Eliminating Iodine Deficiency in China: Achievements, Challenges and Global Implications.

The prevention of iodine deficiency through salt iodization has been recognized as a global success story, and China stands at the forefront of this achievement with one of the most successful programs in the world. High level political commitment, national mandatory legislation, a state-managed edible salt industry and a complex and highly sophisticated surveillance system have facilitated the success of the program. Challenges have arisen however, including: (i) concern that adequate iodine status in pregnant women cannot be achieved without causing above adequate iodine intakes in children; (ii) declining iodine intake as a result of reductions in salt consumption and increased consumption of processed foods, which may not be made with iodized salt; (iii) the existence of areas with high iodine content in the water; and (iv) declines in household use of iodized salt due to concerns about excess iodine intake and thyroid disease. This article reviews the achievements and challenges of the Chinese Iodine Deficiency Disorders (IDD) Elimination Program and reflects on lessons learned and implications for other national salt iodization programs.

Expression of organic anion transporting polypeptide 1c1 and monocarboxylate transporter 8 in the rat placental barrier and the compensatory response to thyroid dysfunction.

Thyroid hormones (THs) must pass from mother to fetus for normal fetal development and require the expression of placental TH transporters. We investigate the compensatory effect of placental organic anion transporting polypeptide 1c1 (Oatp1c1) and monocarboxylate transporter 8 (Mct8) on maternal thyroid dysfunction. We describe the expressions of these two transporters in placental barriers and trophoblastic cell populations in euthyroidism and thyroid dysfunction resulting from differential iodine nutrition at gestation day (GD) 16 and 20, that is, before and after the onset of fetal thyroid function. Immunohistochemistry revealed that in the blood-placenta barrier, these two TH transporters were strongly expressed in the villous interstitial substance and were weakly expressed in trophoblast cells. Levels of Oatp1c1 protein obviously increased in the placental fetal portion during maternal thyroid deficiency at GD16. Under maternal thyroid deficiency after the production of endogenous fetal TH, quantitative PCR analysis revealed down-regulation of Oatp1c1 occurred along with up-regulation of Mct8 in trophoblast cell populations isolated by laser capture microdissection (LCM); this was consistent with the protein levels in the fetal portion of the placenta. In addition, decreased D3 mRNA at GD16 and increased D2 mRNA on two gestational days were observed in trophoblast cells with thyroid dysfunction. However, levels of Oatp1c1 mRNA at GD16 and D3 mRNA at GD20 were too low to be detectable in trophoblast cells. In conclusion, placental Oatp1c1 plays an essential compensatory role when the transplacental passage of maternal THs is insufficient at the stage before the fetal TH production. In addition, the coordinated effects of Oatp1c1, Mct8, D2 and D3 in the placental barrier may regulate both transplacental TH passage and the development of trophoblast cells during thyroid dysfunction throughout the pregnancy.

Developmental thyroid hormone disruption: prevalence, environmental contaminants and neurodevelopmental consequences.

Thyroid hormones (TH) are critical for growth and development and particularly brain development. There are numerous environmental agents that lead to marginal reductions of circulating TH. Although it is clear that severe developmental hypothyroidism is profoundly detrimental to neurodevelopment, there is less information regarding the consequences of modest degrees of thyroid. The impact of low level TH disruptions induced by environmental contaminants has not been defined. This paper is a synopsis from four invited speakers who presented at the 13th International Neurotoxicology Association meeting held in Xi'an, China during the summer of 2011. An overview of the role of TH in brain development and a review of human and animal data on the neurological sequelae of disruption of the thyroid axis in the pre- and early post-natal periods were presented by Mary Gilbert and Joanne Rovet. Iodine deficiency, a common cause of TH insufficiency and mental retardation in many countries, including China, was addressed by Zupei Chen. In this presentation the current incidence of iodine deficiency and neurological outcome in China and the efficacy of recently implemented iodinization programs to eliminate this cause of mental retardation were reviewed. Joanne Rovet described the impact of TH disruption during pregnancy and under conditions of congenital hypothyroidism. Children born with normal thyroid function, but who experienced TH insufficiency in the womb, display subtle cognitive impairments and abnormalities in brain imaging. Despite early detection and treatment, deficiencies also exist in children born with thyroid disorders. Different patterns of cognitive effects result from prenatal versus postnatal TH insufficiency. Mary Gilbert reported on the effects of environmental contaminants with thyroid disrupting action on brain development in animals. Results of neurophysiological, behavioral, structural and molecular alterations that accompany modest perturbations of the thyroid axis were reviewed. Noriyuki Koibuchi described molecular targets of TH-mediated signalling accompanying exposure to persistent organic pollutants. Both polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs) are prevalent environmental contaminants that disrupt TH signalling at the receptor level. This action by these chemical classes could contribute to the negative impact of these chemicals on brain function. In summary, epidemiological, preclinical and animal research has clearly identified the critical role of TH in brain development. Additional work is required to understand the impact of low level perturbations of the thyroid axis to evaluate the risk associated with environmental contaminants with thyroid action.

Exploration of the safe upper level of iodine intake in euthyroid Chinese adults: a randomized double-blind trial.

BACKGROUND: The beneficial health effects associated with Universal Salt Iodization are well known. Yet, little is known about the possible adverse health effects in people with high iodine intake and the safe daily intake upper limit in the Chinese population. OBJECTIVE: The objective of this study was to explore the safe upper level of total daily iodine intake among adults in China. DESIGN: A 4-wk, double-blind, placebo-controlled, randomized controlled trial was conducted in 256 euthyroid adults. Participants were randomly assigned to 12 intervention groups with various iodine supplement doses ranging from 0 to 2000 µg/d. Total iodine intake included iodine from both supplements and diet. Multiple outcome measures were used to evaluate possible adverse effects, including thyroid function, thyroid size, and urinary iodine. RESULTS: The mean iodine intake from the diets and salt intake of the participants were 105 ± 25 and 258 ± 101 µg/d, respectively. In comparison with the placebo group, all iodide-supplemented groups responded with significant increases in median urinary iodine concentrations (P < 0.05) and in thyroid-stimulating hormone concentration (P < 0.05). Thyroid volume decreased after 4 wk in the high-iodine intervention groups (1500-2000 µg). Subclinical hypothyroidism appeared in the groups that received 400 µg I (5%) and 500-2000 µg I (15-47%). CONCLUSIONS: This study showed that subclinical hypothyroidism appeared in the participants who took the 400-µg I supplement, which provided a total iodine intake of ∼800 µg/d. Thus, we caution against a total daily iodine intake that exceeds 800 µg/d in China and recommend further research to determine a safe daily upper limit.

Trimester- and method-specific reference intervals for thyroid tests in pregnant Chinese women: methodology, euthyroid definition and iodine status can influence the setting of reference intervals.

OBJECTIVE: The importance of diagnosis and treatment of thyroid dysfunction during pregnancy has been widely recognized. We therefore established trimester- and method-specific reference intervals for thyroid testing in pregnant women according to the NACB recommended criteria. Several factors can affect the setting of reference intervals, in particular manufacturer's methodology, euthyroid definition and iodine status. DESIGN: Cross-sectional dataset analysis. SUBJECTS: Five hundred and five normal pregnant women at different stages of gestation were rigorously selected for setting reference intervals. All were healthy, iodine sufficient, euthyroid and negative for both serum thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TgAb). MEASUREMENTS: Thyrotrophin (TSH), total and free thyroxine (TT4 and FT4), total and free triiodothyronine (TT3 and FT3) and anti-TPOAb and anti-TgAb were measured using the Bayer ADVIA Centaur system. Iodine content in drinking water, salt and urine was determined by national standard methods. The 2·5th and 97·5th percentiles were calculated as the reference intervals for thyroid hormone levels during each trimester. RESULTS: All participants had long-term consumption of iodized salt and median urinary iodine of 150-200 µg/l during each three trimester. The reference intervals for the first, second and third trimesters were, respectively, TSH 0·03-4·51, 0·05-4·50 and 0·47-4·54 mIU/l and FT4 11·8-21·0, 10·6-17·6 and 9·2-16·7 pmol/l. The manufacturer's method, euthyroid definition and iodine status may influence TSH and FT4 reference intervals. Alterations in thyroid hormone concentrations during pregnancy differed at different stage of gestation and to those of a nonpregnant state. CONCLUSIONS: The trimester- and method-based reference intervals for thyroid tests during pregnancy are clinically appropriate. Some variables should be controlled when establishing reference intervals.

The impact of dietary iodine intake on lipid metabolism in mice.

The present study has been designed to investigate the impact of dietary iodine intake on lipid metabolism in mice, including iodine deficiency and iodine excess. Different amounts of iodine mixed in the drinking water were continuously administered to mice. The body weights and the levels of urinary iodine were measured 8 months after the treatment. Thyroid hormones in the serum were detected by chemiluminescence immunoassay. Serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol and low-density lipoprotein cholesterol (LDL-C) were determined enzymatically by automatic analyzer. Results showed that the urine iodine concentrations paralleled the amounts of iodine intakes. No statistical differences of body weights among different groups were found. The levels of thyroid hormones were dramatically decreased in iodine deficiency while no significant differences were found between iodine excess groups and normal iodine group. In iodine deficiency groups, the levels of TG, TC, and LDL were increased at varying degrees. In iodine excess groups, the levels of TG in the male mice and the levels of TC in the female mice were much lower than normal iodine group. In conclusion, dietary iodine intake may affect the metabolism of serum lipids. Hypothyroid function induced by iodine deficiency may be responsible for the changes of lipids. Higher iodine intake might benefit lipid metabolism.

Cretinism revisited.

Endemic cretinism includes two syndromes: a more common neurological disorder with brain damage, deaf mutism, squint and spastic paresis of the legs and a less common syndrome of severe hypothyroidism, growth retardation and less severe mental defect. Both conditions are due to dietary iodine deficiency and can be prevented by correction of iodine deficiency before pregnancy. Endemic cretinism is now included in the spectrum of the effects of iodine deficiency in a population termed the 'iodine deficiency disorders (IDDs)', which also includes a wide range of lesser degrees of cognitive defect that can be prevented by the correction of iodine deficiency. Iodine deficiency is now recognised by the World Health Organization (WHO) as the most common preventable cause of brain damage with in excess of 2 billion at risk from 130 countries. A global United Nations (UN) programme of prevention has achieved 68% household usage of iodised salt by the year 2000 compared with less than 20% prior to 1990.

Characteristics of an scFv antibody fragment that binds to immunoglobulin G of Graves' disease patients and inhibits autoantibody-mediated thyroid-stimulating activity.

Thyroid-stimulating antibodies (TSAbs) are responsible for hyperthyroid Graves' disease (GD). Although two peptides that bind to GD immunoglobulin G (IgG), and some monoclonal antibodies to the TSH receptor (TSH-R), have been reported to inhibit stimulation of cAMP production by patient serum TSAb, our work is the first to use phage-display technology to produce a mouse single-chain Fv antibody fragment (scFv) that binds to GD IgG and acts as a powerful TSAb (and TSH) antagonist. The specificity characteristics and relative affinity (2.8 mol/L) of T17 were identified by competitive inhibition ELISA and thiocyanate elution. The purified T17 scFv was then tested for its effect on stimulation of cAMP production by Graves' patients' sera in TSH receptor-transfected Chinese hamster ovary (CHO) cells. T17 was an effective antagonist of TSAb activity in 13 of 16 patients with GD. In addition, (125)I-TSH binding to TSH-R was also inhibited by T17 (57% inhibition at 1 mg/mL). This new scFv suggests in vitro applications such as purification of TSAb or diagnosis of GD. In addition, it may have in vivo usefulness such as treatment of TSH-R mediated ophthalmic symptoms of Graves' disease.

[The effects of iodine/selenium on the function of antigen presentation of peritoneal macrophages in rats].

OBJECTIVE: To observe the effects of iodine/selenium on the function of antigen presentation of peritoneal macrophages in rats and explore the immunological mechanisms of iodine/ selenium's role in pathogenesis of autoimmune thyroid diseases (AITD). METHODS: Female Lewis rats were randomly divided into four groups including (1) low selenium and normal iodine group (L(sE)N(I)) (2) low selenium and high iodine group (L(Se)H(I)) (3) normal selenium and normal iodine group (N(Se)N(I) ) (4) normal selenium and high iodine group (N(Se)H(I)). All rats were fed by a special diet with lower selenium and iodine in it and drunk ion-free water containing different levels of iodine and selenium for 3 months. Peritoneal macrophages of each group and OVA allergized T cells were prepared and cultured together. Then the function of antigen presentation were estimated by detecting the levels of IL-2 in the culture supernatant. The levels of the expression of co-stimulator CD86 in the spleen of each group were determined by RT-PCR. RESULTS: The level of IL-2 in the supernatant in N(Se)H(I) (43.22 +/- 3.27) pg/ml was much stronger than N(Se)N(I) [the level of IL-2 was (25.74 +/- 2.45) pg/ml, P < 0.05]. The level of IL-2 in L(Se)N(I) (15.79 +/- 2.13) pg/ml was significantly lower than N(Se)N(I) (P < 0.05). The expression of CD86 mRNA in N(Se)H(I) (CD86/beta-actin: 0.52 +/- 0.10) were higher than N(Se)N(I) (CD86/beta-actin: 0.35 +/- 0.04), P < 0.05. CONCLUSIONS: High iodine could promote the presentation function of macrophages to a higher state than normal. Therefore, high iodine intake might become an importantly inducing factor in thyroid autoimmunity. Low selenium could weaken the ability of recognizing and presenting OVA antigen of peritoneal macrophages which might destroy immunological homeostasis and thus the low selenium intake might also become an inducer of AITD.

[Overdose of iodine on expression of CCK gene in rat brains].

OBJECTIVE: To observe the effect of overdose iodine on the expression of CCK gene in brains of rats and identify the possible mechanisms. METHODS: One-month weaning Wistar rats were randomly divided into five groups which were fed with normal feedstuff and water supplemented with different concentrations of potassium iodide, named A group (iodine ration was about 6.15 microg per day), B group (iodine ration was about 30.75 microg per day), C group (iodine ration was about 61.5 microg per day), D group (iodine ration was about 307.5 microg per day) and E group (iodine ration was about 615 microg per day). Rats were sacrificed after being fed for three or six months. Then serum thyroid hormones were measured by radioimmunoassay and the mRNA level of CCK gene was studied by using RT-PCR technique. RESULTS: At the end of three months, the values of thyroid hormones in E group [TT4 (45.2 +/- 13.7) nmol/L, TI'3 (0.65 +/- 0.20) nmol/L, FT3 (0.93 +/- 0.45) pmol/L, FT4 (7.07 +/- 2.43) pmol/L, rT3 (0.15 +/- 0.04) nmol/L] were all lower than those in A group [TT4 (76.0 +/- 18.8) nmol/L, TT3 (1.34 +/- 0.41) nmol/L, FT3 (2.45 +/- 0.62) pmol/L, FT4 (15.12 +/- 3.40) pmol/L, rT3 (0.24 +/- 0.04) nmol/L]. There were significant differences between E group and A group on the levels of serum TH (F values are 14.68, 16.03, 21.16, 20.25, 13.52 respectively, P < 0.01); FT3 levels in C and D groups were significantly decreased as compared to A and B groups (F = 21.16, P < 0.05). rT3 level in D group was significantly decreased compared with A,B and C groups (F = 13.52, P < 0.05). At the end of six months, the levels of serum TH in E group (TT4 (51.84 +/- 15.83) nmol/L, TT3 (0.77 +/- 0.22) nmol/L, FT4 (6.88 +/- 2.23) pmol/L, FT3 (0.74 +/- 0.28) pmol/L, rT3 (0.14 +/- 0.03) nmol/L) were lower than those in any other groups (F values were 6.05, 12.22, 11.25, 13.42, 5.89 respectively, P < 0.05). At the end of both three and six months, the mRNA levels of CCK gene in E group were lower than any other groups (F values were 4.04, 3.95 respectively, P < 0.01). The results of correlation analysis showed that serum FT4 had linear correlation with levels of CCK mRNA (r values were 0.990, 0.948 respectively; P < 0.05); However serum FT3 had no linear correlation with the levels of CCK mRNA (r values are 0.970, 0.932 respectively). CONCLUSIONS: Exposure to overdose of iodine (iodine ration was 100-fold higher than that of A group) could decrease the mRNA level of CCK gene. Compared with FT3, FT4 might have more important role on the regulation of CCK mRNA induced by excess of iodine.

[Study on content of iodine in food in Tianjin market and iodine nutrition conditions among college students].

OBJECTIVE: To know about content of iodine in foods sold in Tianjing markets presently, and the iodine nutrition conditions in college students. It was also aimed to probe the functions of the iodized salt complement with the dietary iodine intake, and whether the urine iodine could reflect dietary iodine intake. METHODS: 278 food samples in markets were collected by a randomly stratified sampling method, while the arsenic-cerium catalytic contact method was used to determine the content in food. The dietary information of students for seven days was recorded, and the urine iodine was determined through the arsenic-cerium catalytic spectrophotometry. RESULTS: The determination of 47 kinds and 278 food samples indicated that the content of iodine within animal foods (7.8 microg/100 g - 30.8 microg/100 g) was higher than that within plant foods (1.8 microg/100 g - 16.1 microg/100 g). The investigation also showed that students who regarded vegetarian food as principle accounted for 70. 19%. The amount of dietary iodine intake among those students, based on the dietary survey, was (111.67 +/- 53.18) microg/d, while supplementary iodine from iodized salt was about (230.27 +/- 45.55) microg/d. Therefore, the total iodine provided from diet would be (341.95 +/- 89.58) microg/d. Modified by urine creatinine, the median of urine iodine was 271.28 microg/gCr, and the urine iodine and dietary iodine intake was found positively related (r(s) = 0.463, P < 0.01). CONCLUSIONS: Regarding the vegetarian food as the principle, most of students investigated are not rich. The dietary iodine intake is lower than RDA (150 microg), but it can be obtained the iodized salt by 230. 27 microg, which is the possible supplement to the shortage from foods.

Type 1 iodothyronine deiodinase activity and mRNA expression in rat thyroid tissue with different iodine intakes.

BACKGROUND: Type 1 deiodinase (D1) plays an important role in the metabolism of thyroid hormone and has close relationship with thyroid function. In this study we explore the effects of iodine intake on D1 activity and its mRNA expression and its possible mechanism. METHODS: Forty-eight Wistar rats were randomly divided into six groups with 8 in each: low iodine (LI), normal iodine (NI), five-fold iodine (HI(5)), ten-fold iodine (HI(10)), fifty-fold iodine (HI(50)), one hundred-fold iodine (HI(100)) group. Three months, six months and twelve months after admistration of potassium iodate, they were sacrificed and thyroids were excised. The expression of D1 mRNA in the thyroid tissue was determined by RT-PCR and D1 activity was analyzed by (125)I-rT3 as substrate. The thyroid hormone was measured with radioimmunoassay method. RESULTS: Compared with NI group, D1 mRNA expression in LI groups slightly decreased, and D1 activity greatly increased. Both T(3) and T(4) in thyroid tissue significantly decreased, but the T(3)/T(4) ratio increased. D1 mRNA expression decreased in all HI groups, and D1 activity was significantly lower in HI groups. There was a tendency of decrease in D1 activity with increased doses of iodine intakes. There was no significant difference in T(4) in thyroid tissue between HI groups and NI group, but a tendency of decrease in T(3) level was found in all HI groups. CONCLUSIONS: In the case of iodine deficiency, D1 activity increased greatly in order to convert more T(4) to T(3). Excess iodine can inhibit both D1 mRNA expression and its activity to protect organism from being injured by excessive T(3).

[Experimental study on effects of iodine deficiency and excess on thyroid autoimmunity].

OBJECTIVE: To observe the effects of iodine on the level of CD4/CD8 cells and the production of thyroglobulin autoantibody (TGAb) and thyroid peroxidase autoantibody (TPOAb) in Wistar rats and to investigate the role of iodine in thyroid autoimmunity. METHODS: Rat models with different iodine intakes including low iodine (LI,), normal iodine (NI,), 5 times normal iodine (5HI), 10 times normal iodine (10HI), 50 times normal iodine (50HI) and 100 times normal iodine (100HI) were established. The amount of iodine intake per rat per day in every group was about < 1, 6.15, 30.75, 61.50, 307.50, 615.00 microg separately. The levels of CD4 and CD8 immune cells in peripheral blood were measured by using flow cytometry. Radioimmunoassay (RIA) was used to determine the titers of TGAb and TPOAb in the serum. RESULTS: In peripheral blood, the level of CD4 cells in LI group was (57.9 +/- 4.3)%, being much higher than in NI group (51.2 +/- 4.9)%. When the level of CD8 cells in 100HI group was (18.4 +/- 3.1)% showing significantly lower than in NI group (26.5 +/- 4.1)%, thus making the ratio of CD4/CD8 cells in the above two groups (LI: 2.4 +/- 0.40 and 100 HI: 2.7 +/- 0.4) higher than in NI group (1.9 +/- 0.3). As comparing with NI group (2099 +/- 220) CPM, the level of TGAb in LI group (1510 +/- 221) CPM was significantly decreased; while in 50HI group (3986 +/- 286) and 100HI group (3550 +/- 378) CPM, the levels of TGAb were both increased, and the levels of TPOAb in 10HI group (2066 +/- 184) CPM and in 50HI group (2141 +/- 163) CPM were both distinctly lower than in NI group (2372 +/- 245) CPM. CONCLUSIONS: Iodine might exert influence on the level of CD4/CD8, and thus the production of thyroid antibodies might directly or indirectly take part in the process of thyroid autoimmunity. Both low iodine and 100 times normal iodine intakes might activate the immune state on some degrees. The effects of iodine on immune responses of TG and TPO antigen in thyroid autoimmunity might not be completely the same.

[Meta-analysis on the relationship between children's intelligence and factors as iodine deficiency, supplement iodine and excessive iodine].

OBJECTIVE: To estimate the role and extent of iodine deficiency, iodine supplement and iodine excess on mental development of children. METHODS: Meta-analysis was applied to study 128 independent items from 63 published and non-published papers and reports. The standards of references collected included: age of sample declared by references was 5 - 15; belong to comparison study; children lived in iodine deficiency disorders (IDD) and iodine excess areas; no difference of social economic and culture development level between the study group and the control group. RESULTS: Sixty-seven percent and 79% of the reports mainly involved severe IDD areas respectively. Hunter test of each studies, i.e. iodine deficiency, iodine supplement and excessive iodine group had not discovered statistic difference at the level of alpha = 0.05. The weighted average ES of damage affecting on children's intelligence by iodine deficiency achieved 0.69, which was equivalent to a marked drop in 10.4 IQ points [95% confidence interval (CI): 9.9 - 10.9] when comparing with the children living under non-IDD. The weighted average ES of protective effect on children's intelligence by iodine supplement reached 0.81, which meant that the IQ of children born after correction of iodine deficiency increased 12.2 points (95% CI: 11.5 - 12.9) in comparison with those born at least one year before the correction of iodine deficiency. Most of the references about the relationship between iodine excess and intelligence were gathered from proceedings, while the others were from journals. They location were in some areas of Shandong, Hebei, Shanxi and Inner Mongolia. The mean ES of the role of iodine excess on intelligence was 0.21, which was corresponding to 3.2 IQ points (95% CI: 2.5 - 4.0). CONCLUSION: 1) Iodine deficiency played a role of intermediate strength compared with other causes in delaying brain development making children to be at least 10 IQ points loss in IDD areas. 2) Effective iodine supplement plays a remarkable strengthening role in promoting brain development and can cause 12 IQ points increase for children who were born after the correction of iodine status. 3) Iodine excess has not shown significant important role in children's intelligence.