Urinary Iodine Concentration and Mortality Among U.S. Adults

Assessing and Monitoring Nutrition Security in the United States: A Narrative Review of Current Measures and Instruments

PURPOSE OF REVIEW

Because nutrition plays a crucial role in the development of chronic diseases, ensuring nutrition security is important for promoting population health. Nutrition security is defined as having consistent and equitable access to healthy, safe, affordable foods essential to optimal health and well-being. Distinguished from food security, nutrition security consists of two constructs: healthy diets and nutritional status. The study aimed to identify population measures that reflect the important constructs of nutrition security (i.e., healthy diets and nutritional status) to inform U.S. nutrition security assessment and monitoring.

RECENT FINDINGS

Through a narrative review conducted across multiple databases, associations between subconstructs of healthy diets and nutritional status were identified. Of the six subconstructs that constitute healthy diets, nutrient adequacy and moderation were most often used to assess and monitor healthfulness of U.S. population diets and were associated with health outcomes. There is little evidence of an association between health outcomes and macronutrient balance or diversity in the U.S. Thirteen instruments were identified as potentially suitable for measuring at least one subconstruct of healthy diet in the population. This review highlights the importance of nutrition security in addressing population health challenges. It emphasizes the potential use of multiple instruments and measures to comprehensively monitor population nutrition security and inform intervention strategies. Identifying feasible and practical measures for assessing and monitoring nutrition security is imperative for advancing population health and mitigating the burden of chronic diseases.

Cardiac Electrical and Structural Changes after Iodinated Contrast Media Administration: A Longitudinal Cohort Analysis

Background: Iodinated contrast is commonly used for radiological procedures, with one dose delivering several hundred-fold the daily requirements needed for normal thyroid hormone production. Risks of excess iodine include incident thyroid dysfunction, which is associated with adverse cardiac outcomes, yet there are no prospective studies investigating the changes in cardiac physiology following iodine contrast administration. This study was conducted to investigate the longitudinal relationships between the amount of iodinated contrast administration and changes in cardiac electrophysiology and structure. Methods: A longitudinal cohort study was conducted with prospectively enrolled participants who received iodine contrast for elective computed tomography or coronary angiography. Serum thyroid function tests, electrocardiograms (EKG), and transthoracic echocardiograms were obtained serially until 36 months. Trends of electrical and structural cardiac changes following iodine contrast administration were assessed using mixed effect models. Results: The cohort was composed of 129 patients (median age, 70 [interquartile range: 63, 75] years; 98% male). Larger amounts of iodine exposure were associated with increases in QRS and QTc durations and decreased ejection fraction (EF), and these associations were still observed for follow-up EF after additionally adjusting for baseline values (the high-iodine contrast group vs. the low-iodine contrast group, -4.23% [confidence interval, -7.66% to -0.79%]). Dose-response analyses also showed lower EF with larger amounts of iodine received; these trends were not significant for the EKG parameters studied. Conclusions: Over a period of up to 36 months, a larger amount of administered iodine contrast was associated with lower EF among participants. Further investigation is needed to elucidate the long-term trends of electrical and structural cardiac function after iodine contrast administration.

Risks of Iodine Excess

Iodine is a micronutrient that is required for thyroid hormone synthesis. The iodide cycle in thyroid hormone synthesis consists of a series of transport, oxidation, organification, and binding/coupling steps in thyroid follicular cells. Common sources of iodine include the consumption of an iodine-rich diet or iodine fortified foods, the administration of amiodarone, iodine-containing supplements, or iodinated contrast media, and other miscellaneous sources. Methods to assess population iodine status include the measurement of urinary iodine concentrations, blood thyroglobulin levels, prevalence of elevated neonatal TSH levels, and thyroid volume. Although excessive iodine intake or exposure is generally well tolerated, an acute iodine load may result in thyroid dysfunction (hypothyroidism or hyperthyroidism) in certain susceptible individuals due to the failure to escape from the Wolff-Chaikoff effect and to the Jod-Basedow phenomenon, respectively. In this review, we discuss the associations between excessive iodine intake or exposure, with particular focus on iodinated contrast media as a common source of excess iodine in healthcare settings, and risks of incident thyroid dysfunction. We also summarize the risks of iodine excess in vulnerable populations and review current guidelines regarding the screening and monitoring of iodinated contrast-induced thyroid dysfunction. Finally, we discuss the long-term potential nonthyroidal health risks associated with iodine excess and suggest the need for more data to define safe upper limits for iodine intake, particularly in high-risk populations.

The correlation between iodine and metabolism: a review

Iodine is involved in the synthesis of thyroid hormones and plays a crucial role in human life. Both iodine deficiency and excess are common issues in certain populations. Iodine also has extrathyroidal effects on organs that can uptake it independently of thyroid hormones. Recently, multiple clinical studies have shown a connection between iodine intake and metabolic disorders, such as metabolic syndrome, obesity, diabetes, hypertension, and dyslipidemia. However, the results of these studies have been inconsistent, and the mechanisms behind these associations are still not well understood. Therefore, in this review, we aim to examine the recent research progress regarding the relationship between iodine and metabolic disorders, along with the relevant mechanisms.

Association study of urinary iodine concentrations and coronary artery disease among adults in the USA: National Health and Nutrition Examination Survey 2003-2018

Iodine is a vital trace element in the human body and is associated with several important coronary artery disease (CAD) risk factors. We aimed to explore the correlation between urinary iodine concentration (UIC) and CAD. Data from 15 793 US adults in the National Health and Nutrition Examination Survey (2003-2018) were analysed. We conducted multivariable logistic regression models and fitted smoothing curves to study the correlation between UIC and CAD. Furthermore, we performed subgroup analysis to investigate possible effect modifiers between them. We found a J-shaped association between UIC and CAD, with an inflection point at Lg UIC = 2·65 μg/l. This result indicated a neutral association (OR 0·89; 95 % CI 0·68, 1·16) between UIC and CAD as Lg UIC < 2·65 μg/l, but the per natural Lg [UIC] increment was OR 2·29; 95 % CI 1·53, 3·43 as Lg UIC ≥ 2·65 μg/l. An interaction between diabetes and UIC might exist. The increase in UIC results in an increase in CAD prevalence (OR 1·84, 95 % CI 1·32, 2·58) in diabetes but results in little to no difference in non-diabetes (OR 0·98, 95 % CI 0·77, 1·25). The J-shaped correlation between UIC and CAD and the interaction between diabetes and UIC should be confirmed in a prospective study with a series of UIC measurements. If excessive iodine precedes CAD, then this new finding could guide clinical practice and prevent iodine deficiency from being overcorrected.

Age-dependent association of high urinary iodine concentration with major depression in adults: NHANES 2007-2020

Excessive iodine exposure can have detrimental effects on thyroid function and overall health. This study aimed to investigate the age-dependent association between high urinary iodine concentration (UIC) and major depression symptoms in adults, using data from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2020. To perform stratified analysis by age, we utilized a rolling window method with a 15-year window width to examine the trend of the odds ratios (ORs) of UIC on depression symptoms with age. Full-factor and one-factor multinomial logistic regression models were employed to calculate the ORs, and violin plots were utilized to depict the ORs of UIC on major depression. The LASSO regression was applied to select variables for one-factor models. The bootstrap method was utilized to ensure the robustness of the results, and the Games-Howell test was applied to compare the differences in the bootstrapped ORs of different UIC groups. Our results indicate that, after age 46, the ORs of high UIC (≥ 300 μg/L) on major depression are significantly higher than those of normal UIC (100-199 μg/L). The bootstrapped ORs of high UIC on major depression calculated by the full-factor and one-factor multinomial logistic regression models are 1.9 (1.28, 2.82) and 1.42 (1.02, 1.93) among participants aged 46 and older, respectively. Based on these findings, we conclude that major depressive symptoms are significantly associated with high UIC among older individuals aged 46 and above.

Association between iodine nutrition and cervical lymph node metastasis of papillary thyroid microcarcinoma

We aimed to investigate the association between iodine intake and nodal metastasis stratified by central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) of papillary thyroid microcarcinoma (PTMC). Urinary iodine concentration (UIC) and clinicopathological characteristics were used to identify factors associated with CLNM and LLNM using logistic regression analysis. A sum of 3,858 PTMC patients were enrolled. The median UIC (MUI) of patients with CLNM or LLNM was not statistically different from those without nodal metastasis. Male patients had a higher MUI than females (183.4 μg/L vs. 173.6 μg/L). Female patients with extracapsular extension had a higher MUI than those without it (210.0 μg/L vs. 172.1 μg/L). Male patients with LLNM had a significantly lower MUI than those without LLNM (134.7 μg/L vs. 187.9 μg/L). Female patients with more than adequate iodine intake were more likely to present with CLNM and extrathyroidal extension than those with adequate iodine intake with an odds ratio (95% confidence interval) of 1.23 (1.01-1.51) and 1.59 (1.09-2.32) after adjustment. Iodine nutrition was not found to be associated with LLNM. In addition, patients with a younger age, larger tumors, extrathyroidal extension, and intrathyroidal spread were more likely to be CLNM, whereas nodular goiter presented with a protective factor; CLNM was the only factor associated with LLNM of PTMC in both genders. In conclusion, iodine nutrition has a much closer association with female than male patients, and high iodine intake may be associated with CLNM and extrathyroidal extension in female PTMC patients.

Dietary protein intake affects the association between urinary iodine and clinically relevant depression: Evidence from NHANES 2007-2018

Both iodine concentration and protein intake are important nutritional factors that may influence the development of depressive symptoms. However, there are no studies on the effect of protein intake on the relationship between iodine concentration and the risk of depression. The study aimed to explore the relationship between iodine and the risk of clinically relevant depression (CRD) according to protein intake. This study analyzed the adults (≥18 years) who participated in the 2007-2018 National Health and Nutrition Cross-sectional Survey (N = 10,462). CRD was assessed using the Patient Health Questionnaire (PHQ-9). Protein intake was assessed using two 24-h dietary recalls and urinary iodine concentration (UIC) was measured using inductively coupled plasma dynamic response cell mass spectrometry. Weighted multivariate logistic regression and restrictive cubic splines were performed to assess the relationship between UIC and CRD according to protein category (low protein intake <0.8 g/kg/day; high protein intake: ≥0.8 g/kg/day). After controlling for sociodemographic, behavioral, chronic diseases, and dietary factors, a positive correlation was observed between UIC (log10) and CRD (OR: 1.36, 95% CI: 1.026, 1.795). Low UIC (<100 μg/L) was associated with a lower prevalence of CRD (OR: 0.73, 95% CI: 0.533, 0.995) in high protein intake individuals, whereas this relationship did not exist in those with low protein intake. Moreover, restrictive cubic splines confirmed a near L-shaped relationship between UIC and CRD in the low-protein group (nonlinear p = .042) and a linear relationship between them in the high-protein group (nonlinear p = .392). This study illustrates that protein intake affects the relationship between UIC and CRD. Combining lower UIC and high protein intake may help reduce the prevalence of CRD, which would have significant implications for managing patients with depressive CRD in the clinical setting.

Associations between urinary iodine concentration and the prevalence of metabolic disorders: a cross-sectional study

Background

Few studies have examined the role of iodine in extrathyroidal function. Recent research has shown an association between iodine and metabolic syndromes (MetS) in Chinese and Korean populations, but the link in the American participants remains unknown.

Purpose

This study aimed to examine the relationship between iodine status and metabolic disorders, including components associated with metabolic syndrome, hypertension, hyperglycemia, central obesity, triglyceride abnormalities, and low HDL.

Methods

The study included 11,545 adults aged ≥ 18 years from the US National Health and Nutrition Examination Survey (2007-2018). Participants were divided into four groups based on their iodine nutritional status(ug/L), as recommended by the World Health Organization: low UIC, < 100; normal UIC, 100-299; high UIC, 300-399; and very high, ≥ 400. The Odds ratio (OR) for MetS basing the UIC group was estimated using logistic regression models for our overall population and subgroups.

Results

Iodine status was positively associated with the prevalence of MetS in US adults. The risk of MetS was significantly higher in those with high UIC than in those with normal UIC [OR: 1.25; 95% confidence intervals (CI),1.016-1.539; p = 0.035). The risk of MetS was lower in the low UIC group (OR,0.82; 95% CI: 0.708-0.946; p = 0.007). There was a significant nonlinear trend between UIC and the risk of MetS, diabetes, and obesity in overall participants. Participants with high UIC had significantly increased TG elevation (OR, 1.24; 95% CI: 1.002-1.533; P = 0.048) and participants with very high UIC had significantly decreased risk of diabetes (OR, 0.83; 95% CI: 0.731-0.945, p = 0.005). Moreover, subgroup analysis revealed an interaction between UIC and MetS in participants aged < 60 years and ≥ 60 years, and no association between UIC and MetS in older participants aged ≥ 60 years.

Conclusion

Our study validated the relationship between UIC and MetS and their components in US adults. This association may provide further dietary control strategies for the management of patients with metabolic disorders.

Iodine status in pregnant women in northern Spain. Effect of iodised salt and iodine supplements on thyroid function

INTRODUCTION

Iodine deficiency is linked to thyroid dysfunction, particularly in pregnant women. The objective of this study was to ascertain the iodine levels of women in the second trimester of pregnancy, analysing the influence of iodine ingestion on urinary iodine concentration (UIC) and maternal thyroid function.

METHODS

A prospective observational study of pregnant women from Health Area IV of Asturias (northern Spain) recruited before 13 weeks of gestation between May and June 2017. A questionnaire on iodine intake was completed at the first visit, and urine and serum samples were collected at baseline and again during the second trimester. UIC, thyroid stimulating hormone (TSH) and free thyroxine (FT4) obtained in the second trimester of gestation were analysed and related to iodine intake. Thyroid autoimmunity was also analysed in half of the pregnant women at baseline.

RESULTS

A total of 241 pregnant women were studied. Of these, 56.7% used iodised salt, 46.7% consumed ≥2 servings of dairy products daily and 88.1% took iodine supplements. Median UIC was 191μg/l (135.3-294μg/l), with 68.1% of the women having UIC ≥150μg/l. Only iodised salt consumption provided protection against iodine deficiency (odds ratio 0.35 [0.20-0.63], p=0.001). In women with no autoimmune thyroid disease (n=88), mean levels of TSH were lower in those that consumed iodised salt than in those that did not (respectively, 2.08±0.89mIU/l vs. 2.56±1.02mIU/l, p=0.025). In women with autoimmune thyroid disease (n=30), mean levels of TSH were higher in those that took iodine supplements than in those that did not (respectively, 2.97±1.25mIU/l vs. 1.16±0.41mIU/l, p=0.002).

CONCLUSIONS

The pregnant women studied from Health Area IV in Asturias maintain adequate nutritional iodine status in the second trimester of gestation. In our sample, only the consumption of iodised salt was associated with adequate iodine nutrition, without affecting maternal thyroid function. Most of the women used iodine supplements, which was linked to higher levels of TSH in pregnant women with autoimmune thyroid disease.

TSH levels within the normal range and risk of cardiovascular and all-cause mortality among individuals with diabetes

BACKGROUND

Evidence regarding thyroid-stimulating hormone (TSH) levels within the normal range and mortality in adults with diabetes is scarce. This study aimed to identify the association between TSH levels and cardiovascular disease (CVD) and all-cause mortality among euthyroid patients with diabetes.

METHODS

This prospective cohort study included 1830 adults with diabetes from the Third National Health and Nutrition Examination Survey III. Mortality outcomes were ascertained by linkage to National Death Index records through December 31, 2019. Participants were categorized by tertiles of TSH levels (low-normal, 0.39-1.30 mIU/L; medium-normal, 1.30-2.09 mIU/L; high-normal, 2.09-4.60 mIU/L). Multivariable Cox proportional hazards models were used to explore the association between TSH levels within the normal range and overall and CVD mortality. Furthermore, restricted cubic spline analyses were used to determine the nonlinear relationship between TSH levels and mortality.

RESULTS

During a median follow-up of 17.1 years, 1324 all-cause deaths occurred, including 525 deaths from CVD. After multivariate adjustment, a U-shaped relationship was observed between TSH levels in euthyroid status and all-cause or CVD mortality among patients with diabetes (both P < 0.05 for nonlinearity). Compared with participants with medium-normal TSH levels, those with high-normal TSH levels had a significantly higher risk of all-cause (hazard ratio, 1.31; 95% confidence interval, 1.07-1.61) and CVD (1.52; 1.08-2.12) mortality. Similarly, low-normal TSH levels also increased all-cause (1.39; 1.12-1.73) and CVD (1.69; 1.17-2.44) mortality risk. In stratum-specific analyses, we found that high-normal TSH levels were associated with higher mortality risk in younger (< 60 years) patients with diabetes but not in older (≥ 60 years) participants.

CONCLUSION

Low- and high-normal serum TSH levels were associated with increased all-cause and CVD mortality in euthyroid adults with diabetes. Further studies are needed to confirm the present observation in a wider population.

Association of Urinary Iodine Concentration with Depressive Symptoms among Adults: NHANES 2007-2018

The association between iodine status and depressive symptoms has not been investigated in the general population. Therefore, we drew 8935 participants from the National Health and Nutrition Examination Survey (NHANES) 2007-2018 to explore their association. In NHANES, Inductively Coupled Plasma Dynamic Reaction Cell Mass Spectroscopy was utilized to measure urinary iodine concentration (UIC), and Patient Health Questionnaire-9 was used to assess depressive symptoms. Meanwhile, we fitted logistic regression and restricted cubic spline models. We found that high UIC was associated with a higher prevalence of depressive symptoms than the normal UIC group (OR: 1.50, 95% CI: 1.04-2.16). This association was particularly pronounced and further strengthened among females (OR: 1.90, 95% CI: 1.19-3.01) and participants aged 40-59 (OR: 1.90, 95% CI: 1.11-3.25). Moreover, we found that low UIC was associated with a high prevalence of depressive symptoms among females (OR: 1.50, 95% CI: 1.02-2.18). Moreover, the dose-response relationship between UIC and depressive symptoms presented a general trend of decreased, steady transiently, and then increased. We found that participants with high UIC had a higher prevalence of depressive symptoms than those with normal UIC. Meanwhile, we also found that females with low UIC had higher odds of reporting depressive symptoms.

The utility of low-iodine diet in preparation for thyroid cancer therapy with radioactive iodine—A cohort study

Objective: A low-iodine diet (LID) of <50μ iodine/day is recommended as preparation for radioactive iodine (RAI) therapy in patients with differentiated thyroid cancer (DTC). The 24-h urinary iodine excretion (UIE) is utilized to evaluate the iodine-depleted status. The aim of this study was to test the association between UIE and progression-free survival (PFS).

Patients and methods: In total, 70 patients with intermediate- or high-risk DTC, post-total thyroidectomy, adhered to 2 weeks of LID and had UIE measured before RAI therapy. A Cox regression model was performed to study the contribution of UIE to PFS.

Results: The study group consisted of 68% (48/70) of women, aged 41.5 [IQR 31.0, 54.0] years, with tumor size 2.8 [IQR 1.8–4.5] cm, and presence of distant metastases in 22.9% (16/70) of patients. Patients were treated with 1–5 RAI dosages with the median cumulative activity of 150 [IQR 102–314] mCi (5.5 [IQR 3.8–11.6] GBq). During the follow-up of 3.7 [IQR 1.5–6.5] years, 21.4% (15/70) of patients had disease progression. The risk of progression was significantly higher in patients with UIE ≥200 µg/day at the time of RAI administration than in those with UIE <200 µg/day (HR 3.35, 95% CI 1.09–10.34, and p = 0.02). However, the multivariate Cox proportional hazards regression analysis adjusted for age, tumor size, and presence of distant metastases suggested that only distant metastases were independently significantly associated with the risk of progression (HR 5.80 (1.17–28.67), p = 0.03).

Conclusions: Although UIE ≥200 µg/day might be associated with worse PFS in RAI-treated DTC patients, the presence of distant metastases is a strong independent predictor of progression. Less stringent LID might be sufficient to achieve a UIE of <200 µg/day.

Urinary iodine and sodium concentration and thyroid status in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

OBJECTIVES

To evaluate urinary iodine concentration (UIC) in civil servants aged 35-74 years of the Brazilian Study of Adults Health (ELSA-Brasil) to analyze its relationship with sociodemographic, clinical risk factors, lifestyle, urinary Na and thyroid status.

DESIGN

Cross-sectional study in six Brazilian cities.

METHODS

This analysis included 792 participants with information about urinary iodine concentration (UIC). Thyroid status was defined by serum levels of TSH/FT4 and the current use of antithyroid drugs for treatment of overt hyperthyroidism or levothyroxine to treat overt hypothyroidism. The determination of UIC was carried out with an inductively coupled plasma mass spectrometer (ICP-MS) and was expressed as median with Interquartile Range (IQR).

RESULTS

In 792 participants, thereof 52% women, mean age was 51.9 (9.0) years. The median UIC was 219 (IQR, 166-291) for all persons studied, thereof 211 (IQR, 157-276) for women and 231 (IQR, 178-304) for men. According to the WHO classification, for all persons studied, 60% had more than adequate iodine-supply (UIC ≥200 μg/L), 37% were adequately supplied (UIC 100-199 μg/L) and <3% had a deficient iodine status (<100 μg/L). In the 35-44-year age strata, which includes women of childbearing age, 23.2% of women presented less than 150 μg/L of UIC. No differences in UIC were detected according to thyroid status. (P = 0.39) The correlation between Ur-Na and UIC showed a Spearman coefficient of 0.52 (P < 0.0001) and it was also found an association of Ur-Na with UIC: Beta of 1.76 (95% Confidence Interval (95% CI): 1.01 to 2.51. The urinary Na concentration showed a synergy with the UIC, that means medians of 57, 72, 107 and 141 mmol Na/L urine (P < 0.001) in the groups with the four UIC classes according to the WHO grading mentioned above. The very low Na content in the persons exhibiting <100 μg/L UIC seems to reflect also a higher urine volume due to the frequent use of diuretics. The strong relationship between the urinary Na concentration and the UIC points to a dependence of the UIC on the individual consumption of iodized salt, which should be more considered in future studies. The strong relationship between the urinary Na concentration and the UIC points to a dependence of the UIC on the individual consumption of iodized salt, which should be more considered in future studies.

CONCLUSIONS

Euthyroid persons were dominating by more than four fifths and no significant association was found between UIC and thyroid status. Although most of the persons studied present more than adequate iodine intake it was observed that nearly a quarter of women in childbearing age are iodine deficient.

The association between subclinical hypothyroidism and metabolic syndrome: an update meta-analysis of observational studies

The association between subclinical hypothyroidism (SCH) and metabolic syndrome (MetS) has been widely discussed. This study aimed to conduct an update and comprehensive meta-analysis to reveal the risk of MetS and its components in SCH. PubMed, Embase and ISI Web of Knowledge were searched to identify relevant studies through February 20^th, 2020. Review Manager 5.3 and Stata 14.0 were used to conduct the meta-analysis. Both fixed-effects and random-effects models were used. In total, 18 articles (19 studies) incorporating 79,727 participants were included. The pooled OR for MetS comparing subjects with SCH with euthyroid subjects was 1.28 (95% CI: 1.19 to 1.39, p = 0.04, I² = 40%). Subgroup analysis results showed significant associations of SCH and MetS in the adult subgroup (OR = 1.28, 95% CI: 1.18-1.40), Asian population subgroup (OR = 1.30, 95% CI: 1.19-1.42) and cross-sectional study design subgroup (OR = 1.31, 95% CI: 1.16-1.47). Significant associations of SCH and MetS also existed in all MetS definition criteria subgroups except the Chinese Diabetes Society (CDS) subgroup. SCH was correlated with MetS and was not affected by the subgroup analysis stratified by the proportion of females in the total population, the TSH cutoff value in SCH diagnostic criteria, or the adjustment for confounding factors. SCH was identified to be associated with an increased risk of obesity, hypertension, high triglyceride (TG) levels and low high-density lipoprotein cholesterol (HDL-C) levels. In conclusion, SCH is significantly associated with an increased risk of MetS and four out of five components of MetS.

Iodine Deficiency and Mortality in Spanish Adults: Di@bet.es Study

Background: Longitudinal data assessing the impact of iodine deficiency (ID) on mortality are scarce. We aimed to study the association between the state of iodine nutrition and the risk of total and cause-specific mortality in a representative sample of the Spanish adult population. Methods: We performed a longitudinal observational study to estimate mortality risk according to urinary iodine (UI) concentrations using a sample of 4370 subjects >18 years representative of the Spanish adult population participating in the nationwide study Di@bet.es (2008-2010). We used Cox regression to assess the association between UI at the start of the study (<50, 50-99, 100-199, 200-299, and ≥300 μg/L) and mortality during follow-up (National death registry-end of follow-up December 2016) in raw models, and adjusted for possible confounding variables: age, sex, educational level, hypertension, diabetes, obesity, chronic kidney disease, smoking, hypercholesterolemia, thyroid dysfunction, diagnosis of cardiovascular disease or cancer, area of residence, physical activity, adherence to Mediterranean diet, dairy and iodinated salt intake. Results: A total of 254 deaths were recorded during an average follow-up period of 7.3 years. The causes of death were cardiovascular 71 (28%); cancer 85 (33.5%); and other causes 98 (38.5%). Compared with the reference category with adequate iodine nutrition (UI 100-300 μg/L), the hazard ratios (HRs) of all-cause mortality in the category with UI ≥300 μg/L were 1.04 (95% confidence interval [CI 0.54-1.98]); however, in the categories with 50-99 UI and <50 μg/L, the HRs were 1.29 [CI 0.97-1.70] and 1.71 [1.18-2.48], respectively (p for trend 0.004). Multivariate adjustment did not significantly modify the results. Conclusions: Our data indicate an excess mortality in individuals with moderate-severe ID adjusted for other possible confounding factors.

Urinary Iodine and Genetic Predisposition to Hashimoto's Thyroiditis in a Chinese Han Population: A Case-Control Study

Background: We aimed to examine the association of urinary iodine concentration with Hashimoto's thyroiditis (HT) risk, and particularly, to investigate whether the HT-related genetic variations might modify the effects of urinary iodine on HT in the Chinese Han population. Methods: We conducted a case-control study with 1723 Chinese (731 cases, 992 controls). The associations between urinary iodine concentration and HT risk were analyzed using logistic regression models. The effects of interactions between the genetic risk scores (GRSs) and urinary iodine on HT risk were assessed by including the respective interaction terms in the models. We also applied restricted cubic spline regression to estimate the possible nonlinear relationship. The multinomial logistic regression models were performed to determine the associations of urinary iodine with euthyroid-HT and hypothyroidism-HT. Results: After controlling for potential confounders, the odds of HT increased with increasing quartiles of urinary iodine concentration: adjusted odds ratios (ORs) and 95% confidence intervals [CIs] were 1.45 [1.06-1.99], 1.66 [1.17-2.34], and 2.07 [1.38-3.10] for the quartiles 2, 3, and 4, respectively, compared with the first quartile (p for trend <0.001). Multivariable restricted cubic spline regression analysis further demonstrated that there was a near-linear association between urinary iodine concentration and HT risk (p-overall <0.001; p-nonlinear = 0.074). However, we did not find significant interactions between urinary iodine and GRSs on the risk of HT (all p for interaction >0.05). Interestingly, we found that each increment of urinary iodine was associated with a more than twofold increase in the odds of hypothyroidism-HT (adjusted OR = 2.64 [CI = 1.73-4.05]), but not with euthyroid-HT (p > 0.05). Conclusions: Higher urinary iodine concentration was associated with increased risk of HT, and this association was near linear, indicating that increased urinary iodine has a continuous and graded impact on HT risk. Moreover, the iodine-HT association was not modified by genetic predisposition to HT. Interestingly, urinary iodine concentration was significantly associated with increased risk of hypothyroidism.

Iodine nutrition status and its association with microvascular complications in urban dwellers with type 2 diabetes

Background

The principal function of iodine acts on thyroid function, but in recent years, the role of iodine deficiency in metabolism has also been gradually revealed. We aimed to investigate the current status of iodized salt consumption and urinary iodine concentration (UIC) in an urban Chinese population with type 2 diabetes, and to further explore whether UIC was associated with diabetic microvascular complications.

Methods

Four thousand five hundred fifty-nine subjects with diabetes from 7 communities in downtown Shanghai were enrolled in the cross-sectional Metal Study in 2018. UIC was detected using an inductively coupled plasma-mass spectrometer. Diabetic kidney disease (DKD) was defined as urinary albumin-to-creatinine ratio (UACR) > 30 mg/g or estimated glomerular filtration rate < 60 mL/min/1.73 m². Diabetic retinopathy (DR) was evaluated by high-quality fundus photographs and was remotely read by ophthalmologist.

Results

The median UIC of subjects with diabetes was 115.4 μg/L (78.9–170.8) in downtown Shanghai. Among all the subjects, 52.7% consumed non-iodized salt and 40.4% were iodine deficient. Iodine deficiency (UIC < 100 μg/L) was associated with an increased odds of DKD (OR 1.17; 95%CI 1.01–1.37) after adjustment for age, sex, education, current smokers, BMI, HbA1c, duration of diabetes, dyslipidemia, thyroid-stimulating hormone and free thyroxine. No association was observed between UIC and DR after multivariable adjustment.

Conclusions

A concerning number of subjects with diabetes consumed non-iodized salt and suffered from iodine deficiency in coastal regions of China. Low UIC might be a risk factor for DKD, which should be further confirmed by longitudinal prospective studies.

U-Shaped Associations Between Urinary Iodine Concentration and the Prevalence of Metabolic Disorders: A Cross-Sectional Study

Background: Iodine is important in both thyroid function and human metabolism. Studies have explored the effect of iodine on metabolic disorders through thyroid function. This study aimed to investigate the relationship between iodine status and metabolic disorders, such as metabolic syndrome (MetS), hypertension, impaired glucose metabolism, central obesity, and dyslipidemia. Methods: A total of 51,795 subjects aged ≥18 years from the TIDE (Thyroid Disorders, Iodine Status and Diabetes, a national epidemiological cross-sectional study) program were included. The prevalence of metabolic disorders and its related diseases was calculated based on the level of urinary iodine concentrations (UICs) using the chi-square method. To further explore whether the prevalence was associated with UIC, quadratic and UIC-stratified logistic regression models were used. Results: The prevalence of metabolic disorders as a function of UIC was found to be U-shaped with a lower prevalence of 76.0% at an UIC of 300-499 μg/L. Participants with an UIC of 300-499 μg/L showed an association with metabolic disorders (odds ratio [OR] = 0.857, 95% confidence interval [CI 0.796-0.922]) and hypertension (OR = 0.873 [CI 0.814-0.936]). An UIC of 300-799 μg/L was found to be associated with the occurrence of MetS and impaired glucose tolerance. An UIC of 500-799 μg/L was associated with the occurrence of prediabetes (OR = 0.883 [CI 0.797-0.978]). An UIC of ≥300 μg/L was associated with the occurrence of hypertriglyceridemia, hypercholesterolemia, and high levels of low-density lipoprotein cholesterol. Furthermore, an UIC of <100 μg/L showed an association with hypertension (OR = 1.097 [CI 1.035-1.162]) and hypercholesterolemia (OR = 1.178 [CI 1.117-1.242]). Conclusions: The association between UICs in adults and metabolic disorders and its related diseases is U-shaped. The association between UIC and metabolic disorders disappears in cases of iodine deficiency (<100 μg/L) or excess (≥500 μg/L).

Association of Hypothyroidism and Mortality in the Elderly Population: A Systematic Review and Meta-Analysis

CONTEXT

The evidence of whether hypothyroidism increases mortality in the elderly population is currently inconsistent and conflicting.

OBJECTIVE

The objective of this meta-analysis is to determine the impact of hypothyroidism on mortality in the elderly population.

DATA SOURCES

PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases were searched from inception until May 10, 2019.

STUDY SELECTION

Studies evaluating the association between hypothyroidism and all-cause and/or cardiovascular mortality in the elderly population (ages ≥ 60 years) were eligible.

DATA EXTRACTION

Two reviewers independently extracted data and assessed the quality of the studies. Relative risk (RR) was retrieved for synthesis. A random-effects model for meta-analyses was used.

DATA SYNTHESIS

A total of 27 cohort studies with 1 114 638 participants met the inclusion criteria. Overall, patients with hypothyroidism experienced a higher risk of all-cause mortality than those with euthyroidism (pooled RR = 1.26, 95% CI: 1.15-1.37); meanwhile, no significant difference in cardiovascular mortality was found between patients with hypothyroidism and those with euthyroidism (pooled RR = 1.10, 95% CI: 0.84-1.43). Subgroup analyses revealed that overt hypothyroidism (pooled RR = 1.10, 95% CI: 1.01-1.20) rather than subclinical hypothyroidism (pooled RR = 1.14, 95% CI: 0.92-1.41) was associated with increased all-cause mortality. The heterogeneity primarily originated from different study designs (prospective and retrospective) and geographic locations (Europe, North America, Asia, and Oceania).

CONCLUSIONS

Based on the current evidence, hypothyroidism is significantly associated with increased all-cause mortality instead of cardiovascular mortality among the elderly. We observed considerable heterogeneity, so caution is needed when interpreting the results. Further prospective, large-scale, high-quality studies are warranted to confirm these findings.

Long-term iodine nutrition is associated with longevity in older adults: a 20 years’ follow-up of the Randers–Skagen study

Iodine intake affects the occurrence of thyroid disorders. However, the association of iodine intake with longevity remains to be described. This led us to perform a 20 years’ follow-up on participants from the Randers–Skagen (RaSk) study. Residents in Randers born in 1920 (n 210) and Skagen born in 1918–1923 (n 218) were included in a clinical study in 1997–1998. Mean iodine content in drinking water was 2 µg/l in Randers and 139 µg/l in Skagen. We collected baseline data through questionnaires, performed physical examinations and measured iodine concentrations in spot urine samples. Income data were retrieved from Danish registries. We performed follow-up on mortality until 31 December 2017 using Danish registries. Complete follow-up data were available on 428 out of 430 of participants (99·5 %). At baseline, the median urinary iodine concentration was 55 µg/l in Randers and 160 µg/l in Skagen residents. Participants were long-term residents with 72·8 and 92·7 % residing for more than 25 years in Randers and Skagen, respectively. Cox regression showed that living in Skagen compared with Randers was associated with a lower hazard ratio (HR) of death in both age- and sex-adjusted analyses (HR 0·60, 95 % CI 0·41, 0·87, P = 0·006), but also after adjustment for age, sex, number of drugs, Charlson co-morbidity index, smoking, alcohol and income (HR 0·60, 95 % CI 0·41, 0·87, P = 0·008). Residing in iodine-replete Skagen was associated with increased longevity. This indicates that long-term residency in an iodine-replete environment may be associated with increased longevity compared with residency in an iodine-deficient environment.

Association of Subclinical Hypothyroidism and Cardiovascular Disease With Mortality

IMPORTANCE

Subclinical hypothyroidism is a common clinical entity among US adults associated in some studies with an increase in the risk of cardiovascular disease (CVD) and mortality. However, the extent to which CVD mediates the association between elevated serum thyrotropin (TSH) and mortality has not yet been well established or sufficiently quantified.

OBJECTIVE

To elucidate the extent to which subclinical hypothyroidism, elevated serum TSH and normal serum free thyroxine, or high-normal TSH concentrations (ie, upper normative-range TSH concentrations) are associated with mortality through CVD among US adults.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study relied on representative samples of US adults enrolled in the National Health and Nutrition Examination Survey in 2001 to 2002, 2007 to 2008, 2009 to 2010, and 2011 to 2012 and their mortality data through 2015. Data were analyzed from January to August 2019.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards regression models were used to investigate associations between the TSH concentration category (subclinical hypothyroidism or tertiles of serum TSH concentrations within the reference range; low-normal TSH, 0.34-1.19 mIU/L; middle-normal TSH, 1.20-1.95 mIU/L; and high-normal TSH, 1.96-5.60 mIU/L) and all-cause mortality. Mediation analysis was used within the counterfactual framework to estimate natural direct associations (not through CVD) and indirect associations (through CVD).

RESULTS

Of 9020 participants, 4658 (51.6%) were men; the mean (SD) age was 49.4 (17.8) years. Throughout follow-up (median [interquartile range], 7.3 [5.4-8.3] years), serum thyroid function test results consistent with subclinical hypothyroidism and high-normal TSH concentrations were both associated with increased all-cause mortality (subclinical hypothyroidism: hazard ratio, 1.90; 95% CI, 1.14-3.19; high-normal TSH: hazard ratio, 1.36; 95% CI, 1.07-1.73) compared with the middle-normal TSH group. Cardiovascular disease mediated 14.3% and 5.9% of the associations of subclinical hypothyroidism and high-normal TSH with all-cause mortality, respectively, with the CVD mediation being most pronounced in women (7.5%-13.7% of the association) and participants aged 60 years and older (6.0%-14.8% of the association).

CONCLUSIONS AND RELEVANCE

In this study, CVD mediated the associations of subclinical hypothyroidism and high-normal TSH concentrations with all-cause mortality in the US general population. Further studies are needed to examine the clinical benefit of thyroid hormone replacement therapy targeted to a middle-normal TSH concentration or active CVD screening for people with elevated TSH concentrations.

Urinary Iodine Concentration in a Cohort of Adult Outpatients with Thyroid Diseases in Liguria 14 Years after the Law on Salt Iodization

Italy is considered a mildly iodine-deficient country. The aim of this study was to evaluate the iodine status of a cohort of adults living in Liguria after the 2005 salt iodization program. We searched all medical records of patients examined in two endocrine outpatient clinics in Genoa and Savona for data on urinary iodine. Subjects were under evaluation for thyroid diseases. Information on the type of salt used was found in few clinical records. Iodized salt use was reported in 29%, 20%, and 13% of records of people living in Genoa districts, the Savona district and nearby districts, respectively. The average urinary iodine concentration was 112.9 ± 62.3 µg/L (n = 415, median 101.0 µg/L). Non-significant differences (p > 0.05) were found between subjects with (median 103.5 µg/L) and without (median 97.5 µg/L) a thyroid gland, between the periods 2009–2013 (median 105.0 µg/L) and 2014–2018 (median 97.5 µg/L), and between Genoa (median 94.0 µg/L), Savona (median 105.0 µg/L) and the other districts (median 114.5 µg/L). No correlation with age, body mass index, creatinine, free thyroxine, thyroglobulin, levo-thyroxine dosage, or thyroid volume was observed. These data suggest a borderline status of iodine sufficiency in this cohort.

Perfluoroalkyl Substances and Maternal Thyroid Hormones in Early Pregnancy; Findings in the Danish National Birth Cohort

BACKGROUND

Maternal thyroid hormones are essential for fetal brain development in early gestation. Perfluoroalkyl substances (PFASs)-widespread and persistent pollutants-have been suggested to interfere with maternal thyroid hormones in the second or third trimesters, but evidence for an association in the early pregnancy period is sparse.

OBJECTIVES

Our goal was to evaluate the gestational-week specific associations of maternal thyroid-stimulating hormone (TSH) and free thyroxine (fT4) levels with plasma concentrations of six PFAS chemicals in the first and second pregnancy trimester.

METHODS

A cross-sectional analysis was conducted using 1,366 maternal blood samples collected between gestational weeks (GWs) 5 and 19 (median, 8 gestational weeks) in the Danish National Birth Cohort (DNBC) during 1996-2002. We estimated the percentage changes of serum TSH and fT4 levels according to concentrations (in nanograms per milliliter) of six PFAS chemicals modeled as per interquartile range (IQR) increase or by exposure quartiles. Moreover, we contrasted the estimated week-specific TSH or fT4 levels by PFAS quartile and estimated ORs for binary high or low TSH and fT4 status based on the week-specific distribution according to IQR increase of PFAS.

RESULTS

TSH levels followed a U-curve trend in early pregnancy with a nadir at GW10, whereas fT4 levels were less fluctuated in the samples. There were no apparent associations between any of the PFASs and changes of average TSH or fT4 levels in total samples. In gestational-week-specific analyses, we found that the estimated TSH values were higher among the highest perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), perfluorohexane sulfonate (PFHxS), and perfluoroheptane sulfonate (PFHpS) quartiles compared with the lower quartiles from GW5 to GW10, but the difference became null or even reversed after GW10. For binary outcomes, perfluorodecanoic acid (PFDA) was associated with high fT4 status before GW10 [OR=1.46 (95% CI: 1.04, 2.05)].

CONCLUSIONS

We observed some gestational-week-specific associations between high exposure to several PFAS and TSH level in early gestations. Further research of the biology and the potential clinical impact regarding thyroid hormones disruptions in early pregnancy is needed. https://doi.org/10.1289/EHP5482.

Bisphenol A exposure and risk of thyroid nodules in Chinese women: A case-control study

BACKGROUND

Thyroid nodules (TNs) are highly prevalent worldwide and have a pattern of female predominance. Bisphenol A (BPA) is an endocrine disruptor that can lead to adverse effects in human health. However, epidemiologic studies revealing the association between BPA exposure and TNs are limited and the results are inconsistent. We aimed to examine the association between urinary BPA and TNs in women who are more susceptible to TNs.

METHODS

We conducted a case-control study with 1416 women aged 18 years or older (705 cases, 711 controls). All participants underwent thyroid ultrasonography. Urinary total BPA (free and conjugated) concentration was quantified using the HPLC-MS/MS. We analyzed the association between urinary BPA concentration and the risk of TNs using crude and multivariable logistic regression models. Participants were further stratified into thyroid autoantibody positive group (at least one positive) and thyroid autoantibody negative group (both negative) according to the thyroglobulin antibody (TGAb) and thyroid peroxidase antibody (TPOAb) levels, and restricted cubic spline regression was also applied to determine the possible nonlinear relationship between urinary BPA and TNs.

RESULTS

Compared with women in the first quartile, the odds of TNs was 72% (adjusted OR = 1.72, 95% CI: 1.25 to 2.35) higher for those in the second quartile, 54% (adjusted OR = 1.54, 95% CI: 1.12 to 2.12) higher for those in the third quartile, and 108% (adjusted OR = 2.08, 95% CI: 1.50 to 2.90) higher for those in the fourth quartile after adjusting for age, BMI, education, HDL-C, LDL-C, triglyceride, total cholesterol, urinary iodine, TGAb and TPOAb. When the study population was stratified into thyroid autoantibody positive group and thyroid autoantibody negative group, we found that only in the positive group, the association was significant in model 1 (crude OR = 2.80; 95% CI = 1.90 to 4.12), model 2 (adjusted OR = 2.84; 95% CI = 1.91 to 4.22), model 3 (adjusted OR = 4.01; 95% CI = 2.57 to 6.27) and model 4 (adjusted OR = 3.71; 95% CI = 2.36 to 5.83). Multivariable-adjusted restricted cubic spline analysis demonstrated a similar result that in the thyroid autoantibody positive group, the association between urinary BPA and TNs risk was near linear (P-overall <0.001; P-non-linear = 0.054).

CONCLUSION

In Chinese women, higher urinary BPA concentration was associated with increased risk of TNs only in those with positive thyroid autoantibodies. Moreover, this association was near linear, indicating that any rise in BPA exposure was associated with elevated TNs risk.