New reference values for thyroid volume by ultrasound in iodine-sufficient schoolchildren: a World Health Organization/Nutrition for Health and Development Iodine Deficiency Study Group Report.

BACKGROUND: Goiter prevalence in school-age children is an indicator of the severity of iodine deficiency disorders (IDDs) in a population. In areas of mild-to-moderate IDDs, measurement of thyroid volume (Tvol) by ultrasound is preferable to palpation for grading goiter, but interpretation requires reference criteria from iodine-sufficient children. OBJECTIVE: The study aim was to establish international reference values for Tvol by ultrasound in 6-12-y-old children that could be used to define goiter in the context of IDD monitoring. DESIGN: Tvol was measured by ultrasound in 6-12-y-old children living in areas of long-term iodine sufficiency in North and South America, central Europe, the eastern Mediterranean, Africa, and the western Pacific. Measurements were made by 2 experienced examiners using validated techniques. Data were log transformed, used to calculate percentiles on the basis of the Gaussian distribution, and then transformed back to the linear scale. Age- and body surface area (BSA)-specific 97th percentiles for Tvol were calculated for boys and girls. RESULTS: The sample included 3529 children evenly divided between boys and girls at each year ( +/- SD age: 9.3 +/- 1.9 y). The range of median urinary iodine concentrations for the 6 study sites was 118-288 micro g/L. There were significant differences in age- and BSA-adjusted mean Tvols between sites, which suggests that population-specific references in countries with long-standing iodine sufficiency may be more accurate than is a single international reference. However, overall differences in age- and BSA-adjusted Tvols between sites were modest relative to the population and measurement variability, which supports the use of a single, site-independent set of references. CONCLUSION: These new international reference values for Tvol by ultrasound can be used for goiter screening in the context of IDD monitoring.

World status of monitoring iodine deficiency disorders control programs.

Monitoring and evaluation are the last phases of a national iodine deficiency disorders (IDD) control program but among the most important. This paper summarizes the latest recommendations by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the International Council for Control of Iodine Deficiency Disorders (ICCIDD) about indicators and their normative values for monitoring the progress of IDD elimination and illustrates the successful monitoring programs in Switzerland and in China. Salt is the usual vehicle for iodine supplementation and quality control for iodine content can be assessed quantitatively by titration and qualitatively by simple test kits that can be used in the field. The most useful indicator of iodine nutrition is the median urinary iodine concentration. Thyroid size, especially by ultrasound, and neonatal thyrotropin (TSH) are also valuable. In Switzerland, access to iodized salt on a voluntary basis started in 1922. The initial level of iodization, 1.9-3.75 ppm iodine as potassium iodide (KI), was slowly increased to 15 ppm, and recently to 20 ppm, after careful epidemiologic and biologic monitoring. Elimination of IDD has been highly successful. The program costs US dollars 0.07 per year per person. In China, a national program of iodized salt (10-30 ppm) started in 1960 under the authority of the central government and rapidly expanded. National monitoring surveys have taken place every 2 years since 1993. Median urinary iodine, initially low, increased to 165 microg/L in 1995 and to 306 microg/L in 1999, prompting a decrease in the amount of iodine added to salt. The total goiter rate decreased to 20.4% in 1995 and to 8.8% in 1999. IDD can presently be considered as eliminated in China. Review of monitoring in the 128 other major countries affected by IDD shows extremely variable achievements, with evidence of IDD elimination in at least 18 additional countries. Some countries that were severely iodine deficient in the past are now exposed to iodine excess and risk its effects. Sustainable elimination of IDD is within reach and would constitute an unprecedented global success story in the field of noncommunicable diseases, but continuing vigorous action is required to attain this goal.

Iodine nutrition improves in Latin America.

Iodine deficiency has been a public health problem in most Latin American countries. Massive programs of salt iodization have achieved great progress toward its elimination but no consistent monitoring has been applied. We used the ThyroMobil model to visit 163 sites in 13 countries and assess randomly selected schoolchildren of both genders 6-12 years of age. The median urinary iodine concentration (8208 samples) varied from 72 to 540 microg/L. One national median was below the recommended range of 100-200 microg/L; five were 100-200 microg/L, and seven were higher than 200 microg/L, including three greter than 300 microg/L. Urinary iodine concentration correlated with the iodine content of salt in all countries. Median values of thyroid volume were within the normal range for age in all countries, but the goiter prevalence varied markedly from 3.1% to 25.0% because of scatter. The median iodine content of salt from local markets (2734 samples) varied from 5.9 parts per million (ppm) to 78 ppm and was greater than 15 ppm in 83.1% of all samples. Only seven countries had higher than 15 ppm iodine in 80% of the samples, and only three had greater than 15 ppm in at least 90%. Iodized salt was available at retail level in all countries but its median iodine content was within the recommended range (20-40 ppm) in only five. This study, the first to apply a standardized assessment strategy to recent iodine nutrition in Latin America, documents a remarkable success in the elimination of iodine deficiency by iodized salt in all but 1 of the 13 countries. Some iodine excess occurs, but side effects have not been reported so far, and two countries have already decreased their legal levels of salt iodization and improved the quality control of iodized salt, in part because of our results. The present work should be followed by regular monitoring of iodine nutrition and thyroid function, especially in the countries presently exposed to iodine excess.

Standardized evaluation of iodine nutrition in West Africa: the African phase of the thyromobil program.

Extensive programs of iodine supplementation by iodated salt have been implemented in Africa during the last decade. The present work evaluated their effectiveness in Benin, Burkina Faso, Mali, and Togo. A van equipped with a sonographic device visited 39 sites in the four countries. The prevalence of goiter was evaluated on the basis of the determination of thyroid volume by ultrasonography in 4,011 randomly selected 6- to 12-year-old schoolchildren of both sexes in the 39 sites. The concentration of urinary iodine was measured in 1,545 of these children. The iodine content of table salt collected at home by the children was measured by test kits in 3,202 salt samples, 415 of which were also analyzed by titration. Based on the results obtained by the kits, 83.7% to 97.9% of the salt samples contained iodine. However, the test kits had a low sensitivity and specificity in comparison with titration. The median urinary iodine was within an acceptable range (100-300 14 g/L) in the four countries, but almost one-third of the values were still below normal. The prevalence of goiter was normal (< 5%) in Benin and Togo, and it was 22.4% and 13.4%, respectively, in Burkina Faso and Mali. These results indicate marked improvement of the status of iodine nutrition in comparison with the situation reported only a few years ago in the same countries, but quality control of the iodine content of salt and monitoring of the iodine status of the populations need to be improved.

[Iodine deficiency: current situation and future prospects]. / La carence iodée: bilan et perspectives pour le futur.

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

Iodine requirements during pregnancy, lactation and the neonatal period and indicators of optimal iodine nutrition.

OBJECTIVE: This paper re-evaluates the requirements for iodine during pregnancy, lactation and the neonatal period, and formulates original proposals for the median concentrations of urinary iodine (UI) that indicate optimal iodine nutrition during these three critical periods of life. This paper also discusses the measurements that are used to explore thyroid functions during the same periods. DESIGN: An extensive and critical review of the literature on thyroid physiopathology during the perinatal period. SETTING: Human studies conducted in various regions throughout the world. SUBJECTS: Pregnant women, lactating women, and newborns. RESULTS: The following proposals are made after extensive review of the literature: the requirement for iodine by the mother during pregnancy is 250-300 microg day-1; during lactation the requirement is 225-350 microg day-1; and during the neonatal period the requirement of the infant is 90 microg day-1. The median UI that indicates an optimal iodine nutrition during these three periods should be in the range of 150-230 microg day-1. These figures are higher than recommended to date by the international agencies. CONCLUSIONS: Pregnant women and young infants, but especially the second group, are more sensitive to the effects of an iodine deficiency (ID) than the general population because their serum thyroid-stimulating hormone (TSH) and thyroxine are increased and decreased, respectively, for degrees of ID that do not seem to affect thyroid function in the general population. Systematic neonatal thyroid screening using primary TSH could be the most sensitive indicator to monitor the process of ID control.

Iodine supplementation for pregnancy and lactation-United States and Canada: recommendations of the American Thyroid Association.

The fetus is totally dependent in early pregnancy on maternal thyroxine for normal brain development. Adequate maternal dietary intake of iodine during pregnancy is essential for maternal thyroxine production and later for thyroid function in the fetus. If iodine insufficiency leads to inadequate production of thyroid hormones and hypothyroidism during pregnancy, then irreversible fetal brain damage can result. In the United States, the median urinary iodine (UI) was 168 microg/L in 2001-2002, well within the range of normal established by the World Health Organization (WHO), but whereas the UI of pregnant women (173 microg/L; 95% CI 75-229 microg/L) was within the range recommended by WHO (150-249 microg/L), the lower 95% CI was less than 150 microg/L. Therefore, until additional physiologic data are available to make a better judgment, the American Thyroid Association recommends that women receive 150 microg iodine supplements daily during pregnancy and lactation and that all prenatal vitamin/mineral preparations contain 150 microg of iodine.

Iodine deficiency in Europe and its consequences: an update.

This paper updates the information on the prevalence of the disorders induced by iodine deficiency (IDD) in Europe. Thirty-two European countries were still affected by mild to severe iodine deficiency in the late 1990s. The most severely affected countries were in Eastern Europe, including Central Asia, but Western Europe was also still affected. National surveys recently conducted in 11 of these countries show that, with the exception of the Netherlands, none has yet reached a state of iodine sufficiency, though very significant improvement in the situation has been evidenced in many of them, e.g. Poland, Bulgaria and Macedonia. The consequences of persisting iodine deficiency are goitre, hyperavidity of the thyroid for iodide (which increases the risk of thyroid irradiation in the event of a nuclear accident) and subclinical hypothyroidism during pregnancy and early infant (with a concomitant risk of minor brain damage and irreversible impairment of the neuropsychointellectual development of offspring). Access to iodised salt at the household level in European countries affected by IDD increased from 5%-10% in 1990 to 28% in 1999. This constitutes encouraging progress. However, in terms of access of iodine-deficient countries to iodised salt, Europe remains the worst region in the world, as shown by the fact that the mean figure worldwide in 1999 was 68%. In Latin America it even reached 90%. Salt iodisation has to be further implemented in Europe. Until that goal is achieved, iodine supplementation in those groups most sensitive to the effects of iodine deficiency (pregnant and lactating women and young infants) will have to be considered in the most severely affected areas.

Determining median urinary iodine concentration that indicates adequate iodine intake at population level.

OBJECTIVE: Urinary iodine concentration is the prime indicator of nutritional iodine status and is used to evaluate population-based iodine supplementation. In 1994, WHO, UNICEF and ICCIDD recommended median urinary iodine concentrations for populations of 100- 200 micro g/l, assuming the 100 micro g/l threshold would limit concentrations <50 micro g/l to 100 micro g/l. The total population was 55 892, including 35 661 (64%) schoolchildren. Median urinary iodine concentrations were 111-540 (median 201) micro g/l for all populations, 100-199 micro g/l in 23 (48%) populations and >/=200 micro g/l in 25 (52%). The frequencies of values <50 micro g/l were 0-20.8 (mean 4.8%) overall and 7.2% and 2.5% in populations with medians of 100-199 micro g/l and >200 micro g/l, respectively. The frequency reached 20% only in two places where iodine had been supplemented for <2 years. CONCLUSION: The frequency of urinary iodine concentrations <50 micro g/l in populations with median urinary iodine concentrations >/=100 micro g/l has been overestimated. The threshold of 100 micro g/l does not need to be increased. In populations, median urinary iodine concentrations of 100-200 micro g/l indicate adequate iodine intake and optimal iodine nutrition.

Bioavailability of seaweed iodine in human beings.

The major procedure used to correct iodine deficiency is the universal salt iodization by addition of iodide or iodate to salt with an iodine content varying from 7 to 100 mg/kg of salt depending on the country legislation. As an important fraction of consumers in the world prefers natural products over artificial ones, we investigated the industrial feasibility of naturally iodized salt using seaweed as source of iodine. We report the results of the iodine bioavailability in healthy subjects from two seaweeds: Laminaria hyperborea and Gracilaria verrucosa selected due to their high level in iodine as a mineral or an organic form and low levels of heavy metals. As a control we studied in a normal man the bioavailability of pure mineral iodine such as potassium iodide which was excellent i.e. 96.4% and of pure organic iodine such as monoiodotyrosine which was a little lower i.e. 80.0%. Iodine bioavailability from these two seaweeds was studied in nine normal subjects from Marseille (France) which is an iodine sufficient area based on a median urinary iodine level of 137 microg/day and innine normal subjects from Brussels (Belgium) who present a mild iodine deficiency with a value of 73 microg/day. The iodine bioavailability of Gracilaria verrucosa is better than for Laminaria hyperborea (101% versus 90% in Marseille, t=0.812, NS; 85% versus 61.5% in Brussels, t = 2.486, p = 0.024, S*). The urinary excretion of iodine is lower in Brussels than in Marseille for the same seaweed because part of the iodine is stored in the thyroid (101% versus 85% for Gracilaria verrucosa, t = 1.010, NS; 90% versus 61.5% for Laminaria hyperborea, t = 3.879, p= 0.001, S***).

The nutritional iodine supply of Belgian neonates is still insufficient.

UNLABELLED: Belgium used to be affected by mild iodine deficiency. Improvement in iodine nutrition has been recently documented in schoolchildren in Belgium in spite of the absence of any systematic programme of iodine supplementation. The question arises as to whether this 'silent iodine prophylaxis' affected also the neonates. A total of 185 random urine samples were collected from 90 full term and 65 preterm neonates in Brussels on day 5 and repeated on day 30 in 30 preterms who were bottle-fed with iodine-enriched formula-milk. The iodine content was also determined in 58 samples of breast-milk on day 5. The median urinary iodine on day 5 in full term neonates was 86 micro g/l, which is markedly higher than the figure of 48 micro g/L reported 15 years previously in neonates in the same area but still much lower than normal for this age group (150-200 micro g/l). The mean iodine content of breast-milk was 78 micro g/l, which is unchanged as compared to 15 years ago and is about 66% of normal. Finally, the median urinary iodine increased from 60 micro g/l on day 5 to 150 micro g/l on day 30 in preterms bottle-fed with iodine-enriched formula-milk. CONCLUSION: the status of iodine nutrition has also improved spontaneously in Belgian neonates but has not yet normalised. Lactating and probably pregnant women remain clearly iodine deficient. The iodine-enriched formula-milk for preterms is efficient in correcting their iodine deficiency. National measures are urgently required for correction of iodine deficiency in Belgium.

Iodine status remains critical in mother and infant in Central Anatolia (Kayseri) of Turkey.

BACKGROUND: Severe iodine deficiency disorders have been eradicated in many parts of the world, but milder forms still exist and may escape detection. Turkey has long been known to be a mild to moderate iodine deficiency area. AIM OF THE STUDY: The aim of this study was to assess the iodine nutritional status and the thyroid function of pregnant women and their neonates in the region of Kayseri (central Anatolia of Turkey) that appeared to be iodine deficient in previous studies performed before the introduction of mandatory salt iodization. METHODS: A cross-sectional voluntary screening study was performed in the Maternity Unit of a university hospital. A total of 70 mothers and their healthy full-term neonates were included in this study. Urinary iodine concentration was estimated in spot urine samples obtained from mothers and their neonates on day 5. All the neonates were breastfed. The iodine content was determined in the breast milk of all mothers on day 5. Serum concentrations of TSH, thyroglobulin (Tg), free triiodothyronine (FT3) and free thyroxine (FT4) were investigated in the cord serum of neonates and compared to those of mothers immediately after parturition RESULTS: The median urinary iodine on day 5 in mothers and their babies were 30.20 and 23.80 microg/l, respectively. These figures are much lower than normal for these age groups (150-200 microg/l). The median iodine content of breast-milk was 73 microg/l. It is again much lower than in iodine sufficient areas, indicating that the status of iodine nutrition of pregnant and lactating women is clearly insufficient. The median concentrations (and ranges) of neonatal TSH, Tg, FT3 and FT4 were 7.44 mU/l, 71.62 ng/ml, 1.30 pg/ml and 1.34 ng/dl respectively. The corresponding levels for the mothers during labor were 2.19 mU/l, 25.65 ng/ml, 1.31 pg/ml and 1.23 ng/dl respectively. The median neonatal serum concentrations of TSH and Tg were significantly higher than the corresponding maternal levels (P < 0.0001, P < 0.0001, respectively) and 27.1% of the neonates had serum TSH concentrations above 10 mU/l and 57.1 % had cord blood serum Tg concentrations above 54 ng/ml. None of the mothers showed TSH concentrations above 5 mU/l and 41.4% had serum Tg concentrations above 30 ng/ml. CONCLUSION: Iodine deficiency with low urinary iodine excretion and high serum Tg and TSH concentrations were recognized among pregnant women and their babies in Kayseri in spite of the program of salt iodization. National measures are urgently required for improving the correction of iodine deficiency in Turkey. This includes regular supplementation with iodine, starting at preconception or in early pregnancy and continuing during the period of nursing in this region.