Determination of Urinary Iodine Excretion (UIE) to Assess Iodine
Deficiency Disorder (IDD) among Pregnant Women in District
Hospital of Sindhupalchowk, Nepal

Submitted toSociety for Eliminating Nepalese Iodine Deficiency (SENID), Osaka,Japan

Submitted by

Public Health and Infectious Disease Research Center (PHIDReC)
Kathmandu, Nepal

March, 20141

Study Team
Investigators
Prof. Chitra Kumar Gurung, M.Sc., MPH
Dr. Suresh Prasad Bastola, MBBS, MPH
Dr. Megha Raj Banjara, PhD
Mr Krishna Raj Pant, MBS
Mr Naba Raj Bista, MA
Advisors
Prof. Chikayoshi Atsuta
Dr Jiro Okawa, MD
Mr. Rajan Malla
Ms. Noriko Malla

2

Acknowledgements

We would like to express sincere gratitude to Prof. Chikayoshi Atsuta, Chairman,
Society for Eliminating Nepalese Iodine Deficiency (SENID) Osaka, Japan, forproviding technical and financial support to the study. We would like to express sincere
thanks to Mr. Rajan Malla and Ms. Noriko Malla, for their co-operation in the study. We
would like to thank Mrs. Dropada Nepal, Public Health Nurse, Chautara Hospital,
Sindhupalchok for her support for sample and data collection.

We would like to express sincere thanks to pregnant women who provided us
information and allowed us for collection of urine samples.

The financial support for this survey was provided Prof. Chikayoshi Atsuta and SENID,
Osaka, Japan.
PHIDReC Team
March, 2014
Kathmandu

3Summary
Pregnant women and infants are risk populations of iodine deficiency disorders (IDD).
Our previous studies also revealed that pregnant women are at risk of non-visible IDD.
Therefore, this study has been designed to explore the status of Iodine Deficiency
Disorders (IDD) among pregnant women through analysis of urinary iodine excretion(UIE). A total of 100 pregnant women from Chautara Hospital Sindhupalchowk was
included to analyze UIE. Although the general clinical status of women was satisfactory,
the urinary iodine excretion revealed that still 27 percent of pregnant women in
Sindhupalchowk had insufficient iodine intake. This indicates that pregnant women are
still at risk of iodine deficiency disorder and they should be in priority population for
the IDD prevention program.

4

1. Introduction
Iodine Deficiency Disorder (IDD) is the world’s single most significant cause of
preventable brain damage and mental retardation. Twenty nine percent of the population(1570 million people) is at risk of iodine deficiency today in the world. The immense
danger to health due to IDD arises from the fact that these disorders can began even
before the child is born. Although iodine is needed in small amount on an average of
150 mcg (100 to 300) per person per day, 1, 2 lack of iodine is associated with wide rangeof clinical and sub-clinical conditions. The most obvious sign of IDD is goiter, which isa gross enlargement of the thyroid gland in the neck, with a global prevalence of 12%.
In addition to goiter, IDD leads to infant mortality, stillbirths, birth complications,mental retardation and depressed psychomotor functions. Moderate IDD in earlychildhood has been estimated to lower the intelligence quotient by about 10-15 points,
while in adults it causes lethargy. 3
IDD is an important major micronutrient deficiency problem in Nepal. In some isolated
mountainous area of Nepal, most of the adult woman had goiter and up to 10% of
population were cretins, the severest form of IDD. 4
In areas with severe iodine deficiency (<50 mcg intake/day), goitrogenesis as well as
hypothyroidism were frequently observed in mother and newborn as a result of theinability of the thyroid gland to adjust to changes in thyroid economy associated withpregnancy. Hence, the pregnant woman and the newborn have been considered primarytargets for iodine supplementation in such areas.5 Ministry of Health and Population hasprioritized Iodine Deficiency Disorders as a high level activity in its Nutrition Policy
and Strategy 2004. By the year 2017 iodine deficiency disorders will be eliminatedvirtually from Nepal. 7
We implemented iodine supplementation among pregnant mothers in Antenatal Care
(ANC) Clinic of Chautara Hospital Sindhupalchowk. We found significant positive
outcome in mothers and children born from iodine supplemented mothers.
All these findings associated with pregnant women justify the burning issue for the
research on iodine deficiency disorders among pregnant mother and newborn. With
these motivations, this study was designed to screen among pregnant women andnewborn in Beni Hospital Myagdi in 2012 and 2013 analyzing urinary iodine. This5

study also provided health education to the women of rural community regarding theuse of two children logo containing iodized salt.

2. Objectives
To determine the status of Iodine Deficiency Disorders (IDD) in pregnant women in
Chautara Hospital Sindhupalchowk.
Specific objectives
1. To assess the physical health including blood pressure measurement of women.
2. To determine the status of IDD among pregnant women analyzing urinary iodine
excretion.
3. To provide health education to pregnant mothers and mother’s group in the ruralcommunity regarding iodized salt and IDD.

3. Methodology
3.1 Research design
This cross-sectional study was conducted to determine the status of IDD among
pregnant mothers in Chautara Hospital Sindhupalchowk during September, 2013 to
February 2014. In addition, health education on iodized salt and iodine deficiency
disorder were provided to women. This was a follow up study with adding somevariables for assessing IDD among pregnant women.
3.2 Study site
The site of this study was Chautara Hospital Sindhupalchowk. Sindupalchowk district issituated in hilly ecological region of Central Region of Nepal.
3.3 Sample size and sampling
We enrolled 100 pregnant mothers seeking ANC in Chautara Hospital. Urine samples
from those women were collected for determination of urinary iodine excretion. We also
provided health education for those women. In addition, 4 mothers group in adjoining
6

VDCs of Chautara were provided health education. Mothers group is a group of women
formed by female community health volunteers (FCHVs).
3.4 Physical examination of pregnant women
Women visiting Chautara District Hospital for antenatal check up were examined forblood pressure. The attending nurse/ANM measured the blood pressure of examined
mothers.
3.5 Collection of urine samples
Urine samples were collected from 100 pregnant women in the hospital for the analysis
of Urinary Iodine Excretion (UIE) to screen IDD status. The urine samples werecollected in clean leak proof container. The collected urine samples were kept inrefrigerator at -200C until analysis. The UIE analysis was conducted at BP Koirala
Institute of Health Sciences (BPKIHS), Dharan.
3.6 Health education on iodine to pregnant mothers, women and Female
Community Health Volunteers
Pregnant women were counseled and health education was provided regarding
importance of iodine during pregnancy. We also assessed mother’s knowledge on IDD.
Health education was provided to pregnant mothers in the hospital. In addition, healtheducation was given to mother groups in their mother group meeting along with Female
Community Health Volunteers (FCHVs) in the rural community of Sindhupalchowk.
The health education was provided to 4 mothers groups in the district. The mothers
group of the dalit, janajati and disadvantaged community were selected for healtheducation package. In the meeting in the community, iodized salt packet with twochildren logo was distributed to motivate them to use iodized salt.
Pregnant women with high blood pressure were counseled in the hospital during her
follow up ANC visit not to take too much salt.
3.7 Data collection
Knowledge on iodine and IDD, perceptions of mothers on iodized salt were collected7using questionnaire from mothers. The UIE test data were collected after sample
analysis. The descriptive qualitative information regarding the mother’s perceptions on
iodized salt were collected through interview and focus group discussion. Focus group
discussion was conducted with mothers in their mother group meeting.
3.8 Data management and analysis
Collected data were entered in SPSS version 13 and analyzed. Descriptive analyses aswell as qualitative data were presented. The following classification of urinary iodine
excretion (UIE) for pregnant women was used.
Table 1: WHO classification of iodine deficiency disorders (IDD) on the basis of urinary
iodine excretion for pregnant womenMedian Urinary Iodine (µg/L)

Iodine intake

Iodine status<150 μg/L
150-249μg/L

Insufficient
Adequate

Severe iodine deficiency
Adequate iodine nutrition

250–499 μg/L

Above
requirements
Excessive

Riskof
iodineinducedhyperthyroidism
Risk of adverse health consequences≥500 μg/L

8

4. Findings
Characteristics of women involved in the study
The age range of women included for UIE was 16-40 years. The mean age of thewomen was 22.8 years (SD-4.1 years). Majority of women (63.4 percent) were of age
21-35 years.
Table 2: Characteristics of the womenCharacteristics

Number (n=101)

Percent< or equal to 20

36

35.6

21-35

64

63.4

More than 35

1

1.0

Mean age (S.D.)

22.8±4.1 (Min.-16; Max.-40)

Mean weight (Kg)52.0±6.6 (Min.-35; Max.-68)

Age distribution (in years)

About 11 percent of mothers had hypotension whereas one mother had hypertension.
Table 3: Blood pressure category of women
Blood pressure

Number

Percent

Normal89

88.1

Hypotension

11

10.9

Hypertension

1

1.0

Ninety percent of women had normal clinical status whereas two percent had abnormal
clinical status.
Table 4: General clinical status of women
Clinical status

Number

Percent

Normal9998.0

Abnormal

2

2.0

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Urinary iodine level among pregnant women
Urinary iodine excretion (UIE) level indicates that 27 percent of women had insufficient
iodine intake. Similarly, 31 percent of women had excessive UIE greater than 500 μg/l.
Table 4: Urinary iodine excretion level and iodine intake status
UIE level (μg/l)

Number (n=100)

Percent

Insufficient (<150)

27

27.0

Adequate (150-249)

17

17.0

Above requirements (250-499)

25

25.0

Excessive (≥500)

31

31.0

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5. Conclusion

Although the general clinical status of women was satisfactory, the urinary iodine
excretion revealed that still 27 percent of pregnant women in Sindhupalchowk had
insufficient iodine intake. This indicates that pregnant women are still at risk of iodine
deficiency disorder and they should be in priority population for the IDD prevention
program.

11

References
1. ICCIDD, UNICEF. Progress towards the Elimination of Iodine Deficiency Disorder(IDD).
2. WHO, the world Health Report 2002, was reducing Risks, Promoting Healthy Life
Geneva, 2002.
3. Dunn JT. Glinoer D. 1993 Specific recommendations on iodine nutrition for mothers

4.
5.
6.
7.

and infants in Europe. In: Delange F, Dunn JT, Glinoer D, eds. Iodine deficiency inEurope: a continuing concern. New York: Plenum Press; 478.
HMG, Ministry of Health (1967). Endemic Goiter in Nepal, WHO/SEA/26, October
1967.
HMG/N, New ERA, Micronutrient Initiative, UNICEF Nepal, and WHO.
NMSS (1998). Nepal Micronutrient Status Survey 1998. Katmandu, Nepal: Ministryof Health, Child Health Division,
MoHP Department of Health Services National Nutrition Policy and Strategy(NNPS), 2004.

8. Glinoer D. The regulation of thyroid function in pregnancy: pathways of endocrine
adaptation from physiology to pathology. Endocr Rev 1997; 18: 404-433.
9. Glinoer D, De Nayer P, Delange F, et al. 1995 A randomized trial for the treatmentof mild iodine deficiency during pregnancy: maternal and neonatal effects. J Clin
Endocrinal Metab. 80:258–269.
10. WHO. Iodine Status Worldwide, WHO Global Database on Iodine Deficiency, 2004.
11. Joshi AB, Banjara MR, Rikimaru T and Pandey S. Assessment of Current Status of
IDD for the Development of Future Control program JICA Nepal. 2004.
12. DOHS, UNFPA .Annual Report 2004 -2005. 2006, Nepal

12

Annexes
Performa for collection of urine samples from pregnant women
Date:
Name of the mother:
Name of the husband:
Address: District:

VDC:

Village:

Ward No.:
Name of the Hospital:
1. Age of the mother:
2. Caste:
3. Religion:
4. Blood pressure (mmHg):
5. Weight:
6. General clinical statusa. Normalb. Not normal
7. Urine sample collected in filter papera. Yesb. No

13

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ue{jtL cfdfx?df lk;fadf cfof]l8gsf] dfqf kl/If0f dfkm{t cfof]l8gsf]
sdLnfO{ lgwf{/0f sfo{qmd, @)&)
ue{jtL dlxnfx?af6 lk;fasf] gd'gf ;+sng ubf{ eg]{ kmf/d
kmf/fd g+=
ldltM
cffdfsf]
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gfdM=====================================================
lhNnfM==========================uf=lj=;=M=================================j8f
g+=M==============================
c:ktfnsf]]
gfdM=============================================================!= cfdfsf] pd]/M==========================-aif{df_@= hftM=======================================#= wd{M==========================================$=/Qmrfk (Blood Pressure in mm of Hg)………………….
%=tf}nM ===========================-s]hLdf_^=;fdfGo lslnlgsn cj:yf (General Clinical Status)-s_ ;fdfGo (Normal)-v_ c;fdfGo (Abnormal)&= lkmN6/ k]k/df lk;fasf] gd'gf ;+sng ul/Psf] 5÷5}g <-s_ 5-v_ 5}gtkfO{n] cGt/jftf{sf] nflu ;do lbg' eO{ d}n] ;f]w]sf k|Zgx?sf] hjfkm lbg'

14

ePsf]df wGojfb Û

15

Information Sheet for Pregnant Women and Parents of Children
Name of Principle Investigator:
Name of Organization: Public Health and Infectious Disease Research Center (PHIDReC)
Name of Sponsor: Society for Eliminating Nepalese Iodine Deficiency Disorder (SENID) Japan

Information sheet for individuals participating in the research"Screening of Iodine Deficiency Disorder (IDD) and Supplementation of Iodine among

Pregnant Women in Beni Hospital, Myagdi, Nepal”(I am ..................................... and I work at the PHIDReC Kathmandu. We are doing some researchon the Iodine Deficiency Disorder to determine its burden in risk population such as pregnant
women and children.)Purpose of the research
Iodine Deficiency Disorder (IDD) is an important major micronutrient deficiency problem in Nepal.
In areas with severe iodine deficiency (<50 mcg intake/day), goitrogenesis as well as
hypothyroidism were frequently observed in mother and newborn as a result of the inability of the
thyroid gland to adjust to changes in thyroid economy associated with pregnancy. Hence, thepregnant woman and the newborn have been considered primary targets for iodine supplementationin such areas.
All these findings associated with pregnant women justify the burning issue for the research on
iodine deficiency disorders among pregnant mother and newborn. With these motivations, this pilot
study has been designed to screen IDD in children born from iodine supplemented mothers during
pregnancy and pregnant mothers testing TSH in order to implement iodine supplementation inpregnant women.
Procedures
The site of this study is Beni Hospital Myagdi. We will collect urine samples from 400 pregnant
mothers when they seek ANC. We also assess knowledge and perceptions of mothers on IDD andiodine. The mothers will also be assessed clinically. Similarly, urine samples will also be collectedfrom newborns from the same hospitals during the study period. Urine samples will be analyzed for
urinary iodine excretion using standard procedure.
Risks and Discomforts
There will be no any risks during collection of urine sample. The urine sample will be collectedusing sterile leak proof container in the hospital when you seek ANC.
Benefits
Your participation is likely to help us to find out more about what is the burden of Iodine Deficiency
16

Disorder (IDD) in high risk population in Nepal and this information will be useful to implement
iodine deficiency control programme.
Incentives
You will not be provided any incentive to take part in the research.
Confidentiality
The information that we collect from this research will be kept confidential. Information about youthat will be collected from the study will be stored in a file which will not have your name on it, but
a number assigned to it. Which number belongs to which name will be kept under lock and key, andwill not be divulged to anyone except the researchers, and research sponsors.
Right to refuse or withdraw
You do not have to take part in this research if you do not wish to do so, and this will not affect the
future treatment of your family at the health facility at the District Hospital in any way. You will still
have all the benefits that you would otherwise have.
You may stop participating in the research at any time that you wish to, without losing any of yourrights as a patient or otherwise.
Who to contact
If you have any questions you may ask those now or later. If you wish to ask questions later, you
may contact: (Prof. Chitra Kumar Gurung, PHIDReC, Kathmandu, Phone: +977-1-4494254).

17

Consent Form from Pregnant Women for Blood Sample Collection for IDD
Screening

I have read/has been read to me the foregoing information. I have had the opportunity to ask
questions about it and any questions I have asked have been answered to my satisfaction. I consent
voluntarily to participate as a participant in this study and understand that I have the right towithdraw from the study at any time without in any way affecting me and my family as a health careseeker.
Participant’s Name:
Signature:
Place:
Date:

Witness (Name):
Place:
Signature:Date:18