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Nicol K, Nugent AP, Woodside JV, Hart KH, Bath SC. Iodine and plant-based diets: a narrative review and calculation of iodine content. Br J Nutr 2024; 131:265-275. [PMID: 37622183 PMCID: PMC10751939 DOI: 10.1017/s0007114523001873] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/25/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
An increasing number of food-based recommendations promote a plant-based diet to address health concerns and environmental sustainability in global food systems. As the main sources of iodine in many countries are fish, eggs and dairy products, it is unclear whether plant-based diets, such as the EAT-Lancet reference diet, would provide sufficient iodine. This is important as iodine, through the thyroid hormones, is required for growth and brain development; adequate iodine intake is especially important before, and during, pregnancy. In this narrative review, we evaluated the current literature and estimated iodine provision from the EAT-Lancet reference diet. There is evidence that those following a strict plant-based diet, such as vegans, cannot reach the recommended iodine intake from food alone and are reliant on iodine supplements. Using the EAT-Lancet reference diet intake recommendations in combination with iodine values from UK food tables, we calculated that the diet would provide 128 μg/d (85 % of the adult recommendation of 150 μg/d and 51–64 % of the pregnancy recommendation of 200–250 μg/d). However, if milk is replaced with unfortified plant-based alternatives, total iodine provision would be just 54 μg/d (34 % and 22–27 % of the recommendations for adults and pregnancy, respectively). Plant-based dietary recommendations might place consumers at risk of iodine deficiency in countries without a fortification programme and where animal products provide the majority of iodine intake, such as the UK and Norway. It is essential that those following a predominantly plant-based diet are given appropriate dietary advice to ensure adequate iodine intake.
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Affiliation(s)
- Katie Nicol
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
| | - Anne P. Nugent
- Institute for Global Food Security, School of Biological Sciences, Queens University Belfast, Northern Ireland, UK
| | - Jayne V. Woodside
- Institute for Global Food Security, School of Biological Sciences, Queens University Belfast, Northern Ireland, UK
- Centre for Public Health, Queens University Belfast, Belfast, UK
| | - Kathryn H. Hart
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
| | - Sarah C. Bath
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
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Darrat M, Kayes L, Woodside JV, Mullan K, Abid N. Congenital hypothyroidism in Northern Ireland: 40 years' experience of national screening programme. Clin Endocrinol (Oxf) 2023; 99:409-416. [PMID: 37278153 DOI: 10.1111/cen.14940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/19/2023] [Accepted: 05/25/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The incidence of congenital hypothyroidism (CHT) has progressively increased in several regions around the world but has yet to be evaluated in Northern Ireland (NI). CHT screening programme was introduced in NI in 1980 and has had a relatively unchanged protocol since its inception. The purpose of the study was to evaluate the incidence of CHT in NI from 1981 to 2020 and to explore possible contributing factors to any changes seen over the 40-year period. DESIGN This was a retrospective database review of children diagnosed with CHT in NI between 1981 and 2020. Data was collected from the patients' medical (paper and electronic) records, including epidemiological, clinical, laboratory, and radiological features as well as outcomes at 3 years. RESULTS Of 800,404 new-borns who were screened for CHT in NI between January 1981 and March 2020, 471 were diagnosed with CHT. There was a steady and significant increase in incidence of CHT over time with an incidence of 26 cases per 100,000 livebirths in 1981 versus 71 cases per 100,000 in 2019 (p < .001). Of these 471, 77 new-borns (16%) were born preterm. The incidence of CHT was observed twice as much in female compared to male new-borns. Diagnostic imaging including radioisotope uptake and thyroid ultrasound scans were performed in 143 cases (30%). Of these, 101 (70%) cases had thyroid dysgenesis and 42 (30%) cases had thyroid dyshormonogenesis. There were 293 (62%) of 471 patients had confirmed permanent CHT, and 90 patients (19%) had transient CHT. Over that period at least 95% of the population were recorded as having United Kingdom/Ireland as country of birth. CONCLUSION Our findings demonstrate a nearly tripling of the CHT incidence observed over the last 40 years. This is against a background of a relatively stable population demographics. Future research should focus on the underlying cause(s) of this condition which may include changing environmental exposures in utero.
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Affiliation(s)
- Milad Darrat
- Regional centre for endocrinology and diabetes, Royal Victoria Hospital, Belfast, UK
| | - Lucy Kayes
- Regional centre for endocrinology and diabetes, Royal Victoria Hospital, Belfast, UK
- Centre for Public Health, Queen's University, Belfast, UK
| | | | - Karen Mullan
- Regional centre for endocrinology and diabetes, Royal Victoria Hospital, Belfast, UK
| | - Noina Abid
- Paediatric Endocrinology Department, Royal Belfast Hospital for Sick Children, Belfast, UK
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A review of current knowledge about the importance of iodine among women of child-bearing age and healthcare professionals. J Nutr Sci 2022; 11:e56. [PMID: 35836700 PMCID: PMC9274385 DOI: 10.1017/jns.2022.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022] Open
Abstract
Iodine is required for thyroid hormone synthesis and fetal neurogenesis. Recent population studies in the United Kingdom (UK) have found iodine deficiency among schoolgirls, women of child-bearing age and pregnant women. This review explores knowledge and awareness of iodine among women of child-bearing age and healthcare professionals (HCPs) in the UK, set within a global context. We aimed to identify gaps in iodine knowledge in the current UK setting of iodine deficiency without iodine fortification and where iodine is not included in antenatal guidelines. The search terms ‘iodine knowledge’ and ‘iodine awareness’ were used to identify relevant papers. Iodine knowledge is poor among women of child-bearing age in the UK according to four studies using questionnaires and qualitative methods. They were unsure of dietary sources of iodine and were not consistently provided with relevant information from HCPs during clinical care. Midwives have been recognised as the main providers of dietary information during pregnancy and, although they recognised the importance of their role in providing nutrition advice, they did not feel equipped to do so and lacked confidence in addressing nutritional concerns. Globally, there was a similar lack of knowledge, however, this was somewhat improved by the inclusion of iodine in antenatal care guidelines. Midwives’ knowledge of iodine was poor, as was knowledge among women of child-bearing age. Improved HCP knowledge and effective communication of information to pregnant women and women planning to conceive may help to improve iodine status which is of particular concern in pregnancy.
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Mullan K, McMullan P, Kayes L, McCance D, Hunter A, Woodside JV. Thyroglobulin levels among iodine deficient pregnant women living in Northern Ireland. Eur J Clin Nutr 2022; 76:1542-1547. [PMID: 35513447 DOI: 10.1038/s41430-022-01144-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Iodine deficiency has re-emerged among pregnant cohorts in the UK. Thyroglobulin (Tg) is a protein produced uniquely by the thyroid gland which appears to mount a U-shaped response to extremes of iodine status. Tg has been suggested as an alternative marker for chronic iodine deficiency but the value of Tg in pregnancy has not been fully elucidated. A recent non-European study suggested a median Tg ≤10 µg/L with <3% of values >44 µg/L was indicative of sufficiency in the second trimester of pregnancy. METHODS We measured serum Tg levels in each trimester in 241 pregnant women living in Northern Ireland, a population with mild iodine deficiency at all stages of pregnancy as defined by urinary iodine concentration (UIC) and iodine: creatinine ratio (ICR). Women with Tg antibodies (6% in 1st trimester) were excluded. RESULTS The median UIC in this cohort was in the deficient range at 73, 94 and 117 µg/L in sequential trimesters (adequacy ≥ 150 µg/L). Corresponding median Tg levels were 19, 16 and 16 µg/L respectively. Median Tg for all samples was 17 μg/L (IQR 11-31) suggestive of iodine deficiency. Tg was >44 μg/L in 14.3%, 9.4% and 12.4% of women in sequential trimesters respectively. Women with either UIC/ICR below the cut-offs 150 µg/L and 150 µg/g creatinine had higher Tg concentrations in 1st and 2nd trimester (p < 0.01; p < 0.001) but not in 3rd trimester. CONCLUSION This study adds to the evolving evidence that Tg measurement is of value in reflecting iodine status in pregnancy.
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Affiliation(s)
- Karen Mullan
- Royal Victoria Hospital (Regional Centre for Endocrinology and Diabetes), Belfast, Antrim, UK
| | - Paul McMullan
- Royal Victoria Hospital (Regional Centre for Endocrinology and Diabetes), Belfast, Antrim, UK
| | - Lucy Kayes
- Royal Victoria Hospital (Regional Centre for Endocrinology and Diabetes), Belfast, Antrim, UK.
| | - David McCance
- Royal Victoria Hospital (Regional Centre for Endocrinology and Diabetes), Belfast, Antrim, UK
| | - Alyson Hunter
- Royal Jubilee Maternity Hospital, Royal Victoria Hospital, Belfast, Antrim, UK
| | - Jayne V Woodside
- Centre for Public Health, Institute of Clinical Science, Queens University Belfast, Belfast, UK
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Zgliczynska M, Ostrowska M, Szymusik I, Ciebiera M, Kosinska-Kaczynska K. Maternal thyroid function in multiple pregnancies - a systematic review. Front Endocrinol (Lausanne) 2022; 13:1044655. [PMID: 36733802 PMCID: PMC9887021 DOI: 10.3389/fendo.2022.1044655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The function of the thyroid gland during pregnancy undergoes physiological changes to ensure the proper amount of thyroid hormones for both the pregnant woman and the fetus. Multiple pregnancies (MP) are characterized by specific differences compared to single pregnancies, e.g., higher concentrations of human chorionic gonadotropin, which also affect thyroid function. The aim was to collect available knowledge on maternal thyroid function in MP. METHODS We have systematically searched three databases: the PubMed/MEDLINE, Scopus and the Cochrane Library. The last search was run on the 4th of August 2022. We included full-text original observational and experimental studies written in English. Case reports, editorials, letters, conference abstracts, reviews and meta-analyses were excluded. No time criterion was established. Studies were considered eligible if at least one maternal thyroid function test was performed and reported. Studies on MP with a co-existing mole were excluded. The risk of bias was assessed with the use of the AXIS tool. The qualitative synthesis of evidence was applied. RESULTS The search strategy resulted in the identification of 821 manuscripts. After removing duplicates, we screened the titles and abstracts of 552 articles, out of which 57 were selected for full-text analysis. Finally, 12 articles were included in the review. They were conducted in 6 different countries and published between the years 1997 and 2022. The number of examined women with MP ranged from 9 to 1 626. DISCUSSION AND CONCLUSIONS Thyroid function differs between women with MP and SP. Scarce data are available on the topic, but MPs are most likely characterized by higher HCG levels, which influences thyroid-stimulating hormone and free thyroid hormone levels. These differences are mainly expressed in the 1st trimester of pregnancy. Separate population-based reference ranges are needed to correctly diagnose thyroid diseases in MP and to avoid unnecessary treatment. Further research is needed to fill the knowledge gaps.
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Affiliation(s)
- Magdalena Zgliczynska
- Department of Obstetrics, Perinatology and Neonatology, Centre of Postgraduate Medical Education, Warsaw, Poland
- *Correspondence: Magdalena Zgliczynska,
| | - Magdalena Ostrowska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Warsaw, Poland
| | - Iwona Szymusik
- Department of Obstetrics, Perinatology and Neonatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michal Ciebiera
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Katarzyna Kosinska-Kaczynska
- Department of Obstetrics, Perinatology and Neonatology, Centre of Postgraduate Medical Education, Warsaw, Poland
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Exploration of the optimal range of urinary iodine concentration in Chinese pregnant women in mildly iodine-deficient and -sufficient areas. Eur J Nutr 2021; 61:1221-1230. [PMID: 34739565 DOI: 10.1007/s00394-021-02693-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE There is some uncertainty about the optimal ranges for urinary iodine concentration (UIC) during pregnancy. This study aimed to explore associations between maternal UIC and thyroid function in iodine sufficient and mildly iodine deficient areas. METHODS It was a cross-sectional study in which 1461 healthy pregnant women were enrolled to collect their blood and urine samples during their routine antenatal care in Tianjin and Wuqiang, China. Wuqiang was a mildly iodine-deficient region, while Tianjin was iodine sufficient. UIC, free triiodothyronine (FT3), free thyroid hormone (FT4), thyroid stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TgAb), serum iodine concentration (SIC) including total serum iodine concentration (tSIC) and non-protein bound serum iodine concentration (nbSIC) were assessed during the routine antenatal care visits. RESULTS The median UIC in pregnant women was 174 (113, 249) μg/L in Tianjin and 111 (63, 167) μg/L in Wuqiang, respectively. Compared with Tianjin, UIC, FT3 and TSH were lower, and FT4, tSIC, nbSIC, rates of TPOAb and TgAb positivity and the thyroid dysfunction rate (TDR) were higher in Wuqiang (P < 0.001). FT3, FT4, tSIC and nbSIC increased during pregnancy in Tianjin with increasing UIC, while only FT3 and nbSIC increased in Wuqiang (P < 0.05). In Tianjin, the TDR increased with UIC and peaked at UIC ≥ 500 μg/L (P = 0.002), while in Wuqiang, the TDR showed a weak "U-shaped" relationship with UIC and the rate was lowest with UIC 100-149 μg/L. CONCLUSIONS In iodine-deficient areas, there was a lower TDR in pregnant women with UIC 100-149 μg/L. We suspected that the optimal UIC criteria recommended by WHO may be a little high for pregnant women in mild-to-moderate iodine-deficient countries.
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Evaluation of iodine nutritional status during pregnancy by estimated 24-h urinary iodine excretion: population variation range and individual accuracy. Public Health Nutr 2021; 25:237-247. [PMID: 34380579 PMCID: PMC8883787 DOI: 10.1017/s1368980021003335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective: To explore the accuracy of estimated 24-h urinary iodine excretion (24-h UIEest) in assessing iodine nutritional status. Design: Fasting venous blood, 24-h and spot urine samples were collected during the day. The urinary iodine concentration (UIC) and urinary creatinine concentration (UCrC) were measured, and the urinary iodine-to-creatinine ratio (UI/Cr), 24-h UIEest, and 24-h urinary iodine excretion (24-h UIE) were calculated. At the population level, correlation and consistency between UIC, UI/Cr, 24-h UIEest and 24-h UIE were assessed using correlation analysis and Bland–Altman plots. At the individual level, receiver operating characteristic (ROC) curves were used to analyse the accuracy of the above indicators for evaluating insufficient and excessive iodine intake. The reference interval of 24-h UIEest was established based on percentile values. Setting: Indicator can accurately evaluate individual iodine nutrition during pregnancy remains controversial. Participants: Pregnant women (n 788). Results: Using 24-h UIE as standard, the correlation coefficients of 24-h UIEest from different periods of the day ranged from 0·409 to 0·531, and the relative average differences ranged from 4·4 % to 10·9 %. For diagnosis of insufficient iodine intake, the area under the ROC curve of 24-h UIEest was 0·754, sensitivity and specificity were 79·6 % and 65·4 %, respectively. For diagnosis of excessive iodine intake, the area of 24-h UIEest was 0·771, sensitivity and specificity were 66·7 % and 82·0 %, respectively. The reference interval of 24-h UIEest was 58·43–597·65 μg. Conclusions: Twenty-four-hour UIEest can better indicate iodine nutritional status at a relatively large sample size in a given population of pregnant women. It can be used for early screening at the individual level to obtain more lead time for pregnant women.
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Bu Y, Yuan L, Tian C, Zhao C, Ji C, Gao X, Cai Y, Sun D, Liu Y. 24 h urinary creatinine excretion during pregnancy and its application in appropriate estimation of 24 h urinary iodine excretion. J Trace Elem Med Biol 2021; 66:126751. [PMID: 33836494 DOI: 10.1016/j.jtemb.2021.126751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/11/2021] [Accepted: 03/22/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Urinary creatinine can be used to adjust urinary iodine to evaluate iodine nutritional status during pregnancy. However, the reference intervals and impact factors of urinary creatinine are unknown. METHODS 24 h urine creatinine concentration (24 hUCr) and spot UCr at four different time periods of the day of pregnant women from Part 1 (n = 743) were measured. Linear regression analysis was performed to identify the impact factors of 24 h urinary creatinine excretion (24 hUCrE) and obtain the estimated 24 h urinary creatinine excretion (24 hUCrEest). Then measured urinary iodine concentration (UIC) of 24 h and at fasting of pregnant women from Part 2 (n = 325), used spot urinary iodine to creatinine concentration ratio (UIC/UCr) and 24 hUCrEest to calculate the estimated 24 h urinary iodine excretion (24 hUIEest), finally checked the consistency and correlation of 24 hUIEest and 24 h urinary iodine excretion (24 hUIE). RESULTS In Part 1, the median 24 hUCrE was 1.24(IQR0.98-1.76)g, and the reference interval was 0.61-2.93 g. The median 24 hUCr was 0.76 (IQR0.57-1.01)g/L, and the reference interval was 0.36-1.88 g/L. Multiple linear regression results showed that pregnancy weight was an influencing factor to 24 hUCrE after adjusting by gestational weeks, age, pre-pregnancy BMI, and percentage of body fat (F = 45.029, p<0.001). In Part 2, there was no statistically significant difference between 24 hUIEest and 24 hUIE (Z =-0.767, p = 0.443). Using 24hUIE as the gold standard, the relative average difference in 24hUIEest was 4.2 %, the relative average differences for UIC and UIC/UCr were 32.4 % and 37.2 %. The reference interval of 24 hUIE and 24 hUIEest were 88.43-585.90 μg and 50.97-700.39 μg, respectively. CONCLUSIONS The reference intervals of 24 hUCrE, spot UCr, 24 hUIE, and 24 hUIEest during pregnancy were established. 24 hUCrE has important application value in iodine nutrition evaluation to gain more lead time for pregnant women with iodine nutrition-related diseases.
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Affiliation(s)
- Ye Bu
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, National Health and Family Planning Commission & Education Bureau of Heilongjiang Province, Key Laboratory of Etiology and Epidemiology (23618504), Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, 150086 Heilongjiang, China; The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Lin Yuan
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Chunyuan Tian
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, National Health and Family Planning Commission & Education Bureau of Heilongjiang Province, Key Laboratory of Etiology and Epidemiology (23618504), Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, 150086 Heilongjiang, China.
| | - Chunyan Zhao
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Chunlei Ji
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Xiaoxu Gao
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Yan Cai
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Dianjun Sun
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, National Health and Family Planning Commission & Education Bureau of Heilongjiang Province, Key Laboratory of Etiology and Epidemiology (23618504), Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, 150086 Heilongjiang, China.
| | - Ying Liu
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, National Health and Family Planning Commission & Education Bureau of Heilongjiang Province, Key Laboratory of Etiology and Epidemiology (23618504), Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, 150086 Heilongjiang, China.
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González-Martínez S, Riestra-Fernández M, Martínez-Morillo E, Avello-Llano N, Delgado-Álvarez E, Menéndez-Torre EL. Nutritional Iodine Status in Pregnant Women from Health Area IV in Asturias (Spain): Iodised Salt Is Enough. Nutrients 2021; 13:nu13061816. [PMID: 34071767 PMCID: PMC8228027 DOI: 10.3390/nu13061816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Iodine deficiency during pregnancy may have adverse effects on the neurodevelopment of the foetus. Recent studies of pregnant women in Asturias (Spain) indicate that nutritional iodine levels are sufficient. The objective of this study was to confirm the appropriate nutritional iodine status and to analyse the influence of the ingestion of iodine on maternal urinary iodine concentration (UIC) and thyroid function. Methods: An observational study was carried out between May and June 2017 on women in the first trimester of pregnancy from Health Area IV in Asturias. The women completed a questionnaire related to their consumption of iodine and samples were taken to analyse UIC and thyroid function. Results: Three hundred and eighteen pregnant women were involved. Of these, 51.10% used iodised salt, 48.90% consumed ≥ 2 servings of dairy products daily and 87.08% took iodine supplements. The median UIC was 171.5 μg/L (116–265 μg/L) and 60.41% of women had UIC ≥ 150 μg/L. Multivariate logistic regression analysis demonstrated that iodised salt had a protective effect on UIC < 150 μg/L (odds ratio (OR) 0.404 (0.237–0.683), p = 0.001), but not iodine supplements (OR 0.512 (0.240–1.085), p = 0.080). The average level of thyroid stimulating hormone (TSH) was 2.26 ± 0.94 mIU/L; 68.40% of pregnant women taking iodine supplements had TSH < 2.5 mIU/L compared to 30.00% of those who were not taking supplements (p = 0.031). Conclusions: The pregnant women in our health area are maintaining appropriate nutritional iodine levels. The consumption of iodised salt protects against iodine deficiency; thus, iodine supplements should be taken on an individualised basis.
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Affiliation(s)
- Silvia González-Martínez
- Endocrinology and Nutrition Service, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (E.D.-Á.); (E.L.M.-T.)
- Endocrinology, Nutrition, Diabetes and Obesity Research Group (ENDO), Health Research Institute of Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Correspondence:
| | - María Riestra-Fernández
- Endocrinology, Nutrition, Diabetes and Obesity Research Group (ENDO), Health Research Institute of Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Endocrinology and Nutrition Service, Hospital Universitario de Cabueñes, 33203 Gijón, Spain
| | - Eduardo Martínez-Morillo
- Clinical Biochemistry Service, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (E.M.-M.); (N.A.-L.)
| | - Noelia Avello-Llano
- Clinical Biochemistry Service, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (E.M.-M.); (N.A.-L.)
| | - Elías Delgado-Álvarez
- Endocrinology and Nutrition Service, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (E.D.-Á.); (E.L.M.-T.)
- Endocrinology, Nutrition, Diabetes and Obesity Research Group (ENDO), Health Research Institute of Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Faculty of Medicine, University of Oviedo, 33011 Oviedo, Spain
| | - Edelmiro Luis Menéndez-Torre
- Endocrinology and Nutrition Service, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (E.D.-Á.); (E.L.M.-T.)
- Endocrinology, Nutrition, Diabetes and Obesity Research Group (ENDO), Health Research Institute of Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Faculty of Medicine, University of Oviedo, 33011 Oviedo, Spain
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Iron, iodine and vitamin D deficiencies during pregnancy: epidemiology, risk factors and developmental impacts. Proc Nutr Soc 2021; 80:290-302. [PMID: 33988109 DOI: 10.1017/s0029665121001944] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Micronutrient deficiency persists throughout the world, and although the burden is higher in low-resource settings, it is also prevalent in wealthy countries, a phenomenon termed 'hidden hunger'. Due to their high requirements for vitamins and minerals relative to their energy intake, young women and children are particularly vulnerable to hidden hunger. As they share several risk factors and impact on overlapping outcomes, we consider how deficiency of iron, iodine and vitamin D can have profound impacts on perinatal health and infant development. We review the epidemiology of these micronutrient deficiencies during pregnancy, including social, environmental and dietary risk factors. We identify the main challenges in defining nutritional status of these nutrients using validated diagnostic criteria linked with meaningful clinical outcomes. Public health strategies are urgently required to improve the overall health and nutritional status of women of reproductive age. Obesity prevention and early detection of malnutrition with standardised screening methods would detect pregnant women at increased risk of iron deficiency. Development of sensitive, individual biomarkers of iodine status is required to protect maternal health and fetal/infant brain development. Risk assessments of vitamin D requirements during pregnancy need to be revisited from the perspective of fetal and neonatal requirements. International consensus on standardised approaches to micronutrient assessment, analysis and reporting as well as sensitive, clinically validated infant and child neuro-behavioural outcomes will enable progression of useful observational and intervention studies.
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Woodside JV, Mullan KR. Iodine status in UK-An accidental public health triumph gone sour. Clin Endocrinol (Oxf) 2021; 94:692-699. [PMID: 33249610 DOI: 10.1111/cen.14368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/16/2020] [Accepted: 10/27/2020] [Indexed: 11/30/2022]
Abstract
The improvement in iodine status among the UK population from the 1930s onwards has been described as an 'accidental public health triumph' despite the lack of any iodine fortification program. However, iodine deficiency in the UK has re-emerged in vulnerable groups and is likely due to a combination of changing farming practices, dietary preferences and public health priorities. The UK is now among only a minority of European countries with no legislative framework for iodine fortification. The experience of folic acid fortification and the 28-year delay in its implementation lays bare the political difficulties of introducing any fortification program in the UK. If iodine fortification is not an imminent possibility, then it is important to explore other options: how to change farming practice especially on organic farms; encourage dairy intake; protect and expand our public health programs of milk provision for vulnerable groups and embark on education programs for women of childbearing potential and healthcare professionals. This review explores how the UK may have arrived at this juncture and how the iodine status of the nation may be improved at this time of major political and public health upheaval.
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Affiliation(s)
- Jayne V Woodside
- School of Medicine, Dentistry and Biomedical Sciences, Institute for Global Food Security, Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Karen R Mullan
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, BHSCT, Belfast, UK
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12
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Wang Z, Wu Y, Shi Z, Song J, Wang G, Xu C, Song Q, Jin W, Cui X, Wu C, Zang J, Guo C. Association of iodine-related knowledge, attitudes and behaviours with urinary iodine excretion in pregnant women with mild iodine deficiency. J Hum Nutr Diet 2020; 34:314-323. [PMID: 33210387 DOI: 10.1111/jhn.12837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Subsequent to the implementation of the universal salt iodisation policy, China has all but eliminated the iodine deficiency disorders. However, pregnant women are still experiencing mild iodine deficiency. The present study explored factors that could relate to mild iodine deficiency in pregnant women. METHODS In total, 2400 pregnant women were enrolled using a multistage, stratified, random sampling method in Shanghai. Data were collected via a standardised questionnaire. The urine samples and household cooking salt samples were collected for the detection of urinary iodine and salt iodine concentrations. RESULTS The median urinary iodine concentration (MUIC) was 148.0 μg L-1 for all participants, and 155.0 μg L-1 , 151.0 μg L-1 and 139.6 μg L-1 in the first, second and third trimesters. The MUIC in the third trimester was significantly lower than that of the first trimester (P < 0.05). The usage rates of iodised salt and qualified-iodised salt were 71.5% and 59.4%, respectively. Iodine-related knowledge score composition ratio was significantly different between the high and low UIC groups (P < 0.05). Participants' MUIC increased significantly with the increases in iodine-related knowledge score (P < 0.001). The third trimester was a significant risk factor for high UIC, whereas high iodine-related knowledge score, actively learning dietary knowledge and having a habit of consuming iodine-rich food were significant protective factors for high UIC (P < 0.05). CONCLUSIONS Iodine level is adequate among pregnant women in Shanghai during the first and the second trimesters, although it is is insufficient in the third trimester. Good iodine-related knowledge, attitudes and behaviours are important for pregnant women with respect to maintaining adequate urinary iodine.
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Affiliation(s)
- Z Wang
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Y Wu
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Z Shi
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - J Song
- Laboratory for the Determination of Biological Markers, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - G Wang
- Laboratory for the Determination of Biological Markers, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - C Xu
- Traditional Chinese Medicine Department, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Q Song
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - W Jin
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - X Cui
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - C Wu
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - J Zang
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - C Guo
- General Office, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
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13
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Iodine status of pregnant women with obesity from inner city populations in the United Kingdom. Eur J Clin Nutr 2020; 75:801-808. [PMID: 33184453 DOI: 10.1038/s41430-020-00796-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/14/2020] [Accepted: 10/26/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND/OBJECTIVES Iodine is essential for foetal neurodevelopment and growth. Requirements increase in pregnancy to support increased thyroid hormone synthesis for maternal and foetal requirements, and for foetal transfer. Iodine deficiency in pregnancy is widely reported, and obesity has been associated with sub-optimal thyroid function. We evaluated iodine status and its relation with birthweight in a secondary analysis of pregnant women with obesity from multi-ethnic inner-city settings who participated in the UK Pregnancies Better Eating and Activity trial (UPBEAT). SUBJECTS/METHODS Iodine and creatinine concentrations were evaluated in spot urine samples in the second (15+0-18+6 weeks, n = 954) trimester of pregnancy. We assessed iodine status as urinary iodine concentration (UIC) and urinary iodine-to-creatinine ratio (UI/Cr) and applied WHO/UNICEF/IGN population threshold of median UIC > 150 µg/L for iodine sufficiency. Relationships between iodine status and birthweight were determined using linear and logistic regression with appropriate adjustment, including for maternal BMI and gestational age. RESULTS Median (IQR) UIC and UI/Cr in the second trimester of pregnancy were 147 µg/L (99-257) and 97 µg/g (59-165), respectively. An UI/Cr <150 μg/g was observed in 70% of women. Compared to women with UI/Cr >150 µg/g, there was a trend for women with UI/Cr <150 µg/g to deliver infants with a lower birthweight (β = -60.0 g; 95% CI -120.9 to -1.01, P = 0.05). CONCLUSIONS Iodine status of pregnant women with obesity from this cohort of UK women was suboptimal. Lower iodine status was associated with lower birthweight.
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14
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Mullan KR, McMullan P, Hunter A, McCance DR, Smyth P, Bath SC, Rayman M, Woodside JV. Selenium status in a Northern Irish pregnant cohort with iodine deficiency. Eur J Clin Nutr 2020; 75:403-405. [PMID: 33168959 DOI: 10.1038/s41430-020-00721-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/01/2020] [Accepted: 08/04/2020] [Indexed: 01/16/2023]
Abstract
Selenium and iodine are trace elements that are maximally concentrated in the thyroid. Iodine is a substrate for thyroid hormone synthesis, while the selenoproteins protect the thyroid from the oxidative stress incurred. We measured plasma selenium concentration in 241 pregnant women in 1st trimester, previously reported to have iodine deficiency. Mean age was 30.3 years (SD 5.4), BMI 26.2 kg/m2 (SD 4.9) and 53% reported taking supplements. Median urinary iodine concentration was 73 μg/L (IQR 37-122) (WHO recommendation, ≥150 μg/L). Mean plasma selenium concentration was 75 µg/L (SD 7.7) which is below the 80-125 µg/L reported to be optimal. Four-day food diaries revealed a selenium intake of 43 µg/day (SD 15.9), also below the 55-70 µg/day reported to be optimal. This is the first report of selenium status in pregnancy on the island of Ireland. The possible combined effects of iodine and selenium deficiencies in pregnancy merit further investigation.
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Affiliation(s)
- K R Mullan
- Regional Centre for Endocrinology and Diabetes Royal Victoria Hospital, Belfast, UK.
| | - P McMullan
- Regional Centre for Endocrinology and Diabetes Royal Victoria Hospital, Belfast, UK
| | - A Hunter
- Regional Royal Maternity Hospital, Belfast, UK
| | - D R McCance
- Regional Centre for Endocrinology and Diabetes Royal Victoria Hospital, Belfast, UK
| | - P Smyth
- University College, Dublin, Ireland.,National University Ireland, Galway, Ireland
| | - S C Bath
- Department of Nutrition al Sciences, Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - M Rayman
- Department of Nutrition al Sciences, Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - J V Woodside
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Science, Queens University, Belfast, UK
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15
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Øyen J, Aadland EK, Liaset B, Fjære E, Dahl L, Madsen L. Lean-seafood intake increases urinary iodine concentrations and plasma selenium levels: a randomized controlled trial with crossover design. Eur J Nutr 2020; 60:1679-1689. [PMID: 32856189 PMCID: PMC7987597 DOI: 10.1007/s00394-020-02366-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/10/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Iodine deficiency due to insufficient nutritional intake is a public health challenge in several European countries, including Norway. Lean-seafood has a high iodine and arsenic (As) content and is a good source of selenium (Se). Evidence of a direct effect of increased intake of lean-seafood on iodine status is limited. The main aims were to determine the iodine status at baseline and to investigate possible dietary effects on urinary iodine concentration (UIC) after intervention with lean-seafood versus non-seafood. Plasma Se, and plasma and urinary As concentrations were also measured. METHODS A randomized controlled crossover study comprising two 4 weeks experimental periods with two balanced diets varied in main proteins (60% of total dietary proteins) of lean-seafood and non-seafood, separated by a 5 week washout period. RESULTS Twenty participants (7 males, 13 females) were included and the mean ± SD age was 50.6 ± 15.3 years for all participants. Fasting UIC was median (25th, 75th percentile) 70 (38, 110) and 79 (49, 94) µg/L in the lean-seafood and non-seafood intervention at baseline, respectively. UIC increased after 4 weeks of the lean-seafood intervention to 135 (110, 278) µg/L, but not after the non-seafood intervention [58 (33, 91) µg/L] (P diet-effect < 0.001). Fasting plasma Se increased in the lean-seafood intervention and decreased in the non-seafood intervention (P diet-effect = 0.001). Fasting urinary and plasma As increased in the lean-seafood intervention and was unchanged in the non-seafood intervention (P diet-effect < 0.001). CONCLUSION The participant's UIC was below the recommended median (100 µg/L) at baseline, but increased sufficiently after a 4 week intervention with lean-seafood.
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Affiliation(s)
- Jannike Øyen
- Institute of Marine Research, P.O. Box 1870 Nordnes, 5817, Bergen, Norway.
| | - Eli Kristin Aadland
- Institute of Marine Research, P.O. Box 1870 Nordnes, 5817, Bergen, Norway.,Department of Sport, Food and Natural Sciences, Western Norway University of Applied Science, Bergen, Norway
| | - Bjørn Liaset
- Institute of Marine Research, P.O. Box 1870 Nordnes, 5817, Bergen, Norway
| | - Even Fjære
- Institute of Marine Research, P.O. Box 1870 Nordnes, 5817, Bergen, Norway
| | - Lisbeth Dahl
- Institute of Marine Research, P.O. Box 1870 Nordnes, 5817, Bergen, Norway
| | - Lise Madsen
- Institute of Marine Research, P.O. Box 1870 Nordnes, 5817, Bergen, Norway.,Department of Biology, University of Copenhagen, Copenhagen, Denmark
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Azzeh F, Refaat B. Iodine adequacy in reproductive age and pregnant women living in the Western region of Saudi Arabia. BMC Pregnancy Childbirth 2020; 20:370. [PMID: 32571259 PMCID: PMC7310473 DOI: 10.1186/s12884-020-03057-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 06/16/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Despite the serious maternal and foetal complications associated with iodine deficiency during pregnancy, surveys related to pregnant women in the Kingdom of Saudi Arabia (KSA) are lacking. This study, therefore, measured urine iodine concentrations (UIC) alongside the potential socioeconomic factors contributing towards iodine inadequacy in reproductive age and pregnant Saudi women from the Western province of KSA. METHODS Spot urine samples were collected from 1222 pregnant and 400 age-matched non-pregnant/non-lactating reproductive age women. The socioeconomic characteristics were obtained through a structured questionnaire. The WHO criteria for iodine sufficiency in non-pregnant (100-199 μg/L) and pregnant (150-249 μg/L) women were applied. RESULTS The median UIC in the non-pregnant women (101.64 μg/L; IQR: 69.83-143.55) was at the lowermost WHO recommended cut-off, whereas the pregnant group was iodine deficient (112.99 μg/L; IQR: 81.01-185.57). Moreover, the median UIC was below adequacy across the different trimesters. The use of non-iodised salt significantly increased the risk of iodine deficiency in the non-pregnant (OR = 2.052; 95%CI: 1.118-3.766) and pregnant women (OR = 3.813; 95%CI: 1.992-7.297), whereas taking iodine supplements significantly lowered the risk in both groups (OR = 0.364; 95%CI: 0.172-0.771 and OR = 0.002; 95%CI: 0.001-0.005, respectively). Passive smoking was also an independent risk factor for iodine deficiency in the non-pregnant (OR = 1.818; 95%CI: 1.097-3.014) and pregnant (OR = 1.653; 95%CI: 1.043-2.618) groups. Additionally, BMI correlated independently and significantly with median UIC in the non-pregnant and pregnant populations. However, multiparity (OR = 3.091; 95%CI: 1.707-5.598) and earning below the minimum wage (2.520; 95%CI: 1.038-6.119) significantly increased the risk of iodine deficiency only in the non-pregnant women. CONCLUSIONS This study is the first to show borderline iodine sufficiency in reproductive age Saudi women from the Western province, whereas mild iodine deficiency was observed in the pregnant population and could represent a serious public health problem. This study also advocates the necessity to establish routine iodine dietary advice services by the health authorities to foster adequate iodine intake in pregnant women to avoid the perilous consequences of iodine deficiency on maternal-foetal health.
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Affiliation(s)
- Firas Azzeh
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al Abdeyah, PO Box 7607, Makkah, Saudi Arabia
| | - Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al Abdeyah, Holy Makkah, PO Box 7607, Makkah, Saudi Arabia.
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Shaw M, Nugent AP, McNulty BA, Walton J, McHugh M, Kane A, Moore Heslin A, Morrissey E, Mullan K, Woodside JV. What is the availability of iodised salt in supermarkets on the Island of Ireland? Eur J Clin Nutr 2019; 73:1636-1638. [PMID: 31624363 DOI: 10.1038/s41430-019-0518-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 11/10/2022]
Abstract
Iodine deficiency remains a global nutritional public health challenge, with evidence suggesting borderline adequate or even deficient status for UK and Irish subpopulations such as schoolgirls and pregnant women. The solution, according to the WHO, is salt iodisation, but it is not known how widely available iodised salt is in supermarkets. Iodised salt availability was determined by a shelf survey of 89 supermarket stores on the island of Ireland (n = 30 in Northern Ireland and n = 59 in the Republic of Ireland) from September 2018 to January 2019, to take into account factors such as store type, location, population density, socioeconomic status and ethnicity. Availability was calculated as the number of stores selling iodised salt as a percentage of the total. Iodised salt was only available in 11 stores (12%), of which 10 were ethnic stores. This indicates a lack of access for the majority of the Irish and Northern Irish populations.
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Affiliation(s)
- Mark Shaw
- Institute for Global Food Security, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Anne P Nugent
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Breige A McNulty
- Institute of Food and Health, School of Agriculture and Food Science, University College Dublin, Dublin, Dublin 4, Ireland
| | - Janette Walton
- Department of Biological Sciences, Cork Institute of Technology, Cork, Ireland
| | - Michaela McHugh
- Institute for Global Food Security, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Ashley Kane
- Institute for Global Food Security, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Aoibhin Moore Heslin
- Institute of Food and Health, School of Agriculture and Food Science, University College Dublin, Dublin, Dublin 4, Ireland
| | - Eoin Morrissey
- Department of Biological Sciences, Cork Institute of Technology, Cork, Ireland
| | - Karen Mullan
- Regional Centre for Endocrinology & Diabetes, Belfast Health & Social Care Trust, Belfast, UK
| | - Jayne V Woodside
- Institute for Global Food Security, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.
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