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TECHNICAL BRIEF: Key Barriers to Global Iodine Deficiency Disorder Control: a Summary

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TECHNICAL BRIEF: Key Barriers to Global Iodine Deficiency Disorder Control: a Summary Key Barriers to Global Iodine Deficiency Disorder TECHNICAL BRIEF Control: A Summary Michael Zimmermann, M.D. THE SCIENTIFIC BASIS OF decreased vitamin A-mediated suppression of the pituitary TSHβ gene. CURRENT POLICIES TO CONTROL IODINE DEFICIENCY Iodine deficiency produces a spectrum of abnormalities, grouped under the heading of iodine Iodine deficiency is a major global public health deficiency disorders (IDD), which reflect thyroid problem, particularly for young children and pregnant dysfunction. Goiter and cretinism are the most visible women. The most serious effect of iodine deficiency is manifestations; the others include hypothyroidism, mental retardation. It is one of the world’s major decreased fertility rate, increased perinatal death and causes of preventable cognitive impairment, posing a infant mortality. Impaired neurocognitive threat to the social and economic development of development is the most important effect of iodine countries. This is the motivation behind the current deficiency. Lack of iodine resulting in hypothyroidism worldwide drive to eliminate iodine deficiency. during the vulnerable period of brain development, that is, fetal life and the first year, can cause The primary cause of iodine deficiency is a low dietary irreversible impairment in brain structure and supply of iodine, typically in environments where the function. soil lacks iodine due to past glaciation, often compounded by the leaching effects of precipitation In areas of severe iodine deficiency, cretinism can or flooding. These remove iodine from the soil, and affect 5 to 15 percent of the population. Individuals plants and livestock become iodine deficient. Iodine living in areas of mild or moderate iodine deficiency deficiency may be aggravated by intake of natural exhibit more mild neurological and intellectual deficits. goitrogens in staple foods such as cassava, which A meta-analysis estimates that severe iodine deficiency contains thiocyanate that inhibits thyroid iodide is responsible for a mean IQ loss of 13.5 points in transport. Deficiencies of selenium, iron, and vitamin affected populations. Correction of iodine deficiency A also exacerbate the effects of iodine deficiency. in a population reduces or eliminates all its Glutathione peroxidase and the deoidinases are consequences. Recurrence of IDD occurs predictably selenium-dependent enzymes. In selenium deficiency, when an effective IDD control program lapses in a accumulated peroxides may damage the thyroid, and previously iodine deficient population. deiodinase deficiency impairs thyroid hormone The recommended indicators for assessing the severity synthesis. These effects have been implicated in the and extent of iodine deficiency in a population are the etiology of myxedematous cretinism. Iron deficiency median urinary iodine (UI) concentration and the total reduces heme-dependent thyroperoxidase activity in goiter prevalence. The median UI is recommended for the thyroid and impairs production of thyroid monitoring interventions for IDD control, rather than hormone. In goitrous children, iron deficiency anemia goiter prevalence, because it responds faster to the blunts the efficacy of iodine prophylaxis while iron correction of iodine deficiency and is sensitive to supplementation improves the efficacy of iodized oil current iodine intake. According to WHO, IDD is a and iodized salt. Vitamin A deficiency in iodine- public health problem in populations where median deficient children increases the thyroid stimulating UI is <100 µg/l, or in areas where more than five hormone (TSH) and risk for goiter, probably through percent of children aged 6 to 12 years have goiter. 1 For more information about the A2Z project: Call: 202-884-8970 • Email: [email protected] • Visit: www.a2zproject.org However, often these two indicators are discrepant in (WHA) in 2005 reaffirmed the importance of the years following introduction of iodized salt due to controlling iodine deficiency indicated in previous a lag in goiter resolution. WHA resolutions (WHA 49.13 and WHA 52.24) and endorsed by the 2002 UN GASS resolution on IDD control programs should focus on pregnancy, sustained elimination of IDD. For salt iodization to be lactation, and infancy. However, the assessment of successful there needs to be close interaction with the iodine status during these life stages is challenging and salt industry. The Network for the Sustained monitoring these groups has historically been Elimination of Iodine Deficiency was formed in 2002 underemphasized. There are no established reference to foster this interaction. At the moment the Network criteria for median UI for pregnancy, lactation, or functions mainly as a clearing house for country infancy. Although a median UI in school-age children services by ICCIDD, WHO, and UNICEF; its future (SAC) and adults in the range of 100-199 µg/L role needs to be better defined. indicates adequate iodine intake, this criterion has not been validated in pregnant and lactating women or In 2001 the CDC established a program, Ensuring the infants, and may, if applied to these target groups, Quality of Urinary Iodine Procedures (EQUIP), underestimate the true burden of IDD. designed to improve the quality of UI measurements worldwide. The CDC, using the reference method for A recent WHO expert meeting on this issue UI, ICP-MS, and UI laboratories worldwide recommended an increase in the current FAO/WHO participate in a round robin measuring unknown RNI for iodine during pregnancy and lactation from samples provided by the CDC. CDC uses the results 200 µg/day to 250 µg/day. A daily intake greater than to prepare a statistical report for the participating this is not necessary and preferably should not exceed laboratories, and this feedback provides external 500 µg/day. The RNI for infancy has not changed, control regarding performance. In this way, EQUIP remaining at 90 µg/day. These recommendations are provides important quality control for laboratories based mainly on theoretical considerations of the active in the process of monitoring the elimination of physiology of iodine nutrition, as there is little data IDD around the world. from these population groups. The median UI is recommended as the best indicator to use in The global control of IDD through universal salt population surveys to assess the iodine nutrition of iodization (USI) constitutes one of the most cost pregnant and lactating women, and of children less effective development efforts contributing to than two years of age. The median UI that indicates economical and social development. The international adequate iodine intake in pregnant women was community has made substantial progress in USI estimated to be 150 – 249 µg/L, and in lactating coverage, and more than two billion more people have women and children aged zero to two years old, ≥100 adopted the use of iodized salt in the last decade. µg/L. In lactating women, the figures for median UI During this period, the world population’s household are lower than the iodine requirements because of the access to iodized salt has risen from <20 percent to iodine excreted in breast milk. In countries or regions >70 percent. Despite this, WHO estimates that 54 in which systematic neonatal screening for congenital countries out of 126 still have inadequate iodine hypothyroidism is done using the concentration in nutrition (i.e. median UI <100 µg/l), and 23 million blood of the thyroid stimulating hormone (TSH), an babies each year globally are still born with inadequate elevated concentration of TSH reflects an insufficient iodine nutrition. One third of the world’s population supply of maternal and/or fetal thyroid hormone to still remains at risk, mostly in the poorest and the developing brain and indicates a risk of irreversible economically least developed areas. The most affected brain damage. regions, by absolute number of people affected and in Most of the effort in producing and marketing salt decreasing order of magnitude, are South-East Asia, iodization, in implementing policies, in educating Europe, the Western Pacific, Africa, the Eastern people and leaders, and in monitoring has been Mediterranean and the Americas. Mild iodine undertaken by national entities, with the support of deficiency is currently re-emerging in areas where it the international agencies—the International Council was believed to have been eliminated, such as for Control of Iodine Deficiency Disorders Australia. This underscores the need to sustain IDD (ICCIDD), UNICEF, the World Health Organization control efforts. (WHO), the World Food Program (WFP), and the Micronutrient Initiative (MI). Kiwanis International, USAID, CIDA, AUSAID, and the Gates Foundation have channeled funds through UNICEF for these efforts. The Fifty-Eighth World Health Assembly 2 For more information about the A2Z project: Call: 202-884-8970 • Email: [email protected] • Visit: www.a2zproject.org WYD Iodine Checker needs to be thoroughly CURRENT SCIENTIFIC ISSUES validated against titration. Iodine nutrition in pregnancy and infancy Metabolic interactions of iodine and other The optimal indicators to assess iodine nutrition micronutrient deficiencies during pregnancy, lactation, and infancy need to be The affects of vitamin A, iron, zinc, and selenium identified. The use of newborn serum thyroid deficiencies in the setting of iodine deficiency should stimulating hormone (TSH) concentration as an be investigated. indicator of iodine status in pregnancy needs further validation. Other potential
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