A STRATIFIED CROSS-SECTIONAL CLUSTER MODEL SURVEY OF IODINE NUTRITION IN ARMENIA AFTER A DECADE OF UNIVERSAL SALT IODIZATION.

Objective: Iodine is a necessary nutrient for the synthesis of thyroid hormones and essential in human development. Being naturally deficient in iodine, Armenia launched a national universal salt iodization (USI) strategy in 2004. Although high rates of goiter continued to be reported, iodine status has not been studied since 2005. Therefore, this study sought to assess the current situation of population iodine nutrition in Armenia. Methods: We used a selective cross-sectional model to recruit three groups: school-age children (SAC), pregnant women (PW), and nonpregnant women of reproductive age (WRA) from each province. We collected casual urine and table salt samples from each participant, which were analyzed for iodine concentration. A repeat urine sample was collected in a subset of participants to adjust the results for within-person variation in iodine concentration. Group-wise urinary iodine concentrations (UICs) were compared with international reference criteria for iodine status. Results: Urine samples were collected from 1,125 participants from 13 different towns in Armenia; a total of 1,078 participants were included in the final analysis: 361 SAC (mean age, 10.5 years, 46.6% female), 356 PW (mean age, 26.1 years), and 361 WRA (mean age, 35.5 years). Population and geographically weighted median UIC were: SAC, 242 µg/L ([25th percentile] 203 to [75th percentile] 289 µg/L); PW, 226 µg/L (209 to 247 µg/L); WRA, 311 µg/L (244 to 371 µg/L). A total of 1,041 table salt samples were sufficient for laboratory analysis: 973 (93.4%) of the salt iodine measurements were within the national standard range of 40 ± 15 mg/kg. Conclusion: The results of household salt sampling indicated a successful USI strategy. While the present study did not achieve a truly representative sample of Armenia's population, the UIC results support the conclusion that iodine deficiency has not recurred and is not an underlying factor for any remaining high goiter prevalence in Armenia. Abbreviations: PW = pregnant women; SAC = school-age children; SI = salt iodine; UIC = urinary iodine concentration; USI = universal salt iodization; WHO = World Health Organization; WRA = women of reproductive age.

IODINE NUTRITION IN THE REPUBLIC OF ARTSAKH (NAGORNO KARABAKH).

OBJECTIVE: Iodine is a required nutrient for thyroid function. The mountainous terrain in the Republic of Artsakh (Nagorno Karabakh) in the south Caucasus suggests that it is likely to be endogenously deficient in iodine. The region is heavily dependent on neighboring Armenia for food imports including iodized salt. Since 2005, iodine is a government-sanctioned compulsory supplemental ingredient in salt in Armenia. However, there has never been a study of iodine nutrition in Artsakh. We sought to determine the level of iodine nutrition in Artsakh and the iodine content of table salt in the region. METHODS: Using a cross-sectional modified cluster model, we measured urine and salt iodine concentrations from a representative sample of children living in Artsakh. From 30 schools throughout the territory, we obtained 772 urine samples from children aged 8 to 10, and 323 samples of table salt. Repeat urine samples from 18.6% of participants were obtained. RESULTS: The median adjusted urinary iodine content was 203 µg/L (mean 206 µg/L, 95% confidence interval 202-210), within the range indicating sufficient iodine nutrition. There were small but statistically significant differences between the 8 administrative regions; however, there were no differences between individual sites. We found that 97.2% of table salt samples tested had iodine concentrations within the standard of 25 to 55 mg/kg. CONCLUSION: Among school-age children in Artsakh, iodine nutrition is adequate, and the salt is appropriately iodized. These results illustrate the remarkable success of the Armenian salt iodization program in providing sufficient but not excessive iodine to the mountainous territory of Artsakh. Abbreviation: UIC = urinary iodine concentration.

Constituent analysis of iodine intake in Armenia.

OBJECTIVE: We sought to assess the universal salt iodization (USI) strategy in Armenia by characterizing dietary iodine intake from naturally occurring iodine, salt-derived iodine in processed foods and salt-derived iodine in household-prepared foods. DESIGN: Using a cross-sectional cluster survey model, we collected urine samples which were analysed for iodine and sodium concentrations (UIC and UNaC) and household salt samples which were analysed for iodine concentration (SI). SI and UNaC data were used as explanatory variables in multiple linear regression analyses with UIC as dependent variable, and the regression parameters were used to estimate the iodine intake sources attributable to native iodine and iodine from salt in processed foods and household salt. SETTING: Armenia is naturally iodine deficient; in 2004, the government mandated a USI strategy. SUBJECTS: We recruited school-age children (SAC), pregnant women (PW) and non-pregnant women of reproductive age (WRA). RESULTS: From thirteen sites covering all provinces, sufficient urine and table salt samples were obtained from 312 SAC, 311 PW and 332 WRA. Findings revealed significant differences between groups: contribution of native iodine ranged from 81% in PW to 46% in SAC, while household salt-derived iodine contributed from 19% in SAC to 1% in PW. CONCLUSIONS: Differences between groups may reflect differences in diet. In all groups, household and processed food salt constituted a significant part of total iodine intake, highlighting the success and importance of USI in ensuring iodine sufficiency. There appears to be leeway to reduce salt intake without adversely affecting the iodine status of the population in Armenia.

Vitamin D status in Armenian women: a stratified cross-sectional cluster analysis.

BACKGROUND: Vitamin D plays a critical role in skeletal development and maintenance, thus sufficiency is an important goal for public health programs. Given the absence of foods fortified in vitamin D in Armenia, we hypothesized that vitamin D insufficiency would be widespread. METHODS: We conducted a random modified cluster model survey of vitamin D status of women in the country. We measured 25-hydroxyvitamin D [25(OH)D] by liquid chromatography mass spectrometry in dried blood spot samples and utilized a questionnaire to assess lifestyle factors. RESULTS: In summer, we sampled 1206 participants from 40 communities in Armenia. Mean 25-OH D level among women aged 18-24 was 20 ± 8 ng/mL; aged 25-64 was 21 ± 7 ng/mL; and >65 was 18 ± 8 ng/mL. The country-wide mean of the entire female population was 20 ± 8 ng/mL. A majority (>54%) had 25-OH D levels <20 ng/mL with nearly 13% having 25-OH D levels <12 ng/mL. Participants who reported calcium, vitamin D, or multivitamin supplementation had higher levels of 25-OH D (p values 0.004, 0.0002, and 0.03 respectively) as did pre- vs. postmenopausal women (p = 0.01), pregnant vs. nonpregnant women (p = <0.0001), and women who had experienced a sunburn in the past year (p = 0.004). CONCLUSION: In Armenia, there is a high prevalence of vitamin D insufficiency. This information provides data that can be used to inform public health directives to address this pervasive threat to optimal health.

Neonatal thyrotropin (TSH) screening as a tool for monitoring iodine nutrition in Armenia.

BACKGROUND: Neonatal thyrotropin (TSH) is influenced not only by the infant's own thyroid function, but also by maternal thyroid status, and can thus provide a general index of thyroid health in the community. METHODS: In 2012, the Republic of Armenia implemented a program of universal neonatal hypothyroidism screening by means of measuring the serum TSH level. The Arabkir Medical Center in Yerevan, Armenia, has maintained records of neonatal TSH screening data comprising nearly 100% of all births in Armenia from 2012 through 2016. We analyzed these data to determine the frequency of neonatal TSH levels higher than the cut point of 5 mIU/L, indicative of sufficient iodine nutrition status, and to detect any time dependence over years or regional variation. RESULTS: A total of 127,177 records from 2012 to 2016 were included. The geographic distribution of neonatal TSH records was reflective of the population of Armenia; the national percentage of records over 5 mIU/L ranged from a high of 2.88% in 2012 to a low of 1.71% in 2016. Minimal regional variation was noted, from a 2012-2016 cumulative high of 2.93% of records over 5 mIU/L in Shirak province to a low of 0.95% in the Vayots Dzor province. CONCLUSIONS: From all years and from all regions, values were consistently and uniformly below the cut point of 5 mIU/L. These results show no evidence of iodine deficiency in Armenia, and suggest that neonatal TSH may be a useful tool for monitoring iodine nutrition in Armenia.