Iodine and the Thyroid

Mark Vanderpump
UK National Coordinator
Iodine Global Network
Thyroid gland
 Thyroid hormone target tissues
Retina Brain

Pituitary Inner ear

Thyroid hormones act
everywhere
Heart Spleen

Liver Gut

Basal metabolic rate

Growth and development
Temperature regulation
Fat production
Blood vessels Bone Muscle
Skin
Hair
Bone marrow
Kidney
Lung
Thyroid hormones
Thyroid hormone biosynthesis
 Iodine
An important element in the manufacture
of thyroid hormones
Most iodine is present in sea water which
evaporates and returns to the soil in rain
Low iodine levels are common in
mountainous regions far away from the sea
The major source is bread and milk
 Iodine deficiency disorders
Fetus: abortion, stillbirth, congenital anomalies,
perinatal mortality, endemic cretinism
Neonate: goitre, hypothyroidism, mental
retardation
Child: goitre, (subclinical hypothyroidism),
impaired mental function, delayed physical
development
Adults: goitre, hypothyroidism, impaired mental
function, spontaneous hyperthyroidism, iodine-
induced hyperthyroidism
Criteria for assessing iodine nutrition
(WHO, 2007)
 Severe iodine deficiency in
pregnancy and neurodevelopment
Northern Himalayas (n=4000)
Goitre 92% and hypothyroidism 40%
Iodised oil shrunk goitres and reversed
symptoms and signs of hypothyroidism
No cretins or deaf mutes born despite
previous incidence 20-25%
(Ibbertson, 1971)
 Severe iodine deficiency in
pregnancy and neurodevelopment
Papua New Guinea (n=160,000)
Placebo-controlled trial of iodised oil
injections pre-conception or early pregnancy
Reduced incidence of cretinism and improved
motor/cognitive function
(Pharoah et al, 1971)
 The Bronchocele
(Prosser, 1769)
A tumour arising on the fore-part of the neck. It generally first
appears sometime betwixt the age of eight and twelve years, and
continues gradually to increase for three, four, or five years; and
often the last half-year of this time, it grows more than it had for
a year or two before.
It very rarely happens to boys, indeed I have never been able to
make out one instance of it, in a man or boy.
It is very common in many counties in England, Derbyshire
especially, where from its frequency it has the name of Derby
Neck, and some other countries are almost free from it.
This disease.affects the inhabitants about the Alps, and other
parts of Italy.
The present state of Derbyshire
(Pilkington, 1789)
There is one disease to which the inhabitants
of Derbyshire are so much subject, that it has
taken its name from its great prevalence in
this situation."
Some thought it was hereditary, others that it
was caused by living "on the bleak sides of
hills." They all agreed that women, particularly
"child-bearing poor women" were the main
victims of "this very unfortunate female
disease.
UK iodine status: Early studies
1924 survey of 375,000 schoolchildren in
England and Wales: Visible goitre in 30%
1948 MRC survey: Visible goitre in 50%
adult women in Oxford, 43% girls in Dorset,
26% of children in St Albans, 2% in Essex
1958 repeat MRC survey: Goitre prevalence
in girls in Oxford from 40% from 27%
1963-66: Goitre in Sheffield (12% men, 25%
women), E Lothian (0.3% men and 4%
women), Durham (1% men, 9% women)
Accidental public health triumph
(Phillips, 1997)
Rise in iodine content of milk especially winter
Changes in UK farming practice from 1940s
with iodine-rich artificial feeds/disinfectants
UK governments post WWII encouraged
compulsory milk consumption in schools
Iodine content of milk alone sufficient to meet
recommended daily requirement 150g
UK iodine status: Later studies
1990: Thyroid enlargement no longer
detectable in schoolchildren in South Wales
1994: Median UIC 102g/g in NE England
National monitoring aimed to avoid
concerns re iodine toxicity not deficiency
2002-2009: 50% of pregnant women in
small surveys (Middlesbrough, Dundee,
Cardiff, Guildford) median UI 66g/L
2006: Iodine deficiency in pregnant women
in Ireland especially in summer months
2007: Survey of 36 household salt
preparations in supermarkets for iodine
sufficient in only 2 (Lazarus & Smythe)
 UK iodine status
A national survey

Generously supported by
Clinical Endocrinology Trust
UI concentrations in UK schoolgirls
(n=737)
%

Median 80g/L
 Summer
Urine samples n=537
Median 76g/L

Aberdeen 82g/L

Winter
Urine samples n=200
Median 95g/L Belfast 62g/L Newcastle/
Gateshead 75g/L

P<0.001

Birmingham 75g/L

Cardiff 80g/L London 85g/L

Exeter 83g/L
UK iodine survey: Milk intake
National iodine status based on
UI in schoolchildren
(WHO 2011)
Impact of mild-moderate iodine
deficiency
Hypothyroxinaemia not raised serum TSH
Maternal T4 crucial before 13 weeks gestation
Children born to women may have psycho-
neurological deficits and delayed mental
function compared with controls
Functional consequences in older children is
unclear
How to correct iodine deficiency?

Salt iodisation is safe, equitable, self-financing

and extremely cost-effective
Mandatory bread salt iodisation in NZ and
Australia has increased iodine intake
Oral potassium iodide supplements for most
susceptible groups eg women pre-pregnancy
 Iodine status in industrialised
countries
Strong public health objective to lower salt
intake to reduce risk of hypertension
10% of UK salt intake is added to food at table
Cows milk intake up to 50% and although UK
milk iodine stable (300mcg/l) but evidence
consumption falling
Dialogue with food/salt industries ?feasibility
of adding iodised salt to processed foods
How provide reassurance at population level?
 Iodine awareness in UK
(Combet et al, 2015)
Recent study of 1026 pregnant or recent post-
partum women in Glasgow
Nutritional recommendations 96%
Iodine specific recommendations 16%
Identification of milk as source 9%
50% of UK pregnancies unplanned
 Conclusions
UK is example of increase in mild-moderate
iodine deficiency in industrialised countries
Mild perturbations of fetal and maternal thyroid
function have impact upon neurodevelopment
and potential impact in older children
Iodine supplementation is required in mild-
moderate iodine deficiency
Variation in UI in different population groups
with young women most vulnerable group
How can this group be targeted with a
population-based intervention?