Iodine Deficiency Disorders in Khorasan Razavi Province, Iran: Assessing Salt Iodization and Iodine Intake Patterns

doi:10.21203/rs.3.rs-4711019/v1

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Iodine Deficiency Disorders in Khorasan Razavi Province, Iran: Assessing Salt Iodization and Iodine Intake Patterns

https://doi.org/10.21203/rs.3.rs-4711019/v1

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Considering iodine deficiency, researchers examine salt consumption by healthcare providers, health ambassadors and the general population in Khorasan Razavi province, Iran. This cross-sectional study used validated questionnaires and tested salt samples with standardized test kits and iodometry. Analyses were descriptive and kappa-based.

This study included 3115 participants, including 812 health workers and 912 health ambassadors, as well as 1,391 households. Higher levels of iodine deficiency may be detected due to new and stricter WHO standards that was least likely to be met all participants. (Kappa=0.0793) shows poor concordance. More than 90% of participants buy bagged salt but 31-63% store salt away from light, heat, and humidity. 42-66% store their salt in dark containers. Up to 38% of health workers add salt after cooking. Only 30-63% of groups knew about iodine deficiency diseases. About 37-66 % of participants consider iodization when purchasing salt.

Our findings provide rural and urban areas face disparities, as do households and health workers. Using updated WHO/UNICEF/ICCIDD standards to assess iodine deficiency led to lower compliance rates. The region can address iodine deficiency disorders with targeted interventions, awareness campaigns, monitoring, and quality control to enhance public health.

Health sciences/Health care/Health services

Health sciences/Health care/Public health

Congenital Hypothyroidism

Iodination

Iodized salt

Healthcare Providers

Population Surveillance

Iran

Thyroid hormones are essential for the central nervous system, brain, muscles, kidneys, and liver (1). Iodine, a crucial component of these hormones, is vital for metabolism and cognitive function (1), including organ and tissue function and neurodevelopment (2). However, iodine deficiency disorders (IDD) can lead to serious health issues such as cretinism, goiter, hypothyroidism, and reduced intelligence and height (3, 4). Goiter, one of the most common diseases caused by IDD, affects about 2.2 billion people worldwide (1). The prevalence of goiter varies globally, with the highest rates in Africa (28.3%) and the lowest in the United States (4.7%) (3). IDD is more common in inland regions, mountainous areas, and flood-prone zones, such as parts of Africa, the central U.S., Central Asia, the Alps, the Himalayas, and Southeast Asia (1).

In the 1920s, iodine deficiency was a significant issue in the U.S. To address this, the World Health Organization (WHO) introduced the salt iodization program in the 1990s (1), significantly reducing iodine deficiency in many countries, including the UK, U.S., Australia, and Iran (5). Despite these efforts, nearly 30% of the global population still suffers from iodine deficiency (1). By the 1980s, IDD had become a major health concern (3). In response, the WHO implemented the salt iodization program as the primary dietary iodine source in 1996 (4).

Iran, with a long history of IDD, adopted this program and initiated various measures, including monitoring iodine levels in salt production, tracking household consumption of iodized salt, and educating the public and health professionals on iodine's importance (3). By 2018, over 80% of salt in Iran contained sufficient iodine, and household consumption of iodized salt reached 98%, leading to a noticeable decline in hypothyroidism rates (4).

Health professionals, particularly primary health care workers, play a crucial role in reducing hypothyroidism and goiter risks by educating the public about iodine consumption and monitoring iodine intake (6, 7).

Despite the success of the national salt iodization program in Iran, there are still challenges to maintaining adequate iodine levels in the population and preventing the recurrence of IDD (8). One challenge is the consumption of iodized salt in some population groups. Studies have shown that some groups, such as rural households and individuals with low socioeconomic status, may not consume enough iodized salt (8). Another challenge is maintaining the quality of iodine in iodized salt throughout the supply chain. Iodine can evaporate from salt over time, especially if the salt is stored in improper conditions (8).

Moreover, recent studies indicate a shift towards non-iodized salts like sea salt and pink salt, influenced by claims of health benefits such as reduced hypertension and improved immune function (9). So, it seems that this shift has coincided with a rise in congenital and adult hypothyroidism cases, particularly in regions like Razavi Khorasan province in Iran.

This study aims to investigate the iodine content of salt consumed by three groups: health ambassadors (often serving as community health educators), health workers, and households in Khorasan Razavi province, Iran. The study also assesses the knowledge and practice of these groups about iodine and salt iodization.

The findings of this study will provide valuable information about the current status of iodine intake in Khorasan Razavi province and will help identify areas where interventions are needed to improve iodine consumption. The study will also contribute to the understanding of factors that influence iodine intake and will inform the development of effective strategies for promoting salt iodization and preventing IDD.

Study Design:

This cross-sectional study aimed to assess iodized salt consumption among three target groups in Khorasan Razavi Province, Iran.

Setting and Population:

A study was conducted in the northeastern province of Khorasan Razavi, which has a population of approximately 6.4 million.:

Primary healthcare service providers (public health officers, midwives, nutritionists, mental health officers, environmental health officers, and physicians)

Health ambassadors (selected from family members and often serving as community health educators)
The general population covered by Mashhad University of Medical Sciences (MUMS) healthcare services

Sampling:

A stratified random sampling approach was used. Individuals within each target group were identified using the SINA. SINA is an EHR software system developed by Mashhad University of Medical Sciences in Iran. This system provided access to demographics, contact information and health information of the targeted population in Razavi Khorasan province. The sample size estimation in each group was based on the study by Sarlak et al. (10), with a household iodine mean and standard deviation of 59.85±15.52, a 95% confidence interval, and a precision of 1, resulting in a sample size estimate of 239. Considering 6 occupational groups (public health officers, midwives, nutritionists, mental health officers, environmental health officers, and physicians) and an 80% response rate, 800 to 1200 individuals per group (healthcare workers, households, and health ambassadors) was targeted, resulting in a total sample size of about 3,200 participants

First, the list of individuals was divided into two strata: those living in Mashhad (the provincial capital) and those living in other cities.
The following sample selection criteria were used:

Healthcare Service Providers: We randomly selected a sample of health workers from each profession category.
Health Ambassadors and Households: Health ambassadors and household heads were randomly selected from the list of individuals covered by Mashhad University of Medical Sciences (MUMS)

Instrument:

Data collection was conducted using a validated and reliable questionnaire developed by Sarlak et al. (10) Specifications of consumed salt, salt storage, and use, as well as awareness of iodized salt and iodine deficiency disorders were covered in the survey.

Data Collection Methods:
- A self-administered questionnaire was distributed to health service providers and health ambassadors, who were asked to bring salt samples for standardized iodine testing.
- Telephone interviews were conducted with household heads to collect data on households. In order to test the iodine level in salt samples, door-to-door visits were conducted using standardized test kits.
- Iodometry analysis of the collected salt samples was performed at MUMS's Food and Drug Administration office.

The iodine content in salt can be classified into three categories according to the previous (Health Department) and new standards (WHO/UNICEF/ICCIDD) of our country (11).

Previous Standard:

Good: 30-50 µg/g
Acceptable: 20-29 µg/g
Unacceptable: <20 µg/g or >50 µg/g

New Standard:

Compliant: 30-60 µg/g
Non-compliant: <30 µg/g or >60 µg/g

Data Analysis:

The prevalence of iodized salt consumption was estimated using descriptive statistics (frequencies, percentages, means, and standard deviations), and five key features of a dataset were represented by box plots: the minimum, the first quartile, the median, the third quartile, and the maximum. Cohen's kappa (κ) was used to assess the agreement between two methods for testing iodine levels. A kappa coefficient is calculated based on two components: Observed agreement (Po): This is the proportion of times that raters agree on the same category, and Expected agreement (Pe): This is the proportion of times that raters would agree by chance.

The formula for Cohen's kappa is:

κ = (Po - Pe) / (1 - Pe)

Kappa Classification:

0.00 - 0.01: No agreement
0.01 - 0.20: Slight agreement
0.21 - 0.40: Fair agreement
0.41 - 0.60: Moderate agreement
0.61 - 0.80: Substantial agreement
0.81 - 1.00: Almost perfect agreement.

All analyses were done with Stata14 software (StataCorp, College Station, TX, USA).

Ethical considerations

This research was approved by the Ethics Committee of Mashhad University of Medical Sciences (Ethics ID: IR.MUMS.REC.1402.174). We followed ethical guidelines and obtained informed consent from all participants in our study.

The datasets used and during the current study available from the corresponding author on reasonable request.

A total of 3,115 participants enrolled in this study, including 812 health workers, 912 health ambassadors, and 1,391 households in Razavi Khorasan province.

Table 1

Salt Consumption Patterns by Study Group (Frequency and Percentage)
Study Group	Iodized and Refined Salt	Unrefined Salt	Mixed Salt
Health Ambassadors	750 (83.24%)	86 (9.54%)	65 (7.21%)
Health Workers	772 (94.72%)	18 (2.21%)	25 (3.07%)
Households	1,062 (81.13%)	135 (10.31%)	112 (8.56%)

According to the self-reported data, more than 80% of respondents said they used iodized salt. As expected, health workers (94.72%) consumed the most iodized salt, but ambassadors and households consumed the same amount. The least commonly used salt types were unrefined and mixed salts. It was health workers who consumed the least salt, followed by health ambassadors and households who consumed moderate amounts of these salt(Table 1).

Table 2

Salt distribution Patterns by Study Group and Residence Area (Frequency and Percentage)
Residence Area	Study Group	Iodized and Refined Salt	Unrefined Salt	Mixed Salt
Urban	Health Ambassadors	509 (81%)	73 (12%)	46 (7%)
	Health Workers	241 (88%)	13 (5%)	19 (7%)
	Households	726 (78%)	118 (13%)	87 (9%)
Rural	Health Ambassadors	119 (97%)	4 (3%)	0 (0%)
	Health Workers	17 (45%)	25 (66%)	0 (0%)
	Households	335 (89%)	42 (11%)	0(0%)

Urban health workers in urban areas are most likely to use iodized and refined salt, with a prevalence of 88%. A high percentage of rural health ambassadors also preferred iodized and refined salt (97%). It was generally found that all groups used little unrefined salt. inexpertly unrefined salt was used by a higher proportion of rural health workers (66%) than by other groups in their area. All groups used relatively little mixed salt (Table 2).

Table 3

Test Kit and Iodometry Results in Salt Consumption (mg/g) according to groups
	Observations (n)	Iodometry				Test Kit
Study Group	Observations (n)	Mean (mg/g)	Std. Dev. (mg/g)	Min (mg/g)	Max (mg/g)	Mean (mg/g)	Std. Dev. (mg/g)	Min (mg/g)	Max (mg/g)
Health Ambassadors	51	59.06	29.41	0	148.1	33.89	15.46	0	50
Health Workers	54	55.62	32.97	0	116.4	36.06	13.27	0	50
Households	48	60.75	32.22	0	119.6	31.81	15.76	0	50

The average iodine content of health ambassadors by iodometry method was 59.06 mg/g, followed by households (60.75 mg/g) and health workers (55.62 mg/g). Variability (standard deviation) is relatively high in all groups, indicating a wide range of iodine content.

Based on the average values of the test kit, all groups appear to have sufficient levels of iodine (health ambassadors: 33.89, health workers: 36.06, households: 31.81). Test kit results might not capture the full range of iodine content observed in iodometry (0-148.1 mg/g vs. 0–50 mg/g) (Table 3).

Components of a Box Plot:

Box: The rectangular box in the center of the plot represents the middle 50% of the data (the interquartile range, or IQR). The height of the box shows the range between the first quartile (Q1) and the third quartile (Q3).
Center Line: The line running through the middle of the box represents the median of the data (Q2).
Whiskers: The lines extending from the ends of the box show the maximum and minimum values of the data, up to 1.5 times the IQR.
Outliers: Data points that fall outside the whiskers are considered outliers and are shown as individual points.

Figure 1 shows the distributions of iodometry and test kit results for each study group. In general, health ambassadors have the highest levels of iodine in both test methods. The iodine content of health workers is generally lower than that of health ambassadors, but higher than that of households. In both test methods, households have the lowest iodine content. When using the iodometry method, iodine content is generally higher than when using the iodide test kit. Iodine content in salt should be between 30 and 60 micrograms per gram. It appears, however, that some of the values measured with the iodometry method are outside this range.

Table 4

Test Kit and Iodometry Results of Salt Consumption (mg/g) by group and Residence Area
Study group	residence	Test Kit				Iodometry
		Mean	Std. Dev.	Min	Max	Mean	Std. Dev.	Min	Max
Health ambassadors	urban	33.93	15.60	0	50	59.16	25.75	3.2	116.4
Health ambassadors	rural	33.78	15.12	0	50	58.81	37.82	0	148.1
Health workers	urban	36.30	13.293	0	50	56.07	36.87	0	116.4
Health workers	rural	34.65	13.11	0	50	54.54	21.98	26.5	111.1
Households	urban	31.54	16.19	0	50	60.22	30.78	0	119.6
Households	rural	32.50	14.59	0	50	62.17	37.11	0	111.1

The two methods of measurement (test kit and iodometry) give differing results, and the wide variances, especially in the iodometry method, cause concern.

In both urban and rural areas, health ambassadors had the highest mean iodine levels, especially when using the iodometry method. Health workers in urban areas had higher iodine levels than those in rural areas, especially when using test kits. Rural areas had higher iodine levels than urban areas, especially when measured by iodometry (Table 4).

This boxplot in Fig. 2 shows the iodine content in salt for two groups ("Health Ambassadors" and "Health Workers"), two regions ("Urban" and "Rural"), and two measurement methods ("Test Kit" and "Iodometric Titration"). There is more iodine in salt of "Health Ambassadors" in both 'Urban' and 'Rural' regions compared to "Health Workers". "Urban" salt is higher in iodine than "Rural" salt for health ambassadors and household. These are more likely when salt iodine is less than 30 g/g or mor than 60 g/g. The median iodine in salt for the "Iodometric Titration" method is higher than the "Test Kit" method in all groups and regions. There are outliers in some groups, which may indicate measurement errors or unusual values.

Table 5

Comparison of Iodometry Results of Salt Consumption by study population according to the previous (Health Department) and new standards (WHO/UNICEF/ICCIDD)
Study groups	Previous Standard						New Standard
	Good		Acceptable		Unacceptable		Compliant		Non-compliant
	Freq.	Percent	Freq.	Percent	Freq.	Percent	Freq.	Percent	Freq.	Percent
Health ambassadors	10	20.00	0	0.00	40	80.00	20	39.22	31	60.78
Health workers	11	20.37	6	11.11	37	31.48	15	27.78	39	72.22
Households	11	22.92	1	2.08	36	75.00	18	37.50	30	62.50

Table 6

Comparison of Test Kit Results of Salt Consumption by study population according to the previous (Health Department) and new standards (WHO/UNICEF/ICCIDD)
Study groups	Previous Standard						New Standard
	Good		Acceptable		Unacceptable		Compliant		Non-compliant
	Freq.	Percent	Freq.	Percent	Freq.	Percent	Freq.	Percent	Freq.	Percent
Health ambassadors	723	79.02	55	6.01	137	14.97	723	79.02	192	20.98
Health workers	746	85.85	43	4.95	80	9.21	746	85.85	123	14.15
Households	986	74.08	120	9.02	225	16.90	986	74.08	345	25.92

Salt samples were tested for iodine content using the iodometry method (Table 5) and the test kit (Table 6) as well as three populations (health ambassadors, health workers, and households).According to the previous standards (Health Department) as well as the new standards (WHO/UNICEF/ICCIDD), the results are categorized accordingly.

In both old and new standards, 74–86% of samples were classified as "Good" or "Compliant" with rapid test kits. However, iodometric titration results show that only 20–40% of samples meet the "Good" or "Compliant" criteria. This is a significant concern, since it suggests a significant proportion of our population may not be able to access or use salt with adequate iodine content.

Table 7

Comparison of Iodometry Results of Salt Consumption according to the previous (Health Department) and new standards (WHO/UNICEF/ICCIDD) in study groups and area
Study Group	residence	Previous Standard							New Standard
			Good		Acceptable		Unacceptable		Compliant		Non-compliant
			Freq.	Percent	Freq.	Percent	Freq.	Percent	Freq.	Percent	Freq.	Percent
Health ambassadors	urban	7		19.44	0	0	29	80.56	15	41.67	21	58.33
Health ambassadors	rural	3		21.43	0	0	11	78.57	5	33.33	10	66.67
Health workers	urban	5		13.16	4	10.53	29	76.32	6	15.79	32	84.21
Health workers	rural	6		37.50	2	12.50	8	50.00	9	56.25	7	43.75
Households	urban	8		22.86	1	2.86	26	74.29	15	42.86	20	57.14
Households	rural	3		23.08	0	0	10	76.92	3	23.08	10	76.92

Table 8

Comparison of Test Kit Results of Salt Consumption according to the previous (Health Department) and new standards (WHO/UNICEF/ICCIDD) in study groups and area
Study Group	residence	Previous Standard						New Standard
		Good		Acceptable		Unacceptable		Compliant		Non-compliant
		Freq.	Percent	Freq.	Percent	Freq.	Percent	Freq.	Percent	Freq.	Percent
Health ambassadors	urban	510	79.69	34	5.31	96	15.00	510	79.69	130	20.31
Health ambassadors	rural	213	77.45	21	7.64	41	14.91	213	77.45	62	22.55
Health workers	urban	637	86.20	33	4.47	69	9.34	637	86.20	102	13.80
Health workers	rural	108	83.72	10	7.75	11	8.53	108	83.72	21	16.28
Households	urban	693	72.87	90	9.46	168	17.67	693	72.87	258	27.13
Households	rural	293	77.31	29	7.65	57	15.04	293	77.31	86	22.69

Results of iodometry and test kits for assessing iodine deficiency are shown in Table 7 and 8 by study group (health ambassadors, health workers, households) and area (urban, rural). These tables illustrate the differences between the old and new standards for assessing iodine deficiency. The new WHO/UNICEF/ICCIDD standards for iodometry testing appear to be more stringent, possibly resulting in a higher detection rate of iodine deficiency. However, the test kit results suggest the new standards might be more lenient.

Health ambassador salt samples from urban areas were found to contain adequate iodine content regardless of classification standards. Similarly, even under the stricter new standard, both methods consistently showed adequate iodine content in salt samples from health ambassadors. health workers in urban iodometry results showed a slight decrease in compliance under the new standard, while test kit results remained consistent; however, Rural Iodometry results showed a much greater decline in compliance under the new standard, while test kit results remained relatively the same. Rural households had the lowest compliance rates under the new standard, with households in rural areas showing a substantial decrease in compliance under both methods.

Table 9

Evaluation of Agreement between Iodine Testing Methods in Salt Consumption
		Iodometry Results
Test Kit Results		< 30 µg/g	30–60 µg/g	> 60 µg/g	Total
	< 30 µg/g	16	15	17	48
	30–60 µg/g	13	38	54	105
	> 60 µg/g	0	0	0	0
	Total	29	53	71	153

Kappa coefficient falls into the range of "poor agreement", The Z-score of 2.08 and p-value of 0.0188 indicate that there is a statistically significant association between the results of the two methods (Table 9).

This study examined several factors that can influence how much iodine stays in table salt. These factors include:

Purchase Location
Paying attention to the date of production and expiration
The type of container the salt is stored in (Storage Container)
Where and how the salt is kept (Storage Conditions)
Whether salt is added to food before or after cooking (Timing of Salt Addition to Food)
People's understanding of the health problems caused by not having enough iodine (Awareness of Consequences of Iodine Deficiency)

More than 98% of urban and rural health workers, approximately 91% of rural health ambassadors, 87% of urban households, and 91% of rural households obtain their salt from inside of stores and off the shelf.

About 51% of urban and rural ambassadors, 84% of urban and 87% of rural health workers, and around 49% of urban and rural households pay attention to the production and expiration dates on table salt packages.

66.44 percent and 62.78%, respectively, of health workers in urban and rural districts store iodized salt in dark containers. Furthermore, 57.97% of urban ambassadors and 47.27% of rural ambassadors store salt in dark containers. Salt is stored in dark containers by 42.06 percent of households in urban areas and 37.15 percent of households in rural areas. Approximately 45% of urban and 46% of rural health ambassadors; 58% of urban and 63% of rural health workers; and 33% of urban and 31% of rural households store their salt containers in locations away from heat, light, and humidity.

There are 18% of urban and 21% of rural health ambassadors; 28% of urban and 38% of rural health workers; and 16% of urban and rural households who put salt on food after it has been cooked.

According to the survey, only 45% of urban and 46% of rural health ambassadors, 58% of urban and 63% of rural health workers, and 33% of urban and 31% of rural households have adequate information about iodine deficiency diseases in humans.

However, approximately 70% of urban and rural ambassadors, 92% of urban health workers, and 94% of rural health workers, 63% of urban and 57% of rural households, pay attention to the iodization and purification of salt when buying it.

The problem of iodine deficiency disorders (IDD) remains a major national health issue, particularly in developing countries. To monitor the effectiveness of IDD prevention strategies, accurate assessments of salt iodine content are essential (12)

This study investigated salt consumption and iodine content patterns in three groups (Health workers, ambassadors, and households) in Razavi Khorasan province and offers valuable insights into iodine intake practices, the effectiveness of salt iodization programs and several important considerations for the prevention of IDD in this region based on the consumption and quality of iodized salt.

Comparison of Iodine Content Across Groups and Regions:

According to the study, salt samples from health ambassadors contained more iodine than those from health workers and households, regardless of location. This suggests that health ambassadors may have better access to and utilization of adequately iodized salt. As community health educators, health ambassadors often serve as advocates for iodized salt and play a vital role in promoting its use. A disparity in iodine content between urban and rural salt samples was also evident, with urban salt samples containing higher levels of iodine than rural salt samples. The results of this study are consistent with what has been observed in similar studies in developing countries (13). It is possible that rural areas have lower levels of iodine because they have fewer options for adequately iodized salt, a lower socioeconomic status, and a lower awareness of the health benefits of iodized salt.

Salt consumption and iodine content patterns:

According to our study, 74-86% of salt samples met iodine content standards using rapid test kits, with higher compliance among health workers and lower compliance among households. The Indian study found that 85.7% of salt samples from schools and 71.1% of household samples were adequately iodized (≥15 ppm) using rapid test kits. According to this study, institutional settings have higher compliance rates than households, which is in line with the 74-86% range mentioned (14).

In some districts in Tehran, Iran, household salt has an average iodine content of 18.53 g/g, which is below the recommended level, salt iodine content was assessed using the iodometric method, ranging from 34% to 67% at the distribution level and was 0% at the consumption level (10).

In other hand, we found a significant discrepancy between results obtained from rapid test kits and iodometric titration for calculating iodine content in salt samples. This discrepancy raises doubts about the accuracy of rapid test kits to measure iodine content. Compared to an iodometric titration, rapid test kit results provide a much more favorable picture of salt iodine content. Discrepancies like this suggest that rapid test kits overestimate iodine levels in salt samples. Other studies have reported similar discrepancies. In Nepal, for instance, rapid test kits indicated 75.5% of salt samples contained adequate iodine content, higher than iodometric titration. As a result, rapid test kits may overestimate iodine levels (15).

Several factors could contribute to this discrepancy

According to kappa coefficient analysis and other results, the two methods used to detect iodine levels (iodometry and kit testing) showed poor agreement. In order to enhance consistency and reliability, further investigation into the methodologies and potential sources of variation is needed.

a. Rapid test kits may not be sensitive enough to measure iodine levels at lower concentrations

b. Color changes in rapid test kits may be misinterpreted subjectively, leading to misclassification.

c. False positives can occur when other compounds in salt interfere with rapid test kit results.

To address this issue, improve rapid test kit accuracy: Develop more sensitive and specific rapid test kits for iodine detection in salt with manufacturers, standardize procedures: Standardize testing procedures and implement strict quality control measures to minimize variability in results, and Provide thorough training to field workers on how to properly use and interpret rapid test kits so that subjectivity is reduced (16-18).

Frequency of key factors that can help maintain acceptable iodine content in table salt:

There are several factors that can influence the iodine content of table salt, including the location of purchase (19), storage conditions (20), timing of salt addition to food (21), and awareness of iodine deficiency disorders (22). According to the results, many people, particularly in rural areas, aren't aware of how to properly handle and use iodized salt or have inadequate access to it. According to the study, a high percentage of households, especially in rural areas, fail to pay attention to production and expiration dates or store salt in dark containers. Furthermore, many people, especially in rural areas, add salt to food before cooking, which can cause iodine loss. As a result of these findings, targeted educational campaigns and interventions are needed to improve the storage and use of iodized salt at all levels of society.In line with studies in Iran (23) and South Africa (19), this research confirms that urban areas have higher levels of iodine in salt than rural areas. There is a lack of awareness and improper storage/handling of iodized salt among households, especially in rural areas. In studies like in Etiupia, similar problems have been documented (24). A study from Tanzania supports the importance of education and targeted interventions to improve iodized salt consumption and storage practices (25). The availability and use of iodized salt are also strongly influenced by factors such as socioeconomic status, education level, and access to information (26, 27)

There are some limitations for this study. The iodometry results tend to differ from the test kit results for a variety of reasons. The sensitivity of the test kit and calibration procedures may be partly responsible. Further research is needed to determine the reason for the discrepancy.

The study does not examine the factors influencing salt selection decisions among different groups. Further research into these factors, including price, availability, and taste preferences, could help inform targeted public health campaigns.

Our knowledge of change salt consumption over time is limited to cross-sectional studies, but longitudinal studies would be beneficial in tracking the impact of interventions.

The study examines salt consumption patterns, but does not assess how storage practices affect iodine content over time. A laboratory analysis of salt samples collected at different times after purchase may be used to assess storage-related changes in iodine content in future studies.

The study provides valuable insights into the consumption and quality of iodized salt in Iran's Khorasan Razavi province. There are significant differences in iodine content between urban and rural areas, as well as between households, health ambassadors and health workers. Using updated WHO/UNICEF/ICCIDD standards for assessing iodine deficiency led to lower compliance rates, according to the research. Evaluation of iodine status needs to be based on appropriate classification criteria. An effective strategy for addressing iodine deficiency disorders in the region must include:

1. Implementing targeted interventions to improve rural and underserved areas' access to adequately iodized salt.

2. Raising awareness of proper storage and use of iodized salt in households.

3. Monitoring and evaluating iodized salt consumption and iodine status on an ongoing basis to inform and refine efforts.

4. Addressing both supply-side and demand-side barriers to ensure universal access to and proper utilization of adequately iodized salt.

5. Improving quality control and enforcement of salt legislation.

Implementing these strategies will help the region control and prevent iodine deficiency disorders, ultimately improving public health.

Conflict of Interest

All authors declare no competing interests.

Author Contribution

N.E: Concepts, Design, Data analysis, Statistical analysis, Manuscript preparation, Manuscript editing, Manuscript reviewM. JB: Concepts, Manuscript reviewSJ.H: Concepts, Design, Manuscript editing, Manuscript reviewZ.A: Design, Manuscript editingO.E and Z.N and A.G: Data acquisitionZ.IM: Manuscript reviewM.O: Manuscript editing

Acknowledgment

This research was supported by Mashhad University of Medical Sciences

Hatch-McChesney A, Lieberman HR. Iodine and Iodine Deficiency: A Comprehensive Review of a Re-Emerging Issue. Nutrients. 2022;14(17).
Kayes L, Mullan KR, Woodside JV. A review of current knowledge about the importance of iodine among women of child-bearing age and healthcare professionals. Journal of Nutritional Science. 2022;11:e56.
Rezaie M, Dolati S, Hariri Far A, Abdollahi Z, Sadeghian S. Assessment of Iodine Status in Iranian Students Aged 8-10 Years: Monitoring the National Program for the Prevention and Control of Iodine Deficiency Disorders in 2016. Iran J Public Health. 2020;49(2):377-85.
Jeddi M, Habib A, Salehi A. Sustained Elimination of Iodine Deficiency Within the Third Decade After Compulsory Iodine Supplementation Policy in the South of Iran: A Population-Based Cross-Sectional Study. Curr Dev Nutr. 2023;7(1):100013.
Health NIo. Iodine, Fact Sheet for Health Professionals 2024 [Available from: https://ods.od.nih.gov/factsheets/Iodine-HealthProfessional/.
Czubek E, Alcer K, Varjacic M, Romaniuk P. The importance and effectiveness of nutritional counselling in patients with autoimmune thyroid diseases in Poland. Cost Effectiveness and Resource Allocation. 2022;20(1):63.
Johnsen M, Braaten T, Skeie G, Laholt H, Hansen S. Midwives and public health nurses' knowledge and clinical practice in securing sufficient iodine status in relation to pregnancy: A cross‐sectional study. Nursing Open. 2023;10(7):4321-35.
Azizi F, Sheikholeslam R, Hedayati M, Mirmiran P, Malekafzali H, Kimiagar M, et al. Sustainable control of iodinedeficiency in Iran: beneficial results of the implementation of the mandatory law on salt iodization. J Endocrinol Invest. 2002;25(5):409-13.
Chanmuang S, Kim B-M, Gu S-Y, Son Y-J, Le H-G, Nam Y-D, et al. Effects of sea salt intake on metabolites, steroid hormones, and gut microbiota in rats. PLOS ONE. 2022;17(8):e0269014.
Sarlak F, Nabizadeh R, Yunesian M, Rastkari N. Investigate the iodine content in table salts used by families covered by health services of Tehran University of Medical Sciences in year 2017. 2019.
Iran National Standards Organization. Food grade iodized salt- specifications and test methods. Tehran, Iran: Iranian National Standards Organization; 2016.
Delange F, Bürgi H, Chen ZP, Dunn JT. World status of monitoring of iodine deficiency disorders control programs. Thyroid. 2002;12(10):915-24.
Abdurrahim M, Haque SEM, Roy DC, Arefin P, Ruchita FF, Sarkar MR, et al. Iodine concentration in edible salt from production to retail level in Bangladeshi territory: A comparative study following standard regulations. Journal of Food Composition and Analysis. 2023;120:105334.
Kapil U, Sareen N. Iodine Nutritional Status in Uttarakhand State, India. Advances in Nutrition. 2016;7(1):9A.
Nepal AK, Shakya PR, Gelal B, Lamsal M, Brodie DA, Baral N. Household salt iodine content estimation with the use of rapid test kits and iodometric titration methods. Journal of clinical and diagnostic research: JCDR. 2013;7(5):892.
Gorstein J, van der Haar F, Codling K, Houston R, Knowles J, Timmer A. Performance of rapid test kits to assess household coverage of iodized salt. Public health nutrition. 2016;19(15):2712-24.
Pandav CS, Arora NK, Krishnan A, Sankar R, Pandav S, Karmarkar MG. Validation of spot-testing kits to determine iodine content in salt. Bulletin of the World Health Organization. 2000;78(8):975-80.
Diosady L, Alberti J, Mannar MV, FitzGerald S. Stability of iodine in iodized salt used for correction of iodine-deficiency disorders. II. Food and Nutrition Bulletin. 1998;19(3):240-50.
Jooste P, Upson N, Charlton KE. Knowledge of iodine nutrition in the South African adult population. Public health nutrition. 2005;8(4):382-6.
Mannar MV, Dunn JT, Initiative M, Disorders ICfCoID, UNICEF. Salt iodization for the elimination of iodine deficiency: ICCIDD, NL; 1995.
Zimmermann MB. The importance of adequate iodine during pregnancy and infancy. Hidden Hunger. 2016;115:118-24.
Pandav CS, Yadav K, Srivastava R, Pandav R, Karmarkar M. Iodine deficiency disorders (IDD) control in India. Indian Journal of Medical Research. 2013;138(3):418-33.
Dadban Shahamat Y, Mojerlo S, Dehghan S, Niksiar P, Ghahrchi M, Moghiseh Z. Investigation of iodine content in iodized salts distributed in Gorgan, 2016. Journal of Environmental Science Studies. 2021;6(1):3407-11.
Gebremariam HG, Yesuf ME, Koye DN. Availability of adequately iodized salt at household level and associated factors in Gondar town, Northwest Ethiopia. International Scholarly Research Notices. 2013;2013(1):160582.
Assey VD, Peterson S, Kimboka S, Ngemera D, Mgoba C, Ruhiye DM, et al. Tanzania national survey on iodine deficiency: impact after twelve years of salt iodation. BMC Public Health. 2009;9:1-11.
Govender L. The potential of provitamin A-biofortified maize and sweet potato, and bambara groundnut for improving the nutritional status of rural communities in KwaZulu-Natal, South Africa 2020.
Abuye C, Berhane Y. The goitre rate, its association with reproductive failure, and the knowledge of iodine deficiency disorders (IDD) among women in Ethiopia: cross-section community based study. BMC Public Health. 2007;7:1-7.

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Iodine Deficiency Disorders in Khorasan Razavi Province, Iran: Assessing Salt Iodization and Iodine Intake Patterns

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