.
To assess the magnitude of IDD in Jammu region and also assess the salt consumption patterns in the region.
Cross-sectional study.
Primary schools in both urban and rural areas.
Study Tools:
Clinical examination of study population for goiter, laboratory assessment of casual urine sample for urinary iodine estimation of I2 content of salt samples collected from sub-samples of study population.
School children in the age group of 6-12 years were selected for study using WHO 30-cluster methodology, urine samples were collected from 15% of selected children and salt samples from 5% of sub-sample.
Ethical Concern:
No ethical issues were involved.
An overall goiter prevalence of 11.98% was observed in the region. Females had a prevalence of 16.1% and males 10.1%. The median urinary iodine excretion in the region was 96.5 μg/l (range: 29.0-190.0 μg/l). Forty-nine percent of subjects had biochemical iodine deficiency with 6.7% having moderate and 42.53% mild iodine deficiency. In Jammu region, 74.47% of households consume powdered salt with 98.17% powdered salt samples having an I2 content of greater than 15 ppm.
Iodine deficiency remains a public health problem in the region, though the region seems to be in a state of nutritional transition from iodine deficiency to iodine sufficiency.
PMCID: PMC2782220  PMID: 19966989
Crystalline salt; excretion; goiter; powdered salt; prevalence; urinary iodine
17.  Iodine deficiency in children: A comparative study in two districts of south-interior Karnataka, India 
Iodine is an essential component of the hormones produced by the thyroid gland that are essential for mammalian life. Although goiter is the most visible sequelae of iodine deficiency, the major impact of hypothyroidism as a result of iodine deficiency is impaired neurodevelopment, particularly early in life. According to the World Health Organization, it is the single most preventable cause of mental retardation and brain damage. The simplest, most effective and inexpensive preventive method is the consumption of iodized salt.
The objective of the following study is to estimate the prevalence of goiter in children in the rural areas of Mysore and Coorg districts in India and estimate iodine levels in salt samples.
Materials and Methods:
A cross-sectional study in the age group of 6-12 years, using population proportionate to size systematic sampling method. The total sample size was 10,082: out of which 5337 was from Mysore and the rest from Coorg district. Clinical examination of the thyroid gland was done and salt samples collected for the estimation of Iodine.
The total prevalence of goiter was 19.01% in children of 6-12 years in Coorg district and 8.77% in Mysore district and it was more in females than in males.
It was observed that iodine deficiency disorders is endemic in both districts, with a prevalence of 19.01% in children aged 6-12 years in Coorg district and 8.77% in Mysore district. Analysis of salt samples suggested that most of the samples were inadequately iodised (73.92% in Coorg and 45.92% in Mysore).
PMCID: PMC3966096  PMID: 24696633
Cross sectional study; dox plot; iodine deficiency; prevalence
18.  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
19.  Early effects of iodine deficiency on radial glial cells of the hippocampus of the rat fetus. A model of neurological cretinism. 
Journal of Clinical Investigation  1997;99(11):2701-2709.
The most severe brain damage associated with thyroid dysfunction during development is observed in neurological cretins from areas with marked iodine deficiency. The damage is irreversible by birth and related to maternal hypothyroxinemia before mid gestation. However, direct evidence of this etiopathogenic mechanism is lacking. Rats were fed diets with a very low iodine content (LID), or LID supplemented with KI. Other rats were fed the breeding diet with a normal iodine content plus a goitrogen, methimazole (MMI). The concentrations of -thyroxine (T4) and 3,5,3'triiodo--thyronine (T3) were determined in the brain of 21-d-old fetuses. The proportion of radial glial cell fibers expressing nestin and glial fibrillary acidic protein was determined in the CA1 region of the hippocampus. T4 and T3 were decreased in the brain of the LID and MMI fetuses, as compared to their respective controls. The number of immature glial cell fibers, expressing nestin, was not affected, but the proportion of mature glial cell fibers, expressing glial fibrillary acidic protein, was significantly decreased by both LID and MMI treatment of the dams. These results show impaired maturation of cells involved in neuronal migration in the hippocampus, a region known to be affected in cretinism, at a stage of development equivalent to mid gestation in humans. The impairment is related to fetal cerebral thyroid hormone deficiency during a period of development when maternal thyroxinemia is believed to play an important role.
PMCID: PMC508116  PMID: 9169500
20.  SUBCLINICAL HYPOTHYROIDISM—Recognition and Treatment 
California Medicine  1962;97(5):263-267.
Often patients in whom there is little to suggest myxedema or cretinism have subclinical hypothyroidism. Once the condition is suspected, it can be diagnosed by determination of protein-bound iodine and, if the PBI is low, by response to therapy with thyroid hormone.
Patients in the following categories should have protein-bound iodine determination: Those having (1) a history of previous treatment for hypothyroidism; (2) suboptimal development in children; (3) ovarian dysfunction, infertility, habitual abortion or unusual menopausal disorders; (4) symptoms of malaise and debility, such as undue fatigue, somnolence, mental asthenia and anxiety; (5) unexplained anemia; (6) colloid goiter, adenomatous goiter and cancer of the thyroid gland.
If hypothyroidism is diagnosed, administration of thyroid hormone in increasing amounts, as determined by serial serum PBI tests, should be carried out indefinitely. Instruction of the patient is essential.
PMCID: PMC1575523  PMID: 13983502
21.  Two cases of fetal goiter 
Anterior fetal neck masses are rarely encountered. Careful routine ultrasound screening can reveal intrauterine fetal goiters (FGs). The incidence of goitrous hypothyroidism is 1 in 30,000-50,000 live births. The consequences of both FG and impaired thyroid function are serious.
Aims and Objectives:
To emphasize role of ultrasound in both invasive and non-invasive management of FG.
Materials and Methods:
Two pregnant patients, during second trimester, underwent routine antenatal ultrasound revealing FG, were investigated and managed.
Case 1: Revealed FG with fetal hypothyroidism. Intra-amniotic injection l-thyroxine given. Follow-up ultrasound confirmed the reduction of the goiter size. At birth, thyroid dyshormogenesis was suspected and neonate discharged on 50 mcg levothyroxine/day with normal growth and development so far. Case 2: Hypothyroid mother with twin pregnancy revealed FG, in twin 1, confirmed on magnetic resonance imaging (1.5 × 1.63 cm). The other twin had no thyroid swelling. Cordocentesis confirmed hypothyroidism in twin 1. Maternal thyroxine dose increased as per biochemical parameters leading to reduction in FG size. Mother delivered preterm and none of the twins had thyroid swelling. Fetal euthyroidism was confirmed on biochemical screening.
FG during pregnancy should be thoroughly evaluated, diagnosed and immediately treated; although in utero options for fetal hypothyroidism management are available, emphasis should be laid on non-invasive procedures. Newer and better resolution techniques in ultrasonography are more specific and at the same time are less harmful.
PMCID: PMC3603076  PMID: 23565428
Fetal goiter; hypothyroidism
22.  Urinary Iodine and Goiter Prevalence in Belarus: Experience of the Belarus–American Cohort Study of Thyroid Cancer and Other Thyroid Diseases Following the Chornobyl Nuclear Accident 
Thyroid  2011;21(4):429-437.
Because iodine deficiency can influence background rates of thyroid disease or modify radiation dose–response relationships, we compiled descriptive data on iodine status among participants in a Belarusian–American screening study who were exposed in childhood to radioiodine fallout from the Chornobyl nuclear accident. We have used the data from two consecutive screening cycles to examine whether indicators of iodine status changed before and after documented government initiatives to improve iodine intake.
Urinary iodine concentrations in spot samples and prevalence of diffuse goiter by palpation were assessed in 11,676 exposed subjects who were 18 years or younger at the time of the accident on April 26, 1986, and were screened beginning 11 years later in connection with the Belarus–American Thyroid Study. Data for the first (January 1997–March 2001) and second (April 2001–December 2004) screening cycles, which largely correspond to time periods before and after official iodination efforts in 2000/2001, were compared for the cohort overall as well as by oblast of residence (i.e., state) and type of residency (urban/rural).
Median urine iodine levels among cohort members increased significantly in the later period (111.5 μg/L) compared to the earlier (65.3 μg/L), with the cycle 2 level in the range defined as adequate iodine intake by the World Health Organization. During the same period, a significant decline in diffuse goiter prevalence was also observed. In both cycles, urinary iodine levels were lower in rural than in urban residents. Urinary iodine levels, but not rates of goiter, varied by oblast of residence. In both periods, adjusted median urine iodine concentrations were similar in Gomel and Minsk oblasts, where ∼89% of cohort members resided, and were lowest in Mogilev oblast. Yet Mogilev oblast and rural areas showed the most marked increases over time.
Trends in urinary iodine concentrations and prevalence of diffuse goiter by palpation suggest that iodination efforts in Belarus were successful, with benefits extending to the most iodine-deficient populations. Iodine status should be considered when evaluating thyroid disease risk in radioiodine-exposed populations since it can change over time and may influence rates of disease and, possibly, dose–response relationships.
PMCID: PMC3070334  PMID: 21323597
23.  Epidemiology of thyroid diseases in Africa 
Thyroid disorders are common endocrine disorders encountered in the African continent. Environmental and nutritional factors are often implicated in the occurrence of some thyroid disorders that occur in this part of the world. This is a narrative review that seeks to document the pattern, prevalence, and management of thyroid disorders in the continent.
Materials and Methods:
The search engine used for this review were PubMed and Google scholar. All available articles on thyroid disorders from the sub-African continent, published until May 2011, were included.
Iodine deficiency disorders (IDD) which top the list of thyroid disorders and remain the commonest cause of thyroid disorders in the continent is often affected not only by the iodine status in the region but sometimes also by selenium deficiency and thiocyanate toxicity. The reported prevalence rates of endemic goiter range from 1% to 90% depending on the area of study with myxedematous cretinism still a prominent feature of IDD in only a few regions of the continent. The extent of autoimmune thyroid disorders remains unknown because of underdiagnosis and underreporting but the few available studies note a prevalence rate of 1.2% to 9.9% of which Graves diseases is the commonest of these groups of disorders. Rarer causes of thyroid dysfunction such as thyroid tuberculosis and amiodarone related causes are also documented in this review. The onset of new thyroid diseases following amiodarone usage was documented in 27.6% of persons treated for arrhythmia. Reports on thyroid malignancies (CA) in Africa abound and differentiated thyroid malignancies are noted to occur more commonly than the other forms of thyroid CA. The documented prevalence rates of thyroid CA in the African continent are as follows (papillary: 6.7–72.1%, follicular: 4.9–68%, anaplastic: 5–21.4%, and medullary: 2.6%–13.8%). For the differentiated thyroid CA, there is a changing trend toward the more frequent occurrence of papillary CA compared to follicular CA and this may be attributable to widespread iodization programs. Our review shows that diagnosis and evaluation of thyroid disorders are reliant in most regions of the continent on clinical acumen and suboptimal diagnostic facilities and expertise are what obtain in many practices. The frequently employed management options of thyroid disorders in the continent are pharmacological and surgical treatment modalities.
Diagnosis and management of thyroid disorders in the African continent remain suboptimal. Thyroid registries may be helpful to determine the scope of the burden of thyroid disorders since this knowledge may help change policies on the approach to the management of these disorders.
PMCID: PMC3169867  PMID: 21966659
Africa; epidemiology; thyroid
24.  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.
PMCID: PMC3927550  PMID: 24500936
25.  Iodine Deficiency Disorder Control Programme Impact in Pregnant Women and Status of Universal Salt Iodization 
Several studies pertaining to current status of Iodine Deficiency Disorder Control Programme in India have revealed goiter prevalence in the range of 1.5–44.5%, mean urinary iodine excretion level ranging from 92.5–160 mcg/L and iodized salt coverage ranging from 37–62.3%. Most of these studies were based on school children. However, very few studies have focused on pregnant women. This population is very sensitive to marginalized iodine deficiency throughout their gestational period.
This 40 cluster cross sectional study was done in Raipur district. Iodine content of salt was estimated by using “Rapid Salt Testing Kits” along with observing salt storage practices, at household and in shops. Pregnant women were interviewed by using semi structured comprehensive questionnaire, which was based on knowledge attitude, and practices about salt use pattern and awareness about IDDCP, UIE level were also estimated.
Prevalence of goiter was 0.17%. Many (41.12%) pregnant women had <15ppm iodine content in the salt sample and 51.58% of women had subnormal iodine uptake. Wrong salt storage practice was observed in 36.3% of households.
There were lacunae in Iodine deficiency control program in Chhattisgarh. Implementation and monitoring of program was weak. Thus for monitoring purpose IDD Cell & IDD Laboratory should be established at district level. This will lead to periodic assessment of Iodine Deficiency Disorders, by monitoring of Iodine intake and all other preventive, promotive as well as curative measures in the state.
PMCID: PMC3481648  PMID: 23113082
Iodine Deficiency Disorder Control Program (IDDCP); Monitoring; Evaluation; Goiter; Universal Salt Iodization (USI); Median Urinary Iodine Excretion (MUIE)

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