IODINE DEFICIENCY DISORDERS

OBJECTIVE of THE COURSE AT THE END OF THE SESSION STUDENT WILL BE ABLE TO: Understand the magnitude of the IDD problems Know the RDA of iodine and daily intake for special conditions Know the adverse effect of iodine excess Identify the endemic area Solve the IDD problems by designing some programs Arrange the collaboration Monitor the program

Iodine Deficiency Disorders Data are from the WHO and the International Council for the Control of Iodine Deficiency Disorders

BACKGROUND

Normal levels of thyroid hormones are required for optimal development of the brain. In areas of iodine deficiency, where thyroid hormone level are low, brain development is impaired. The result of extreme condition of iodine deficiency is cretinism. The much greater public health importance are the more subtle degrees of brain damage and reduce cognitive capacity which affect the entire population. The potential of a whole community is reduced by iodine deficiency The most critical period is from the second trimester of pregnancy to the third year after birth

IDD at critical stages during pregnancy and early childhood results in impaired of the brain & consequently in impaired mental function People living in areas affected by severe IDD may have an IQ of up to about 13.5 points below that of those comparable communities in areas where there is no IDD Most areas of Indonesia were in endemic condition

Elimination of IDD is a most important health & social goal. IDD are among the easiest and cheapest of all disorders to prevent Doctors are often facing with the condition in their practice

IODINE DEFICIENCY DISORDERS Iodine deficiencies occurs when iodine intake falls below recommended levels. When iodine intake falls below recommended levels, the thyroid may no longer be able to synthesize sufficient amount of thyroid hormone. The resulting low level oh thyroid hormone in the blood (hypothyroidism) is the principal factor responsible for the damage done to the developing brain and other harmful effects known collectively as IDD. IDD refer to all of the ill-effect of iodine deficiency in a population

IODINE METABOLISM Daily intake: 500 µg I- 120 µg I- 40 µg I- THYROID As T3 & T4: 80 µg I- Extra cell fluid LIVER & OTHER TISSUES 60 µg I- Urine: 480 µg I- Feces: 20 µg I-

CURRENT MAGNITUDE of IDD by GOITER by WHO REGION (1999) Population Population affected by goitre In millions % of the Region Africa 612 124 20% The Americas 788 39 5% South East Asia 1477 172 12% Europe 869 130 15% Eastern Mediteranian 473 152 32% Western Pacific 1639 8% TOTAL 5858 741 13%

RECOMMENDED DIALY INTAKE of IODINE (WHO,2001) 90 µg for preschool children (0 to 59 months) 120 µg for school children (6 to 12 years) 150 µg for adults (above 12 years) 200 µg for pregnant and lactating women

IODINE TOXICITY In the range 0f 150-600 µg/day, does not interact adversely with any food or drug Too much iodine (>2000 µg/day) can result in eruption of acne-like skin lesions Iodine excess of 4.5 mg/day produce a metalic taste and sores in the mouth, swollen salivary glands, diarrhea, and vomiting

ENDEMIC GOITER Goiter Endemic goiter It only takes several months for inadequate iodine intake for the thyroid gland to begin enlarging into a goiter (enlarge thyroid gland) When dietary iodine is inadequate, the thyroid gland swells Endemic goiter An area with iodine deficiency that produce enlargement of thyroid gland. The TGR is more than 5%

SIMPLIFIED CLASSIFICATION of GOITER by PALPATION GRADE PHYSICAL EXAMINATION Grade 0 No palpable or visible goiter Grade 1 A goiter that is palpable but not visible when the neck is in the normal position Grade 2 A swelling in the neck that is clearly visible when the neck is in a normal position and is consistent with an enlarged thyroid when the neck is palpated the specificity & sensitivity of palpation are low in grade 0 & 1 TGR (total goiter rate) = number with goiters of grades 1 & 2 total examined TGR ≥ 5% of schoolchildren 6-12 years of age be used to signal the presence of a public health problem

THE SPECTRUM OF ABNORMALITIES THE SPECTRUM of IDD AGE THE SPECTRUM OF ABNORMALITIES FETUS abortion stillbirths congenital anomalies increased perinatal mortality increased infant mortality psychomotor defects neurological cretinism - mental deficiencies - deaf mutism - spastic diplegia squint myxoedematous cretinism - mental deficiencies, - dwartism, hypothyroidism NEONATE neonatal hypothyroidism CHILD & ADOLESCENT mental retardation physical retardation ADULT goiter & its complications Iodine induced hyperthyroidism ALL AGES goiter hypothyroidism impaired mental function increased susceptibility to nuclear radiation

EPIDEMIOLOGICAL CRITERIA for ASSESSING THE SEVERITY of IDD BASED ON THE PREVALENCE of GOITER IN SCHOOL-AGED CHILDREN Degrees of IDD, expressed as percentage of the total of the number of children surveyed none mild moderate severe Total Goiter Rate 0.0-4.9% 5.0-19.9% 20.0-29.9% ≥ 30%

MEDIAN URINARY IODINE (µG/L) EPIDEMIOLOGY CRITERI FOR ASSESSING IODINE NUTRITION BASED ON MEDIAN URINARY IODINE CONCENTRATION in SCHOOL AGED CHILDREN MEDIAN URINARY IODINE (µG/L) IODINE INTAKE IODINE NUTRITION < 20 Insufficient Severe iodine deficiency 20 – 4 0 Moderate iodine deficiency 50 – 99 Mild iodine deficiency 100 – 199 Adequate Optimal 200 – 299 More than adequate Risk of iodine-induced hyperthyroidism within 5-10 years following introduction of iodized salt in susceptible groups > 300 Excessive Risk of adverse health consequences (iodine-induced hyperthyroidism, autoimmune thyroid diseases)

CRITERIA FOR MONITORING PROGRESS TOWARDS SUSTAINABLE ELIMINATION of IDD AS A PUBLIC HEALTH PROBLEM INDICATORS GOALS Salt iodization proportion of household using adequately iodized salt > 90% Urinary iodine proportion below 100 µg < 50% proportion below 50 µg < 20% Programmatic indicator attainment of the indicators specified on the opposite page At least 8 of the 10

MAJOR COMPONENTS REQUIRED TO CONSOLIDATE THE ELIMINATION of IDD Political support Administrative arrangements Assessment and monitoring systems

OPTION CORRECTION of IDD Administration of iodized oil capsules every 6-18 months Direct administration of iodine solutions, Lugol’s iodine, at regular intervals (once a month is sufficient) Iodization of salt supplies Iodization of water supplies by direct addition of iodine solution Via special delivery mechanism

SALT IODIZATION PROGRAM A successful program at national level depends upon the implementation of a set of activities by various sectors: Government ministries (legislation & justice, health, industry, agriculture, education, communication, and finance) Salt producers, salt importers & distributors, food manufactures Concerned civic groups Nutrition, food & medical scientists Other key opinion makers

RECOMMENDED IODINE CONCENTRATION IN SALT Iodine concentration in salt at the point of production should be within the range of 20-40 mg of iodine per kg of salt (20-40 ppm) The iodine should be added as Na or K iodate RDA: 150 µg of iodine/person/day By 150 µg iodine intake, median urinary iodine levels will vary from 100-200 µg/l

FACTORS THAT DETERMINE SALT IODINE CONTENT Variability in the amount of iodine added during the iodization process Distribution of the iodized salt Packaging process Loss of iodine due to environmental conditions during storage and distribution 20% lost during distribution Loss of iodine due to food processing 20% lost during cooking before consumption

CRITERIA FOR MONITORING PROGRESS TOWARDS SUSTAINABLE ELIMINATION of IDD AS A PUBLIC HEALTH PROBLEM INDICATORS GOALS Salt iodization proportion of household using adequately iodized salt > 90% Urinary iodine proportion below 100 µg < 50% proportion below 50 µg < 20% Programmatic indicator attainment of the indicators specified on the opposite page At least 8 of the 10

SUMMARY IDD is a world wild problems The much greater public health importance are the more subtle degrees of brain damage and reduce cognitive capacity which affect the entire population. The potential of a whole community is reduced by iodine deficiency It can be prevented. A successful program at national level depends upon the implementation of a set of activities by various sectors

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