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1.  Iodine deficiency disorders (IDD) control in India 
Iodine deficiency disorders (IDD) constitute the single largest cause of preventable brain damage worldwide. Majority of consequences of IDD are invisible and irreversible but at the same time these are preventable. In India, the entire population is prone to IDD due to deficiency of iodine in the soil of the subcontinent and consequently the food derived from it. To combat the risk of IDD, salt is fortified with iodine. However, an estimated 350 million people do not consume adequately iodized salt and, therefore, are at risk for IDD. Of the 325 districts surveyed in India so far, 263 are IDD-endemic. The current household level iodized salt coverage in India is 91 per cent with 71 per cent households consuming adequately iodized salt. The IDD control goal in India was to reduce the prevalence of IDD below 10 per cent in the entire country by 2012. What is required is a “mission approach” with greater coordination amongst all stakeholders of IDD control efforts in India. Mainstreaming of IDD control in policy making, devising State specific action plans to control IDD, strict implementation of Food Safety and Standards (FSS) Act, 2006, addressing inequities in iodized salt coverage (rural-urban, socio-economic), providing iodized salt in Public Distribution System, strengthening monitoring and evaluation of IDD programme and ensuring sustainability of IDD control activities are essential to achieve sustainable elimination of IDD in India.
PMCID: PMC3818611  PMID: 24135192
India; iodine deficiency disorders; iodized salt; National Iodine Deficiency Disorders Control Programme; sustainable elimination
2.  Iodized Salt Consumption in Sudan: Present Status and Future Directions 
Iodine Deficiency Disorders (IDD) Control Programme in Sudan adopted salt iodization as the long-term strategy in 1994. In 2000, it was found that less than 1% of households were using adequately-iodized salt. The objectives of this study were to: (i) study the coverage and variation of different geographical regions of Sudan regarding access to and use of iodized salt, (ii) explore the possible factors which influence the use of iodized salt, (iii) develop recommendations to help in the implementation of the Universal Salt Iodization (USI) strategy in Sudan. This paper is based on the Sudan Household Health Survey (SHHS) dataset. A total sample of 24,507 households was surveyed, and 18,786 cooking salt samples were tested for iodine levels with rapid salt-testing kits. Nationally, the percentage of households using adequately-iodized salt increased from less than 1% in 2000 to 14.4%, with wide variations between states. Access to iodized salt ranged from 96.9% in Central Equatoria to 0.4% in Gezira state. Population coverage with iodized salt in Sudan remains very low. The awareness and political support for USI programme is very weak. National legislation banning the sale of non-iodized salt does not exist. Utilization of the already-existing laws, like the National Standardization and Metrology Law (2008), to develop a compulsory national salt specification, will accelerate the USI in Sudan.
PMCID: PMC3763614  PMID: 23304909
Iodine deficiency disorders; Salt legislations; Universal Salt Iodization; Sudan
3.  Limited Access to Iodized Salt among the Poor and Disadvantaged in North 24 Parganas District of West Bengal, India 
Iodine deficiency is endemic in West Bengal as evident from earlier studies. This community-based, cross-sectional descriptive study was conducted in North 24 Parganas district during August-November 2005 to assess the consumption of adequately-iodized salt and to ascertain the various factors that influence access to iodized salt. In total, 506 households selected using the multi-stage cluster-sampling technique and all 79 retail shops from where the study households buy salt were surveyed. The iodine content of salt was tested by spot iodine-testing kits. Seventy-three percent of the households consumed salt with adequate iodine content (≥15 ppm). Consumption of adequately-iodized salt was lower among rural residents [prevalence ratio (PR): 0.8, 95% confidence interval (CI) 0.7-0.9], Muslims (PR: 0.8, 95% CI 0.7-0.9), and households with monthly per-capita income of ≤US$ 10 (PR: 0.7, 95% CI 0.6-0.8). Those who heard and were aware of the risk of iodine-deficiency disorders and of the benefit of iodized salt were more likely to use appropriate salt (PR: 1.2, 95% CI 1.1-1.3). Those who were aware of the ban on non-iodized salt were more likely to consume adequately-iodized salt (PR: 1.1, 95% CI 1.01-1.3). The iodine content was higher in salt sold in sealed packets (PR: 2.9, 95% CI 1.8-4.8) and stored on shelves (PR: 1.6, 95% CI 1.3-2.0). Seventy-two percent of the salt samples from the retail shops had the iodine content of ≥15 ppm. The findings indicate that elimination of iodine deficiency will require targeting the vulnerable and poor population.
PMCID: PMC2965328  PMID: 20824980
Community-based studies; Cross-sectional studies; Descriptive studies; Goitre; Iodine; Iodine deficiency; Iodized salt; Socioeconomic factors; India
4.  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
5.  Status of Iodized Salt Coverage in Urban Slums of Cuttack City, Orissa 
For sustainable elimination of iodine deficiency disorders (IDD), it is necessary to consume adequately iodized salt on a regular basis and optimal iodine nutrition can be achieved through universal salt iodization.
To assess the extent of use of adequately iodized salt in the urban slums of Cuttack.
Materials and Methods:
Using a stratified random multi-stage cluster sampling design, a cross-sectional study involving 336 households and 33 retail shops selected randomly from 11 slums of Cuttack was conducted in 2005. A predesigned pretested schedule was used to obtain relevant information and salt iodine was estimated qualitatively by using a spot testing kit and quantitatively using the iodometric titration method.
Statistical Analysis:
Proportion, Chi-square test.
Only 60.1% of the households in urban slums of Cuttack were using adequately iodized salt i.e., the iodine level in the salt was ≥15 ppm. Iodine deficiency was significantly marked in sample salts collected from katcha houses as compared with salts collected from pucca houses. Households with low financial status were using noniodized/inadequately-iodized salt. Both crystalline and refined salts were sold at all retail shops. Crystalline salts collected from all retailers had an iodine content < 15 ppm and refined salts collected from one retailer had iodine content < 15 ppm. About 48.5% of salt samples collected from retail shops were adequately iodized.
In the urban slums of Cuttack, retailers were selling crystalline salts, which were inadequately iodized- this would be a setback in the progress towards eliminating IDD.
PMCID: PMC2781123  PMID: 19966962
Iodized salt; mental retardation; sustainable elimination; urban slum
6.  Variable Iodine Intake Persists in the Context of Universal Salt Iodization in China123 
The Journal of Nutrition  2012;142(9):1728-1734.
Iodine deficiency disorders were prevalent in China until the introduction of universal salt iodization in 1995. Concerns have recently arisen about possible excess iodine intake in this context. To document iodine intake and the contribution from iodized salt in China, we surveyed dietary iodine intake during China’s nationally representative 2007 total diet study (TDS) and during an additional TDS in 4 coastal provinces and Beijing in 2009. Iodine intake was broken down by age and sex in 2009. Mean daily iodine and salt intake and the contribution from different food and beverage groups (and in 2009, individual items) was measured. The iodine in food cooked with iodized and noniodized salt was also assessed. The mean calculated iodine intake of a standard male in China was 425 μg/d in 2007 and 325 μg/d in coastal areas in 2009, well below the upper limit (UL) in all provinces. In 2009, iodine intake was above the UL in only 1–7% of age-sex groups, except among children (18–19%). A concerning number of individuals consumed less than the WHO-recommended daily allowance, including 31.5% of adult women. Salt contributed 63.5% of food iodine, and 24.6% of salt iodine was lost in cooking. Overall salt consumption declined between the surveys. Salt iodization assures iodine nutrition in China where environmental iodine is widely lacking. The risk of iodine excess is low, but planned decreases in salt iodization levels may increase the existing risk of inadequate intake. Regular monitoring of urinary iodine and more research on the impact of excess iodine intake is recommended.
PMCID: PMC3417834  PMID: 22810983
7.  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)
8.  Household Salt Iodine Content Estimation with the Use of Rapid Test Kits and Iodometric Titration Methods 
Background: Universal salt iodization remains the best strategy for controlling iodine deficiency disorders in Nepal.
Aims: This study was designed to study the salt types and the household salt iodine content of school aged children in the hilly and the plain districts of eastern Nepal.
Material and Methods: This cross-sectional study was carried out on school children of seven randomly chosen schools from four districts, namely, Sunsari, Dhankuta, Sankhuwasabha and Tehrathum of eastern Nepal. The school children were requested to bring two teaspoonfuls (approx. 12-15 g) of the salt which was consumed in their households, in a tightly sealed plastic pouch. The salt types were categorized, and the salt iodine content was estimated by using rapid test kits and iodometric titrations. The association of the salt iodine content of the different districts were tested by using the Chi-square test. The sensitivity, specificity, positive predictive values, and negative predictive values of the rapid test kits were compared with the iodometric titrations.
Results: Our study showed that mean±SD values of the salt iodine content in the four districts, namely, Sunsari, Dhankuta, Sankhuwasabha and Tehrathum were 34.2±17.9, 33.2±14.5, 27.4±15.1 and 48.4±15.6 parts per million (ppm). There were 270 (38.2%) households which consumed crystal salt and 437(61.8%) of the households consumed packet salts.
Conclusions: Our study recommends a regular monitoring of the salt iodization programs in these regions. More families should be made aware of the need to ensure that each individual consumes iodized salt.
PMCID: PMC3681063  PMID: 23814736
Iodine deficiency; Salt iodine content; Nepal
9.  Post-production Losses in Iodine Concentration of Salt Hamper the Control of Iodine Deficiency Disorders: A Case Study in Northern Ethiopia 
Iodine is essential for good function of the thyroid, and its deficiency is of public-health importance in Ethiopia. Iodization of salt is an effective and sustainable strategy to prevent and control iodine deficiency in large populations. The effectiveness of salt-iodization programmes depends on the conservation of iodine concentration in salt at various stages of the supply-chain. The overall objective of the study was to assess the loss of iodine in salt from production to consumption and to estimate the proportion of adults, especially pregnant women, at risk of dietary iodine insufficiency. A cross-sectional study was conducted during February-April 2007 in northern Ethiopia. Iodine concentrations of salt samples from producers (n=41), retailers (n=7), and consumers (n=32) were determined using iodiometric titration. A risk assessment was conducted for dietary iodine insufficiency among adults, including pregnant women, using a semi-probabilistic approach. The concentration of iodine in the sampled salts decreased by 57% from the production site to the consumers. The assessment of exposure showed that adults in 63% (n=20) of the households, including 90% (n=29) with pregnant women, were at risk of insufficient iodine intake. A monitoring and evaluation system needs to be established to ensure adequate supply of iodine along the distribution chain. Special attention is needed for the retailers and consumers. At these levels, dissemination of information regarding proper storage and handling of iodized salt is necessary to address the reported loss of iodine from salt.
PMCID: PMC2980888  PMID: 20635634
Cross-sectional studies; Iodine; Iodine deficiency; Salt; Ethiopia
10.  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
11.  Peace impact on health: population access to iodized salt in south Sudan in post-conflict period 
Croatian Medical Journal  2011;52(2):178-182.
To determine the population access to salt/iodized salt during and after the armed conflict in south Sudan and to illustrate geographical variations in population consumption of iodized salt in south Sudan after the armed conflict.
The sources of data for the conflict period were the 2004 Toward a Baseline: Best Estimates of Social Indicators for Southern Sudan study report and the 2000 Multiple Indicators Cluster Survey, and for the post-conflict period the 2005 Sudan Household Health Survey (SHHS) data set.
After peace agreement, population access to salt increased by 6.8% (Z = 5.488, P < 0.001) and the consumption of iodized salt increased by 32.9% (Z = 24.668, P < 0.001). More than 73% of families were using iodized salt but geographical differences existed between states.
Peace had positive impact on population access to iodized salt in south Sudan. Public health authorities in south Sudan need to establish quality monitoring and surveillance systems to track progress toward Universal Salt Iodization goal defined by the World Health Organization, United Nations Children’s Fund, and the International Council for the Control of Iodine Deficiency Disorders.
PMCID: PMC3083250  PMID: 21495201
12.  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.
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.
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.
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.
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.
PMCID: PMC2194698  PMID: 17996043
13.  Successful Efforts Toward Elimination Iodine Deficiency Disorders in India 
Iodine deficiency (ID) is the world's single most important preventable cause of brain damage and mental retardation. Iodine deficiency disorders (IDDs) is a public health problem in 130 countries, affecting 13% of the world population. The simplest solution to prevent the IDD is to consume iodized common salt every day. In India, significant progress has been achieved toward elimination of IDD, in the last 30 years. Satisfactory levels of urinary iodine excretion and iodine content of salt have been documented by the research surveys conducted by research scientists. The results indicate that we are progressing toward elimination of IDD. IDD is due to a nutritional deficiency, which is prima-rily that of iodine, in soil and water. IDD is known to re-appear if the IDD Control Program is not sustained. To ensure that the population continues to have intake of adequate amount of iodine, there is a need of i) periodic surveys to assess the magnitude of the IDD with respect to impact of iodized salt (IS) intervention; ii) strengthening the health and nutrition education activities to create demand for IS and iii) development of a monitoring information system (MIS) for ensuring that the adequately IS is available to the beneficiaries.
PMCID: PMC3026120  PMID: 21278862
Goiter; iodine; salt; urinary iodine excretion
14.  Prevalence and Severity of Iodine Deficiency Disorder Among Children 6–12 Years of Age in Shebe Senbo District, Jimma Zone, Southwest Ethiopia 
Iodine deficiency disorder is a major problem worldwide, especially during pregnancy and childhood. The magnitude of the problem is quite big in Ethiopia. The main aim of the present study was to determine the prevalence and severity of iodine deficiency disorders.
A cross-sectional survey was conducted in Shebe Senbo District on January 2011. Three elementary schools were selected by lottery method from 20 schools. From each school, students were selected by simple random sampling. Spot urine sample (5 ml) was taken to measure urine iodine level; physical exam was made to palpate goiter and salt samples were collected to estimate iodine content.
Out of 389 participants, 179 (46%) were males. The total goiter rate was 59.1% (Grade 1: 35.2%; Grade 2:23.9%). The median urinary iodine level was 56 4g/L that indicates iodine deficiency. Out of 389 households in the study area, 277 (71.2%) were using non-iodinated salt, 102 (26.2%) of the households were using iodinated salt. Cabbage usage was significantly associated with goiter.
Endemic goiter is quite prevalent in the study area. Median urinary iodine value of the study samples was found to be far lower than standards. Quality of the salt used by the study population was found to be poor in its iodine content. The use of cabbage (goitrogen) has shown remarkable influence on the development of goiter. Therefore, awareness creation and distribution of iodized salt are highly recommended.
PMCID: PMC3511898  PMID: 23209354
Iodine deficiency disorders; goiter; median urinary iodine; severity; prevalence
15.  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
16.  Universal salt iodization is successful in Kashmiri population as iodine deficiency no longer exists in pregnant mothers and their neonates: Data from a tertiary care hospital in North India 
Normal pregnancy results in a number of important physiological and hormonal changes that alter thyroid function. In pregnancy, the thyroid gland being subjected to physiological stress undergoes several adaptations to maintain sufficient output of thyroid hormones for both mother and fetus. Consequently, pregnant women have been found to be particularly vulnerable to iodine deficiency disorders (IDD), and compromised iodine status during pregnancy has been found to affect the thyroid function and cognition in the neonates.
Two decades after successful universal salt iodization (USI) in the country, there is scarce data on the iodine status of the pregnant women and their neonates. This is more relevant in areas like Kashmir valley part of sub-Himalayan belt, an endemic region for IDD in the past. The objective was to estimate Urinary Iodine status in pregnant women, the most vulnerable population.
Materials and Methods:
We studied thyroid function [free T3 (FT3), T3, free T4 (FT4), T4, thyroid stimulating hormone (TSH)] and urinary iodine excretion (UIE) in the 1st, 2nd, and 3rd trimesters and at early neonatal period in neonates in 81 mother–infant pairs (hypothyroid women on replacement) and compared them with 51 control mother–infant pairs (euthyroid).
Mean age of cases (29.42 + 3.56 years) was comparable to that of controls (29.87 + 3.37 years). The thyroid function evaluation done at baseline revealed the following: FT3 2.92 ± 0.76 versus 3.71 ± 0.54 pg/ml, T3 1.38 ± 0.37 versus 1.70 ± 0.35 ng/dl, FT4 1.22 ± 0.33 versus 1.52 ± 0.21 ng/dl, T4 9.54 ± 2.34 versus 13.55 ± 2.16 μg/dl, and TSH 7.92 ± 2.88 versus 4.14 ± 1.06 μIU/ml in cases versus controls (P > 0.01), respectively. The 2nd to 6th day thyroid function of neonates born to case and control mothers revealed T3 of 1.46 ± 0.44 versus 1.48 ± 0.36 ng/dl, T4 of 12.92 ± 2.57 versus 11.76 ± 1.78 μg/dl, and TSH of 3.64 ± 1.92 versus 3.82 ± 1.45 μIU/ml, respectively.
UIE was similar (139.12 ± 20.75 vs. 143.78 ± 17.65 μg/l; P = 0.8), but TSH values were higher in cases (7.92 ± 2.88) as compared to controls (4.14 ± 1.06). Although UIE gradually declined from 1st trimester to term, it remained in the sufficient range in both cases and controls. Thyroid function and UIE was similar in both case and control neonates.
We conclude that pregnant Kashmiri women and their neonates are iodine sufficient, indicating successful salt iodization in the community. Large community-based studies on thyroid function, autoimmunity, malignancies, etc., are needed to see the long-term impact of iodization.
PMCID: PMC3683211  PMID: 23776909
India; neonates; pregnancy; thyroid function; urinary iodine excretion
17.  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
18.  Education Achievements and Goiter Size Ten Years After Iodized Salt Consuming 
Approximately 2.2 billion (2200 million) of the world population are living in the area with Iodine deficiency (ID), most of them in the developing countries. In IRAN about 2 million are exposed to Iodine deficiency. Most of the complications of ID are not curable, especially brain damage. On the other hand, adding iodine to daily salt is a suitable program for decreasing iodine deficiency. This has been the main aim of IDD National committee since 1986. This study is a before-after preventive trial, and was conducted to determine the effect of iodized salt in preventing the disorders of Iodine deficiency.
This study was a preventive field trial in 2 stages before and after prevention. Since 1995, Iodized salt has been distributed in Tabas in Yazd province. Sample of 2,150 students aged 6-18 years were chosen by stratified cluster random sampling method from 24 schools, 12 schools from rural and 12 from urban areas. Goiter frequency and educational status were determined using WHO criteria and mean scored, respectively.
Prevalence of goiter has decreased from 34 to 25 percent after 10 years (P < 0.001). The prevalence in urban areas has decreased from 35.8 to 23.5 percent and in rural from 35.6 to 28.5 percent (P = 0.02). Prevalence of Goiter has changed from 32.8 to 20 percent and from 39.5 to 31.5 in boys and girls, respectively (P < 0.001). There was a statistically significant relation between educational status and goiter frequency before and after prevention (P = 0.01). There was also a statistically significant relation between educational status in 2 stages, before and after intervention (P < 0.001).
Although, there are some confounding variables, such as: educational resources development, improved educational methods, and enhanced family emphasis on extracurricular education, increased frequency of students in higher education after intervention shows the iodine effects on mental function.
PMCID: PMC3775163  PMID: 24049612
Educational status; goiter; iodine deficiency; prevention
19.  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
20.  Double-Fortified Salt Is Efficacious in Improving Indicators of Iron Deficiency in Female Indian Tea Pickers123 
The Journal of Nutrition  2014;144(6):957-964.
Poor iron status affects 50% of Indian women and compromises work productivity, cognitive performance, and reproduction. Among the many strategies to reduce iron deficiency is the commercial fortification of iodized table salt with iron to produce a double-fortified salt (DFS). The objective of this study was to test the efficacy of DFS in reducing iron deficiency in rural women of reproductive age from northern West Bengal, India. The participants were 212 women between 18 and 55 y of age who worked as full-time tea pickers on a large tea estate. Participants in the randomized, controlled, double-blind study were assigned to use either DFS or a control iodized salt for 7.5 to 9 mo. The DFS was fortified with 3.3-mg ferrous fumarate (1.1-mg elemental iron) per kg of iodized salt, whereas the control salt contained only iodine (47 mg/kg potassium iodate), and both salt varieties were distributed gratis to the families of participants at 0.5 kg/mo for each 2 household members. At baseline, 53% of participants were anemic (hemoglobin <120 g/L), 25% were iron deficient (serum ferritin <12 μg/L), and 23% were iron-deficient anemic. Also, 22% had a transferrin receptor concentration >8.6 mg/L and 22% had negative (<0.0 mg/kg) body iron stores. After 9 mo the participants receiving DFS showed significant improvements compared with controls in hemoglobin (+2.4 g/L), ferritin (+0.13 log10 μg/L), soluble transferrin receptor (−0.59 mg/L), and body iron (+1.43 mg/kg), with change in status analyzed by general linear models controlling for baseline values. This study demonstrated that DFS is an efficacious approach to improving iron status and should be further evaluated for effectiveness in the general population. This trial was registered at as NCT01032005.
PMCID: PMC4018955  PMID: 24744318
21.  Increased prevalence of subclinical hypothyroidism in females in mountainous valley of Kashmir 
Iodine-rich diet is necessary for proper thyroid gland function. Subclinical hypothyroidism (SCH) is associated with serious complications. Substantial numbers of patients have risk of SCH getting converted into primary hypothyroidism.
The objectives of the present study are to survey dietary iodine intake pattern in ethnic population of Kashmir and to study the prevalence of SCH.
Materials and Methods:
A retrospective, cross-sectional referral hospital study was conducted. Sample size comprised of 2550 patients who were referred to Department of Biochemistry, Government Medical college, Srinagar diagnostic laboratory from OPD and IPD of associated SMHS hospital. Assessment of thyroid function over a period of one year from March 2010 to March 2011 in the serum has been performed by electro-chemiluminescence immunoassay method on ECLIA 2010 fully automatic analyzer. Interview cum questionnaire methods were used to record the patient history and dietary iodine intake pattern. Iodine status of these patients was assessed by measuring urinary iodine excretion.
Total patients were 2550 comprising of 44.6% males and 56.4% females. Subjects with elevated and normal thyroid stimulating hormone (TSH) levels in the serum were 30.51 and 69.4% respectively. About 550 patients (21.56%) had subclinical hypothyroidism which includes both males and females. Prevalence of SCH was more in females (81.8%) than in males (18.2%). Most of the patients presenting with SCH were in the age group of 20–65 years.
The percentage of SCH amongst the study sample patients was 21.56%, which is much higher as compared to other parts of the world. The highest percentage of SCH was found in females (81.8%) as compared to males (18.2%). On the basis of the present study, we suggest that routine screening of selected populations, especially women between 20 and 65 years of age, may be advocated. Further community level awareness programs need to be organized wherein people in mountainous valley of Kashmir are motivated to take salt in iodized form and diet rich in iodine to ensure proper thyroid gland functioning.
PMCID: PMC3683204  PMID: 23776902
Dairy products; iodine rich food; strawberries; subclinical hypothyroidism; thyroid stimulating hormone; urinary iodine excretion
22.  Tanzania national survey on iodine deficiency: impact after twelve years of salt iodation 
BMC Public Health  2009;9:319.
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.
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.
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.
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.
PMCID: PMC2749826  PMID: 19728863
23.  Goiter and Multiple Food Allergies 
Severe iodine deficiency results in impaired thyroid hormone synthesis and thyroid enlargement. In the United States, adequate iodine intake is a concern for women of childbearing age and pregnant women. Beyond this high risk group iodine deficiency is not considered to be a significant problem. This case report describes a 12-year-old male with severe iodine deficiency disorder (IDD) resulting from restricted dietary intake due to multiple food allergies. We describe iodine replacement for this patient and continued monitoring for iodine sufficiency. Children with multiple food allergies, in particular those with restrictions to iodized salt and seafood, should be considered high risk for severe iodine deficiency.
PMCID: PMC2777012  PMID: 19956702
24.  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
25.  Dietary Salt Reduction and Cardiovascular Disease Rates in India: A Mathematical Model 
PLoS ONE  2012;7(9):e44037.
Reducing salt intake has been proposed to prevent cardiovascular disease in India. We sought to determine whether salt reductions would be beneficial or feasible, given the worry that unrealistically large reductions would be required, worsening iodine deficiency and benefiting only urban subpopulations.
Methods and Results
Future myocardial infarctions (MI) and strokes in India were predicted with a Markov model simulating men and women aged 40 to 69 in both urban and rural locations, incorporating the risk reduction from lower salt intake. If salt intake does not change, we expect ∼8.3 million MIs (95% CI: 6.9–9.6 million), 830,000 strokes (690,000–960,000) and 2.0 million associated deaths (1.5–2.4 million) per year among Indian adults aged 40 to 69 over the next three decades. Reducing intake by 3 g/day over 30 years (−0.1 g/year, 25% reduction) would reduce annual MIs by 350,000 (a 4.6% reduction; 95% CI: 320,000–380,000), strokes by 48,000 (−6.5%; 13,000–83,000) and deaths by 81,000 (−4.9%; 59,000–100,000) among this group. The largest decline in MIs would be among younger urban men, but the greatest number of averted strokes would be among rural men, and nearly one-third of averted strokes and one-fifth of averted MIs would be among rural women. Only under a highly pessimistic scenario would iodine deficiency increase (by <0.0001%, ∼1600 persons), since inadequate iodized salt access—not low intake of iodized salt—is the major cause of deficiency and would be unaffected by dietary salt reduction.
Modest reductions in salt intake could substantially reduce cardiovascular disease throughout India.
PMCID: PMC3435319  PMID: 22970159

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