Thyroid review

1. Asia Pac J Clin Nutr. 2010;19(2):250-5.

Poor iodine status and knowledge related to iodine on the eve of mandatory iodinefortification in Australia.

Charlton KE, Yeatman HR, Houweling F.

Smart Foods Centre, Faculty of Health and Behavioural Sciences, University ofWollongong, Wollongong, NSW 2522, Australia. [email protected]

BACKGROUND: Mandatory fortification of bread with iodised salt is proposed toaddress the re-emergence of iodine deficiency in Australia and New Zealand. Theimpacts of fortification require baseline data of iodine status among vulnerable sectors of the population.OBJECTIVE: To assess the iodine status of healthy women and to investigateconsumer understanding and attitudes related to the proposed mandatory iodinefortification programme.DESIGN: Cross-sectional sample of 78 non-pregnant women aged 20-55 y wasconveniently sampled in Wollongong, NSW. A single 24-hr urine sample wascollected for urinary iodine concentration (UIC). A self-administeredquestionnaire assessed consumer understanding, perceptions and attitudes related to iodine fortification.OUTCOMES: Median UIC = 56 microg/L (IQR = 41-68), indicating mild iodinedeficiency. Knowledge about iodine was poor with less than half associating lowiodine status with adverse pregnancy outcomes. Health education andsupplementation, particularly at the medical practitioner interface, wasconsidered the best strategy for improving low iodine levels.CONCLUSIONS: The iodine status of women in one region of New South Wales was low.These data add support to the need for a national approach to address iodineintake which includes an accompanying consumer education campaign.

PMID: 20460240 [PubMed - indexed for MEDLINE]

2. Med Educ. 2009 Dec;43(12):1210-7.

Do worked examples foster medical students' diagnostic knowledge ofhyperthyroidism?

Kopp V, Stark R, Kühne-Eversmann L, Fischer MR.

Institute for Teaching and Educational Research in Health Sciences, PrivateUniversity of Witten/Herdecke, Germany.

OBJECTIVES: In an initial experimental study in the domain of learning abouthypertension, a case-based, worked example approach was found to be mosteffective when erroneous examples and elaborated feedback were provided. However,combining erroneous examples with knowledge of correct result (KCR) feedbackimpaired learning. This study was designed to establish whether these findingscould be replicated in the domain of learning about hyperthyroidism.METHODS: A total of 124 medical students were randomly assigned to the fourconditions of a 2 x 2 design (with errors versus without errors; elaboratedfeedback versus KCR feedback). Diagnostic knowledge was operationalised by amultiple-choice test, key feature problems and problem-solving tasks. Acceptance and subjective learning outcomes were assessed on three rating scales.RESULTS: The combination of erroneous examples and elaborated feedback was the

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most effective learning condition, whereas erroneous examples with KCR feedbackimpaired knowledge acquisition. These effects were independent of differences in prior knowledge and time on task and replicated key findings of the study onhypertension diagnostics. Additionally, results showed that students inconditions with elaborated feedback assessed their learning outcomes assignificantly higher than students receiving KCR feedback only.CONCLUSIONS: By providing erroneous examples in combination with elaboratedfeedback in a computer-based learning environment, diagnostic knowledge wasfostered. The approach of 'learning from worked examples' was successfullyadapted to a complex domain and was found to support the acquisition of complexcompetencies.


3. East Afr J Public Health. 2008 Dec;5(3):163-8.

The role of changing diet and altitude on goitre prevalence in five regionalstates in Ethiopia.

Abuye C, Berhane Y, Ersumo T.

Ethiopian Health and Nutrition Research Institute (EHNRI), Faculty of Medicine,Addis Ababa University (AAU), Ethiopia. [email protected]

OBJECTIVE: Iodine Deficiency Disorders (IDD) as one of the leading nutritionalproblems has been increasing through time due to iodine deficiency, aggravatingfactors and IDD knowledge in many parts of Ethiopia. The effect of changing diet and altitude on goitre prevalence is assessed.METHODOLOGY: Randomly selected five regional states (Amhara, Oromiya, Tigray,SNNP and Benshangul-Gumuz) were used to conduct cross-sectional study on IDD. In each region cluster sampling method was applied to select study subjects. Lowland and adjacent high land were independently sampled to investigate the role ofaltitude on goiter prevalence. Totally 6960 children and the same number ofbiological mothers of the children were included in the clinical examination for goiter and household interview. Urine samples were collected from children forurinary iodine examination/analysis (UIE). Besides, in all clusters qualitativedata were collected on IDD knowledge and cassava introduction, cultivation andconsumption.RESULTS: Cassava consumption and living in high altitude were found to be riskfactors for IDD. In the two regions (SNNP and Benshangul-Gumuz) among three wherecassava is cultivated, those who consume cassava frequently were significantly (p< 0.001) affected by goitre than those consuming rarely or not. In the lastthirty years cassava consumption has been increasing with the concomitantincrease in goitre rate and other associated health problems. Acute cyanideintoxication in children from cassava meal was reported. In Amhara region, goitrerate was significantly (p < 0.05) higher in high altitudes than in low both forchildren and mothers. This was due to significantly (p < 0.01) low level ofiodine intake in high lands than in low as indicated by UIE. Due to stigma,parents do not send goitrous children to schools and goitrous girls are notwanted for marriage.CONCLUSION: Besides low level of iodine intake, cassava consumption and living inhigh altitude were responsible for the observed variation and severity in goitre rates. IDD affects several dimensions of human life including school enrolmentand marriage. Addressing IDD in-terms of salt iodization and training communitieson cassava processing techniques to remove cyanide, awareness creation on IDD and

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soil conservation are highly recommended.


4. Eur J Endocrinol. 2009 Oct;161(4):623-9. Epub 2009 Aug 6.

Familial risks for hospitalized Graves' disease and goiter.

Hemminki K, Shu X, Li X, Ji J, Sundquist K, Sundquist J.

Division of Molecular Genetic Epidemiology, German Cancer Research Center (DKFZ),Im Neuenheimer Feld 580, D-69120 Heidelberg, Germany.

OBJECTIVES: Familial clustering of a disease is an indicator of a possibleheritable cause, provided that environmental sharing can be excluded. Thus, data on familial risks are important for genetic studies and for clinical geneticcounseling.DESIGN: We carried out a nationwide family study on nontoxic and toxic nodulargoiters, and Graves' disease in order to search for familial clustering of these diseases at the population level.METHODS: The Swedish Multigeneration Register on 0-75 year old subjects waslinked to the Hospital Discharge Register from years 1987 to 2007. Standardizedincidence ratios (SIRs) were calculated for offspring of affected parents and forsiblings by comparing to those whose relatives had no hospitalization for thyroiddisease.RESULTS: The number of hospitalized patients in the offspring generations was 11 659 for nontoxic goiter, 9514 for Graves' disease, and 1728 for toxic nodulargoiter. Familial cases accounted for 8.2, 5.2, and 2.1% of all patientsrespectively. The highest familial risk for offspring of affected parents wasnoted for Graves' disease (SIR 3.87), followed by toxic nodular goiter (3.37) andnontoxic goiter (3.15). Familial risks were higher for affected siblings: toxicnodular goiter (11.66), Graves' disease (5.51), and nontoxic goiter (5.40).Weaker familial associations were observed between the three diseases.CONCLUSIONS: To our knowledge this is a first population-based family study onthese thyroid diseases. The observed high familial aggregation for definedthyroid diseases cannot be explained by the known genetic basis, calling forfurther studies into genetic and environmental etiology of thyroid diseases.


5. Eur J Intern Med. 2009 Mar;20(2):158-61. Epub 2008 Aug 5.

Skin findings in thyroid diseases.

Artantaş S, Gül U, Kiliç A, Güler S.

Numune Education and Research Hospital, 2nd Dermatology Clinic, Ankara, Turkey.

BACKGROUND: In cases of thyroid diseases, many of the symptoms arise on the skin.In this study, we aimed to detect and compare the skin findings and accompanying dermatoses of patients with thyroid diseases.MATERIALS AND METHODS: 220 patients with thyroid diseases, who did not have anymedical cure, and 90 healthy individuals as a control group attended our study.

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All of the cases were examined, and the skin findings and/or dermatoses wererecorded. The skin findings in the patients and the control group were comparedstatistically.RESULTS: Among 220 cases, in 125 (56.8%) skin findings were detected. The mostfrequently observed skin findings were chronic urticaria (6.8%), vitiligo (6.8%),diffuse alopecia (6%), acne vulgaris (5%) and acne rosacea (3.6%). No significantdifference was detected statistically between the patients and control group interms of skin findings. When compared for the presence of each dermatosis,chronic urticaria, vitiligo and pruritus were found to be significantly higher inthe patient group with thyroid diseases than in the control group. In terms ofthe presence of skin findings, no statistical difference was detected betweenautoimmune hyperthyroidism and non-autoimmune hyperthyroidism, between autoimmunehypothyroidism and non-autoimmune hypothyroidism, or between autoimmuneeuthyroidism and non-autoimmune euthyroidism. Chronic urticaria, vitiligo, anddiffuse alopecia were found to be significantly higher in patients withautoimmune thyroid diseases than in the control group. Vitiligo and diffusealopecia were found to be higher in autoimmune hyperthyroidism patients than inthe control group. Vitiligo was found to be significantly higher in autoimmunehypothyroidism patients than in the control group.CONCLUSION: To our knowledge, no report investigating the skin findings amongthyroid diseases exists in literature. We believe this study would provide datafor further studies.


6. Nutr Health. 2009;20(1):21-30.

Salt fortification with iodine: Sudan situation analysis.

Izzeldin SH, Crawford MA, Ghebremeskel K.

Institute of Brain Chemistry and Human Nutrition, London Metropolitan [email protected]

Iodine deficiency disorders (IDD) constitute a severe public health problem inSudan. IDD affects children and women throughout life. More than 2 out of 10school age children have goiter. The prevalence reaches 40% in some regions ofthe country. Several interventional measures were introduced to control the IDDproblem. While the situation with regard to production and supply of iodized saltwas thus deteriorating, an Emergency Food Security and Nutrition AssessmentSurvey (EFSNA) revealed that the prevalence of IDD among adult women, asreflected in the presence of visible goiter, was as high as 25.5%. We haveconducted a situation analysis survey in the Republic of Sudan to review theprevailing situation and suggest a benchmark that would help in developingeffective control measures and in monitoring their implementations. SWOTanalysis, questionnaire, focus groups discussion beside a combination of rapidassessment approach and qualitative method were used to critically evaluate thesalt iodization situation in the country and assess the prevailing IDD situation in and propose a plan of action to overcome the bottlenecks. The survey concludedthat Iodine deficiency affects children and women all through Sudan. Theprevalence is even greater in some regions of the country and there is nosupportive policy environment for successful universal salt iodization. Toovercome this aggravated situation Sudan will need to conduct a baseline study toprovide data on the prevalence of IDD, geographic distribution, knowledge,attitudes and practices relating to iodine deficiency. This will provide a

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benchmark that will help in developing effective control measures and inmonitoring their implementation. The study recommended a set of actions to thegovernment to overcome the prevailing situation and strengthening the currentpolicy and implementation.


7. J Pediatr Endocrinol Metab. 2008 Jan;21(1):79-87.

Determination of iodine nutrition and community knowledge regarding iodinedeficiency disorders in selected tribal blocks of Orissa, India.

Bulliyya G, Dwibedi B, Mallick G, Sethy PG, Kar SK.

Regional Medical Research Centre, Indian Council of Medical Research,Chandrasekharpur, Bhubaneswar, India. [email protected]

AIM: To determine the status of iodine nutrition and knowledge of iodinedeficiency disorders (IDD) in selected tribal mountainous blocks of Orissa,India.DESIGN: A community-based survey was performed, adopting the 30-cluster sampling and surveillance methodology for assessment of IDD recommended byWHO/UNICEF/ICCIDD.SUBJECTS: School-age children (6-12 years) and their mothers.METHODS: Total goitre rate (n=623) and urinary iodine excretion of children(n=530), iodine content in edible salt (n=505) and water (n=21) were measured.Community knowledge regarding IDD and awareness of iodized salt (n 20) wasassessed.RESULTS: Total goitre rate was 23.6%, of which visible goiter was 6.9%.Prevalence of goiter increased with age in female and tribal children. Medianurinary iodine was 38 Cmicro.Tl(-1) and 51.7% of children had urinary iodinevalues <100 pmicrogtl(-1) The mean iodine content for drinking water ranged from 1.22-3.6 pmicro.Tl(-1) Only 9.9% of salt samples had adequate iodine content (>or =5 ppm). Over 80% of respondents did not have knowledge of IDD and were notaware of salt iodization.CONCLUSIONS: Study results show moderate iodine deficiency with poor communityknowledge of iodine nutrition. There is need to strengthen the monitoring of saltiodization and intensive education activities in the tribal areas.


8. Aust J Rural Health. 2008 Apr;16(2):109-14.

Evaluation of iodine levels in the Riverina population.

Uren LJ, McKenzie G, Moriarty H.

The Manilla Pharmacy, Manilla.

OBJECTIVE: To assess the iodine status in a random group of adults in a ruralregion.DESIGN: A cross-sectional study; urinary iodine concentrations (UIC) werecorrelated with results of a questionnaire that collected demographic

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information.SETTING: Primary care.PARTICIPANTS: A total of 173 adults from the Riverina region provided a morningmidstream urine sample and completed a questionnaire. There were no exclusioncriteria.MAIN OUTCOME MEASURES: Iodine status was based upon mean UIC (MUIC) values andcategorised according to World Health Organisation criterion. Subgroups wereclassified according to sex, age, town, salt usage, vitamin/supplement usage,pregnant or breast-feeding status and diet.RESULTS: The MUIC for the study population was 79 microg L(-1); 29% wereiodine-replete, 52% had mild deficiency and 18.5% were moderately to severelydeficient. Use of iodised salt produced a non-clinically significant increase in MUIC of 81 microg L(-1)compared with 71 microg L(-1)(P = 0.1907). Daily vitaminsupplementation led to iodine sufficiency with a MUIC of 111 microg L(-1)(P =0.0011). Participants aged 50-59 years had a significantly lower MUIC thanparticipants aged 18-39 years (67 versus 89 microg L(-1), respectively, P =0.0106). Further, the MUIC decreased with age from 18 to 59 years (P = 0.0208).CONCLUSIONS: A mild iodine deficiency was found in this sample of the Riverinapopulation, consistent with other Australian studies. Salt iodisation might notbe an effective strategy to correct iodine deficiencies within Australia.


9. BMC Public Health. 2007 Nov 8;7:316.

The goitre rate, its association with reproductive failure, and the knowledge of iodine deficiency disorders (IDD) among women in Ethiopia: cross-sectioncommunity based study.

Abuye C, Berhane Y.

Food and Nutrition Research Department, Ethiopian Health and Nutrition ResearchInstitute, Addis Ababa, Ethiopia. [email protected]

BACKGROUND: Iodine deficiency is severe public health problem in Ethiopia.Although urinary iodine excretion level (UIE) is a better indicator for IDD thegoitre rate is commonly used to mark the public health significance. The range ofill effect of IDD is however beyond goitre in Ethiopia. In this study theprevalence of goitre and its association with reproductive failure, and theknowledge of women on Iodine Deficiency were investigated.METHODS: A cross-section community based study was conducted during February toMay 2005 in 10998 women in child bearing age of 15 to 49 years. To assess thestate of iodine deficiency in Ethiopia, a multistage "Proportional to Population Size" (PPS) sampling methods was used, and WHO/UNICEF/ICCIDD recommended methodfor goitre classification.RESULTS: Total goitre prevalence (weighted) was 35.8% (95% CI 34.5-37.1), 24.3%palpable and 11.5% visible goitre. This demonstrates that more than 6 millionwomen were affected by goitre. Goitre prevalence in four regional states namelySouthern Nation Nationalities and People (SNNP), Oromia, Bebshandul-Gumuz andTigray was greater than 30%, an indication of severe iodine deficiency. In therest 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 majorpublic health problem in Ethiopia. Women with goitre experience more pregnancyfailure (X2 = 16.5, p < 0.001; OR = 1.26, 1.12 < OR < 1.41) than non goitrouswomen. Similarly reproductive failure in high goitre endemic areas was

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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 importanceof iodated salt.CONCLUSION: Ethiopia is at risk of iodine deficiency disorders. The findingspresented in this report emphasis on a sustainable iodine intervention programtargeted at population particularly reproductive age women. Nutrition educationalong with Universal Salt Iodization program and iodized oil capsule distributionin some peripheries where iodine deficiency is severe is urgently required.

PMCID: PMC2194698PMID: 17996043 [PubMed - indexed for MEDLINE]

10. Rev Med Univ Navarra. 2007 Jan-Mar;51(1):18-22.

[Management of subclinical hyperthyroidism].

[Article in Spanish]

Galofré JC.

Departamento de Endocrinologia y Nutrición, Clínica Universitaria, Facultad deMedicina, Universidad de Navarra, España. [email protected]

Management of subclinical hyperthyroidism (low TSH and normal thyroid hormones)is controversial. Knowledge of its causes, clinical context and associatedmorbidity is required. It is recommended to follow six steps in exploration andtreatment: 1) confirmation, 2) estimation of severity, 3) cause assessment, 4)study of complications, 5) balance whether treatment is needed and 6) ifnecessary, choice of the most appropriate form. In its management, the sametreatments are used as in overt hyperthyroidism.


11. Public Health Nutr. 2005 Jun;8(4):387-94.

Women's iodine status and its determinants in an iodine-deficient area in theKayes region, Mali.

Torheim LE, Granli GI, Sidibé CS, Traoré AK, Oshaug A.

Pedriatric Ward, Rikshospitalet, Oslo, Norway. [email protected]

OBJECTIVE: To assess iodine status and its determinants in women of childbearing age in a rural area in the Kayes region, Mali, West Africa.DESIGN: Cross-sectional study where women's iodine status was indicated byurinary iodine concentration (UIC) and level of goitre based on palpation. Saltiodine was assessed semi-quantitatively at household level. Individualcharacteristics were collected using questionnaires.SETTING: Fifteen villages in a rural area in the Kayes region of Mali.SUBJECTS: Women aged 15-45 years (n=423).RESULTS: Median UIC was 2.7 microg dl(-1), and only 6% of the women had adequate iodine status of UIC >10 microg dl(-1). Most women (60%) had visible goitre, and only 9% were classified as without goitre. Only 39% of the households were using

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salt with any iodine, and level of knowledge about salt iodisation was low. Main determinants of UIC were breast-feeding and level of salt iodisation; currentlybreast-feeding women had lower UIC, and UIC increased with increasing level ofiodine in household salt. Prevalence of goitre was lower in older women withhigher body mass index.CONCLUSION: The study indicates severe iodine deficiency in the study area.Urgent action is needed to improve the situation through enforcing saltiodisation legislation and increasing the level of knowledge about the importanceof iodised salt in the population.


12. Public Health Nutr. 2005 Jun;8(4):382-6.

Knowledge of iodine nutrition in the South African adult population.

Jooste PL, Upson N, Charlton KE.

Divison of Nutrition and Dietetics, School of Health and Rehabilitation Sciences,University of Cape Town, Cape Town, South Africa. [email protected]

OBJECTIVES: To determine the level of knowledge regarding iodine nutrition andits relationship with socio-economic status in the South African population.DESIGN: A cross-sectional population survey collecting questionnaire information on knowledge of iodine nutrition and sociodemographic variables in a multistage, stratified, cluster study sample, representative of the adult South Africanpopulation.SETTING: Home visits and personal interviews in the language of therespondent.Subjects: Data were collected from one adult in each of the selected2164 households, and the participation rate was 98%.RESULTS: Only 15.4% of respondents correctly identified iodised salt as theprimary dietary source of iodine, 16.2% knew the thyroid gland needs iodine forits functioning, and a mere 3.9% considered brain damage, and 0.8% consideredcretinism, as the most important health consequence of iodine deficiency.Compared with respondents from high socio-economic households, respondents fromlow socio-economic households were considerably less informed about aspects ofiodine nutrition covered in this study.CONCLUSIONS: The knowledge level of iodine nutrition is low among South Africans,particularly among the low socio-economic groups. These data suggest that theinternational emphasis on brain damage resulting from iodine deficiency has notbeen conveyed successfully to the consumer level in this country.


13. Probl Sotsialnoi Gig Zdravookhranenniiai Istor Med. 2005 Jan-Feb;(1):25-6.

[Prevention of iodine-deficient diseases].

[Article in Russian]

Dzhatdoeva FA, Syrtsova LE, Gerasimov GA, Zubrilova TE, Salpagarova ZN.

The Interregional center of public health and development assisted by Sechenov

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Moscow Medical Academy undertook, 1999-2000, a study of the standard ofknowledge, attitude and conduct of consumers in respect to the use of iodinatedsalt (IS) in the prevention of iodine-deficient diseases (IDD). It wasdemonstrated that, on the average per one district, 19% of city respondents and13% of rural respondents used IS only. About 31% of city respondents used IS whenit was available at the next-door shop, i.e. from time to time. This figurereached 48% in Irkutsk and Orenburg Regions. The share of those who used ISsometimes in rural regions made an average of 20.7%. 67.2% of those who believethat IDD can be prevented think that ID can also be prevented. Less than 5% ofthem say ID cannot be regarded as a reliable tool in the prevention of IDD.


14. East Afr Med J. 2003 Oct;80(10):532-9.

Iodine concentration in salt at household and retail shop levels in Shebe town,south west Ethiopia.

Takele L, Belachew T, Bekele T.

South People Nations and Nationalities People's Regional Health Bureau, Jimma,Ethiopia.

OBJECTIVES: To determine the level of iodine in the salt at the retail shop andconsumption levels and assess the knowledge, attitude and practice (KAP) of food caterers and shopkeepers about iodized salt and iodine deficiency disorders(IDD).DESIGN: Cross-sectional community based.SETTING: Retail shops and households in Shebe town-Jimma zone, southwest Oromiya region.SUBJECTS: Thirty three shopkeepers and 299 food caterers of households in Shebetown.RESULTS: The iodine content of household salt samples ranged, from 0-75 PPM andthat of the shop samples ranged from 0.1-75 PPM. Eighty one per cent of householdsalt samples and 82% of shop salt samples have iodine levels below the minimumstandard set by the Quality and Standard Authority of Ethiopia. Knowledge aboutiodized salt was fairly lower for food caterers (21%) than shopkeepers (57.6%).More (80%) of shopkeepers have favourable attitude than household food caterers(50.6%). Improper practices of food caterers related to iodized salt were foundto be associated with female sex (P<0.01), Amhara ethnicity (P<0.001), Orthodoxreligion (P=0.008), literacy status (P=0.04) and occupation (P=0.01). Goodknowledge, about iodized salt was significantly associated with favourableattitude among food caterers (P<0.001).CONCLUSION: This study demonstrated that high proportions of residents in Shebetown were consuming inadequately iodized salt. There is a marked loss of iodinefrom salt by the time it reaches to consumption level in that some householdswere found to use salt with zero iodine content, whereas, all salt samplescollected from the shops have at least some iodine. Poor awareness about iodized salt among food caterers and even in shopkeepers was also disclosed in thisstudy. Socio-demographic factors such as ethnicity, religion, sex, lowereducational level of food caterers might have an influence on poor, householdpractices like exposure of salt to sunlight. Information, education andcommunication on the importance consuming iodized salt and its proper handling inthe house and regular monitoring of the salt iodine level at consumer level isessential for elimination of IDD.

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15. Mymensingh Med J. 2002 Jan;11(1):22-5.

Use of iodized salt and the prevalence of goiters in an endemic area ofBangladesh.

Sarker FH, Taufiqun-Nessa UK, Chowdhury SA.

Department of Community Medicine, Mymensingh Medical College.

To find out the prevalence of goitre and assess the knowledge regarding goitreand iodized salt among the respondents in a selected goitre endemic area. Thiscross-sectional study included 155 respondents of purposively selected endemicvillages of Nilphamary Sadar upazilla. Information was collected from allhouseholds of the villages considering one responsible person from eachhousehold. Data was collected by face to face interview through pre-testedquestionnaire and checklist. Study population was 747. Department of CommunityMedicine, National Institute of Preventive & Social Medicine, Mohakhali, March toJune 2001. Out of 155 respondents 63.87% was female and 36.13% were male. Meanage was 34.13 with +/- 10.87 and mean monthly family income was 1974.74 with +/- 1025.92 taka, only 65% had > 5000 taka. Level of education SSC and above wasminimum (6.46%). Mean occupation was cultivation, day labour and housewife. Only 11.6% respondents had correct knowledge regarding goitre and 77.30% had knowledgeabout iodized salt. But only 58.71% respondents' families are using iodized salt according to test result by iodized salt testing solution. The prevalence ofgoitre among 747 people was found 8.3%, among them 4.53% were male, 12% werefemale and 6.96% were grade I and 1.07% were grade II (visible) goitre. The studyresult indicate that the prevalence of goitre still high, knowledge regardinggoitre is minimum and use iodized salt is not satisfactory.


16. Br J Nutr. 2002 Jan;87(1):61-9.

Dietary iodine intake and urinary iodine excretion in a Danish population: effectof geography, supplements and food choice.

Rasmussen LB, Ovesen L, Bülow I, Jørgensen T, Knudsen N, Laurberg P, Pertild H.

Institute of Food Research and Nutrition, Danish Veterinary and FoodAdministration, Søborg, Denmark. [email protected]

I deficiency diseases remain a health problem even in some developed countries.Therefore, measurement of I intake and knowledge about food choice related to Iintake is important. We examined I intake in 4649 randomly selected participants from two cities in Denmark (Copenhagen and Aalborg) with an expected differencein I intake. I intake was assessed both by a food frequency questionnaire and by measuring I in casual urine samples. I excretion was expressed as a concentrationand as estimated 24-h l excretion. Further, subgroups with low I intake wererecognized. I intake was lower in Aalborg than in Copenhagen for all expressions,and lower than recommended in both cities if I intake from supplements was not

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included. Milk was the most important I source, accounting for about 44% of the Iintake, and milk (P<0.001) and fish (P=0.009) intake was related to I excretionin a multiple linear regression model. Thus, risk groups for low I intake wereindividuals with a low milk intake, those with a low intake of fish and milk,those not taking I supplements and those living in Aalborg where the I content indrinking water is lower. Even individuals who followed the advice regardingintake of 200-300 g fish/week and 0.5 litres milk/d had an intake below therecommended level if living in Aalborg.



Elimination of iodine deficiency disorders by 2000 and its bearing on the people in a district of Orissa, India: a knowledge-attitude-practices study.

Mohapatra SS, Bulliyya G, Kerketta AS, Geddam JJ, Acharya AS.

Regional Medical Research Centre, Indian Council of Medical Research,Bhubaneswar, India. [email protected]

A knowledge-attitude-practices (KAP) study was conducted along with a prevalence study of iodine deficiency disorders (IDD) between 1998-99 in the district ofBargarh, Orissa state, India. A total of 635 people were interviewed by apretested structured questionnaire, adopting the probability proportional to sizecluster sampling method. The aim was to assess the baseline information on theKAP of the people regarding IDD. Only 37% of the males and 29.3% of the femalesperceived goitre as a disease. Less than 5% of both sexes knew how goitre iscaused. Only 16.4% used iodised salt regularly. The awareness and perception ofIDD does not correspond with the time and effort we have spent in education ofthis disease. The implications of this poor knowledge about IDD and consequentpoor use of iodised salt is contrasted to the optimistic target of elimination ofIDD. This aspect is discussed in this paper, at a time when we are at thebeginning of the new millennium.


18. Asia Pac J Public Health. 2000;12(1):27-31.

Estimation of salt intake and recommendation for iodine content in iodized saltin Mongolia.

Yamada C, Oyunchimeg D, Erdenbat A, Enkhtuya P, Buttumur D, Naran G, Umenai T.

Division of Nursing, School of Medicine, University of [email protected]

In 1996, the Mongolian Government pledged to eliminate iodine deficiencydisorders by 2001 using salt iodization as its primary strategy. Iodine contentin salt was set at 50 +/- 10 PPM based on an assumption of 5 g of daily saltintake. In 1998, the authors suspected that salt intake was more than 5 g andthat pregnant women consumed more salt than non-pregnant women. Over 1,600 adultsof both sexes were studied in five provinces. In this study we estimated salt

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intake based on urinary excretion of sodium and creatinine. A formula was used tocalculate salt intake from excreted volumes of sodium and creatinine. Averagevalues for pregnant women, non-pregnant women, and men, were found to be 15.6 g(n = 499), 12.6 g (n = 598), and 14.6 g (n = 571), respectively. We concludedthat appropriate iodine content in salt should range from 20 to 40 PPM. It isrecommended that health education regarding proper levels of salt intake becarried out with the general public, with emphasis on pregnant women.


19. Indian J Pediatr. 1998 Jan-Feb;65(1):115-20.

Knowledge beliefs and practices regarding iodine deficiency disorders among thetribals in Car Nicobar.

Mallik AK, Anand K, Pandav CS, Achar DP, Lobo J, Karmarkar MG, Nath LM.

Centre for Community Medicine, All India Institute of Medical Sciences, NewDelhi.

It is estimated that 1,570 million people are at risk of iodine deficiency.Because of the wide spectrum of disorders that IDD includes, and lack of anyobvious association between iodine deficiency and its health effects, IDD is not perceived as a major public health problem. For any disease to be effectivelycontrolled, awareness at all levels from community to policy makers is necessary.This study was conducted to assess knowledge, beliefs and practices regardingiodine deficiency Disorders in Car Nicobar districts of Andaman and NicobarIslands. The population is predominantly tribals involved in coconut plantations.All the village heads of the sixteen villages and parents of 10% of the schoolchildren examined for goiter were interviewed. Initial focus group discussionswere conducted as no prior knowledge about local names for goitre or otherrelated IDD information was available. The interview schedule was designed inEnglish which was then translated into Hindi and Nicobarese and back translatedinto Hindi and English. A total of 114 persons were interviewed 60 males, 54females. The local name for goiter was "Rulo" and 44% felt that it only affected females. No one had correct knowledge of the cause of goiter. About half of therespondents believed that these swellings caused problems. Sixty three (55.3%) ofrespondents believed that there was treatment, of which 33 said there was medicaltreatment, 18 respondents said traditional treatment by "LAM-EEN" and 12 feltthat both therapies are required. Majority (85%) brought salt samples from theGovernment canteen. They did not now whether this salt was iodised. Salt was not washed before use and storage practice was satisfactory. The awareness about IDD needs reinforcement. At present the community is a passive participant in theI.D.D. Control Programme.


20. Coll Antropol. 1998 Jun;22(1):31-41.

The prevalence of goitre and cretinism in a population of the west Ivory Coast.

Kouamé P, Bellis G, Tebbi A, Gaimard M, Dilumbu I, Assouan A, Roux F, Mayer G,Chastin I, Diarra N, Chaventré A.

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National Institut of Public Health, Abidjan, Ivory Coast.

Iodine deficiency is a major public health problem in developing countries. Themain areas where goitre is prevalent have been identified, but the differentdegrees of severity and the populations affected have not. Most countries are nowattempting to obtain reliable and more extensive data. A pilot study was carried out in the Ivory Coast in order to improve epidemiological knowledge of iodinedeficiency and collect the information required to set up an eliminationprogramme. The aim of this study was to assess the prevalence of goitre andcretinism and to measure the main biochemical indicators of thyroid function (T3,T4 and TSH). The study involved 1433 people identified from a census. Theprevalence of goitre was 50.3%. There was a significant difference between theexamined ethnic groups: 52.7% of the Yacouba and 28.6% of the non-Yacouba hadgoitre. The most affected age group was 15-45 year. The predominance of womendemonstrated the susceptibility of women at child-bearing age to develop thecondition. The prevalence of cretinism was approximately 1.5%. Through theassessment carried out using a grid of clinical indicators, it was possible toidentify 10 cases of laboratory proven myxedematous cretinism due tohypothyroidism. The concentration of iodine in foodstuffs was below the limit of detection (< 7.5 micrograms/kg) and iodine could not be detected in the water (< 1 microgram.l) The biological profile of the population was affected to a verylimited extent, with a mean value (+/- standard deviation) for TSH of 1.93 (+/-1.56) mIU/l (0.1-4.0) and a free T4 value of 10 (+/- 3.46) pmol/l (8.2-20). Theseinitial results confirm the high prevalence of endemic goitre and the low iodine content of the soil, water and food in the investigated region. The study will becomplemented by a nutritional investigation to improve the understanding ofiodine balance, after which an appropriate action plan will be proposed.


21. Z Ernahrungswiss. 1996 Mar;35(1):6-12.

Influence of knowledge on iodine content in foodstuffs and prophylactic usage of iodized salt on urinary iodine excretion and thyroid volume of adults in southernGermany.

Metges CC, Greil W, Gärtner R, Rafferzeder M, Linseisen J, Woerl A, Wolfram G.

Massachusetts Institute of Technology Clinical Research Center, Cambridge 02142, USA.

Thyroid volume, urinary iodine excretion as well as personal nutritionalknowledge and individual iodine prophylaxis were determined during a healtheducation program on iodine deficiency and prophylaxis in 1992. Participants were472 male and 568 female (mean age 27.7 years) students and employees of fiveuniversities in the southern part of Germany. The study aimed to clarify therelationship between personal knowledge on iodine, individual iodine prophylaxis and parameters of iodine deficiency (thyroid volume, iodine excretion) in a well known iodine deficient area. Mean thyroid volume (mean +/- SD) was 19.7 +/- 8.3ml in males and 15.8 +/- 7.1 ml in females. 25.5% of females and 19.9% of malesshowed thyroid volume above the upper normal values. Total mean urinary iodineexcretion was 70.7 +/- 42 micrograms I/g creatinine reflecting WHO-grade-I iodinedeficiency. 80.8% of total subjects used iodized salt and 43.2% stated to consumesalt-water fish to meet their iodine requirement. The female non-users had

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significantly lower iodine excretion (no iodized salt, no salt-water fish: 61.4+/- 31.3 vs. +iodized salt, +salt-water fish: 83.9 +/- 47.6 micrograms I/gcreatinine; p < 0.05), however, thyroid volume was identical in these groups. Thearea of residence over the last 10 years did not significantly influence thethyroid volume. The goiter incidence increased with age. Although our studypopulation was highly educated (81.8% students) and the subjects were providedwith educational brochures immediately prior to the study, knowledge about iodinecontent of food was poor. We conclude that despite a high degree of voluntaryiodine prophylaxis and educational programs the iodine intake is insufficient.The use of iodized salt in households, cafeterias, and also in food manufacturingmust be increased for sufficient iodine prophylaxis.


22. Indian J Public Health. 1995 Oct-Dec;39(4):135-40.

Iodine deficiency disorders (IDD) and iodised salt in Assam: a few observations.

Patowary AC, Kumar S, Patowary S, Dhar P.

UNICEF, Calcutta.

PIP: During 1992-1993 in India, a UNICEF-supported survey was conducted inDibrugarh District of Assam State to determine the prevalence of iodinedeficiency disorders (IDD), especially goiter. The prevalence of goiter remained high (42.2%) in Dibrugarh District (65.8% in 1989). 46.95% of all iodated saltshad less than the optimum level of iodine (15-29.99 ppm). Storage practicesaffected the iodine content of the salt. For example, within a month and a half, the iodine content of salt stored in earthenware pots is reduced to about 25%.82.4% of all women 14-45 years old did not perceive goiter as a disease. 98.13%did not know that iodized salt was available in their neighborhood. Yet, the saleof non-iodized salt has been banned in Assam since 1989. An in-depth study wasconducted in Sonitpur and Tinsukia districts to determine whether raw salt wasimported from the west coast (e.g., Gujarat) to Assam. Transport of iodized salt in remote areas (e.g., Sadia and Lido) took a long time in Tinsukia and storagein earthenware pots, resulting in deterioration of the quality of salt. Salt istransported to Assam in open wagons, which exposes the salt to the sun and therains. Wholesalers store salt in thick polythene bags which are in turn kept incovered godowns. Retailers sell the salt from open verandas, which exposes thesalt to rain and sun. Household storage practices include plastic or glass jarswith or without a cover (80.89% and 12.15%, respectively), gourd shells (1.5%),bamboo containers (2.05%), and earthenware pots (3.41%). The quality of iodizedsalt sold by fraudulent traders was much lower than that sold by reputed firms.The government of India's IDD program monitors the quality of iodized salt. Itprovides feedback to the state government. Monitoring should be a systematic and continuous process. Assam's government has set up its own monitoring program,focusing on the household level (salt samples: 64.8%). During 1993-1994, 79.7% ofsalt samples had a satisfactory level of iodine and 2.7% had no iodine at all.


23. Lancet. 1983 Nov 12;2(8359):1126-9.

Iodine deficiency disorders (IDD) and their eradication.

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Hetzel BS.

Disorders resulting from severe iodine deficiency affect more than 400 millionpeople in Asia alone. These disorders include stillbirths, abortions, andcongenital anomalies; endemic cretinism, characterised most commonly by mentaldeficiency, deaf mutism, and spastic diplegia and lesser degrees of neurological defect related to fetal iodine deficiency; and impaired mental function inchildren and adults with goitre associated with subnormal concentrations ofcirculating thyroxine. Use of the term iodine deficiency disorders, instead of"goitre", would help to bridge the serious gap between knowledge and itsapplication. Iodised salt and iodised oil (by injection or by mouth) are suitablefor the correction of iodine deficiency on a mass scale. A single dose of iodisedoil can correct severe iodine deficiency for 3-5 years. Iodised oil offers asatisfactory immediate measure for primary care services until an iodised saltprogramme can be implemented. The complete eradication of iodine deficiency istherefore feasible within 5-10 years.



Indicators to monitor progress of National Iodine Deficiency Disorders ControlProgramme (NIDDCP) and some observations on iodised salt in west Bengal.

Kumar S.

UNICEF, Calcutta.

Iodine Deficiency Disorders (IDD) are widely prevalent in our country and theirconsequences for human development are well known. The scope of National GoitreControl Programme (NGCP) launched in 1962 was expanded and the programme wasrenamed as National Iodine Deficiency Disorders Control Programme (NIDDCP) toconnote wider implications of iodine deficiency in population. It is necessary tomonitor the progress of NIDDCP using quantifiable indicators to ensureachievement of programme objectives. Prevalence of iodine deficiency disorders,status of iodised salt and level of knowledge. Attitude & practice (KAP) ofcommunity regarding IDD and iodised salt are a few such indicators. Children inthe age group of 8-10 years are considered most appropriate target group tomonitor IDD prevalence. The quality of iodised salt assessed at various levels inWest Bengal (using field testing kit) indicated 'satisfactory' iodine content(i.e. > or = 15 ppm) at wholesalers (84.3 per cent), retailers (74.3 per cent)and consumers (71.2 per cent) level. It is suggested that the quality of iodised salt should be periodically assessed and intensive educational campaigns on IDDbe launched to create increased demand for consumption of iodised salt in thecommunity.

PIP: In India, the goal of the National Iodine Deficiency Disorder ControlProgramme (NIDDCP) is elimination of iodine deficiency disorders (IDD) by 2000.It aims to supply iodized salt to all of India and to assess the impact of thesupply of iodized salt. Quantifiable indicators used to monitor its progressinclude the prevalence of IDD, iodine content of salt, and knowledge, attitudes, and practices (KAP) regarding iodized salt. The program targets school children

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8-10 years old for assessing IDD prevalence. It prefers the community-basedsurvey to the school-based survey, since the former includes children notenrolled in school. The indicators health workers use to assess IDD prevalenceare thyroid size (palpation and ultrasonography), urinary iodine, and level ofthyroid-stimulating hormones in serum. Spot testing kits and iodometric titrationmethod are used to measure iodine content in salt. Salt with at least 15 ppmiodine is classified as satisfactory. A goiter survey requires a minimum of 5salt samples (about 20 g). The KAP survey needs a minimum of 5 differenthouseholds in each cluster site. Issues related to salt addressed in the KAPsurvey include existence of iodized salt, importance of iodized salt consumption,consequences of IDD (e.g., poor physical and mental growth of children, stillbirths, cretinism), packaging of iodized salt, price, storage of iodized salt,use of bagara salt, prior washing of salt, and source of iodized salt. In WestBengal, only iodized salt can be sold. In 1994, West Bengal met its annualrequirement of edible salt. A survey at rake unloading points in West Bengal in1994 revealed that most salt from Gujarat had adequate iodine levels, while allbut 5.3% of the salt from Rajasthan had insufficient iodine levels. Healthworkers and food inspectors in West Bengal routinely monitor different districts at various levels (household, retailers, and wholesalers). In 1995, 84.3% ofsamples at wholesalers, 74.3% at retailers, and 71.2% at households hadsatisfactory levels of iodine. The Goitre Cell of the West Bengal government has an IDD educational program involving teachers and panchayats.



National Iodine Deficiency Disorders Control Programme in India.

Tiwari BK, Kundu AK, Bansal RD.

DGHS, Nirman Bhavan, New Delhi.

Iodine Deficiency Disorders are one of the biggest worldwide public healthproblem of today. Their effect is hidden and profound affecting the quality ofhuman life. An attempt has been made to describe the various aspects of theNational Iodine Deficiency Disorders control Programme (NIDDCP) being implementedin the country. The paper also focuses about the problems associated inimplementing this national programme.

PIP: In India, 167 million people are at risk of iodine deficiency disorders(IDDs). 54.4 million people have a goiter. About 8.8 million people haveIDD-related mental/motor handicaps. IDD is a problem in every state and unionterritory. It is a major public health problem in 211 of the 245 districtssurveyed. Even though IDDs cannot be cured, they can be easily prevented. Dailyconsumption of iodized/iodated salt is the most effective and inexpensive way to prevent IDD. In 1962, the government of India implemented the National GoitreControl Programme, now called the National Iodine Deficiency Disorders ControlProgramme (NIDDCP). In 1982, the government made a policy decision to iodate all edible salt in India by 1992. During 1994-1995, India's private sector produced34 lakh metric tons of iodated salt per year. The government expects iodated saltproduction to increase to 50 lakh metric tons in the near future. Iodated salt istransported on the railways under a priority category that is second only todefense. In 19 states and 6 union territories, the sale of noniodated salt hasbeen completely banned. The remaining state governments have been urged to ban

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the sale of noniodated salt and to include iodated salt under the publicdistribution system. Each State Health Directorate has been advised to set up an IDD Control Cell. The biochemistry division of the National Institute ofCommunicable Diseases has a national reference laboratory for monitoring of IDD, and it also trains medical and paramedical personnel. District health officers inall endemic states have test kits to conduct on-the-spot qualitative testing toensure quality control of iodated salt at the consumption level. NIDDCP provides IDD surveys, health education, and publicity campaigns. Its information,education, and campaign activities include video films, posters, and radio/TVspots.



Iodine deficiency disorders (IDD) and iodised salt in Assam: a few observations.

Patowary AC, Kumar S, Patowary S, Dhar P.

UNICEF, Calcutta.

PIP: During 1992-1993 in India, a UNICEF-supported survey was conducted inDibrugarh District of Assam State to determine the prevalence of iodinedeficiency disorders (IDD), especially goiter. The prevalence of goiter remained high (42.2%) in Dibrugarh District (65.8% in 1989). 46.95% of all iodated saltshad less than the optimum level of iodine (15-29.99 ppm). Storage practicesaffected the iodine content of the salt. For example, within a month and a half, the iodine content of salt stored in earthenware pots is reduced to about 25%.82.4% of all women 14-45 years old did not perceive goiter as a disease. 98.13%did not know that iodized salt was available in their neighborhood. Yet, the saleof non-iodized salt has been banned in Assam since 1989. An in-depth study wasconducted in Sonitpur and Tinsukia districts to determine whether raw salt wasimported from the west coast (e.g., Gujarat) to Assam. Transport of iodized salt in remote areas (e.g., Sadia and Lido) took a long time in Tinsukia and storagein earthenware pots, resulting in deterioration of the quality of salt. Salt istransported to Assam in open wagons, which exposes the salt to the sun and therains. Wholesalers store salt in thick polythene bags which are in turn kept incovered godowns. Retailers sell the salt from open verandas, which exposes thesalt to rain and sun. Household storage practices include plastic or glass jarswith or without a cover (80.89% and 12.15%, respectively), gourd shells (1.5%),bamboo containers (2.05%), and earthenware pots (3.41%). The quality of iodizedsalt sold by fraudulent traders was much lower than that sold by reputed firms.The government of India's IDD program monitors the quality of iodized salt. Itprovides feedback to the state government. Monitoring should be a systematic and continuous process. Assam's government has set up its own monitoring program,focusing on the household level (salt samples: 64.8%). During 1993-1994, 79.7% ofsalt samples had a satisfactory level of iodine and 2.7% had no iodine at all.


4. BMC Public Health. 2007 Nov 8;7:316.

The goitre rate, its association with reproductive failure, and the knowledge of iodine deficiency disorders (IDD) among women in Ethiopia: cross-sectioncommunity based study.

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Abuye C, Berhane Y.

Food and Nutrition Research Department, Ethiopian Health and Nutrition ResearchInstitute, Addis Ababa, Ethiopia. [email protected]

BACKGROUND: Iodine deficiency is severe public health problem in Ethiopia.Although urinary iodine excretion level (UIE) is a better indicator for IDD thegoitre rate is commonly used to mark the public health significance. The range ofill effect of IDD is however beyond goitre in Ethiopia. In this study theprevalence of goitre and its association with reproductive failure, and theknowledge of women on Iodine Deficiency were investigated.METHODS: A cross-section community based study was conducted during February toMay 2005 in 10998 women in child bearing age of 15 to 49 years. To assess thestate of iodine deficiency in Ethiopia, a multistage "Proportional to Population Size" (PPS) sampling methods was used, and WHO/UNICEF/ICCIDD recommended methodfor goitre classification.RESULTS: Total goitre prevalence (weighted) was 35.8% (95% CI 34.5-37.1), 24.3%palpable and 11.5% visible goitre. This demonstrates that more than 6 millionwomen were affected by goitre. Goitre prevalence in four regional states namelySouthern Nation Nationalities and People (SNNP), Oromia, Bebshandul-Gumuz andTigray was greater than 30%, an indication of severe iodine deficiency. In therest 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 majorpublic health problem in Ethiopia. Women with goitre experience more pregnancyfailure (X2 = 16.5, p < 0.001; OR = 1.26, 1.12 < OR < 1.41) than non goitrouswomen. Similarly reproductive failure in high goitre endemic areas wassignificantly 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 importanceof iodated salt.CONCLUSION: Ethiopia is at risk of iodine deficiency disorders. The findingspresented in this report emphasis on a sustainable iodine intervention programtargeted at population particularly reproductive age women. Nutrition educationalong with Universal Salt Iodization program and iodized oil capsule distributionin some peripheries where iodine deficiency is severe is urgently required.



Elimination of iodine deficiency disorders by 2000 and its bearing on the people in a district of Orissa, India: a knowledge-attitude-practices study.

Mohapatra SS, Bulliyya G, Kerketta AS, Geddam JJ, Acharya AS.

Regional Medical Research Centre, Indian Council of Medical Research,Bhubaneswar, India. [email protected]

A knowledge-attitude-practices (KAP) study was conducted along with a prevalence study of iodine deficiency disorders (IDD) between 1998-99 in the district ofBargarh, Orissa state, India. A total of 635 people were interviewed by apretested structured questionnaire, adopting the probability proportional to sizecluster sampling method. The aim was to assess the baseline information on theKAP of the people regarding IDD. Only 37% of the males and 29.3% of the females

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perceived goitre as a disease. Less than 5% of both sexes knew how goitre iscaused. Only 16.4% used iodised salt regularly. The awareness and perception ofIDD does not correspond with the time and effort we have spent in education ofthis disease. The implications of this poor knowledge about IDD and consequentpoor use of iodised salt is contrasted to the optimistic target of elimination ofIDD. This aspect is discussed in this paper, at a time when we are at thebeginning of the new millennium.


6. Indian J Pediatr. 1995 Sep-Oct;62(5):545-55.

Towards the elimination of iodine deficiency disorders in India.

Pandav CS, Anand K.

Centre for Community Medicine, All India Institute of Medical Sciences, NewDelhi.

Iodine deficiency disorders (IDD) are an important public health problem in Indiawith an estimated 270 million people at risk of IDD. India has adopted thestrategy of salt iodization for control of IDD and has the goal of "Universaliodization of salt by 1995 and elimination of IDD by 2000". There is a highdegree of political commitment which need to continue if the goal is to beachieved. Currently the ban on ale of un-iodized salt is only applicable to salt on human consumption. There is a need for extending the ban to include salt foranimal consumption as IDD affects livestock as well. India has the installedcapacity to produce its requirement of 5 million tonnes iodised salt.Communication strategies have to be strengthened especially to educate people whohave concerns about of iodine toxicity. The success to a large extent depends on the quality control and monitoring of iodine content of salt at all stages fromproduction to consumption. NGO's and the community have to be encouraged toparticipate in this process. To sustain the elimination of IDD, a partnership of various stakeholders IDD elimination is essential.



Iodised salt is safe.

Ranganathan S.

National Institute of Nutrition, Indian Council of Medical Research, Hyderabad.

Iodine deficiency disorders are prevalent in all the States and Union Territoriesin India. Under the National Iodine Deficiency Disorders control programme, theGovernment of India has adopted a strategy to iodisation of all edible salt inthe country which is a long term and sustainable preventive solution to eliminateiodine deficiency disorders. The benefits to be derived from universal saltiodisation are more to the population. Iodised salt is safe and does not causeany side effect.

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PIP: In India, about 167 million people are at risk of iodine deficiencydisorders (IDD). 54 million have a goiter, 2.2 million have cretinism, and 6.6million have mild neurological disorders. Iodization of all edible salt in India is expected to be achieved by 1996. A safe daily intake of iodine is between 50mcg and 1000 mcg. Yet, in India, daily iodine intake may be as low as 100-160mcg/day compared to 3000 mcg/day in Japan. Since iodine is concentrated in thetop soil and the environment continues to be degraded, supplementary dietaryiodine is needed. In areas endemic to goiter, the iodine content of drinkingwater is 3-16 mcg/l, while it is 5-64 mcg/l in nonendemic areas. Regardless offood type, iodine content was higher in nonendemic areas than in areas endemic togoiter (e.g., lentils: 13 vs. 4 mcg/1000g). Iodine is readily absorbed from thegastrointestinal tract and distributed rapidly throughout the body. The thyroidtakes up about 30% of the iodine entering the body for hormone synthesis. Thekidneys excrete the rest. The iodine content of regional diets in India rangesfrom 170-300 mcg/day. The loss of iodine in cooking practices ranges from 30-70%.The National Iodine Deficiency Disorders Control Programme (NIDDCP) aims toeliminate IDD by the year 2000. The Food Adulteration Act states that iodizedsalt at the manufacturing level should have no less than 30 ppm and at theconsumer level no less than 15 ppm. One of the greatest obstacles to NICCDP ispoor iodine stability. Appropriate technologies now produce iodized salt with along shelf life in some factories in Tamil Nadu, Andhra Pradesh, and Gujarat. An important component of NIDDCP is monitoring of iodized salt. Susceptible peopleand people with pre-existing abnormalities of the thyroid gland may have adverse effects of excess iodine intake. It appears that iodine rarely causes an allergicreaction. The lethal dose low (LDLO) for potassium iodate may be 531 mg/kg ofbody weight. Thus, 32 g is the LDLO for an Indian of average body weight of 60kg. A review of case reports show that iodine intake of less than 1000 mcg/day issafe for most people.


8. J Trop Pediatr. 2000 Oct;46(5):264-6.

Assessment of iodine deficiency disorders using the 30 cluster approach indistrict Kangra, Himachal Pradesh, India.

Kapil U, Sohal KS, Sharma TD, Tandon M, Pathak P.

Department of Human Nutrition, All India Institute of Medical Sciences, AnsariNagar, New Delhi. [email protected]

Iodine deficiency is an important public health problem in Himachal Pradesh.District Kangra is a known iodine deficiency endemic area. A survey conducted in 1956 reported a goitre prevalence of 55 per cent in the district. A more recentpilot study (1994) in four blocks of the district reported the total goitre rate (TGR) as 7 per cent. A continued prevalence of goitre in more than 5 per cent of school-aged children was found in pilot study, in spite of the distribution ofiodised salt. The present study was conducted to assess the prevalence of iodine deficiency disorders (IDD) and to estimate the iodine content of salt consumed bythe population in district Kangra. The '30 cluster' sampling methodology andindicators for assessment of IDD, as recommended by the joint WHO/UNICEF/ICCIDDconsultation, were utilized for the survey. A confidence level of 95 per cent, a relative precision of 10 per cent and a design effect of three were taken intoaccount for calculation of the sample size. A total of 23,348 school children in the age group 6-11 years were included in the study. The total goitre prevalence

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rate was found to be 12.1 per cent. The median urinary iodine excretion of thechildren studied was found to the 15.00 mcg/dl. About 12.7 per cent of familiesconsumed salt with an iodine content of less than 15 ppm. The results of thepresent study indicated that the population of district Kangra is in a transitionphase from iodine deficient to iodine sufficient nutrition and that there is aneed for further strengthening of the system of monitoring the quality of iodisedsalt made available to the population to eliminate IDD from the Kangra Valley.


9. J Pediatr Endocrinol Metab. 2008 Jan;21(1):79-87.

Determination of iodine nutrition and community knowledge regarding iodinedeficiency disorders in selected tribal blocks of Orissa, India.

Bulliyya G, Dwibedi B, Mallick G, Sethy PG, Kar SK.

Regional Medical Research Centre, Indian Council of Medical Research,Chandrasekharpur, Bhubaneswar, India. [email protected]

AIM: To determine the status of iodine nutrition and knowledge of iodinedeficiency disorders (IDD) in selected tribal mountainous blocks of Orissa,India.DESIGN: A community-based survey was performed, adopting the 30-cluster sampling and surveillance methodology for assessment of IDD recommended byWHO/UNICEF/ICCIDD.SUBJECTS: School-age children (6-12 years) and their mothers.METHODS: Total goitre rate (n=623) and urinary iodine excretion of children(n=530), iodine content in edible salt (n=505) and water (n=21) were measured.Community knowledge regarding IDD and awareness of iodized salt (n 20) wasassessed.RESULTS: Total goitre rate was 23.6%, of which visible goiter was 6.9%.Prevalence of goiter increased with age in female and tribal children. Medianurinary iodine was 38 Cmicro.Tl(-1) and 51.7% of children had urinary iodinevalues <100 pmicrogtl(-1) The mean iodine content for drinking water ranged from 1.22-3.6 pmicro.Tl(-1) Only 9.9% of salt samples had adequate iodine content (>or =5 ppm). Over 80% of respondents did not have knowledge of IDD and were notaware of salt iodization.CONCLUSIONS: Study results show moderate iodine deficiency with poor communityknowledge of iodine nutrition. There is need to strengthen the monitoring of saltiodization and intensive education activities in the tribal areas.


10. Indian J Public Health. 1998 Jul-Sep;42(3):75-80.

Dr. P. C. Sen Memorial Award Paper. Status of salt iodisation and iodinedeficiency in selected districts of different states of India.

Kapil U, Nayar D.

Dept. of Human Nutrition, A.I.I.M.S., New Delhi.

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Iodine deficiency disorders (IDD) is a major public health problem. Surveysconducted by the National Goitre Survey team of the Directorate General of HealthServices during the past three decades have revealed a high prevalence of endemicgoitre in different states. Out of a total of 267 districts surveyed till date,226 have been reported to be endemic to iodine deficiency. A successful measurefor the prevention of IDD is salt iodisation. The Salt department, Government of India has taken an intensive programme of production of iodised salt in thecountry. The production has increased from 1.5 lakh metric tonnes in 1984 to 40lakh metric tonnes in 1996. To assess the impact of increased production ofiodised salt on the availability of iodised salt at the beneficiary and traderlevel and also on the status of iodine deficiency, surveys were undertaken inselected districts of 10 states and 2 union territories of the country. Thesestudies have been presented and discussed here.


11. Indian J Pediatr. 2002 Jul;69(7):589-96.

Current status of iodine deficiency disorders (IDD) and strategy for its control in India.

Vir SC.

UNICEF (India Country Office), Lucknow Field Office.

Iodine Deficiency Disorders (IDD) reflects the broad manifestations of iodinedeficiency including the implications on reproductive functions and lowering ofIQ levels in school aged children. Today, IDD is a public health problem in 130countries and affects 13% of world's population. In India, no state is free from iodine deficiency and 200 million people are 'at risk' of IDD. Daily consumption of salt fortified with iodine is a proven effective strategy and is the measurestressed by the Government of India. The paper describes the major five phases ofthe IDD Control Programme in India. The paper describes the major five phases of the IDD Control Programme in India since 1962 and synthesizes the spectrum ofactivities that significantly attributed to the Universal salt Iodisation (USI)efforts launched in 1992. The sustainability of the USI programme is criticalsince IDD prevalence will rise if programme of salt iodisation weakens. A twopronged strategy needs to be institutionalized for ensuring continued demand for iodised salt, linked to ongoing health, nutrition and education programmes aswell as for ensuring supply of quality iodised salt.


12. N Z Med J. 1999 Jul 23;112(1092):266-8.

Persistence of iodine deficiency 25 years after initial correction efforts in theKhumbu region of Nepal.

Murdoch DR, Harding EG, Dunn JT.

Kunde Hospital, Solukhumbu District, Nepal. [email protected]

Comment in:

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N Z Med J. 1999 Oct 8;112(1097):389-90.

AIMS: To assess the current status of, and understanding about iodine deficiency disorders among Sherpa residents of the Khumbu region of Nepal, 25 years afterthe introduction of iodised oil injections.METHODS: Several groups of Khumbu Sherpas were studied and goitre rate, urinaryiodine level and cretinism prevalence were measured as indicators of iodinedeficiency. Subjects were also questioned in detail about their food consumption,with particular reference to salt use, and about their understanding of thecauses and treatment of iodine deficiency disorders.RESULTS: The prevalences of goitre, deaf-mutism and cretinism were 21%, 1.3% and 0.5% respectively (compared to 92%, 4.7% and 5.9% in 1966). No cretins had beenborn since 1966. The median urine iodine concentration was 35 microg/L. Mostpeople preferred uniodised Tibetan rock salt, although 44% regularly consumediodised salt. All granulated salt tested from the local market contained adequateamounts of iodine. Only 11% of those surveyed knew that goitre was caused byiodine deficiencyCONCLUSIONS: Although prevalences of iodine deficiency disorders are much lessthan 30 years ago, iodine deficiency continues to be a major problem in Khumbuand demands a clear control strategy, combining ongoing iodine supplementationand education. Iodised salt is usually the best approach to control of iodinedeficiency disorders for most regions of the world but the Khumbu experienceshows that local cultural and commercial factors can severely limit its impact.To be successful, control programme for iodine deficiency disorders also needsassessment of the salt trade, monitoring, education and occasional targetedinterventions with iodised oil or other supplements.


13. Indian Pediatr. 1997 Dec;34(12):1087-91.

Assessment of iodine deficiency in selected blocks of east and west Champarandistricts of Bihar.

Kapil U, Singh J, Prakash R, Sundaresan S, Ramachandran S, Tandon M.

Department of Human Nutrition, All India Institute of Medical Sciences, AnsariNagar, New Delhi.

OBJECTIVE: A survey conducted in 1964 reported a goitre prevalence of 40.3% inEast and West Champaran districts of Bihar. No recent survey has been documented on the prevalence of iodine deficiency in these districts. The present study was therefore undertaken (i) to assess the prevalence of IDD in these districts, and (ii) to estimate the iodine content of salt consumed by population.METHODOLOGY: In each district, one block was selected. In each block more than630 children in the age group of 6-12 years were included in the study and wereclinically examined. Urine samples were collected from 261 children and wereanalyzed using standard laboratory procedures. A total of 456 salt samples werecollected from children and 35 from traders from the two districts and analyzedusing the standard iodometric titration method.RESULTS: The total goiter prevalence was 11.6%. The percentage of children with <2, 2.0-4.9, 5.0-9.9 and > or = 10 mcg/dl of urinary iodine excretion level were12.3, 13.4, 23.4 and 51.0, respectively. The median urinary iodine excretion ofthe children was 10.0 mcg/dl. None of the families were consuming salt with a niliodine content and about 29.3%, were consuming salt with less than 15 ppm of

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iodine. Of the 35 salt samples collected from traders, all had iodine and about17% had less than 15 ppm of iodine.CONCLUSION: The study stresses the need for strengthening the existing system of monitoring of quality of salt being provided in the East and West Champarandistricts by Government of Bihar.


14. Sante. 2002 Jan-Mar;12(1):9-17.

[Iodine deficiency: current situation and future prospects].

[Article in French]

De Benoist B, Delange F.

Département de nutrition pour la santé et le développement, Organisation mondialede la santé, CH 1211 Genève 27, Suisse. [email protected]

Iodine deficiency disorders (IDD) is a major public health problem worldwide. WHOestimates that 740 million people are currently affected by goitre. Theconsequences of iodine deficiency on health are the results of hypothyroidism andthe main one is impaired development of foetal brain. IDD is the first cause ofpreventable brain damage in children. The recommended strategy to correct IDDrests upon salt iodisation. Over the last 20 years, the international communitymobilised to eliminate IDD under the leadership of WHO, Unicef and ICCIDD. Itresulted in remarkable progress in IDD control, especially in Africa and in SouthEast Asia where the endemic is the most severe. It is estimated that 68% of thepopulations of affected countries have currently access to iodised salt. However,out of the 130 affected countries, about 30 have no programme. Besides, saltquality control and monitoring of population iodine status are still weak in manycountries, thus exposing the population to an excessive iodine intake andsubsequently to the risk of iodine-induced hyperthyroidism. In addition, IDD isre-emerging in some countries, especially in Eastern Europe after it haddisappeared. In order to reach the goal of IDD elimination, it is important toinsist on the sustainability of salt iodisation programmes, which implies anincreased commitment of both health authorities and representatives of the saltindustry.



Study of biochemical prevalence indicators for the assessment of iodinedeficiency disorders in adults at field conditions in Gujarat (India).

Brahmbhatt SR, Fearnley R, Brahmbhatt RM, Eastman CJ, Boyages SC.

Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, NSW,Australia. [email protected]

The main objective of this study was to assess the severity of iodine deficiency disorders (IDD) in the adult populations of the Baroda and Dang districts from

24

Gujarat, western India using biochemical prevalence indicators of IDD. The other aim of this study was to establish a biochemical baseline for adequate iodineintake as a result of program evolution in the face of multiple confoundingfactors, like malnutrition and goitrogens responsible for goiter. A total of 959 adults (16-85 years) were studied from two districts (Baroda and Dang) and datawas collected on dietary habits, anthropometric and biochemical parameters suchas height, weight, urinary iodine (UI) and blood thyroid stimulating hormone(TSH). Drinking water and cooking salt were analyzed for iodine content. Allsubjects, irrespective of sex and district, showed median UI = 73 microg/L andmean blood TSH +/- SD = 1.59+/-2.4 mU/L. Seven per cent of the studied populationhad blood TSH values > 5 mU/L. Females in Baroda and males from Dang districtwere more affected by iodine deficiency as shown by a lower median UI. Mean TSHwas significantly higher in women from both districts as compared to men (P =0.001). The blood spots TSH values > 5 mU/L were seen in 20% of women from Dang. The normative accepted WHO values for UI and TSH for the severity of IDD as asignificant health problem are not available for target population of adults.Urinary iodine normative limits and cut-offs are established for school-agedchildren. Blood spot TSH upper limit and cut-off values are available for neonatepopulations. The IDD has not been eliminated so far, as more than 20% of bothmale and female subjects had UI < 50 microg/L. Males were more malnourished than females in both districts (P < 0.05). Pearl millet from Baroda containedflavonoids like apigenin, vitexin and glycosyl-vitexin. Dang district waterlacked in iodine content. Iodine deficiency disorder is a public health problemin Gujarat, with the Baroda district a new pocket of IDD. High amounts of dietaryflavonoids in Baroda and Dang, malnutrition and an additional lack of iodine inDang water account for IDD.


16. Indian J Public Health. 1996 Jan-Mar;40(1):10-2.

A study of spectrum of iodine deficiency disorders in rural area of UttarPradesh.

Lal RB, Srivastava VK, Chandra R.

Upgraded Department of social & preventive Medicine, King George's MedicalCollege, Lucknow.

In the present study, attempt has been made to study the spectrum of the iodinedeficiency disorders (IDD) in a sub Himalayan hyperendemic area. Iodinedeficiency has been found to enhance the conditions like abortion, still birth,higher infant mortality, neonatal chemical hypothyroidism, congenital anomalies, retarded growth, hypothyroidism, endemic goitre and endemic cretinism.

PIP: Iodine deficiency disorder (IDD) affects approximately 200 million peopleworldwide. An estimated 150 million people in India are at risk of IDD. Theauthors studied the full spectrum of IDD in the Colonelganj community developmentblock of Gonda district, an area in which the prevalence of goiter has beenreported to be 60-80%. Findings are based upon interview and clinical examinationfindings for 500 subjects contacted in a door-to-door survey. Data were confirmedwith auxiliary nurse midwife and primary health center records. IDD was found to enhance conditions such as abortion, still birth, infant mortality, neonatalchemical hyponyroidism, congenital anomalies, retarded growth, hypothyroidism,

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endemic goiter, and endemic cretinism.


17. J Indian Med Assoc. 2006 Apr;104(4):165-7.

Status of iodine nutriture and universal salt iodisation at beneficiaries levels in Kerala State, India.

Kapil U, Singh P, Dwivedi SN, Pathak P.

Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi110029.

Iodine deficiency disorders are an important public health problem in India. Itis wrongly believed that populations residing in coastal areas do not suffer fromiodine deficiency as they consume sea foods which are rich in iodine. A highprevalence of iodine deficiency has been reported in 11 districts of Keralaranging between 9.3 and 44.5%. In spite of the high prevalence of iodinedeficiency, the state government of Kerala has not banned the sale of non-iodisedsalt in the state. Thus, the present study was conducted to assess the currentstatus of iodine nutriture and level of salt iodisation in Kerala state. Thestudy was conducted in all the 14 districts in the state by utilising the uniformsampling methodology. A total of 2110 salt samples were collected randomly fromchildren. On the spot casual urine samples were collected from 689 children. The results revealed that overall 43.8% of the families in the state were consumingsalt with 15ppm and more of iodine. It was found that three districts namelyKasargod, Idukki and Kottayam had median urinary iodine excretion level < 100.0microg/l and also more than 20% of the samples had urinary iodine excretionlevels less than 50 microg/l. The findings of the present study revealedcontinued iodine deficiency amongst the three districts identified as endemicearlier. This indicates the need of immediate ban on the sale of non-iodised saltfor the edible purposes and intensive information, education and communicationactivities for promotion of consumption of iodised salt.



Iodine deficiency disorders in Bangladesh, 2004-05: ten years of iodized saltintervention brings remarkable achievement in lowering goitre and iodinedeficiency among children and women.

Yusuf HK, Rahman AM, Chowdhury FP, Mohiduzzaman M, Banu CP, Sattar MA, Islam MN.

Department of Biochemistry and Molecular Biology, University of Dhaka,Bangladesh. [email protected]

A survey was conducted to monitor the current status of iodine deficiencydisorders in children aged 6-12 years and women aged 15-44 years in Bangladesh asmeasured by goitre prevalence and urinary iodine excretion. Conducted betweenSeptember 2004 and March 2005, the survey followed a stratified multistagecluster sampling design to provide nationally representative data, withself-weighted rural-urban disaggregation. A total of 7233 children and 6408 women

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were examined for goitre and 4848 urine samples (2447 from children and 2401 fromwomen) were analyzed for iodine. In addition, 5321 household salt samples wereanalyzed for iodine. In children, the total goitre rate (TGR) was 6.2%, compared to 49.9% in 1993 and the TGR among women was 11.7%, while in 1993 it was 55.6%.Prevalence of iodine deficiency (Urinary Iodine Excretion <100 microg/L) was33.8% in children and 38.6% in women (compared to 71.0% and 70.2%, respectivelyin 1993). Iodine nutrition status in urban areas was considerably better than in rural areas. There was a clear inverse relationship between iodine deficiency andthe coverage of households using adequately iodized salt (> or =15 ppm). Thefindings of the survey revealed that Bangladesh has achieved a commendableprogress in reducing goitre rates and iodine deficiency among children and women ever since the universal salt iodization programme was instituted 10 years ago.However, physiological iodine deficiency still persists among more than one-thirdof children and women, which points to the need for all stakeholders to redouble their efforts in achieving universal salt iodization.


19. Indian J Pediatr. 2004 Jan;71(1):25-8.

Iodine deficiency disorders in 15 districts of India.

Toteja GS, Singh P, Dhillon BS, Saxena BN.

Central Co-ordinating Unit, Indian Council of Medical Research, New Delhi, [email protected]

METHODS: A multicentre study to assess iodine deficiency disorders (goitre anddeaf-mutism/cretinism) in 1, 45, 264 children (6 - <12 years old) from 15districts of ten states was carried out during 1997-2000. Urinary iodineexcretion was also determined in 27481 children, while iodine content wasestimated in 5881 samples of edible salt. The sampling methodology followed was a"30 cluster survey".RESULTS: The overall prevalence of goitre was 4.78% (4.66% of grade I and 0.12%of grade II) amongst the children examined. The highest prevalence of 31.02%goitre was observed in Dehradun district, while the lowest prevalence of 0.02%goitre was recorded in Bishnupur and Badaun districts. The overall prevalence of cretinism among children examined from seven districts was 0.072% whereas that ofdeaf-mutism was 0.27% among children examined from 8 districts. Median urinaryiodine values was marginally less than the WHO cut-off values only in children ofthe 3 out of the 15 districts surveyed. Iodine content was found to be adequatein 55.45% of the salt samples.CONCLUSION: The results suggested a significant decline in the prevalence ofgoitre in most parts of the country.


20. J Trop Pediatr. 2006 Aug;52(4):288-92. Epub 2006 Mar 13.

Assessment of iodine deficiency disorders in Purulia district, West Bengal,India.

Biswas AB, Chakraborty I, Das DK, Roy RN, Ray S, Kunti SK.

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R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India.

Iodine deficiency disorders IDD are major public health problems in India,including West Bengal. Existing programme to control IDD needs to be continuouslymonitored through recommended methods and indicators. The objective of this studywas to assess the prevalence of goitre, status of urinary iodine excretion UIElevel and to estimate iodine content of salts at the household level in Puruliadistrict, West Bengal. A school-based, cross-sectional study was conducted duringJune-September 2005; among 2,400 school children, aged 8-10 years. The "30cluster" sampling methodology and indicators for assessment of IDD, asrecommended by the joint WHO/UNICEF/ICCIDD consultation, were utilized for thestudy. Goitre was assessed by standard palpation technique, urinary iodineexcretion was analyzed by wet digestion method and salt samples were tested byspot iodine testing kit. The total goitre rate TGR was 25.9% (95% Cl=24.1-27.1%) with grade I and grade II (visible goitre) being 19.5% and 6.4% respectively.Goitre prevalence did not differ by sex but significant difference was observedin respect of age. Median urinary iodine excretion level was 9.25 microg/dl and31.6% children had value less than 5 microg/dl. Only 33.4% of the salt samplestested had adequate iodine content of > or = 15 ppm, High goitre prevalence(25.9%) and median urinary iodine (9.25 microg/dl) below normal range indicateexistence of current iodine deficiency in Purulia district. The district is stillin the iodine-deficient state. Moreover, salt iodisation level far below therecommended goal highlights IDD as major public health problems in the district. Intensified information, education and communication activities along withsustained monitoring are urgently required.


21. Afr Health Sci. 2002 Aug;2(2):63-8.

Monitoring the severity of iodine deficiency disorders in Uganda.

Bimenya GS, Olico-Okui, Kaviri D, Mbona N, Byarugaba W.

College of Health Sciences, Makerere University, PO BOX 7072 Kampala, Uganda.

BACKGROUND: Iodine deficiency disorders (IDD) cover a variety of pathologicalconditions including goitre, mental retardation and perinatal mortality inmillions of individuals globally. IDD was initially identified as a problem in1970 and was confirmed in 1991. In 1993, the Uganda government introduced apolicy of Universal Salt Iodization (USI) requiring all household salt to beiodized. After 5 years this study evaluates the USI programme.OBJECTIVES: To determine goitre prevalence rate, establish the proportion ofhousehold consuming iodized salt and determine the levels of iodine intake in thesample districts.METHODS: A sample of 2880 school children aged 6-12 years from 72 Primary schoolsin 6 districts of Uganda was studied in October 1999. Goitre was established bypalpation, salt iodine was analysed by thiosulphate titration, while urinaryiodine was analyzed using ICCIDD recommended method F in which iodine is detectedcolorimetrically at 410 nm.RESULTS: The over all total goitre rate was 60.2% down from 74.3 in 1991 andvisible goitre was 30% down from 39.2% in 1991. The proportion of householdstaking adequately iodized salt was 63.8% and the median urinary iodine was 310microg/L. Whereas 36% of 95 urine samples analysed in 1991 had urinary iodine

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below 50 microg/L, only 5% of the 293 urine samples studied in 1999 had the same urine levels. This represents a considerable improvement in iodine intake, which is confirmed by the fact that 63.8% of the study households consume adequatelyiodized salt. If maintained and evenly spread, this will enable Uganda to controlIDD.CONCLUSION: USI has improved iodine intake in Uganda. However, iodinemalnutrition is still a severe public health problem because some communities in this study such as in Kisoro still have low iodine consumption, while others suchas Luwero now have iodine excess. The latter is likely to predispose tohyperthyroidism.RECOMMENDATION: The national set standard of household salt iodine of 100 ppm be revised. Locally produced salt be iodized, and a national iodine monitoringprogramme be instituted to ensure evenly spread consumption of adequately iodizedsalt by all communities in the country.


22. Indian J Public Health. 2008 Jul-Sep;52(3):130-5.

Elimination of iodine deficiency disorders--current status in Purba Medinipurdistrict of West Bengal, India.

Biswas AB, Chakraborty I, Das DK, Chakraborty A, Ray D, Mitra K.

B. S. Medical College, Bankura.

BACKGROUND AND OBJECTIVES: Towards sustainable elimination of iodine deficiencydisorders (IDD), the existing programme needs to be monitored through recommendedmethods and indicators. Thus, we conducted the study to assess the current statusof IDD in Purba Medinipur district, West Bengal.METHODS: It was a community based cross-sectional study; undertaken from October 2006-April 2007. 2400 school children, aged 8-10 years were selected by '30cluster' sampling technique. Indicators recommended by the WHO/UNICEF/ICCIDD wereused. Subjects were clinically examined by standard palpation technique forgoitre, urinary iodine excretion was estimated by wet digestion method and saltsamples were tested by spot iodine testing kit.RESULTS: The total goitre rate (TGR) was 19.7% (95% CI = 18.1-21.3 %) with grade I and grade II (visible goitre) being 16.7% and 3% respectively. Goitreprevalence did not differ by age but significant difference was observed inrespect of sex. Median urinary iodine excretion level was 11.5 mcg/dL and nonehad value less than 5 mcg/dL. Only 50.4% of the salt samples tested wereadequately iodised (> or = 15 ppm).CONCLUSION: The district is in a phase of transition from iodine deficiency toiodine sufficiency as evident from the high goitre prevalence (19.7%) and median urinary iodine excretion (11.5 mcg/dL) within optimum limit. But, salt iodisationlevel far below the recommended goal highlights the need for intensified efforts towards successful transition.


23. Indian Pediatr. 2003 Feb;40(2):147-9.

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Assessment of iodine deficiency disorders in district Bharatpur, Rajasthan.

Kapil U, Singh P, Pathak P, Singh C.

Department of Human Nutrition, All India Institute of Medical Sciences, AnsariNagar, New Delhi - 110 029, India. [email protected]

Iodine deficiency disorders (IDD) is a public health problem in India. A ban onthe sale of uniodised salt for household consumption has been introduced inRajasthan State since 1992. The present study was conducted in the district ofBharatpur, Rajasthan with the objective to assess the prevalence of iodinedisorders in school children as no data is available on this aspect. A total of3072 children in the age group of 6-12 years were included in the study and were clinically examined. On the spot urine samples were collected randomly from 450children. A total of 1064 salt samples were collected randomly from the families of the children. The total goiter prevalence was found to be 7.2% in the subjectsstudied. It was found that the percentage of children with urinary iodineexcretion <20.0; 20.0-49.9, 50.0-99.9 and 100 mcg/L and above was 1.1, 1.1, 7.8and 90.0% respectively. The assessment of iodine content of salt revealed that56% of the families were consuming iodised salt. The findings of the presentstudy indicated that the population is in a transition phase from iodinedeficient (as revealed by the TGR) to iodine sufficient (as revealed by themedium UIE of 200.0 mcg/L) nutriture.


24. Southeast Asian J Trop Med Public Health. 2000;31 Suppl 2:32-40.

Community based intervention of iron deficiency anemia in females and iodinedeficiency disorders in school children in Lao PDR.

Souphanthong K, Siriphong B, Sysouphanh B, Bounnhong P, Phonhpadith M,Sanchaisuriya P, Saowakontha S, Merkle A, Schelp FP.

Maternal and Child Health Institute, Ministry of Health,Vientiane, Lao PDR.

Under the supervision of the central and local health authorities, a pilotproject was conducted in four villages in the Luangprabang Province, Lao PDR. Theobjective of the project was to test different regimes to supplement females withoral iron preparations to reduce iron deficient anemia (IDA) and control iodinedeficiency disorders (IDD) in school children. Compared with iron sulphatetablets, iron fumerate tablets were well accepted and good compliance resultswere achieved. Hemoglobin concentration improved only in the group of femalestaking iron fumerate tablets. The goiter rate decreased from approximately 90% toabout 45% for school children, regardless of whether iodine salt were used bytheir families or whether iodine capsules were used to treat the children. Thelatter attempt was hampered by the fact that also in the control village iodinefortified salt was used. This was due to a governmental attempt to control IDDnation-wide. Therefore, also in the control village a significant decrease in thegoiter rate was observed.


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25. East Mediterr Health J. 2004 Nov;10(6):761-70.

Experiences in the prevention, control and elimination of iodine deficiencydisorders: a regional perspective.

Azizi F, Mehran L.

Shaheed Beheshti University of Medical Sciences, Tehran, Islamic Republic ofIran.

Before 1987, iodine deficiency was not considered an issue of major importance inthe countries of the Eastern Mediterranean Region (EMR). Progress began with asystematic national study of goitre and other iodine deficiency disorders (IDD)in the Islamic Republic of Iran in 1983. Following a major review of theprevalence of IDD in member states, Guidelines for national programmes for thecontrol of iodine deficiency disorders in the EMR were published by the WorldHealth Organization (WHO) in 1988. This paper discusses progress towardselimination of iodine deficiency by reviewing the status of IDD in the countries of EMR and programmes for prevention and control of IDD with particular referenceto the Islamic Republic of Iran, the first country to be declared IDD-free byWHO.



Assessment of iodine deficiency in Kottayam district, Kerala State: a pilotstudy.

Kapil U, Jayakumar PR, Singh P, Aneja B, Pathak P.

Department of Human Nutrition, All India Institute of Medical Sciences, AnsariNagar, New Delhi. [email protected]

Iodine is one of the essential micro-elements required for normal human growthand development. Iodine Deficiency Disorders (IDD) are an important public healthproblem in India. There has been no data on the prevalence of IDD from theKottayam district, India and hence, the present pilot study was conducted in the year 1999 to assess whether iodine deficiency existed in the district or not and to estimate the iodine content of salt consumed by the population. A total of1872 children in the age group of 6-12 years were included in the study and were clinically examined. On the spot urine samples were collected from 251 children. A total of 420 salt samples were collected randomly from the families of thechildren. The total goitre prevalence was found to be 7.05% in the subjectsstudied. It was found that the percentage of children with urinary iodineexcretions of < 2, 2- < 5, 5-9 and 10 microg/dL and above were 6.4%, 6.0%, 20.7%,and 66.9%, respectively. Assessment of the iodine content of salt by theiodometric titration method revealed that 60.6% of the children were consumingsalt with an iodine content of 15 p.p.m. and more, which was the stipulated levelof salt iodisation. The findings of the present study indicated that thepopulation is in a transitional phase from iodine deficient, as revealed by totalgoitre rate, to iodine sufficient nutriture, as revealed by the median urinaryiodine excretion level of 17.5 microg/dL.

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27. Indian Pediatr. 2001 Mar;38(3):247-55.

Biochemical assessment of iodine deficiency disorders in Baroda and Dangdistricts of Gujarat State.

Brahmbhatt SR, Fearnley RA, Brahmbhatt RM, Eastman CJ, Boyages SG.

Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, NSW 2145, Australia. [email protected]

Comment in: Indian Pediatr. 2001 Jul;38(7):804-6.

OBJECTIVE: (i) To assess the severity of Iodine Deficiency Disorders (DD) inBaroda and Dang Districts of Gujarat, using biochemical prevalence indicators of IDD; and (ii) To establish a biochemical baseline, in a sub-sample of the largepopulation of Gujarat, that could be used to monitor the effectiveness of iodine replacement program.METHODS: 1,363 children (<1-15 years) were studied and data was collected ondietary habits, anthropometric and biochemical parameters such as height, weight and urinary iodine (UI) and blood TSH respectively. BSA and BMI were calculated. Drinking water and salt were analyzed for iodine content.RESULTS: Median true urinary iodine was 65 microg/I (interquartile-range 38-108).Mean TSH was 2.08 mU/1 (SD +/- 2.06) and 6% of the studied population had wholeblood TSH values > 5 mU/1. Females from both districts were affected more byiodine deficiency as evidenced by lower true urinary iodine and higher mean TSHlevels. The interfering substances were significantly higher in Baroda boys andDang girls as compared to their counterparts (< 0.001). Boys were moremalnourished than girls as evidenced by lower BMI. Dang district was moreseverely affected by IDD as compared to Baroda. Drinking water in Dang districtwas lacking in iodine content. Iodine in salt varied at around 7 to 2000 PPM.CONCLUSIONS: IDD is a public health problem in Gujarat. Baroda district is a new pocket of IDD. Dang district is the worse affected. The expression of IDD inthese two districts of Gujarat revealed interplay of multiple factors.


28. Int J Health Serv. 2009;39(2):343-62.

Toward an ecosocial epidemiological approach to goiter and other iodinedeficiency disorders: a case study of India's technocratic program for universal iodization of salt.

Priya R, Kotwal A, Qadeer I.

Center for Social Medicine and Community Health, Jawaharlal Nehru University, NewDelhi, India. [email protected]

The program of universal salt iodization (USI) was intensified in the 1990s.Unfortunately, a recent World Health Organization review finds that there was aglobal increase of 31.7 percent in total goiter rate from 1993 to 2003. However, the WHO review places only 1 country as severely, 13 as moderately, and 40 as

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mildly deficient in populations' iodine nutrition, and places 43 countries atoptimal, 24 at high, and 5 at excessive levels of iodine nutrition. Thus, it isimperative to weigh the benefits and risks of intensifying USI further. The WHOreview places India in the category of "adequate" iodine nutrition, but in 2005the Government of India promulgated a universal ban on sale of non-iodized salt, calling iodine deficiency disorders (IDDs) a major public health problem. Thisarticle attempts to understand these contradictions and weigh the benefits andcosts of USI. Based on a review of studies since the 1920s, the authorsreconstruct the evolution of IDD control in India. Conceptual and methodological limitations challenge the evidence base and rationale of stricter implementation of USI now. Finding evidence for its negative impact, the authors recommend areexamination of the USI strategy and propose a safer, people-centered, ecosocialepidemiological approach rather than a universal legal ban.


29. Indian J Med Res. 2005 Nov;122(5):419-24.

Iodine nutritional status & prevalence of goitre in Sundarban delta of South24-Parganas, West Bengal.

Chandra AK, Tripathy S, Ghosh D, Debnath A, Mukhopadhyay S.

Endocrinology & Reproductive Physiology Laboratory, Department of Physiology,University College of Science & Technology, University of Calcutta, Kolkata,India. [email protected]

BACKGROUND & OBJECTIVE: In post salt iodization phase endemic goitre andassociated iodine deficiency disorders (IDD) were found prevalent in a randomlyselected rural area of Sundarban delta and its adjoining areas of West Bengal.The present investigation was thus undertaken to study the total goitre rate,urinary iodine and thiocyanate excretion pattern of the school going children,iodine content in edible salt and drinking water in the Sundarban delta of South 24-Parganas in West Bengal.METHODS: A total of 4656 school children (6-12 yr) were clinically examined forgoitre from 13 different areas in the delta region. Urinary iodine andthiocyanate levels were measured in 520 (40 from each area) samples collectedrandomly to evaluate the iodine nutritional status and consumption pattern ofdietary goitrogen. Simultaneously iodine content was determined in 104 (8 fromeach area) drinking water samples and 455 (35 from each area) edible salt samplescollected from the areas.RESULTS: Children of all the areas were affected by endemic goitre. Theprevalence rates were in the ranges from 25-61 per cent; overall goitreprevalence was 38.2 per cent (grade 1--34.0%; grade 2--4.2%). Median urinaryiodine level in the studied areas was 225 microg/l (range 115-525 microg/l)indicating no biochemical iodine deficiency in the region. Mean urinarythiocyanate levels were in the range from 0.326-1.004 mg/dl. Iodine content indrinking water samples were in the ranges from 22-119 microg/l, and 55.6 per centedible salt samples had iodine level above the recommended 15 ppm at theconsumption point.INTERPRETATION & CONCLUSION: The severity of endemic goitre was high in thestudied population though the iodine nutritional status was found satisfactory inthe region indicating no biochemical iodine deficiency. The people of the region consumed iodine through iodized salt but about 44 per cent of the salt samples athousehold level contained inadequate iodine, however their iodine intake was

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compensated through iodine in water and food. They also consumed dietarygoitrogen. Environmental factors other than iodine deficiency may have possiblerole for the persistence of endemic goitre in the region. More investigations arethus necessary to arrive at certain definite cause of high goitre rates in thispopulation.


30. Sci Total Environ. 2000 Dec 18;263(1-3):127-41.

Selenium and iodine in soil, rice and drinking water in relation to endemicgoitre in Sri Lanka.

Fordyce FM, Johnson CC, Navaratna UR, Appleton JD, Dissanayake CB.

British Geological Survey, Edinburgh, UK. [email protected]

Endemic goitre has been reported in the climatic wet zone of south-west Sri Lankafor the past 50 years, but rarely occurs in the northern dry zone. Despitegovernment-sponsored iodised salt programmes, endemic goitre is still prevalent. In recent years, it has been suggested that Se deficiency may be an importantfactor in the onset of goitre and other iodine deficiency disorders (IDD). Prior to the present study, environmental concentrations of Se in Sri Lanka and thepossible relationships between Se deficiency and endemic goitre had not beeninvestigated. During the present study, chemical differences in the environment(measured in soil, rice and drinking water) and the Se-status of the humanpopulation (demonstrated by hair samples from women) were determined for 15villages. The villages were characterised by low (< 10%), moderate (10-25%) andhigh (> 25%) goitre incidence (NIDD, MIDD and HIDD, respectively). Results showthat concentrations of soil total Se and iodine are highest in the HIDD villages,however, the soil clay and organic matter content appear to inhibit thebioavailability of these elements. Concentrations of iodine in rice are low (< or= 58 ng/g) and rice does not provide a significant source of iodine in the SriLankan diet. High concentrations of iodine (up to 84 microg/l) in drinking water in the dry zone may, in part, explain why goitre is uncommon in this area. Thisstudy has shown for the first time that significant proportions of the Sri Lankanfemale population may be Se deficient (24, 24 and 40% in the NIDD, MIDD and HIDD villages, respectively). Although Se deficiency is not restricted to areas where goitre is prevalent, a combination of iodine and Se deficiency could be involved in the pathogenesis of goitre in Sri Lanka. The distribution of red ricecultivation in Sri Lanka is coincident with the HIDD villages. Varieties of redrice grown in other countries contain anthocyanins and procyanidins, compoundswhich in other foodstuffs are known goitrogens. The potential goitrogenicproperties of red rice in Sri Lanka are presently unknown and require furtherinvestigation. It is likely that the incidence of goitre in Sri Lanka ismulti-factorial, involving trace element deficiencies and other factors such aspoor nutrition and goitrogens in foodstuffs.


31. Indian J Pediatr. 2007 Feb;74(2):135-7.

Iodine status and goiter prevalence after 40 years of salt iodisation in the

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Kangra District, India.

Kapil U, Sharma TD, Singh P.

Department of Human Nutrition, All India Institute of Medical Sciences, AnsariNagar, New Delhi, India. [email protected]

Thirty primary schools were selected in district Kangra utilizing the population proportionate to size cluster sampling methodology in the year 2004. A total of6939 children were included in the study. The clinical examination of the thyroidof each child was conducted. On the spot casual urine sample and salt sampleswere collected from a 'sub set of' children included in the study. The Totalgoiter rate (TGR) was found to be 19.8%. The median Urinary iodine excretionlevel was 200 microg/l and only 64% of the salt samples had the stipulated level of iodine. The findings of the present study revealed that current iodine status of population is adequate, however, TGR showed mild iodine deficiency (chronic)and there is a need of continued monitoring the quality of iodised salt provided to the beneficiaries under the Universal salt iodisation programme in order toachieve the goal of elimination of Iodine deficiency disorders from districtKangra.


32. Biol Trace Elem Res. 1992 Jan-Mar;32:229-43.

Iodine deficiency, other trace elements, and goitrogenic factors in theetiopathogeny of iodine deficiency disorders (IDD).

Thilly CH, Vanderpas JB, Bebe N, Ntambue K, Contempre B, Swennen B, Moreno-Reyes R, Bourdoux P, Delange F.

Cemubac University of Brussels.

Severe goiter, cretinism, and the other iodine deficiency disorders (IDD) havetheir main cause in the lack of availability of iodine from the soil linked to a severe limitation of food exchanges. Apart from the degrees of severity of theiodine deficiency, the frequencies and symptomatologies of cretinism and theother IDD are influenced by other goitrogenic factors and trace elements.Thiocyanate overload originating from consumption of poorly detoxified cassava issuch that this goitrogenic factor aggravates a relative or a severe iodinedeficiency. Very recently, a severe selenium deficiency has also been associated with IDD in the human population, whereas in animals, it has been proven to play a role in thyroid function either through a thyroidal or extrathyroidalmechanism. The former involves oxidative damages mediated by free radicals,whereas the latter implies an inhibition of the deiodinase responsible for theutilization of T4 into T3. One concludes that: 1. Goiter has a multifactorialorigin; 2. IDD are an important public health problem; and 3. IDD are a goodmodel to study the effects of other trace elements whose actions in many humanmetabolisms have been somewhat underestimated.


33. Indian J Pediatr. 1998 May-Jun;65(3):451-3.

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Iodine deficiency in district Kinnaur, Himachal Pradesh.

Kapil U, Sharma NC, Ramachandran S, Nayar D, Vashisht M.

Department of Human Nutrition, All India Institute of Medical Sciences, NewDelhi.

The state of Himachal Pradesh is a known iodine deficiency endemic region sincethe last 40 years. The state government is supplying iodised salt to the districtsince 1970. No recent survey has been conducted on the prevalence of iodinedeficiency from the district Kinnaur which is located at an average altitude of10,000 feet above sea level. A total of 1094 children in the age group of 6-10years were included in the study and clinically examined. The total goitreprevalence of 6.1% was found in the subjects studied. Urine samples werecollected from 226 children and were analysed using standard laboratoryprocedures. It was found that the percentage of children with < 2 mcg/dl, 2-4.9mcg/dl, 5-9.9 mcg/dl and 10 and above mcg/dl of urinary iodine excretion (UIE)level was 1.3, 5.8, 10.6 and 82.3 respectively. A total of 242 salt samples were collected and analysed using the standard iodometric titration method. Resultsshowed that almost 90% of the families were consuming salt with an iodine contentof 15 ppm and more which is the stipulated level of iodisation of salt. Thefindings of the study indicate that iodine nutrition is in the transition phasefrom iodine deficient to iodine sufficient. Findings revealed a need for further strengthening the monitoring of the quality of salt being distributed in Kinnaur to achieve elimination of iodine deficiency.


34. Indian J Pediatr. 2007 Oct;74(10):917-21.

Iodine deficiency in urban slums of Bhubaneswar.

Sethy PG, Bulliyya G, Mallick G, Swain BK, Kar SK.

Regional Medical Research Centre, Indian Council of Medical Research,Bhubaneswar, India.

OBJECTIVE: The present study aimed at assessing the population prevalence ofgoiter and iodine deficiency in school children of 6-12 yr living in urban slums of Bhubaneswer, the capital city of Orissa.METHODS: A cross-sectional study was performed using the 30-cluster samplingmethodology and surveillance methods for iodine deficiency as recommended byWHO/ICCIDD/UNICEF. The total goitre rate (n=1248), urinary iodine concentration(UIC) (n=411) and iodine content of edible salt (n=368) were measured.RESULTS: The goitre prevalence was 23.6% (grade 1=18.9%, grade 2=4.7%) with nosignificant gender variation. Goitre prevalence was significantly higher inchildren of 10-12 yr (P=0.012) and scheduled caste and tribe (P=0.003). Medianurinary iodine concentration was 50.0 microg/l with 85.7% of children havingvalues less than 100 microg/l, indicating as biochemical iodine deficiency.Median UIC was inversely in association with gradations of goitre. Children of10-12 yr and scheduled caste/tribe communities had significantly higher medianUIC (P=0.001) than their counterpart peers. About 51% of children were consuming salt having stipulated iodine content of 15 ppm.CONCLUSION: The study indicates moderate iodine deficiency in the population,

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despite a mandatory salt iodization programme in Orissa that has been in forcesince 1989. There is a need to improve the situation through enforcing monitoringof salt iodization to ensure quality and increasing the level of awareness about the iodized salt for sustainable prevention and control of iodine deficiency.


35. Mymensingh Med J. 2002 Jan;11(1):22-5.

Use of iodized salt and the prevalence of goiters in an endemic area ofBangladesh.

Sarker FH, Taufiqun-Nessa UK, Chowdhury SA.

Department of Community Medicine, Mymensingh Medical College.

To find out the prevalence of goitre and assess the knowledge regarding goitreand iodized salt among the respondents in a selected goitre endemic area. Thiscross-sectional study included 155 respondents of purposively selected endemicvillages of Nilphamary Sadar upazilla. Information was collected from allhouseholds of the villages considering one responsible person from eachhousehold. Data was collected by face to face interview through pre-testedquestionnaire and checklist. Study population was 747. Department of CommunityMedicine, National Institute of Preventive & Social Medicine, Mohakhali, March toJune 2001. Out of 155 respondents 63.87% was female and 36.13% were male. Meanage was 34.13 with +/- 10.87 and mean monthly family income was 1974.74 with +/- 1025.92 taka, only 65% had > 5000 taka. Level of education SSC and above wasminimum (6.46%). Mean occupation was cultivation, day labour and housewife. Only 11.6% respondents had correct knowledge regarding goitre and 77.30% had knowledgeabout iodized salt. But only 58.71% respondents' families are using iodized salt according to test result by iodized salt testing solution. The prevalence ofgoitre among 747 people was found 8.3%, among them 4.53% were male, 12% werefemale and 6.96% were grade I and 1.07% were grade II (visible) goitre. The studyresult indicate that the prevalence of goitre still high, knowledge regardinggoitre is minimum and use iodized salt is not satisfactory.


36. Cochrane Database Syst Rev. 2002;(3):CD003204.

Iodised salt for preventing iodine deficiency disorders.

Wu T, Liu GJ, Li P, Clar C.

Department of Clinical Epidemiology, West China Medical Centre, SichuanUniversity, Chengdu, China. [email protected]

BACKGROUND: Iodine deficiency is the main cause for potentially preventablemental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world.OBJECTIVES: To assess the effects of iodised salt in comparison with other forms of iodine supplementation or placebo in the prevention of iodine deficiencydisorders.

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SEARCH STRATEGY: We searched the Cochrane Library, Medline, the Register ofChinese trials developed by the Chinese Cochrane Centre, and the Chinese MedDatabase. We performed handsearching of a number of journals (Chinese Journal of Control of Endemic Diseases, Chinese Journal of Epidemiology, Chinese Journal of Preventive Medicine, and Studies of Trace Elements and Health up to February2001), and searched reference lists, databases of ongoing trials and theInternet. Date of latest search: November 2001.SELECTION CRITERIA: We included prospective controlled studies of iodised saltversus other forms of iodine supplementation or placebo in people living in areasof iodine deficiency. Studies reported mainly goitre rates and urinary iodineexcretion as outcome measures.DATA COLLECTION AND ANALYSIS: The initial data selection and quality assessmentof trials was done independently by two reviewers. Subsequently, after the scope of the review was slightly widened from including only randomised controlledtrials to including non-randomised prospective comparative studies, a thirdreviewer repeated the trials selection and quality assessment. As the studiesidentified were not sufficiently similar and not of sufficient quality, we didnot do a meta-analysis but summarised the data in a narrative format.MAIN RESULTS: We found six prospective controlled trials relating to ourquestion. Four of these were described as randomised controlled trials, one was aprospective controlled trial that did not specify allocation to comparisongroups, and one was a repeated cross-sectional study comparing differentinterventions. Comparison interventions included non-iodised salt, iodised water,iodised oil, and salt iodisation with potassium iodide versus potassium iodate.Numbers of participants in the trials ranged from 35 to 334; over 20,000 peoplewere included in the cross-sectional study. Three studies were in children only, two investigated both groups of children and adults and one investigated pregnantwomen. There was a tendency towards goitre reduction with iodised salt, although this was not significant in all studies. There was also an improved iodine statusin most studies (except in small children in one of the studies), althoughurinary iodine excretion did not always reach the levels recommended by the WHO. None of the studies observed any adverse effects of iodised salt.REVIEWER'S CONCLUSIONS: The results suggest that iodised salt is an effectivemeans of improving iodine status. No conclusions can be made about improvementsin other, more patient-oriented outcomes, such as physical and mental developmentin children and mortality. None of the studies specifically investigateddevelopment of iodine-induced hyperthyroidism, which can be easily overlooked if just assessed on the basis of symptoms. High quality controlled studiesinvestigating relevant long term outcome measures are needed to address questionsof dosage and best means of iodine supplementation in different population groupsand settings.


37. Indian J Med Res. 2008 Nov;128(5):601-5.

Dietary supplies of iodine & thiocyanate in the aetiology of endemic goitre inImphal East district of Manipur, north east India.

Chandra AK, Singh LH, Debnath A, Tripathy S, Khanam J.

Department of Physiology, University of Calcutta, Kolkata, [email protected]

BACKGROUND & OBJECTIVE: The present investigation was undertaken to study the

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iodine nutritional status of school children of Imphal east district in Manipurwhere endemic goitre persists during post-salt iodization phase along with theinvestigation of the factors responsible for the occurrence of goitre endemicity.METHODS: A total of 1,286 children (6-12 yr) were clinically examined for goitre from study areas of Imphal east district. A total of 160 urine samples werecollected and analyzed to measure urinary iodine and thiocyanate levels. Iodinecontent was measured in 140 salt samples and 16 drinking water samples.RESULTS: Overall goitre prevalence was about 30 per cent (grade 1-24.7%; grade2-5.3%) and median urinary iodine level was 17.25 microg/dl. The mean urinarythiocyanate level was 1.073 +/- 0.39 mg/dl. Iodine/thiocyanate ratio (microg/mg) was in the ranges from 15.65 to 22.34. The mean iodine content in drinking water samples was 2.92 +/- 1.75 microg/l and 97.8 per cent of edible salts had iodinelevel above 15 ppm at the consumption point.INTERPRETATION & CONCLUSION: Our findings showed that in spite of no biochemical iodine deficiency, iodine deficiency disorders (IDD) is a serious public healthproblem in Imphal east district of Manipur. The consumption pattern of certainplant foods containing thiocyanate (or its precursors) was relatively high thatinterfere with thyroid hormone synthesis resulting in the excretion of moreiodine. Thus, the existing dietary supplies of thiocyanate in relation to iodine may be a possible aetiological factor for the persistence of endemic goitre inthe study region during post salt iodization period.


38. Bull World Health Organ. 2005 Jul;83(7):518-25.

Current global iodine status and progress over the last decade towards theelimination of iodine deficiency.

Andersson M, Takkouche B, Egli I, Allen HE, de Benoist B.

Department of Nutrition for Health and Development, World Health Organization,Geneva, Switzerland.

OBJECTIVE: To estimate worldwide iodine nutrition and monitor country progresstowards sustained elimination of iodine deficiency disorders.METHODS: Cross-sectional data on urinary iodine (UI) and total goitre prevalence (TGP) in school-age children from 1993-2003 compiled in the WHO Global Databaseon Iodine Deficiency were analysed. The median UI was used to classify countries according to the public health significance of their iodine nutrition status.Estimates of the global and regional populations with insufficient iodine intake were based on the proportion of each country's population with UI below 100microg/l. TGP was computed for trend analysis over 10 years.FINDINGS: UI data were available for 92.1% of the world's school-age children.Iodine deficiency is still a public health problem in 54 countries. A total of36.5% (285 million) school-age children were estimated to have an insufficientiodine intake, ranging from 10.1% in the WHO Region of the Americas to 59.9% inthe European Region. Extrapolating this prevalence to the general populationgenerated an estimate of nearly two billion individuals with insufficient iodine intake. Iodine intake was more than adequate, or excessive, in 29 countries.Global TGP in the general population was 15.8%.CONCLUSION: Forty-three countries have reached optimal iodine nutrition.Strengthened UI monitoring is required to ensure that salt iodization is havingthe desired impact, to identify at-risk populations and to ensure sustainableprevention and control of iodine deficiency. Efforts to eliminate iodine

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deficiency should be maintained and expanded.


39. J Nutr. 1994 Aug;124(8 Suppl):1473S-1478S.

Iodine deficiency disorders: contemporary scientific issues.

Maberly GF.

Center for International Health, Emory School of Public Health, Atlanta, GA30329.

Iodine deficiency is the leading cause of preventable intellectual impairment andis associated with a spectrum of neurologic and developmental pathology. Morethan one billion people are at risk. The developing fetus, newborn, and youngchild are the most susceptible to the effects of an iodine-deficient diet. Ifintervention is not initiated in a timely fashion, the pathophysiologicabnormalities become resistant to treatment and permanent intellectual,neurologic, and somatic deficits result. The technology of iodine deficiencyintervention is well established. Iodized salt, the preferred method, is easy to produce, administer in physiologic doses, and is cost effective. The distributionof iodized salt and social marketing are key to a successful iodine deficiencyelimination program. In remote regions, iodized oil is a useful interimintervention. However, it is clear that technology is not enough. Any nationaleffort to eliminate iodine deficiency must extend far beyond the Ministry ofHealth. The program will require the full participation of a range of nationalgovernment ministries and agencies and the full support and participation oflocal or regional governments.


40. Zhonghua Liu Xing Bing Xue Za Zhi. 2002 Dec;23(6):461-5.

[Systematic review of randomised controlled trial of iodised salt for preventing iodine deficiency disorders].

[Article in Chinese]

Wu T, Liu G, Li P.

Department of Clinical Epidemiology, West China Hospital, Sichuan University,Chengdu 610041, China.

OBJECTIVE: To assess the effect of iodised salt for preventing iodine deficiency disorders.METHOD: Cochrane systematic review.RESULTS: Four randomised controlled trials were included. Subgroup analysisperformed lay on different ages, interventions and controls. Prevalence of goitrewas reduced close to 5% when using distributed iodised salt and market iodisedsalt plus iodine oil capsule which showed more effective than using marketiodised salt alone (OR = 0.10, 95% CI: 0.02 - 0.17). The latter's prevalence of

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goitre was 14.7%. When using market iodised salt, the iodine urea excretion levelshowed different results in children group in different countries. Basically, themarket iodised salt for preventing iodine deficiency of pregnancy women wereeffective, but a part of them did not achieve to the ideal status of iodinenutrition.CONCLUSIONS: The needs to be strictly controlled quality of iodised salt andmarket iodised salt plus iodised oil capsule thus can effectively reduce theprevalence of iodine deficiency disorders. However there was not enough evidence to support that market iodised salt can effectively eliminate these disorders,particularly in children. More eligibility trials are needed for providing moreevidences.


41. Bull World Health Organ. 1988;66(5):637-42.

Towards the eradication of iodine-deficiency disorders in Brazil through a saltiodination programme.

Medeiros-Neto GA.

Iodine-deficiency disorders have been a serious public health problem in Brazilbecause of the failure of a salt iodination programme established in 1953. Thereasons for this failure were logistical, e.g., potassium iodide was not suppliedto all salt-producers, iodination of salt was largely erratic, and part of thepopulation at risk used only non-refined salt, which was not iodinated. In 1978 atask force was therefore formed to implement measures to eliminateiodine-deficiency disorders from the country. For this purpose, potassium iodate was distributed, free-of-charge, to all salt mills and an iodate dosing spray wassupplied without cost to small salt producers. Also, regional laboratories fordetermining iodine in salt were set up, inspectors made regular visits to thesalt mills, and samples of salt from commerce and from the producers wereanalysed. More than 90% of the samples contained 10-30 mg iodine per kg. In threetypical areas of the country with endemic goitre the urinary excretion of iodine increased from an average of less than 40 mug iodine to 125 +/- 38 mug iodine perg creatinine. In conclusion, the salt iodination programme was a complete successand could serve as a model for other countries with a high prevalence ofiodine-deficiency disorders.


42. Indian J Matern Child Health. 1997 Jul-Dec;8(3-4):90-1.

Status of unikersal iodisation of salt programme in the selected districts ofBihar.

Kapil U, Singh J, Prakash R, Sunderesan S, Ramachandran S, Tandon M.

PIP: Iodine Deficiency Disorders (IDD) are a major public health problem inIndia. However, salt with an iodine content of 15 ppm at the consumer level canmeet the human body's iodine requirement. The government of Bihar under theNational Iodine Deficiency Disorder Control Program (NIDDCP) has therefore

41

followed a policy of universal salt iodization (USI) since 1976 under which thestate's population receives edible salt with a minimum of 15 ppm iodine. Saltsamples were collected from 1052 families through schools in 5 districts ofwestern Bihar and analyzed using the standard iodometric titration method toassess the iodine content of salt being consumed. While all samples containedsome degree of iodine, 28.5% contained less than the recommended 15 ppm. Theseresults suggest that the government of Bihar has given only low priority to theNIDDCP program and to monitoring the quality of salt through the Prevention ofFood Adulteration (PFA) system. However, the iodine content was satisfactorycompared to other states largely because all salt was procured only via railwayrakes from production centers in Gujarat and Rajasthan.


43. Probl Sotsialnoi Gig Zdravookhranenniiai Istor Med. 2005 Jan-Feb;(1):25-6.

[Prevention of iodine-deficient diseases].

[Article in Russian]

Dzhatdoeva FA, Syrtsova LE, Gerasimov GA, Zubrilova TE, Salpagarova ZN.

The Interregional center of public health and development assisted by SechenovMoscow Medical Academy undertook, 1999-2000, a study of the standard ofknowledge, attitude and conduct of consumers in respect to the use of iodinatedsalt (IS) in the prevention of iodine-deficient diseases (IDD). It wasdemonstrated that, on the average per one district, 19% of city respondents and13% of rural respondents used IS only. About 31% of city respondents used IS whenit was available at the next-door shop, i.e. from time to time. This figurereached 48% in Irkutsk and Orenburg Regions. The share of those who used ISsometimes in rural regions made an average of 20.7%. 67.2% of those who believethat IDD can be prevented think that ID can also be prevented. Less than 5% ofthem say ID cannot be regarded as a reliable tool in the prevention of IDD.


44. Sante. 2007 Jan-Mar;17(1):33-9.

[Thyroid diseases in sub-Saharan Africa].

[Article in French]

Sidibé el H.

Centre médical Marc Sankalé, BP 5062, Fann Dakar, Sénégal. [email protected]

Thyroid gland diseases vary according to the environment. In sub-Saharan Africa, they are also influenced by population isolation and the absence of foodself-sufficiency, both factors affecting the onset and persistence ofiodine-deficiency goiters. More cosmopolitan diseases are now added to thesethyroid disorders. Women are mainly affected (94.2%), most often with euthyroidgoiters (54.7%), followed by Graves disease (13.1%), hypothyroidism (8.8%),thyroiditis (6.6%), toxic multinodular goiters (6.6 %) and unclassified goiters(10%) [Gabon]. The paucity of laboratories specializing in endocrinology and of

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nuclear medicine facilities, the delay in diagnosis that results in compressiveor recurrent goiters, and endemic goiters are all typical in Africa. In children and adolescents, death rates increase with congenital or acquired thyroiditis as with delayed physical or mental development. In this environment, thyroiditis canalso be pregnancy-related. Very recent surveys show a prevalence of endemicgoiters of 28.6% in the community of Sekota, Ethiopia, 64-70% in Sahel-Sudan(population aged 10-20 years), 20-29% in KwaZulu-Natal (school children),14.3-30.2% in Namibia (school children), 0.21% (congenital hypothyroidism orcretinism) in Plateau State, Nigeria, 55.2% at Zitenga, Burkina Faso (210 persons0-45 years), and 10% in Hararé and Wedza, Zimbabwe (newborn TSH >10.1microIU/mL). The prevalence of goiters is 43.6% in children emigrating fromEthiopia to Israel. Millet from semi-arid zones contains apigenin at aconcentration of 150 mg/kg and luteolin at 350 mg/kg, both of which can interferewith thyroid function. The harmful effects of cassava (also known as manioc) are better known: milling cassava reduces its goitrogenic potential. In addition toiodine deficiency, selenium deficiency, and the effect of the thiocyanates incassava, ion concentrations in soil and drinking water appear to play a role. Theproportion of thyroid surgery indicated for hyperthyroidism has tripled, nowaccounting for 18.5% of all such operations. This disorder is found today insubjects older than 50 years, mainly from rural areas, and caused most often byGraves disease (25 of 51 cases). Graves disease in young women can cause serious problems during pregnancy; in such cases assessment of the minimal effective doseof antithyroid agents is essential. Carbimazole leads to remission in 61% ofcases of Graves disease. Hypothyroidism can be auto-immune and often in patentforms because of insufficient screening in Africa: 24 cases in Dakar (1984) and37 others noticed by us (1998). Single-nodule tumors were assessed in 89 patientsin Khartoum: they were found to be simple goiters in 72% of cases, follicularadenoma in 13.5%, cancer in 13.5% (with 6 of the 12 cases follicular, 5papillary, and 1 anaplastic). The sex ratio for thyroid cancer in Ouagadougou is 0.22, thus mainly women. It affects mainly women in their 30s. Thyroid cancer at Ibadan was found to be papillary carcinoma in 45.3% of cases; follicular formswere seen in 44.5% and this series includes 5% of medullary cancers (7 cases),with a mean age of 34 years. Already 4 other cases from Francophone sub-SaharanAfrica have been noticed. Iodine deficiency is suggested to play a role becausefollicular cancer in southern Africa accounts for up to 55% of thyroid cancers.Thyroid cancers in Algeria are associated with low socioeconomic status andcharacterized by a high prevalence of cancers discovered at an advanced stage andof anaplastic carcinomas. Oral potassium iodate is recommended: 30 mg of iodate amonth or 8 mg every two weeks. Iodized oil has been recommended by some authors, as well as a combination of iodine and sugar, and the iodation of drinking water;these are in addition to the proposed methods of opening up areas by newinfrastructure). In conclusion, thyroid disease is due predominantly to iodinedeficiency and goitrogenic products, but we also note the increasing emergence ofhyperthyroidism, especially Graves disease, atrophic auto-immune hypothyroidism, and thyroid cancer. The insufficiency of infrastructure in transportation,endocrinology, and nuclear medicine are a public health challenge for the thirdmillennium.


45. Baillieres Clin Endocrinol Metab. 1988 Aug;2(3):719-35.

Endemic goitre and iodine deficiency disorders--aetiology, epidemiology andtreatment.

43

Eastman CJ, Phillips DI.

Disorders caused by iodine deficiency continue to be a major health problem inmany underdeveloped areas of the world. The most significant is the impairedmental and physical development which occurs as a result of iodine deprivationearly in life. Individuals in affected communities show a spectrum ofabnormalities which can be attributed to two interacting pathological processes. Fetal hypothyroidism in the first and early second trimester predominantlyaffects the developing nervous system causing deaf-mutism and mental retardation.If hypothyroidism occurs in the early postnatal period the main abnormalities aregrowth stunting and related somatic abnormalities. Subclinical deficits ofintellectual and motor development may also be found in apparently normalindividuals living in affected areas. Although dietary iodine deficiency isclearly the major aetiological factor in both endemic goitre and cretinism,cofactors such as goitrogens, other trace element deficiencies and immunological mechanisms may greatly modify the expression of these disorders. Iodinesupplementation programmes form the basis of the public health strategy incombatting these disorders. Where the iodization of foodstuffs is not feasible,an alternative is the use of iodine containing oil which can be given orally orintramuscularly to provide a long-lasting supply of iodine.


46. Arch Med Res. 2007 Jan;38(1):1-14.

Goiter and other iodine deficiency disorders: A systematic review ofepidemiological studies to deconstruct the complex web.

Kotwal A, Priya R, Qadeer I.

Management Information Systems Organization, Integrated HQ Min of Defence (Army),New Delhi, India. [email protected]

Erratum in: Arch Med Res. 2007 Apr;38(3):366.

Comment in: Arch Med Res. 2007 Jul;38(5):586-7; author reply 588-9.

A systematic review of the available literature on goiter and other iodinedeficiency disorders (IDDs) was carried out with the aim of analyzing availableevidence and providing inputs to the policy makers and program formulatorsregarding the entire issue. The findings point to major issues such as thefollowing: methodological issues in epidemiology of goiter and other iodinedeficiency disorders (IDDs); lacunae in causal linkages; inadequate attention to multicausality; flawed assessment of the impact of intervention, i.e., iodizedsalt; and harmful effects of iodine not given due cognizance. Most of theresearch to date has been unidirectional and does not provide comprehensive data on all aspects of IDDs. To further compound the issue, many independentresearchers, on finding something different from the existing dominant paradigm(iodized salt as panacea for goiter) have tended to ignore these in their finalconclusions and recommendations. Thus, evidence from this systematic reviewdemonstrates enough basis to start a debate on the entire issue, recognizingopposing research findings while continuing with the present strategy. Thisimposes specific problems and necessitates area-specific solutions instead of a

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universal solution, which apart from being less effective may be harmful in thelong run.


47. Eur J Clin Nutr. 1997 Nov;51 Suppl 4:S3-8.

The challenge of the global elimination of iodine deficiency disorders.

van der Haar F.

Program Against Micronutrient Malnutrition, Department of International Health,Emory University School of Public Health, Atlanta, Georgia 30322, USA.

Most nations of the world are well positioned for success in their pursuit of thevirtual elimination of iodine deficiency disorders (IDD) by the year 2000. In1990 at the World Summit for Children, Heads of State and Government had agreedon this global goal and in 1992 at the International Conference on Nutrition,multi-sector country delegations from all over the world developed the prototype framework for national action. Following a special recommendation of the UnitedNations Joint Committee on Health Policy, universal salt iodization (USI) is now being applied in almost all countries with an IDD problem recognized as being of public health significance. The core components of national IDD programmes based on USI are presented in this paper, and examples are given of effective actionsongoing in a number of countries. While in principle all components such ascommunications, information management and laboratory support should integrateand complement with ongoing efforts for general nutritional improvement, nationalIDD programmes also have specific needs which require separate arrangements.Sources of support and information, available from the international publicnutrition community are indicated. The global conquest of IDD provides an examplefor other effective public nutrition practices from the important lessons thatare being learned. Particularly, the role of the private food sector as fullpartner in national programmes is relevant to ongoing and future attempts toreduce and eliminate other major global malnutrition problems.


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Thyroid review

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