University of Nigeria Research Publications

NWAMARAH, Joy Ugo A

utho

r

PG/Ph.D/02/33558

Title

Iodine Status, Growth and Parasitic infestation of

Primary School Children in Obukpa, a Rural Nigerian Community

Facu

lty

Agricultural Sciences

Dep

artm

ent

Home Science, Nutrition and Dietetics

Dat

e

May, 2006

Sign

atur

e

IODINE STATUS, GROWTH AND PARASITIC INFESTATION OF PRIMARY SCHOOL CHILDREN IN OBUKPA, A RURAL NIGERIAN COMMUNITY

A Thesis

Submitted in Partial Fulfilment of the Requirements For the Award of Doctor of Philosophy Degree in

Human Nutrition

Nwamarah, Joy Ugo PGlPh.Dl02133558

DEPARTMENT OF HOME SCIENCE, NUTRITION AND DIETETICS

UNIVERSITY OF,. NIGERIA, NSUKKA

10th MAY, 2006.

Nwamarah Joy Ugo (MRS), a post graduate student of the Department of Home Science, Nutrition and Dietetics, Registration Number: PGIPh.Dl02133558, has satisfactorily completed the requirements for research work for the degree of Doctor of Philosophy in Human Nutrition. The work embodied in this thesis is original and has not been submitted in part or full for any other Diploma or Degree of this or any other University.

------------ Prof. (MRS.) E. Chinwe Okeke

( ~ u ~ e ~ v i s o r ) (Head of Department)

Prof. M, A . Akpapurrarrs External Examiner

DEDICATION

This thesis is dedicated to my husband, Goodluck Mbamaonyeukwu

Nwamarah and children, Obinna, Chichi and Nenyes.

ACKNOWLEDGEMENT

I am excited and most grateful to the Almighty God, who is Omni-Scientific, my heavenly

Father who made it all possible. He was so gracious to me, and was generous to me

with strength, health and grace throughout the duration of this work.

I wish to express my profound gratitude to my supervisor, Professor (Mrs.)

E.Chinwe Okeke, for her advice, suggestions, frequent prompting and quest for

excellence that helped me to complete this thesis. The advice and concern of Prof. (Mrs) H.

N. Ene-Obong and my other lecturers and colleagues in the Department of Home Science,

Nutrition and Dietetics contributed to the outcome of the quality of the work.

My gratitude also goes to the.headmasters and mistress of Ajuona, Owerre-

Obukpa and Umuorua/Amagu community primary schools, respectively for their

assistance and co-operations. I am most grateful to them for all the sacrifices they made

to make the data collection less stressful and laborious. The cooperation of parents and

all the pupils that took part in the study is highly appreciated.

Again my gratitude goes to Dozie (Lopez) and Nenye Nwamarah, Chukwudi and

Emezie Onuigbo, Onyekachi Uwaomah and Nkechi Nwafor who assisted with data

collection, Safety and Hezekiah laboratories who used their labs for the biochemical

analysis.

I am highly indebted to Dr Agomuo Emmanuel (Associate Dean of Student

affairs) and Mr Ugbor Kalu (Dept of .Economics) for their assistance with statistical . , 4 1 . ' .'> '

analysis. Nenye Nwamarah (Final yr Pharmacy student) and Chichi Nwamarah (Medical

student) who word processed the work.

The last but not the least I appreciate the moral and financial support from my

husband, Nwamarah G.M. (Director MIS Ucit).

The awesome God in His mercies and love bless you and reward you according

to His Word.

TABLE OF CONTENT

PAGES

TITLE PAGE ... ... ... ... ... ... ... ... ... ... ... ... ... .. . CERTIFICATION.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEDICATION.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENT.. . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . .

TABLE OF CONTENTS ... ... .. . ... ... ... ... ... ... ... ... LIST OF TABLES.. . . . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . LIST OF FIGURES ... ... ... . . . ... ... ... .. . ... .. . ... .. . ABSTRACT. . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i

II

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xiv

xvii

xvi i i

CHAPTER ONE: INTRODUCTION

1 .I Background Information . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . 1

1.2 Statement of the Problem and Justification ... ... ... ... ... ... ... 5

1.3 Objectives of the Study ... ... ... ... ... ... ... ... .. . ... ... .. 6

1.4 Hypotheses.. . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . 6

1.5 Significance of the Study.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8

CHAPTER TWO: LITERATURE REVIEW

2.1 Iodine an Essential Nutrient.. . .. . .. . .. . ... .. . . . . .. . .. . .. . .. 9

2.1 .I Absorption, Bioavailability, ,Tr&nsp,~fl and Storage of Iodine.. . .. 9

2.1.2 Iodine.. . .. . .. . . . . .. . .. . .. . .. . ... .. . .. . .. . .. . .. . .. . .. . 10

2.1.3 Properties of Iodine., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.1.3.1 Occurrence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 , I . . 2.1.4 Compounds.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.1.5 Production.. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .. . . . . 2.1.6 Uses.. . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. . . . . . . . . . . . . 2.1.7 Functions of Iodine.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.1.8 Inter Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Parasites.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intestinal Helminthes

Prevalence among Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lntestinal Parasitic Infestation and Growth and Nutritional Status ..

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Morbidity and Mortality

. . . . . . . . . . . . . . . . . . . . . . Share of Children who are Underweight

. . . . . . . . . . . . . . . . . . Toxic Substances and Anti-nutritional Factor

Cassava Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathophysiology of Cyanide Intoxication

. . . . . . . . . . . . . . . . . . . . . Goitrogens and Antithyroid Compounds

. . . . . . . . . . . . . . . . . . . . . . . . . . . Sulphur-containing Compounds

. . . . . . Selenium-deficiency-related Thyroid Dyshormonogenesis

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Iodine Deficiency

Prevention of Iodine Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Iodine Value or Iodine Number

. . . . . . . . . . . . . . . . . . . . . . . . Diagnosis and Treatment of Goitre

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Causes and Types of Goitre

Micronutrient Malnutrition: a Global Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vulnerable Groups Affected

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reasons for Iodine Deficiency

Health Consequences of Iodine Deficiency . . . . . . . . . . . . . . . . . . Solution to Iodine Deficiency Disorder . . . . . . . . . . . . . . . . . . . . . . . .

....... wr. ....... ?>

2.1 1.1 Choice of Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 1 .I. 1 Nutrition Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.1.2 Dietary Diversification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.1.3 Dietary Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . 2.1 1.1.4 Food Fortification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 2 Hidden Hunger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.13 Selecting the Right Vehicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.13.1 Feasibility of Triple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.14 Food Fortification Gains Support in Africa . . . . . . . . . . . . . . . . . . . . . 2.15 Priority for Child Nutrition Needed . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.16 Correcting Iodine Deficiency

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.17 Monitoring and Evaluation

2.18.1 Assessing Iodine Deficiency Disorders for Public Health

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Programmes

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.18.2 Estimation of Thyroid Size

2.18.3 Estimation of the Consistency of the Thyroid by Palpation ... 2.18.4 Definition of Endemic Goitre as a Public Health Problem . . . . .

. . . . . . . . . . . . . . . . . . 2.18.5 Urine Iodine Excretion Determination

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.19 Sub Clinical IDD

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.19.1 Three Grades of Severity

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.19.2 Iodine in Drinking Water

2.20 Prevention and Eradication of IDD require Continual Vigilance ... . . . . . . . . . . . . . . . 2.20.1 Countries who Successfully Eliminated Iodine

2.21 Adverse Effects Associated with High Nutritional lntakes of

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Iodine

. . . . . . . . . . . . . . . . . . . . . . . . . . . 2.22 Physiological Need for Iodine

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.22.1 Usual Salt Intakes

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.22.2 Other Sources of Iodine

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.22.3 Iodine Availability

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.22.4 Iodine Requirements

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.22.5 Required Iodine Levels in Salt

. . . . . . . . . . . . . . . . . . . . . . . . . . 2.22.6 Quality of Available Salt:::' '':.'.''::.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.22.7 Trace Elements

. . . . . . . . . . . . . . . . . . . . . . . . 2.23 Biological Roles of Trace Elements

CHAPTER THREE: MATERIALS AND METHODS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Study Area

3.1 . 1 Study Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.2 Approach to the Local Community . . . . . . . . . . . . . . . . . . . . . . . . 3.1.3 Design and Sampling Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.3.1 Sample Size Calculation . . . . . . . . . . . . . . . . . . . . . . . .

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3.1.3.2 Sampling Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Training of Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Data Collection Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Basic Data by Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anthropometric Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Height

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Weight

Growth Monitoring and Velocity Measurement . . . . . . . . . . . .

Urine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Urinary Iodine Excretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parasitic Load

Stool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6.1.1 Qualitative Direct Wet Smear Technique . . . . . . . . . . . . . . . . .

3.8 Salt Monitoring (spot-test kit) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.9 Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.9.1 Questionnaire

3.9.1 . 1 Data on Anthropometric Assessment Analyzed Under

Stunting. Wasting and Underweight . . . . . . . . . . . . . . . . . . . . . . . . . . 66

3.9.2 Worm Load Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

CHAPTER FOUR: RESULTS ' " '"" "'

. . . . . . . . . . . . . . . . . . General Characteristics of the Subjects 68

Socio-demographic Characteristics of the Household

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of the Subjects 70 .. Socio-economic Characteristics . . . . . . . . . . . . . . . . . . . . . . . 72

Contribution for the Upkeep of Household . . . . . . . . . . . . . . . . 74

Health Facilities and Health Practices . . . . . . . . . . . . . . . . . . . . . . 77

Morbidity and Health History of Children . . . . . . . . . . . . . . . . . . 79

. . . . . . . . . Symptoms Associated with Iodine Deficiency Disease 81

Household Food Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Respondents' Knowledge of lodized Salt and Iodine Deficiency

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disorders (IDD) 83

The Result of the Mean Ratings (x) and Standard Deviation of

the Attitude of the Women to Iodized Salt and Iodine Deficiency.. . 85

Results of the Respondents' Practices with Iodized Salt and

Iodine Deficiency Disorders (IDD). . . . . . . . . . . . . . . . . . . . . . . . 87

Anthropometric Measurements . . . . . . . . . . . . . . . . . . . . . . . . . 89

Percentage Distribution of the Nutritional Status of the Children

According to their Weight-for-age, Height-for-age and

Weigh t-for-height.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Nutritional Status Classification According to Gender.. . . . . . . . . . . 89

Nutritional Status Classification According to Age-group.. . . . . . . . 89

Mean Weight Velocities for Boys According to School Attended

and in the Different Seasons,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Mean Height Velocities for Boys According to School Attended

and in the Different Seasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Mean Weight Velocities for Girls According to School Attended

and in the Different Seasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Mean Height Velocities for Girls According to School Attended

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and in the Different Seasons 95

Result of T-test Comparing the Weight and Height Velocities of

. the Boys and the Girlsaga Resirlt of the Seasonal Variations.. 99

Comparing Mean Weight, Height Velocities in the Wet and Dry

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Seasons of Boys, Girls and Both 102

Mean W.eight and Height Velocities According to Age Group I! . .

in Different Quarters.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Mean Weight-for-age and Height-for-age During the Four

Seasons Pooled together for Boys and Girls Compared to

NCHS-WHO 5oth Percentile.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Results for Parasitic Infestation of the Children in the Studied

Communities.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Determination of the Existence of any Difference in the Worm

. . . . . . . . . . . . . . . . . . . . . . . . . . . lnfestation of the Boys and Girls

Determination of the Existence of any Differences in the

Hookworm lnfestation of the Pupils According to the Schools

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attended..

Result for Iodine Status of the Children in the Studied

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communities

Determination of the Existence of any Difference in the Mean

. . . . . . . . . . . . . of Urine Iodine Level of the Boys and Girls..

Determination of the Existence of any Differences in the Urinary

Iodine Levels of the Pupils According to the Schools Attended

Correlation Coefficient (r) Values Expressing the Relationship

Between the Urinary Iodine ~ e v e l and Underweight, Stunting

and Wasting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results of Relationship Between the Worm Infestation,

Underweight, Stunting and Wasting.. . . . . . . . . . . . . . . . . . . . . Percentage Frequency of Urinary Iodine Level of the Underweight

and the Normal in Weight-for-age of the Children.. . . Percentage Frequency of Urinary Iodine Level of the Stunted and

the Normal in Height-for-age of the Children.. . . . . . . . . . . . . . Practical Determination of the Iodine Levels of the Salt Used

. * , . I

in the Home and ~a rke t . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER FIVE: DISCUSSION

. . . . . . . . . . . . . . . . . . . . . . 5.1 The Iodine Status of the Children..

... 5.2 The Iodine Levels of the Salt Used in the Homes and Market

5.3 Knowledge, Attitude and Practice (KAP) of Mothers on Iodized

Salt and Iodine Deficiency Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 Parasitic lnfestation

5.5 The Anthropometric Status of the Children: Underweight,

Stunting and Wasting.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Seasonal Variations in Growth Velocity of the Children.. . . . . . . . 128

The Relationship Between Parasitic Infestation and

(i) Underweight (ii) Stunting and (iii) Wasting . . . . . . . . . 131

CONCLUSION.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

RECOMMENDATIONS ... . . .,. . . . . . .. . . .. . . . . . . . . . . . . . . . . . . .. 134

REFERENCES.. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

APPENDICES ... ... ... ... ... ... ... ... ... .... .... ... .... .... 147

Appendix 1 - Table 4.17 Nutritional Status according to

Age-group for fig 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Appendix II - Table 4.18 for fig. 1 to fig. 3 Nutritional Status

Classification according to Age-group.. . . . . . . . . . . . . . . . . . . . . . . 148

Appendix I11 - Table 4.1 9 for fig. 4: Mean Weight Velocities (kg) for

Boys according to Schools Attended and in the Different Seasons.. 149

Appendix Ill- Table 4.20 for fig. 5: Mean Height Velocities (cm) for

Boys according to Schools Attended and in the Different Seasons. 149

Appendix IV - Table 4.21 for fig. 6: Mean Weight Velocities (kg) for

Girls according to Schools Attended and in the Different Seasons.. 150

Appendix IV - Table 4.22 for fig. 7: Mean Height Velocities (cm) for

Girls according to schools attended and in the different seasons.. . 150

Appendix V - Table for fig. 8: Weight Velocities for Boys and Girls 151

Appendix V - Table for 'fi&gi'~eight Velocities for Boys and Girls.. . 151

Appendix VI - Table for figures 10 and 11: Comparing Weight, Height

Velocities In the Wet and Dry Seasons of the Boys, Girls and Both .. 152

Appendix VI - Table for fig 12: Mean. Weight Velocities according to I I

Age-groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 152

Appendix VII - Table for fig 13: Mean Height Velocities according to

Age-groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I53

Appendix VII - Table for fig 14: Mean Weight-for-age (kg) during

The Four Seasons Pooled together for Boys and

Girls (6-1 2yrs 10mths) Compared to NCHS-WHO 1976.. . . . . . . . .. . ..I53

Appendix Vlll - Table for fig. 15: Mean Height-for-age (cm) during the

Four Seasons Pooled together for Boys and

Girls (6-1 2yrs 1 Omths) compared to NCHS-WHO 1976 . . . . . . . . . . . . 154

Appendix IX- Fig. 16: Percentage Hookworm Load Infestation of

Pupils according to Schools Attended.. . . . . . . . . . . . . . . . . . . . . . . . . ... 155

Appendix IX- Fig. 17: Percentage Urinary Iodine Level according to

Sex.. . . . . . .. . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. . 155

Appendix X- Fig. 18: Percentage Urinary Iodine for the Underweight

and the Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I56

Appendix XI - Table 4.39: Comparing Urinary Iodine Level of the

Normal in Height-for-age with the Stunted Children . ... ... ... ... 157

Appendix XI1 -Table 4.40: Iodine Levels of the Salt Samples

from the Homes of the Pupils in the Three Communities . . . . . . . . . I58

Appendix XI1 - Table 4.41 : Iodine Levels of Marketed and Home

Salt Samples ... ... ... .. . .. . ... ... . . . . . . . . . . . . . . . .. . . . I58

Appendix Xlll -The Questionnaire Used in Collecting Basic Data .. 159

Appendix XIV - Goitre Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Appendix XV Height Measurement at Owerre-Obukpa CPS . . . .. . . 172

Appendix XVI Weight Measurement at Ajuona CPS . . . . . .. . . .. . . . 173

. . . X l l l

LIST OF TABLES

Table

Share of Children who are Underweight

Epidemiological Criteria for Assessing Iodine

Nutrition based on Medium Urinary Iodine Concentration

in School-age Children

ICCID-UNICEF-WHO Recommended Levels of Iodine in Salt.

Examples of Desirable Average Levels at Various Points in

the Salt Distribution Chain, Depending on Climate, Salt Intake and Conditions Affecting Packaging and Distribution 5 1

Iodine Trace Elements for Human Nutrition 5 6

Background of the Subjects 67

Socio-demographic Characteristics of Respondents'

Household (parents) 69

Educational Attainment and Occupation of Respondents

Household Heads 7 1

Source of Income, Amount and Expenditure on Food in the

Household 73

Health Facilities and Health Practices in the Three Communities 75

Goitre History 76

Morbidity and History of Children 78

Possible symptoms of Iodine Deficiency as Reported by Mothers 80

Source of Food and Meal Pattern of Respondents 80

Knowledge of lodized Salt and Iodine Deficiency Diseases (IDD) ,, r n 1 7. *

by Respondents 82

Lack of Knowledge of lodized Salt and IDD by Different

Communities Used in the Study 8 2

The Mean Ratings (x) of the Attitude of the Women to lodized

Salt and Iodine Deficiency - 84 Practices Based on Knowledge on lodized Salt and Iodine

Deficiency Disorders by Mothers 86

Comparing the Practices Based on Knowledge on lodized Salt and

Iodine Deficiency Disorders by Mothers of the Three Communities 86 Anthropometric Measurements of Children in the Study 88

Nutritional Status Classification According to Gender 88

Mean Weight and Height Velocities of Children According

Page

2 1

to Season 96

4.24 Result of T-test Comparing the Weight Velocities of the Boys and

Girls during the Seasons 96

4.25 Result of T-test Comparing the Height Velocities of the Boys

and Girls during the Seasons 97

4.26 A Comparison of the Mean Weight and Height Velocities during the

Wet and Dry Seasons 101

4.27 Mean Weight and Height Velocjties of Children According

to Age-group

Percentage Distribution of Intestinal Parasitic lnfestation

of Children

Percentage Distribution of the Intestinal Parasitic lnfestation of

Children According to Sex

Hookworm lnfestation According to School Attended

Result of T-test Comparing the Effect of Parasitic lnfestation

of Boys and Girls

Iodine Status of the Children

Iodine Status of the Children According to Sex

Mean ( S D ) Urinary Iodine Level of Pupils According to Schools

Mean Urinary Iodine Levels According to Sex

Differences in Urinary Iodine Level of the Pupils in the

Different Schools

Correlation Coefficient (r) Values Expressing the Relationship

Between the Iodine Level in the Urine, Worm lnfestation and

Mal-nutritional Status:-{(i) Underweight, (ii) Stunting

and (iii) Wasting}

Comparing Urinary Iodine Level of the Underweight, with the

Normal Weight-for-age Children

, I

LIST OF FIGURES

Figure

Fig 1 Weight-for-height of Children According to Age-groups

Fig 2 Weight-for-age of Children According to Age-groups

Fig 3 Height-for-age of Children According to Age-groups

Fig 4 Seasonal Weight Changes in Boys According to School Attended

Fig 5 Seasonal Height Changes in Boys According to School Attended

Fig 6 Seasonal Weight Changes in Girls According to School Attended

Fig 7 Seasonal Height Change in Girls According to School Attended

Fig 8 Mean Weight Velocities of Boys and Girls According to Season

Fig 9 Mean Height Velocities of Boys and Girls According to Season

Fig10 Weight Velocities of Boys, Girls and Both Combined

in Wet and Dry Seasons

Fig 11 Height Velocities of Boys, Girls and Both Combined

in Wet and Dry Seasons

Fig 12 Mean Weight Velocities by Age-groups in Different Seasons

Fig 13 Mean Height Velocities by Age-groups in Different Seasons

Home Salt Samples

Page

90

90

9 1

92

92

96

96

98

98

ABSTRACT

Recently, iodine deficiency has been recognized as the leading worldwide cause

of preventable intellectual impairment, spontaneous abortions, stillbirth, impaired

fetal development and childhood growth defects. Eliminating iodine deficiency

disorder (IDD) is a global public health priority. Sub-clinical iodine deficiency can

be detected by measuring urinary iodine or assessing thyroid function. Iodine is

an element that directly affects thyroid gland secretions, which themselves to a

great extent control heart action, nerve response to stimuli, rate of body growth

and metabolism. Intestinal disorders, parasitic infestation and nutrient

interactions can impair iodine absorption and utilization. This study was designed

to access the iodine status, growth and the parasitic infestation of primary school

children. The study also tried to ascertain knowledge, attitude and practice (KAP)

of mothers on iodine deficiency disorder and iodized salt utilization, thereby

determining their effect on iodine status growth velocities of the children.

Sampling of the three schools (Ajuona CPS, Owerre-Obukpa CPS and

AmagulUmuorua CPS) was by random sampling using balloting from five

schools in the community, while the children were selected by stratified method

using the class register in each school. Questionnaires were used to elicit basic

information from the children's parents on social and demographic characteristics

of households, health facilities and practices, health records, morbidity, health

status, knowledge, attitude and practice (KAP) of mothers on iodized salts and . ,. , . m , ... ,

iodine deficiency disorder (IDD). The anthropometric measurements of 272

children composing of 154 boys and 146 girls aged 6-12years were taken to

assess their nutritional status using standard procedures. A sub-sample of 33

children was monitored for 12 months to assess their growth velocities; 11

children from each school were randomly selected. Their stools were collected

for assessing the parasitic load, and urine for biochemical analysis of urine iodine

levels. Salt from their homes were tested for iodine content with iodine spot-test

kit. Means, standard deviation, Student t-test, analysis of variance and

correlation coefficient were used where applicable. Anthropometric

measurements of the children revealed that 25% were stunted, 13% were

underweight while 6.3% were wasted. More girls (3.0%) than boys (2.3%) were

wasted. The weight velocities of the children were higher in the dry season

(0.57kg) than in the wet season (0.29kg). Also their height velocities were higher

in the dry season (1.98cm) than in wet season (0.62cm). There were significant

differences in the mean weight velocities of the children in wet and dry seasons

(t= 3.674, P<0.05). There were differences but not significant (t=0.712, P>0.05)

in the mean weight velocities of the boys (0.30kg) and girls (0.26kg), as well as in

the height velocities (t= 1.03, P>0.05) of the boys (0.95cm) and girls (1.00cm).

The weight velocities for boys according to schools attended showed differences

(Ajuona CPS, 0.36kg; Amagu/Umuorua CPS, 0.32kg; and Owerre-Obukpa CPS,

0.30kg; but were not significant, f=3.85, P>0.05) and for height (Ajuona CPS,

0.61cm; AmaguIUmuorua CPS, 1.61cm; and Owerre-Obukpa CPS, 0.65cm; but

were not significant, f=3.89, P>0.05). There were differences in the weight

velocities for girls (Ajuona CPS, 0.46kg; AmaguIUmurua CPS, 0.29kg and

Owerre-Obukpa CPS, 0.23kg; but they were not significant, f=3.77, P>0.05), and

height (Ajuona CPS, 1.14cm; AmaguIUmurua CPS, 1.41 cm and Owerre-Obukpa

CPS, 0.76cm; but were not significant, f=3.95, P>0.05). More than fifty percent

(58.33%) of the children were severely iodine deficient, boys (33.33%) and girls

(25%). The urinary iodine level ranged from about (10 to 650pgIL). The intestinal

parasitic loads were generally low. There were no significant relationships

between worm infestations of children in the various schools and their urine

iodine levels. Wasting in- ~h'ildien'~was positively correlated with the worm

infestation and this was significant (r=0.467, P<0.01). There were positive

relationships between urinary iodine level and stunting (r=0.314, P>0.05) and

underweight (r=0.240, P>0.05) in the children, but were not significant. Low

urinary iodine excretion was more in the stunted children (60.0%) than in the

normal children (21.2%). Most of the salts consumed in the homes were

adequate in iodine. About 91% of marketed salt and 97% of salt brought from

homes were iodized above 3oppm' iodine level. However, there was generally

poor knowledge about iodized salt and iodine deficiency disorders by the

mothers.

CHAPTER ONE

INTRODUCTION

1 . I BACKGROUND INFORMATION

Iodine deficiency is a condition in which an organism does not take or utilize

enough iodine. Iodine is an element that directly affects thyroid gland secretions,

which themselves to a great extent control heart action, nerve response to

stimuli, rate of body growth, and metabolism (Sofra et a/., 1998). Kennedy et a/.

(2003) defined iodine as an essential mineral required by the body to synthesize

thyroid hormones, the most important of which is thyroxine, a metabolism-

regulating substance.

Iodine deficiency has traditionally been associated with goiter and

cretinism. More recently, iodine deficiency has been recognized as the leading

worldwide cause of preventable intellectual impairment (United Nations, 1993;

Kennedy et a/., 2003). lntellectual and neurologic deficits occur because of a lack

of thyroid hormone during critical phases of brain development. Clinical iodine

deficiency, therefore, is detected by the presence of goiter (swelling of the

thyroid gland) (Kennedy et a/., 2003). . ,. . .I. ..' J

Elimination of iodine deficiency disorder (IDD) is a global publ~c health

priority (Maberly et a/., 1994; Ramalingaswami, 1992; WHO, 1991). In 1990,

seventy-one Heads of State and senior policy-makers from eighty other

countries attended "The World 'Sumriiit for Children" and endorsed "The World

Declaration and 1990-2000 plan of Action on the Survival, Protection and

Development of Children" (UNICEF, 1990). This "plan of Action" included the

virtual elimination of iodine deficiency. Universal access to iodized salt was

recommended as long-term intervention strategy to eliminate IDD, and many

countries set this as a 1995 goal (UNICEF-WHO, 1994).

CHAPTER ONE

INTRODUCTION

1 .I BACKGROUND INFORMATION

Iodine deficiency is a condition in which an organism does not take or utilize

enough iodine Iodine is an element that directly affects thyroid gland secretions.

which themselves to a great extent control heart action, nerve response to

stimuli, rate of body growth, and metabolism (Sofra et a/., 1998). Kennedy et a/.

(2003) defined iodine as an essential mineral required by the body to synthesize

thyroid hormones, the most important of which is thyroxine, a metabolism-

regulating substance.

Iodine deficiency has traditionally been associated with goiter and

cretinism. More recently, iodine deficiency has been recognized as the leading

worldwide cause of preventable intellectual impairment (United Nations, 1993;

Kennedy et a/., 2003). Intellectual and neurologic deficits occur because of a lack

of thyroid hormone during critical phases of brain development. Clinical iodine

deficiency, therefore, is detected by the presence of goiter (swelling of the

thyroid gland) (Kennedy eta/., 2003). ., ,, . ml. 5 : . ,

Elimination of iodine deficiency disorder (IDD) is a global publrc health

priority (Maberly et a/., 1994; Ramalingaswami, 1992; WHO, 1991). In 1990,

seventy-one Heads of State and senior policy-makers from eighty other

countries attended "The World 'Surnriiit for Children" and endorsed "The World

Declaration and 1990-2000 plan of Action on the Survival, Protection and

Development of Children" (UNICEF, 1990). This "plan of Action" included the

virtual elimination of iodine deficiency. Universal access to iodized salt was

recommended as long-term intervention strategy to eliminate IDD, and many

countries set this as a 1995 goal (UNICEF-WHO, 1994).

2

WHO (2001) reported the latest estimates of the global prevalence of

goiter. It indicated that 741million people or 13 percent of the world's population

are affected by goiter (FAO, 2003). Kennedy et a/. (2003) noted that the true

prevalence of iodine deficiency is even more widespread than the numbers of

those affected with goiter would seem to indicate. However, there are no global

estimates for prevalence of low urinary iodine, which is the best sub-clinical

indicator. Sub-clinical iodine deficiency is detected by measuring urinary iodine

or assessing thyroid function (Kennedy et a/., 2003).

Egbuta (2003) showed, that the median urinary iodine excretion for the

sampled population in Nigeria, drawn mostly from IDD-endemic areas, was

14.65ugdl-I. The mean value was 13.39pgdl-I. He reported that Nigeria has

achieved the goal of universal salt iodization and should now focus its attention

on constant monitoring to sustain this iodization level.

The IDD study carried out by Okeke et al. (1997) in Enugu State revealed

that most traders and consumers (94%) had increased knowledge of iodized salt

programme in Nigeria. Fifty-eight percent of families in Nsukka used salts

containing 50ppm of iodine, 33% used salt between 7 and 50ppm iodine and 9%

used non-iodized salts. Most consumers bought salt according to brand name

and cost, even though some salis.d,id.:not contain iodine.

Okeke et a/. (1997) noted that about 23% traders had little knowledge of

iodized salt, and careless handling occured during transportation, storage and

sale of salts.. Okeke et a/. (1997) saw the need for closer monitoring, increased ,, . ..

consumer awareness, systematic evaluation of procurement, marketing,

distribution, consumption, and follow-up of the effects on IDD.

NutriView (1997) reported that intestinal disorders, parasitic infestation

and nutrient interactions can impair iodine absorption and utilization. Furnee et

a/. (1997) in their study with school children reported that intestinal parasitic

3

infestations reduce the efficiency of oral supplementation with iodized ethyl

esters by interfering with absorption.

A common misconception is that IDD primarily affects only remote rural

populations. This belief may have developed because goiter, the most common

visible evidence of iodine deficiency, is usually most prevalent in rural

populations. United Nations (1993) stressed the interactions of low content of

iodine in the local environment with poverty and remoteness. This is as a result

of little contribution of food from outside an iodine-deficient area to the diet; as is

the case with much subsistence agriculture. Poverty, with poor sanitation and

general malnutrition, may worsen the effect of iodine deficiency. Goiter may be

the most common visible evidence of IDD, it is just the 'tip of the iceberg' of the

consequences of IDD, which include lower intelligence quotient (IQ), increased

fetal, infant and child mortality, poorer growth and birth defects (Boyages et a/.,

1989; Hetzel, 1994).

One of the most devastating consequences of iodine deficiency is

reduced mental capacity. Fifty million people worldwide are mentally

handicapped as a result of iodine deficiency (WHO, 2002). International council

for the control of iodine deficiency disorders (ICCIDD, 2002) has estimated that

100,000 children are bohl' edch ybar with irreversible brain damage because

their mothers lacked iodine prior to pregnancy. Maternal iodine deficiencies can

also lead to spontaneous abortions, stillbirth and impaired fetal development. In

infancy and childhood, deficiency is manifested by poor mental development and

growth defects. Persons living in communities with endemic iodine deficiency

may show an intelligence quotient 13.5 points lower than persons from similar

communities with adequate iodine supplies (WHO, 2001).

Growth is the increase in body size and anthropometric measurements of

growth are good indicators of nutritional status of children. With adequate

nutrition and under normal circumstances, a child would grow to its full genetic

potentials. Such conditions are more likely in developed countries. The thyroid

hormones have extensive effects throughout the body. They influence metabolic

rate, protein synthesis, enzyme function, cellular transport, and other

physiological processes. They have specific effects on growth in children: low

levels retard growth, causing stunting and poor development (United Nations,

I 993).

In many developing countries however, children hardly grow to their full

potential as a result of many environmental factors such as malnutrition and

infections (Asworth and Millard, 1986; Scrimahaw et a/., 1968). Children from

poor or less privileged families in those countries are the most affected due to

food insecurity, inadequate facilities, infection and poor general environmental

sanitations. The lack of adequate toilet facilities, water supply, unsanitary

environment, for example, predispose infestation leads to or increases intensity

of malnutrition (UNINigeria Working paper, 1992). Growth faltering is the result of

many factors including inadequate diets, worm infestation, infections and

unsanitary environment. NutriView (1 997) pointed out that poor food hygiene,

inadequate methods of preparation, cooking and storage can reduce the

nutritional content of fdod"~"'cohsiderab1y. Intestinal disorders, parasitic

infestations and nutrient interactions can impair micronutrient absorption and

utilization.

Most of the iodine status ,,monitbring and parasitic studies done are

outside Nigeria. Thus, there is the inadequate documentation on the iodine

status, growth velocity and intestinal parasitic load of the Nigerian school age

children. This group of children is also susceptible to iodine deficiency disorder

and parasitic infection.

5

This study was aimed at assessing the iodine status, growth velocity of

the school children in a rural community and some factors that may influence it.

Such factors may include intestinal parasitic infection, poor knowledge of iodized

salt and iodine deficiency disorders.

1.2 Statement of the problem and justification

There is inadequate documentation on the iodine status and growth pattern of

Nigerian school children. Most lacking is the information on the relationship

between growth, intestinal parasite infection and iodine status. Though not the

most vulnerable, these children are susceptible to iodine deficiency disorder and

infestation, which may result in growth faltering, poor performance at school and

problem in later life. One of the main causes of iodine deficiency disorder in this

group of children is dietary insufficiency and worm infestation (NutriView, 1997).

Adequate and current information on the growth, prevalence and intensity of

parasitic infestation and IDD status of Nigerian school children are necessary for

effective intervention.

Indeed in rural communities it is a common practice for pupils to gather

infected fruits and eat on their way to school. In general, most eat snacks with

soiled hands after work.andlp'tay, 'as there are little or no facilities for washing

hands at school. The lack of adequate toilet facilities and their unhygienic

condition, inadequate water supply (quality and quantity) and poor environmental

sanitation predisposes these child,ren to:intestinal infection (UN-FGN, 1992).

The extent of iodine deficiency in school children is not fully documented.

In Nsukka (a semi urban-town) and the neighbouring villages, not all families

have knowledge of the all celebrated iodized salt. There is also insufficient water

supply (Onofiok, 1998) as such, personal hygiene is poor, coupled with

unsanitary environment.

1.3 Objectives of the study

The general objective of this study was to assess the iodine status, growth and

the parasitic infestation of primary school children in rural Nigerian community

(Obukpa).

The specific objectives were as follows: to

monitor anthropometric status of the children;

determine the variations in growth velocity of the children in different

seasons of the year using established methods;

assess intestinal parasitic load of the children;

determine the iodine status of the children;

ascertain knowledge, attitude and practice (KAP) of mothers, on iodine

deficiency disorder and iodized salt utilization;

determine the iodine levels of the salt used in the homes and sold in the

market.

Hypotheses

The following null hypotheses were tested:

Hol: There is no significant difference (p>0.05) in the effect of seasonal , ,' . * I . "' z

variations on the weight velocities of boys and girls.

Ho2: There is no significant difference (p>0.05) in the effect of seasonal

variations on the height velocities of boys and girls. , I

Ho3: There is no significant difference (p>0.05) in the effect of seasonal

variations on the weight velocities of the pupils according to school

attended.

7

Ho4: There is no significant difference (p>0.05) in the effect of seasonal

variations on the height velocities of the pupils according to school

attended.

Ho5: There is no relationship between the salt iodine level marketed and the

ones brought by the pupils from their homes.

Ho6: There is no relationship between the iodine level in the urine of the

children and

(i) Underweight

(ii) Stunting

(iii) Wasting

Ho7: There is no relationship between the level of worm infestation and

Underweight

(i) Stunting

(ii) Wasting .

Ho8: There is no significant difference (p>0.05) in the effect of urinary excretion

of iodine level on the children with stunted growth and normal growth

children.

Hog: There is no signifiCant4~ifferdhce (p>0.05) in the iodine level of the boys

and the girls.

HolO: There is no significant difference (p>0.05) in the worm load of the boys I f . ..

and the girls.

Ho l I : There is no significant 'difference (p>0.05) of iodine levels of the pupils

according to the school attended.

Ho12: There is no significant difference (p>0.05) in the worm load of the pupils

according to the school attended.

8

1.5 Significance of the study

This study will be useful to the Nigerian Government, National Agency for Food

and Drug Administration and Control (NAFDAC) and UNICEF who are currently

interested in the assessment of the prevalence of micronutrient deficiency and

control in Nigeria (FMHHS, 1992). It will identify some primary school children

who are at high risk of iodine deficiency and parasitic infestation as target for

necessary interventions. Anthropometric measurements are useful indicators in

food and nutrition policy and planning (Nnanyelugo, 1982a.b.c) and their wider

application in clinical and field surveys have been underscored (Nnanyelugo and

Ngwu, 1985). This present study added to the body of information on school

health for long term planning and periodic evaluation of health, educational and

agricultural services and action. The data will be of value to health workers,

groups and organizations concerned with the welfare of children, especially in

the rural areas.

CHAPTER TWO

LITERATURE REVIEW

2.1 Iodine an Essential Nutrient

Iodine is recognized as an essential nutrient for all animal species, including

man. The human body contains about 25 mg of iodine, 10mg of which is in the

thyroid gland. It is an integral component of the thyroid hormones, thyroxine and

triiodothyronine, both of which have important metabolic roles (Price, 1997).

2.1 . I Absorption, bioavailability, transport and storage of iodine

Iodine in foods is primarily in the inorganic iodide (I-) form, which is readily

absorbed from the stomach and upper small intestine. Other forms of iodine in

foods are reduced to iodide before or after absorption. One exception is iodine

in the form of erythrosine (tetraiodofluorescien), a red food dye which is 58%

iodine ("I,). The iodine from erythrosine is only about 2-5% bioavailable.

Absorbed iodine is rapidly cleared from the plasma by the thyroid gland, the

kidney, salivary glands, gastric mucosa cells, and the lactating mammary glands.

Urinary iodine is one means .of assessing iodine status because iodine intake in

excess of requirement is excreted primarily by this route (Pennington, 1993).

Thyrotrophic stimulating hormone (TSH), from the anterior lobe of the

pituitary gland, stimulates the active transport of inorganic iodide from the blood I

I I

into the thyroid gland. Within the thyroid cells, iodide is oxidized to iodine and

combined with tyrosine to form the thyroid hormones. These actions are also

stimulated by TSH. Thyroid hormones are stored in the thyroid gland bound to

thyroglobulin, a glycoprotein. The total amount of iodine in the body is about 10-

50 mg for an adult, and most of this is concentrated in the thyroid gland as

thyroglobulin. Proteolytic enzymes release the thyroid hormones from

thyroglobulin so that the hormones may diffuse into the blood. In the blood,

thyroxine (T4) is found primarily bound to globulin and albumin. The secretion of

thyroid hormones into the blood is regulated by TSH through a biofeedback

system. When dietary iodine is adequate, thyroid hormone is produced in

normal amounts at a low level of TSH; if dietary iodine is limited, TSH secretion

is increased to promote iodine uptake by the thyroid. The thyroid gland stores

enough thyroid hormone to last several months in the event that dietary iodine is

not available (Pennington.,l993).

2.1.2 Iodine

Iodine is a member of a family of non-metal chemical elements called the

halogens. As a solid, iodine is a gray-black crystal with a shiny metallic

appearance. But even at ordinary room temperatures, iodine can change from

solid directly into a purple vapour with a strong irritating odour. The process of

changing from a solid into a gas without first becoming a liquid is called

sublimation (Price, 1997 and Fischer, 1993).

Iodine is very active chemically. It combines easily with other substances

by gaining or losing electrons to form chemical compounds. In fact, iodine is . ,, . * I . r.' .

never found alone in nature. It is always combined with other elements.

A major source of iodine is Chile saltpeter, a mineral that is found in great

quantities in Chile. It was during the processing of saltpeter that the French

manufacturer Bernard Courtois fd'und' i'odine in 181 1. The salty water found

underground near petroleum deposits, called oil-well brine, is another source of

iodine.

Humans need iodine in order to stay healthy. Most people get enough

iodine from the food and water in their diet. Table salt with iodine added can be

used in regions where the food and water do not contain enough iodine, such as

the Alps of South Central Europe and the Great lakes area of the United States

(Price, 1997).

Light sensitive iodine compounds are used in making photographic film.

Other iodine compounds are used in making bread. For a long time, tincture of

iodine - iodine dissolved in alcohol - was used as a disinfectant (germ killer) on

cuts and scratches. Now other forms of iodine less irritating to the skin and

tissues are used as first-aid antiseptics.

Compounds of iodine are also used to treat cancer and other diseases of

the thyroid gland, to locate a variety of tumours, and to trace chemical

substances as they travel through the body.

2.1.3 Properties of iodine

Chemical symbol I

Atomic number 53

Atomic Weight 126,904

Melting point 11 3.5OC (236.3OF)

Boiling point 1 84.35OC (363.83OF)

(The New Encyclopaedia Britannica, 2003) . ,, . n l . 5.' ,

The stable isotope '*'I is the only atomic species in nature, but numerous

radioactive isotopes ranging from l o 9 1 to 14' I have been prepared artificially. The

l3'l, with a'half life of 8 days,. is wildely used as a radioactive tracer. Iodine has

seven electrons in its outermost shell. Its principal oxidation states are + I , +3,

+5 and +7 (The New Encyclopaedia Britannica, 2003; Price, 1997 and Fischer,

1993).

Iodine is only slightly soluble in water, but it does dissolve in organic

solvents such as benzene, carbon disulfide, carbon tetrachloride, chloroform,

and ethyl alcohol. Some iodine solutions are violet and others are brown.

Although iodine is very active chemically, it is generally less active than the other

members of the halogen family - fluoride, chloride and bromine.

2.1.3.1 Occurrence: Iodine is a relatively rare element in that it makes up only a

very small percentage of the earth's crust. Its concentration is low, however the

distribution of the element is widespread. It is found in rocks, soils, underground

brines, minerals and seawater. The concentration of iodine in seawater is low

(about 0.05ppm). Some seaweed, particularly the brown varieties, can extract

and accumulate the element from the sea. Seaweed, laminaria, contains up to

0.45% iodine (dry weight) (Price, 1997 and Fischer, 1993).

2.1.4 Compounds: Iodine forms compounds with all other elements except the

inert gases, sulfur and selenium; however, it does not react directly with carbon,

nitrogen or oxygen and but reacts only at high temperature with platinum. The

most common and important inorganic iodine compound is hydrogen iodide (HI)

a colourless gas that fumes strongly in air. Hydrogen iodide dissolves readily in

water to form hydrodic acid. Potassium iodide (KI) is used in preparing iodides

of other metal. It is also used as the carrier for radioactive iodine, l3'l, when this , . . w , . , * ' . a '

isotope is employed in medicme. Silver iodide (Agl) is a light yellow salt that is

insoluble in water.

Iodine forms several compounds with other halogens, such as iodine i

monochloride (ICI), iodine pentafluoride -(IF,), Iodine heptaflouride (IF5), Iodine

trichloride (IC13) and iodine monobromide (IBr). With Oxygen, iodine forms

several oxides such as lo3, I4O9 and I2O3. Iodine pentaoxide (I2O5) is the most

important and stable of the halogen oxides. It is available commercially and

dissolves in water to form iodic acid (H103). lodic acid and iodates (salts of iodic

acid) are powerful oxidizing agents (Sofra et a/., 1998).

13

The organic compounds containing iodine have a higher density, lower

vapour pressure, greater reactivity and lower stability than the chloro or bromo

analogs, methyl iodide (CH31) is an effective methylating agent and is also used

as a fumigant. Methylene iodide (CH2I2) is utilized in organic synthesis, and

because of its high density, it is also used in separating heavy minerals from light

materials, such as silicates. lodoform (CHI3) is a greenish yellow, crystalline

solid that has been used as a disinfectant. However, recently other germicides

have largely displaced it. Ethyl iodide (CH3CH21) is utilized commercially in the

production of pharmaceuticals and as an intermediate for the preparation of

organic chemicals. lodobenzene (C6H51) is a pale yellow liquid useful in the

synthesis of compounds containing positive iodine.

2.1.5 Production: The first commercial source of iodine was from the ashes of

seaweed. In Japan seaweed still serves as a major source of the element.

However, in the 1840s iodine was discovered in the nitrate deposits in Chile,

mainly in the form of the mineral lautarite (anhydrous Calcium iodate). The

deposits once constituted the world's most important source of iodine.

In the 1920s and 1930s iodides were discovered in the oil well brines in

Louisiana and California and Iaer'in the brine wells of Michigan (USA). Several

processes for the isolation of iodine from brines are currently employed. One

process precipitates the iodine as silver iodide by treatment of the brine with

silver nitrate. The silver iodide is then' converted to ferrous iodide and metallic

silver by subsequent treatment with iron. Iodine is then liberated from the

ferrous iodide by treatment with chlorine (Sofra eta/., 1998).

Iodine is isolated from the Chilean nitrate deposits by extraction, as

sodium iodate, from nitrate-bearing earths called caliche. Treatment of the

sodium iodate with excess sodium bisulfite solution converts the iodate to iodide.

Further treatment of the iodide solution with fresh iodate solution liberates the

free iodine, which is filtered, dried and sublimed in concrete-lined iron retorts.

2.1.6 Uses: The most important uses of iodine are in metabolism and in

medicine as an antiseptic. In metabolism, iodine is necessary for the normal

functioning of the thyroid gland. The element is an important part of the thyroid

hormone thyroxin (Cl5Hl1I4NO4). An iodine deficiency results in a condition

known as endemic goiter. The radioisotope (I3'l) is used in the diagnosis and

treatment of goiter. A solution of Potassium iodide and iodine in alcohol called

tincture of iodine is a widely used and effective topical antiseptic (The New

Encyclopedia Britannica, 1993).

Iodine is utilized in several dyes, the most important being erythrosine,

which serves as an orthochromatic sensitizer for photographic, emulsions and as

a food colouring. Silver iodide is used in photography in negative emulsion and

as a smoke for the seeding of clouds to induce rainfall.

One of the factors affecting the output of thyroid hormones by the thyroid

gland is iodine availability. In the absence of sufficient iodine, the gland attempts

to compensate for the deficiency by increasing its secretory activity and this . ,, . * T . ? ' .'

cause the gland to enlarge. This condition is known as simple or endemic goiter,

(The New Encyclopedia Britannica, 2003). Besides iodine deficiency, certain

environmental agents, both naturally occurring and man-made interfere with

thyroid function. They may cause 'goiter and thyroid dysfunction by acting

directly on the thyroid gland or indirectly by altering its regulatory mechanisms

and thyroid hormone homeostasis. They are thus called goitrogens, or

antithyroid compounds (Vanderpas, 1993).

15

2.1.7 Functions of iodine

The sole function of iodine is for making the iodine-containing hormones

secreted by the thyroid gland, which regulate the rate of oxidation within the

cells. In so doing influence physical and mental growth, the functioning of the

nervous and muscle tissues, circulatory activity, and the metabolism of all

nutrients (Sofra et a/., 1998 and Pennington, 1993).

2.1.8 lnter relationships

Certain foods (especially plants of cabbage family - cabbage, kale, turnips,

cauliflower, rapeseed, and mustard seeds) contain goitrogens, which mterfere

with the use of thyroxin and may produce goiter. Fortunately, goitrogenic action

is prevented by cooking, and an adequate supply of iodine inhibits or prevents it.

lnter relationships: Jointly occurring deficiencies of iodine and vitamin A

are likely to cause a more severe thyroid disorder than lack of iodine alone.

Besides iodine deficiency, certain environmental agents, both naturally

occurring and man-made, interfere with thyroid functions. They may cause

goiter and thyroid dysfunction by acting directly on the thyroid gland or indirectly

by altering its regulatoji 'mechanisms and thyroid goitrogens or anti thyroid

compounds. (The New Encyclopedia Britannica, 2003 and Vanderpas, 1993).

2.2 Parasites

Intestinal parasitic and protozoal infections are common with humans being most

prevalent in poor communities in developing countries (Savioli et a/., 1992).

Many children in developing countries are exposed from birth to intestinal

parasites as a result of crawling, contaminated foods and water, inadequate

16

sanitation and poor personal hygiene (Hall, 1993). The effect of intestinal

parasites on IDD and growth are well documented.

2.2.1 Intestinal helminthes

The most common intestinal helminthes in humans are nematodes: Ascaris

lumbricoides, Tricharis trichiura, and hookworms (Nector americanus and

Ancylostoma duodenal) (Bundy et a/., 1992). Soil is the transmission medium.

Helminth eggs and larvae can live for long periods of time in the soil (Kowal,

1988).

2.2.2 Prevalence among children

Until recently, most of the parasitic studies and target for treatment has been

focused on the preschool child (under 5 years old), while the school-age children

have been neglected (Bundy et a/., 1992). Thus, information on the prevalence

of school-age children is most scanty. However, Tanner et a/. (1987) in

longitudinal study on the health status of children in rural Tanzanian community

observed that the prevalence and incidence of parasitic infection was high and

varied with the specie hookworm (N. americanus), Strongyloides spp. and

Schistosoma haematobiljm weFe f h n d to be highly prevalent In a high annual

incidence rates. Ascaris and Trichuris were of minor importance. They reported

that the prevalence and incidence of parasitic infestation did not differ by sex.

Multiparasitism was reported to be very' frequent and < I 1% of all children were

parasite-free in each year. Bundy etal. (1992), noted that children aged between

5 and 15 years were infected with at least one species of worm. Wan et a/.

(1989), found that the incidence of parasitic infestation of preschool children

particularly by Ascaris lumbricoides and Trichuris trichura was extremely high in

2 villages in Malaysia (70.3% and 41.2%).

17

In Nigeria, some researchers (Gilles and Akufo, 1965; Cowper, 1967) had

observed high prevalence of intestinal parasites among children. It is presumed

that children from rural communities or those living in poor sanitary environment

or deprived communities and those of poor socio-economic group would have

high prevalence and incidence of intestinal parasitic infestation (Noor et a/., 1989;

Al-baloa et al., 1993).

However, Hall (1993) in his review on intestinal parasitic infestation

observed that studies which classify children as simply infected or uninfected

were inadequate as the effect of intestinal parasite will depend on the intensity

(worm burden), the worm specie and the nutritional status of the child. He noted

that heavily infected children are most often from deprived and vulnerable

sections of the community.

In Nigeria, the poor economy, high inflation rate, and lack of facilities

would probably make children vulnerable to heavy load of intestinal parasitic

infestation. According to a recent survey, about 66%, 32% and 7% of urban,

semi-urban and rural areas respectively had access to safe pipe-borne water by

1989. Boreholes naturally accounted for 4%, 19% and 15% in urban, semi-

urban and rural areas respectively. Generally, it could be seen that about 70%,

50% and 22% of urbari,"s~mi~urban and rural centers had access to safe water

in Nigeria by 1989 (UN-FGN, 1992). It was also observed that 18% of urban, 3%

of semi-urban and 0% of rural dwellers were using water closet, while the rest

were using pit toilet, dam hill or bush. .'

2.3 Intestinal parasitic infestation and growth and nutritional status

The effect of intestinal parasite depends on the duration of infection before

treatment (Hall, 1993). A long-standing, worm burden would have more effect

on growth than a newly acquired load of similar intensity. This explains why

18

some researchers did not observe any change in growth after treatment (Tanner

et a/., 1987; Noor el a/., 1989).

Blumenthal and Myron (1976) observed that their control group tended to

exceed the infected in percentile of weig ht-for-heig ht, especially the moderate

and heavily infected. They also found that scars of angular stomatitis, (another

sign, associated with adequate riboflavin nutrition) were noted more often in

parasitized children, though the difference was not significant. Tanner et a/.

(1987) reported a high degree of stunting (35-71%) and a substantial proportion

of wasting (3-20%) among rural Tanzania children infected with intestinal

parasites. It was further noted that the anthropometric assessment did not

improve substantially when compared with the untreated group. Gupta (1980)

and Gupta and Urrutia (1982) observed an increased height gain among

Guatemalan pre-school children treated against G. lambia.

In their own contribution, Wan et a/. (1989) reported that Malaysian village

children who were heavily infected with Ascaris and Trichuris were

malnourished. They noted that 28% and 34.3% of children from two villages

were suffering from chronic malnutrition. Blumenthal and Myron (1976) and

Venkatachalam and Patwardhen (1953) shown that ascariasis of moderate to . ,, . .! 3''

severe intensity caused in test ha^ protein loss amounting to about 7% of dietary

protein intake.

Other ways in which intestinal parasite interfere with the host nutrition

includes malabsorption, production-'of antiproteolytic substances and anorexia in

the host (Venkatachalam and Patwardhen, 1953).

Furnee el a/. (1997) in their study with school children indicated that

intestinal parasitic infestations reduce the efficiency of oral supplementation with

iodized esters by interfering with absorption.

2.4 Morbidity and mortality

Most of the deaths and serious illnesses occurring among Nigerians were due to

conditions that are easily preventable or can be treated with simple remedies

(DHS, 1990). Communicable diseases especially those associated with

inadequate environmental sanitation and poor personal hygiene predominate

and are often compounded by malnutrition. While the lack of timely and

appropriate care often increases the risk (UN-FGN, 1992). Nnanyelugo et a/.

(1990) rightly noted that the high mortality rate in two rural communities they

studied was associated with the existing over-all environmental problems.

Although, the cause of death was not usually known, diarrhoea and vomiting

were usually reported to have occurred. The common types of infective and

parasitic diseases in order of occurrence in Nigeria are malaria, dysentery and

diarrhoea1 diseases, measles, pneumonia, gonorrhea, whooping cough,

schistosomiasis, chicken-pox, tuberculosis, meningitis (UN-FGN, 1992).

The five most common causes of death in hospitals in Nigeria according

to national health Policy of 1988 are as follows: Communicable and parasite

diseases, respiratory disease, accidents, poison and violence, disease of the

circulatory system and diseases of the digestive system (UN-FGN, 1992).

According to the World Bank Development Reports (1990) Nigerian infants

mortality rate (IMR) hassdecreasecl steadily from 138 in 1974 to 98 in 1990. It

was also observed that mortality rates are higher for rural than urban areas and

higher for male than female children. Statistics have revealed that infant

mortality .is responsible for almost 50% of all death in the 0-4 years old, whilst, , I

under-five child mortality accounts for 93% of these deaths, 70% of which is

attributed to preventable diseases (FOS, 1984). It was also reported that trend

from 1981 -1 986 for four immunizable diseases namely, measles, tuberculosis,

tetanus and whooping cough showed remarkable decline in incidence within the

12 months of the launching of the expanded Programme of Immunization in

Nigeria (FOS, 1984).

2 0

Although, there is improvement in immunization coverage, other factors

such as nutritional status, health knowledge of mothers, access to health centers

and services, level of household, food security, access to clean water, safe

sanitation and the general environmental conditions of child, which influence

morbidity and mortality need to be improved in Nigeria (UN-FGN, 1992)..

I ne srtuatlon In NSukka (slte ot study) IS not dltterent trom the general

picture described above. Obukpa being a rural community may have high

incidence of child morbidity and mortality.

2.4.1 Share of children who are underweight

The commission on the Nutrition Challenges of the 21St century in its report titled

"Ending Malnutrition by 2020, An Agenda for change in the Millennium", has

pointed out that some 30 million infants are born each year in developing

countries with intrauterine growth retardation, representing about 24% of all new

births in these countries, (Phillip et a/., 2000). Low birth weight (LBW) children

are characterized by mental impairment. Worldwide, there are more than 150

million underweight pre-school children (Table 1) and more than 200 million

stunted children. At current rates of progress in fighting these maladies, about

one billion children will be growing up by 2020 with impaired mental . *l. "' r

development. What wh" be the impact of such a denial to the child of

opportunities for the full expression on its innate genetic potential for mental and

physical development of the intellectual property of a nation? Denying the child

an opportunity for mental and physical development even at the foetal stage is

the cruelest form of inequity. Swaminathan (2000) at the International Congress

on Nutrition Vienna reported that sustained efforts are also needed to eliminate

iodine deficiency disorder.

Table I: Share of Children who were underweight

Country Share Underweight (Percent)

Bangladesh 58

India 53

Ethiopia 48

Vietnam 40

Nigeria 39

Indonesia 34

Source: Gardner and Halwail, 2000

22

2.5 Toxic Substances and Anti-nutritional Factors

Root crops, in common with most plants contain small amounts of potential

toxins and antinutritional factors such as trypsin inhibitors. Apart from cassava,

which contains cyanogenic glucosides, cultivated varieties of most edible tubers

and roots do not contain any serious toxins. Wild species may contain lethal

levels of toxic principles and must be correctly processed before consumption.

These wild species are useful reserves in times of famine or food scarcity. Local

people are aware of the potential risks in their use and have developed suitable

techniques for detoxifying the roots before consumption.

2.5.1 Cassava toxicity: The main toxic principle which occurs in varying

amounts in all parts of the cassava plant is a chemical compound called

linamarm (Nartey, 1981). It often co-exists with its methyl homologue called

Methyl-linamarin or lotaustralin. Linamarin is a cyanogenic glycoside which is

converted to toxic hydrocyanic acid or prussic acid when it comes into contact

with linamarase, an enzyme that is released when the cells of cassava roots are

ruptured. Otherwise linamarin is a rather stable compound which is not changed

by boiling the cassava. If it is absorbed from the gut to the blood as the intact . $ 4 . 1. ..

glycoside it is probably excreteb unchanged in the urine without causing any

harm to the organism. However, ingested linamarin can liberate cyanide in the

gut during digestion (Coursey, 1973).

Hydrocyanic acid or HCN is a.'volatile compound. It evaporates rapidly in

the air at temperatures over 28OC and dissolves readily in water. It may easily

be lost during transport, storage and analysis of specimens. The normal range

of cyanogens content of cassava tubers falls between 15 and 400 mg HCNIkg

fresh weight (Coursey, 1973). The concentration varies greatly between

varieties and also with environmental and cultural conditions. The concentration

23

of the cyanogenic glycosides increases from the center of the tuber outwards

(Bruijn, 1973). Generally, the cyanide content is substantially higher in the

cassava peel. Bitterness is not necessarily a reliable indicator of cyanide

content.

2.5.2 Pathophysiology of cyanide intoxication

Cyanide is detoxicated in the body by conversion to thiocyanide, a sulphur

containing compound with goitrogenic properties. The conversion is catalysed

by an enzyme thiosulphate cyanide sulphur transferase (rhodanase) present in

most tissues in human, and to a lesser extent by mercaptopyruvate cyanide

sulphur transferase which is present in red blood cells (Fielder and Wood, 1956).

The essential substrates for conversion of cyanide to thiocyanate are

thiosulphate and 3-mercaptopyruvate, derived mainly from cysteine, cystine and

methionin, the sulphur-containing amino acids. Vitamin B12 in the form of

hydroxycobalamin probably influences the conversion of cyanide to thiocyonate.

Hydroxycobalamin has been reported to increase the urinary excretion of

thiocyanate in experimental animals given small doses of cyanide (Wokes and

Picard, 1955; Smith and Duckett, 1965). About 60 to 1090 percent of the

injected cyanide in toxic cbf'icetrtration is converted to thiocyanate within 20

hours and enzymatic conversion accounts for more than 80 percent of cyanide

detoxification (Wood and Cooley, 1956). Thiocyanate is widely distributed

throughout body fluids including,,saliv;l, in which it can readily be detected. In

normal health, a dynamic equilibrium between cyanide and thiocyanate is

maintained. A low protein diet, particularly one which is deficient in sulphur-

containing amino acids may decrease the detoxification capacity and thus make

a person more, vulnerable to the toxic effect of cyanide (Oke, 1969; 1973).

24

Excessive consumption of cassava as the sole source of dietary energy and

main source of protein could thus increase vulnerability to cyanide toxicity.

2.5.3 Goitrogens and Antithyroid Compounds

The unique known function of iodine in mammals is its role in the synthesis of

thyroid hormones. The uptake of iodide by the thyroid gland is stimulated by the

hormone, thyrotrophin (TSH), and it can be multiplied 20-40 times in a TSH

stimulated gland. Some goitrogens, such as thiocyanate and isothiocyanate,

interfere with iodide uptake ( Vanderpas, 1993).

After being concentrated by the thyroid gland, iodide is oxidized and

bound to some specific tyrosyl residues of thyroglobulin, forming mono

iodotyrosine (MIT) and diiodotyrosine (DIT); oxidation of iodide and iodination of

selected tyrosyl residues is catalysed by a membrane bound enzyme,

thyroperoxidase (TPO). The same enzyme couples two iodotyrosines to form

thyroxine (T4; four iodine atoms) and triiodothyronine (T3; three iodine atoms).

The ratio of T4 to T3 in thyroglobulin is closely dependent on serum TSH

concentration and iodine supply: in euthyroidism (normal healthy function of

thyroid gland) 85% of the hormonal content of thyroid is represented by T4, while . ,, ."

in the hypothyroid state,"the ratioe~4:T3 is closer to unity. Most of the goitrogens

(Phenol derivatives, dihydrobenzoic acid, flavones, goitrin, disulphides,

polycyclic aromatic hydrocarbons, excess iodine) interfere with TPO activity (

Vanderpas, 1993).

lntrathyroid proteolysis of thyroglobulin results in the release of T4 and T3

in the systematic circulation; this step is inhibited by lithium and excess iodine.

Secreted in the systematic circulation, serum T4 and T3 are bound to albumin,

thyroxine binding-globulin and transthyretin (also named thyroxine-binding

prealbumin). The binding of thyroid hormones to serum proteins is partly

2 5

inhibited by flavonoids resulting in alterations of circulating free hormone

concentrations and adaptation of feedback regulation.

Thiocyanate and cyanide do not occur in the intact plant as free anions.

When the plant is crushed, a thioglucosidase or a glucosidase (such as

linamarase in cassava) is released, which hydrolyses the thioglucoside or the

cyanogenic glucoside, yielding the active goitrogens.

The principal vegetables containing thioglucosides are Kale, cabbage,

sprouts, broccoli, kohlrabi, turnips, Swedes, rapeseed, and mustard. The main

vegetables containing cyanogenic glucosides are bamboo shoots, and sweet

potatoes ( Vanderpas, 1993) .

The inhibitory action of thiocyanate on iodine uptake is due to a

competitive effect of the pseudohalide with the mechanism of iodide

concentration. However, under experimental conditions, rather high plasma

concentration of thiocyanate is required for inhibiting the iodide uptake by the

thyroid gland. In the thiocyanate suppression test, administration of 3 g of

thiocyanate results in serum levels in the range of 8.0 - 15.0 mgdl-I, far

exceeding the levels attained in populations exposed to environmental

thiocyanate overload (around 2.0 mgdl'l). In order to move closer to the

physiological 'coridifions: ' rats were exposed to chronic moderate

supplementation of thiocyanate (0.25 mg per day) and to a low-iodine diet for 11

weeks. This prolonged administration of thiocyanate markedly reduced radio-

labelled pertechnate in the thyroid without change in radioiodine thyroid uptake

(pertechnate is concentrated in the thyroid by the same pathway as iodide, but it

is neither oxidized nor bound to tyrosyl residues by TPO). Decreased iodide

uptake associated with thiocyanate overload, and increased iodide organification

owing to TSH stimulation could explain these discrepancies. The net result is

reduction of circulating thyroxine induced by thiocyanate supplementation in rats

receiving a low-iodine diet ( Vanderpas, 1993).

The role of cassava is the aetiology of endemic goiter in a human

population was first suspected in Nigeria on the basis of geographical overlap of

areas affected by goiter and by tropical neuropathy (presumably resulting from

chronic cyanide poisoning by consumption of poorly processed cassava). A few

years later, extensive studies in eastern and in northern Zaire, have documented

thiocyanate overload resulting from elevated intake of cassava poorly detoxified

through traditional preparation procedures (Sun-drying). The methods of

preparing cassava vary widely from one ethnic group to another; in the ethnic

group with the highest prevalence of goiter, cassava is not soaked; the roots are

peeled, dried in the sun for 1 or 2 days then bruised in a mortar with corn that

has been steeped for 12-24h in water. The flour is eaten as gruel (fuku)

prepared in boiling water (Ermans et al., 1980).

2.5.4 Sulphur-containing compounds

Cabbage has been recognized as a goitrogen in rabbits since 1928. The

antithyroid properties of thiocyanate were shown in 1936 in patients treated for

hypertension with thiocy8hdtk'"as "vasodilator. An important staple food in

tropical countries - cassava - has been recognized to play a major role in the

epidemiology of goiter in central Africa ( Vanderpas, 1993).

Antithyroid sulphur-containing organic identified in vegetable foodstuff can

be divided into two categories according to the way they act on iodine

metabolism:

1. thiocyanate and thiocyanate-derived compounds primarily inhibit the

active concentration mechanism of iodide, and their goitrogenic activitiy

can be overcome by iodine administration.

2. goitrin ( or 1,5-vinyl-2-thiooxazolidone) is analogous to thiourea in its

action, interfering with thyroperoxidase activity and its action cannot

usually be antagonised by iodine ( Vanderpas, 1993).

2.6 Selenium-deficiency-related thyroid dyshormonogenesis

Selenium has been identified as the constitutive compound of 5'deiodinase I, the

main enzyme converting the prohormone thyroxine (T4) to the thyromimetically

active T3 and degrading reverse T3, a further metabolite of T4. The

selenocysteine in the active site is encoded by the amber stop codon, TGA, and

selenium is incorporated in S'deiodinase I enzyme by a specific transfer

ribonucleic acid (tRNA) at the cotranslational level. In vitro, in selenium

deficiency conditions, the level of S'deiodinase I activity is reduced to 10% of the

initial level. In iodine-and selenium-deficient subjects (northern Zaira), Selenium

supplementation in the absence of serum T4 and of serum reverse T3

concentrations; subjects with no loss of thyroid functional capacity (iodine-

deficient, otherwise normal school children), the decrease of serum T4 was not

accompanied by an aggravation of hypothyroidism, as serum Tg and serum TSH

remained stable. In contrast, in subjects with a low thyroid functional capacity

(myxoedematous cretins),'lhZi &crease of serum T4 was accompanied by an

increase of serum TSH and a decrease of serum T3, clearly showing that an

aggravation of hypothyroidism occurred after selenium supplementation in the

absence of sufficient iodine supply, .'According to the results gotten from the

areas which are both iodine and selenium deficient, it is mandatory to correct

iodine deficiency before selenium supplementation; selenium deficiency should

be corrected thereafter too ( Vanderpas, 1993).

2 8

2.7 Iodine deficiency

Iodine deficiency is a condition in which an organism does not take in enough

iodine, an element that directly affects thyroid gland secretions, which

themselves to a great extent control heart action, nerve response to stimuli, rate

of body growth, and metabolism.

Simple goiter (enlargement of the thyroid gland) is the most common form

of iodine deficiency illness and is found particularly in mountainous regions and

areas far from salt water. Lowest incidence of this disease occurs along

seacoasts. When the supply of iodine is moderately deficient, the thyroid gland

works harder to synthesize hormones in normal quantities, but the affected

individual may continue in general good health despite possible presence of

goiter. In case of severe and prolonged deficiency, however, there may be a

deficit of thyroid hormones, resulting in myxedema, a condition characterized by

dry skin, loss of hair, puffy face, flabbiness and weakness of muscles, weight

increase, diminished vigour, and mental sluggishness (The New Encyclopedia

Britannica, 2003 and Mashid and Mason, 1993).

2.7.1 Prevention of iadlrie'd'efl'dieficy

This is most simply accomplished by eating seafood regularly or by use of

iodized table salt. To overcome natural iodine deficits, government health

officials i n Canada and otherllnat&ns have made dietary iodine additives

mandatory.

Sporadic goiter remains a mystery because it occurs in areas where

iodine intake is more than adequate. Foods such as cabbage and turnips

contain a potential dangerous progoitrin substance believed to inhibit normal

29

intake of iodine by body tissues. During the heat of cooking, however, the

offending enzyme usually is destroyed.

A lack of iodine during infancy may cause a condition known as cretinism,

in which mental and physical development is severely impaired. This condition

can be prevented if the mother maintains a diet of foods high in iodine during

pregnancy (The New Encyclopedia Britannica, 2003; Kavishe, 1993 and Hetzel

et a/., 1987).

2.7.2 Iodine value or iodine number

In analytical chemistry, measure of the degree of unsaturation of an oil, fat or

wax. Saturated oils, fats and waxes take up no iodine, therefore, their iodine

value is zero; but unsaturated oils, fats and waxes take up iodine, (unsaturated

compounds contain molecules with double or triple bonds, which are very

reactive toward iodine). The more iodine is attached, the higher is the iodine

values, and the more reactive less stable, softer and more susceptible to

oxidation and rancidification is the oil, fat, or wax. In performing the test, a

known excess of iodine, usually in the form of iodine monochloride, is allowed to

react with a known weight,~f,Jhe,oil, fat, or wax and then the amount of iodine

remaining unreacted is determined by titration (The New Encyclopedia

Britannica, 2003 and Sofra et a/., 1998).

Drying oils used in the paint and vanish industry have relatively high ,I

iodine values (about 190). Semi drying oils, such as soybean oil, have

intermediate iodine values (about 130). Non drying oils, such as olive oil, used

for soap making and in food products, have relatively low iodine values (about

80).

Iodized salt: Table salt with small amounts of iodine added, usually as

potassium iodide, to ensure against dietary deficiency of iodine. Where iodized

30

salt is used, particularly in Switzerland and the United States, endemic goiter has

disappeared.

In United States, iodized salt contains 1 part in 100,000 iodide and in

Switzerland, I part in 200,000. The World Health Organisation recommends 1

part in 100,000 (The New Encyclopedia Britannica, 2003).

2.7.3 Diagnosis and treatment of goitre

The enlargement of the human thyroid gland results into a prominent swelling at

the front of the neck. A normal human thyroid gland weighs 20-30 g (about 0.75

ounce), a goitrous gland as much as 1 kg (more than 2 pounds). A very large or

extensive goiter may produce sensations of choking and can cause difficulty in

breathing and swallowing.

2.7.4 Causes and types of goitre

One class of goiter arises as a result of any of a variety of defects in the thyroid

glands synthesis of thyroid hormone. The gland is unable to secrete sufficient

amounts of that hormone and grow inadequate secretion by producing more.

Other types of goiter occur When the thyroid gland has normally functioning

tissue but enlarges for reasons that have not been exclusively determmed.

Still other types of enlarged gland produces too much hormones

(hyperthyroidism), resulting in the ~onditjPns known as exophthalmic goiter, or

Grave's disease, and toxic multinodular goiter or Plummer's disease.

The most common type of goiter is called simple or endemic goiter and

results from an inadequate intake of iodine, which is one of the two raw materials

necessary to make thyroid hormone. When the body does not receive iodine in

sufficient quantities, the thyroid gland grows larger in an effort to produce an

3 1

adequate amount of hormone. Endemic goitre is five times more common

among women than men. It occurs most frequently in inland or mountainous

regions where the iodine content of drinking water and food is exceedingly low.

It is prevented by the use of iodized salt in one's diet. In the early stages of

endemic goiter, regression of the gland may be complete if iodine is ingested in

adequate amounts. The most effective treatment in more advanced cases is the

administration of thyroid hormone. Surgical removal of the thyroid gland may be

necessary if the gland has grown so large that it is obstructing breathing (Sofra

et a/., 1998).

2.8 Micronutrient malnutrition: a global problem

Chronic diet-related diseases are a public health problem throughout the world.

Despite concerted efforts to reduce poverty, improve nutrition education and

secure access to healthy foods. Blum (1997) reported that more than two billion

people are sick or disabled and million die prematurely each year as a result of

micronutritient deficiencies.

Blum (1997) further noted that the commonest micronutrient deficiencies

of Public health significance are Vitamin A deficiency, Iron deficiency and iodine

deficiency. For proper.fu~ctici'ninQ the body relies on interactions between wide

ranges of nutrients; thus the earlier statement should be considered in isolation.

Hence, food should be provided in adequate and balanced amounts. Even

marginal deficiencies may increape the'risk of poor health.

2.8.1 Vulnerable groups affected

Women of childbearing age, young children and the elderly are the groups most

susceptible to micronutrient deficiencies. In areas where the soil lacks iodine,

deficiencies of this mineral may strike the whole population (NutriView, 1997).

3 2

According to estimates by the World health Organisation (WHO), iodine

deficiency affects one thousand million people worldwide. It is the commonest

cause of preventable mental retardation: 25 million people are affected; 6 million

of them develop cretinism (NutriView, 1997).

Females are consistently more affected than males, because goiter

usually develops in periods when metabolic rate is high, such as during puberty

and pregnancy. It should be noted that not all goiter is simple goiter due to lack

of iodine. Another type of goiter, called Exophthalmic goiter (Grave's disease), is

due to over-activity of the thyroid gland, which is usually but not always,

enlarged.

2.9 Reasons for iodine deficiency

Iodine deficiency disorders (IDD) are endemic in areas where soils have been

depleted of iodine. In mountain regions soils have been leached by glacial

erosion, whereas in tropical areas leaching is due to continuous rainfall. Crops

grown in depleted soils lack iodine. As a result, humans and animals dependent

on these foods become iodine deficient. Only sea foods (fish, shellfish, and 4 T I . 7.'

seaweed) are naturally rich in iodine (NutriView, 1997). Intestinal disorders

parasitic infestation and nutrient interaction can impair iodine absorption and

utilization (NutriView, 1997).

Some vegetables and staple foods (cassava) contain glycosinolates,

which have been shown to interfere with the proper utilization of iodine, further

aggravating iodine deficiency disorders.

33

2.10 Health consequences of iodine deficiency

Iodine deficiency is the World's greatest single cause of preventable brain

damage and mental retardation. Severe iodine deficiency during pregnancy

inhibits fetal growth, increases the risk of stillbirth and impairs the mental

development of the unborn child, resulting in cretinism and permanent mental

retardation. Milder deficiency results in subtle but significant reductions in

cognitive development.

2.1 1 Solution to iodine deficiency disorder:

2.1 1.1 Choice of strategies

International organizations active in micronutrient projects (WHO, UNICEF,

IVACG, INACG) recommend four key strategies to eradicate micronutrient

malnutrition: nutrition education, dietary diversification, dietary supplementation

and food fortification (Nutriview, 1997).

2.11.2 Nutrition education

Food choices are often made on the basis of availability, price, personal

preferences, habits and cultural traditional taboos. A lack of knowledge about . .,, . , l . ..' .

nutrition, and its role In health and disease makes it difficult to introduce

changes. Nutrition education is therefore an essential part of any program.

Knowledge alone, however, is not enough to ensure people eat a balance diet.

They need to have a strong'' motivation to adapt. Activities directed at

encouraging new habits have been termed 'social marketing'. This uses

techniques employed in commercial selling (radio, TV, newspapers, advertising,

competitions, gimmicks, etc) adapted to an ideal rather than a product

(NutriView, 1997).

3 4

2.1 1.3 Dietary diversification

Dietary diversification is seen by many as the ultimate solution to malnutrition.

Eating a variety of nutritious foods is the natural way to obtain the nutrients

needed for health. Dietary diversification requires people to change their eating

habits. It may also involve the need to increase production, distribution and

consumption of micronutrient-rich crops and animal products. Its success is

limited by climatic conditions, the fact that certain foods may be culturally

unacceptable or too expensive, and the lack of effective communication and

motivation programmes (NutriView, 1997).

2.11.4 Dietary supplementation

Administration of supplements is an effective way to rapidly correct existing

deficiencies or avoid their development in high-risk populations. It requires close

contact between health-care workers and the target population, and is mainly

indicated as an emergency strategy because of complicated logistics and high

costs. Supplementation should be replaced by a suitable strategy, such as

dietary diversification or food fortification.

Dietary supplementation has been successfully implemented to reduce

suffering in iodine defickrif'women ki th iodized oil capsules (NutriView, 1997).

2.11.5 Food fortification

Addition of vitamins, mineralslland .trace elements to stable foods has been

practiced in numerous industrialized countries for many years with considerable

success. This method has long proven its value as an effective public health

measure to correct nutritional deficiencies in whole populations or specific

segment at risk. Food fortification does not require the active participation of the

customer. If a suitable food vehicle can be identified, traditional food

3 5

consumption patterns can be maintained; technology is available for a wide

variety of foods. Costs are negligible compared with the medical and public

health costs associated with malnutrition. In many cases, fortification costs can

be recovered by a small price increase at the retail level. Fiscal measures such

as sales tax reductions can be used as an incentive to promote fortification

(NutriView, 1997). The earliest example of fortification is the iodization of a table

salt in Switzerland since 1923 to prevent goiter and cretinism which was

widespread throughout the alpine region until then (NutriView 1997).

2.12 Hidden hunger

Micronutrient malnutrition is also called "hidden hunger", because people have

no innate appetite or hunger for these essential vitamins or minerals. It poses a

threat to 2 billion people across the globe and affects 1 billion of them, mostly,

but not exclusively in developing countries. Most people suffering from the

condition may get enough food to eat - the problem is shortages of important

vitamins and minerals in their food. Besides iodine, iron and vitamine A,

deficiencies of zinc, folic acid, the B vitamins and vitamin D also cause concern

(Roche, 1997).

Iodine deficiencjl L4Sb'ine'?.6 billion people in 95 countries are at risk of

iodine deficiency, especially those living in mountainous or flood-prone areas,

where the soil lacks iodine. Lack of iodine can permanently lower the IQ of

children by at least 10 points. Some.655 million people suffer goiter, a swelling

of thyroid gland in the neck caused by a lack of iodine. It is also the most

common cause of preventable mental retardation. Today, there are 43 million

cases of mental retardation and 6 million cases of cretinism (Roche, 1997).

2.13 Selecting the right vehicle

To select a suitable vehicle for fortification, certain criteria have to be met.

Above all, the food must be consumed regularly by the target population in

appropriate amounts; fortification should supply optimal amounts of the required

nutrients without changing the characteristics of the food or increasing its price

substantially. In this regard, instant noodles emerged as the ideal candidate, in

Asia (Asia, 1996).

Report shows that lnstant noodles were consumed by 15-49 year old

Thais of both sex and from all socio-economic levels. Nineteen ninety three,

annual per capita consumption was equivalent to 30 packs (Asia, 1996). lnstant

noodles have acceptable sensory characteristics and good shelf stability. Their

shelf life at room temperature is at least six months.

To combat the problem in endemic area, potassium iodated solution has

been added to the drinking water supplies of households, communities and

schools for many years. Since 1994 table salts have been fortified with 50ppm

of potassium iodated or potassium iodide (Nutrition Division, 1996).

2.13.1 Feasibility of triple fortification

In late 1994, the ministetial'committee agreed that a study should be undertaken

to test if triple fortification of instant noodles with iodine, iron and vitamin A is

feasible. The committee and the manufacturers of instant noodles agreed to

fortify the seasoning powder, because this need only little additional cooking

before consumption and it is well protected in a separate bag within the package.

The project is being conducted on a voluntary basis, and representatives from

the manufacturers are working jointly with the committee members (Chavasit

and Tontisirin, 1998).

3 7

For the feasibility study, data on the fortificants to be used, and the

sensory acceptability, cost and shelf stability of the fortified products were

evaluated. A premix (20 mg per package of instant noodle) containing

potassium iodide, encapsulated iron and vitamin A palmitate was used for

fortification. The fortification dosage were set at 50 pg for iodine, 5 mg for iron,

and 267 pg for vitamin A (Chavasit and Tontisirin, 1998).

Judged mainly by appearance, most of the fortified seasoning powders

have a shelf life of about three months. The incubated seasoning powders from

each period were later analyzed for micronutrient content at the Institute of

Nutrition. The results showed that the added micronutrients are stable under

accelerated incubation conditions. There were no significant differences in

sensory qualities between the original and the fortified products. Fortification has

only a minimal effect on the cost of the product.

2.14 Food fortification gains support in Africa

Several African countries have recently started staple food fortification or are at

an advanced stage of preparation. Others are considering fortification of sugar

(Lesotho, Madagascar, and Malawi) and/or maize flour (Kenya, Lesotho, Malawi,

Tanzania). In additiori,"aWvari& of fortified commercial products (lemonade

powder in Tanzania, Malted and instant chocolate beverages in Nigeria,

Complementary Foods for infants in several countries) are being sold (NutriView,

2001/1).

It is apparent that an increasing number of donors, national governments

and food manufacturers are committed to this strategy for reducing the health

burden due to malnutrition. A major challenge is to sustain activities, secure

more top-level commitment, and establish effective measures of legislation and

monitoring.

2.15 Priority for child nutrition needed

Proper nutrition throughout childhood is the foundation for healthy life as well as

for human development. Addressing the nutritional problems among Asian

children, both Professor Aree Valyasevi (President of the Congress of Peadiatric

Nutrition held in Chiang Mai, Thailand, on November 28 - December 1, 2000)

and Professor Keyou Ge (Director of the Institute of Nutrition and Food Hygiene

Chinese Academy of Preventive medicine) stressed the importance of

implementing the solutions urgently.

Due to inadequate food intake, poor nutrition knowledge and infections

there are still too many undernourished children in many Asian countries.

Under-nutrition during pregnancy leads to intrauterine growth retardation

(IUGR) and low birth weight (LBW) (NutriView, 200112).

NutriView, (200112) recommendations for intellectual development in Nigeria:

to access the effects of early nutrition on growth and intellectual

development, Ab~doye conducted a retrospective survey of 285, approximately

10 year old primary school children in Nsukka, Nigeria. Less than a third of the

pupils had normal weight for height or height for age. Current nutritional status

significantly affected sctiob14peffoiri7ance.

The main factors affecting later school performance were the level of

maternal education and occurrence of complications in pregnancy and childbirth.

There seemed to be no relationship betiveen performance and duration of breast

feeding, frequency of feeding during preschool years or anaemia (found clinically

in 39% of the pupils).

To improve nutritional status and academic performance status, Abidoye

(2000) recommends establishing a clear policy that includes compulsory free

education to secondary school level for girls, a ban on marriage before age 18,

promotion of exclusive breastfeeding up to 6 months of age, subsidized school

feeding and health programs.

A recent hypothesis also suggests that increased oxidative stress in

micronutrient deficient individuals precipitates genetic changes in viruses,

making them more virulent (King, Black and Doyle, 2001).

In the light of the multiple factors, constraints and deficiencies, multiple

approaches may be the only effective way to combat micronutrient deficiencies.

Among the other suggestions for the way forward in Africa made during the

International congress of Nutrition (NutriView, 200014):

Provide practical nutrition education including food preparation. People must understand the importance of eating micronutrient-rich foods. A major problem of local foods is their high content of absorption inhibitors. Methods to improve micronutrient availability, such as soaking should be taught and encouraged.

Promote multiple micronutrient supplementation and small-scale multiple micronutrient fortification. A multiple micronutrient approach through supplementation could be facilitated through government or regional efforts to support local manufacture.

2.16 Correcting iodine deficiency:

The occurrence of cretinisrh,"'chdracterized by physical and mental retardation,

increases significantly when the mother's daily intake of iodine falls below 20pg

(the normal daily intake for adults being 80-150pg). Simple public health

measures can be taken to prevent iodine deficiency and the birth of children

disable in this way (Hetzel and Orley, 1985).

Iodine deficiency also causes swelling of the thyroid gland, termed simple

goiter; compression in the neck may result but this is not a major public health

problem. Goiter, however, especially when it affects more than 50% of an adult

population, is a reliable indicator of sufficiently severe iodine deficiency to cause

frequent births of disabled children.

Maternal iodine deficiency is also associated with increased incidences of

other congenital abnormalities, stillbirth, abortion and low birth weight, which are

reduced by iodine supplementation. Past studies in Papua New Guinea and

Indonesia (Hetzel, 1983) have demonstrated a coordination defect in otherwise

normal children exposed to iodine deficiency in pregnancy; isolated deaf, mutism

and mental deficiency also occur, probably reflecting a less severe iodine

deficiency at a foetal stage. In china, partial correction of iodine deficiency

disorders has been reported in children with relatively mild handicaps (Ma et a/.,

1982).

Iodine deficiency probably also has some effect on the mental functioning

of older children and adults, because of a reduced level of circulating thyroxine.

In the foetus, on the other hand, a low level of circulating iodine seems more

likely to be the critical factors. In a small highland village in Bolivia where goiter

was very prevalent, a double-blind control study was conducted on the effect of a

single dose of oral iodized oil in 100 school children. Observations made 22

months after treatment revealed a reduction in goiter size and improved

intellectual performance, particularly in girls (Bautista et a/., 1982).

Iodine deficiency often occurs in isolated mountainous areas where the 4 . l ..'

iodine has been leached from the soil. Affected populations are usually poor and

politically weak, with little prospect of pressurizing governments into tackling the

problem; technical difficulties also hinder iodine supplementation. As outside

influences grow, foods containing iobine are introduced and deficiency is

reduced. In some parts of the world, action programmes have been mounted

involving either the addition of an iodide or an iodate to salt or other food

products, or the administration of iodine to individuals, typically by injecting

iodized oil, which can be effective for up to five years. Unfortunately, salt does

not always return added iodine, especially if it becomes damp. In many areas,

4 1

legal enforcement of the use of iodized salt, which may be marginally more

expensive than non-iodized salt, is necessary. Where a community obtains salt

from several sources, however, it is difficult to enforce or control iodization. The

injection of iodized oil may only be necessary for women of childbearing age,

although this is not always acceptable to other members of a population. The

treatment of a whole population in this way is about 20 times more expensive

than the use of iodized salt. However, the cost can be considerably reduced by

restricting the provision of iodized oil to those most in need. Syringes are a

major component in the expense of injection, and consequently work is

proceeding on the development of a cheap and stable oil formulation capable of

giving long lasting protection after oral administration. Iodine supplementation

for a woman must be given before pregnancy so that the developing fetus is

protected during the first trimester (Bautista etal., 1982).

2.17 Monitoring and evaluation

The most direct method of assessing success or failure in correcting iodine

deficiency is by determining urinary iodine as in the initial situation analysis. This

can in due course be supported by evidence of regression of goiter rates and the

prevention of cretinism." '"if'" labbratory services permit, determining blood

thyroxine in adults or neonatal thyroxine in cord blood samples will also indicate

whether iodine deficiency has been corrected.

Monitoring and evaluation are' essential for iodization programmes,

particularly because of the need to ensure quantitative correction of iodine

deficiency in order to reduce foetal damage and impaired mental function in

children. As already indicated there should be more use of prescriptive

measures for quantitative correction and hence prevention and control of IDD.

The availability of iodized oil with a follow-up of iodized salt makes elimination of

IDD a feasible goal (May eta/., 1997).

2.18.1 Assessing iodine deficiency disorders for public health programmes

In public health programmes carrying out iodine supplementation, the problem is

to assess a population or group living in an area or region that is suspected of

being iodine-deficient. The data required include the following (Stanbury and

Hetzel, 1980):

The total population including the number of children under 15 years of

age (in which the effects of iodine deficiency are so important);

The goiter rate, including the prevalences of palpable or visible goiter

classified according to accepted criteria;

The rates of cretinism and 'cretiniodism' in the population;

Urinary iodine excretion;

The level of iodine in the drinking water;

The level of serum thyroxine (T-4) in various age groups. Particular

attention is now focused on the levels in the neonate because of the

importance of the. X-4hl.evel.f~r early brain development.

2.18.2 Estimation of thyroid size

A slight modification of the system of Perez et a/. (1960) is recommended. I1

Stage 0 No goiter

Stage 1 a Goitre detectable

Stage 1 b Goitre is palpable and visible only, when the neck is fully

extended. This stage also includes nodular glands, even, if

not goitrous;

common even when all known environmental factors are controlled (United

Nations, 1993).

2.18.5 Urine Iodine excretion determination

The difficulties associated with the collection of 24 hour samples made Follis

(1963) originally suggest casual samples collection for determination of iodine

from a group of 30 subjects (Thrilly eta/., 1980). The iodine levels are expressed

mcglg of creatinin excretion and the range plotted out as a histogram. This

provides a reference point for the level of iodine excretion which is also a good

index of the level of iodine nutrition.

2.19 Sub- clinical IDD

Until the 1990s total goiter prevalence (TGP) was the recommended indicator for

assessing population iodine status. Today, however, urinary iodine (UI) and

goiter are the most common indicators of iodine status. UI is thus the preferred

indicator for monitoring and evaluating salt iodization programmers. The current

global and regional prevalence of iodine deficiency has been estimated based on

the most representative UI data available to WHO in June 2003 from surveys

carried out among school-age children between 1993 and 2003 iodine deficiency . , 4 1 . : . > .

is considered to be a public health problem in populations of school-age children

(6-12 years) where median U1 concentration is below 100 p11

(ICCIDDIUNICEFNVHO, 2001). The severity of iodine deficiency is assessed for

each country using criteria baskd on-median UI.

common even when all known environmental factors are controlled (United

Nations, 1993).

2.18.5 Urine Iodine excretion determination

The difficulties associated with the collection of 24 hour samples made Follis

(1963) originally suggest casual samples collection for determination of iodine

from a group of 30 subjects (Thrilly et a/., 1980). The iodine levels are expressed

mcglg of creatinin excretion and the range plotted out as a histogram. This

provides a reference point for the level of iodine excretion which is also a good

index of the level of iodine nutrition.

2.19 Sub- clinical IDD

Until the 1990s total goiter prevalence (TGP) was the recommended indicator for

assessing population iodine status. Today, however, urinary iodine (UI) and

goiter are the most common indicators of iodine status. UI is thus the preferred

indicator for monitoring and evaluating salt iodization programmers. The current

global and regional prevalence of iodine deficiency has been estimated based on

the most representative UI data available to WHO in June 2003 from surveys

carried out among school-age children between 1993 and 2003 iodine deficiency . ,' 4 .1 ,.' r

is considered to be a public health problem in populations of school-age children

(6-12 years) where median UI concentration is below 100 pl1

(ICCIDDIUNICEFNVHO, 2001). The severity of iodine deficiency is assessed for

each country using criteria based on me'aian Ul.

Table 2: Epidemiological Criteria for Assessing Iodine Nutrition Based on Medium Urinary Iodine Concentration in School-age Children

Median Urinary Iodine intake Iodine nutrition iodine (vg11)

Insufficient Severe Iodine deficiency

Insufficient Moderate Iodine deficiency

50-99 Insufficient Mild Iodine deficiency

100-299 Optimal Optimal

>= 300 Excessive Risk of adverse health consequences (iodine- induced hyperthyroidism, autoimmune thyroid disease)

Source: Adapted from WHOIUNICEFIICCIDD (2001)

2.19. I Three grades of severity

It has been suggested that there are three grades of severity of iodine deficiency

in a population that may be determined by urinary excretion (Querido et a/.,

1974). These are as follows:

Grade I: Goitre endemias with an average urinary iodine excretion of more than

50 mcglg of creatinine: At this level, a thyroid hormone supply adequate

for normal mental and physical development can be anticipated. This

group could be described as suffering from 'mild IDD'.

Grade 2: Goitre endemias with an average urinary iodine excretion of between

25 and 50 mcglg of creatinine: In these circumstances, adequate thyroid

hormone, formation may be impaired. This group is at risk of

hypothyroidism but not of overt cretinism (moderate IDD)'

Grade 3: Goitre endemias with an average urinary iodine excretion below 25

mcglg of creatinine: Endemic creatinism is a serious risk in such a

population (severe IDD).

2.1 9.2 Iodine in drinking water

The level of iodine in drinking water indicates the level of iodine in the soil which

in turn determines the ley,et.af ,i~dine in the crops and animals in the area. Iodine

levels of water in iodine-deficient areas are usually below 2 mcgllitre (2ppm)

(United Nations, 1993).

Severity of IDD Provide the Indication for an lodization Programme ,I

The gradation of severity of IDD provides the indications for an iodization

programme.

Mild IDD (Grade I): With urinary iodine (median) more than 50 mcglg of

creatinine, requires iodized salt (or possibly economic development alone) for

the correction and the prevention of goiter.

47

Moderate ID0 (Grade 2): With urinary iodine (median) in the range 25-

50 mcg/g creatinine, may be prevented by an effective iodized-salt programme;

often iodized oil may be necessary in addition to produce a quantitative

correction for the more severely iodine-deficient groups.

Severe ID0 (Grade 3): With urinary iodine (median) less than 25 mcglg

of cretinine, requires iodized oil for quantitative correction. Iodized salt might be

used as a follow-up measure if economic development permits; but if substitute

agriculture continues, administration of iodized oil needs to be continued (United

Nations, 1993).

2.20 Prevention and eradication of IDD require continual vigilance

It should be emphasized that prevention and eradication of IDD require continual

vigilance through regular feedback of epidemiological data including: estimates

of iodine content of salt; iodine content of urine in the vulnerable population

(especially school children who are readily accessible through school

attendance); goiter prevalence; and levels of T-4 including neonates if possible

(Hetzel, 1987).

2.20.1 Countries who sllc1c~sSfuIly eliminated iodine deficiency disorder

In the last 50 years, many countries in the America, Asia, Europe and Oceania

have successfully eliminated IDD, or made substantial progress in their control,

largely as a result of salt iodization kith potassium iodide or potassium iodate

and through dietary diversification. For example in Switzerland, where salt

iodization began in 1922, cretinism has been eliminated and goiter has

disappeared, while there has been negligible evidence of any adverse effects

from iodine intake.

48

Universal salt iodization (is defined as fortification of all salt for human and

animal consumption) has been endorsed in numerous international fora by

heads of state, senior government officials, and representatives of international

intergovernmental and non-governmental organizations. The most important of

these forums are the World health assembly, in resolutions WHA39.31 (1986)

and WHA 43.2 (1990), the World Summit for Children (UNICEF, 1990), the

Policy Conference on ending Hidden Hunger (Montreal, 1991) and the

International Conference on Nutrition (Rome, 1992). Nevertheless, WHO

continues to receive queries from national health authorities and others seeking

reassurance about the safety of providing iodized salt to non-deficient

population. As with all preventive public health measures, the decision to ensure

universal salt iodization will be made by weighing the potential risk of excess

intake for the few against the well-documented risk of mental and physiological

impairment for the many if a deficiency is uncorrected.

2.21 Adverse effects associated with high nutritional intakes of iodine

Since iodine, when ingested in large amounts, is easily excreted through the

kidneys into the urine, iodine intakes even at very high levels (milligram , ,, 4 R l . ..'

amounts) can be consumed safely. However, the following adverse effects,

though rare, have been reported:

Allergic reactions to iodine in food: skin rashes and acne have

occasionally been attributed to iodized salt. Such reports are extremely

rare, however, and thus these conditions are unlikely to occur following

salt iodization. For example, among 20,000 children in USA suffering

from allergy during the period 1935-1974, not a single case was reported

of allergic hypersensitivity to iodine in food. Following publication in

Annals of allergy of a request for notification of allergy to iodine, not a

49

single report was recorded between 1974 and 1980 (Stanbury and Hetzel,

1980)

High intakes of dietary iodine and thyroid diseases: Through adaptive

mechanisms, normal people exposed to excess iodine remain euthyroid

and free of goiter. In certain susceptible individuals, iodide goiter and

Hashimoto thyroiditis with hypothyroidism have been observed after

iodine intakes of 500-3000pglday. The prevalence of susceptible

individuals in different countries is not fully known. It has been suggested

that high nutritional intake of iodine substantiated by urinary iodine of

1000-10,00Opg/litre - as observed in one country in up to 2% of the

population - could have an adverse effect in susceptible individuals and in

patients with pre-existing abnormalities of the thyroid gland (Stanbury and

Hetzel, 1980). In this small proportion of the population, chronic excess

intake might contribute to the development of Hashimoto thyroiditis, iodide

and colloid goiter, and thyroid carcinoma. However, the incidence of

follicular thyroid cancer, a more severe form of cancer, is lower in iodine-

sufficient than in iodine-deficient areas. There is little indication that

iodine in the amounts noted influences the development of any of these

thyroid diseases. " ' "" '" ' '

In Japan, where dietary iodine-intakes are high, it has been shown that:

normal people who are not iodine-deficient can maintain normal thyroid

function states even at intakes of several milligrams of dietary iodine per

day;

the incidence of non-toxic diffuse goiter and toxic nodular goiter is

markedly decreased by high dietary iodine intake;

5 0

the incidence of Grave's disease and Hashimoto disease does not appear

to be affected by high intakes of dietary iodine.

However, high intakes of dietary iodine may induce hypothyroidism in auto-

immune thyroid diseases and may inhibit the effects of thionamide drugs (WHO,

1 994).

2.22 Physiological need for iodine

Based on studies of balance and excretion over 24 hour period, a safe daily

intake of iodine has been estimated to be between a minimum of 5019 and a

maximum of at least 10001g (WHO, 1991 and Stanbury and Hetzel, 1980). A

generally accepted desirable adult intake is 100-300pglday. At all intake levels,

a proportionate amount of iodine is excreted in the urine, which is the

biochemical basis for assessing iodine status (Dunn et a/., 1993).

2.22.1 Usual salt intakes

Average daily intakes vary from country to country. Usually, consumption levels

are within the 5-15gldayWlrange for children and adults. No increase in salt

consumption is called for. Rather, the recommended level of salt iodization

should be adjusted to provide approximately 150pg of iodine per day. Actually

consumed, taking into account usual climatic factors like heat and humidity,

which can affect retention of this element. The recommended quantities of

iodate to be added to salt under different conditions are provided in Table 3

(ICCIDDIUNICEFNVHO, 1993). Although potassium iodide was first used in salt

iodization, the use of iodate is now recommended since it is more stable than

iodide under varying climatic conditions. Because iodate, on ingestion is very

rapidly reduced to iodide, its use in iodinated salt is equivalent to iodide.

Table3: ICCID-UNICEF-WHO recommended levels of iodine in salt. Examples of desirable average levels at various points in the salt distribution chain, depending on climate, salt intake and conditions affecting packaging and distribution

Parts of iodine per million parts of salt, i.e micrograms per gram, milligrams per

kilograms or grams per tone

Climate and Requirement of Requirement of Requirement at retail Requirement at daily salt factory outside factory inside the sale (shoplmarket) household level

consumption the country country (glperson) Packaging

Bulk Retail Bulk Retail pack Bulk (sack) Retail (sack) pack (Sack) (<2kg) pack

(<2kg) (<2kg) Warm Moist %I 100 80 90 70 80 60 50 109 50 40 45 35 40 30 25

Warm dry or cool moist 34 90 70 80 60 70 50 45 109 45 35 40 30 35 25 22.5 Cool dry 59 80 60 70 50 60 45 40 1 og 40 30 35 25 30 22.5 20

Source: Adapted from World Summit for Children mid-decade goal: Iodine deficiency disorders (Geneva, 1994).

UNICEF-WHO Joint Committee on health Policy, document JCHPSSl9412.7 and

reference 5.

N.B: 168.6 mg of K103 contains 100mg of iodine . ,, 4 -1 . ,!'

N.B: These are indicative i n i t i a l h l s , which should be adjusted in the light of

urinary iodine measurement.

2.22.2 Other sources of iodine

Poultry and eggs from animals that consume fish flour as part of their feed

and iodoform in water that is used as a disinfectant.

- Cow's milk and dairy products from animals fed seaweed, producing an

iodine content

- Breed and baked goods through the iodates used as oxidants in dough

conditioners and cleaning agents for bakery equipment

The iodine-containing colouring agents added to some drugs including

many multivitamins, minerals, and antacids as a creating or colouring

agent), beverages, foods including some brands of dry cereal that contain

as much as 850 pg of iodine per 209 of product) and cosmetics.

2.22.3 Iodine availability

The iodine content of food actually consumed is not necessarily equivalent to

that of raw food since some iodine is lost during cooking. For example, losses of

about 20% occur in the iodine content of fish by frying or grilling and as much as

58% by boiling. Iodine consumed in food is generally well absorbed, with the

possible exception of people suffering from protein-energy malnutrition, which is

of particular concern in lhigh.:.prwalence, endemic goiter areas of developing

countries.

The uptake of radioactive iodine by an individual thyroid is dependent on

the amount of stable, i.e. non-radjoactive, iodine in the diet. This is the basis for

using radioactive iodine to evaluate thyroid function. Studies from Chernoby

following the nuclear reactor accident in 1986 indicate high thyroid cancer rates,

especially among young children. It is postulated that the thyroids of children in

this iodine-deficient area experienced an unusual uptake of radioactive iodine

released into the atmosphere following the accident. It has been estimated that,

53

in general, iodine prophylaxis, e.g. use of iodized salt, should reduce by two fold

to three fold the risk of thyroid irradiation resulting from a nuclear accident

(Rubery and Samles, 1990).

Daily iodine intakes of up to Img, i.e. IOOOpg, appear to be entirely safe.

lodization of salt at a level that assures an intake of 150-300pglday thus keeps

intakes well within a safe daily range for all populations, irrespective of their

iodine status. Daily consumption of log of salt containing 50 parts per million of

iodine would add a maximum of only 500pg of iodine. Thus the likelihood of

exceeding an iodine intake of Imglday from iodized salt is quite small.

In susceptible individuals - a minority of adults, usually over 45 years of

age, who may or may not have nodular goiters - transient side-effects have

been reported at usual intakes exceeding 500-3000pglday. The benefits to be

derived from universal salt iodization by the more than 1500 million people

estimated to be at risk or deficient, and the absence of significant adverse effects

among others in the same areas that are not iodine-deficient, far outweigh any

risk of excess intake for a small minority (Rubery and Samles, 1990).

2.22.4 Iodine requirements

90pg for children (2~8,yeim of'age)

120 pg for school children (7-12 years of age)

150 pg for adults (beyond 12 years of age)

200 pg for pregnant and lactqting Women (WHOINUT, 1996).

2.22.5 Required Iodine levels in Salt

Taking into account the following revised assumptions, which are based on new

information:

iodine lost from salt is 20% from production site to household,

another 20% is lost during cooking before consumption,

- average salt intake per capita is IOgIday,

In order to provide 150 pglday of iodine concentration in salt at the point

of production should be within the range of 20-40mg of iodine (or 34-66mg

potassium iodate) per kg of salt, when all salt used in processed food is iodized,

the lower limit (20mg) is recommended. Under these circumstances, median

urinary iodine levels will vary from 100-200 pgll (WHOINUT, 1996).

2.22.6 Quality of available Salt

(WHOINUT, 1996) reported that in many situations in developing countries,

however, despite improvements in salt production and marketing technology, the

quality of available salt is poor, or salt that has been correctly iodized

deteriorates due to excessive or long term exposure to moisture, light, heat and

contaminants. Under these circumstances, iodine losses can be 50% or more

from the moment salt is produced until it is actually consumed, and median

urinary iodine levels could thus fall below the recommended range (100-200

pgll). In addition, salt consumption is sometimes considerably less than

10glpersonlday. All these factors should be taken carefully into account,

particularly when establi~h7rig"the initial level of iodine in salt.

2.22.7 Trace elements are those elements of the periodic table that occur in the

body in pglg amounts or less. They may be essential (i.e. indispensable for

growth and health), or they may be non-essential, fortuitous reminders of our

geochemical origins or indicators of environmental exposure. All that trace

elements are potentially toxic when intake is excessive. Trace elements known

to be essential to humans are chromium, cobalt, copper, iodine, iron,

molybdenum, selenium, zinc and possibly boron.

5 5

An element is considered nutritionally essential if an organism can neither

grow nor complete its life cycle in the absence of the element (Nielson, 1991).

An element is nutritionally essential if a dietary deficiency consistently

results in a suboptimal biological function that is preventable or reversible by

physiological amounts of the element. In this definition, physiological is

construed as those quantities usually found in biological material.

2.23 Biological roles of trace elements

Trace elements have four known roles in living organisms.

1. In close association with enzymes, some trace elements are an integral

part of the catalytic centers at which the reactions of biological chemistry

occur. Working in concert with a protein, and frequently with other

organic coenzymes, the trace element attracts substrate molecules that

facilitate their conversion to a specific end product.

2. Some trace elements donate or accept electrons in reactions of reduction

or oxidation. These redox reactions are of primary importance in the

generation and utilization of metabolic energy through the "burning" of

foods in cells. Chemical transformations of molecules frequently involve

redox reactions:' '.' '" '

3. Some race elements (especially iron), bind, transport and release oxygen

in the body

4. Some trace elements ,,have:structural roles, i.e imparting stability and

three-dimensional structure to important biological molecules (Nielson,

1991).

Table 4.0: Iodine -trace elements for human nutrition

Trace Adult Recommended Daily Essential Biological function element human daily intake sources status for

body human content

Iodine I lgm 150 IJS @ Iodized salt, Essential Component of thyroid sea food, food from high-iodine soils

hormones, thyroxine (T4) and triiodothyronine (T3)

(a) Recommended dietary allowance established by the National Academy of Sciences (Nielson, 1991).

The most common manifestation of iodine deficiency is goiter, or

enlargement of the thyroid gland. With severe and prolonged iodine deficiency

hypothyroidism, or myxedema, occurs. Myxedema is characterized by reduced

metabolic rate and the accumulation of a jellylike substance, mucin, in the body;

these in turn, cause a great number of their characteristic abnormalities. A

deficiency of iodine during pregnancy, infancy or early childhood may result in

cretinism. Cretinism is characterized by mental retardation, retarded growth,

deafness, deaf mutism, delayed psychomotor development, and various

neurological abnormalities.

Excessive intake of iodine may cause hyperthyroidism (thyrotoxicosis).

The symptoms are hyperthyroidism, goiter, bulging eyes, rapid heart beating,

fatigue, weakness, increased appetite and weight loss. Iodine intakes of 2000

pglday have been suggested as being excessive.

Both iodine deficiency and toxicity are practical nutritional concerns.

However, iodine deficiency seldom occurs in the United States because of the

use of iodine-containing compounds in the dietary and baking industries salt.

iodine deficiency continues to be a significant problem in some mountainous,

third world countries found in the Andes Chain, parts of Africa, and south-east

and central Asia. G'oit&''occurs as a consequence of large intakes of dietary

iodine in Japan and other Oriental countries were seaweed containing high

mounts of iodine is commonly eaten.

Urinary iodine excretion is.'the most appropriate outcome indicator for

iodine (Pardede, 1998). Iodine deficiency is the leading cause of mental

impairment and has serious effects on the physical development of children, on

young child mortality and on the reproductive performance of women as

indicated by increased rates of abortion, stillbirth and congenital abnormalities,

(Hetzel, 1983). The most notable clinical sign of iodine deficiency is goiter.

5 8

Iodine deficiency, which is the primary cause of preventable mental

retardation in children, remains a major global public heath problem. There has

been widespread mobilization in the international community over the last

decade in support of eliminating iodine deficiency disorders (IDD). Most

countries where IDD is a public health problem have taken measures to control

iodine deficiency mainly through universal salt iodization programmes.

In May 2002, the United Nations General assembly in its special session

on children endorsed the goal of IDD elimination by 2003. The World Health

Organisation (WHO) continually updates its Global Database on IDD as part of

its mandate to track progress made by countries in meeting this goal, to follow

trends and to monitor the sustainability of implemented salt iodisation

programmes. Updated global estimates of iodine deficiency were recently

released (De Benoist, Anderson, Egli and Takkouche, 2003).

CHAPTER THREE

3.0 MATERIALS AND METHODS

3.1 Study Area

The study was carried out in Obukpa in Nsukka Local Government Area of

Enugu State, which is a town of Northern lgbo culture area. Seven towns helm

Obukpa in. In the south are Nsukka and Ero-Uno; in the east are Orba and

Ovoko; in the north are Iheakpu-Awka and Ibagwa-Aka; and flanked in the west

by Ibagwa-Ani and the small settlement Okpaligo (Ugwu, 1987). Obukpa was

selected because it is a typical rural community and one of the catchment

communities to the University of Nigeria Teaching Hospital (UNTH). Not much in

terms of research has been documented about it.

Obukpa community is divided into three quarters, namely: Ajuona, Owerre

and Obige. Each quarter is made up of sub-quarters which have several

kindreds (Ugwu, 1987). There are at least seven community primary schools:

sited at Ihe, Owerre, Ajuona, Amagu Umuora, Ime-Okpe, Ugbagu and Central

School Obukpa at Eluagu. There is one community secondary school at

Ochikum. ., ,, . 9 .r, ,:' , . ..:,a '

As in most rural communities, there is no pipe borne water except the

borehole sited at Eluagu. Almost all of the villages are electrified. In each set up,

women and children fetched water from the borehole or University borehole or , I

from local stream and/or harvested rainwater. There is a UNTH Comprehensive

Health Centre at Umuekwu. Obukpa holds two small markets at "Nkwo" and

"Eke" (native market days) every four days. The inhabitants are mostly farmers

and traders on food items.

The community has two main seasons namely: dry (November to March)

and wet (April to October). Petty farming is practiced in the wet season. The

60

main staple includes cassava (Manihot esculenta), maize (Zea mays), cocoa

yam (Colocasia spp), pigeon pea (Cajanus cajan), and sweet potatoes (Ipomoea

batatas). Obukpa has a population of 210, 1800 (FOS, 1992).

3.1.1 Study population

The subjects consist of primary school children aged 6-12 years. The ages of

the children were derived from the school registers or available information

possible to ascertain their ages.

3.1.2 Approach to the local community

The names and population. of all the schools in the community were collected

from the Local Primary Education Board at Nsukka town. A letter of introduction

and approval from the Chief of the Obukpa community was presented to the

headmaster of each school. Mothers were addressed at their monthly meetings

and their consent and cooperation were solicited.

3.1.3 Design and sampling procedure

The study was longitudinal lasting from March 2004 to February 2005. Three out . " 1 . ..'

of the seven primary schools in fhe community were randomly selected for study.

3.1.3.1 Sample size calculation

The sample size was calculated using the formula:

Where N = total number of children required

p = proportion of the subjects assumed to have subnormal iodine urine

excretion and nutritional status.

6 1

p = 28%

IlTA (2004) reported that 27.5% of the children suffered various degrees of

iodine deficiency

W = required precision level or probability level for the study

W = 0.05(5%)

In order to make up for drop outs, this figure approximated to 330. The

sub-sample for determining casual urinary iodine excretion, stool biochemistry

and anthropometric measures were obtained using 10% of the total sample as

follows:

3.1.3.2 Sampling Procedure: The sampling frame comprised all school

children from class one to five.

The source of sample frame was obtained from the school register.

This was done by stratified systematic random sampling and simple random

sampling. The three schools constituted the three strata. The total sample size

was three hundred and thirty children.

The procedure for systematic random sampling is given below:

The population sampled was obtained from the school registers; the count of

units was known i.e. 330. The total number of the units in the sampling frame

(N) i.e. (children population) was, divided by the required number of units in the

sample (n) to obtain the sampling interval (K)

K=N/n

The first unit from the population was selected randomly using some method of

simple random selection. The rest of the units were chosen systematically by

selecting every Kth unit on the list.

3.2 Training of personnel

Two research assistants from the community were trained on carrying out the

interview schedule, and filing of questionnaire plus collection of urine, stool

samples and taking anthropometric measurements. The researcher tested the

salt samples using the test kit and supervision of the work.

3.3 Data Collection: - Methods

Basic data by questionnaire

A validated and pretested questionnaire were used to gather basic information

from the mothers on social demographic characteristics of the household, health

facilities, health records and practices, morbidity and health status, IDD and

health status, food intake, 24-hour dietary recall and KAP of mothers on iodized

salt ADD. The questionnaire will be filled with the assistance of field workers.

3.3 Clinical examination

Each pupil in the sub-sample was clinically examined in detail for iodine

deficiency disorders. To avoid bias, the visible goiter (Grade II) was used for

estimating the level of 10d; 'shce the contour of the neck, and the fat pad of the

neck especially girls, might give a false impression of Grade I thyroid swelling.

3.4 Anthropometric measur;ements

General initial anthropometric measurements were made on all the units in the

sample size to determine their nutritional status. The measurements were

carried out every month on a sub-sample of ten percent of the sample size for a

year to determine growth velocity (rate). Anthropometric measurements

included height and weight

3.4.1 Height: The heights of the subjects were measured without shoes and

stockings with microtoise anthropometer. In measuring the height, the subjects

were made to stand on a horizontal platform with feet parallel to each other. The

back and knee were made straight. The subjects stretched upwards to the fullest

extent by applying a gentle traction by holding the subject's head at each side

over the mastoid process (just behind the ear). Then the head piece lowered by

a second person and the reading taken to the nearest centimeter and recorded.

The subject's heels matched to make sure that they did not leave the ground

while the traction was being applied (WHO, 1986; Lohman et a/., 1988).

3.4.2 Weight: weight of children would be obtained on a scale (C.M.S.

Weighing Equipment Ltd), with a capacity of 100kg and accuracy of 59. The

children would be weighed wearing only shorts or minimum clothing. All

measurements would be made according to standardized procedure (Lohman et

a/., 1988).

3.4.3 Growth monitoring and velocity measurement: longitudinal monthly

monitoring of weight ahB h"eGht for one year by anthropometric measurements

would assess growth. Changes in weight (kg) and height (cm) during the one-

year period would represent the weight and height velocities per year or the

annual growth rate for each child. Mean monthly and quarterly velocities were

calculated.

3.5 Urine: Samples of urine were collected from the pupils in sterilized clean

containers marked, numbered and distributed to the children on the day of

collection. The samples transported in an ice pack to the laboratory and were

64

analysed immediately, with the help of a biochemist, using "method H", as

recommended by IDD Newsletter ( I 998).

3.5.1 Urinary iodine excretion

Casual urine samples were collected from the subject (the school children) to

determine the urinary iodine excretion using "method H". The currently

recommended technique is "method H" (IDD Newsletter, 1998). Small samples

of urine (250-500 microlitres) were digested with ammonium per sulfate at 90-

1 looF degrees; arsenious acid and uric ammonium sulfate were then added. The

decrease in yellow colour over a fixed time period was measured by a

spectrophotometer and plotted against a curve constructed from standards with

known amounts of iodine, ran in the same assay. This method required a heating

block and a spectrophotometer, and plotted against a curve constructed from

standards with known amounts of iodine, ran in the same assay.

Frequency distribution curves are necessary for full interpretation,

because urinary iodine values from population are usually not normally

distributed; therefore, the median value should be used rather than the mean. An

indicator for iodine deficiency elimination was a median iodine concentration of 4 * I ..'

100 microgrammes iodhe per litre, that was, 50% of the samples should be

above 100microgrammes iodine per litre. Urine and not more than 20% of

samples should be below 50 microgrammes per litre. The urinary iodine

concentration was currently the most practical biochemical marker for iodine

nutrition. It assessed iodine nutrition only at the time of measurement, whereas

thyroid size reflected iodine nutrition over months or years. Therefore,

populations may have attained iodine sufficiency by median urinary iodine

concentration, yet goiter may persist in children.

65

3.6 Parasitic load

3.6.1 Stool: Containers were marked, numbered and distributed to children a

day to the day of collection. Instruction on how to collect a small sample the

following morning was given to the children. Collection was done in batches of

eleven samples per day. The samples were transported in an ice pack to the

laboratory and analyzed immediately by a pathologist.

3.6.1 .I Qualitative direct wet smear technique

The method was used to detect protozoa e.g. flagellates, Entamoeba and their

cyst.

Method

About 29 of stool was taken and emulsified in 5mls of normal saline.

About 2 loopful of the emulsified stool were taken unto a slide.

Then slide was covered with the cover slip.

And viewed with XI 0 Objective and confirmed with x40 and for details.

3.8 Salt monitoring (spot-test kit): The iodine content of the salt sample

collected from the pupils"was'"estimated with the spot-test kit from UNICEF,

Enugu.

3.9 Data analysis: Statistical pack&e for the social sciences (SPSS) was

used.

3.9.1 Questionnaire

Data on questionnaires were analyzed using frequencies, percentages, and

correlation of information gathered on KAP.

Data for the iodine deficiency information statements formulated to elicit the

attitudes of the respondents were all given above-average mean ratings (> 3.00)

on a 5-point Likert type scale. The five points on the Likert type scale were

weighed in order of degree of agreement: Strongly agree (SA) = 5; Agree (A) =

4; Undecided (UD) = 3; Disagree (D) = 2 and Strongly Disagree (SD) = 1. The

overall level of agreement with the eight iodized salt and iodine deficiency

statements was determined by dividing the grand mean score by eight .

3.9.1.1 Data on anthropometric assessment was analyzed under stunting, wasting and underweight

Stunting = Height -for-age at <-2 standard deviations (SD) of the mean value of

NCHSNVHO Standard. Severe stunting is defined as <-3 SD.

Wasting = Weight-for-height at <-2 standard deviations (SD) of the mean value

of NCHSNVHO standard. Severe wasting was defined as <-3 SD.

Underweight = Weight-for-age at <-2 standard deviations (SD) of the Mean

value of NCHSNVHO standard.

3.9.2 Worm load analysis

Mean and correlation analysis. were used to correlate variables, such as:

Worm load and Iodine in urine

Worm load and stunting

Worm load and underweight , I . ..

Worm load and wasting

Iodine in urine and stunting

Iodine in urine and underweight

Iodine in urine and wasting

CHAPTER FOUR

Result

Table 4.1 Background of the subjects

Parameter No %

School Community primary 112 37.3 School (C.P.S.) Ajuona

Community primary 101 School (C.P.S.) Owerre Obukpa

Community primary 87 29.0 School (C.P.S.) Amagul Umuorua Total 272 100.0 Sex Male 154 51.3 Female 146 48.7 Total 272 100.0 Age group 6-7 years I I months 68 22.7 8-9 years I I months 98 32.6 10-1 1 years I I months 90 30.0 12-1 2 years I I months 44 14.7 Total 272 100.0

4.1 General characteristics of the subjects

Table 4.1 showed that 37.3% were from community primary school (C.P.S)

Ajuona; 33.7% from community primary school (C.P.S) Owerre-Obukpa and

29.0% from community primary school (C.P.S) AmaguIUmuorua. In age group,

32.6% were within 8-9 years I lmonths, 22.7% were within 6-7years I Imonths

and 14.7% were within 12-12years I Imonths. Of this number, 51.3% were boys

and 48.7% were girls.

Table 4.2: Socio - demographic characteristics of respondents' household (parents).

Parameter No Percent Headship of household Male Female Total Gender of respondents Male Female Total Family size 1-5 6-1 0 17-15 Total Religion Christian Muslim Traditionalist Total Marital status Married Single Divorced Separated Widow Total Community or kindred Ajuona Owerre Obukpa Amagu/Umuoru . ,* ...

70

4.2 Socio- demographic characteristics of the household of the subjects

Most subjects (64.0%) said they were not heads of their household while

(36.0%) were heads (Table 4.2). The total respondents were female, two

hundred and seventy two in number.

Most households (61.8%) had 6 to 10 members, while (31.3%) had 1 to 5

members. Almost ninety percent (89.7%) were Christians, while (10.3%) were

traditionalists.

The marital status of the respondents showed that most of them were

married (76.9%) while a few (14.0%) were widowed.

The respondents from Owerre-obukpa and Amagu/Umuoru were slightly

more in number (33.8%) than respondents from Ajuona (32.4%) (Table 4.2).

Table 4.3: Educational attainment and occupation of respondents and household heads

Respondents Household heads

Parameter No % No %

Education None

Primary school Uncompleted

lo school Completed

2' school Uncompleted

2' school Completed

Post 2' school

University

Total Occupation Trading

Farming

Skilled work

Unskilled work

Civil servant

Full timelhome- Makers

Total 272 99.9 272 99.9

72

4.3: Socio- economic characteristics

Most of the mothers and the household heads had little or no formal education

(41.2% and 35.0%) respectively. About nineteen percent (1 9.1 %) of respondents

and (23.9%) of household heads completed primary school. Those who were

unable to complete primary schools were 15.4% and 17.6% respectively. A few

had secondary school, post secondary schools, and university education: 11.4%

and 9.6%, 6.6% and 5.9% 4.4% and 7.4% respectively, (Table 4.3).

Petty trading was the major occupation of the respondents (46.3%), while

farming was the major occupation of the family heads (32.75). Twenty-nine

percent of respondents engaged in farm work and a few in teaching (5.9%) and

civil service (5.1%). A few family heads (24.6%) engaged in trading, civil service

(23.5%) and (15.1%) in skilled work (Table 4.3).

Table 4.4: Sources of income, amount and expenditure on food

Expenditure (N) No % 500-3,500 73 26.8 3,501 -6,5000 108 39.7 6,501-9,500 40 14.7 9,501-1 2,500 29 10.7 12,501-13,000 22 8.1 Total 272 100.0 Contributions from relatives per month

Response No % Yes 7 3 26.8 No 199 73.2 Total 272 100.0 Amount per month No % N 500 - 1,500 31 42.47 PC 1,501 - 2,500 28 38.36 N 2,501 - 3,500 4 5.48 Above N 3,501 10 13.70 Total 272 100.0 Sources of Income Parameter No % Salary 52 19.1

Sales from farm proceeds 130 47.8 Trading 84 30.9 Others specify 6 2.2 Total 272 100.00

One pound sterling = N240 at time of sunley One dollar = N133.5 at time of study

4.4 Contribution for the upkeep of household

Above fourty percent (39.7%) of families spent from 443,501 to 446,500 on food

per month followed by (26.8%) who spent 44 500 - 3,500 on food per month.

About (33.5%) spent between 81 6,501 to 81 13,000 on food per month as shown

in Table 4.4.

Data from Table 4.4 revealed that most families (73.2%) did not receive

financial assistance for the upkeep of their household from other relatives, while

(26.8%) did. About (43.0%) of those who received financial assistance got

between 44500 - 44 1,500 per month. Then followed by (38.36%) of families

received 441,501- 442,500 and about fourteen percent (13.7%) received above 44

3,501; while five percent (5.48%) received 442,501 - 3,500 monthly. In Obukpa

community most households (47.8%) depended on sales of farm produce as

source of income, while 30.9% obtained their income from trading, (Table 4.4).

Table 4.5: Health facilities and health practices in the three communities Number of available health facilities No %

Health centreslhospitals

None One Two Three Source of drinking water

Public tap Borehole RiverslSpring Tankers Rain water Other specify (combination of sources) Water Treatment None Filtering Bo~ling Boiling and filtering Addition of Milton Addition of alum Washing of pots Once a week Twice a week Thrice a week Daily Once a month Once a while Toilet Facilities Bucket Pit Bush Water closet Times mothers ensure hand washing by children After toileting After back from school. Before eating After play All of the above No time . , I . * I . r t ' +

After toilet and before eating No. of woman with goiter Yes No Treatment received by goiter patients Operation Iodine salt , I

Oil iodine injection Nothing Herbal Last time children were de-wormed 1-3 months ago 4-6 months ago A year ago 1 -2years Never Total 272 100.1

Table 4.6: Goiter History

No %

Women with goiter

Yes 28 10.3

No

Total

Treatment received by goiter

patients

Operation

Iodine salt

Oil iodine injection

Nothing

Herbal

Total 28 100.0

4.5 Health facilities and health practices

Modern health centers/hospitals were sited at least one (85.3%) in Obukpa

community to meet with the health needs of the people (Table 4.5).

There were combined sources (82.0%) of drinking water for the people of

Obukpa: rain water during rainy season, borehole, tankers and spring water

during dry seasons. Drinking water were rarely treated (72.4%), while 14.3%

filter their drinking water (5.5%) boiled, (5.5%) boiled and filtered and (2.2%)

added alum to water (Table 4.5). With regards to cleaning water pots 28.3% did

so once a while, 23.9% twice a week, 19.1% thrice a week, 18.8% once a week,

9.6% daily and 0.4% once a month.

Precisely 57.7% of the surveyed households had pit toilet and 37.9%

defecate in the bush (Table 4.3, while 4.4% had water closet.

Sixty point seven percent of mothers ensured hand-washing before

meals (Table 4.5) 14.3% did ensure hand-washing after toileting and before

eating, while 6.3% did not bother. Table 4.5 showed that most children (49.3%)

were last de-wormed 4-6months ago. Eleven percent of mothers reported they

never de-wormed their children.

Ten percent (10.3%) of respondents had history of goiter. Subsequently

67.9% of goiter patients did not treat their goiter while 25.0% had the goiter

operated upon and 7.1% hw'he'rbal treatment (Table 4.6).

Table 4.7: Morbidity and health history of children

Parameters No Oh

Common ailments

FeverJmalaria 125 46 Diarrhea 48 17.6 Nothing 19 7.0 Measles 27 9.9 Coughkatarrh 33 12.1 Hepatitis 2 0.7 Typhoid fever 5 1.8 Worm 13 4.8 Total 272 99.9 Reasons for hospitalization Malaria 86 31.6 Diarrhea 37 13.6 Cough 23 8.5 Measles 23 8.5 Hepatitis - - Typhoid fever 4 1.5 No hospitalization 99 36.4 Total 272 100.1

4.6 Morbidity and health history of children

The commonest ailments reported by the mothers included malarialfever

(46.0%), diarrhea (17.6%), coughlcatarrh (12.1%), measles (9.9%) (Table 4.7).

Ailments that led to the hospitalization of children were malaria /fever

(31.6%), diarrhea (13.6%), measles (8.5%) and cough (8.5%) as shown in

(Table 4.7).

Table 4.8: Possible symptoms of iodine deficiency as reported by mothers

Parameter No YO Deafnesslhard hearing Yes 6 2.5 No 266 97.8 Muteness Yes No 272 100% Slow to understanding Yes 10 3.7 No 262 96.3 Poor performance at school Yes 7 0 25.7 No 202 74.3 Abnormally short Yes No 272 100 Goiter swelling Yes No 272 100 Abnormal behavior Yes 3 1.1 No 269 98.9 Congenital abnormalities ,

Yes 2 0.7 No 270 99.3 Squint Yes 2 0.7

Table 4.9: Source of food and meal pattern of respondents

Sources No YO Mostly home produced 57 21 .O Partly home produced and Partly purchase

, ,, .nl 3.' r

21 5 79.0 Mostly purchased Meals children eat in the day Break fast only 17 6.3 Lunch only 17 6.3 Super only 15 5.5 Breakfast, lunch and super 125 46.0 Bread fast and lunch 16 5.9 Breakfast and supper 37 13.6 Breakfast, lunch, supper and occasional 4 5 16.5 snacks 24hr Dietary recall Carbohydrate 147 54 Protein 79 29 Oil and fats 5 1.8 Fruits and vegetables 41 15.1

4.7 Symptoms associated with iodine deficiency disease

Table 4.8 showed that mothers observed the following symptoms of iodine

deficiency in their children: deafnesslhard hearing (2.5%), slow in understanding

(3.7%), poor performance at school (25.7%), abnormal behavior (1.1%),

congenital abnormalities (0.7%), and squint (0.7%) (Table 4.8).

4.8 Household food security

Table 4.9 showed that (79.0%) of the household foods were partly home

produced and partly purchased, while (21.0%) mostly produced their foods at

home.

The meals children eat in a day about (46.0%) ate breakfast/lunch/supper,

16.5% ate breakfast/lunch/supper and occasional snacks; and (13.6%) had

breakfast and supper only. About (5.9%) had breakfast only or lunch only, while

5.5% had supper only (Table 4.9).

Table 4.10: Knowledge of iodized salt and iodine deficiency diseases (IDD) by respondents

Had knowledge Had no knowledge

Variable No 1 Knowledge of iodized salt 36 2 Causes of goiter 25 3 Iodine deficiency causes goiter 26 4 Other consequences of iodine deficiency 6 5 Iodized salt in container with tight lid is 10

better preserved 6 Iodine in salt may evaporate when 26

exposed for a long period under the sun 7 High temperature causes loss of iodine 28

from iodized salt 8 Knowledge of the banning of non-iodized 22

salt

Table 4.1 1 Lack of knowledge of iodized salt and ID0 by different communities used in the study

Variable Ajuona Owerre- Amagul Total p-value (No) Obukpa Umuorua (No)

(No) (No)

Had knowledge of iodised salt 55 80 69 204 17.281NS P>0.05

Causes of goiter 58 86

The awareness that iodine deficiency 57 81 causes goiter

Other consequences of iodine deficiency .,+ 63 .. ,, 4 m l , 7 1

Iodized salt in container with tight lid is 62 69 better preserved

Iodine in salt may evaporate when 42 64 exposed for a long period under the sun ,,

High temperature causes loss of iodine 65 89 from iodised salt

The awareness of the banning of non- 81 77 iodized salt

d.f.= 4 NS=Not significant

4.9 Respondents' knowledge of Iodized salt and iodine deficiency disorders (IDD)

Entries in Table 4.10 revealed that majority (86.8%) did not have the knowledge

of what iodized salt was, while (13.2%) had knowledge of it.

The table also showed that 90.8% of the respondents had no knowledge of what

caused goiter, while 9.2% knew the cause.

The knowledge that goitre was due to iodine deficiency was shown by

9.6% of the respondents, while 90.4% did not have the knowledge that goitre

was due to iodine deficiency. More respondents (97.8%) were not aware of other

consequences of iodine deficiencies, while 2.2% were aware. On better

preservation of iodized salt in container with lid, only 3.7% of the respondents

knew about it while 96.2% did not.

Majority (90.4%) of the respondents had no knowledge that exposure of

salt under the heat of the sun for a long period cause evaporation of the iodine,

while 9.6% had this knowledge. Majority of the respondents (89.7%) did not

know that high temperature caused loss of iodine from iodized salt, while 10.3%

knew about it. Awareness of the banning of non-iodized salt was another point

raised but majority (91.9%) of the respondents were not aware of the banning

order by the Federal Government of Nigeria of non-iodized salt as indicated in

Table 4.1 0.

In the relationship of the mothers' lack of knowledge of the iodized salt . , 1 . . > '

and IDD to their different communities, majority of the mothers who lacked

knowledge were from Amagu/Umuorua community followed by Owerre-Obukpa.

Using Chi-square analysis in Table 4.1 1 showed that there were no significant

differences in the relationships between the variables of knowledge on iodized

salt and IDD and the three communities of the mothers at (p>0.05).

Table 4.12: The mean ratings of the attitude of the women to iodized salt and iodine deficiency

Iodized Salt and Iodine Deficiency Mean Standard Rating Information Statement Importance in creating IDD awareness I could be a source of creating awareness Should encourage iodized salt productionlmarketing Prevent iodine vaporising from iodised salt Iodine deficiency causes goiter in patients Waterlmoisture should not come in contact with iodized salt Avoids goitre patients

Ratings 3.86 3.64

3.63

3.53

3.48

3.32

3.00

Deviation k0.97 k0.96

k0.91

k0.82

k0.82

k0.995

kl.178

Position 1 2nd

3rd

4'h

5'

6'"

7'h Favours banning of non-iodized salt 1.74 k0.93 8th

Grand mean score = 26.2

Level of agreement with iodized salt and iodine deficiency information statements = 3.28

On a 5-point Likert scale

4.10 The result of the mean ratings and standard deviation distribution of the attitude of the women to iodized salt and iodine deficiency

Attitude to iodized salt and iodine deficiency

Data in Table 4.12 showed that statement no.1 "importance in

creating IDD awareness", received the highest mean rating of 3.86 * 0.97. The

statement no. 2 "1 could be a source of creating awareness" had a mean rating of

3.64 k 0.96. The statement no. 4 "should I encourage iodized salt

productionlmarketing" took the 3rd rating position with a mean of 3.63 * 0.91.

Statement no. 5 "Do not allow iodine vaporizes from iodized salt" had 41h position

with mean rating 3.53 k 0.82. No. 3 statement "iodine deficiency causes goitre in

patients" took the 5th position with mean rating 3.48 k 0.82. "Waterlmoisture

should not come in contact with iodized salt" is the No.6 statement with 61h

position having mean rating 3.32 k 0.995. Statement no. 8 "Avoids goitre

patients" took the penultimate position 71h with mean rating 3.00 k 1.178 and the

81h position with mean rating 1.74 k 0.93 is the statement "favours banning of

non-iodized salt".

Table 4.13: Practices based on knowledge on iodized salt and iodine deficiency disorders by mothers

Practice based on No Practice Iodized salt and iodine deficiency knowledge

disorder indices No % No YO Creating IDD awareness 34 12.5 238 87.5

Recommending iodized salt to goitre 36 13.2 236 86.76 patients

Iodized salt container covered 37 13.6 235 86.4

Table 4.14: Comparing the practices based on knowledge on iodized salt and iodine deficiency disorders by mothers of the three communities

Indices Ajuona Owerre- Amagul Total p-value Obukpa Umurua

(No) (No) (No) (No)

Creating IDD awareness 68 67 69 203 1.817~' p>0.05

Recommending iodized 67 5 5 72 194 18.525~' salt to goitre patients - " '"'. "' " ' p>0.05

Iodized salt container 68 56 7 1 195 8.098~' covered p>0.05

d.f.=4 NS=Not significant

4.11 Results of the respondents' practices with iodized salt and iodine deficiency disorders (IDD)

Table 4.13 showed that majority (87.5%) of the respondents did no practice,

"creating IDD awareness and recommending iodized salt to goitre patients while

12.5% did.

Iodized salt as a therapy for goiter patients as shown in Table 4.13

revealed more respondents (86.76%) did not practice "recommending iodized

salt to goitre patients" and 13.21% did recommend it.

Container for iodized salt covered, was not practiced by 86.4% of the

respondents while 36.6% practiced it.

Table 4. I 4 Using chi-square analysis there were no significant differences

as regards the relationship of the mothers from different communities and their

lack of practice of iodized salt and IDD (p>0.05).

Table 4.15 Anthropometric measurements of children in the study

-

Nutritional WIA HiA WIH

status No % No % No %

(Low) 39 13.0 75 25.0 16 6.3

(Normal) 258 86.0 221 73.7 271 90.3

(High) 3 1.0 4 1.3 13 4.3

Table 4.16: Nutritional status classification according to gender

Boys Girls Weig ht-for- N O/O N O/O

age < -2SD 20 6.7 19 6.3 -2 to +2SD 131 43.7 127 42.3 >+2 SD 3 1 .O - - Total 154 51.3 146 48.7 Heig ht-for- age < -2SD 4 1 13.7 34 11.3 -2 to +2SD 11 1 37 110 36.7 >+2 SD 2 0.7 2 0.7 Total 154 51.3 146 48.7 Weig ht-heig ht N % N YO < -2SD * ,, 7d. .,. . a 2.3 9 3.0 -2 to +2SD 139 46.3 132 44.0 >+2 SD 8 2.7 5 1.7 Total 154 51.3 146 48.7

<-2SD = LOW -2 to +2SD = nol'tnal. -. >+2SD - - above normal

Low indicated underweight, stunting and wasting depending on the indicator. Z-scores of <- 2.0 standard deviation from NCHS median value was used as cut -off. W/A - Weight -for - age

H/A - Height - for -age W/H - Weight - for - height

4.12 Anthropometric Measurements

Percentage distribution of the nutritional status of the children according to their weight-for-age, height-for-age and weight-for-height

In Table 4.15 using weight-for-age thirteen percent (1 3.0%) of the surveyed

population were underweight, while 86.0% were normal and 1.0% overweight.

Using height-for-age, 25.0% were stunted, while 73.7% were normal and (1.3%)

too tall. Using weight-for-height, 5.3% were wasted, while 90.3% were normal

and 4.3% obese.

4.13 Nutritional status classification according to gender

Table 4.16 showed that more girls (3.0%) than boys (2.3%) were wasted while

more boys (2.7%) than girls (1.7%) were above normal. For normal weight-for

height there were more boys (46.3%) than girls (44%).

4.14: Nutritional status classification according to age-group

Table 4.17 showed that more of age-group 6 to 9years I lmonths (3.3%) than of

age-group 10 to 12yea~~~ll.montt;ts (2.0%) were wasted.

(-2 to *2SD) N2SD

Ntritional status

fig1 Weight-torheight of ohildren aooording to age-roups

Nutritional status

67yrsllmth 89yrllmth 10-llyrllrnth o 12-12yrllmth

Fig. 2 Weight-for-age of children according to agelgroups

<-2SD (-2 to +2SD) >+2SD

Nutritional status

I 6-7ynl1 mth ~3'-95/r1 rffith' 10-1 l y r l 1 mth o 12-12yr11 mth I Rg. 3 Height-mr-age of children according to age-groups

LRS Seasons as LDS

I --Ajuona CPS -0werre Obukpa CPS AmagulUmrua CPS /

Fig. 4: Seasonal weight changes in boys according to school attended

ERS LRS EDS Seasons

LDS

/ + Ajuona CPS - h e r r e Obukpa CPS - -An-~g JUrmorua CPS

Fig. 5: Seasonal height charges in boys according to school attended

ERS- early rainy season, LRS- late rainy season, EDS- earty dry season, LDS- late dry season

4.15 Mean weight velocities for boys according to school attended and in the different seasons

Fig.4 showed that Ajuona had the highest weight velocity (0.57kg) in late rainy

season (LRS) as compared to other boys from other schools, Owerre-Obukpa

(0.42kg) and Amagu/Umuorua (0.22kg). In early dry season (EDS)

Amagu/Umuorua boys had the highest weight velocity (0.44kg) than Ajuona (-

0.02) and Amgu/Umuorua (-0.06kg). Ajuona and Owerre-Obukpa had the same

weight velocities (0.54kg) than Amagu/Umuorua (0.29kg) in late dry season

(LDS). In Table 4.19 using ANOVA in comparing the weight velocities of the

boys from the three schools with the degree of freedom (d.f.) 2,69 and p-value

3.851 (p>0.05) there was no significant difference.

4.16 Mean height' velocities for boys according to school attended and in the different seasons

Fig. 5 compared the height velocities of the boys in the three schools during the

various seasons. Owerre-Obukpa boys had the highest height velocity (0.69cm)

in LRS than Ajuona (0.51cm) and Amagu/Umuorua (0.46cm). In EDS the boys of

Owerre-Obukpa had the highest height velocity (0.33cm) than Amagu/Umuorua

(0.28cm) and Ajuona (0.26cm). Amagu/Umuorua boys had the highest height . , 4 7 . ,, , . I

velocity (4.08cm) compared to Ajuona (1.06cm) and Owerre-Obukpa (0.92cm) in

LDS. In Table 4.20 using ANOVA in comparing the height velocities of the boys

from the three schools with the degree of freedom (d.f.) 2,69 and p-value 3.878 ' I '

(p>0.05) there was no significant difierence.

ERS LRS EDS LDS seasons

-Ajuona CPS Owerre Obukpa CPS - -ArnagulUmrorua CPS --

Fig. 6: Seasonal weight changes in girls according to school attended

I.J , 0 I I

ERS LRS EDS LDS Seasons

+ Ajuona CPS - Owerre Obukpa CPS - -AmagulUrnuorua CP

Fig. 7: Seasonal heighi changes in girls according to school attended

ERS- early rainy season, LRS- late rainy seeson, EDS- early dry season, LDS- late dry season

4.17 Mean weight velocities for girls according to school attended and in the different seasons

Fig. 6 showed that in LRS season, Ajuona C.P.S. girls had the highest (0.67kg)

mean weight velocity than Owerre-Obukpa C.P.S (0.24kg) and Amagu/Umuorua

C.P.S (0.lOkg). In LDS Ajuona C.P.S. girls also had a higher mean weight

velocity (0.63kg) followed by Amagu/Umuorua C.P.S. (0.57kg) and Owerre-

Obukpa C.P.S. (0.38kg). In EDS, Amagu/Umuorua C.P.S had the highest mean

weight velocity (0.21kg) than Owerre-Obukpa (0.09kg) and Ajuona C.P.S.

(0.08kg). In Table 4.21 ANOVA was used to compare the mean weight velocities

of the girls from the three schools with the degree of freedom (d.f.) 2,73, p-value

3.770 (p>0.05) there was no significant difference.

4.18 Mean height velocities for girls according to school attended and in the different seasons

Fig.7 revealed that LDS season had the highest mean height velocity for

Amagu/Umuorua, Ajuona and Owerre-Obukpa C.P.S. girls (3.00cm, 1.47cm and

1.32cm) respectively. In sea season Ajuona had the highest (1.04cm) mean

height velocity than Amagu/Umuorua (0.85cm) and Owerre-Obukpa (0.81cm). ., ,, .. . .v, w , ,,.v> '

Ajuona C.P.S. girls had the highest mean weight velocity (0.92cm) followed by

Amagu/Umuorua (0.38cm) and Owerre-Obukpa C.P.S. (0.15cm) in EDS. In

Table 4.22 using ANOVA to compare the mean height velocities of the girls from

the three schools, with degree 'bf figedom (d.f.) 2,73, p-value 3.951 (p>0.05)

there was no significant difference.

Table 4.23 Mean weight and height velocities of children according to season

Seasons Weight velocity 95% CI Height velocity 95% CI kg (SE) cm (SE)

LRS 0.83 (0.1 9) 0.35 to 1.32 0.87 (0.18) 0.41 to 1.33

EDS 0.78 (0.25) . 0.14 to 1.43 0.70 (0.25) 0.046 to 1.35

LDS 1.18 (0.21) 0.66 to 1.71 1.10 (0.16) 0,70 to 1.54

SE = Standard error LRS = Late rainy season EDS = Early dry season LDS = Late dry season d.f. = degree of freedom

S = significant

Table 4.24: Result of t-test comparing the weight velocities of the boys and girls during the seasons

Sex N Mean Standard Degree Observed Critical Remarks deviationv.. .. o f (calculated) (Tabulated) (decision) (SD) freedom t value T value

- (d.0

Boys 72 8.44 5.28 0 . ..

Girls 76 7.86 4.79

Not

.712 1.645 Significant

p>O. 05

Table 4.25: Result of t-test comparing the height velocities of the boys and girls during the seasons

Sex N Mean Standard Degree Observed Critical Remarks deviation of (calculated) (Tabulated) (decision) (so) freedom t value t value

- (d.0

Boys 72 8.40 8.31

Girls 76 7.11 7.04

Not

Significant

at p O . 05

ERS LRS EDS

Seasons

LDS

gl Boys u Girls L Fig. 8 Mean weight velocitiesof boys and girls according to season

ERS LRS EDS LDS

Seasons

la Boys o Girls I Fig. 9 Mean height velocities of boys and girlsaccording to season

ERS- early rainy season, EDS- early dry season

LRS- late rainy season, LDS late dry season

4.19: Result of t-test comparing the weight and height velocities of the boys and girls as a result of the seasonal variations

Fig. 8 compared the weight velocities of the boys and girls of the study groups in

the various seasons. The boys had higher weight velocities throughout the

seasons. The result from the data in Table 4.18a showed that there was no

statistical significant difference that existed between the weight velocities of the

boys and girls as a result of seasonal variations. At p>0.05 level of significance

within 146 degrees of freedom the observed (calculated) t value of 0.712 was

found less than the critical (tabulated) t value of 1.645.This showed that the

seasonal variations did not affect the weight velocities of the boys differently to

that of the girls.

For height velocities in fig. 9 the girls had higher velocities in the LRS and

EDS while in LDS the boys had higher velocity. Statistically in Table 4.18b

showed that no significant difference existed between the height velocities of the

boys and girls as a result of skasonal variations. At p>0.05 level of significance

within 146 degrees of freedom the observed (calculated) t value of 1.03 was

found less than the critical (tabulated) t value of 1.645 respectively. This showed

that the seasonal variations did not affect the height velocities of the boys and .,,..... y..r.... ..v1 '

girls differently.

!AM season

Vlkt season Dryseason

Dry season

Seasons Boys r!l Girls o Both combined

Seasons

Fig 11 : Height velocities of boys, girls and both combined in wet am dry seasons

a Boys Girls a Both combine Fig 10 Weight velocities of boys, girls and both combined in wet

and dry seasons

Table 4.26 A Comparism of the mean weight and height velocities during

the wet and dry seasons

Season N Mean d.f p=value

(SE)

Wet season 2 2(.58) 4 -3.674'

P<0.05

Dry season 2 . 5(.58)

SE= standard error

d. f= degree of freedom

S= significant difference

Table 4.27 Mean weight and height velocities of children according to age- group

Age-group N Weight 95% CI Height velocity 95% CI

velocity Mean (SE)

Mean (SE) - ,. . , I .. .1

6-7,11 yrs 18 5.00(2.517) -5.83 to 15.83 6.67 (2.333) -3.37 to 16.71

8-9,11 yrs 51 5.33(2.186) -4.07 to 14.74 7.33 (1.453) 1.08 to 13.58

10-1 I , I lyrs 64 5.00 (.577) ' 2.52.to 7.48 6.00 (3.055) -7.14 to 19.14

12-12,l Iyrs 15 6.33 (1.333) 0.60 to 12.07 6.00 (2.517) -4.83 to 16.83

df 3,144 p>0.05 df 3,144 p >0.05

p=value 0. 1 2oN" p=value 0.070 ' I S

NS=Not Significance

4.20 Comparing mean weight, height velocities in the wet and dry seasons of boys, girls and both

During the dry season in fig.10 the boys had the highest weight velocity (0.60kg)

than girls (0.53kg), both had (0.57kg). Again the dry season had a higher

(0.50kg) weight velocity as compared to the wet season (0.29kg).

The height velocities followed the same trend. Dry season had a higher

velocity (1.98cm) than wet season (0.62cm) and the girls had (0.69cm) higher

than boys (0.55cm) in wet season, while in dry season boys had a higher

(2.02cm than girls (1.93cm height velocities). Statistically there were significant

differences at pc0.05, d.f 4 and p=value -3.674; using t-test analysis for mean

weight velocity.

4.21 Mean weight and height velocities according to age group in different quarters

Fig. 12 showed that in the 3rd quarter (July-September 2004), age group 6 to

7years I lmonth had the highest mean weight velocity (0,57kg), followed by 8 to

9years I lmonths (0.50kg), 12 to 12years I 1 months (0.25kg and 10 to I lyears

I lmonths (0.24kg). In the 4'h quarter (October-December 2004), 6 to 7years

I 1 months and 8 to 9years I lmonths had reductions in weight velocities (-0.33kg

and -0.03kg) respectkely;'T2 ta 12years I 1 months and 10 to I 1 years I 1 months

had (0.25kg and 0.24kg) respectively. Statistically in Table 4.27 there was no

significant difference ( p>0.05) comparing the mean weight velocities of the four

age-groups with the degree of freedo;m (d.0 3,144 and p-value 0.120.

Fig. 1 1 revealed that age group 12 to 12years I I months had the highest

height velocity (1.08cm) than 8 to 9years I 1 months, 6 to 7years I 1 months and

10 to I I years I I months (0.93cm, 0.73cm and 0.1 I cm) respectively, in the 3rd

quarter (July-September 2004). In the 4'h quarter (October-December 2004), the

highest height velocity was in age-group 8-9years I I months (0.47cm) followed

103

by 10-1 I years I I months, 6-7years I I months and 12-1 2years I I months

(0.37cm, 0.20cm and 0.09cm) respectively. In the lS' quarter (January- March

2005) 10 to I I years I I months had the highest height velocity (2.57cm) than

6years to 7years I I months, . ( I .33cm), 8 to 9years I I months (1.21 cm) and

12years to 12years Ilmonths (1.03cm). Statistically in Table 4.27 there was no

significant difference ( p>0.05) comparing the mean weight velocities of the four

age-groups with the degree of freedom (d.9 3,144 and p-value 0.070.

Y

I

Aprilto June2004 Jldyto Sql2004 Jan to March ZOC5 Quarterly intervals

Rg. 12 Man weight wkciies by agegoups in d i i ren t seasons

April to Jure 2004 July to Sept 2004 Od to Dec 2004 Jan t o March 2(

Quarterly intervals

I t 6-7,l lyrs -- 8-9,l lyrs 10-1 l,l lyrs + 12-12.1 1yn /

Fig. 13 Mean height velocities by age-groups in different seasons

4.22 Mean weight-for-age and height-for-age during the four seasons pooled together for boys and girls compared to NCHS-WHO 5oth percentile ,

Fig. 14 and 15 compared the mean weight-for-age, height-for-age of the boys

and girls with their reference NCHS-WHO 5oth percentile. Fig.14 showed that the

entire age-groups of the boys fell below the NCHS-WHO reference 50Ih

percentile. There were fluctuations in weight as the ages increased but from

10years on there was a steady increase.

Fig. 14 showed that the girls in the age-groups also fell below their

NCHS-WHO reference 501h percentile, even though the girls had a steady

appreciation in weight as the ages increased.

All the boys in the age-groups fig. 15 had height growth rate below their

NCHS-WHO reference 5oth percentile, at 9-9years Ilmonths they had a

reduction in height.

In fig. 15 unlike the boys, girls of age-groups 6-6years I lmonths grew

above, and 8-8years I lmonths fell below their NCHS-WHO references followed

appreciations in heights which were not up to the reference age-groups.

Age ranges

-+- NCHS-WHO Boy i- BOYS NCHS-WHO Girls + Girls

Fig. 14: Mean weight-for-age during the four seasons pool together for boys and girls compared to NCHS-WHO 197€

I +- NCHSWHO Boy - Boys NCHS-WHO Grb -w-- Girk (

flg 16: Mean helght-torsgo durlng the tour seasons pooled together tor boys and glrls compared to NCHS-WWO 1976

Table 4.28: Percentage distribution of intestinal parasitic infestation of children

Intestinal parasite No %

Hookworm 20 13.5

Entamoebic hystolytica 4 2.7

Intestinal flagellet 4 2.7

No parasite 120 81.1

Total 148 100.0

Table 4.29: Percentage distribution of intestinal parasitic infestation of children according to sex

Intestinal Parasites Boys Girls Total

Hookworm 12 8.1 8 5.4 20 13.5

Entamoeba histolytica 4 2.7 - - 4 2.7

Intestinal flagellet - - 4 2.7 4 2.7

No parasite -'56-"57:8“ 64 43.2 120 81.1

Total 72 48.6 76 51.3 148 100.0

4.23 Result for parasitic .infestation of the children in the studiec communities

Table 4.28 showed that 13.5% of the surveyed children had hookworm, 2.79

had Entamoeba histolytica and intestinal flagellate respectively while 81 .I % ha(

no parasites. Table 4.29 showed more boys (8.1%) than girls (5.4%) ha(

hookworm, and boys (2.7%) than girl (0%) had Entamoeba histolytica. Howeve

more girls (2.7%) than boy (0%) had intestinal flagellet. More girls (43.2%) that

boys (37.8%) had no parasitic infestation.

Table 4.30 Hookworm infestation according to school attended

N Mean %

Ajuona CPS . I2 1.75 32

Owerre-Obukpa CPS 12 2.00 36

Amagu/Umuorua CPS

Table 4.31 : Result of t-test. comparing parasitic infestation of boys and girls

Worm No Mean d.f 0 bsewed Critical Remarks

infestations calculated t (tabulated) t (decision)

of value value

Boys 72 3.39 146 -1.397 1.645 Not significant

., ,.. ..6 r? , ..'a '

Girls 76 3.63

Level of significance pO.05 ,I . ..

4.24 Determination of the existence of any difference in the worm infestation of the boys and girls

Table 4.30 showed that Owerre-Obukpa C.P.S the highest percentage worm

load infestations (36%) than Ajuona and Amagu/Umuorua C.P.S. (32%) each.

However, statistically there was no significant differences d.f=2,33 and p-

value=1.83 (p>0.05). Table 4.31 showed that there was no significant

difference in mean ratings of stool analysis for worm load infestation of the boys

and the girls (P>0.05) with d.f 146, p-value -1.397.

4.25: Determination of the existence of any differences in the hookworm infestation of the pupils according to the schools attended

There was no significant difference in hookworm infestation of the pupils in

different schools (Table 4.31).

Table 4.32: Iodine status ofthe children

Iodine in urine No % ( ~ 2 0 pg/L severe iodine deficiency) 21 58.33

20 - 49 pg/L (moderate iodine deficiency) 2 5.56

50 - 99 pg/L (mild iodine deficiency)

100 - 199 pg/L (optimal)

200 - 299 pg/L (more than adequate)

>300 pg/L (possible excess)

Total

Table 4.33: Iodine status of the children according to sex

Boys Girls Total

Iodine level in urine N % N % N %

Total

Notec2Opg/L - Severely iodine deficient 20 - 49pg/L - Moderately iodine deficient 50 - 99 pg/L - Mild iodine deficient 100 - 199 pg/L - Optimal iodine 200 - 299 pg/L - More than adequate >300 pg/L - Possible excess

4.26 Result for iodine status of the children in the studied communities

Table 4.32 revealed that majority (58.33%) of the children had c20pgIL iodin

This denotes severe iodine deficiency. About 13.89% had 50-99pgIL (mild iodir

deficiency), and 11.1 1% had >300pg/L (possible excess). On the other han

8.33% 5.56% and 2.78% had 100-199pgIL (optimal), 20-49pglL (modera

iodine deficiency) and 200-299pglL (more than adequate) respectively. Tak

4.33 showed that more boys (33.33%) than girls (25%) had C20pglL (seve

iodine deficiency level) and more girls (13.89%) than boy (0%) had 50-99pg

(mild iodine deficiency). More girls (5.56%) than boys (2.78%) had 100-199pg

(optimal) iodine in urine. However, only girls (2.78%) had 200-299pglL (mo

than adequate) and more boys (8.33%) than girls (2.78%) had >300pg

(possible excess) iodine.

Table 4.34 Mean (fSD) urinary iodine level of pupils according to schools

School attended N Mean Std. Deviation Ajuona C.P.S 13 93.92~glL 234.48

Owerre Obukpa 12 56.07pgIL

C.P.S

AmaguIUmuorua 11 164.48pglL

C.P. S

Total 36 102.2OpglL 186.49

Note<2OpgL - severely iodine deficient d.f 2,33 20 - 49pg/L - Moderately iodine deficient F= 3.32 NS p>0.05 50 - 99 pgL - Mild iodine deficient 100 - 199 pg/L - Optimal iodine 200 - 299 pgk - More than adequate >300 pgL - Possible excess NS - Not Significant

Table 4.35: Mean urinary iodine levels according to sex

Urine No Mean) d.f Observed Critical Remarks

iodine level . . ., ,. .. -6 -1' ...... :..' ' .

(calculated) t (tabulated) t (decision) in value value

Boys 17 128.20 34 .787 1.697 Not

significant . I! . ..

Girls 19 78.93

Level of significance: p > 0.05

Table 4.36: Differences in urinary iodine level of the pupils in the different schools

Source d.f Sum of Mean F Observed F Critical Remarks

squares square (calculated) (tabulated) (decision)

Between 2 71361.68 35680.84

groups

Within 33 1 145950 34725.75

groups

Total 35 1217311

Not

Significant

Level of significance: p > 0.05

4.27: Determination of the existence of any difference in the mean of urine iodine level of the boys and girls

Table 4.34 showed that Amagu/Umuorua CPS had the highest (164.48pglL

k210.11) mean urinary iodine level followed by Ajuona CPS (93.92plL k234.48)

and Owerre-Obukpa (56.OpgIL k65.75).

Table 4.35 showed that there was no significant difference between the

mean ratings of iodine level of the boys and girls. The calculated t-value 0.787

was less than the tabulated t-value of 1.697.

4.28: Determination of the existence of any differences in urinary iodine levels of pupils according to schools attended

Table 4.36 showed that the result of One-way classification analysis of variance

(ANOVA) f-test to determine the existence of any difference in the urinary iodine

level of the pupils in the different schools had no significant difference in urinary

iodine levels on growth rate of the pupils according to the schools attended (p>

0.05).

Table 4.37: Correlation coefficient (r) values expressing the relationship between the iodine level in the urine, worm infestation and mal- nutritional status: {(i) underweight, (ii) stunting and (iii) wasting)

Iodine level in

Variables Underweight Stunted Wasted urine Worm Underweight 1 .351(*) -.I10 ,240 -.222

N 36 36 36 36 36 Stunted .351(*) 1 -.398(*) ,314 -.316

N Wasted

N Iodine level in urine

N Worm

Correlation is significant at 0.05 level (2-tailed). '* Correlation is significant at 0.01 level (2-tailed).

4.29: Correlation coefficient (r) values expressing relationship between the Urinary iodine level and underweight, stunting and wasting

Table 4.37 showed that the correlation coefficient (r) of relationship between

urinary iodine level of the pupils and the underweight and stunted had positive

values (r = 0.240) and (r = 0.314) respectively and the wasted had negative

value (r = -0.179). The relationship was stronger among stunted children and

urinary iodine level (r = 0.314). However, it was generally weak with other

nutritional status.

Stunted children'had the highest urinary iodine correlation coefficient (r

=0.314) level. This relationship could be regarded as below average within the

degree range of 0 to 1.

Table 4.37 showed ' a correlation coefficient (r) (r =0.351) between

underweight and stunting as being significant (Pc0.05). There was a negative

relationship (r =-0.398) between wasted and stunted and was significant

(P<0.05).

4.30: Results of relationship among worm infestation, underweight, stunting and wasting

Table 4.37 showed that the correlation coefficient (r) values were both negative

and positive. There,+Ww a'-negative relationship (r = -0.222) between

underweight and hookworm infestation as well as stunted and hookworm

infested children (r =-0.316). Wasted and hookworm infestation had a positive

relationship (r =0.467) which was , significant . . (P<0.01).

Table 4.37 showed that there was a positive (r=0.351) between

underweight and stunted nutritional status. The correlation was significant (P<

0.05). Stunted and wasted had a negative correlation coefficient (r =-0.398)

which was significant (P< 0.05). There was least negative (r =-0.110) between

wasted and underweight.

Table 4.38: Comparing urinary iodine level of the underweight with the normal weight-for-age children

Iodine level in urine -3 to -1SD (Underweight) -1 to +lSD (Normal)

Total 20 60.6 13 39.4

Note<POpg/L - Severely iodine deficient 20 - 49pgL - Moderately iodine deficient 50 - 99 pgL - Mild iodine deficient 1 00 - 199 pg/L - Optimal iodine

200 - 299 pgL - More than adequate >300 pgL - Possible excess

4.31: Percentage frequency of urinary iodine level of the undetweight and the normal in weight- for- age of the children

Table 4.38 showed that more underweight (36.4%) than normal (21.2%) children

were severely iodine deficient (<20pg/L). However, only 6.1 % of underweig ht

were moderately iodine deficient (20-49pgIL). Mild iodine deficiency (50-99pglL)

was, more underweight (9.1 %) than normal (6.1 %). Underweight and normal

(3.0%) each had optimal iodine (100-199pgIL). Only normal (3.0%) were more

than adequate (200-299pglL). Underweight and normal (6.1%) each had

possible excess (>300pg/L) urinary iodine.

(-1 to +lsD)

Height-for-age nutritional status

- ~

Fig. 19 Percentage distribution of urinary iodine level of the stunted and the normal in height-for-age of the children

4.32: Percentage frequency of urinary iodine level of the stunted and the normal in height- for- age of the children

Table 4.39 and (fig. 19) showed that there were more stunted (39.4%) than

normal (18.2%) children who were severely iodine deficient (<20pg/L). There

were more stunted (6.1%) than normal (0%) that were moderately iodine

deficient (20-49uglL). More stunted (12.12%) than normal (3.03%) children had

mild iodine deficiency (50-99~gIL). The optimal (100-199pglL) iodine deficient

children were stunted and normal (3.0%) each. However, the children that had

more than adequate (200-299~gIL) urinary iodine level were normal (3.0%) than

stunted (0%) pupils. More normal (9.1%) than stunted (3.0%) children had

(>300pg/L) possible excess urinary iodine level. Table 4.39 appears to suggest

that more stunted pupil had low urinary iodine level.

Table 4.39 showed that there was equal value between calculated value

(1.67) and the tabulated (1 .,697). This indicated that the levels of urinary iodine of

the stunted and normal children were the same (P>0.05). There was no

difference between the urinary iodine level of the stunted and the normal children

(P>0.05).

Ajuona Owerre-Obukpa A magulUmuorua

Communities

Above 30pprn iodine level 13 30ppm iodine level IN no iodine

Fig.20 Iodine spot-test kit result of the salt samples from the homes

Marketed salt Homesalt I t . ..

Sources

I 0 Above 30 ppm iodine leuel 130ppm iodine level 0 No iodine I Fig. 21 Spot-test kit result of iodine leml of marketed and home salt

samples

4.33 Practical determination of the iodine levels of the salt used in the home and market

Table 4.40 and (fig 20) showed the results of iodine content of salts pupils

brought from homes. About 96.83% of these salts had over 30ppm iodine, some

had (1.90%) 30ppm iodine and others (1.27%) had no iodine. The non-iodized

salts were those of pupils from AmagulUmuorua C.P.S.

Table 4.41 and (fig 21) showed that (90.76%) of the salt samples

marketed had over iodine 30ppm and 9.23% had 30ppm iodine. The salt

samples namely - cassava salt, royal salt, Dangote, Uncle palm, Super power

king salt and E-Nuel table salt, and some unidentified salt samples being sold

with measuring cups were among those tested.

CHAPTER FIVE

DISCUSSION

5.1 The iodine status of the children

The 58.33% severe iodine deficiency (<20pg/L), 5.56% moderate iodine

deficiency (20-49pg/L), and 13.89% mild iodine deficiency (50-99 yg/L) were

observed in this survey. Kennedy et a/. (2003) also noted that the true

prevalence of iodine deficiency is even more widespread than the number of

those affected with goitre would seem to indicate; however, he reported that

there were no global estimates for prevalence of low urinary iodine, which is the

best sub-clinical indicator. The study agreed with Kennedy et a/. (2003) that sub

clinical iodine deficiency was detected by measuring urinary iodine which was an

indication of low iodine intake and/or utilization. The low urinary iodine level

reported in this study may be an indication of poor utilization of iodine consumed.

The market survey showed that all the salt samples were iodized and the salt

samples from the homes were almost iodized; but this study did not get into the

area of utilization of iodine. NutriView (1997) pointed out that food hygiene;

inadequate methods'*&.pl;eparation, cooking and storage can reduce the

nutritional content of foods considerably. Furnke et a/. (1997) in their study with

school children reported that intestinal parasitic infestations reduce the efficiency

of oral supplementation with iodized ethyl esters by interfering with absorption. I' . .

United Nations (1993) stressed the interactions of low content of iodine in the

local environment with poverty and remoteness, when there is little contribution

of food from outside an iodine-deficient area to the diet; as is the case of

subsistence agriculture

Low urinary iodine level of the stunted children was observed in this

study. Stunting may be the effect of low iodine utilization, although there are

other predisposing factors, such as infections and poor nutrition that could give

rise to stunting. Sofra et a/. (1998) defined iodine as an essential mineral

required by the body that directly affects thyroid gland secretions, which

themselves to a great extent controls heart action, nerve response to stimuli, rate

of body growth and metabolism estimates for prevalence of low urinary iodine,

which is the best sub clinical indicator.

5.2 The iodine levels of the salt used in the homes and market

The high level iodized salt in these communities agreed with Egbuta (2003) who

reported that Nigeria in general terms, had achieved the goal of universal salt

iodization and should now focus its attention on constant monitoring in order to

sustain this iodization level. The IDD study carried out by Okeke et a/. (1997) in

Enugu State revealed that 58% of families in Nsukka used salts containing

50ppm of iodine, 33% used salt between 7 and 50ppm iodine and 9% used non-

iodized salts. This study therefore has revealed an upward trend in the use of

iodized salt in Nigeria, indicating success of the IDD programme of the nation.

Okeke et a/. (1997) stated that most consumers bought salt according to brand

name and cost. This study ,however revealed that most mothers bought salt - < ,. .. 1.1. 4' , . . . . . I >

based on what was available in the market. A survey in late 2002 found 98% of

the salt at production and market was adequately iodized. Of households 88.6%

consumed adequately iodized salt, another 9.7% used poorly iodized and only

1.7% received no iodine from kalt ( I ~ D Newsletter, 2004). Even though most

mothers lacked the awareness of iodized salt and iodine deficiency disorders,

they bought and used iodized salt based on it's availability in the market. Most

semi-rural community mothers did not know the brand names but bought the

ones measured out to them. This study was not extended to preferences of

cheapness or brand names, but majority bought salt measured out with cups. It

was noted that the 2.0% non-iodized salt samples were observed to have come

from Amagu/Umuorua community primary school. The market salt test were

carried out on salts sold in the city market not on the ones in rural market were

there could be the possibilities of selling locally moulded baked salts that were

not iodized.

5.3 Knowledge, attitude and practice (KAP) of mothers on iodized salt and iodine deficiency disorders

The low mean knowledge of mothers (8.24%) on iodized salt and iodine

deficiency disorders in this study could possibly be as a result of lack of

awareness creation in the rural and semi-rural communities. In rural communities

there may be poor communication gaps or poor access to news media as to

have a glimpse of NAFDAC'S jingles on iodization of salt. Some may be unable

to purchase radios and television set due to their poverty level. Okeke et a/.

(1997) reported that about 94% traders and consumers had knowledge of

iodized salt programme in Nigeria. The attitudes of the mothers to iodized salt

and iodine deficiency disorders were above average rating; there is a positive

attitude towards iodization programme. The low practical application of the

knowledge of iodized salt and iodine deficiency disorders was an indication of

the consequences of poor, knowledge of same. None educational (41.2%) - . , a '..!;*'.. .... :.> '

background level of the mothers could have contributed to their lack of

knowledge of IDD. Again activities by mothers in taking care of large size

families (6-10 persons) could affect their social lives especially in acquiring

current knowledge on iodization of kalt. dkeke et a/. (1 997), reported the need for

closer monitoring, increased consumer awareness, systematic evaluation of

procurement, marketing, distribution, consumption and follow-up of the effect of

IDD.

127

5.4 Parasitic infestation

The study revealed that 19.4% of the surveyed children had hookworm,

Entamoeba histolytica (2.7%) and intestinal flagellate (2.7%). The low

prevalence was not in agreement with earlier study conducted in Obimo, Nsukka

(Onofiok, 1998) and lloputeife (2004) who reported a higher load of worm

infestations. Onofiok observed 62.9% infestation with hookworm, Trichuris and

ascariasis among children. The low incidence of parasitic infestation reported in

this present study may be due to the influence of the modern health

centrelhospitals cited in each of the three communities. Again most mothers

(89.6%) reported de-worming their children once a year. Majority of the mothers

(49.3%) did de-worm every four to six months. The common ailments reported

by mothers, worm infestation (4.8%) is low compared to others reported. Hall

(1993) noted that the effect of intestinal parasite depended on the duration of

infection before treatment. A longstanding worm burden would have more effect

on growth than a newly acquired load of similar intensity.

Generally, intestinal parasitic infestations persist and flourish where there

is poverty (Tanner et a/., 1987), unsanitary condition, insufficient health care and

overcrowding (Compton and Savioli, 1993; Bundy et al., 1992). In this study, only

a few families use bush"fo!'defecation the rest made use of pit toilet and water

closet which reduces the infection of the green vegetables consumed with ova of

helminths. Drinking water was derived from combined sources: mainly

boreholes, harvested rain water,. tankers and local streamlspring. Mothers

ensured hand washing before eating. The faecal-oral transmission of

geohelminths in these communities was reduced.

5.5 The anthropometric status of the children: underweight, stunting and wasting

The 25.0% stunting, 13.0% underweight and 6.3% wasting observed in this

survey agreed with those of Granthan-McGregor et a/., (1989) who observed that

globally stunting is much more prevalence. The FGNIUNICEF (1994) study

observed more stunting (36-52%) and underweight (27-45%) than wasting (5-

12%). On the other hand, the magnitude of stunting and wasting observed in the

present study was lower than that of Nnanyelugo et a/. (1990). They observed

50.0% stunting and 70.0% wasting. Onofiok, (1998) reported 43.0%

underweight, (33.0%) stunting and (1 8.6%) wasting.

The explanation for the differences might be that the previous studies

were conducted in rural farmland communities who depended heavily on

cassava consumption. Obukpa community is a semi-urban who consumed a lot

of mixed cereals, legumes and vegetables dishes. These foods are rich in

nutrients and essential amino acids which are more energy dense than cassava.

The community is very close to the University of Nigeria Teaching Hospital,

coupled with improved maternal literacy.

The causes of the recent malnutrition might be attributed to inadequate

dietary intake, anaemia, inadequate iodine utilization, worm infestation, infection . ,, 4 * , 1 7 ' I *

and general ill health.

5.6 Seasonal variations in growth velocity of the children

The mean weight velocity of 1.5kg p& year reported in this study was lower,

while the mean height velocity of 5.96cm per year was higher than that reported

by Onofiok (1998). Onofiok had mean weight of 2.3kglyear and mean height

velocity 4.38cmlyear. Other researchers have reported a higher rate in other

countries (Spurr et a/., 1983). There are many factors that could contribute to

impaired growth rate in the present study such as maternal illiteracy and socio-

129

economic factors. In the present inflation rate, cost of food items is very high,

only 39.7% of the families spent up to about 813,501 to 81 6,500 monthly for

feeding a family of more than five persons. Again about 46.0% of the children ate

up to three meals per day with poor diets and high disease load. About 93% of

the children reported one common ailment or the other while hospitalization

(63.7%) was as a result of one or more common ailment. Karlberg et a/. (1994)

reported that impaired growth is associated with many factors such as socio-

economic strata, maternal illiteracy, overcrowding, high disease load, improper

diets and their interaction. Attributing impaired growth to a particular cause in

developing countries is therefore misleading.

The seasonal and quarterly effects on weight and height velocity were

not contrary to expectation. Generally, growth rate was better in dry season than

in the wet season. The period of highest growth in late dry season (January-

March) contrary to other researcher who observed highest growth in October to

December (Onofiok, 1998). In this study highest growth corresponded to post

harvest of major staples like yam, cocoyam, pigeon pea and sweet potatoes. It is

also a period when some beans species and some other food-stuffs are

relatively cheaper than the preceding months. It should be noted that increase in

height gave the histov'of past'adequate nutritional intake.

The highest mean weight and height growth velocities corresponded with

the period food was in abundance before farming period. Staple foods like yam,

cocoyam, pigeon pea and sweet pdtatoes were harvested. It was also the time

where rice, cowpea and other foodstuffs were relatively cheaper than the

' preceding months. The weight velocity also reflected current nutritional status of

the children. The period of least growth was in October to December (early dry

season), this observation was not in agreement with the findings of other

researchers for example Onofiok, (1998) reported that in Obimo Nsukka the

130

period of least growth was in (April-June). Again, in this study the initial

measurements commenced in the month of April, this could also explain there

was no record of growth velocities. Also the observation in this present study

could be explained as a result of the fluctuations in the cost of fuel in the country

that affect the cost of transportation which subsequently hike up cost of food

items. But it should be noted that early and late dry seasons pooled together

was the highest weight and height velocities. While the least mean growth

velocity was in the wet season which was the planting period during which food

items were expensive and scarce. Children at this time were involved in some

levels of farming activities both at home and schools. Most households at this

period were food secure. This is supported by the possible lower energy and

protein intakes by the children at this period of the year. Nnanyelugo et a/. (1985)

reported that in Nsukka, food items were scarce and expensive in the wet

season. In Gambia, the weight and height gains of infants were reported lowest

in rainy season (June-November) but increased in December when it was dry

season (Waterlow, 1994).

The mean weight velocity for boys and girls were the same while there

was higher mean height velocity in girls (l.lOcm/quarter) than in boys

(0.95cmlquarter). Onofiok,.$(1$98) ported that girls had a higher (2.68kgIyr)

mean weight and mean height (4.71cmlyr) velocities than boys (2.03kglyr and

4.14cmlyr respectively). The present study did not indicate preferential treatment

in work allocation and care of girls over boys. The explanation could be that girls

grow taller than boys at this stage of adolescence. Later the boys overtake them

(Eke, 2004 ).

5.7 The relationship between parasitic infestation and (i) underweight (ii) stunting and (iii) wasting

The study revealed that 19.4% of the surveyed children had hookworm,

Entamoeba histolytica (2.7%) and intestinal flagellate (2.7%). The low

prevalence was not in agreement with earlier study conducted in Obimo, Nsukka

(Onofiok, 1998). Onofiok observed 62.9% infestation with hookworm, Trichuris

and Ascariasis among children. The low incidence of parasitic infestation

reported in this study may be due to health education received from modern

health centre cited in each of the three communities. Again most mothers

(89.6%) reported de-worming their children once a year. Majority of the mothers

(49.3%) did de-worm every four to six months. The common ailments reported

by mothers, worm infestation (4.8%) was low compared to others reported. Hall

(1993) noted that the effect of intestinal parasite depended on the duration of

infection before treatment. A longstanding worm burden would have more effect

on growth than a newly acquired load of similar intensity.

Generally, intestinal parasitic infestations persist and flourish where there

is poverty (Tanner eta/., 1987), unsanitary condition, insufficient health care and

overcrowding (Compton and Savioli, 1993; Bundy et al., 1992). In this study, only

a few families use bush for defecation the rest made use of pit toilet and water . , ' IJ

closet. Drinking water was derived from combined sources: mainly boreholes,

harvested rain water, tankers and local streamlspring. Mothers ensured hand

washing before eating. The faecal-oral transmission of geohelminths in these

communities was reduced.

CONCLUSION

The following interesting highlights have been synthesized from this study based

on the anthropometric measurements, urine iodine tests and stool analysis done.

The study indicated a higher prevalence of stunting than underweight and

low hookworm infestations. The existence of stunting, underweight and

wasting in the school children in the semi-rural community may have

serious implications in the general well being of the children and their

achievement and attainment later as adults.

There were evidences of the influence of seasonal variation and possible

less hookworm infestation in the growth velocity of the children.

There was evidence of the intakelutilization of inadequate iodine as

evidence in the urinary output. Urinary iodine is one of the means of

assessing iodine status because iodine intake in excess of requirement is

excreted primarily by this route (Kennedy eta/., 2003).

Although, the urinary iodine was low, the parasitic infestation was also

low. The later was an evidence of the influence of the primary health

centres situated in the communities and mothers1 awareness of de-

worming their ~hildrpp. ,,

Generally, the actual knowledge, attitudes and practices (KAP) of mothers

towards iodized salt and iodine deficiency disorders were inadequate.

However, it was &pected .to appreciate with the recent (NAFDAC)

promotions of iodized salt and iodine deficiency disorders, programmes

on the news media.

The salts consumed were adequate but there seemed to be utilization

interferences by possible goitrogens in both sexes.

A very important finding of this study is that it provided information on the

relationship between growth, parasitic infestation and iodine deficiency.

133

This has also provided significant information on the nutritional status of

Obukpa rural school children which can be extrapolated to

underprivileged children in similar circumstances.

The study has provided baseline information needed for this particular

community, which can be extrapolated to other rural communities in the

whole Federation for the purpose of intervention programmes, such as

eradication of micronutrient deficiency.

The study also can be used as a guide on the nature of creating

awareness programme that is on-going by FGNIUNICEF on food

fortification strategy for Nigeria perhaps for the control of iodine

deficiency.

The study has also shown evidence of multi-factors of malnutrition as

related to growth retardation lending support to multi-directional approach

for appropriate intervention progrmmes with particular reference to

environmental, hygienic and low urinary iodine.

Lastly this study contradicts some previous studies on poor iodization of

marketed salt and also revealed low urine iodine level despite

consumption of iodized salt. . ,, ..'.,' I >

The most devastating consequences of iodine deficiency is reduced

mental capacity, and fifty million people worldwide are mentally handicapped as

a result of iodine deficiency. WHO (2002) had estimated that 100,000 children

were born each year with irreversible brain damage because their mothers

lacked iodine prior to pregnancy; these reaffirms the need to continue to pursue

systematic iodization of salt and iodine deficiency disorders promotion activities.

Therefore, taking the overall, there is good reason to expect that activities

would improve the growth and health (mental and physical) of children

134

particularly in the developing countries. Taken together, they constitute one of

the most cost-effective interventions that can be carried out in the area of public

health care.

For Nigeria to contribute effectively to achieving the goal of reducing the

prevalence of iodine deficiency disorders, as proposed by the World Summit for

children in "Ending Hidden Hunger" by year 2000, which has come and past. The

above problems should therefore be given serious considerations.

5.9 RECOMMENDATIONS

The following are recommended for future action:

1. This study revealed high incidence of low urinary iodine in the children.

Thus it is recommended that steps be taken to improve iodine utilization

by studying goitrogenic factors that can hinder the utilization of iodine

since there is high percentage iodization of salt.

2. There were incidences of stunting and underweight amongst the children.

Stunting indicates history of past malnutrition at the vulnerable years of

childhood, the outcome of which manifests later in life. Priority therefore . , , ..., ? ' t >

should be given to the feeding of this group of children.

3. Food and nutrient intakes were significantly affected by seasons. Efforts

should be made to improve and expand storage facilities in rural

communities to reduce 'the adverse impact of seasonal fluctuations on

food supply. Possibilities for farming all year round through irrigation are

also recommended as a long-term solution.

4 Education level and economic status of mothers are known to have

significant influence on the nutritional status of children. The mothers in

this study had little or no education and this explains the low nutritional

135

status of the children. It is therefore recommended that efforts be made to

improve education and economic empowerment of rural women in

general. This could be achieved through adult education and skill

acquisition opportunities and health talks.

5. There is still serious gap in knowledge of iodized salt and iodine

deficiency disorders which influence growth velocity. In view of this,

further studies in this area are recommended. Such studies could assess

the different food consumed and their iodine levels with their effects on

the height velocity and the extent to which worm infestation and iodine

intake contribute to iodine deficiency disorder

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APPENDICES

Appendix 1

Table 4.17 Nutritional status according to age-group for fig 1

Weight-height 6-9yrs I I mths 10-12yrs I lmths

Total 166 55.3 1 34 44.7

Appendix I I

Table 4.18 for fig.1 to fig.3 Nutritional status classification according to age -group

Weight- 6-7yrs -7yrs 8-9yrs I I mths 10-llyrs 12-1 3yrs height I I mths I I mths Ilmths

N % N % N % N %

<-2sd

-2 to +2SD

>+2SD

Weig ht-for- age

<-2sd

-2 to +2SD

>+2SD

Height- for-age <-2sd

-2t0 +2SD

>+2SD

Appendix 4 11

Table 4.19 for fig.4: Mean weight velocities (kg) for boys according to schools attended and in the different seasons

ERS LRS EDS LDS

Ajuona CPS Mean . 20.44 22.17 22.33 24.50 Change - 1.73 .O. 16 2.17 Velocity - 0.57 -0.02 0.54

Owerre-Obukpa Mean 24.50 25.75 25.58 27.75 CPS

Change - 1.25 -0.17 2.17 Velocity - 0.42 -0.06 0.54

AmagulUmuorua Mean 27.33 28.00 29.33 30.50 CPS

Change - 0.67 1.33 1.17 Velocity - 0.22 0.44 0.29

ERS- early rainy season, LRS- late rainy season, EDS- early dry season, LDS- late dry season Using ANOVA d.f 2,69 p-value 3.851 NS p>0.05

Table 4.20 for fig. 5: Mean height velocities for boys according to schools attended and in the different seasons

ERS LRS EDS LDS

Ajuona

CPS

Owerre

Obukpa

CPS

Amagu

Umuorua

CPS

Mean

Change

Velocity

Mean

Change

Velocity

Mean

Change

Velocity

ERS- early rainy season, LRS- late rainy season, EDS- early dry season, LDS- late dry season Using ANOVA d.f 2, 69 p-value 3.878 NS p>0.05

Appendix 1V

Table 4.21 for fig. 6: Mean weight velocities (kg) for girls according to schools attended and in the different seasons

ERS LRS EDS LDS

Ajuona CPS Mean Change Velocity

Owerre-Obukpa Mean CPS

Change Velocity

AmagulUmuorua Mean CPS

Change Velocity

ERS- early rainy season, LRS- late rainy season, EDS- early dry season, LDS- late dry season Using ANOVA d.f 2,73 p-value 3.770 NS p>0.05

Table 4.22 for fig. 7: Mean height velocities (cm) for girls according to schools attended and in the different seasons

ERS LRS EDS LDS

Ajuona CPS Mean 120.88 124.00 126.75 132.63 Change - 3.13 2.75 5.88 Velocity . ,. . .. ,,. - p 1 .04 0.92 1.47

Owerre-Obukpa Mean 124.57 127.14 127.57 132.86 CPS

Change ' - 2.57 0.43 5.29 Velocity - 0.81 0.15 1.32 \

AmagulUmuorua Mean 127.94 . 130.50 131.63 143.63 CPS

Change - 2.56 1.13 12.00 Velocity - 0.85 0.38 3.00

ERS- early rainy season, LRS- late rainy season EDS- early dry season, LDS- late dry season Using ANOVA d.f 2.73 p-value 3.951 NS p>0.05

Appendix V

Table for fig 8: Weight velocities for boys and girls Seasons ERS LRS EDS LDS

Boys Mean 24.08 25.3 1 25.74 27.58

Change - 1.23 0.43 1.84

Velocity 0.3 1 0.14 0.46

Girls Mean 24.73 25.75 26.04 27.76

Change - 1.02 0.29 1.72

Velocity - 0.26 0.10 0.43

ERS- early rainy season, LRS- late rainy season, EDS- early dry season, LDS- late dry season

Table for fig 9: Height velocities for boys and girls

Seasons ERS LRS EDS LDS

Boys Mean 126.05 128.26 129.13 137.20

Change - 2.2 1 0.87 8.07

Velocity - 0.55 0.29 2.02

Girls Mean 124.46 127.2 1 128.65 136.47

Change - 2.75 1.44 7.72

Velocity - 0.69 0.48 1.93

ERS- early rainy season. LRS- late rainy season, EDS- early dry season, LDS- late dry season

Appendix V l

Table for figures 10 and 11: Comparing weight, height velocities in the wet and dry seasons of the boys, girls and the pupils

Weight velocities Height velocities

Wet season Dry season Wet season Dry season

Boys 0.31 0.60 0.55 2.02

Girls 0.26 0.53 0.69 1.93

Pupils 0.29 0.57 0.62 1.98

Table for fig 12: Mean weight velocities according to age groups April-June July-Sept 2004 Oct-Dec 2004 Jan-March

2004 2005

6yrs - 7yrsllmonths Mean 18.6 20.3 20.55 21.40 Change - 1.70 -0.1 1 .OO Velocity - 0.57 -0.33 0.25

* , . . . , * .'

8yrs - 9yrsl lmonths Mean 20.91 22.42 22.33 24.54 Change - 1.5 -0.08 2.2 1 Velocity 0.5 -0.03 0.55

I I

lOyrs - l lyrs llmonths Mean 28.73 29.47 30.20 32.07 Change 0.73 0.73 1.87 Velocity - 0.24 0.24 0.47

12yrs - 12yrsllmonths Mean 28.75 29.50 30.25 32.5 Change - 0.75 0.75 2.25 Velocity - 0.25 0.25 0.56

Appendix V11

Table for fig 13: Mean height velocities according to age-groups April-June July-Sept 2004 Oct-Dec 2004 Jan-March

2004 2005 6yrs - 7yrs llmonths Mean 115.8 118.0 1 18.6 123.9 Change 2.2 0.6 5.3 Velocity - 0.73 0.20 1.33

8yrs-9yrsl1 months Mean 1 17.33 120.13 121.54 126.38 Change 2.79 1.42 4.83 Velocity - 0.93 0.47 1.21

l0yrs-llyrsllmonths Mean 130.69 132.81 133.91 144.19 Change 2.13 1.09 10.28 Velocity 0.1 1 0.37 2.57

12yrs - 12yrsll months Mean 13 1.75 135.00 135.25 139.38 Change 3.25 0.25 4.13 Velocity 1.08 0.09 1.03

Table for fig 14: Mean weight-for-age (kg) during the four seasons pooled together for boys and girls (6-12years IOmonths) compared to NCHS-WHO 1976, .

6-6yrs 7-7yrs 8-8yrs 9-9yrs 10-1 Oyrs I 1-1 I yrs 12-1 2yrs 1Omths 1Omths 10mths 10mths 1Omths 1Omths 1Omths

NCHS- 24.7 26.9 , 29.4 32.9 38.8 41.7 W HO(B0ys) 1, . ,

Boys 20.3 22.7 20.8 25.3 28 30.8

NCHS- 20.7 23.6 26.6 31.8 34.2 39.5 42.5 WHO(Girls)

Girls 18 20 22.5 25 25.8 29 30.5

Appendix Vlll

Table for fig. 15: Mean height-for-age (cm) during the four seasons pooled together for boys and girls (6-12years 10months) compared to NCHS-WHO 1976

6-6yrs 7-7yrs 8-8yrs 9-9yrs 10- I 1-1 I yrs 12-1 2yrs IOmths IOmths IOmths IOmths 1Oyrs IOmths IOmths

1 Omths

NCHS- 123.9 131.3 134.3 139.8 148.2 152.2 WHO(Boys)

Boys 1 18 123.1 119.5 129.3 134.4 135.1

NCHS- 117.9 121.7 129.2 137.3 140.7 149.8 153.3 WHO(Girls)

Girls 120.5 124.8 116.7 128 131.4 137.8 144.4

Appendix I X

Ajuona CPS m Ow erre-ObukpaCPS AmgulLkrwrua CPS

Fig. 16:Petcentage hookworm load inkstation of pupils accodng to schools attended

% Boys % Girls

Gender

<2O uglL 0 20-49uglL .50-99ugIL 0 ao-199uglL .20@299ug/L rn ~300ugIL m

Rg.17 Percentage urinary iodine kvel according to sex

Appendix X

% underw eight D 96 normal I

4 0 uglL 20-49uglL 50-99uglL QO-199uglL 200- >300uglL

Urinary iodine l e ~ l 299uglL

3fg 18 Pertentlge rlinlty iodine fot the rnlmbGight and the normal

Appendix X I

Table 4.39: Comparing urinary iodine level of the normal in height-for-age with the stunted children

Iodine level in urine -3 to -lSD (Stunted) -1 to +1SD (Normal)

200-299pgIL - - 1 3 . 0

>3OOpg/L 1 3 . 0 3 9 .1

Total 21 63.6 12 36.4

Note<POpgL - Severely iodine deficient d.f=33 p-value=l. 6YS p>0.05 20 - 49pg5 - Moderately iodine deficient 50 - 99 pg5 - Mild iodine deficient 100 - 199 pgYL - Optimal iodine

200 - 299 pg5 - More than adequate >300 pg5 - Possible excess

NS - Not Significant

158

Appendix X I I

Table 4.40 iodine levels of the salt samples from the homes of the pupils in the three communities

Community Above 30ppm 30ppm iodine No Total

iodine level level iodine

Ajuona 1 17 37.02 3 0.94 - - 120 37.96

Owerre-Obukpa 97 30.69 3 0.94 - - 100 31.63

Total 306 96.82 6 1.88 4 1.26 316 99.96

Table 4.41 Iodine levels of marketed and home salt samples

Sources Above 30pprn iodine 30ppm iodine No iodine

level level

N , Yo N % N %

Market 43 90.,76 : 2 9.24 - -

Home 306 96.83 6 1 .90 4 1.27

Total 349 93.80 8 5.57 4 0.64

Appendix X I 11

UNIVERSITY OF NIGERIA, NSUKKA DEPARTMENT OF HOME SCIENCE, NUTRITION AND DIETETICS

IODINE STATUS, GROWTH AND PARASITIC INFESTATION OF PRIMARY SCHOOL CHILDREN IN RURAL NIGERIAN COMMUNITY OBUKPA

The Questionnaire used in collecting basic data

INSTRUCTION: To be filled by mothers or care-giver of primary school children. Tick (V) or fill in the appropriate answer. All information will be kept confidential.

SECTION A: General Characteristics

Respondent's Code [ ]

Are you the head of your household: (a) Yes [ ] (b) No 1 1

Sex of Respondent (a) Male [ ] (b) Female [ ]

No. of people in the Household (people who live and eat from the same pot):---

Religion: (a) Christianily'["] @) Muslim [ ] (c) Traditional religion [ ]

What is your marital status? Married [ I Single [ ] Divorced [ ] Separated [ Widow [ ]

,I

SECTION B: Socio-economic Characteristics

10. Educational attainment of respondent. a. None [ ] b. Primary uncompleted [ ] c. Primary completed [ ] d. Secondary uncompleted [ ] e. Secondary completed [ ] f. Post Secondary School [ ] g. University [ 1

11. Educational Level of household (if difference from 10 above) [ ]

a. None [ ] b. Primary uncompleted [ ] c. Primary completed [ ] d. Secondary uncompleted [ ] e. Secondary completed [ ] f. Post Secondary School [ ] g. University [ ]

Occupation of respondentlmother; a. Trading [ ] B. farming[ ] c. hair dressing [ ] d. Teaching [ ] e. Sewing f. Civil servant [ ] g. House wife [ ] h. others (specify)

Occupation of head of household: a. trading [ ] b. farming [ ]c. Skilled work [ ] d. unskilled work [ ] e. civil servant f. house wife [ I g. others (specify)

How much do you spend on food per month? a. less than N500 [ ] b. N500-N1000 [ ] c. N100-N1,500 [ I d. N1,500-N2000 [ ] e. N2,000-N3,000 [ ] f. N3,000-N4000 [

Does any other person earn income or contribute to he up keep of the household? a. Yes [ ] b. No [ ]

If yes, about how much is earned or contributed monthly by such person(s)? a. Less than N500 [ ] b. N500-1000 [ ] C. N1,000-N2000 [ ] d. N2,000-N3,000 [ ] e. Above N3,000 1 -

What are the sources of income in your household? a. Salary [ ] b. Sales from farm proceeds [ ]

c. Trading [ ] d. . Others (specify) II . .

SECTION C: HEALTH FACILITIES AND HEALTH RECORDS AND PRACTICES 18. How many modern centers/hospitals do you have in this

village/community a. None [ ] b. One [ ] c. Two [ ] d. Three[ ]

19. Are there herbal centers in this area? a. Yes [ ] b. No [ ]

Which of the health centers do your family members attend frequently? a. Modern health centerlhospital [ ] b. Traditional healing homes [ ] c. Prayer houses [ ]

What are your major reasons for attending modern health1 hospital services? a. cheaper [ ] b. More expensive [ ]c. short distance[ ] d. receives better treatment [ ] e. save times [ If. family likes it [ ]

What are your major for attending berbal centres? a. cheaper [ ] b. close to the house [ ]c. receive better

treatment [ ] d. saves time[ ] e. our family likes it[ ] f. Any other (specify)

How do you usually get to the clinic? a. walk [ ] b. bus [ ] c. motor-cycle[ ] d. bicycle [ ] f. Others

(specify)

Do you have1 had goiter before? Yes [ ] No[ 1

How are you treatingltreated it? A. Operation [ ] b. Iodine salt [ ] c. Oil Iodine injection [ ] d. Nothing e. State others please -

How many miscarriages had? a. None[ ] b. One [ ] c. Two [ ] d. Three[ ] e. More than three [ ]

Have you still births? A. None [ ] b. One [ ] c. two [ ] d. three [ ] e. more than three [ ]

How many surviving children do you have? a. None [ ] b. One [ ] c. Two [ ] d. Three [ ] e. Four [ ] f. More than Four [ ]

How many children died in the first year of life? a. None [ ] b. One L, 1. . c. Two [ ] d. Three [ ] e. Four [ ] f. Five [ ] g. More than five [ ]

What was the cause of death? a. convulsions [ ] b. diarrhea [ ] c. vomiting [ ] d. fevers [ ] e. measles [ ] f. Pneumonia [ ] g. others please specify

How many children dies after 5 years of age?

a . None [ ] b. One [ ] c. Two [ ] d. Three [ ] e. Four [ ] f. Five [ ] g. More than five [ ]

How many abnormally behaved children do you have? a . None [ ] b. One [ ] c. Two [ ] d. Three [ ] e. Four [ ] f. Five [ ] g. More than five [ ]

How many dwarfed children do you have? a . None [ ] b. One [ ] c. Two [ ] d. Three [ 1 e. Four [ ] f. Five [ ] g. More than five [ ]

What are the sources of drinking water for member of your family? a. Public tap [ ] b. borehole [ ] c. Rivers, spring [ I d. tanker [ ] e. rain-water [ ] f. Others (specify)

What treatment do you normally give your drinking water? a. None [ ] b. filtering [ ] c. boiling [ ] d. boiling &filtering [ ] e. addition of Milton [ ] f. addition of alum [ ] g. alum & filtering [ ]

How often do you clean your water pot? a. Once a week [ ] b. Twice a week [ ] c. Thrice a week [ ] d. Daily [ ] e. Once a month [ ] f. Once a while [ ]

Which toilet facility do have? a. Bucket [ ] b. Pit [ ] c. Bush [ ] d. Others (specify)

Do you ensure that children wash their hands? a. Yes [ ] b. No [ ]

" $. 4 * i r. 1.-

If yes, when? a. after using the toilet [ ] b. after coming back from school [ I c. before eating [ ] d. after play [ ] e. no time [ ]

SECTION D: MORBIDITY AND HEALTH STATUS

40. When last did you give them worm medicine?

41. Has any of your children suffered from any of the following diseases in the last 3 months? (children 6-15 years only). Start with the youngest.

SIN

1

2

3

4

5

6

7

8

9

Disease

FeverlMalaria

Diarrhea

Vomiting

Measles

Coughlcatarrh

Hepatitis

Typhoid fever

Worm . ,.

Others (specify)

Age

4 . I . \.

Child 2 Child 4 Child 1

+

Child 3 Child 5

42. Which of these children have been admitted into the hospital in the last 3 months and why?

43. Is any of your children aged 6-15 years on drug (medicine)? If so, which and what type of drug?

Children

Child 1

Child 2

Child 3

Child 4

Child 5

None

44. Has any of your children any of the following problem I I

Malaria

Others (specific)

r

SIN

1

2

3

4

5

6

Hepatitis

SECTION E: IDD STATUS

SIN

1

2

3

4

Typhoid fever

Diarrhea

Children

Child 1

Child 2

Ch~ld 3

Child 4

Child 5

None

Problem

Deafness

Muteness

Slow to understanding

Doesn't do well at school

Cough

Panadol

* ,. 4

Measles

Age

Malaria drug

<.' .v I >

No. of Children

Antibiotic Multivite

6 I Goitre

5 Abnormally short

Food intake

45. Is your food

7

8

9

(a) Mostly home-product ( )

(b) Partly home-produced, partly purchased ( )

(c) Mostly Purchased ( )

(d) Others (Please' Specify)

Abnormal Behaviour

Congenital Abnormalies

Squint

School Children response

46. Which of the meals do you take in a day? (Please indicate below) I

24-Hour Dietary Recall

47 Which of these food items did you eat yesterday?

Breakfast

A. Cereals: (i) Rice ( ) (ii) Bread (iii) Maize ( ) (iv) pap ( )

(v) Others (Please Specify)

B. . Roots and tubers: (i) ,;Yams1 ) (ii) Sweat potatoes ( ) (iii) Plantain ( ) (iv) Garri ( ) (v) Coco Yams ( ) (vi) Cassava (fufu) ( )

Snack

C. Legumes: (i) Soya beans ( ) (ii) Cowpea ( ) (iii) Groundnut ( )

(iv) Pigeon pea ( ) (v) African yam bean (Nkikisi) ( )

(vi) Bambara groundnut (Okpa) ( )

(vii) Others (Please Specify)

Lunch Snack Supper Snack

D. Vegetables: (i) Okro ( ) (ii) Dark green Vegetables ( ) (iii)

Tomatoes ( ) (iv) Pepper ( ) (v) Carrot ( ) (vi) Others

(Please specify)

E. Fruits: (i) Mango ( ) (ii) Orange ( ) (iii) Pawpaw ( ) (iv)

Pineapple ( ) (v) Sausop ( ) (vi) Avacado pear ( ) ( vii)

Coconut ( ) (viii) Cashew ( ) (xi) Guava ( ) (x) Velvet

tamarind (Ichekwu) ( ) (xi) Local apple (udara) ( ) (xii)

Banana ( )

(xiii) Others (specify)

F. Fish and Meat: (i) Dried fish ( ) (ii) Frozen fish ( ) (iii) Chicken ( )

(vi) Egg ( ) (v) Goat meat ( ) (vi) Beef ( ) (vii) Liver ( )

(viii) Stock fish ( ) (ix) Crayfish ( ) (x) Snail ( )

(xi) Turkey meat ( )

(xii) Others (Please specify)

G. Oilloil seeds: (i) Palm oil ( ) (ii) Groundnut oil ( ) (iii) Butter ( )

(iv) Melon seed (egusi) ( ) (v) Dikanut (Ogbono) ( )

(vi) Others (please specify)

, ,. . 4 . r . ... ?'

H. Beverages: Cow's milk ( ) (ii) Palm wine ( ) (iii) Breast milk ( )

(iv) Beer ( ) (v) Tea ( ) (vi) Cocoa drinks ( )

(vii)Others (please specify) . I . ..

I. Snacks: (i) Roasted groundnut ( ) (ii) Akara ( ) (iii) Roasted corn ( )

(iv) Pop corn (v) Okpa ( ) (vi) Moimoi ( ) (vii) Bread ( )

(viii) Boiled Groundnuts ( ) Others (please specify)

J. Seasoning/Condiments: (i) Fermented oil bean (ukpaka) ( ) (ii)

Fermented melon seed (Ogiri) ( ) (iii) Onoin ( ) (v) Nchuanwn ( )

(vi) Curri ( ) (vii) Garlic ( ) (viii) Thyme ( ) (ix) Salt ( )

(x) Others (Please specify)

48 How do you use palm oil?

(i) Bleached ( . ) (ii) Normal form ( ) (iii) Others (Please

specify

49. Do you have any food taboo (food@) that your culture or religious

forbids)? If yes please list

50. Which foods serve as your favourite foods? (Please name the

food)

SECTION E: KNOWLEDGE ATTITUDE AND PRACTICE (KAP) OF MOTHER ON IODIZED SALTllDD

I 51. Question

1

2

3

4

Response

Do you Know what is Iodized salt?

Do you Know what causes goiter?

Do you Know That goiter is due to Iodine deficiency?

Are you aware of other. consequences of IDD?

5

[ 8 Are you aware of the order banning non-iodine salt? I I

Do you know that stored iodized salt with lead is better preserved?

6

7

No Response Yes

Are you aware that iodine in salt evaporates when expased for a long period?

Do you also know that high temperature causes loss of iodine from salt?

No

52. ATTITUDE

SA = Strongly Agreeable; A = Agreeable; NR =No Response; DA = Disagreeable;

SD = Strongly Disagreeable

D A

- 1

2.

3.

4.

5.

6. -

7.

8.

PurchAsing of Iodized Salt

54. The salt you buy is it a. iodized [ ] b. non-iodized [ ]

c. I don't know [ ]

56. Do you buy salt

a. Packaged [ ] b. Unpackaged [ ]

SD S A Question

Creation of awareness of IDD is

Sources of awareness could be me

Giotre Patients are Iodine deficient

Iodized salt productionlmarketing should be encouraged

Iodine from salt should not be allowed to evaporize.

Waterlmoisture should not get in touch with iodized salt

Are you in favour of banning non- iodized salt?

Do you avoid goitee patients?

53. PRACTICE

A

I

NR

Question

1

2.

Response

I help to create the awareness of iodine deficiency dosprders. . ,. . I -

Goiter patients should be given well iodized salt1 foods

Yes

3. 1 I cover my iodized salt

No No Response

I 1

Storage of Salt

Do you store your salt near the fireplace? Yes [ ] No [ ]

Do you store your salt in an open space? Yes [ ] No [ ]

Do you store your salt in a damp place? Yes [ ] No [ ]

Do you store salt purchased salt more than six months? Yes [ ] (state

how long please)

Do you purchase salt exposed to Sunlight? Yes [ ] No [ ]

Do you purchase salt to moisture? Yes [ ] No [ ]

What type of container do you store salt? A. Plastic [ ] b. Class [ ]

c. Wood [ ] d. Clay [ ] e. Metal [ ] f. state others please

Is the container with well-fitting lid? Yes [ ] No [ ] No lid at all [ ]

Adding salt in food

65. Do you add salt in food (a) Before cooking [ ] b. During cooking [ ] c.

After cooking [ ]

66. Do you wash salt before use to remove impurityldirt Yes [ ] No [ ]

Anthopometric measurement

Sex: Male [ ] Female [ ] ,,

Weigh (kg)

Height (cm)

Arm

Circumference

(cm)

Enlargement on the neck

Seen

Squint

Deafness

Muteness

Abnormal behaviour

Congenital

No seen

Tool Analysis

Ascaris Lumbrocoides

Trichuris triciura I

Hook worm

Entamoeba histlytica

Giardis

Flagelettes

, ,. 4 . . 0' $ +

Mean Urinary Iodine (uglL)

Salt test

Severe Iodine Deficiency C 20

(With rapid test Kit)

Moderate Iodine deficiency 20-49

Mild iodine deficiency 50-99

Optimal Iodine . deficiency ' 100-199

More than adequate

200-299

Possible excess

> 300

Appendix XIV

---

Goitre Patient

Appendix XV

neight Measurement at Owerre-Obukpa C.P.a

Appendix XVI

weight Measurement at Ajuona C.P.S

Appendix XVll

Weight Measurement at Owerre-Obukpa C. P.S