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Inicio Endocrinología y Nutrición (English Edition) Eradication of iodine deficiency in Spain. Close, but not there yet
Journal Information
Vol. 59. Issue 8.
Pages 471-473 (October 2012)
Vol. 59. Issue 8.
Pages 471-473 (October 2012)
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Eradication of iodine deficiency in Spain. Close, but not there yet
Erradicación de la deficiencia de yodo en España. Cerca, pero no en la meta
Sergio Donnaya,
Corresponding author

Corresponding author.
, Lluís Vilab, on behalf of the task force on disorders related to iodine deficiency and thyroid dysfunction
a Servicio de Endocrinología y Nutrición. Hospital Universitario Fundación Alcorcón. Alcorcón, Madrid, Spain
b Servicio de Endocrinología y Nutrición, Hospital de Sant Joan Despí Moisès Broggi, Sant Joan Despí, Barcelona, Spain
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Iodine deficiency (ID) in Spain, well documented since the 1960s,1 has persisted with different grades of intensity for more than four decades. In 2004, the World Health Organization (WHO) included Spain among the countries with optimum iodine nutrition based on studies conducted during the previous five years on schoolchildren and adults from various regions.2

It is very difficult to summarize the most relevant facts leading to this substantial progress in ID correction in Spain, and one runs the risk of inadvertently omitting some of them. In addition to the prolonged and continuous activity of the working group on disorders related to iodine deficiency (IDDs)3 of the Spanish Society of Endocrinology and Nutrition, various clinical and epidemiological research findings reported in the international literature during the past decade have confirmed the significance of ID, thus promoting the search for measures to correct it. Thus, the demonstration of deficient psychoneurological development in children born to mothers with low thyroxine levels during pregnancy secondary to maternal hypothyroidism4,5 or ID during pregnancy6,7 supported the results of basic studies8,9 and led virtually the entire Spanish medical community to assume the significance of optimum nutritional status and thyroid function in pregnant women. The gradual increase in understanding and acceptance by a large number of physicians of the benefits of iodine prophylaxis and adequate transmission of this information to the population through educational health campaigns has significantly contributed to ID correction in Spain. Finally, the availability on the National Health Service of potassium iodide supplements to correct ID in the pregnant population since 200510 has not only made it possible to improve the nutritional iodine status of pregnant women, but has very probably induced in a great part of this population group an increased awareness of the need for taking measures aimed at achieving an adequate nutritional iodine status for the whole family.

At the annual meeting of the IDD work group held in Barcelona in December 2011, two studies concerning the current nutritional iodine status of the Spanish population were presented. Both of them were led by group members. Dr. Vila reported that the Tirokid11 study, conducted on almost 2000 children from all over Spain aged between 6 and 7 years, had found median urinary iodine levels of 173μg/L. Dr. Soriguer, in turn, reported that the Di@betes12 study, conducted on an adult population recruited from 16 of the 17 Spanish autonomous communities, had found median urinary iodine levels of 117μg/L. The Arena and Emparanza study,13 which reported median urinary iodine values of 127μg/L in a group of healthy children aged 6 months to 3 years, was published at the beginning of the year. Thus, the results of these recent studies conducted on different groups of the Spanish population, by finding median urinary iodine levels higher than 100μg/L in all cases would appear to confirm that Spain continues to be among the countries with optimum iodine nutrition. However, some data from these same studies should temper our optimism, so that we do not make the false assumption that ID has definitively been eradicated in Spain. The proportions of children of pre-school age13 and adults12 with urinary iodine levels less than 100μg/L, close to 40%, and the reported use of iodinated salt in less than 50% of households suggest that the eradication of ID is far from being achieved according to the criteria established by the WHO and other international organizations.14 These include, amongst others, the availability and use of iodinated salt in more than 90% of households.

In this issue of Endocrinología y Nutrición, Dr. Arrizabalaga et al.,15 in their study on changes over time in the nutritional iodine status of schoolchildren from the Basque Country, found progressive correction of ID, recording an increase in median urinary iodine levels from 65μg/L in the 1992 to 147μg/L in the 2005 Nutrition Survey. The analysis performed by the authors on the factors influencing iodine intake increase in the Basque Country is of particular interest. Careful verification of the type of salt used at households by reading the label or measuring iodine contents of the salt pack available at the surveyed household showed a low percentage for the use of iodinated salt (IS), slightly above 50%, similar to that reported by other studies.16 Although urinary iodine levels were higher in schoolchildren taking IS than in those taking unfortified salt, normalization of iodine intake occurred in both groups. The authors therefore suggest that other dietary sources of iodine have contributed to the correction of ID in the Basque Country. The marked seasonal pattern seen in the urinary iodine levels of schoolchildren points to the consumption of iodine-rich milk and dairy products as one of the most important factors implicated in the increased iodine intake recorded in their study. Arena and Emparanza13 reached similar conclusions after finding an adequate nutritional iodine status in children of pre-school age in their study, despite the fact that IS was routinely used in less than 40% of households.

Various prior studies17,18 had already shown a close relationship between the consumption of dairy products and the urinary iodine levels found in school populations. On the other hand, the significant iodine content found in cow's milk consumed in Spain,19 higher than 200μg/L in all cases, supports the idea that milk intake is very probably one of the factors which contributes most significantly to ID correction in our country. Similarly to what happened in the United Kingdom during the 1980s and 1990s, it is likely that another “accidental triumph of public health”20 has occurred in Spain, with increased iodine intake being achieved through an increase, neither promoted nor controlled, in the consumption of iodine-rich milk and dairy products.

The WHO and other international organizations14 recommend universal iodination, i.e. iodination of any salt intended for human and animal use, including salt used by the food industry, as the best way to guarantee adequate iodine provision in the diet. The correction of ID through other dietary sources of iodine, such as milk and dairy products, has the disadvantage of the lack of control of the iodine entering the human food chain.21 In this regard, changes in iodine content in milk, secondary to changes in stock practices have resulted in the reappearance of ID in previously iodine-sufficient countries such as Australia.22 In the United Kingdom, where iodine provision in milk had allowed for the recommended daily requirements of iodine being achieved20 despite the lack of salt iodination programs, ID has very recently reappeared,23 and this country is currently among the countries with the highest numbers of schoolchildren with inadequate iodine intake.24 The evolution of nutritional iodine status in these countries would appear to confirm the lack of sustainability and the risks associated with this “silent” or uncontrolled iodine prophylaxis, which has repeatedly been denounced in Spain.25,26

Although we can congratulate ourselves on the adequate nutritional iodine status achieved by Spanish schoolchildren and adults, other population groups such as pregnant women are very likely to still have ID.27 The increased availability and consumption of iodine-rich foods, mainly milk and dairy products, has made an uncontrolled contribution to the improvement in nutritional iodine status. However, universal iodination and the use of iodinate salt in more than 90% of households, measures that guarantee adequate iodine provision in the diet14 and that have been shown to be of value for controlled and sustained ID eradication in some countries,28 have continuously been dismissed by Spanish healthcare administrations. Regular monitoring of the actual iodine content in table salt in accordance with the regulations and control of the stable iodine content in milk are potential actions by health administrations that would undoubtedly improve the nutritional iodine status of the Spanish population.

At the start of this century, the WHO and other international organizations29 defined the characteristics or circumstances of areas erroneously reported as not having ID which do in fact have IDDs. These include countries where ID is supposed to have been eradicated by prophylactic programs or general dietary changes. Unfortunately, the possibility that Spain, having no decided and unequivocal political will to eradicate ID, could be included in this category or be added to the list of countries in which the reappearance of ID has recently been shown appears to be high.

Appendix 1
Work group on disorders related to iodine deficiency and thyroid dysfunction

Coordinator: Donnay Candil, Sergio

Arena, José. Ares, Susana. Arrizabalaga, Juan José. Arrobas, Teresa. Bandrés Nivela, María Orosia.

Berbel, Pere. Caballero, Ageda. de la Vieja Escolar, Antonio. Espada, Mercedes. García Fuentes, Eduardo. Gentil, Alfonso. Iglesias Reymunde, Teresa. Lucas, Anna. Muñoz Márquez J, Menéndez, Edelmiro. Millón Ramírez, Maria del Carmen. Moll Mascaró, Gracia. Moreno, Jose Carlos.

Pineda Arrivas, José Javier. Riestra, María. Santiago, Piedad. Santiesteban, Pilar. Soriguer, Federico.

Torres Costa, María Teresa. Tortosa, Frederic. Vich Sastre, Francisca. Vila, Lluis, Wengrowicz, Silvia.

L. Ferreiro, F. Escobar del Rey.
100 años de literatura sobre el bocio endémico en España.
Endocrinología, 34 (1987), pp. 4-14
Iodine status worldwide.
WHO Global Database on Iodine Deficiency,
L. Vila.
Progress in eradication of iodine deficiency in Spain.
Endocrinol Nutr, 57 (2010), pp. 87-89
N. Mansura, J. Konishi.
Transient hypothyroidism in infant born to mothers with chronic thyroiditis. A nationwide study of twenty-three cases. The Transient Hypothyroidism Study Group.
Endocrinol Jpn, 37 (1990), pp. 369-379
J.E. Haddow, G.E. Palomaki, W.C. Allan, J.R. Williams, G.J. Knight, J. Gagnon, et al.
Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child.
N Engl J Med, 341 (1999), pp. 549-555
G.F. Fenzi, L.F. Giusti, F. Aghinini-Lombardi, L. Bartalena, C. Marcocci, F. Santini.
Neuropsychological assessment in schoolchildren from an area of moderate iodine deficiency.
J Endocrinol Invest, 13 (1990), pp. 427-431
F. Vermiglio, V.P. Lo Presti, M. Moleti, M. Sidoti, G. Tortorella, G. Scaffidi, et al.
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J Clin Endocrinol Metab, 89 (2004), pp. 6054-6060
G. Morreale, M.J. Obregón, R.M. Calvo, F. Escobar del Rey.
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L. Vila.
Estudio de la yodación en la población infantil española: Proyecto Tirokid.
XI Jornada de Grupo TDY-DT, (2011),
F. Soriguer.
Ingesta de yodo en población adulta española. Estudio Di@betes.
XI Jornada de Grupo TDY-DT, (2011),
J. Arena, J.I. Emparanza.
Study of iodine intake in children from 6 months to three years-old in Guipúzcoa.
An Pediatr (Barc), 76 (2012), pp. 65-68
World Health Organization, UNICEF, International Council for Control Iodine Deficiency Disorders.
Assessment of iodine deficiency disorders and monitoring their elimination.
A guide for programme managers, 3rd ed., World Health Organization, (2007),
J.J. Arrizabalaga, N. Larrañaga, M. Espada, P. Amiano, J. Bidaurrazaga, K. Latorre, et al.
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Endocrinol Nutr, 59 (2012), pp. 474-484
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Assessment of dietary habits related to iodine intake and iodine concentration and thyroid dysfunction in a non-preselected population in Spain (the Thyrobus Project).
Endocrinol Nutr, 57 (2010), pp. 407-413
M.C. Millón, F. Soriguer, R. Muñoz, I. Mancha, R. Gómez-Huelga, E. Goiburu, et al.
Determinant factors of ioduria in a scholar population in the south of Spain.
Endocrinol Nutr, 48 (2001), pp. 104-109
P. Santiago-Fernández, R. Torres-Barahona, J.A. Muela-Martínez, G. Rojo-Martínez, E. García-Fuentes, M.J. Garriga, et al.
Intelligence quotient and iodine intake: a cross-sectional study in children.
J Clin Endocrinol Metab, 89 (2004), pp. 3851-3857
F. Soriguer, C. Gutiérrez-Repiso, S. González-Romero, G. Olveira, M.J. Garriga, I. Velasco, et al.
Iodine concentration in cow's milk and its relation with urinary iodine concentrations in the population.
Clin Nutr, 30 (2011), pp. 44-48
D.I.W. Phillips.
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J Epidemiol Commun Health, 51 (1997), pp. 391-393
J.J. Arrizabalaga.
Nutrición y yodo. Prevención y control de los trastornos causados por deficiencia de yodo.
Mateu Sanchís S, coordinadora. Yodo y salud en el siglo xxi, European Pharmaceutical Law Group, (2004),
M. Li, C. Eastman, K. Waite, G. Ma, M. Zacharin.
Are Australian children iodine deficients. Results of the Australian National Nutrition Study.
Med J Aust, 184 (2006), pp. 165-169
M.P. Vanderpump, J.H. Lazarus, P.P. Smyth, P. Laurberg, R.L. Holder, K. Boelaert, et al.
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M. Andersson, V. Karumbunathan, M.B. Zimmermann.
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J Nutr, 142 (2012), pp. 744-750
I. Dominguez, S. Reveriego, G. Rojo-Martinez, M.J. Valdés, R. Carrasco, I. Coronas, et al.
Iodine deficiency and thyroid function in healthy pregnant women.
Med Clin, 122 (2004), pp. 449-453
J. Arena Ansótegui, S. Ares Segura.
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An Pediatr (Barc), 72 (2010), pp. 297-301
E.M. Wong, M.K. Sullivan, G.C. Perrine, L.M. Rogers, J.P. Peña-Rosas.
Comparison of median urinary iodine concentration as an indicator of iodine status among pregnant women, school-age children, and nonpregnant women.
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M.B. Zimmermann.
Iodine deficiency.
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World Health Organization, UNICEF, International Council for Control Iodine Deficiency Disorders.
Assessment of iodine deficiency disorders and monitoring their elimination.
A guide for programme managers, 2nd ed., World Health Organization, (2001),

The composition of the task force on disorders related to iodine deficiency and thyroid dysfunction is included in Appendix 1.

Please cite this article as: Donnay S, Vila L. Erradicación de la deficiencia de yodo en España. Cerca, pero no en la meta. Endocrinol Nutr. 2012;59(8):471–3.

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