1. IODINE DEFICIENCY DISORDERS

2. 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

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

4. BACKGROUND

5. 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

6. 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

7. 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

8. 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

9. 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-

11. 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%

12. 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

13. IODINE TOXICITY
In the range 0f 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

14. 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%

15. 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

16. 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

17. 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 % % %
≥ 30%

18. 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)

19. 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

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

21. 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

22. 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

23. RECOMMENDED IODINE CONCENTRATION IN SALT
Iodine concentration in salt at the point of production should be within the range of 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 µg/l

24. 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

25. 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

26. 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

27. Thank You