Overview of IDD in the 21 st century An International Challenge in Nutrition H. Delshad M.D Endocrinologist Research Institute for Endocrine Sciences

● ● ● ● Iodine is a chemical element (as are Oxygen,Hydrogen,Iron) ● Iodine is an essential trace element for the human ● Iodine is an essential part of the chemical structure of thyroid hormones Total quantity present in body is (15-20 mg) Mostly in thyroid gland What is Iodine ?

4 Source of Iodine

● Like most other discoveries, the discovery of Iodine was a fortuitous accident. ● While most scientists discovered something when trying to help people to save their lives, Courtois discovered Iodine when he was trying to kill people. ● Bernard Courtois discovered Iodine in 1811 Discovery of Iodine 5

Recommended daily intake of iodine Preschool children 90  g Schoolchildren (6-12 y) 120  g Adult (>12 y) 150  g Pregnant & Lactating women 250  g 6

The spectrum of IDD Fetus  Abortions  Stillbirths  Congenital anomalies  Increased perinatal mortality  Neurologic creatinism  Psychomotor defects Neonate  Neonatal goiter  Neonatal hypothyroidims Child & adolescent  Goitrous juvenile hypothyroidism  Impaired mental function  Retarded physical development Adult  Goiter with its complications  Hypothyroidism  Impaired mental function 7

IDD : IDD : Iodine Deficiency Disorders The world’s most common endocrine problem The most preventable cause of mental retardation The easiest of the major nutritional deficiencies to correct 8

IDD : Spectrum of Disorders

Cretinism, Tip of the Iceberg 10

11 Endemic Cretinism (Neurologic Form)

12 An adult male from the Congo, with three women of the same age (17-20 years), all of whom are myxedematous cretins. Myxedematous Cretinism

HistoryHistory Awareness regarding goiter goes back to thousands years ago. David Marine in 1915 declared that Endemic goiter is the easiest known disease to prevent. In 1915,for the first time, Hunziger proposed that iodized salt be used for goiter in Switzerland. The first large-scale trials with iodized salt carried out over the period by Marine and Kimbal in Ohio, USA. 13

HistoryHistory 1960 WHO presents the first comprehensive review of goiter on world scale, however in spite of the successful elimination of IDD in a number of industrialized countries, only very slow progress is made in developing countries during the next 15 years The concept of iodine deficiency disorders (IDD) is introduced with emphasis on the effects of iodine deficiency on brain function. 14

With support from UNICEF, WHO & Australian government the ICCIDD is founded in order to bridge the gap between available knowledge and its application 1987 The United Nations Sub-Committee on Nutrition establishes an IDD Working Group to receive an Annual Report of Progress. HistoryHistory

ICCIDD celebrates 25 years of work and creates Basil Hetzel International Award for Communications on iodine nutrition The UNICEF, established the goal of eliminating iodine deficiency worldwide. HistoryHistory

17 Global Iodine Nutrition Global Iodine Nutrition

Epidemiological criteria for assessing iodine nutrition based on median urinary iodine concentration in school-aged children Median Urinary Iodine (  g/L) Iodine Nutrition <20 Sever iodine deficiency Moderate iodine deficiency 50-99Mild iodine deficiency >200More than adequate 18

◙ Iodine sufficient countries before 1990: ●Switzerland ●Scandinavian countries ●Australia ●United States ●Canada ◙ The new global estimate of iodine status data on the 193 WHO Member States. Update on iodine status worldwide 19

20 WHO RegionCountries (n)Proportion (%)Total(millions) Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Global total SAC with insufficient iodine intake, by WHO region, % : severely deficient, 8.1% : moderately deficient, 15.9% : mildly deficient

The top10 iodine deficient countries with the greatest number of SAC with insufficient iodine intake in

The global prevalence of low iodine intakes has fallen over the past decade, from 36.5% in 2003, to 31.5% in 2007 and to 29.8% in

Number of iodine deficient countries in 2003, 2007, and 2011 Over the past decade, the number of countries that are iodine deficient has fallen from 54 to 30 23

24 IODINE INTAKE Insufficient : Sever iodine deficiency100 Insufficient : Moderate iodine deficiency Insufficient : Mild iodine deficiency Adequate More than adequate Excessive5711 Countries with data The number of countries Countries (number) by iodine status over the period The number iodine-sufficient countries has increased from 67 to 106, while the number with excessive iodine intake has increased from 5 to 11.

25 Where do we stand in 2013? Where do we stand in 2013?

26 Overall results Overall results About 70% of households worldwide have access to iodized salt. Out of 128 countries with data, at least 90% of households in 37 countries consume adequately iodized salt, but in 39 countries, coverage rates are below 50%. Tow billion of the global population, including 241 million school children, still have insufficient dietary iodine intakes.

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28 Acknowledgment

29 John Stanbury In 1985, Stanbury founded the International Council for the Control of Iodine Deficiency Disorders (ICCIDD). In 1950, John Stanbury was a young physician at Massachusetts General Hospital. A surgeon from Argentina brought him photographs of patients suffering from enlarged thyroid glands, or goiters, and, like his colleagues, Stanbury had never seen cases like the ones the Argentine displayed. Intrigued, Stanbury and other researchers traveled to Argentina in June of 1951 to investigate further, and through their research showed the first physiological link between goiters and iodine deficiency.

30 Basil Stuart Hetzel, AC (born 13 June 1922) is an Australian medical researcher who has made a major contribution to combating iodine deficiency a major cause of goiter and cretinism worldwide.

31 François Delange ( June 2007) was a Belgian physician and researcher who contributed to thyroid research. He performed field studies on goiter prevalence worldwide and performed pioneering research in early screening for congenital hypothyroidism.

32 Back ground & present state of IDD in IRAN

The history of IDD in IRAN 1969 (1348) The first epidemiological assessment of goiter: High prevalence of goiter in most parts of the country (1362) The assessment of goiter in Shahryar Goiter prevalence : ● 54% in male and 66% in female subjects ● MUI: 65 µg/L

34 Huge Goiter

1984 (1363) The assessment in Tehran, rural areas near Tehran and Kohkiloyeh Boyerahmad : 1984 (1363) The assessment in Tehran, rural areas near Tehran and Kohkiloyeh Boyerahmad : ► Goiter prevalence: ● Hyperendemic ● MUI : ≤ 50 µg/l ► Physical examination:  Mental& physical growth retardation  Psychomotor disturbances  Hearing deficits

1989 (1368) First national survey (Centers and capital cities of 14 provinces and rural areas of 8 provinces) Goiter prevalence: ● Endemic in all and ● Hyper endemic in capital cities of 5 provinces Median Urinary Iodine: ● ≤100 µg/l in all regions

In general  The estimated population at risk for IDD in the country based on the findings of the results of the surveys conducted from 1983 to 1989: 20 millions  Therefore in 1988 iodine deficiency has been accepted as a priority health problem.  In 1989 Iranian National Committee for the Control of Iodine Deficiency ( INCCI) was established by MOH

1996 (1375) Second national survey Goiter prevalence: ● 58% ● Most have low grade goiter Median Urinary Iodine: ● 200 µg/l 7 years after the initiation of salt iodization 2 years after the USI House hold consumption of iodized salt : % 50 o %82; UIC ≥ 100 µg/l o ≤%10; UIC ≤50 µg/l

(1375) 2 nd national survey  MUI in schoolchildren was over than the at least standard value set by WHO/ UNICEF /ICCIDD  Successful salt iodization program I.R.IRAN has announced to be IDD free with fulfilling 10 programmatic indicators set by WHO/ UNICEF /ICCIDD in 2000.

2001 (1380) Third national survey Goiter prevalence: ● 9.8% ● Significant decrease in goiter prevalence especially goiter grade 2 Median Urinary Iodine: ● 167 µg/l 5.8% : UIC<50 µg/l 14% : UIC= µg/l 80.2% : UIC> 100 µg/l Households consumption of iodized salt : % 95

2007 (1386) Forth national survey Goiter prevalence: ● 5.9% ● most with grade 1 goiter Median Urinary Iodine: ● 140 µg/l  % 65 UI >100 µg/l  % 15 UI < 50 µg/l Households consumption of iodized salt : % 97

Diagram of goiter prevalence in Iran from 1989 to

43 Indicator Year Goiter Prevalence Median UIC µg/l % median UIC < 100µg/l 1996 (1375) (1380) (1386) Iodine status of Iranian population

Prevlence Of Goiter In Iran 44

2012 (1390) Fifth national survey ?

Conclusion ● The well-monitored salt iodization program in Iran has ultimately resulted in optimization of UIC, and drastically decreased the goiter rate 17 years after universal salt iodization. ● Our last survey indicates a well established sustainable IDD program in I.R. IRAN. ● Iodized salt programs need to be carefully monitored to ensure adequate iodine intake while avoiding iodine excess.

47 کنترل اختلال های ناشی از کمبود ید در ایران وکشورهای منـــــطقه مدیون تلاش خســتـگی ناپذیـر و همت ماندگار دانشمـند فرهیخـــته جناب آ قای دکتر فریدون عزیزی است. فروغ شادی چشمان مادرانی که دیگر کودکی با عقب ماندگی ذهنی ناشی از کمبود ید بد نیا نمی آورند را تقدیم شما می نماییم.

48 Iodine deficiency is so easy to prevent that it is a crime to let a single child be born mentally handicapped for that reason. Henry Richardson Labouisse, Jr UNICEFF, 1978 Home message

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