Screening of Iodine Deficiency Disorder (IDD) among Pregnant Women inDistrict 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

July, 20121

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

Summary
Iodine deficiency affects children impairing their mental and motor functions, and manifestations
range from small neurological changes, to impaired learning ability. Therefore, this study was
designed to determine the status of Iodine Deficiency Disorders (IDD) among pregnant women
who are at risk of IDD. A total of 98 pregnant women from Chautara Hospital Sindhupalchowk
were included in the study. Urine samples were collected from pregnant women. The urine
samples were analyzed for urine iodine estimation. Using WHO criteria of urinary iodine
excretion for pregnant women, 28.6% (28 women) had severe iodine deficiency, 31.6% (31women) had adequate iodine nutrition, 34.7% (34 women) had risk of iodine induced
hyperthyroidism, and 5.1% (5 women) had risk of adverse health consequences. This evidenceshows that still significant proportion of women (one fourth) in Nepal had severe iodine
deficiency and there is the need of effective intervention and awareness programme of iodine inthis risk population.

3

Acknowledgements
We would like to express sincere gratitude to Prof. Chikayoshi Atsuta, Chairman, Society for
Eliminating Nepalese Iodine Deficiency (SENID) Osaka, Japan, for providing technical andfinancial 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 Ms. Drupada
Nepal, Auxiliary Nurse Midwife (ANM), Chautara District Hospital, Sindhupalchowk for her
support for sample and data collection.
We would like to express sincere thanks to pregnant women who provided us information andallowed us for collection of urine samples.
The financial support for this survey was provided Prof. Chikayoshi Atsuta and SENID, Osaka,
Japan.
PHIDReC Team
July, 2012
Kathmandu

4

Contents
Study Team ..................................................................................................................................... 2
Summary......................................................................................................................................... 3
Acknowledgements......................................................................................................................... 4Contents .......................................................................................................................................... 5
List of Tables .................................................................................................................................. 6
Introduction..................................................................................................................................... 7
Objectives ....................................................................................................................................... 8
Methodology ................................................................................................................................... 9
3.1 Research design..................................................................................................................... 9
3.2 Study site ............................................................................................................................... 9
3.3 Sample size and selection of pregnant women...................................................................... 9
3.4 Collection of urine samples................................................................................................... 9
3.5 Health education on iodine to pregnant women.................................................................... 9
3.6 Data collection....................................................................................................................... 9
3.7 Validity and reliability .......................................................................................................... 9
3.8 Data management and analysis ............................................................................................. 9
Results........................................................................................................................................... 11
4.1 Demographic characteristics of women involved in the study ........................................... 11
4.2 Knowledge of iodine and IDD among pregnant women..................................................... 12
4.3 Urinary iodine level among pregnant women ..................................................................... 12
References..................................................................................................................................... 14
Appendix-I: Study tools................................................................................................................ 15
Appendix-II: Ethical issues........................................................................................................... 18
Appendix-III: Urinary iodine data ................................................................................................ 20

5

List of Tables

Table 1

WHO classification of iodine deficiency disorders (IDD) on the basis of urinary
iodine excretion for pregnant women

Table 2

Demographic characteristics of the women

Table 3

Iodine related information

Table 4

Urinary iodine excretion level and iodine intake status

Table 5

Factors related to IDD

6

Introduction
Iodine Deficiency Disorder (IDD) is the world’s single most significant cause of preventablebrain 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. Althoughiodine 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 range of clinical and sub-clinical conditions. The mostobvious sign of IDD is goiter, which is a gross enlargement of the thyroid gland in the neck, witha global prevalence of 12%. In addition to goiter, IDD leads to infant mortality, stillbirths, birthcomplications, mental retardation and depressed psychomotor functions. Moderate IDD in earlychildhood has been estimated to lower the intelligence quotient by about 10-15 points, while inadults 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 IDD status assessment conducted in 2004 in Nepal
noted that 16.3 percent household salt samples were found to have less than 15 ppm iodine,
35.33 percent samples found to have 15 to 30 ppm, 40 percent samples were found to have 30-50
ppm and 12.64 percent salt samples had iodine greater than 50 ppm.
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 ofthe 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
supplementation in such areas.5 Ministry of Health and Population has prioritized Iodine
Deficiency Disorders as a high level activity in its Nutrition Policy and Strategy 2004. By theyear 2017 iodine deficiency disorders will be eliminated virtually 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, thisstudy was designed to screen among pregnant women in Chautara Hospital Sindhupalchowk in2012 analyzing urinary iodine. This study also provided health education to the women of ruralcommunity regarding the use of two children logo containing iodized salt.

7

Objectives
General objective
To determine the status of Iodine Deficiency Disorders (IDD) in pregnant women in Chautara
Hospital Sindhupalchowk.
Specific objectives
1. To determine the status of IDD among pregnant women analyzing urinary iodine excretion.
2. To provide health education to pregnant mothers and mother’s group in the rural community
regarding iodized salt and IDD.

8

Methodology

3.1 Research design
This cross-sectional study was conducted to determine the status of IDD among pregnant
mothers in Chautara Hospital Sindhupalchowk from January 2012.
3.2 Study site
The site of this study was Chautara Hospital Sindhupalchowk. Sindhupalchowk district was
situated in hilly ecological region of Central region of Nepal.
3.3 Sample size and selection of pregnant women
We enrolled 98 pregnant mothers in Sindhupalchowk district hospital, who attended for antenatal
care from January to June 2012.
3.4 Collection of urine samples
Urine samples were collected from 98 pregnant women in each hospital for the analysis of
Urinary Iodine Excretion (UIE) to screen IDD status. The urine samples were collected in clean
leak proof container. The collected urine samples were kept in refrigerator at -200C until analysis.
The UIE analysis was conducted at BP Koirala Institute of Health Sciences (BPKIHS), Dharan.
3.5 Health education on iodine to pregnant women
After obtaining the result of urinary iodine, pregnant women were counseled and healtheducation was provided regarding importance of iodine during pregnancy. We also assessed
mother’s knowledge on IDD. Health education was provided to 150 women including 98
pregnant mothers in the hospital.
3.6 Data collection
Knowledge on iodine and IDD, perceptions of mothers on iodized salt was collected frommothers using questionnaire. The UIE test data was collected after sample analysis. The
descriptive qualitative information regarding the mother’s perceptions on iodized salt wascollected through interview.
3.7 Validity and reliability
Validity and reliability of the study was considered with high priority to minimize the respective
errors. Standard techniques were used for urine sample collection. Training and orientation for
health workers were conducted as per need.
3.8 Data management and analysis
9Collected data were entered into SPSS version 13 and analyzed. Descriptive analysis was
conducted. 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
Insufficient
Severe iodine deficiency
150-249µg/L
Adequate
Adequate iodine nutrition
250–499 µg/L
Above
Risk of iodine induced
requirements
hyperthyroidism≥500 µg/L
Excessive
Risk of adverse health consequences10

Results
4.1 Demographic characteristics of women involved in the study
Among total 98 pregnant women, majority (76.5%) were in the age group 21-35 years. The mean
age of women was 23.4 years. Among them, 11.2% were illiterate and 25.5% had higher
secondary and above level education. Only a few mothers (3.1%) were employed and most ofthem were 96.9%. About 43% of women had no child and that was the first pregnancy whereas
35.7% had the second pregnancy. About one tenth (11.2%) pregnant women had still birth
history in previous pregnancy.
Table 2: Demographic characteristics of the womenCharacteristics
Age distribution (in years)< or equal to 20
21-35
More than 35
Mean age (S.D.)
Education level
Illiterate
Primary level
Lower secondary level
Secondary level
Higher secondary and above level
Occupation of womenHousewife
Employed
Occupation of husband
Agriculture
Business
Daily labour
Government employee
Private employee
Student
Social service
Number of child
No child
One child
Two or more than two children
Still birth in previous pregnancy
Yes
No

11

Number

Percent

2275
1
23.4 (3.9)

22.4
76.5
1.0

11
31
18
13
25

11.2
31.6
18.4
13.3
25.5

95
3

96.9
3.1

9
11
17
35
19
6
1

9.2
11.2
17.3
35.7
19.4
6.1
1.0

43
35
20

43.9
35.7
20.4

11
87

11.2
88.8

4.2 Knowledge of iodine and IDD among pregnant women
Still, 28.6% of women had not heard about iodized salt. However, the use of iodized salt in thehouseholds was 91.8%. About 43% pregnant women did not take iron/folic acid tablets during
pregnancy. This proportion includes the pregnant women who came to the hospital for the firsttime.
Table 3: Iodine related information
Characteristics
Hear about iodized salt
YesNo
Use of iodized salt in household
YesNo
Use of iron/folic acid tablets during pregnancy
Yes
No

Number

Percent

70
28

71.4
28.6

90
8

91.8
8.2

56
42

57.1
42.9

4.3 Urinary iodine level among pregnant women
Using above mentioned criteria, among the 98 urine samples analyzed at Department ofBiochemistry, BPKIHS, Dharan, 28.6% (28 women) had severe iodine deficiency, 31.6% (31women) had adequate iodine nutrition, 34.7% (34 women) had risk of iodine induced
hyperthyroidism, and 5.1% (5 women) had risk of adverse health consequences.
Table 4: Urinary iodine excretion level and iodine intake status
UIE level (µg/l)
Insufficient (<150)
Adequate (150-249)
Above requirements (250-499)
Excessive (>500)

Number28
31
34
5Percent
28.6
31.6
34.7
5.1

Regarding agewise distribution of urinary iodine excretion, the insufficient iodine level was
found in the age group 21-35 years (30.7%) and less than 20 years of age (22.7%). It is foundthat more illiterate women (54.5%) had insufficient iodine as compared to literate women.
Similarly, among women who had not heard about iodized salt 46.4% had insufficient iodine andamong those who did not use iodized salt 62.5% had insufficient iodine.
Table 5: Factors related to IDD
Characters
Insufficient(<150)
Age (in years)
Less than or equal to 20
5 (22.7)

Adequate(150-249)

Above requirements(250-499)

Excessive(>500)

5 (22.7)

11 (50.0)

1 (4.5)12

21-35More than 35 years
Education level23 (30.7)
0 (0.0)25 (33.3)
1 (100.0)

23 (30.7)
0 (0.0)4 (5.3)0 (0.0)Illiterate
Primary level
Lower secondary level
Secondary level
Higher secondary andabove level
Heard about iodized salt
YesNo
Use iodized salt
YesNo
Consume iron/folic acidYesNo

6 (54.5)
9 (29.0)9 (50.0)
2 (15.4)
2 (8.0)4 (36.4)
11 (35.5)
2 (11.1)
4 (30.8)
10 (40.0)

1 (9.1)9 (29.0)
5 (27.8)
7 (53.8)
12 (48.0)

0 (0.0)2 (6.5)
2 (11.1)
0 (0.0)1 (4.0)15 (21.4)
13 (46.4)

24 (34.3)
7 (25.0)27 (38.6)
7 (25.0)

4 (5.7)
1 (3.6)23 (25.6)
5 (62.5)

30 (33.3)
1 (12.5)

32 (35.6)
2 (25.0)

5 (5.6)0 (0.0)18 (32.1)
10 (23.8)

14 (25.0)
17 (40.5)

20 (35.7)
14 (33.3)

4 (7.1)1 (2.4)13

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 andinfants in Europe. In: Delange F, Dunn JT, Glinoer D, eds. Iodine deficiency in Europe: acontinuing concern. New York: Plenum Press; 478.
4. HMG, Ministry of Health (1967). Endemic Goiter in Nepal, WHO/SEA/26, October 1967.
5. HMG/N, New ERA, Micronutrient Initiative, UNICEF Nepal, and WHO.
6. NMSS (1998). Nepal Micronutrient Status Survey 1998. Katmandu, Nepal: Ministry of
Health, Child Health Division,
7. 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 treatment of 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 forthe Development of Future Control program JICA Nepal. 2004.
12. DOHS, UNFPA .Annual Report 2004 -2005. 2006, Nepal

14

Appendix-I: Study tools
Performa for collection of urine samples from baby

Date:
Newborn baby ID number:
Name of the mother:
Name of the father:
Address: District:

VDC:

Village:

Ward No.:
Name of the Hospital:
1.
2.
3.
4.
5.

Age of the mother:
Caste:
Religion:
Weight of the baby:
General clinical status of the baby
a. Normalb. Not normal
6. Urine sample collecteda. Yesb. No

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:15

3. Religion:
4. Weight:
5. General clinical statusa. Normalb. Not normal
6. Urine sample collected in filter papera. Yesb. No

Mother’s Physical Examination Form

ID No.

Date of examination:………………

Name of the mother:

Age:…………….

Name of the children:
Address: ………………… VDC/Municipality …………..Ward No:…………..
1. Vitals

5. Other examination if any:

BP
Pulse
Temperature (F)Height (CM)Weight (Kg)
BMI
2.General
Skin color, Pallor, Jaundice
Edema
3. Neck:
Thyroid swellingStage I
Stage II
Stage III
Lab. Investigation

16

Blood: HB…gm%

Name of the enumerator:

Designation:

Name of the Hospital:
Signature:

Location:17

Appendix-II: Ethical issues
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
Chautara Hospital, Sindhupalchowk, Nepal”(I am ..................................... and I work at the PHIDReC Kathmandu. We are doing some research on
the Iodine Deficiency Disorder to determine its burden in risk population such as pregnant women andchildren.)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 tochanges in thyroid economy associated with pregnancy. Hence, the pregnant woman and the newborn
have been considered primary targets for iodine supplementation in 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 andpregnant mothers testing TSH in order to implement iodine supplementation in pregnant women.
Procedures
The site of this study is Chautara Hospital Sindhupalchowk. We will collect urine samples from 400
pregnant mothers when they seek ANC. We also assess knowledge and perceptions of mothers on IDD
and iodine. 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 collected using
sterile leak proof container in the hospital when you seek ANC.
Benefits

18

Your participation is likely to help us to find out more about what is the burden of Iodine Deficiency
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 you thatwill 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, and will 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 your rights
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).

Consent Form from Pregnant Women for Urine 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 toparticipate as a participant in this study and understand that I have the right to withdraw from the study at
any time without in any way affecting me and my family as a health care seeker.
Participant’s Name:
Signature:
Place:
Date:
Witness (Name):
Place:
Signature:
Date:

19

Appendix-III: Urinary iodine data
List of mothers and their UIE from Sindhupalchowk District Hospital
S.N.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

Name of the interviewee
Gopini Thakuri
Rama Tirwa
Mira Acharya
Laxmi Mahat
Radhika Bhujel
Binita Nepali
Ganaga Neupane
Sabina Thapa
Sharmita Gadraj
Laxmi Shrestha
Kumari Shrestha
Shova Basnet
Sujata Dulal
Nirmala Devi Das
Sushila Shrestha
Pan Maya Lama
Mana Ghale
Kalpana Rana
Saru Shrestha
Sita Basnet
Tul Maya Shrestha
Mina Nepali
Laxmi Shrestha
Nirmala Giri
Beli B.K.
Saru Basnet
Sushma Lama
Kamala Tamang
Anita Shrestha
Nirmala B.k.
Karishma Shrestha
Suntali Tamang
Rita Shrestha
Sabitr GiriArpana Thapa
Nisha Tamang
Bal Kumari Giri
Sima B.K.
Rita Shrestha
Sita B.K.
Poonam Shrestha
Kabita Bhandari

Age (years)
29
21
26
20
29
21
23
21
21
24
22
24
22
21
21
23
19
23
21
32
31
35
27
30
26
24
24
30
?
24
19
25
19
26
25
21
21
22
19
23
24
20
20

Urinary Iodine Excretion(UIE)
151.24254.405120.295
325.312177.675
248.994
403.402398.643
30.200212.12626.654480.430
517.050130.916
261.67193.073498.479160.368
179.420319.692226.028101.572109.597
122.466
160.368510.700
122.466
150.938
142.435
173.573
123.810250.779335.964223.034
332.047
63.13337.248507.607141.437355.603292.329400.575

43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91

Sarsawati Thapa
Sharada Neupane
Sarita Dnagol
Sushma Tamang
Anju Thapa
Yasoda Shrestha
Bel Kumari Shrestha
Maya Tamang
Suntali Bhujel
Radhika Ghora Saini
Anjana Dhungel
Kewoti Lama
Nir Maya Lama
Manju Thapa
Bimla Kafle
Rama Tirwa
Pushpa Lamsal
Aasmaya Tamang
Sushma Dahal
Nirmala Giri
Kamala GiriRani Nepal
Sunita Shrestha
Sita Lamsal
Salina Thapa
Chameli Giri
Sita Kunwar
Man Kumari Chuwan
ChiniMaya Tamang
Sita Maya Shrestha
Anu Tamang
Reena Tamang
Nirmala Dangal
Shreejana Tamang
Maiya Puri
Rojena Ghatani
Sabita Pariyar
Sita Shrestha
Sun Maya Lama
Ranju Magrati
Binda Dhital
Shreejana B.K.
Radhika Sapkota
SunMaya Tamang
Anju Basnet
Dil Kumari Tamang
Ambika Acharya
Sita Shrestha
Indira Ghale

22
22
23
23
20
34
??
17
22
19
20
20
25
26
28
21
20
21
23
22
25
22
25
25
20
21
20
26
25
20
22
25
22
30
24
24
17
24
24
26
23
29
19
25
21
16
22
23
29
21

161.546196.840384.320348.251
413.339178.654164.230
201.460
220.297150.869
256.493254.211211.863354.283
220.297145.840
417.450225.816112.638448.943251.916
20.725248.523
272.014367.762
197.809178.267
384.382442.248
30.830155.887
203.164240.386331.928561.492
117.657
449.431
89.314100.276
323.057
234.416123.932228.446
41.742443.543
90.459264.368
155.744249.423

92
93
94
95
96
97
98

Dewaki Sharma
Pratikshya K.C.
Sushila Oli
Sangita Shrestha
Sunita Shrestha
Pramila Shrestha
Laxmi Tamang

25
22
20
29
20
23
20

22

255.133
422.260
64.390116.706
439.435133.755
386.456

23

24

25

26