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Original Article

Goiter prevalence and current iodine

deficiency status among school age
children years after the universal salt
iodization in Jamnagar district, India
Naresh R. Makwana, Viral R. Shah, Sumit Unadkat, Harsh D. Shah, Sudha Yadav

Department of
Community Medicine
(PSM), MP Shah Medical
College, Jam Nagar,
Gujarat, India
ABSTRACT
Introduction: Iodine is an essential micronutrient with an RDA of 100-150 µg for normal human
growth and mental development. Iodine deficiency disorder (IDD) refers to complex clinical
and subclinical disorder caused mainly due to inadequate intake of food with sufficient iodine.
Aims and Objectives: The objective was to find out the prevalence of goiter in primary school children;
to determine median urinary iodine concentration; to assess the level of iodine in salt samples at
household. Materials and Methods: A 30-cluster survey was done in Jamnagar district in primary
school children (6-12 years). A total of 70 children from first to seventh standards (35 boys and
35 girls) and 20 children from the community in each cluster were included. Total 2792 children were
taken for the total goiter examination by population proportion to size in each cluster with informed
consent. A total of 360 children were tested for the median urinary concentration and 750 salt samples
were tested on the spot with a test kit from the households of the study population. Results: The total
goiter rate was 4.83% among primary school children aged 6-12 years with no significant difference
between age and sex. As the age increased the goiter prevalence also increased but the difference
was not statistically significant (P > 0.05). The median urinary iodine excretion level of the district was
found 80 mcg/l. It was observed that 81.9% salt samples had more than 15 ppm (as recommended)
iodine content. Conclusion: The goiter prevalence is less in the study district but low median urinary
iodine excretion and use of insufficient iodized salt at households describe the inadequacy in efforts
to eliminate IDDs in the district.

Key words: Goiter, iodine deficiency disorders, iodized salt, school age children

Access this article online

Website: www.thetrp.net
DOI: 10.4103/0973-0354.96030
INTRODUCTION
Quick Response Code:
Iodine deficiency disorders (IDD), a
preventable health problem, has been
recognized in India since years. Unlike other
micronutrients deficiency, iodine deficiency
disorders are due to an inadequate amount
of iodine in water, soil, and foodstuffs. This
health problem affects all age groups of the
Address for
correspondence: population living in the same geographic areas
Dr. Harsh Shah, without depending on their socioeconomical
Near Mahila Mandir, status. People living in areas affected by
Kothariwada,
severe iodine deficiency may have an
Modasa- 383 315,
Dist - Sabarkantha, intelligence quotient (IQ) of up to 13.5
Gujarat, India. points below that of those from comparable
E-mail: communities in areas where there is no iodine
harsh.423@gmail.com
deficiency. This subtle degree of mental
deficiency causes an immediate effect on
the child’s school performance, intellectual
ability, and working capacity and thus, the
quality of life in communities and economic
productivity.[1,2]
It is estimated that about 167 million people
are “at risk” of IDD, about 54.4 million
people have a goiter, and more than 8.8
million people have IDD-related mental/
motor handicaps.[3] The surveys conducted by
Central and State health Directors, ICMR, and
Medical institutes have clearly demonstrated
that not even a single state/UT is free from
IDDs and overall 82% are endemic districts
in the country. In Gujarat, 50% districts were
endemics with prevalence of more than 10%
of the total goiter rate.[4]

40 | Thyroid Research and Practice | May-August 2012 | Vol 9 | Issue 2 |

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Makwana, et al.: Assessment of iodine deficiency among school age children of a Jamnagar district
Fortification of salt with iodine is the widely accepted
preventive strategy to fight against IDD. Several studies
carried out in India have shown a high percentage of
goiter incidence.[5-7] In 1983, mandatory iodization of
all table salt was introduced in India in an attempt to
eliminate iodine deficiency. The Government of India has
relaunched National Iodine Deficiency Disorders Control
Programme (NIDDCP) in the year 1992 with a goal to
reduce the prevalence of IDD to nonendemic level. After
implementation of NIDDCP, India has made considerable
progress toward IDD elimination.[8] During November,
2005, central government has issued notification banning
the sale of noniodized salt for direct human consumption
in the entire country, which was effective from 17th May,
2006 under the Food Adulteration Act.[8] In 2009, the
survey was carried out in Jamnagar district with the aims
to determine the prevalence of goiter in primary school
children aged 6-12 years; to determine median urinary
iodine concentration (UIC); and to assess the level of iodine
in salt samples at households of the surveyed population.
MATERIALS AND METHODS
Selection of the study population, sample size, and sampling
method
The 30-cluster cross-sectional study was conducted in the
entire 10 Talukas of Jamnagar district in 2009. The list of
villages, primary schools, and population were obtained
from the Jilla Panchayat of Jamnagar. Before starting
the survey, consent from the institution, chief district
health officer, Jamnagar, and district education officer,
Jamnagar, were taken. Total 30 villages were selected
from the Jamnagar district by using the cluster sampling
technique. Census 2001 population was used for sampling.
Areas mentioned as urban areas like cities, towns, talukas
headquarters were excluded from the village list to focus
only the rural population of Jamnagar district. The survey
was done among these villages in children studying in
primary schools from first to seventh standards in the
age group of 6-12 years. Total 70 children (35 boys and
35 girls) were examined from each primary school of
selected villages for goiter. About 30% school dropout rate
and absenteeism was considered, 20 students (10 boys
and 10 girls) were examined in the community for iodine
deficiency on the same day in the same village. Cases of
goiter were identified and the following classification was
used for goiter: (a) grade 0 – not visible, not palpable, (b)
grade 1 - palpable, but not visible, and (c) grade 2 - palpable
and visible, as per the WHO/UNICEF/ICCIDD guidelines.[9]
At the end of the survey total 2792 children were examined
against 2700 minimum estimated sample size for the total
goiter rate from the 30 clusters of the villages.
| Thyroid Research and Practice | May-August 2012 | Vol 9 | Issue 2 |
Urine sample
A total of six samples from schools and six from the
community were selected using a simple random-sampling
technique for taking the urine sample. So, in each cluster
12 urine samples were collected including 6 samples
from boys and 6 from girls. In 30 clusters, total 360 urine
samples were collected (0.5-1.0 ml) and tested for urinary
iodine excretion. Plastic bottles with screw caps were
used to collect the urine samples, which were stored in a
cool dry place and sent to state IDD laboratory for testing
by expert technician. Few drops of toluene were added
to each urine sample to inhibit bacterial growth and to
minimize bad odor. Child no., cluster no., and date of urine
collection were mentioned on every bottle of urine sample
to identify it. The ammonium persulfate titration method
was used to detect the urinary iodine excretion level. The
method is based on following principle: urinary iodine
is released after the digestion of urine with ammonium
persulfate. The released iodine catalyzes the reduction of
ceric ammonium sulfate (yellow) to cerous form (colorless)
(Sandell-Kolthoff reaction).[10] The color disappearance is
measured by a spectrophotometer in the form of optical
density (OD), which is then measured by constructing
a standard curve on the graph paper by plotting iodine
concentration in μg/l.
Salt samples
During the survey, 25 salt samples were tested using the
simple random-sampling technique through household
visits from the surveyed children: 12 from the schools
and 13 from the community children in each 30 clusters
to know the level of iodization of salt. Therefore, total
750 salt samples were tested. These samples were tested
qualitatively on the spot with a MIB kit provided by
UNICEF and iodine concentration was recorded as 0,
< 15 and >15 ppm.[8,11]
Data analysis
All the data were entered in MS excel 2007 and analyzed
by using Epi Info software, version 3.5.1. The Chi-square
test was applied where it was needed. P values were kept
significant at the level 0.05.
RESULT
In the present study, a total of 2792 children were studied
from 6 years to 12 years of age group of whom 50.5% were
males and 49.5% were females. The detailed age and
sexwise distribution of children is shown in Table 1. The
overall prevalence of goiter among the study population
was found 4.83%. Table 1 showed that the increase in
prevalence was consistent with increase in age of the
studied children. In the age group of 12 years children,
41
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Makwana, et al.: Assessment of iodine deficiency among school age children of a Jamnagar district

Table 1: Age and sex-wise distribution of grade of goiter of the study district
Grade of goiter
Age group (years) Sex 0 1 2 Total goiter rate (grade 1+2)
No. % No. % No. % No. %
6-7 Female 414 95.83 18 4.17 0 0.00 34 3.9
Male 424 96.36 13 2.95 3 0.68
8-9 Female 369 95.35 17 4.39 1 0.26 37 4.5
Male 413 95.60 16 3.70 3 0.69
10-11 Female 380 95.00 20 5.00 0 0.00 45 5.5
Male 387 93.93 25 6.07 0 0.00
12 Female 149 91.41 14 8.59 0 0.00 19 6.5
Male 121 96.03 3 2.38 2 1.59
Total 2657 95.16 126 4.51 9 0.32 135 4.83
*χ2 = 4.621, DF = 3, P = 0.2017

the prevalence of goiter was found significantly higher Table 2: Taluka-wise distribution of grades of goiter of the
with males and female difference. The overall prevalence study district
of goiter was higher in females 5.1% compared to males Taluka Taluka-wise distribution of grade of goiter
4.6%. The difference of prevalence between sexes was not 0 1 2 Total goiter Total examined
statistically significant. (χ2 = 0.223, degree of freedom = (grade 1+2) % children (n) %
1, P value = 0.63). Bhanvad 255 20 3 23 278
% 91.7 7.2 1.1 8.3** 100.0
Table 2 shows the geographical difference between talukas Dhrol 78 14 0 14 92
regarding the prevalence of total goiter. During the survey, % 84.8 15.2 0.0 15.2** 100.0
Jamjodhpur 175 12 2 14 189
it was found that a mild prevalence was seen in 50% of
% 92.6 6.3 1.1 7.4** 100.0
study areas. Out of studied 10 talukas, 5 talukas had a Jamnagar 443 9 0 9 452
prevalence of mild severity which was more than 5% but % 98.0 2.0 0.0 2* 100.0
less than 19.9%. Jodia 180 5 0 5 185
% 97.3 2.7 0.0 2.7 100.0
During the study, median urinary excretion among the Kalavad 361 12 0 12 373
% 96.8 3.2 0.0 3.2* 100.0
studied children was 80 µg/l from total collected urine
Kalyanpur 438 22 2 24 462
samples (n = 360). From the studied talukas, 60% (6) % 94.8 4.8 0.4 5.2** 100.0
talukas had median urinary excretion less than 100 µg/l Khambhaliya 458 16 1 17 475
within the range of 50-99.9 µg/l [Table 3]. % 96.4 3.4 0.2 3.6* 100.0
Lalpur 179 16 1 17 196
% 91.3 8.2 0.5 8.7** 100.0
On examining salt for iodization, it was observed that
Okha-dwarka 90 0 0 0 90
81.9% (614) salt samples had more than 15 ppm iodine
% 100.0 0.0 0.0 0 100.0
content, 8.5% (64) samples contained less than 15 ppm Total 2657 126 9 135 2792
salt, and 9.6% (72) samples were not iodized [Table 4]. On % 95.2 4.5 0.3 4.8* 100.0
exploring the iodine content of the studied talukas, it was Severity of public health problem: (*) <5% - No; (**) 5-19.9% - Mild; (***) 20 - 29.9%
observed that in four talukas (Jodia, Kalawad, Khambhalia, - Moderate; (****) >30% - Severe.[5]

and Lalpur) more than 95% of samples contained more

than 15 ppm iodine. In the present study, three talukas
were observed of not using noniodized salt (Lalpur, Jodiya,
Dhrol).
DISCUSSION
Iodine deficiency disorders (IDD) are preventable
disorders, but in India previous studies had shown that
no states or union territories of the country were free from
IDD.[3,4] To assess the severity of the iodine deficiency
of any area, WHO/UNICEF/ICCIDD had established the
criteria on the basis of total goiter prevalence (palpable
and visible goiter).[11] An area is classified as endemic for
iodine deficiency when it has a total goiter prevalence
rate of more than 5% among school children aged
6-12 years.[8] In the present study, it was found that the
total goiter prevalence was 4.83% among school children
aged 6-12 years. The sex difference had no impact on the
prevalence of goiter as it was 5.1% and 4.6% in males

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Makwana, et al.: Assessment of iodine deficiency among school age children of a Jamnagar district

Table 3: Distribution of participants according to median Table 4: Taluka-wise distribution of iodization of salt of the
urinary iodine excretion of the study district (n=360) study district (n =750)
Taluka Median UIE (µg/l) Taluka Taluka-wise distribution of iodization of salt
Bhanvad 50 < 15 ppm > 15 ppm Not iodized Total
Dhrol 110 Bhanvad 17 43 18 78
Jamjodhpur 90 % 21.8 55.1 23.1 100.0
Jamnagar 72.5 Dhrol 10 14 0 27
Jodia 110 % 40.7 59.3 0.0 100.0
Kalavad 62.5 Jamjodhpur 4 43 1 48
% 8.3 89.6 2.1 100.0
Kalyanpur 100
Jamnagar 6 82 35 123
Khambhaliya 77.5
% 4.9 66.6 28.5 100.0
Lalpur 85
Jodia 2 51 0 53
Okha-Dwarka 277.5 % 3.8 96.2 0.0 100.0
Total 80 Kalavad 3 92 1 96
% 3.1 95.8 1.1 100.0
Kalyanpur 15 100 12 127
% 11.8 78.7 9.4 100.0
and females respectively, (P = 0.63). Also, there was no
Khambhaliya 1 119 4 124
impact of the age difference on the prevalence of goiter, % 0.8 96 3.2 100.0
(P = 0.066). This study revealed that the distribution of the Lalpur 2 48 0 50
prevalence of goiter was different within the district itself. % 4 96 0.0 100.0
Out of 10 talukas, half of the talukas had a goiter prevalence Okha-
3 20 1 24
Dwarka
of more than 5%, though no talukas were found to have a %
12.5 83.3 4.2 100.0
severe and moderate degree of iodine deficiency disorders. Total 64 614 72 750
% 8.5 81.9 9.6 100.0
The goal of NIDDCP is to reduce the prevalence of iodine
deficiency disorders below 10% by 2012.[8] In the previous
studies conducted in Saurashtra regions, the goiter or eating certain kinds of the foods grown in that area. The
prevalences were reported 20.5%, 11.06%, and 25.2% preventable measures can also be taken by fortification of
in different districts.[12-14] Compared to these studies, the salt with iodine which has been low cost and successful
Jamnagar district had a low prevalence which was 4.83%. intervention throughout the world. In the present study,
a larger population was found using the iodized salt more
Iodine is an essential micronutrient which has a daily
than 15 ppm. But 8% of the studied population was using
requirement of 100-150 μg for normal growth and
salt less than 15 ppm of iodine and 9.6% population was
development. As per the national guidelines,[8] severity
not using iodized salt at all. In NFHS-3, it showed that 51%
of IDD to be a public health problem was classified
population of the country was using adequate iodized salt
in three categories including (1) <20 μg/l – severe,
(>15 ppm) and 24% were using noniodized salt.[20] The goal
(2) 20-49.9 μg/l – moderate, and (3) 50-99.9 μg/l - mild. A
of USI is to cover more than 90% of household to consume
value of 100 μg/l or above is considered as normal. The
iodized salt.[8] The current study revealed that four talukas
median urinary iodine excretion level 100 μg/l and above
was found in almost 40% talukas but the median urinary of the district had adequate consumption (more than 95%)
iodine level was 80 μg/l of all talukas in the current of iodized salt (> 15 ppm) and also, three talukas were free
study. These findings indicated that the populations from the use of noniodized salt which showed the success
of 6 out of 10 studied talukas were having biochemical of the NIDDC program within the district. To maintain
deficiency of iodine. They also indicated it as continued the efforts of elimination within the district, the focus on
but inadequate efforts of ensuring a supply of iodized salt universal salt iodization should be kept on the population-
to the population. Different median urinary iodine levels based data rather than geographical. In the present study,
were reported by different authors indicating deficiency or data revealed that population was using noniodized salt
no deficiency of iodine in respective populations in their (9.6%) and iodized salt less than 15 ppm (8%) could be the
areas.[15-18] A recent study by U. Kapil et al. had shown that future threat to reach the goal of decreasing the prevalence
86% districts of India had a urinary iodine level more than of goiter less than 10%.
100 μg/l.[19] The current study also identified that within
the district median urinary excretion level may vary. The findings of the present study suggest that the Jamnagar
district is in the transition phase from iodine deficient
In India, IDD can be eliminated by changing dietary habits to iodine sufficient with nearly mild goiter prevalence.

| Thyroid Research and Practice | May-August 2012 | Vol 9 | Issue 2 | 43

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Makwana, et al.: Assessment of iodine deficiency among school age children of a Jamnagar district

But detailed data analysis should be done to identify
geographical distribution of goiter prevalence within the
district. Low median urinary iodine excretion and use of
insufficient iodized salt described the present status of
iodine deficiency of the district. These data should be
taken into consideration to enhance the National Iodine
Deficiency Disorder Program which needs sustained
monitoring and intensified IEC activities to eliminate IDD
in near future.
ACKNOWLEDGMENTS
Authors are thankful to Government of Gujarat for providing
financial assistance, CDHO Jamnagar, and District Education
department for providing technical support
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Cite this article as: Makwana NR, Shah VR, Unadkat S, Shah HD, Yadav
S. Goiter prevalence and current iodine deficiency status among school age
children years after the universal salt iodization in Jamnagar district, India.
Thyroid Res Pract 2012;9:40-4.
Source of Support: Government of Gujarat, Conflict of Interest: None.

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