6 IDD NEWSLETTER NOVEMBER 2016 GLOBAL SCORECARD 2016

To estimate the global status of iodine nutrition, recent national and sub-national urinary iodine concentration (UIC) surveys with a population-based sampling frame are considered for inclusion. Between 2003 and 2012 (1-4), global estimates have relied on the median UIC in school-age children (SAC, 6–12 years) as a proxy for iodine status in the general population. Where sur-veys in SAC were not available, UIC data in pre-school children, adults, and other populations were also used. To take a first step towards harmonized data reporting, the 2016 estimate relies exclusively on UIC data in SAC, and the inclusion period has been restricted to 15 years (5). As most national USI programs have grown to maturity, the monitoring focus has expanded to include populations that are particularly vulnerable to the effects of iodine deficiency: women of reproductive age and pregnant women. There is growing evidence that well-imple-mented, sustainable USI programs deliver sufficient iodine to meet the needs of most population groups. In areas where USI implementation has been incomplete, monitoring the iodine status of vulnerable populations has been important in helping to identify gaps in program delivery. Although all at-risk popu-lations should be surveyed, in practice prio-ritization may have occured in some settings at the expense of monitoring in school-age children. Yet, the WHO UIC criteria (Table 1A) to estimate population iodine status have limited value when applied in groups other than SAC: without correcting for urine volume they may under- or overestimate iodine intakes in young children or adults who excrete less or more urine on average. These issues have affected how population iodine status has been reported in 2016.

Despite these changes, the decline in the number of iodine-deficient countries has continued (Figure 1). Since 2015, 19 new nationally-representative surveys in school-age children have been reported (Bangladesh, Burkina Faso, China, Ecuador, Egypt, Ethiopia, Indonesia, Japan, Panama, Paraguay, Peru, Spain, Sri Lanka, Switzerland, UK, Uruguay, Venezuela, Vietnam, and Yemen), and in many coun-tries new data are forthcoming. Yet, the more stringent inclusion cri-teria in the present update have decreased the global data coverage from over 98% of the global population in 2014 to 93% in2016. While 40 countries had no recent or eligible surveys in 2014, there are now 67.

Twenty-eight countries have not reported UIC data in children in the past 15 years. Eight of these have eligible data in other population groups (Finland, France, Iceland, Kazakhstan, Mozambique, PNG, South Korea, and Ukraine) (Table 2). Although the proportion of sub-national surveys is decrea-sing, in 2016 they cover around 27% of the world’s 6-12 years old in 20 countries. As they may misestimate the burden of iodine deficiency at the national level, these data should be interpreted with caution. Overall, the positive trend towards optimal iodine nutrition is captured despite the decline in data coverage (Figure 1).

Global Scorecard 2016: moving toward optimal global iodine status

The IGN Global Scorecard has been updated with 19 new nationally representative surveys in school-age children. Out of 127 countries with data, only 15 countries now report low iodine intake in child-ren. The new Scorecard also brings the first ever global estimate of iodine status in pregnant women.

Małgorzata Gizak Human Nutrition Laboratory, ETH Zurich and the Iodine Global Network

F IGURE 1 The number of iodine deficient WHO countries has declined between 1993 and 2016. The trend can be seen clearly despite the changes in data coverage. In 1993, the estimate is based on total goiter rates (TGR) (6), and later on urinary iodine concentration (UIC) (1-4).

200

180

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100

80

60

40

20

0

Num

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of W

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cou

ntrie

s

6266 63

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85 7

1113

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67 76 105 116

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54 4725

15

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No data

Excessive intake

Adequate intake

Insufficient intake

1993 2003 2007 2011 2015 2016

IDD NEWSLETTER NOVEMBER 2016 GLOBAL SCORECARD 2016 7

F IGURE 2 Global map of iodine nutrition in 2016 based on median urinary iodine concentration (mUIC) in school-age children

Insufficient iodine intake (mUIC <100 µg/L)

Adequate iodine intake (mUIC 100-299 µg/L)

Excess iodine intake (mUIC ≥300 µg/L)

Sub-national data

No data

Pregnant and reproductive-age womenDuring pregnancy, the daily requirement for iodine increases from 150 µg to 250 µg to account for increased renal clearance and to cover the needs of the fetus. In pregnant women, a median UIC <150 µg/L indi-cates that the iodine intake is insufficient, and a median UIC ≥500 µg/L indicates excessive intakes (Table 1B). In 2016, recent surveys in pregnant women cover a third of the world’s countries (65 out of 194 WHO member states). The iodine status of pregnant women is sufficient in 23 coun-tries, which in a majority of cases can be attributed to long-standing salt iodization programs. At the same time, the iodine intake is classified as low in 37 out of the 65 countries with available data. Surveys in women of reproductive age, where they exist, are being considered separately for inclusion in a forthcoming update.To share new country UIC data, please go to: goo.gl/vQw1TJ

AcknowledgmentsThe author would like to thank Maria Andersson, Jonathan Gorstein and all IGN Regional and National Co-ordinators for their support and providing recent UIC data.

References1. Andersson M et al. Current global iodine status and progress over the last decade towards the elimination of iodine deficien-cy. B World Health Organ. 2005; 83(7): 518-25.2. de Benoist B et al. Iodine deficiency in 2007: global progress since 2003. Food Nutr Bull. 2008; 29(3): 195-202.3. Andersson M, Karumbunathan V, Zimmermann MB. Global iodine status in 2011 and trends over the past decade. J Nutr. 2012; 142(4): 744-50.4. Gizak M, Gorstein J, Andersson M. Epidemiology of Iodine Deficiency. In: Pearce EN (ed) Iodine Deficiency Disorders and Their Elimination. Chennai: Springer; [In Press].5. WHO/UNICEF/ICCIDD. Assessment of iodine deficiency disorders and monitoring their elimination. A guide for pro-gramme managers. Geneva: WHO; 2007.6. WHO/UNICEF/ICCIDD. Global prevalence of Iodine Deficiency Disorders. Micronutrient Deficiency Information System (MDIS) Working Paper No. 1. Geneva: MDIS/WHO; 1993.

* For the current analysis, the acceptable range of median UICs in school-age children (100–299 µg/L) has been presented as a single category to indicate that, from a population health perspective, any risks associated with above-adequate iodine intakes are outweighed by the benefits gained if the population iodine intakes are in this range.

The complete Global Scorecard for 2016 and global maps for school-age children and pregnant women can now be downloaded from the IGN website www.ign.org/scorecard

TABLE 1 Epidemiological criteria for asses-ing population iodine nutrition based on median urinary iodine concentrations (mUIC): of school-age children (≥6 years) (A), and pregnant women (B), adapted from (5).

A. Median UIC (µg/L)

Iodine intake School-age children (SAC)

Insufficient <100

Adequate* 100-299

Excessive ≥300

B. Median UIC (µg/L)

Iodine intake Pregnant women (PW)

Insufficient <150

Adequate 150–249

Above requirements 250–499

Excessive ≥500

8 IDD NEWSLETTER NOVEMBER 2016 GLOBAL SCORECARD 2016

School-age children Pregnant women

Country or Median Survey Data Iodine Median Survey Data Iodineterritory UIC (µg/L) date type intake2 UIC (µg/L) date type intake2

in SAC1 in PW1

Afghanistan 171 2013 N Adequate - - - -

Albania 86 2006 N Insufficient 85 2006 N Insufficient

Angola 29 2006 S Insufficient - - - -

Argentina 123 2002-12 S Adequate 151 2004-13 S Adequate

Armenia 313 2005 N Excessive - - - -

Australia 177 2011-12 N Adequate 89 2008 S Insufficient (P)-12

Austria 111 2012 N Adequate 87 2009-11 S Insufficient

Azerbaijan 204 2007 N Adequate 196 2007 N Adequate

Bahrain 247 2012-13 N Adequate - - - -

Bangladesh 146 2011-12 N Adequate 133 2004-05 N Insufficient

Belarus 169 2006 N Adequate 224 2010 S Adequate

Belgium 113 2010-11 N Adequate 124 2010-11 N Insufficient

Benin 318 2011 N Excessive - - - -

Bhutan 183 2010 N Adequate - - - -

Bolivia 191 2005 N Adequate 261 N/A S More than adequate

Bosnia & Herzegovina 157 2005 N Adequate 157 2008 N Adequate

Brazil 277 2016 N Adequate 175 2008-09 S Adequate

Bulgaria 182 2008 N Adequate 165 2003 N Adequate

Burkina Faso 84 2014 N Insufficient 74 2014 N Insufficient

Burundi 70 2005 N Insufficient - - - -

Cambodia 236 2011 N Adequate - - - -

Cameroon 190 2002 N Adequate - - - -

Canada 174 2007-09 N Adequate 221 2009-11 S Adequate

Cabo Verde 115 2010 N Adequate - - - -

Chad 213 2003 N Adequate - - - -

Chile 252 2006 N Adequate - - - -

China 198 2014 N Adequate 155 2014 N Adequate

Colombia 415 2002 N Excessive - - - -

Costa Rica 314 2008-09 N Excessive - - - -

Cote d'Ivoire 203 2004 N Adequate - - - -

Croatia 248 2009 N Adequate 140 2009&15 S Insufficient

Cuba 176 2011-12 N Adequate - - - -

Czech Republic 163 2010 N Adequate - - - -

Denmark 145 2015 S Adequate 101 2012 S Insufficient

Dominican Republic 223 2012 N Adequate - - - -

School-age children Pregnant women

Country or Median Survey Data Iodine Median Survey Data Iodineterritory UIC (µg/L) date type intake2 UIC (µg/L) date type intake2

in SAC1 in PW1

DPR Korea 97 2009-10 N Insufficient - - - -

DR Congo 249 2007 N Adequate - - - -

Ecuador 162 2014 N Adequate - - - -

Egypt 170 2014-15 N Adequate 135 2015 N Insufficient

El Salvador 206 2012 N Adequate - - - -

Ethiopia 104 2015 N Adequate - - - -

Fiji 237 2009 S Adequate - - - -

France - - - - 65 2006-09 S Insufficient

Georgia 321 2005 N Excessive - - - -

Germany 122 2003-06 N Adequate - - - -

Ghana 130 2011 N Adequate 184 2015 N Adequate

Greece - - - - 129 2008-15 S Insufficient (P)

Guatemala 144 2005 N Adequate - - - -

Guinea 139 2003 N Adequate - - - -

Haiti 84 2004-05 N Insufficient - - - -

Honduras 356 2005 S Excessive - - - -

Hungary 228 2005 S Adequate - - - -

Iceland - - - - 180 2007-09 S Adequate

India 153 2002-11 S Adequate 153 2003-13 S Adequate

Indonesia 223 2013 N Adequate 172 2013 N Adequate

Iran 141 2007-08 N Adequate 147 2004-11 S Insufficient

Italy 83 2002-15 S Insufficient 72 2002-13 S Insufficient

Japan 262 2013-16 N Adequate 254 2002-04 S More than adequate

Jordan 203 2010 N Adequate - - - -

Kenya 118 2003-04 N Adequate - - - -

Kuwait 130 2014 N Adequate 174 2014 N Adequate

Kyrgyzstan 114 2007 N Adequate 111 2007 N Insufficient

Lao 103 2013 N Adequate - - - -

Latvia 110 2010-11 N Adequate 69 2013 N Insufficient

Lebanon 66 2013 N Insufficient - - - -

Lesotho 215 2002 N Adequate - - - -

Liberia 244 2011 N Adequate 254 2011 N More than adequate

Liechtenstein 96 2010 N Insufficient - - - -

Luxembourg 148 2002 N Adequate - - - -

Malawi 175 2009 N Adequate - - - -

TABLE 2 2016 Global Scorecard of iodine nutrition

IDD NEWSLETTER NOVEMBER 2016 GLOBAL SCORECARD 2016 9

Legend: 1 Gizak M, Gorstein J, Andersson M. Epidemiology of Iodine Deficiency. In: Pearce EN (ed) Iodine Deficiency Disorders and Their Elimination. Chennai: Springer; [In Press].2 Based on WHO epidemiological criteria in Table 1. P - Date publishedS - Sub-national dataN - Nationally-representative data

School-age children Pregnant women

Country or Median Survey Data Iodine Median Survey Data Iodineterritory UIC (µg/L) date type intake2 UIC (µg/L) date type intake2

in SAC1 in PW1

Malaysia 109 2008 N Adequate - - - -

Maldives 115 2002 N Adequate - - - -

Mali 69 2005 N Insufficient - - - -

Mauritania 179 2012 N Adequate - - - -

Mexico 297 2006-16 S Adequate 214 2008-12 S Adequate

Moldova 165 2006 N Adequate - - - -

Mongolia 171 2010 N Adequate 152 2010 N Adequate

Montenegro 174 2007 N Adequate 134 2007 N Insufficient

Morocco - - - - 31 2015 S Insufficient

Myanmar 124 2006 N Adequate - - - -

Nauru 142 2015 N Adequate - - - -

Nepal 193 2007 N Adequate 290 2015 S More than adequate

Netherlands - - - - 223 2002-06 S Adequate

New Zealand 115 2011&15 S Adequate 38 2005 N Insufficient

Nicaragua 196 2007 N Adequate - - - -

Niger 101 2015 S Adequate 82 2015 S Insufficient

Nigeria 130 2004-05 N Adequate - - - -

Norway - - - - 69 2003-04 S Insufficient

Oman 191 2014 N Adequate - - - -

Pakistan 124 2011 N Adequate 67 2002-05 S Insufficient

State of Palestine 193 2013 N Adequate - - - -

Panama 291 2015 (P) N Adequate - - - -

Papua New Guinea - - - 180 2006 (P) S Adequate

Paraguay 296 2015 N Adequate 229 N/A S Adequate

Peru 262 2009 N Adequate 275 2012-13 N More than adequate

Philippines 168 2013 N Adequate 105 2013 N Insufficient

Poland 112 2009-11 S Adequate 113 2007-08 S Insufficient

Portugal 106 2010 N Adequate 85 2005-07 N Insufficient

Qatar 341 2014 N Excessive - - - -

Romania 102 2004-05 N Adequate 68 2004 N Insufficient

Russian Federation 78 2002-04 S Insufficient 98 2012 S Insufficient

Saudi Arabia 133 2012 N Adequate - - - -

Senegal 104 2010 N Adequate 80 2010 N Insufficient

Serbia 195 2007 N Adequate 158 2007 N Adequate

School-age children Pregnant women

Country or Median Survey Data Iodine Median Survey Data Iodineterritory UIC (µg/L) date type intake2 UIC (µg/L) date type intake2

in SAC1 in PW1

Sierra Leone 158 2003 N Adequate 176 2013 N Adequate

Slovakia 183 2002 N Adequate - - - -

Slovenia 148 2002-03 N Adequate - - - -

Solomon Islands 328 2007 S Excessive - - - -

Somalia 417 2009 N Excessive - - - -

South Africa 215 2005 N Adequate 163 2012 S Adequate

South Sudan 94 2006 S Insufficient - - - -

Spain 173 2011-12 N Adequate 120 2002-11 S Insufficient

Sri Lanka 164 2010 N Adequate 113 2010 N Insufficient

Sudan 66 2006 S Insufficient - - - -

Sweden 125 2006-07 N Adequate 98 2006-07; S Insufficient 2010-12

Switzerland 137 2015 N Adequate 136 2015 N Insufficient

Tajikistan 51 2009 S Insufficient - - - -

Tanzania 204 2004 N Adequate 136 2010-11 N Insufficient

TFYR Macedonia 241 2007 N Adequate - - - -

Thailand 262 2012 N Adequate 156 2014 N Adequate

Togo 171 2005 N Adequate - - - -

Tunisia 220 2013 N Adequate - - - -

Turkey 107 2007 N Adequate 93 2006-12 S Insufficient

Turkmenistan 170 2004 N Adequate - - - -

Uganda 464 2005 N Excessive - - - -

Ukraine - - - - 13 2013 (P) S Insufficient

UAE 162 2008-09 N Adequate 147 2012 N Insufficient

United Kingdom 138 2013-14 N Adequate 99 2002-11 S Insufficient

United States 213 2009-10 N Adequate 129 2005-10 N Insufficient

Uruguay 248 2015 N Adequate - - - -

Uzbekistan 141 2005 N Adequate - - - -

Vanuatu 49 2008-09 S Insufficient - - - -

Venezuela 180 2011 N Adequate 174 2008 S Adequate

Vietnam 84 2013-14 N Insufficient 70 2009-10 S Insufficient

Yemen 122 2015 N Adequate - - - -

Zambia 245 2011 N Adequate - - - -

Zimbabwe 220 2005 S Adequate - - - -

No eligible data available for Algeria, Andorra, Antigua and Barbuda, Bahamas, Barbados, Belize, Botswana, Brunei Darussalam, Central African Republic, Comoros, Congo, Cook Islands, Cyprus, Djibouti, Dominica, Equatorial Guinea, Eritrea, Estonia, Finland, Gabon, Gambia, Grenada, Guinea-Bissau, Guyana, Iraq, Ireland, Israel, Jamaica, Kazakhstan, Kiribati, Libya, Lithuania, Madagascar, Malta, Marshall Islands, Mauritius, Micronesia, Monaco, Mozambique, Namibia, Niue, Palau, Republic of Korea, Rwanda, Saint Kitts and Nevis, Saint Lucia, St Vincent & the Grenadines, Samoa, San Marino, Sao Tome and Principe, Seychelles, Singapore, Suriname, Swaziland, Syria, Timor-Leste, Tonga, Trinidad and Tobago, Tuvalu