community medicine. topic- Nutrition , Subtopic- Iodine and nutrition. Source - Preventive and social medicine by K.Park

1. IODINE AND
ITS
DEFICIENCY
DHRUV KUMAR
36

2. IODINE
– Essential micro-nutrient
– Required for the synthesis of the thyroid hormones
T3(triiodothyronin) and T4 (thyroxine)
– Is essential in minute quantities for the normal growth
and development and well beings of all humans.
– The adult human body contains about 50 mg of iodine,
and the blood level is about 8-12 micrograms/dl.

3. Required Daily Allowance
RDA Of Iodine
Infants 50 mcg
Children 100 mcg
Adult 150 mcg
During Pregnancy 200 mcg

4. SOURCES
– Sea food ( sea fish, sea salt)
– Cod liver oil
– Small amount in milk, meat, vegetables, cereals etc.
– Variable in water (1-50 mcg/L)
– IODINE CONTENT OF WATER AND CROPS DEPEND ON
IODINE CONTENT OF SOIL

5. GOITROGENS
– • Vegetables of Brassica group- cabbage, cauliflower,
Radish etc.
– • Contain goitrogens as thiocyanates and cynoglycosides
– • Make the iodine of food unavailable for body
– • Can be inactivated by heating.

6. ABSORPTION
– Small intestine
– 30% utilized by thyroid gland for the synthesis of
hormone
– Remainder excreted in urine.

7. IODINE DEFICIENCY
DISORDERS
– Iodine Deficiency Disorders refer to a spectrum of health
consequences resulting from inadequate intake of
iodine.
– Major nutritional problem
– Spectrum of diseases (from intrauterine to childhood
and adulthood)

8. PROBLEM BURDEN
– >7 % of World population suffers from iodine deficiency.
– Serious problem of third world countries like India,
Bangladesh, Bhutan, Myanmar, Indonesia, Nepal, Sri
Lanka and Thailand.
– Severity higher in South-East Asia in World

9. • “Sub-Himalayan goitre belt is
world’s most intense goitre
endemic region affecting nearly
120
million people”
• Some extra Himalayan foci close to
low lying hills: Chota Nagpur
region of Bihar, Hilly areas of MP &
CG, Parts of Western Ghats(
Maharashtra, Kerala,
Karnataka),Eastern Ghats (AP and
TN)
9

11. Spectrum with increasing severity
Levels of severityDisorders
Goitre -Grade I
-Grade II
-Grade III
-Multi-nodular
-Varying combination of clinical signs
-Variable severity
-Unilateral
-Bilateral
-Muscle weakness in legs, arms, trunk
- Spastic diplegia
-Spastic quadriplegia
-Hypothyroid cretinism
-Neurological cretinism
Hypothyroidism
Subnormal intelligence Delayed motor
milestones Mental deficiency
Hearing defects Speech
defects
Strabismus (squint) Nystagmus
Spasticity
Neuromuscular weakness
Endemic cretinism
Intrauterine death ( spontaneous abortion,
miscarriage)
11

12. Clinical features through the life cycle
– Retarded mental and physical development, goitre,
– S/S of juvenile hypothyroidism( growth retardation,
– mental retardation, hoarse voice), puffiness, thickened dry skin,
– dry rare hair/eyelashes/eyebrows, delayed sexual maturation
Fetus and neonate Abortion, stillbirth, congenital anomalies ( Umbilical
hernia, large anterior fontanel), high peri-natal and infant
mortality, low birth weight, neonatal goitre, lethargy, poor
feeding, prolonged physiological jaundice
Infant and early
childhood
S/S of cretinism- mental deficiency, squint, short stature,
hoarseness of voice, deaf-mutism, motor spasticity
Child and adolescent
Adult Mental and physical underdevelopment., sleepy and slow,
impaired mental function( decision making), enlarged
thyroid, hypothyroidism S/S(intolerance to cold, weight
gain, somnolence, hoarseness, menorrhagia, non pitting
oedema. 12

13. Epidemiological assessment of Iodine
deficiency
• For surveillance of goitre control program.
• Indicators are- prevalence of goitre
-prevalence of cretinism
-urinary iodine excretion
-thyroid function test
-prevalence of neonatal hypothyroidism

14. Iodine check up
• Iodine can be sublimate
• Constantly lost from salt
• Recommended to consume the salt with 6
months of iodization
• Rapid Test kit-MBI kit by UNIFEC available to test:
1 drop of solution placed on salt containing iodine
produced blue/purple colour.

15. Prevention and
control
Under National IDD control program 4 main
components are:
1. Use of iodized salt or oil
2. Iodine monitoring
3. Manpower training
4. Mass communication
5. Hazards of iodizaton

16. • Most widely used prophylactic
measure
• Iodization of salt with potassium
iodate
• In India iodization is fixed under
Prevention of Food Adulteration
(PFA) Act- ≥ 30 ppm iodine at
production point & ≥15 ppm at
consumer level
• Govt. of India proposed to replace
common salt with iodized salt (
UNIVERSAL IODIZATION)
• Double fortified salt- Two-in-one
salt
1.Using Iodized salt/oil:

17. Iodized oil:
Intramuscular- injection (mostly poppy seed oil)
• NIN Hyderabad developed iodized oil in safflower or
safola oil
• Dose-1ml: provide protection for 4 years
• Expensive
• Reaching every victim is difficult
• Recommended for severely endemic population
where quick response is needed

18. • Iodized oil oral:
• Technically simple
• Oral oil or sodium iodate tablets
• Limited research available
• Costlier than IM oil

19. • Network of laboratories for-
• iodine excretion detection
• Detection of iodine in water soil and food
• Detection of iodine in salt for quality control
• Neonatal hypothyroidism : sensitive pointer of
environmental iodine deficiency & indicator for
monitoring impact of program
2. Iodine monitoring:

20. • to all related to program
• Training in all aspect of goitre control including
legal enforcement and public education, goitre
survey methodology, lab techniques
3.Manpower training:

21. 4.Mass communication: (IEC
activities)
• Tool for nutritional education.
• Creation of public awareness through lectures, road
shows, audio-visual aids, school and women groups etc.
• IEC campaign to increase awareness on consumption of
Iodized salt
• Global IDD day-21st Oct.

22. Chronology and Evolution of IDD
programmes India
• Iodine manifestations have been known to mankind from ancient
times.
• First documented in India in the Himalayan region by McCarrison in
1908
Phase 1: Research Leading to a programme
(1956-83) Khangra Valley study:
First of its kind in India
Provided evidence for iodine and goitre
relationship Major reason for formulation of
NGCP

23. National Goitre Control
Programme, 1962
Launched by GoI, under MoH&FP during 2nd five year plan
With 3 objectives focussing on
• surveys of goitre in endemic areas
• production and distribution of iodised salt in those areas,
• resurveys after 5 years to assess the impact

24. The programme did not achieved
its intended objectives because:
• Low priority
• Focussed only on endemic districts- Himalayan specific
• Public sector only production(Hindustan salt ltd)
• Problems in transport, distribution and supervision
• Poor monitoring of nominees for supply of salt at district level
• Poor enforcement of PFA, non-commitment of states towards surveys.
• IDD was seen as cosmetic. Administrative incompetence, lack of
intersectoral co-ordination, rampant vested and commercial interests.
1983- The central health council adopted USI as policy (hints)
1992- NIDDCP & National level Ban on non-iodised salt.

25. Phase 2: From Goitre to IDD (1983-2000)
Failure of NGCP to address IDDs
Shift from NGCP to NIDDCP
Phase 3: Flip-Flops in ban of non-iodised salt (2000-05)
1997- Ban on Non-iodised salt
2000- Ban lifted (Cost, Politics, Research lack, Personal choice)
Iodised salt introduced in PDS

26. Phase 4: (2005-present)
2005- Ban Reinstated
Revised Policy guidelines on NIDDCP, 2006
Consolidation of sustainable elimination of IDDs
2015- First National Iodine and Salt Intake survey

27. National Iodine Deficiency Disorders
Control Program
• 100% centrally sponsored programme, launched in 1992.
• Currently under NHM, under MoH&FW.
• Last Revision of Guidelines- 2006
Goal:
Reduce the prevalence of Iodine Deficiency Disorders below 10 percent
in the entire country by 2012 A.D.
(12th five year plan- 5%)

28. Objectives:
• Surveys to assess the magnitude of the Iodine Deficiency Disorders.
• Supply of iodinated salt in place of common salt.
• Resurvey after every 5 years to assess the extent of Iodine Deficiency
Disorders and the impact of iodinated salt.
• Laboratory monitoring of iodinated salt and urinary iodine excretion.
• Health education and Publicity.