Iodine deficiency, insufficiency, and public health
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Northwestern University Feinberg School of Medicine
Global Iodine DeficiencyEndocrine–Health and SocietyDaniel Toft, MD
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Iodine Deficiency
Iodine function: component of thyroid hormones (T3 and T4) which regulate a variety of processes, including:
•Metabolic rate•Heart rate•Temperature•Mental function
Signs and symptoms of iodine deficiency:
• In adults/children: hypothyroidism and goiter (thyroid gland hyperplasia due to elevated TSH levels)
•Congenital hypothyroidism (in fetuses of affected mothers): intellectual impairment, short stature, speech and hearing loss
Beth Doerfler, RD
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Iodine Deficiency
Food sources: depends on the iodine content of the soil on which food was raised; good natural sources are seafood and seaweed, and in the U.S., iodized salt, processed foods and dairy products are iodine-rich
Risk factors for deficiency: iodine-poor soil (mountainous areas like Switzerland and the Andes, China), excessive consumption of foods containing goitrogens (which impair iodine absorption), such as cassava (as in Zaire, the Congo)
Beth Doerfler, RD
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In 2014 iodine deficiency remains a major worldwide public health problem
A. Strongly Agree
B. Agree
C. Somewhat Agree
D. Neutral
E. Somewhat Disagree
F. Disagree
G. Strongly Disagree
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Iodine deficiency is an important health issue for my patients
A. Strongly Agree
B. Agree
C. Somewhat Agree
D. Neutral
E. Somewhat Disagree
F. Disagree
G. Strongly Disagree
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Iodine deficiency may impact my health
A. Strongly Agree
B. Agree
C. Somewhat Agree
D. Neutral
E. Somewhat Disagree
F. Disagree
G. Strongly Disagree
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Goiter
Beth Doerfler, RD
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Himalayas
Goiter
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Congenital Hypothyroidism
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Congenital Hypothyroidism
Beth Doerfler, RD
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Congenital Hypothyroidism
Bolivia TanzaniaPakistan
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0 1 2 3 4 5 6 7 8 Birth
Face
Eye
Corpus callosum
Subarachnoid pathways
Cerebral cortex
cochlea
Cerebellum
Dentate of hippocampus
Myelination
from motherfrom child
T4
The Developing Brain Needs T4
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Chicago is in the “Goiter Belt”
Defects Found in Drafted Men (Love 1920)
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A brief history of goiter• 1813 Iodine isolated from seaweed
• Theodor Kocher (1841-1917), who performed over 5000 thyroidectomies for goiter, recognized post-op myxedema in his patients
• 1873 children in Albi, France treated with 7.5 mg of iodine daily for 75 days with clinical improvement in goiter
• 1893 Thyroid extracts found to be useful in treating myxedema
• 1890s Baumann and Roos isolated “thyroiodine” from the thyroid finding it contained 10% iodine
• Osler writes in the 1900s that the cause of goiter and the function of the thyroid are still unknown
J. Nutr. 135: 675–680, 2005
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• 1905 David Marine receives his MD from Johns Hopkins
• 1907 publishes on the iodine content of goitrous dogs vs normal animals finding lower iodine content in goiters
• He began treating patients in his clinic with iodine and noted improvement in goiter
• Cleveland school board rejects his request to begin treating children – “You’ll poison our children”
• 1916 with the help of Kimball Akron, OH agrees to a trial of iodine supplementation to its schoolchildren
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Marine And Kimball’s Seminal Work In Akron, OH
J. Nutr. 135: 675–680, 2005
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“This section of the country…is known for the great number of goiter cases, and a large percentage of the children in the schools have enlarged thyroids.”
“Iodine is gone from the land here and therefore from the water.”
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“In Akron, O., some very fine results have been obtained by giving [iodine] to school children. It was given over a period of ten years and the results watched.
One half of the 10,000 children were given it twice a year. Among those to whom it was administered who were in a normal condition, not one developed goiter.”
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The Problems:
There is widespread dietary iodine deficiency •One-half to two-thirds of the world population at risk
In affected populations, goiter and cretinism in a few coexist with cognitive deficits in all
•In populations where >5% of school children have goiter,
the cognitive performance among apparently healthy
individuals is shifted downward by 10 - 15 IQ points
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The Solution:
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The Solution: Universal Salt Iodization
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Key Components of IDD Elimination
Salt Iodization
StrategyOversight
Advocacy & Evaluation &
Social Mobilization Surveillance
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Advocacy & Social Mobilization
• Accepting the magnitude of the problem
• Overcoming some resistance to universal salt iodization
• Establishing the safety of potassium iodate
• Setting adequate and safe salt iodine levels
• Salt is not an unhealthy product
• Iodization is enrichment of a commonly eaten food
• Support large companies also, not only the cottage industry
• Focus first on areas where success is attainable, not the poorest and most remote
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Strategy Oversight: The Iodine NetworkA global coalition of public, private, international and civic organizationsis championing the sustained elimination of IDD through USI. Currentmembers of the network are:
• China National Salt Industry Corporation
• EU Salt
• Emory University
• Global Alliance for Improved Nutrition (GAIN)
• International Council for Control of Iodine Deficiency Disorders (ICCIDD)
• Kiwanis International
• Salt Commissioner to the Government of India
• Micronutrient Initiative
• Salt Institute
• Tata Chemicals
• US Centers for Disease Control
• UNICEF
• World Health Organization
• World Food Programme
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Unicef data
Advocacy & Social Mobilization
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In the US, is iodization of salt legally mandated?
A. Of course
B. Of course not
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Number Of People And Percent Of Region
At Risk Of Iodine Deficiency (TGR > 5%) And Affected By Goiter In 1993
WHO Region Population At Risk Population Affected by Goiter
Millions % of Region Millions % of Region
AfricaAmericas
E. MediterraneanEurope
Southeast AsiaW. Pacific
181168173141486423
32.823.142.616.735.927.2
86639397176141
15.68.722.911.4139.0
Total 1,572 28.9 655 12
Global prevalence of iodine deficiency disorders (1993)WHO Micronutrient deficiency information system (MDIS) working paper no. 1
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“It can do no harm as I see it and its use may do much good.”
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Deaths from exophthalmic goiter, 1920-1930
The Economic Effects of Micronutrient Deficiencies:The case of iodine.” by Dimitra Politi, Ph.D., Brown University, 2010.
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FIGURE2 A comparison of the number of operations for toxicgoiter carried out at Henry Ford Hospital in Detroit in the years beforeand after the introduction of iodized salt in Michigan in 1924 (-E-); alsothe number of cases presenting with thyrotoxicosis at LauncestonGeneral Hospital before and after the iodization of bread in Tasmaniabegan in 1966 (-F -). The year of introduction is in each case classedas “1”.
J. Nutr. 135: 675–680, 2005
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Salt IodizationRussia•Began iodization efforts in 1950s and achieved success•Dissolution of USSR: fragmentation and collapse of iodization program •Small progress recently but household consumption still very low
China•Premier committed to goal of IDD elimination 1991•High level advocacy meeting 1993 launched USI program•Over 90% coverage within a decade
India• Rapid progress 1986-2000 once iodization open to the private sector
• Lifting of ban on sale of non iodized salt in 2000 led to significant drop in production of iodized salt – subsequently recouped when ban was reinstituted
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Lessons Learned: Education & Social Mobilization
• As visible forms of iodine deficiency (goiter/cretinism) regress the focus is on less visible impacts especially brain damage. Ongoing communication efforts are essential.
• Tailor messages to different audiences with specific calls to action
• Understand common wisdoms & correct misinformation and educate public
• Integrating updated IDD info into technical & education materials of food inspection, health, and education curriculums
• Public education serves to solidify support for IDD elimination and create a demand for iodized salt
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Evaluation & Surveillance
• WHOI 2007 Resolution: Efforts to eliminate IDD require continuous monitoring and oversight and require Member States to establish mechanisms for monitoring iodine nutrition and reporting on their progress.
• UIE trends in school-aged children to be complemented with iodine status of pregnant and lactating women.
• Monitoring of iodine status should not only check for deficiency but also highlight excess.
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Source:de Benoist B et al. Iodine deficiency in 2007: Global progress since 1993.Food and Nutrition Bulletin, vol 29, no. 3, 195-202, September 2008.
Category of public health significance (based on median urinary iodine)
Moderate iodine deficiency (20-49 µg/l)
Mild iodine deficiency (50-99 µg/L)
Optimal (100-199 µg/l)
Risk of iodine induced hyperthyroidism (200-299 µg/l)
Risk of adverse health consequences (>300 µg/l)
No data
Degree of public health significance of iodine nutrition based on median urinary iodine: 1993-2006
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoeveron the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2009. All rights reserved
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Overview of Global Progress• Globally, 70% of households are consuming adequately
iodized salt.
• 34 countries have achieved USI and another 28 are close to the goal.
• 84 million infants are protected annually from the risk of IDD.
• More than 120 countries are implementing USI programs.
• The number of countries where IDD remains a problem has dropped to 47.
UNICEF, May 2008
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Which best describes your eating habits?
A. I rarely eat a home cooked meal
B. I can cook but generally eat out
C. I cook most of my meals
D. I cook and prefer kosher or sea salt
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Emerging Issues: Processed Foods
• Given expanded consumption of process foods, programs relying upon fortification of table salt alone may not be adequate.
• Food processors reluctant to use iodized salt – unfounded concerns about effects on organoleptic properties of foods
• Iodine intake may also be reducing due to other changes e.g. decreased use of iodophors in the dairy industry
• Trade harmonization to mandate use of iodized salt in processed foods to address inter-country variations in micronutrient recommendations may offer a solution.
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Emerging Issues: I Insufficiency
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Effect of inadequate iodine status in UK pregnant women on cognitive outcomes in their children
• Urinary iodine levels on 1040 first trimester singleton pregnancies were measured
• 646 (!) were iodine insufficient (urinary iodine less than 150 µg/g creatinine)
• The IQ at 8 years and reading ability at 9 years of the children were analyzed for an association with maternal iodine sufficiency
Lancet 2013; 382: 331–37
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Effect of inadequate iodine status in UK pregnant women on cognitive outcomes in their children
After adjustment for confounders, children of women with an iodine-to-creatinine ratio of less than 150 μg/g were more likely to have scores in the lowest quartile for
verbal IQ (odds ratio 1·58, 95% CI 1·09–2·30; p=0·02)
reading accuracy (1·69, 1·15–2·49; p=0·007)
reading comprehension (1·54, 1·06–2·23; p=0·02)
Lancet 2013; 382: 331–37
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Why are UK women iodine deficient?
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US Women are Iodine Insufficient
Thyroid. 2013 Aug;23(8):927-37
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More Salt May not be the Answer
n % Urinary I p
Salt consumption n % Urinary I p
White Never or rare 142 27 110 .07
Not often 188 27 144
Often 183 36 148
Black Never or rare 77 24 117 .2
Not often 97 30 132
Often 136 46 116
Hispanic Never or rare 78 17 154 .2
Not often 128 27 542
Often 255 56 165
Thyroid. 2013 Aug;23(8):927-37
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Neither is Seafood
n % Urinary I p
Fish/shellfish consumption
n % Urinary I p
White Yes 353 71 144 0.6
No 159 29 134
Black Yes 244 82 119 0.5
No 66 18 123
Hispanic Yes 339 73 166 0.03
No 128 27 146
Thyroid. 2013 Aug;23(8):927-37
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Dairy consumption matters
Thyroid. 2013 Aug;23(8):927-37
Dairy consumption n % Urinary I p
White Never or rare 149 27 111 0.0001
Not often 167 31 133
Often 216 42 189
Black Never or rare 126 40 111 0.0009
Not often 89 28 109
Often 101 32 151
Hispanic Never or rare 153 31 134 <0.0001
Not often 133 27 163
Often 210 42 185
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Group A: ID areas, no iodine intervention
Group B: ID areas, uncontrolled iodized salt
Group C: ID areas, iodine supplements @ pregnancy or birth
Ming Qian et al, Asia-Pacific J Clin Nutr 2005
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Areas of Controversy
Should iodine be a required component of prenatal vitamins?
Should iodine and thyroid hormone testing be standard preconception/during pregnancy?
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What percentage of the 200+ prenatal vitamins in the US contain iodine?
A. 0 %
B. 20 %
C. 50 %
D. 80 %
E. 100
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Conclusions
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Conclusions• Iodine Deficiency Disorders are widespread in the world
affecting millions of people with a range of physical and mental abnormalities.
• Universal Salt Iodization (USI) of all human and animal salt is the global strategy for elimination of severe iodine deficiency.
• While tremendous progress has been made to make salt iodization universal, 2 billion people are still at risk in the world
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Conclusions• Government Commitment is key for USI
• IDD knowledge needs to be embedded into health sector infrastructure
• Continued advocacy efforts are needed particularly in Europe
• Expand iodization to include salt used in processed foods
• RDA is 150 µg/day for adults; 250 µg/day for pregnant and nursing mothers
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In 2013 iodine deficiency remains a major worldwide public health problem
A. Strongly Agree
B. Agree
C. Somewhat Agree
D. Neutral
E. Somewhat Disagree
F. Disagree
G. Strongly Disagree
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Iodine deficiency is an important health issue for my patients
A. Strongly Agree
B. Agree
C. Somewhat Agree
D. Neutral
E. Somewhat Disagree
F. Disagree
G. Strongly Disagree
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Iodine deficiency may impact my health
A. Strongly Agree
B. Agree
C. Somewhat Agree
D. Neutral
E. Somewhat Disagree
F. Disagree
G. Strongly Disagree