iodine policy in the united states elizabeth n. pearce, m.d., m.sc
TRANSCRIPT
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Iodine Policy in the United States
Elizabeth N. Pearce, M.D., M.Sc.
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Overview
• Dietary iodine requirements and assessment of iodine sufficiency
• Current U.S. iodine nutrition status • Sources of U.S. Dietary Iodine• Iodine recommendations
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Recommended Daily Dietary Iodine Intakes
- U.S. Institute of Medicine 2006- WHO, UNICEF, ICCIDD 2007
U.S. Institute of Medicine WHO, UNICEF, ICCIDD
µg/day µg/day0-6 months (AI) 110 0-5 years 90
7-12 months (AI) 130
1-8 years 90
9-13 years 120 6-12 years 120
>13 years 150 >12 years 150
Pregnancy 220 Pregnancy 250
Lactation 290 Lactation 250
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Increased demand for thyroid hormone (↑ 50%),requires an additional 50-100 μg iodine:- Thyrotropic regulation by hCG- Estrogen-mediated TBG increase
Placental Type 3 deiodinase
Iodide transferred to the fetus(50-75 μg/day)
Increased renal iodine clearance(↑ 30-50%)
Increased Maternal Dietary Iodine Requirementsin Pregnancy
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Increased Dietary Iodine Requirementsin Lactation
• Normal lactating breast ducts concentrate iodide (via sodium iodide symporter), secreting it into milk
• Only source of iodine nutrition for breastfed infants
Tazebay et al Nat Med 2000; 6:859-60
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Tolerable Upper Limits for Iodine Exposure
U.S. Institute of Medicine
WHO, UNICEF, ICCIDD
µg/day µg/day
0-12 months unknown Infants 180
1-3 years 200 Pregnancy 500
4-8 years 300 Lactation 500
9-13 years 600
14-18 years 900
19-50 years 1,100
- U.S. Institute of Medicine 2006- WHO, UNICEF, ICCIDD 2007
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WHO/ICCIDD/UNICEF, 2007
Median Urinary Iodine Concentration (μg/L)
Corresponding Iodine Intake (μg/day)
Iodine Nutrition
<20 <30Severe
deficiency
20-49 30-74Moderate deficiency
50-99 75-149 Mild deficiency
100-199 150-299 Optimal
200-299 300-449More than adequate
>299 >449 Possible excess
Population Urinary Iodine Values and Iodine Nutrition
For children < age 2, Urinary iodine ≥100 μg/L = sufficiency
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Urinary Iodine Values and IodineNutrition in Pregnancy and Lactation
WHO Public Health Nutr 2007
Population groupMedian Urinary Iodine Concentration (μg/L)
Optimal Excessive
Non-pregnant adults
100-199 >299
Pregnant Women 150-249 ≥500
Lactating Women ≥100
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Overview
• Dietary iodine requirements and assessment of iodine sufficiency
• Current U.S. iodine nutrition status • Sources of U.S. Dietary Iodine• Iodine recommendations
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U.S. Goiter Belt (pre-1920s)– 26 - 70% of children had goiter
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Morton Salt, 1920s
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168 160 164144145
320
0
50
100
150
200
250
300
350
400
1971-74
1988-94
2001-02
2003-04
2007-08
2009-10
Total
Males
Females
Median U.S. Urinary Iodine ConcentrationNHANES 1971-2004
Hollowell et al. JCEM 1998; 83:3401-8; Caldwell et al. Thyroid 2005;15:692-9; Caldwell et al. Thyroid 2008;18:1207-14; Caldwell et al. Thyroid 2011;21:419-27; Caldwell et al, Thyroid 2013; 23:927-37
Me
dia
n U
rine
Iod
ine
Co
nce
ntra
tion
(μg
/L)
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% of U.S. Population with Urinary Iodine<50μg/L: NHANES I and NHANES III
JG Hollowell et al. J Clin Endocrinol Metab1998; 83:3401-8
Age (years)
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Median urinary iodine concentration (UIC) among pregnant women, NHANES
Med
ian
UIC
μg
/L
wit
h 9
5%
CI
NHANES Survey
Insufficient iodine intake
Adequate iodine intake
Above requirement iodine intake
Hollowell et al, JCEM 1998; 83:3401-8; Caldwell et al. Thyroid 2005;15:692-9; Caldwell et al. Thyroid 2008;18:1207-14; Caldwell et al. Thyroid 2011;21:419-27; Caldwell et al. Thyroid 2013;23:927-37
Median UIC in pregnancy 129 µg/L2005-2010
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0
100
200
300
400
500
1 2 3 4 5
Me
dia
n U
rin
ary
Iod
ine
(g
/L)
Urinary Iodine by Quintiles
150 g/L~220 g/daydietary intake(RDA for pregnancy)
Urine Iodine in a Sample of100 Pregnant Women Living in Boston
5296
149
230
438
EN Pearce et al. Thyroid 2004; 14:327-8
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Iodine Status of Lactating Boston-Area Women and their Infants
AM Leung et al. Thyroid 2012;22:938-43.
Iodine Concentration in µg/Lmedian (interquartile range)
Breast Milk 45.6 (4.3-1080)
Maternal Urine 101.9 (27-570)
Infant Urine 197.5 (40-785)
64 mother-infant pairsInfants age 1-3 months
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Pearce EN et al. J Clin Endocrinol Metab 2007;92:1673-7
US Infant Formulae Iodine Content
U.S.: allowable 5-75 µg/100 kcal
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JH Gordon et al. Thyroid 2014;1309-13
Urinary Iodine Concentrations in Breastand Bottle-Fed Infants from the Boston Area
n=44 n=39 n=10
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NHANES Survey
Insufficient iodine intake
Adequate iodine intake
Above requirementiodine intake
Excessive iodine intake
Median urinary iodine concentration amongchildren age 6-11, NHANES
Med
ian
UIC
μg/
L w
ith 9
5% C
I
Hollowell et al, JCEM 1998; 83:3401-8; Caldwell et al. Thyroid 2005;15:692-9; Caldwell et al. Thyroid 2008;18:1207-14; Caldwell et al. Thyroid 2011;21:419-27; Caldwell et al. Thyroid 2013;23:927-37
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Overview
• Dietary iodine requirements and assessment of iodine sufficiency
• Current U.S. iodine nutrition status • Sources of U.S. Dietary Iodine• Iodine recommendations
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0102030405060
Dairy
Mea
t, Fis
h, Poul
tryG
rain
Fruit,
Veg
Fats,
Oils
Sugars
Bever
ages
Egg
Median Iodine Content of Adult* Diets2003-2004 FDA Total Diet Study
% D
aily
iodi
ne I
ntak
e
CW Murray et al. J Expo Sci Environmen Epidemiol 2008;18:571-80.
*Women age 25-30
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Salt in the U.S. Diet
77% Restaurant and processed foods
12% Naturally occurring
6% Whileeating
5% While cooking
• ~77% of salt in U.S diet from restaurant/processed food, usually not iodized
•~11% table salt added at the table or in cooking, 53% of table salt in U.S. is iodized at 60-100 ppm
• ~50% of reproductive agewomen never/rarely use table salt
Mattes & Donnelly. J Am Coll Nutr 1991;10(4):383-93.Maalouf J et al. Nutrients 2015;1691-5
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Bread Iodine Content
• Iodate dough conditioners used starting 1940s. Use 1970s-1990s.
• Boston-area supermarkets 2001-2002:– 20 brands measured– 3 breads >313 μg I/slice– Others 2.2-54 μg I/slice (mean 10 μg/slice)
• Package labels inaccurate
EN Pearce et al. J Clin Endocrinol Metab 2004; 89:3421-4
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Mean Iodine Content of New EnglandCows’ Milk by Season
μg
I pe
r 25
0 m
l (~
1 cu
p)
n = 18 brandsp <0.0005
Winter Summer
116
91
EN Pearce et al. J Clin Endocrinol Metab 2004; 89:3421-4
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Iodine Sources in U.S. Cows’ Milk
• Cattle feed– Cows’ milk iodine content increased 300-500%
1965-1980 due to increased I in cattle feed– Organic iodine ethylenediamine dihydroiodine
(EDDI) content of cattle feed limited 1986 to 10mg/cow/day
• Iodophor disinfectant in teat dip/udder wash– Up to 1% available iodine
EN Pearce et al. J Clin Endocrinol Metab 2004; 89:3421-4
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Median Urinary Iodine Levels in U.S. Vegetarians and Vegans
78.5
147
0
50
100
150
200
vegans vegetarians
AM Leung et al. J Clin Endocrinol Metab 2011;96:E1303-7.
Optimal iodine intake (WHO)
(µg/L)
Median U.S.
urinary iodine
164
n=62 n=78
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Overview
• Dietary iodine requirements and assessment of iodine sufficiency
• Current U.S. iodine nutrition status • Sources of U.S. Dietary Iodine• Iodine recommendations
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U.S. Guidelines
Women who are planning to be pregnant or are pregnant or breastfeeding shouldsupplement their diet with a daily oral supplement that contains 150 µg of iodine.
• A Stagnaro-Green et al. Thyroid 2011;21:1081-125• L De Groot L et al. J Clin Endocrinol Metab 2012;97:2543-65• SG Obican et al. Birth Defects Res A Clin Mol Teratol 2012;94: 677-682• AAP Council on Environmental Health. Pediatrics 2014;133:1163-6
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CO Gregory et al. Thyroid 2009;19:1019-20
Percentage of Reproductive Age U.S. WomenReporting Supplement Use Within 30 Days
43.4
76.967.8
20.2 20.314.5
0102030405060708090
Any Supplement
Supplementwith Iodine
Pregnantn=4322 n=983 n=143
Based on NHANES 2001-2006
%
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Prescription prenatal multivitamins
(n = 96)
28% (n=27) contain iodine
Non-prescription prenatal multivitamins
(n = 127)
69% (n=87) contain iodine
Proportion of U.S. Prenatal Multivitamins
Containing Iodine
AM Leung et al. N Engl J Med 2009;360:939-40
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January 27, 2015—Dietary supplement manufacturers should include a daily serving of at least 150 mcg of iodine in all multivitamin/mineral supplements intended for pregnant and lactating women in the U.S., the Council for Responsible Nutrition (CRN) advises in guidelines for industry released today.
CRN recommends that dietary supplement companies comply within twelve months.
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Conclusions• Overall dietary iodine intake is currently
sufficient in the U.S.• However, there are concerns about mild
iodine deficiency among women during pregnancy and lactation– Recommend iodine-containing prenatal
multivitamin
• Further monitoring is needed