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

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

Charlton KE, Yeatman HR, Houweling F.

Smart Foods Centre, Faculty of Health and Behavioural Sciences, University of


Wollongong, Wollongong, NSW 2522, Australia. karenc@uow.edu.au

BACKGROUND: Mandatory fortification of bread with iodised salt is proposed to


address the re-emergence of iodine deficiency in Australia and New Zealand. The
impacts 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 investigate
consumer understanding and attitudes related to the proposed mandatory iodine
fortification programme.
DESIGN: Cross-sectional sample of 78 non-pregnant women aged 20-55 y was
conveniently sampled in Wollongong, NSW. A single 24-hr urine sample was
collected for urinary iodine concentration (UIC). A self-administered
questionnaire assessed consumer understanding, perceptions and attitudes related
to iodine fortification.
OUTCOMES: Median UIC = 56 microg/L (IQR = 41-68), indicating mild iodine
deficiency. Knowledge about iodine was poor with less than half associating low
iodine status with adverse pregnancy outcomes. Health education and
supplementation, particularly at the medical practitioner interface, was
considered 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 iodine
intake 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 of


hyperthyroidism?

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

Institute for Teaching and Educational Research in Health Sciences, Private


University of Witten/Herdecke, Germany.

OBJECTIVES: In an initial experimental study in the domain of learning about


hypertension, a case-based, worked example approach was found to be most
effective when erroneous examples and elaborated feedback were provided. However,
combining erroneous examples with knowledge of correct result (KCR) feedback
impaired learning. This study was designed to establish whether these findings
could be replicated in the domain of learning about hyperthyroidism.
METHODS: A total of 124 medical students were randomly assigned to the four
conditions of a 2 x 2 design (with errors versus without errors; elaborated
feedback versus KCR feedback). Diagnostic knowledge was operationalised by a
multiple-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 feedback
impaired knowledge acquisition. These effects were independent of differences in
prior knowledge and time on task and replicated key findings of the study on
hypertension diagnostics. Additionally, results showed that students in
conditions with elaborated feedback assessed their learning outcomes as
significantly higher than students receiving KCR feedback only.
CONCLUSIONS: By providing erroneous examples in combination with elaborated
feedback in a computer-based learning environment, diagnostic knowledge was
fostered. The approach of 'learning from worked examples' was successfully
adapted to a complex domain and was found to support the acquisition of complex
competencies.

PMID: 19930513 [PubMed - indexed for MEDLINE]

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

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

Abuye C, Berhane Y, Ersumo T.

Ethiopian Health and Nutrition Research Institute (EHNRI), Faculty of Medicine,


Addis Ababa University (AAU), Ethiopia. cherinetabuve1@yahoo.com

OBJECTIVE: Iodine Deficiency Disorders (IDD) as one of the leading nutritional


problems has been increasing through time due to iodine deficiency, aggravating
factors 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. Low
land and adjacent high land were independently sampled to investigate the role of
altitude on goiter prevalence. Totally 6960 children and the same number of
biological mothers of the children were included in the clinical examination for
goiter and household interview. Urine samples were collected from children for
urinary iodine examination/analysis (UIE). Besides, in all clusters qualitative
data were collected on IDD knowledge and cassava introduction, cultivation and
consumption.
RESULTS: Cassava consumption and living in high altitude were found to be risk
factors for IDD. In the two regions (SNNP and Benshangul-Gumuz) among three where
cassava is cultivated, those who consume cassava frequently were significantly (p
< 0.001) affected by goitre than those consuming rarely or not. In the last
thirty years cassava consumption has been increasing with the concomitant
increase in goitre rate and other associated health problems. Acute cyanide
intoxication in children from cassava meal was reported. In Amhara region, goitre
rate was significantly (p < 0.05) higher in high altitudes than in low both for
children and mothers. This was due to significantly (p < 0.01) low level of
iodine 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 not
wanted for marriage.
CONCLUSION: Besides low level of iodine intake, cassava consumption and living in
high altitude were responsible for the observed variation and severity in goitre
rates. IDD affects several dimensions of human life including school enrolment
and marriage. Addressing IDD in-terms of salt iodization and training communities
on cassava processing techniques to remove cyanide, awareness creation on IDD and

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soil conservation are highly recommended.

PMID: 19374318 [PubMed - indexed for MEDLINE]

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 possible


heritable cause, provided that environmental sharing can be excluded. Thus, data
on familial risks are important for genetic studies and for clinical genetic
counseling.
DESIGN: We carried out a nationwide family study on nontoxic and toxic nodular
goiters, 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 was
linked to the Hospital Discharge Register from years 1987 to 2007. Standardized
incidence ratios (SIRs) were calculated for offspring of affected parents and for
siblings by comparing to those whose relatives had no hospitalization for thyroid
disease.
RESULTS: The number of hospitalized patients in the offspring generations was 11
659 for nontoxic goiter, 9514 for Graves' disease, and 1728 for toxic nodular
goiter. Familial cases accounted for 8.2, 5.2, and 2.1% of all patients
respectively. The highest familial risk for offspring of affected parents was
noted for Graves' disease (SIR 3.87), followed by toxic nodular goiter (3.37) and
nontoxic goiter (3.15). Familial risks were higher for affected siblings: toxic
nodular 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 on
these thyroid diseases. The observed high familial aggregation for defined
thyroid diseases cannot be explained by the known genetic basis, calling for
further studies into genetic and environmental etiology of thyroid diseases.

PMID: 19661127 [PubMed - indexed for MEDLINE]

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 any
medical 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 were
recorded. The skin findings in the patients and the control group were compared
statistically.
RESULTS: Among 220 cases, in 125 (56.8%) skin findings were detected. The most
frequently observed skin findings were chronic urticaria (6.8%), vitiligo (6.8%),
diffuse alopecia (6%), acne vulgaris (5%) and acne rosacea (3.6%). No significant
difference was detected statistically between the patients and control group in
terms of skin findings. When compared for the presence of each dermatosis,
chronic urticaria, vitiligo and pruritus were found to be significantly higher in
the patient group with thyroid diseases than in the control group. In terms of
the presence of skin findings, no statistical difference was detected between
autoimmune hyperthyroidism and non-autoimmune hyperthyroidism, between autoimmune
hypothyroidism and non-autoimmune hypothyroidism, or between autoimmune
euthyroidism and non-autoimmune euthyroidism. Chronic urticaria, vitiligo, and
diffuse alopecia were found to be significantly higher in patients with
autoimmune thyroid diseases than in the control group. Vitiligo and diffuse
alopecia were found to be higher in autoimmune hyperthyroidism patients than in
the control group. Vitiligo was found to be significantly higher in autoimmune
hypothyroidism patients than in the control group.
CONCLUSION: To our knowledge, no report investigating the skin findings among
thyroid diseases exists in literature. We believe this study would provide data
for further studies.

PMID: 19327604 [PubMed - indexed for MEDLINE]

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 University.


izzeldin.alsharief@gmail.com

Iodine deficiency disorders (IDD) constitute a severe public health problem in


Sudan. IDD affects children and women throughout life. More than 2 out of 10
school age children have goiter. The prevalence reaches 40% in some regions of
the country. Several interventional measures were introduced to control the IDD
problem. While the situation with regard to production and supply of iodized salt
was thus deteriorating, an Emergency Food Security and Nutrition Assessment
Survey (EFSNA) revealed that the prevalence of IDD among adult women, as
reflected in the presence of visible goiter, was as high as 25.5%. We have
conducted a situation analysis survey in the Republic of Sudan to review the
prevailing situation and suggest a benchmark that would help in developing
effective control measures and in monitoring their implementations. SWOT
analysis, questionnaire, focus groups discussion beside a combination of rapid
assessment approach and qualitative method were used to critically evaluate the
salt iodization situation in the country and assess the prevailing IDD situation
in and propose a plan of action to overcome the bottlenecks. The survey concluded
that Iodine deficiency affects children and women all through Sudan. The
prevalence is even greater in some regions of the country and there is no
supportive policy environment for successful universal salt iodization. To
overcome this aggravated situation Sudan will need to conduct a baseline study to
provide 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 in
monitoring their implementation. The study recommended a set of actions to the
government to overcome the prevailing situation and strengthening the current
policy and implementation.

PMID: 19326717 [PubMed - indexed for MEDLINE]

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

Determination of iodine nutrition and community knowledge regarding iodine


deficiency 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. bulliyyag@rediffmail.com

AIM: To determine the status of iodine nutrition and knowledge of iodine


deficiency 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 by
WHO/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) was
assessed.
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. Median
urinary iodine was 38 Cmicro.Tl(-1) and 51.7% of children had urinary iodine
values <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 not
aware of salt iodization.
CONCLUSIONS: Study results show moderate iodine deficiency with poor community
knowledge of iodine nutrition. There is need to strengthen the monitoring of salt
iodization and intensive education activities in the tribal areas.

PMID: 18404976 [PubMed - indexed for MEDLINE]

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 rural


region.
DESIGN: A cross-sectional study; urinary iodine concentrations (UIC) were
correlated 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 morning
midstream urine sample and completed a questionnaire. There were no exclusion
criteria.
MAIN OUTCOME MEASURES: Iodine status was based upon mean UIC (MUIC) values and
categorised according to World Health Organisation criterion. Subgroups were
classified 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% were
iodine-replete, 52% had mild deficiency and 18.5% were moderately to severely
deficient. 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 vitamin
supplementation 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 than
participants 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 Riverina
population, consistent with other Australian studies. Salt iodisation might not
be an effective strategy to correct iodine deficiencies within Australia.

PMID: 18318853 [PubMed - indexed for MEDLINE]

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-section
community based study.

Abuye C, Berhane Y.

Food and Nutrition Research Department, Ethiopian Health and Nutrition Research
Institute, Addis Ababa, Ethiopia. cherinetabuye1@yahoo.com

BACKGROUND: Iodine deficiency is severe public health problem in Ethiopia.


Although urinary iodine excretion level (UIE) is a better indicator for IDD the
goitre rate is commonly used to mark the public health significance. The range of
ill effect of IDD is however beyond goitre in Ethiopia. In this study the
prevalence of goitre and its association with reproductive failure, and the
knowledge of women on Iodine Deficiency were investigated.
METHODS: A cross-section community based study was conducted during February to
May 2005 in 10998 women in child bearing age of 15 to 49 years. To assess the
state of iodine deficiency in Ethiopia, a multistage "Proportional to Population
Size" (PPS) sampling methods was used, and WHO/UNICEF/ICCIDD recommended method
for goitre classification.
RESULTS: Total goitre prevalence (weighted) was 35.8% (95% CI 34.5-37.1), 24.3%
palpable and 11.5% visible goitre. This demonstrates that more than 6 million
women were affected by goitre. Goitre prevalence in four regional states namely
Southern Nation Nationalities and People (SNNP), Oromia, Bebshandul-Gumuz and
Tigray was greater than 30%, an indication of severe iodine deficiency. In the
rest of the regions except Gambella, the IDD situation was mild to moderate.
According to WHO/UNICEF/ICCIDD this is a lucid indication that IDD is a major
public health problem in Ethiopia. Women with goitre experience more pregnancy
failure (X2 = 16.5, p < 0.001; OR = 1.26, 1.12 < OR < 1.41) than non goitrous
women. Similarly reproductive failure in high goitre endemic areas was

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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 importance
of iodated salt.
CONCLUSION: Ethiopia is at risk of iodine deficiency disorders. The findings
presented in this report emphasis on a sustainable iodine intervention program
targeted at population particularly reproductive age women. Nutrition education
along with Universal Salt Iodization program and iodized oil capsule distribution
in some peripheries where iodine deficiency is severe is urgently required.

PMCID: PMC2194698
PMID: 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 de


Medicina, Universidad de Navarra, España. jcgalofre@unav.es

Management of subclinical hyperthyroidism (low TSH and normal thyroid hormones)


is controversial. Knowledge of its causes, clinical context and associated
morbidity is required. It is recommended to follow six steps in exploration and
treatment: 1) confirmation, 2) estimation of severity, 3) cause assessment, 4)
study of complications, 5) balance whether treatment is needed and 6) if
necessary, choice of the most appropriate form. In its management, the same
treatments are used as in overt hyperthyroidism.

PMID: 17555116 [PubMed - indexed for MEDLINE]

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

Women's iodine status and its determinants in an iodine-deficient area in the


Kayes region, Mali.

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

Pedriatric Ward, Rikshospitalet, Oslo, Norway. livelin.torheim@hiak.no

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 by
urinary iodine concentration (UIC) and level of goitre based on palpation. Salt
iodine was assessed semi-quantitatively at household level. Individual
characteristics 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; currently
breast-feeding women had lower UIC, and UIC increased with increasing level of
iodine in household salt. Prevalence of goitre was lower in older women with
higher body mass index.
CONCLUSION: The study indicates severe iodine deficiency in the study area.
Urgent action is needed to improve the situation through enforcing salt
iodisation legislation and increasing the level of knowledge about the importance
of iodised salt in the population.

PMID: 15975184 [PubMed - indexed for MEDLINE]

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. pieter.jooste@mrc.ac.za

OBJECTIVES: To determine the level of knowledge regarding iodine nutrition and


its 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 African
population.
SETTING: Home visits and personal interviews in the language of the
respondent.Subjects: Data were collected from one adult in each of the selected
2164 households, and the participation rate was 98%.
RESULTS: Only 15.4% of respondents correctly identified iodised salt as the
primary dietary source of iodine, 16.2% knew the thyroid gland needs iodine for
its functioning, and a mere 3.9% considered brain damage, and 0.8% considered
cretinism, as the most important health consequence of iodine deficiency.
Compared with respondents from high socio-economic households, respondents from
low socio-economic households were considerably less informed about aspects of
iodine 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 the
international emphasis on brain damage resulting from iodine deficiency has not
been conveyed successfully to the consumer level in this country.

PMID: 15975183 [PubMed - indexed for MEDLINE]

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 of
knowledge, attitude and conduct of consumers in respect to the use of iodinated
salt (IS) in the prevention of iodine-deficient diseases (IDD). It was
demonstrated that, on the average per one district, 19% of city respondents and
13% of rural respondents used IS only. About 31% of city respondents used IS when
it was available at the next-door shop, i.e. from time to time. This figure
reached 48% in Irkutsk and Orenburg Regions. The share of those who used IS
sometimes in rural regions made an average of 20.7%. 67.2% of those who believe
that IDD can be prevented think that ID can also be prevented. Less than 5% of
them say ID cannot be regarded as a reliable tool in the prevention of IDD.

PMID: 15828388 [PubMed - indexed for MEDLINE]

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 and
consumption 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 Shebe
town.
RESULTS: The iodine content of household salt samples ranged, from 0-75 PPM and
that of the shop samples ranged from 0.1-75 PPM. Eighty one per cent of household
salt samples and 82% of shop salt samples have iodine levels below the minimum
standard set by the Quality and Standard Authority of Ethiopia. Knowledge about
iodized 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 found
to be associated with female sex (P<0.01), Amhara ethnicity (P<0.001), Orthodox
religion (P=0.008), literacy status (P=0.04) and occupation (P=0.01). Good
knowledge, about iodized salt was significantly associated with favourable
attitude among food caterers (P<0.001).
CONCLUSION: This study demonstrated that high proportions of residents in Shebe
town were consuming inadequately iodized salt. There is a marked loss of iodine
from salt by the time it reaches to consumption level in that some households
were found to use salt with zero iodine content, whereas, all salt samples
collected from the shops have at least some iodine. Poor awareness about iodized
salt among food caterers and even in shopkeepers was also disclosed in this
study. Socio-demographic factors such as ethnicity, religion, sex, lower
educational level of food caterers might have an influence on poor, household
practices like exposure of salt to sunlight. Information, education and
communication on the importance consuming iodized salt and its proper handling in
the house and regular monitoring of the salt iodine level at consumer level is
essential for elimination of IDD.

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PMID: 15250627 [PubMed - indexed for MEDLINE]

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

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


Bangladesh.

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 goitre
and iodized salt among the respondents in a selected goitre endemic area. This
cross-sectional study included 155 respondents of purposively selected endemic
villages of Nilphamary Sadar upazilla. Information was collected from all
households of the villages considering one responsible person from each
household. Data was collected by face to face interview through pre-tested
questionnaire and checklist. Study population was 747. Department of Community
Medicine, National Institute of Preventive & Social Medicine, Mohakhali, March to
June 2001. Out of 155 respondents 63.87% was female and 36.13% were male. Mean
age 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 was
minimum (6.46%). Mean occupation was cultivation, day labour and housewife. Only
11.6% respondents had correct knowledge regarding goitre and 77.30% had knowledge
about iodized salt. But only 58.71% respondents' families are using iodized salt
according to test result by iodized salt testing solution. The prevalence of
goitre among 747 people was found 8.3%, among them 4.53% were male, 12% were
female and 6.96% were grade I and 1.07% were grade II (visible) goitre. The study
result indicate that the prevalence of goitre still high, knowledge regarding
goitre is minimum and use iodized salt is not satisfactory.

PMID: 12148391 [PubMed - indexed for MEDLINE]

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

Dietary iodine intake and urinary iodine excretion in a Danish population: effect
of 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 Food


Administration, Søborg, Denmark. lbr@fdir.dk

I deficiency diseases remain a health problem even in some developed countries.


Therefore, measurement of I intake and knowledge about food choice related to I
intake is important. We examined I intake in 4649 randomly selected participants
from two cities in Denmark (Copenhagen and Aalborg) with an expected difference
in 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 concentration
and as estimated 24-h l excretion. Further, subgroups with low I intake were
recognized. 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 I
intake, and milk (P<0.001) and fish (P=0.009) intake was related to I excretion
in a multiple linear regression model. Thus, risk groups for low I intake were
individuals 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 in
drinking water is lower. Even individuals who followed the advice regarding
intake of 200-300 g fish/week and 0.5 litres milk/d had an intake below the
recommended level if living in Aalborg.

PMID: 11895314 [PubMed - indexed for MEDLINE]

17. Asia Pac J Clin Nutr. 2001;10(1):58-62.

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. mohapatrass@hotmail.com

A knowledge-attitude-practices (KAP) study was conducted along with a prevalence


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

PMID: 11708610 [PubMed - indexed for MEDLINE]

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

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

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

Division of Nursing, School of Medicine, University of Hirosaki.


cyamada@cc.hirosaki-u.ac.jp

In 1996, the Mongolian Government pledged to eliminate iodine deficiency


disorders by 2001 using salt iodization as its primary strategy. Iodine content
in salt was set at 50 +/- 10 PPM based on an assumption of 5 g of daily salt
intake. In 1998, the authors suspected that salt intake was more than 5 g and
that pregnant women consumed more salt than non-pregnant women. Over 1,600 adults
of both sexes were studied in five provinces. In this study we estimated salt

11
intake based on urinary excretion of sodium and creatinine. A formula was used to
calculate salt intake from excreted volumes of sodium and creatinine. Average
values 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 concluded
that appropriate iodine content in salt should range from 20 to 40 PPM. It is
recommended that health education regarding proper levels of salt intake be
carried out with the general public, with emphasis on pregnant women.

PMID: 11200214 [PubMed - indexed for MEDLINE]

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

Knowledge beliefs and practices regarding iodine deficiency disorders among the
tribals 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, New
Delhi.

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 any
obvious association between iodine deficiency and its health effects, IDD is not
perceived as a major public health problem. For any disease to be effectively
controlled, awareness at all levels from community to policy makers is necessary.
This study was conducted to assess knowledge, beliefs and practices regarding
iodine deficiency Disorders in Car Nicobar districts of Andaman and Nicobar
Islands. The population is predominantly tribals involved in coconut plantations.
All the village heads of the sixteen villages and parents of 10% of the school
children examined for goiter were interviewed. Initial focus group discussions
were conducted as no prior knowledge about local names for goitre or other
related IDD information was available. The interview schedule was designed in
English which was then translated into Hindi and Nicobarese and back translated
into Hindi and English. A total of 114 persons were interviewed 60 males, 54
females. 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 the
respondents believed that these swellings caused problems. Sixty three (55.3%) of
respondents believed that there was treatment, of which 33 said there was medical
treatment, 18 respondents said traditional treatment by "LAM-EEN" and 12 felt
that both therapies are required. Majority (85%) brought salt samples from the
Government 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 the
I.D.D. Control Programme.

PMID: 10771954 [PubMed - indexed for MEDLINE]

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.

12
National Institut of Public Health, Abidjan, Ivory Coast.

Iodine deficiency is a major public health problem in developing countries. The


main areas where goitre is prevalent have been identified, but the different
degrees of severity and the populations affected have not. Most countries are now
attempting to obtain reliable and more extensive data. A pilot study was carried
out in the Ivory Coast in order to improve epidemiological knowledge of iodine
deficiency and collect the information required to set up an elimination
programme. The aim of this study was to assess the prevalence of goitre and
cretinism and to measure the main biochemical indicators of thyroid function (T3,
T4 and TSH). The study involved 1433 people identified from a census. The
prevalence of goitre was 50.3%. There was a significant difference between the
examined ethnic groups: 52.7% of the Yacouba and 28.6% of the non-Yacouba had
goitre. The most affected age group was 15-45 year. The predominance of women
demonstrated the susceptibility of women at child-bearing age to develop the
condition. The prevalence of cretinism was approximately 1.5%. Through the
assessment carried out using a grid of clinical indicators, it was possible to
identify 10 cases of laboratory proven myxedematous cretinism due to
hypothyroidism. 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 very
limited 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). These
initial 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 be
complemented by a nutritional investigation to improve the understanding of
iodine balance, after which an appropriate action plan will be proposed.

PMID: 10097418 [PubMed - indexed for MEDLINE]

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 southern
Germany.

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 nutritional


knowledge and individual iodine prophylaxis were determined during a health
education program on iodine deficiency and prophylaxis in 1992. Participants were
472 male and 568 female (mean age 27.7 years) students and employees of five
universities in the southern part of Germany. The study aimed to clarify the
relationship 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 +/- 8.3
ml in males and 15.8 +/- 7.1 ml in females. 25.5% of females and 19.9% of males
showed thyroid volume above the upper normal values. Total mean urinary iodine
excretion was 70.7 +/- 42 micrograms I/g creatinine reflecting WHO-grade-I iodine
deficiency. 80.8% of total subjects used iodized salt and 43.2% stated to consume
salt-water fish to meet their iodine requirement. The female non-users had

13
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/g
creatinine; p < 0.05), however, thyroid volume was identical in these groups. The
area of residence over the last 10 years did not significantly influence the
thyroid volume. The goiter incidence increased with age. Although our study
population was highly educated (81.8% students) and the subjects were provided
with educational brochures immediately prior to the study, knowledge about iodine
content of food was poor. We conclude that despite a high degree of voluntary
iodine prophylaxis and educational programs the iodine intake is insufficient.
The use of iodized salt in households, cafeterias, and also in food manufacturing
must be increased for sufficient iodine prophylaxis.

PMID: 8776830 [PubMed - indexed for MEDLINE]

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 in


Dibrugarh District of Assam State to determine the prevalence of iodine
deficiency disorders (IDD), especially goiter. The prevalence of goiter remained
high (42.2%) in Dibrugarh District (65.8% in 1989). 46.95% of all iodated salts
had less than the optimum level of iodine (15-29.99 ppm). Storage practices
affected 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 sale
of non-iodized salt has been banned in Assam since 1989. An in-depth study was
conducted in Sonitpur and Tinsukia districts to determine whether raw salt was
imported 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 storage
in earthenware pots, resulting in deterioration of the quality of salt. Salt is
transported to Assam in open wagons, which exposes the salt to the sun and the
rains. Wholesalers store salt in thick polythene bags which are in turn kept in
covered godowns. Retailers sell the salt from open verandas, which exposes the
salt to rain and sun. Household storage practices include plastic or glass jars
with 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 iodized
salt 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. It
provides 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% of
salt samples had a satisfactory level of iodine and 2.7% had no iodine at all.

PMID: 8690500 [PubMed - indexed for MEDLINE]

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

Iodine deficiency disorders (IDD) and their eradication.

14
Hetzel BS.

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

PMID: 6138653 [PubMed - indexed for MEDLINE]

1. Indian J Public Health. 1995 Oct-Dec;39(4):141-7.

Indicators to monitor progress of National Iodine Deficiency Disorders Control


Programme (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 their
consequences for human development are well known. The scope of National Goitre
Control Programme (NGCP) launched in 1962 was expanded and the programme was
renamed as National Iodine Deficiency Disorders Control Programme (NIDDCP) to
connote wider implications of iodine deficiency in population. It is necessary to
monitor the progress of NIDDCP using quantifiable indicators to ensure
achievement of programme objectives. Prevalence of iodine deficiency disorders,
status of iodised salt and level of knowledge. Attitude & practice (KAP) of
community regarding IDD and iodised salt are a few such indicators. Children in
the age group of 8-10 years are considered most appropriate target group to
monitor IDD prevalence. The quality of iodised salt assessed at various levels in
West 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 IDD
be launched to create increased demand for consumption of iodised salt in the
community.

PIP: In India, the goal of the National Iodine Deficiency Disorder Control
Programme (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 the
supply of iodized salt. Quantifiable indicators used to monitor its progress
include the prevalence of IDD, iodine content of salt, and knowledge, attitudes,
and practices (KAP) regarding iodized salt. The program targets school children

15
8-10 years old for assessing IDD prevalence. It prefers the community-based
survey to the school-based survey, since the former includes children not
enrolled in school. The indicators health workers use to assess IDD prevalence
are thyroid size (palpation and ultrasonography), urinary iodine, and level of
thyroid-stimulating hormones in serum. Spot testing kits and iodometric titration
method are used to measure iodine content in salt. Salt with at least 15 ppm
iodine is classified as satisfactory. A goiter survey requires a minimum of 5
salt samples (about 20 g). The KAP survey needs a minimum of 5 different
households in each cluster site. Issues related to salt addressed in the KAP
survey include existence of iodized salt, importance of iodized salt consumption,
consequences of IDD (e.g., poor physical and mental growth of children, still
births, cretinism), packaging of iodized salt, price, storage of iodized salt,
use of bagara salt, prior washing of salt, and source of iodized salt. In West
Bengal, only iodized salt can be sold. In 1994, West Bengal met its annual
requirement of edible salt. A survey at rake unloading points in West Bengal in
1994 revealed that most salt from Gujarat had adequate iodine levels, while all
but 5.3% of the salt from Rajasthan had insufficient iodine levels. Health
workers and food inspectors in West Bengal routinely monitor different districts
at various levels (household, retailers, and wholesalers). In 1995, 84.3% of
samples at wholesalers, 74.3% at retailers, and 71.2% at households had
satisfactory levels of iodine. The Goitre Cell of the West Bengal government has
an IDD educational program involving teachers and panchayats.

PMID: 8690501 [PubMed - indexed for MEDLINE]

2. Indian J Public Health. 1995 Oct-Dec;39(4):148-51.

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 health
problem of today. Their effect is hidden and profound affecting the quality of
human life. An attempt has been made to describe the various aspects of the
National Iodine Deficiency Disorders control Programme (NIDDCP) being implemented
in the country. The paper also focuses about the problems associated in
implementing 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 have
IDD-related mental/motor handicaps. IDD is a problem in every state and union
territory. It is a major public health problem in 211 of the 245 districts
surveyed. Even though IDDs cannot be cured, they can be easily prevented. Daily
consumption of iodized/iodated salt is the most effective and inexpensive way to
prevent IDD. In 1962, the government of India implemented the National Goitre
Control Programme, now called the National Iodine Deficiency Disorders Control
Programme (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 produced
34 lakh metric tons of iodated salt per year. The government expects iodated salt
production to increase to 50 lakh metric tons in the near future. Iodated salt is
transported on the railways under a priority category that is second only to
defense. In 19 states and 6 union territories, the sale of noniodated salt has
been completely banned. The remaining state governments have been urged to ban

16
the sale of noniodated salt and to include iodated salt under the public
distribution system. Each State Health Directorate has been advised to set up an
IDD Control Cell. The biochemistry division of the National Institute of
Communicable Diseases has a national reference laboratory for monitoring of IDD,
and it also trains medical and paramedical personnel. District health officers in
all endemic states have test kits to conduct on-the-spot qualitative testing to
ensure 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/TV
spots.

PMID: 8690502 [PubMed - indexed for MEDLINE]

3. 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 in


Dibrugarh District of Assam State to determine the prevalence of iodine
deficiency disorders (IDD), especially goiter. The prevalence of goiter remained
high (42.2%) in Dibrugarh District (65.8% in 1989). 46.95% of all iodated salts
had less than the optimum level of iodine (15-29.99 ppm). Storage practices
affected 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 sale
of non-iodized salt has been banned in Assam since 1989. An in-depth study was
conducted in Sonitpur and Tinsukia districts to determine whether raw salt was
imported 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 storage
in earthenware pots, resulting in deterioration of the quality of salt. Salt is
transported to Assam in open wagons, which exposes the salt to the sun and the
rains. Wholesalers store salt in thick polythene bags which are in turn kept in
covered godowns. Retailers sell the salt from open verandas, which exposes the
salt to rain and sun. Household storage practices include plastic or glass jars
with 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 iodized
salt 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. It
provides 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% of
salt samples had a satisfactory level of iodine and 2.7% had no iodine at all.

PMID: 8690500 [PubMed - indexed for MEDLINE]

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-section
community based study.

17
Abuye C, Berhane Y.

Food and Nutrition Research Department, Ethiopian Health and Nutrition Research
Institute, Addis Ababa, Ethiopia. cherinetabuye1@yahoo.com

BACKGROUND: Iodine deficiency is severe public health problem in Ethiopia.


Although urinary iodine excretion level (UIE) is a better indicator for IDD the
goitre rate is commonly used to mark the public health significance. The range of
ill effect of IDD is however beyond goitre in Ethiopia. In this study the
prevalence of goitre and its association with reproductive failure, and the
knowledge of women on Iodine Deficiency were investigated.
METHODS: A cross-section community based study was conducted during February to
May 2005 in 10998 women in child bearing age of 15 to 49 years. To assess the
state of iodine deficiency in Ethiopia, a multistage "Proportional to Population
Size" (PPS) sampling methods was used, and WHO/UNICEF/ICCIDD recommended method
for goitre classification.
RESULTS: Total goitre prevalence (weighted) was 35.8% (95% CI 34.5-37.1), 24.3%
palpable and 11.5% visible goitre. This demonstrates that more than 6 million
women were affected by goitre. Goitre prevalence in four regional states namely
Southern Nation Nationalities and People (SNNP), Oromia, Bebshandul-Gumuz and
Tigray was greater than 30%, an indication of severe iodine deficiency. In the
rest of the regions except Gambella, the IDD situation was mild to moderate.
According to WHO/UNICEF/ICCIDD this is a lucid indication that IDD is a major
public health problem in Ethiopia. Women with goitre experience more pregnancy
failure (X2 = 16.5, p < 0.001; OR = 1.26, 1.12 < OR < 1.41) than non goitrous
women. Similarly reproductive failure in high goitre endemic areas was
significantly higher (X2 = 67.52; p < 0.001) than in low. More than 90% of child
bearing age women didn't know the cause of iodine deficiency and the importance
of iodated salt.
CONCLUSION: Ethiopia is at risk of iodine deficiency disorders. The findings
presented in this report emphasis on a sustainable iodine intervention program
targeted at population particularly reproductive age women. Nutrition education
along with Universal Salt Iodization program and iodized oil capsule distribution
in some peripheries where iodine deficiency is severe is urgently required.

PMCID: PMC2194698
PMID: 17996043 [PubMed - indexed for MEDLINE]

5. Asia Pac J Clin Nutr. 2001;10(1):58-62.

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. mohapatrass@hotmail.com

A knowledge-attitude-practices (KAP) study was conducted along with a prevalence


study of iodine deficiency disorders (IDD) between 1998-99 in the district of
Bargarh, Orissa state, India. A total of 635 people were interviewed by a
pretested structured questionnaire, adopting the probability proportional to size
cluster sampling method. The aim was to assess the baseline information on the
KAP of the people regarding IDD. Only 37% of the males and 29.3% of the females

18
perceived goitre as a disease. Less than 5% of both sexes knew how goitre is
caused. Only 16.4% used iodised salt regularly. The awareness and perception of
IDD does not correspond with the time and effort we have spent in education of
this disease. The implications of this poor knowledge about IDD and consequent
poor use of iodised salt is contrasted to the optimistic target of elimination of
IDD. This aspect is discussed in this paper, at a time when we are at the
beginning of the new millennium.

PMID: 11708610 [PubMed - indexed for MEDLINE]

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, New
Delhi.

Iodine deficiency disorders (IDD) are an important public health problem in India
with an estimated 270 million people at risk of IDD. India has adopted the
strategy of salt iodization for control of IDD and has the goal of "Universal
iodization of salt by 1995 and elimination of IDD by 2000". There is a high
degree of political commitment which need to continue if the goal is to be
achieved. 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 for
animal consumption as IDD affects livestock as well. India has the installed
capacity to produce its requirement of 5 million tonnes iodised salt.
Communication strategies have to be strengthened especially to educate people who
have 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 from
production to consumption. NGO's and the community have to be encouraged to
participate in this process. To sustain the elimination of IDD, a partnership of
various stakeholders IDD elimination is essential.

PMID: 10829921 [PubMed - indexed for MEDLINE]

7. Indian J Public Health. 1995 Oct-Dec;39(4):164-71.

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 Territories
in India. Under the National Iodine Deficiency Disorders control programme, the
Government of India has adopted a strategy to iodisation of all edible salt in
the country which is a long term and sustainable preventive solution to eliminate
iodine deficiency disorders. The benefits to be derived from universal salt
iodisation are more to the population. Iodised salt is safe and does not cause
any side effect.

19
PIP: In India, about 167 million people are at risk of iodine deficiency
disorders (IDD). 54 million have a goiter, 2.2 million have cretinism, and 6.6
million 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 50
mcg and 1000 mcg. Yet, in India, daily iodine intake may be as low as 100-160
mcg/day compared to 3000 mcg/day in Japan. Since iodine is concentrated in the
top soil and the environment continues to be degraded, supplementary dietary
iodine is needed. In areas endemic to goiter, the iodine content of drinking
water is 3-16 mcg/l, while it is 5-64 mcg/l in nonendemic areas. Regardless of
food type, iodine content was higher in nonendemic areas than in areas endemic to
goiter (e.g., lentils: 13 vs. 4 mcg/1000g). Iodine is readily absorbed from the
gastrointestinal tract and distributed rapidly throughout the body. The thyroid
takes up about 30% of the iodine entering the body for hormone synthesis. The
kidneys excrete the rest. The iodine content of regional diets in India ranges
from 170-300 mcg/day. The loss of iodine in cooking practices ranges from 30-70%.
The National Iodine Deficiency Disorders Control Programme (NIDDCP) aims to
eliminate IDD by the year 2000. The Food Adulteration Act states that iodized
salt at the manufacturing level should have no less than 30 ppm and at the
consumer level no less than 15 ppm. One of the greatest obstacles to NICCDP is
poor iodine stability. Appropriate technologies now produce iodized salt with a
long shelf life in some factories in Tamil Nadu, Andhra Pradesh, and Gujarat. An
important component of NIDDCP is monitoring of iodized salt. Susceptible people
and people with pre-existing abnormalities of the thyroid gland may have adverse
effects of excess iodine intake. It appears that iodine rarely causes an allergic
reaction. The lethal dose low (LDLO) for potassium iodate may be 531 mg/kg of
body weight. Thus, 32 g is the LDLO for an Indian of average body weight of 60
kg. A review of case reports show that iodine intake of less than 1000 mcg/day is
safe for most people.

PMID: 8690505 [PubMed - indexed for MEDLINE]

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

Assessment of iodine deficiency disorders using the 30 cluster approach in


district Kangra, Himachal Pradesh, India.

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

Department of Human Nutrition, All India Institute of Medical Sciences, Ansari


Nagar, New Delhi. ukapil@ernet.medinst.in

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 recent
pilot 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 of
iodised salt. The present study was conducted to assess the prevalence of iodine
deficiency disorders (IDD) and to estimate the iodine content of salt consumed by
the population in district Kangra. The '30 cluster' sampling methodology and
indicators for assessment of IDD, as recommended by the joint WHO/UNICEF/ICCIDD
consultation, 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 into
account 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

20
rate was found to be 12.1 per cent. The median urinary iodine excretion of the
children studied was found to the 15.00 mcg/dl. About 12.7 per cent of families
consumed salt with an iodine content of less than 15 ppm. The results of the
present study indicated that the population of district Kangra is in a transition
phase from iodine deficient to iodine sufficient nutrition and that there is a
need for further strengthening of the system of monitoring the quality of iodised
salt made available to the population to eliminate IDD from the Kangra Valley.

PMID: 11077933 [PubMed - indexed for MEDLINE]

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

Determination of iodine nutrition and community knowledge regarding iodine


deficiency 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. bulliyyag@rediffmail.com

AIM: To determine the status of iodine nutrition and knowledge of iodine


deficiency 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 by
WHO/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) was
assessed.
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. Median
urinary iodine was 38 Cmicro.Tl(-1) and 51.7% of children had urinary iodine
values <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 not
aware of salt iodization.
CONCLUSIONS: Study results show moderate iodine deficiency with poor community
knowledge of iodine nutrition. There is need to strengthen the monitoring of salt
iodization and intensive education activities in the tribal areas.

PMID: 18404976 [PubMed - indexed for MEDLINE]

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

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

Kapil U, Nayar D.

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

21
Iodine deficiency disorders (IDD) is a major public health problem. Surveys
conducted by the National Goitre Survey team of the Directorate General of Health
Services during the past three decades have revealed a high prevalence of endemic
goitre 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 measure
for the prevention of IDD is salt iodisation. The Salt department, Government of
India has taken an intensive programme of production of iodised salt in the
country. The production has increased from 1.5 lakh metric tonnes in 1984 to 40
lakh metric tonnes in 1996. To assess the impact of increased production of
iodised salt on the availability of iodised salt at the beneficiary and trader
level and also on the status of iodine deficiency, surveys were undertaken in
selected districts of 10 states and 2 union territories of the country. These
studies have been presented and discussed here.

PMID: 10389517 [PubMed - indexed for MEDLINE]

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 iodine


deficiency including the implications on reproductive functions and lowering of
IQ levels in school aged children. Today, IDD is a public health problem in 130
countries 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 measure
stressed by the Government of India. The paper describes the major five phases of
the 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 of
activities that significantly attributed to the Universal salt Iodisation (USI)
efforts launched in 1992. The sustainability of the USI programme is critical
since IDD prevalence will rise if programme of salt iodisation weakens. A two
pronged strategy needs to be institutionalized for ensuring continued demand for
iodised salt, linked to ongoing health, nutrition and education programmes as
well as for ensuring supply of quality iodised salt.

PMID: 12173699 [PubMed - indexed for MEDLINE]

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

Persistence of iodine deficiency 25 years after initial correction efforts in the


Khumbu region of Nepal.

Murdoch DR, Harding EG, Dunn JT.

Kunde Hospital, Solukhumbu District, Nepal. murdo005@mc.duke.edu

Comment in:

22
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 after
the introduction of iodised oil injections.
METHODS: Several groups of Khumbu Sherpas were studied and goitre rate, urinary
iodine level and cretinism prevalence were measured as indicators of iodine
deficiency. Subjects were also questioned in detail about their food consumption,
with particular reference to salt use, and about their understanding of the
causes 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 been
born since 1966. The median urine iodine concentration was 35 microg/L. Most
people preferred uniodised Tibetan rock salt, although 44% regularly consumed
iodised salt. All granulated salt tested from the local market contained adequate
amounts of iodine. Only 11% of those surveyed knew that goitre was caused by
iodine deficiency
CONCLUSIONS: Although prevalences of iodine deficiency disorders are much less
than 30 years ago, iodine deficiency continues to be a major problem in Khumbu
and demands a clear control strategy, combining ongoing iodine supplementation
and education. Iodised salt is usually the best approach to control of iodine
deficiency disorders for most regions of the world but the Khumbu experience
shows that local cultural and commercial factors can severely limit its impact.
To be successful, control programme for iodine deficiency disorders also needs
assessment of the salt trade, monitoring, education and occasional targeted
interventions with iodised oil or other supplements.

PMID: 10472889 [PubMed - indexed for MEDLINE]

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

Assessment of iodine deficiency in selected blocks of east and west Champaran


districts of Bihar.

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

Department of Human Nutrition, All India Institute of Medical Sciences, Ansari


Nagar, New Delhi.

OBJECTIVE: A survey conducted in 1964 reported a goitre prevalence of 40.3% in


East 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 than
630 children in the age group of 6-12 years were included in the study and were
clinically examined. Urine samples were collected from 261 children and were
analyzed using standard laboratory procedures. A total of 456 salt samples were
collected from children and 35 from traders from the two districts and analyzed
using 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 were
12.3, 13.4, 23.4 and 51.0, respectively. The median urinary iodine excretion of
the children was 10.0 mcg/dl. None of the families were consuming salt with a nil
iodine content and about 29.3%, were consuming salt with less than 15 ppm of

23
iodine. Of the 35 salt samples collected from traders, all had iodine and about
17% 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 Champaran
districts by Government of Bihar.

PMID: 9715554 [PubMed - indexed for MEDLINE]

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 mondiale


de la santé, CH 1211 Genève 27, Suisse. debenoist@who.ch

Iodine deficiency disorders (IDD) is a major public health problem worldwide. WHO
estimates that 740 million people are currently affected by goitre. The
consequences of iodine deficiency on health are the results of hypothyroidism and
the main one is impaired development of foetal brain. IDD is the first cause of
preventable brain damage in children. The recommended strategy to correct IDD
rests upon salt iodisation. Over the last 20 years, the international community
mobilised to eliminate IDD under the leadership of WHO, Unicef and ICCIDD. It
resulted in remarkable progress in IDD control, especially in Africa and in South
East Asia where the endemic is the most severe. It is estimated that 68% of the
populations of affected countries have currently access to iodised salt. However,
out of the 130 affected countries, about 30 have no programme. Besides, salt
quality control and monitoring of population iodine status are still weak in many
countries, thus exposing the population to an excessive iodine intake and
subsequently to the risk of iodine-induced hyperthyroidism. In addition, IDD is
re-emerging in some countries, especially in Eastern Europe after it had
disappeared. In order to reach the goal of IDD elimination, it is important to
insist on the sustainability of salt iodisation programmes, which implies an
increased commitment of both health authorities and representatives of the salt
industry.

PMID: 11943633 [PubMed - indexed for MEDLINE]

15. Asia Pac J Clin Nutr. 2001;10(1):51-7.

Study of biochemical prevalence indicators for the assessment of iodine


deficiency 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. sheelab@westgate.wh.usyd.edu.au

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 iodine
intake as a result of program evolution in the face of multiple confounding
factors, like malnutrition and goitrogens responsible for goiter. A total of 959
adults (16-85 years) were studied from two districts (Baroda and Dang) and data
was collected on dietary habits, anthropometric and biochemical parameters such
as height, weight, urinary iodine (UI) and blood thyroid stimulating hormone
(TSH). Drinking water and cooking salt were analyzed for iodine content. All
subjects, irrespective of sex and district, showed median UI = 73 microg/L and
mean blood TSH +/- SD = 1.59+/-2.4 mU/L. Seven per cent of the studied population
had blood TSH values > 5 mU/L. Females in Baroda and males from Dang district
were more affected by iodine deficiency as shown by a lower median UI. Mean TSH
was 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 a
significant health problem are not available for target population of adults.
Urinary iodine normative limits and cut-offs are established for school-aged
children. Blood spot TSH upper limit and cut-off values are available for neonate
populations. The IDD has not been eliminated so far, as more than 20% of both
male and female subjects had UI < 50 microg/L. Males were more malnourished than
females in both districts (P < 0.05). Pearl millet from Baroda contained
flavonoids like apigenin, vitexin and glycosyl-vitexin. Dang district water
lacked in iodine content. Iodine deficiency disorder is a public health problem
in Gujarat, with the Baroda district a new pocket of IDD. High amounts of dietary
flavonoids in Baroda and Dang, malnutrition and an additional lack of iodine in
Dang water account for IDD.

PMID: 11708609 [PubMed - indexed for MEDLINE]

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

A study of spectrum of iodine deficiency disorders in rural area of Uttar


Pradesh.

Lal RB, Srivastava VK, Chandra R.

Upgraded Department of social & preventive Medicine, King George's Medical


College, Lucknow.

In the present study, attempt has been made to study the spectrum of the iodine
deficiency disorders (IDD) in a sub Himalayan hyperendemic area. Iodine
deficiency 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 people
worldwide. An estimated 150 million people in India are at risk of IDD. The
authors studied the full spectrum of IDD in the Colonelganj community development
block of Gonda district, an area in which the prevalence of goiter has been
reported to be 60-80%. Findings are based upon interview and clinical examination
findings for 500 subjects contacted in a door-to-door survey. Data were confirmed
with auxiliary nurse midwife and primary health center records. IDD was found to
enhance conditions such as abortion, still birth, infant mortality, neonatal
chemical hyponyroidism, congenital anomalies, retarded growth, hypothyroidism,

25
endemic goiter, and endemic cretinism.

PMID: 9090894 [PubMed - indexed for MEDLINE]

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 Delhi
110029.

Iodine deficiency disorders are an important public health problem in India. It


is wrongly believed that populations residing in coastal areas do not suffer from
iodine deficiency as they consume sea foods which are rich in iodine. A high
prevalence of iodine deficiency has been reported in 11 districts of Kerala
ranging between 9.3 and 44.5%. In spite of the high prevalence of iodine
deficiency, the state government of Kerala has not banned the sale of non-iodised
salt in the state. Thus, the present study was conducted to assess the current
status of iodine nutriture and level of salt iodisation in Kerala state. The
study was conducted in all the 14 districts in the state by utilising the uniform
sampling methodology. A total of 2110 salt samples were collected randomly from
children. 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 consuming
salt with 15ppm and more of iodine. It was found that three districts namely
Kasargod, Idukki and Kottayam had median urinary iodine excretion level < 100.0
microg/l and also more than 20% of the samples had urinary iodine excretion
levels less than 50 microg/l. The findings of the present study revealed
continued iodine deficiency amongst the three districts identified as endemic
earlier. This indicates the need of immediate ban on the sale of non-iodised salt
for the edible purposes and intensive information, education and communication
activities for promotion of consumption of iodised salt.

PMID: 16910320 [PubMed - indexed for MEDLINE]

18. Asia Pac J Clin Nutr. 2008;17(4):620-8.

Iodine deficiency disorders in Bangladesh, 2004-05: ten years of iodized salt


intervention brings remarkable achievement in lowering goitre and iodine
deficiency 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. hkmyusuf2003@yahoo.com

A survey was conducted to monitor the current status of iodine deficiency


disorders in children aged 6-12 years and women aged 15-44 years in Bangladesh as
measured by goitre prevalence and urinary iodine excretion. Conducted between
September 2004 and March 2005, the survey followed a stratified multistage
cluster sampling design to provide nationally representative data, with
self-weighted rural-urban disaggregation. A total of 7233 children and 6408 women

26
were examined for goitre and 4848 urine samples (2447 from children and 2401 from
women) were analyzed for iodine. In addition, 5321 household salt samples were
analyzed 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) was
33.8% in children and 38.6% in women (compared to 71.0% and 70.2%, respectively
in 1993). Iodine nutrition status in urban areas was considerably better than in
rural areas. There was a clear inverse relationship between iodine deficiency and
the coverage of households using adequately iodized salt (> or =15 ppm). The
findings of the survey revealed that Bangladesh has achieved a commendable
progress 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-third
of children and women, which points to the need for all stakeholders to redouble
their efforts in achieving universal salt iodization.

PMID: 19114400 [PubMed - indexed for MEDLINE]

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, India.
gstoteja@yahoo.com

METHODS: A multicentre study to assess iodine deficiency disorders (goitre and


deaf-mutism/cretinism) in 1, 45, 264 children (6 - <12 years old) from 15
districts of ten states was carried out during 1997-2000. Urinary iodine
excretion was also determined in 27481 children, while iodine content was
estimated 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 of
deaf-mutism was 0.27% among children examined from 8 districts. Median urinary
iodine values was marginally less than the WHO cut-off values only in children of
the 3 out of the 15 districts surveyed. Iodine content was found to be adequate
in 55.45% of the salt samples.
CONCLUSION: The results suggested a significant decline in the prevalence of
goitre in most parts of the country.

PMID: 14979381 [PubMed - indexed for MEDLINE]

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.

27
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 continuously
monitored through recommended methods and indicators. The objective of this study
was to assess the prevalence of goitre, status of urinary iodine excretion UIE
level and to estimate iodine content of salts at the household level in Purulia
district, West Bengal. A school-based, cross-sectional study was conducted during
June-September 2005; among 2,400 school children, aged 8-10 years. The "30
cluster" sampling methodology and indicators for assessment of IDD, as
recommended by the joint WHO/UNICEF/ICCIDD consultation, were utilized for the
study. Goitre was assessed by standard palpation technique, urinary iodine
excretion was analyzed by wet digestion method and salt samples were tested by
spot 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 observed
in respect of age. Median urinary iodine excretion level was 9.25 microg/dl and
31.6% children had value less than 5 microg/dl. Only 33.4% of the salt samples
tested had adequate iodine content of > or = 15 ppm, High goitre prevalence
(25.9%) and median urinary iodine (9.25 microg/dl) below normal range indicate
existence of current iodine deficiency in Purulia district. The district is still
in the iodine-deficient state. Moreover, salt iodisation level far below the
recommended goal highlights IDD as major public health problems in the district.
Intensified information, education and communication activities along with
sustained monitoring are urgently required.

PMID: 16533800 [PubMed - indexed for MEDLINE]

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 pathological


conditions including goitre, mental retardation and perinatal mortality in
millions of individuals globally. IDD was initially identified as a problem in
1970 and was confirmed in 1991. In 1993, the Uganda government introduced a
policy of Universal Salt Iodization (USI) requiring all household salt to be
iodized. After 5 years this study evaluates the USI programme.
OBJECTIVES: To determine goitre prevalence rate, establish the proportion of
household consuming iodized salt and determine the levels of iodine intake in the
sample districts.
METHODS: A sample of 2880 school children aged 6-12 years from 72 Primary schools
in 6 districts of Uganda was studied in October 1999. Goitre was established by
palpation, salt iodine was analysed by thiosulphate titration, while urinary
iodine was analyzed using ICCIDD recommended method F in which iodine is detected
colorimetrically at 410 nm.
RESULTS: The over all total goitre rate was 60.2% down from 74.3 in 1991 and
visible goitre was 30% down from 39.2% in 1991. The proportion of households
taking adequately iodized salt was 63.8% and the median urinary iodine was 310
microg/L. Whereas 36% of 95 urine samples analysed in 1991 had urinary iodine

28
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 adequately
iodized salt. If maintained and evenly spread, this will enable Uganda to control
IDD.
CONCLUSION: USI has improved iodine intake in Uganda. However, iodine
malnutrition is still a severe public health problem because some communities in
this study such as in Kisoro still have low iodine consumption, while others such
as Luwero now have iodine excess. The latter is likely to predispose to
hyperthyroidism.
RECOMMENDATION: The national set standard of household salt iodine of 100 ppm be
revised. Locally produced salt be iodized, and a national iodine monitoring
programme be instituted to ensure evenly spread consumption of adequately iodized
salt by all communities in the country.

PMCID: PMC2141571
PMID: 12789104 [PubMed - indexed for MEDLINE]

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

Elimination of iodine deficiency disorders--current status in Purba Medinipur


district 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 deficiency


disorders (IDD), the existing programme needs to be monitored through recommended
methods and indicators. Thus, we conducted the study to assess the current status
of 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 '30
cluster' sampling technique. Indicators recommended by the WHO/UNICEF/ICCIDD were
used. Subjects were clinically examined by standard palpation technique for
goitre, urinary iodine excretion was estimated by wet digestion method and salt
samples 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. Goitre
prevalence did not differ by age but significant difference was observed in
respect of sex. Median urinary iodine excretion level was 11.5 mcg/dL and none
had value less than 5 mcg/dL. Only 50.4% of the salt samples tested were
adequately iodised (> or = 15 ppm).
CONCLUSION: The district is in a phase of transition from iodine deficiency to
iodine sufficiency as evident from the high goitre prevalence (19.7%) and median
urinary iodine excretion (11.5 mcg/dL) within optimum limit. But, salt iodisation
level far below the recommended goal highlights the need for intensified efforts
towards successful transition.

PMID: 19189834 [PubMed - indexed for MEDLINE]

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

29
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, Ansari


Nagar, New Delhi - 110 029, India. kapilumesh@hotmail.com

Iodine deficiency disorders (IDD) is a public health problem in India. A ban on


the sale of uniodised salt for household consumption has been introduced in
Rajasthan State since 1992. The present study was conducted in the district of
Bharatpur, Rajasthan with the objective to assess the prevalence of iodine
disorders in school children as no data is available on this aspect. A total of
3072 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 450
children. 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 subjects
studied. It was found that the percentage of children with urinary iodine
excretion <20.0; 20.0-49.9, 50.0-99.9 and 100 mcg/L and above was 1.1, 1.1, 7.8
and 90.0% respectively. The assessment of iodine content of salt revealed that
56% of the families were consuming iodised salt. The findings of the present
study indicated that the population is in a transition phase from iodine
deficient (as revealed by the TGR) to iodine sufficient (as revealed by the
medium UIE of 200.0 mcg/L) nutriture.

PMID: 12626830 [PubMed - indexed for MEDLINE]

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

Community based intervention of iron deficiency anemia in females and iodine


deficiency 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 pilot
project was conducted in four villages in the Luangprabang Province, Lao PDR. The
objective of the project was to test different regimes to supplement females with
oral iron preparations to reduce iron deficient anemia (IDA) and control iodine
deficiency disorders (IDD) in school children. Compared with iron sulphate
tablets, iron fumerate tablets were well accepted and good compliance results
were achieved. Hemoglobin concentration improved only in the group of females
taking iron fumerate tablets. The goiter rate decreased from approximately 90% to
about 45% for school children, regardless of whether iodine salt were used by
their families or whether iodine capsules were used to treat the children. The
latter attempt was hampered by the fact that also in the control village iodine
fortified salt was used. This was due to a governmental attempt to control IDD
nation-wide. Therefore, also in the control village a significant decrease in the
goiter rate was observed.

PMID: 11488444 [PubMed - indexed for MEDLINE]

30
25. East Mediterr Health J. 2004 Nov;10(6):761-70.

Experiences in the prevention, control and elimination of iodine deficiency


disorders: a regional perspective.

Azizi F, Mehran L.

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


Iran.

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

PMID: 16335762 [PubMed - indexed for MEDLINE]

26. Asia Pac J Clin Nutr. 2002;11(1):33-5.

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


study.

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

Department of Human Nutrition, All India Institute of Medical Sciences, Ansari


Nagar, New Delhi. ukapil@medinst.ernet.in

Iodine is one of the essential micro-elements required for normal human growth
and development. Iodine Deficiency Disorders (IDD) are an important public health
problem in India. There has been no data on the prevalence of IDD from the
Kottayam 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 of
1872 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 the
children. The total goitre prevalence was found to be 7.05% in the subjects
studied. It was found that the percentage of children with urinary iodine
excretions 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 the
iodometric titration method revealed that 60.6% of the children were consuming
salt with an iodine content of 15 p.p.m. and more, which was the stipulated level
of salt iodisation. The findings of the present study indicated that the
population is in a transitional phase from iodine deficient, as revealed by total
goitre rate, to iodine sufficient nutriture, as revealed by the median urinary
iodine excretion level of 17.5 microg/dL.

31
PMID: 11890636 [PubMed - indexed for MEDLINE]

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

Biochemical assessment of iodine deficiency disorders in Baroda and Dang


districts of Gujarat State.

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

Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, NSW 2145,


Australia. sheelab@westgate.wh.usyd.edu.au

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

OBJECTIVE: (i) To assess the severity of Iodine Deficiency Disorders (DD) in


Baroda and Dang Districts of Gujarat, using biochemical prevalence indicators of
IDD; and (ii) To establish a biochemical baseline, in a sub-sample of the large
population 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 on
dietary 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 whole
blood TSH values > 5 mU/1. Females from both districts were affected more by
iodine deficiency as evidenced by lower true urinary iodine and higher mean TSH
levels. The interfering substances were significantly higher in Baroda boys and
Dang girls as compared to their counterparts (< 0.001). Boys were more
malnourished than girls as evidenced by lower BMI. Dang district was more
severely affected by IDD as compared to Baroda. Drinking water in Dang district
was 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 in
these two districts of Gujarat revealed interplay of multiple factors.

PMID: 11255300 [PubMed - indexed for MEDLINE]

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

Toward an ecosocial epidemiological approach to goiter and other iodine


deficiency 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, New
Delhi, India. ritu_priya_jnu@yahoo.com

The program of universal salt iodization (USI) was intensified in the 1990s.
Unfortunately, a recent World Health Organization review finds that there was a
global 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

32
mildly deficient in populations' iodine nutrition, and places 43 countries at
optimal, 24 at high, and 5 at excessive levels of iodine nutrition. Thus, it is
imperative to weigh the benefits and risks of intensifying USI further. The WHO
review places India in the category of "adequate" iodine nutrition, but in 2005
the Government of India promulgated a universal ban on sale of non-iodized salt,
calling iodine deficiency disorders (IDDs) a major public health problem. This
article attempts to understand these contradictions and weigh the benefits and
costs of USI. Based on a review of studies since the 1920s, the authors
reconstruct 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 a
reexamination of the USI strategy and propose a safer, people-centered, ecosocial
epidemiological approach rather than a universal legal ban.

PMID: 19492629 [PubMed - indexed for MEDLINE]

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

Iodine nutritional status & prevalence of goitre in Sundarban delta of South


24-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. amark_chandra@yahoo.co.in

BACKGROUND & OBJECTIVE: In post salt iodization phase endemic goitre and
associated iodine deficiency disorders (IDD) were found prevalent in a randomly
selected 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 for
goitre from 13 different areas in the delta region. Urinary iodine and
thiocyanate levels were measured in 520 (40 from each area) samples collected
randomly to evaluate the iodine nutritional status and consumption pattern of
dietary goitrogen. Simultaneously iodine content was determined in 104 (8 from
each area) drinking water samples and 455 (35 from each area) edible salt samples
collected from the areas.
RESULTS: Children of all the areas were affected by endemic goitre. The
prevalence rates were in the ranges from 25-61 per cent; overall goitre
prevalence was 38.2 per cent (grade 1--34.0%; grade 2--4.2%). Median urinary
iodine level in the studied areas was 225 microg/l (range 115-525 microg/l)
indicating no biochemical iodine deficiency in the region. Mean urinary
thiocyanate levels were in the range from 0.326-1.004 mg/dl. Iodine content in
drinking water samples were in the ranges from 22-119 microg/l, and 55.6 per cent
edible salt samples had iodine level above the recommended 15 ppm at the
consumption point.
INTERPRETATION & CONCLUSION: The severity of endemic goitre was high in the
studied population though the iodine nutritional status was found satisfactory in
the 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 at
household level contained inadequate iodine, however their iodine intake was

33
compensated through iodine in water and food. They also consumed dietary
goitrogen. Environmental factors other than iodine deficiency may have possible
role for the persistence of endemic goitre in the region. More investigations are
thus necessary to arrive at certain definite cause of high goitre rates in this
population.

PMID: 16456256 [PubMed - indexed for MEDLINE]

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

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

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

British Geological Survey, Edinburgh, UK. f.fordyce@bgs.ac.uk

Endemic goitre has been reported in the climatic wet zone of south-west Sri Lanka
for the past 50 years, but rarely occurs in the northern dry zone. Despite
government-sponsored iodised salt programmes, endemic goitre is still prevalent.
In recent years, it has been suggested that Se deficiency may be an important
factor in the onset of goitre and other iodine deficiency disorders (IDD). Prior
to the present study, environmental concentrations of Se in Sri Lanka and the
possible relationships between Se deficiency and endemic goitre had not been
investigated. During the present study, chemical differences in the environment
(measured in soil, rice and drinking water) and the Se-status of the human
population (demonstrated by hair samples from women) were determined for 15
villages. The villages were characterised by low (< 10%), moderate (10-25%) and
high (> 25%) goitre incidence (NIDD, MIDD and HIDD, respectively). Results show
that concentrations of soil total Se and iodine are highest in the HIDD villages,
however, the soil clay and organic matter content appear to inhibit the
bioavailability 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 Sri
Lankan 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. This
study has shown for the first time that significant proportions of the Sri Lankan
female 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 rice
cultivation in Sri Lanka is coincident with the HIDD villages. Varieties of red
rice grown in other countries contain anthocyanins and procyanidins, compounds
which in other foodstuffs are known goitrogens. The potential goitrogenic
properties of red rice in Sri Lanka are presently unknown and require further
investigation. It is likely that the incidence of goitre in Sri Lanka is
multi-factorial, involving trace element deficiencies and other factors such as
poor nutrition and goitrogens in foodstuffs.

PMID: 11194147 [PubMed - indexed for MEDLINE]

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

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

34
Kangra District, India.

Kapil U, Sharma TD, Singh P.

Department of Human Nutrition, All India Institute of Medical Sciences, Ansari


Nagar, New Delhi, India. kapilumesh@hotmail.com

Thirty primary schools were selected in district Kangra utilizing the population
proportionate to size cluster sampling methodology in the year 2004. A total of
6939 children were included in the study. The clinical examination of the thyroid
of each child was conducted. On the spot casual urine sample and salt samples
were collected from a 'sub set of' children included in the study. The Total
goiter rate (TGR) was found to be 19.8%. The median Urinary iodine excretion
level 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 to
achieve the goal of elimination of Iodine deficiency disorders from district
Kangra.

PMID: 17337824 [PubMed - indexed for MEDLINE]

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

Iodine deficiency, other trace elements, and goitrogenic factors in the


etiopathogeny 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) have
their 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 the
iodine deficiency, the frequencies and symptomatologies of cretinism and the
other IDD are influenced by other goitrogenic factors and trace elements.
Thiocyanate overload originating from consumption of poorly detoxified cassava is
such that this goitrogenic factor aggravates a relative or a severe iodine
deficiency. 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 extrathyroidal
mechanism. The former involves oxidative damages mediated by free radicals,
whereas the latter implies an inhibition of the deiodinase responsible for the
utilization of T4 into T3. One concludes that: 1. Goiter has a multifactorial
origin; 2. IDD are an important public health problem; and 3. IDD are a good
model to study the effects of other trace elements whose actions in many human
metabolisms have been somewhat underestimated.

PMID: 1375059 [PubMed - indexed for MEDLINE]

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

35
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, New


Delhi.

The state of Himachal Pradesh is a known iodine deficiency endemic region since
the last 40 years. The state government is supplying iodised salt to the district
since 1970. No recent survey has been conducted on the prevalence of iodine
deficiency from the district Kinnaur which is located at an average altitude of
10,000 feet above sea level. A total of 1094 children in the age group of 6-10
years were included in the study and clinically examined. The total goitre
prevalence of 6.1% was found in the subjects studied. Urine samples were
collected from 226 children and were analysed using standard laboratory
procedures. It was found that the percentage of children with < 2 mcg/dl, 2-4.9
mcg/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. Results
showed that almost 90% of the families were consuming salt with an iodine content
of 15 ppm and more which is the stipulated level of iodisation of salt. The
findings of the study indicate that iodine nutrition is in the transition phase
from 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.

PMID: 10771997 [PubMed - indexed for MEDLINE]

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 of


goiter 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 sampling
methodology and surveillance methods for iodine deficiency as recommended by
WHO/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 no
significant gender variation. Goitre prevalence was significantly higher in
children of 10-12 yr (P=0.012) and scheduled caste and tribe (P=0.003). Median
urinary iodine concentration was 50.0 microg/l with 85.7% of children having
values less than 100 microg/l, indicating as biochemical iodine deficiency.
Median UIC was inversely in association with gradations of goitre. Children of
10-12 yr and scheduled caste/tribe communities had significantly higher median
UIC (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,

36
despite a mandatory salt iodization programme in Orissa that has been in force
since 1989. There is a need to improve the situation through enforcing monitoring
of salt iodization to ensure quality and increasing the level of awareness about
the iodized salt for sustainable prevention and control of iodine deficiency.

PMID: 17978450 [PubMed - indexed for MEDLINE]

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

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


Bangladesh.

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 goitre
and iodized salt among the respondents in a selected goitre endemic area. This
cross-sectional study included 155 respondents of purposively selected endemic
villages of Nilphamary Sadar upazilla. Information was collected from all
households of the villages considering one responsible person from each
household. Data was collected by face to face interview through pre-tested
questionnaire and checklist. Study population was 747. Department of Community
Medicine, National Institute of Preventive & Social Medicine, Mohakhali, March to
June 2001. Out of 155 respondents 63.87% was female and 36.13% were male. Mean
age 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 was
minimum (6.46%). Mean occupation was cultivation, day labour and housewife. Only
11.6% respondents had correct knowledge regarding goitre and 77.30% had knowledge
about iodized salt. But only 58.71% respondents' families are using iodized salt
according to test result by iodized salt testing solution. The prevalence of
goitre among 747 people was found 8.3%, among them 4.53% were male, 12% were
female and 6.96% were grade I and 1.07% were grade II (visible) goitre. The study
result indicate that the prevalence of goitre still high, knowledge regarding
goitre is minimum and use iodized salt is not satisfactory.

PMID: 12148391 [PubMed - indexed for MEDLINE]

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, Sichuan


University, Chengdu, China. txwutx@hotmail.com

BACKGROUND: Iodine deficiency is the main cause for potentially preventable


mental 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 deficiency
disorders.

37
SEARCH STRATEGY: We searched the Cochrane Library, Medline, the Register of
Chinese trials developed by the Chinese Cochrane Centre, and the Chinese Med
Database. 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 February
2001), and searched reference lists, databases of ongoing trials and the
Internet. Date of latest search: November 2001.
SELECTION CRITERIA: We included prospective controlled studies of iodised salt
versus other forms of iodine supplementation or placebo in people living in areas
of iodine deficiency. Studies reported mainly goitre rates and urinary iodine
excretion as outcome measures.
DATA COLLECTION AND ANALYSIS: The initial data selection and quality assessment
of trials was done independently by two reviewers. Subsequently, after the scope
of the review was slightly widened from including only randomised controlled
trials to including non-randomised prospective comparative studies, a third
reviewer repeated the trials selection and quality assessment. As the studies
identified were not sufficiently similar and not of sufficient quality, we did
not do a meta-analysis but summarised the data in a narrative format.
MAIN RESULTS: We found six prospective controlled trials relating to our
question. Four of these were described as randomised controlled trials, one was a
prospective controlled trial that did not specify allocation to comparison
groups, and one was a repeated cross-sectional study comparing different
interventions. 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 people
were included in the cross-sectional study. Three studies were in children only,
two investigated both groups of children and adults and one investigated pregnant
women. There was a tendency towards goitre reduction with iodised salt, although
this was not significant in all studies. There was also an improved iodine status
in most studies (except in small children in one of the studies), although
urinary 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 effective
means of improving iodine status. No conclusions can be made about improvements
in other, more patient-oriented outcomes, such as physical and mental development
in children and mortality. None of the studies specifically investigated
development of iodine-induced hyperthyroidism, which can be easily overlooked if
just assessed on the basis of symptoms. High quality controlled studies
investigating relevant long term outcome measures are needed to address questions
of dosage and best means of iodine supplementation in different population groups
and settings.

PMID: 12137681 [PubMed - indexed for MEDLINE]

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

Dietary supplies of iodine & thiocyanate in the aetiology of endemic goitre in


Imphal East district of Manipur, north east India.

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

Department of Physiology, University of Calcutta, Kolkata, India.


amark_chandra@yahoo.co.in

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

38
iodine nutritional status of school children of Imphal east district in Manipur
where endemic goitre persists during post-salt iodization phase along with the
investigation 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 were
collected and analyzed to measure urinary iodine and thiocyanate levels. Iodine
content was measured in 140 salt samples and 16 drinking water samples.
RESULTS: Overall goitre prevalence was about 30 per cent (grade 1-24.7%; grade
2-5.3%) and median urinary iodine level was 17.25 microg/dl. The mean urinary
thiocyanate 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 iodine
level 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 health
problem in Imphal east district of Manipur. The consumption pattern of certain
plant foods containing thiocyanate (or its precursors) was relatively high that
interfere with thyroid hormone synthesis resulting in the excretion of more
iodine. Thus, the existing dietary supplies of thiocyanate in relation to iodine
may be a possible aetiological factor for the persistence of endemic goitre in
the study region during post salt iodization period.

PMID: 19179679 [PubMed - indexed for MEDLINE]

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

Current global iodine status and progress over the last decade towards the
elimination 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 progress


towards 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 Database
on 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 100
microg/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 of
36.5% (285 million) school-age children were estimated to have an insufficient
iodine intake, ranging from 10.1% in the WHO Region of the Americas to 59.9% in
the European Region. Extrapolating this prevalence to the general population
generated 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 having
the desired impact, to identify at-risk populations and to ensure sustainable
prevention and control of iodine deficiency. Efforts to eliminate iodine

39
deficiency should be maintained and expanded.

PMCID: PMC2626287
PMID: 16175826 [PubMed - indexed for MEDLINE]

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, GA


30329.

Iodine deficiency is the leading cause of preventable intellectual impairment and


is associated with a spectrum of neurologic and developmental pathology. More
than one billion people are at risk. The developing fetus, newborn, and young
child are the most susceptible to the effects of an iodine-deficient diet. If
intervention is not initiated in a timely fashion, the pathophysiologic
abnormalities become resistant to treatment and permanent intellectual,
neurologic, and somatic deficits result. The technology of iodine deficiency
intervention is well established. Iodized salt, the preferred method, is easy to
produce, administer in physiologic doses, and is cost effective. The distribution
of iodized salt and social marketing are key to a successful iodine deficiency
elimination program. In remote regions, iodized oil is a useful interim
intervention. However, it is clear that technology is not enough. Any national
effort to eliminate iodine deficiency must extend far beyond the Ministry of
Health. The program will require the full participation of a range of national
government ministries and agencies and the full support and participation of
local or regional governments.

PMID: 8064406 [PubMed - indexed for MEDLINE]

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 analysis
performed lay on different ages, interventions and controls. Prevalence of goitre
was reduced close to 5% when using distributed iodised salt and market iodised
salt plus iodine oil capsule which showed more effective than using market
iodised salt alone (OR = 0.10, 95% CI: 0.02 - 0.17). The latter's prevalence of

40
goitre was 14.7%. When using market iodised salt, the iodine urea excretion level
showed different results in children group in different countries. Basically, the
market iodised salt for preventing iodine deficiency of pregnancy women were
effective, but a part of them did not achieve to the ideal status of iodine
nutrition.
CONCLUSIONS: The needs to be strictly controlled quality of iodised salt and
market iodised salt plus iodised oil capsule thus can effectively reduce the
prevalence 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 more
evidences.

PMID: 12667361 [PubMed - indexed for MEDLINE]

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

Towards the eradication of iodine-deficiency disorders in Brazil through a salt


iodination programme.

Medeiros-Neto GA.

Iodine-deficiency disorders have been a serious public health problem in Brazil


because of the failure of a salt iodination programme established in 1953. The
reasons for this failure were logistical, e.g., potassium iodide was not supplied
to all salt-producers, iodination of salt was largely erratic, and part of the
population at risk used only non-refined salt, which was not iodinated. In 1978 a
task force was therefore formed to implement measures to eliminate
iodine-deficiency disorders from the country. For this purpose, potassium iodate
was distributed, free-of-charge, to all salt mills and an iodate dosing spray was
supplied without cost to small salt producers. Also, regional laboratories for
determining iodine in salt were set up, inspectors made regular visits to the
salt mills, and samples of salt from commerce and from the producers were
analysed. More than 90% of the samples contained 10-30 mg iodine per kg. In three
typical 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 per
g creatinine. In conclusion, the salt iodination programme was a complete success
and could serve as a model for other countries with a high prevalence of
iodine-deficiency disorders.

PMCID: PMC2491181
PMID: 3264765 [PubMed - indexed for MEDLINE]

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 of


Bihar.

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

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

41
followed a policy of universal salt iodization (USI) since 1976 under which the
state's population receives edible salt with a minimum of 15 ppm iodine. Salt
samples were collected from 1052 families through schools in 5 districts of
western Bihar and analyzed using the standard iodometric titration method to
assess the iodine content of salt being consumed. While all samples contained
some degree of iodine, 28.5% contained less than the recommended 15 ppm. These
results suggest that the government of Bihar has given only low priority to the
NIDDCP program and to monitoring the quality of salt through the Prevention of
Food Adulteration (PFA) system. However, the iodine content was satisfactory
compared to other states largely because all salt was procured only via railway
rakes from production centers in Gujarat and Rajasthan.

PMID: 12348464 [PubMed - indexed for MEDLINE]

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 Sechenov


Moscow Medical Academy undertook, 1999-2000, a study of the standard of
knowledge, attitude and conduct of consumers in respect to the use of iodinated
salt (IS) in the prevention of iodine-deficient diseases (IDD). It was
demonstrated that, on the average per one district, 19% of city respondents and
13% of rural respondents used IS only. About 31% of city respondents used IS when
it was available at the next-door shop, i.e. from time to time. This figure
reached 48% in Irkutsk and Orenburg Regions. The share of those who used IS
sometimes in rural regions made an average of 20.7%. 67.2% of those who believe
that IDD can be prevented think that ID can also be prevented. Less than 5% of
them say ID cannot be regarded as a reliable tool in the prevention of IDD.

PMID: 15828388 [PubMed - indexed for MEDLINE]

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. sidibeeh@refer.sn

Thyroid gland diseases vary according to the environment. In sub-Saharan Africa,


they are also influenced by population isolation and the absence of food
self-sufficiency, both factors affecting the onset and persistence of
iodine-deficiency goiters. More cosmopolitan diseases are now added to these
thyroid disorders. Women are mainly affected (94.2%), most often with euthyroid
goiters (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

42
nuclear medicine facilities, the delay in diagnosis that results in compressive
or 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 can
also be pregnancy-related. Very recent surveys show a prevalence of endemic
goiters 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 or
cretinism) in Plateau State, Nigeria, 55.2% at Zitenga, Burkina Faso (210 persons
0-45 years), and 10% in Hararé and Wedza, Zimbabwe (newborn TSH >10.1
microIU/mL). The prevalence of goiters is 43.6% in children emigrating from
Ethiopia to Israel. Millet from semi-arid zones contains apigenin at a
concentration of 150 mg/kg and luteolin at 350 mg/kg, both of which can interfere
with thyroid function. The harmful effects of cassava (also known as manioc) are
better known: milling cassava reduces its goitrogenic potential. In addition to
iodine deficiency, selenium deficiency, and the effect of the thiocyanates in
cassava, ion concentrations in soil and drinking water appear to play a role. The
proportion of thyroid surgery indicated for hyperthyroidism has tripled, now
accounting for 18.5% of all such operations. This disorder is found today in
subjects older than 50 years, mainly from rural areas, and caused most often by
Graves disease (25 of 51 cases). Graves disease in young women can cause serious
problems during pregnancy; in such cases assessment of the minimal effective dose
of antithyroid agents is essential. Carbimazole leads to remission in 61% of
cases of Graves disease. Hypothyroidism can be auto-immune and often in patent
forms because of insufficient screening in Africa: 24 cases in Dakar (1984) and
37 others noticed by us (1998). Single-nodule tumors were assessed in 89 patients
in Khartoum: they were found to be simple goiters in 72% of cases, follicular
adenoma in 13.5%, cancer in 13.5% (with 6 of the 12 cases follicular, 5
papillary, 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 forms
were 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-Saharan
Africa have been noticed. Iodine deficiency is suggested to play a role because
follicular cancer in southern Africa accounts for up to 55% of thyroid cancers.
Thyroid cancers in Algeria are associated with low socioeconomic status and
characterized by a high prevalence of cancers discovered at an advanced stage and
of anaplastic carcinomas. Oral potassium iodate is recommended: 30 mg of iodate a
month 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 new
infrastructure). In conclusion, thyroid disease is due predominantly to iodine
deficiency and goitrogenic products, but we also note the increasing emergence of
hyperthyroidism, 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 third
millennium.

PMID: 17897900 [PubMed - indexed for MEDLINE]

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

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


treatment.

43
Eastman CJ, Phillips DI.

Disorders caused by iodine deficiency continue to be a major health problem in


many underdeveloped areas of the world. The most significant is the impaired
mental and physical development which occurs as a result of iodine deprivation
early in life. Individuals in affected communities show a spectrum of
abnormalities which can be attributed to two interacting pathological processes.
Fetal hypothyroidism in the first and early second trimester predominantly
affects the developing nervous system causing deaf-mutism and mental retardation.
If hypothyroidism occurs in the early postnatal period the main abnormalities are
growth stunting and related somatic abnormalities. Subclinical deficits of
intellectual and motor development may also be found in apparently normal
individuals living in affected areas. Although dietary iodine deficiency is
clearly 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. Iodine
supplementation programmes form the basis of the public health strategy in
combatting these disorders. Where the iodization of foodstuffs is not feasible,
an alternative is the use of iodine containing oil which can be given orally or
intramuscularly to provide a long-lasting supply of iodine.

PMID: 3066326 [PubMed - indexed for MEDLINE]

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

Goiter and other iodine deficiency disorders: A systematic review of


epidemiological 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. atuljyoti2710@hotmail.com

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 iodine


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

44
universal solution, which apart from being less effective may be harmful in the
long run.

PMID: 17174717 [PubMed - indexed for MEDLINE]

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 the
virtual elimination of iodine deficiency disorders (IDD) by the year 2000. In
1990 at the World Summit for Children, Heads of State and Government had agreed
on 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 United
Nations 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 actions
ongoing in a number of countries. While in principle all components such as
communications, information management and laboratory support should integrate
and complement with ongoing efforts for general nutritional improvement, national
IDD programmes also have specific needs which require separate arrangements.
Sources of support and information, available from the international public
nutrition community are indicated. The global conquest of IDD provides an example
for other effective public nutrition practices from the important lessons that
are being learned. Particularly, the role of the private food sector as full
partner in national programmes is relevant to ongoing and future attempts to
reduce and eliminate other major global malnutrition problems.

PMID: 9598785 [PubMed - indexed for MEDLINE]

45

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