Synopsis Nadir Shah Final

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Synopsis : Study of effect of iodine supplementation on IDD among adolescent girls in district Gilgit

SUPERVISOR S CERTIFICATE FOR SUBMISSION OF SYNOPSIS

It is certified that Dr. Nadir Shah; MBBS (Peshawar), ROLL No. Y-571869;Registration No. 07-KGT-0535 has worked under my close supervision for development of synopsis for thesis entitled STUDY OF EFFECT OF IODINE

SUPPLEMENTATION ON IDD AMONG ADOLESCENT GIRLS IN DISTRICT

GILGIT. I have gone through the synopsis and found it satisfactory for the conduct of Research and further discussion by the experts.

Dr Arshad Mahmood UppalMBBS (Pb), MCPS (Pak), FACP (USA),

PGD-Nutrition (Pak), MSc (Pak)

House # DK 61/20, Usman Lane, Street # 1,Bilal Colony, Rawalpindi-46300

PakistanEmail: [email protected]

Dated: September 29, 2010

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TITLE:

Study of effect of iodine supplementation on IDD among adolescent girls in district

Gilgit

INTRODUCTION :

Iodine deficiency disorder (IDD) is the cause of an Ancient Scourge of mankind,

which may take him in the womb. Lest we forget, it is a story of human suffering

cretinism with its tragic and brutal impact, visible goiter and its deformities, and

above all the vast invisible, silent and life-long mental and physical impairment that

are its consequences. Fighting IDD and preventing this suffering, however, is an

inspirational story of unprecedented multidisciplinary societal effort. In terms of its

impact on humanity, IDD threatens and harms more people than many of the most

feared scourges. An estimated two billion people in 130 countries are at risk. Yet,

prevention is today well understood and achievable: regular use of the right kind of

salt, an indispensable and low-cost food for everyone (Hetzel, 2004).

This is more common in the hilly trains of the globe. So Gilgit like other mountainous

areas of the world is endemic for IDD and Hussain et al, (2009) reported the incidenceup to 70% here. The reason mainly reported is washing away of Iodine by glaciation

during the last ice age, which is reflected in low iodine contents of local foods,

notably cabbage (Clements, 1954).

Deficiency during childhood reduces somatic growth and cognitive and motor

function (Zimmermann, 2009). Hence adolescents being in rapidly growing phase fall

an easy prey to it. Adolescents are classified as early 10 to 13 years, middle 14 to 16

years and late 17 to 19 years old on biological, psychological and developmental basis

(Hendee, 1991; Kurz and Welch, 1994). Iodine deficiency in them exists as the single

most common cause of preventable mental retardation, goiter, hypothyroidism,

cretinism, deaf mutism; impaired learning capacity hence impaired school

performance, dwarfism, abortions, still births, and other congenital abnormalities

(Higdon, 2003; WHO, 1995). The main reason in Eastern Mediterranean region,

including Pakistan, is inadequate iodine intake and percentage of households with

access to iodized salt is low i.e. 47.2% (WHO, UNICEF and ICCIDD, 2007).

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Zimmermann, et al. (2008) is of the view that the iodine supplementation is the

mainstay in the prevention of IDDs. According to Foote, (2007) food fortification is

the better and tolerable alternative, which is worth practicing.

STATEMENT OF THE PROBLEM:

IDD is public health problem as its prevalence is more than 5% in the world (WHO,

1995; Ali, et al. 2009). Globally, it is estimated that 2 billion individuals have an

insufficient iodine intake, and South Asia and sub-Saharan Africa are particularly

affected. However, about 50% of Europe remains mildly iodine deficient, and iodine

intakes in other industrialized countries, including the United States and Australia,have fallen in recent years (Zimmermann, et al. 2009; Zimmermann, 2008). In

adolescents it peaks with goiter and is more common in girls. In one study of 348

Swiss adolescents the prevalence of goiter was 15% in the age range of 11-17 years

(Fleury, et al. 1999).

In India this problem was first observed in Sub-Himalayan belt and since has been

found throughout the country. Over the last 20-30 years several district level goiter

prevalence surveys in 236 districts of 29 states/UTs (of the total of 32), goiter was

endemic in 194. These surveys unearthed 2.2 million cretins. The effected were

mainly deficient in urinary iodine (Kofi Annan, 2002).

Akhtar & Ullah, (2003) observed high goiter rate of 52% and 45% in boys and girls

students of age 8-10 years in Swat; Khyber Pakhtoon Khawa province of Pakistan.

The study concludes that the area is still highly endemic to IDD and needs urgent

correction. Ali, at al. (2009) reported total goiter rate (TGR) of 22.2% in Gilgit-

Baltistan province of Pakistan, whereas in Gilgit it was 10.2%. This is sufficient to

alarm it as a public health problem.

RATIONALE OF THE STUDY:

This public health problem needs an urgent attention at all levels of healthcare. In

most countries, the best strategy to control IDD in populations is carefully monitoreduniversal salt iodization, one of the most cost-effective ways to contribute to

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economic and social development. Achieving optimal iodine intakes may minimize

the amount of thyroid dysfunction in populations (Zimmermann, 2009). Iodine (as

iodide) is widely but unevenly distributed in the earths environment. Mountainous

areas are especially deficient in it; hence the crops grown here are iodine deficient

(WHO/ICCIDD/UNICEF, 2007). Previous studies have tapped only the prevalence of

goiter in different areas of the country and mainly addressed the salt iodization as a

remedy. Though it is successful but other areas need to be effectively addressed as the

dietary habits and food fortification. For these we need to have a fresh look at the

problem and address the other facets of IDDs apart from goiter. This study will home

us on the overall improvement in the situation as a result of previous efforts and paint

a fresh picture. This study also intends to have a review of the effect of goitrogenic

foods.

SIGNIFICANCE OF STUDY:

This study will enable us to have a latest review of the situation and iodine profile of the affected population. This will also show the effects of iodization and diet

modification on the affected population.

REVIEW OF THE LITERATURE:

Gray Lussac, in 1813 discovered this essential trace element and gave it the name iode

from the Greek iodes meaning violet colored (Abraham, 2006) and the first iodized

salt was introduced in Switzerland in the province of Appenzell in 1922

(Zimmermann, 2009).

Lv, et al. (2009) conducted a study to evaluate the effectiveness of universal salt

iodization (USI) for the control of IDD in Hebei province of China since it was

implemented in 1995 and identify the problems currently encountered in the

implementation of USI and provide practical proposals for addressing these problems.

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He determined the iodine content of salt with titration method and urinary iodine by

the method of ammonium per sulfate oxidation. They found that the use of iodized salt

increased from 65.0% in 1995 to 98.0% in 1999, then decreased to 88.1% in 2005

which was below the national standard of 90%. The median urinary iodine of children

aged 8-10 years varied between 160.1g/L and 307.4g/L, which were above the

national standard. The proportion of urinary samples with iodine content above

300g/L was over 30% in 2005, implying exorbitant iodine nutrition among the

children. The goiter rate (TGR) among children aged 8-10 years dropped from 11.8%

in 1995 to 2.7% in 2005, indicating that the spread of endemic goiter was under

control. They concluded that to effectively address the problem, management and

supervision of salt market needs to be strengthened to prevent non-iodized salt from

reaching households; updating equipment and modifying techniques are also

necessary to ensure the quality of iodized salt; to clarify the causes of excessive

urinary iodine content, the various sources of iodine from the diet need to be

investigated in the future.

Sen, et al. (2010) found in a community based cross sectional descriptive study that

iodine deficiency was endemic in West Bengal, which had already been reflected in previous studies. Twenty four Northern Parganas were studied during August-

November 2005 to assess the consumption of adequately-iodized salt and to ascertain

the various factors that influence access to iodized salt. In total, 506 households

selected using the multi-stage cluster-sampling technique and all 79 retail shops from

where the study households buy salt were surveyed. The iodine content of salt was

tested by spot iodine-testing kits. Seventy-three percent of the households consumed

salt with adequate iodine content (> or = 15 ppm). Consumption of adequately-iodized

salt was lower among rural residents [prevalence ratio (PR): 0.8, 95% confidence

interval (CI) 0.7-0.9], Muslims (PR: 0.8, 95% CI 0.7-0.9), and households with

monthly per-capita income of < or = US$ 10 (PR: 0.7, 95% CI 0.6-0.8). Those who

heard and were aware of the risk of iodine-deficiency disorders and of the benefit of

iodized salt were more likely to use appropriate salt (PR: 1.2, 95% CI 1.1-1.3). Those

who were aware of the ban on non-iodized salt were more likely to consume

adequately-iodized salt (PR: 1.1, 95% CI 1.01-1.3). The iodine content was higher in

salt sold in sealed packets (PR: 2.9, 95% CI 1.8-4.8) and stored on shelves (PR: 1.6,

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OBJECTIVES OF THE STUDY:

1. To find out the prevalence of IDDs before and after six months of iodine

supplementation.

2. To estimate urinary iodine level before and after six months of iodine

supplementation.

3. To find out iodized salt consumption proportion.

HYPOTHESIS:

There is no association of iodine supplementation with prevalence of IDDs in

adolescent girls of Gilgit district.

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METHODOLOGY:

Research design: This will be a cross sectional, interventional study. The selected

population will be studied twice i.e. before and after iodine supplementation.

Study locale: District Gilgit will be the location of study and it is located at an

altitude of approximately 1500 Meters (4800 Feet) above sea level, in the North east

of Pakistan. The city had been a central point of trade and political activity as early as

1st century AD. Since then it has always been a very strategic point for the neighboring

countries. Surrounded by the massive mountains of Karakorums Gilgit is a small

valley with a ground just enough to form a small city of 500000 persons. Gilgit is thecapital of Gilgit-Baltistan province of Pakistan. Mountains of the region are known to

be the highest and greatest in number around the world. Stretch of Gilgit comes in the

rain shadow of Nanga Parbat Mountain i.e. the moon soon winds are blocked by it,

which cannot reach Gilgit, thus leaving it dry & rugged but the labor of the strong and

willing local population has even claimed the hard mountains for cultivation's. Due to

this there are beautiful green orchids of many fruits in the valley. This makes a

spectacular contrast in the green fields and ruggedness on the mountains topped withwhite snow scenery only found in the northern areas of Pakistan. Its ancient name was

Sargin, later to be known as Gilit, and it is still called Gilit or Sargin-Gilit by local

people. It was an important city on the Silk Road , along which Buddhism was spread

from South Asia to the rest of Asia . The Dards and Chinas appear in many of the old

Pauranic lists of peoples who lived in the region, then came the Hindus , but for the

last five centuries and a half they have been Muslims . They established Trakhan

dynasty and are ruling till date (Imperial Gazetteer of India; Clements, 1954; Dani,

1989).

Study Population: All the adolescent girls (age 10-19 years) will constitute the study

population.

Sampling: Multistage sampling with cluster technique will be applied, which will

include schools, colleges and general population. The total sample size in this study

will be calculated keeping in view following facts: -

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a. Significance level or power of the study will be 5%.

b. Confidence/probability level will be 95%.

c. The incidence of the disease will be taken as 10.2% (Ali, et al. 2009).

d. The formula for such cross sectional studies as described by Hanif & Ahmad,

(2005) is n= [{Z (1-/2)} 2 p (1-P)]/d 2.

e. In this study p will be 0.102.

f. And d=5 percentage points=0.05.

g. Probability level or confidence level (1-) =95%.

h. At this level Z (1-/2) =1.96.

i. So the sample size will be = {(1.96) 2 (0.102) (0.898)}/ (0.05) 2 = 140.75; to

make the figure round it will be taken as 141girls.

Exclusion criteria:

1. Non willing subjects

2. Sick girls

Inclusion criteria:

1. Adolescent girls from schools, college and general population of the Gilgit

district

Limitations:

1. Time and financial constrains for lab tests & logistics may affect the study.

2. Ill be a single person and have no sponsorships.

3. Sample units may be missing in second survey.

Delimitations:

1. Experienced & cooperative supervisor.

2. Primary data collection.

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3. First interventional study in the region

Research instruments:

1. Questionnaire for assessment of iodine salt intake

2. Clinical examination for goiter grading

3. Biochemical evaluation of iodine in urine ( standard methods as recommended

by the WHO will be used).

Ethical issues: Written approval will be taken from the concerned principal of the

school/college and from the municipal/health authorities. Subjects and their parentswill be briefed on the study, their queries will be addressed through personal

communications, teachers and public reps. Consent will be taken from the subjects

after explaining the purpose of study for the collection of urine, blood and salt

consumed in the household for iodine estimation.

Pilot study: 10 adolescent girls from school, colleges & general population will be

selected randomly and given questionnaire for filling as per instruction. They would

be examined for goiter and sample of urine would be collected in the given container

by researcher, colleague lady doctor and a staff nurse trained for the same one week

before conducting the actual survey.

Data collection: Data will be collected on the questionnaire. The process will be

repeated after the iodine supplementation.

Data analysis: Analysis will be done using SPSS latest version after consultation with

a statistician. The study deals with samples, I may find the significant differences

between the outcomes or dependent variables before and after study, which are goiter

and UI levels. Results will be compared with WHO standards for computing outcome

variables. Here paired T test (before and after iodine supplementation) will be

performed. Status of Impact indicators i.e. for UI level e.g. frequency tables,

histogram to show distribution of UI values, levels of median, percentile ranges, TGR,

age proportion for various samples and iodine supplement intake among sample

ranges will be calculated. Sample results will be subjected to chi square test to find out

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whether these results are applicable to the population or not. The p value will be

calculated and significant a value < 0.050 will be considered significant.

Expected outcomes

This study will help me assess whether lipoidal iodine supplementation given to

adolescents under study significantly reduces the TGR and enhances the UI excretion

pre and post exposure for reducing IDD in the region.

References:

Abraham, G. E. (2006). The history of iodine in medicine part 1: from discovery to

essentiality. The Original Internist, 13: 29-36, Spring 2006.

Akhtar, T., Ullah, Z. (2003). Goitre in district Swat, NWFP-Pakistan: Current

situation. Pakistan J. Med. Res. Vol. 42 No.2,

Akhtar , T., Ullah , Z., Paracha , P. I., Lutfullah , G. (2004). Impact assessment of salt

iodization on the prevalence of goiter in district Swat. Pak J Med Sci Oct -

Dec; 20(4): 303-7.

Ali, H., Siddiqui, P. Q. R., Alam, J. M., Kazmi,T. H., Mehdi, G. (2009). Severe IDD

in Pregnancy in Northern Pakistan:a Sentinel Study. IDD Newsletter, Volume

32, number 2, May (2009) p. 9.

Clement, F. W. 1954. Endemic goiter in Australia, New Zealand and Melanesia. Bull.

WHO, 10, 105

Dani, A. H. (1989). History of Northern Areas of Pakistan , p163

Fleury, Y., Melle, G., Woringer, V., Temler, E., Gaillard, R. C., and Portmann, L.

(1999). Iodine nutrition and prevalence of Goiter in the Canton of Vaud.

Schweizerische Medizinische Wochenschrift, 129: 1831-1838.

Hanif, M., Ahmad, M., & Ahmad, A. M. (2005). Biostatistics for Health Students

with manual on software application. 1 st Eds. Published by Islamic Society of

Statistical Sciences; Lahore. Pakistan. ISBN: 969-8858-008. Pp 62-67

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Hendee, W. R. (1991). Sociodemographic trends and projections in the adolescent

population. The health of adolescents. A publication of American Medical

association. Jossey-Bass Publishers, San Francisco 94104, USA. Pp 2.

Hetzel, B. S. (2004). Towards the Global Elimination of Brain Damage Due to Iodine

Deficiency. A global program for human development with a model

applicable to a variety of health, social and environmental problems by

ICCIDD. Oxford University Press. YMCA Library Building, Jai Singh Road,

New Delhi 110001

Higdon, J. (2003). An Evidence-Based Approach to Vitamins and Minerals: Health

Benefits and Intake Recommendations . 1st

Eds. New York: ThiemeMedical Publishers.

Kofi Annan. (2002). Iodine deficiency. Special message from Secretary General of the

United Nations, Annual Meeting 2002. Special supplement, February 2002.

Kurz, K. M., and Welch, J. C. (1994). The nutrition and lives of adolescents in

developing countries. Findings from the nutrition of adolescent girls research

program. ICRW. Imperial Gazetteer of India. Provincial Series: Kashmir and

Jammu , ISBN 0543917762 , Adamant, p107

Lv, S. M ., Xie, L. J ., Zhou, R. H ., Chong, Z. S ., Jia, L. H ., Jing, M. A ., Zhao, J ., Xu,

D. (2009). Control of iodine deficiency disorders following 10-year universal

salt iodization in Hebei Province of China. Biomed Environ Sci. Dec;

22(6):472-9.

Mozaffari , H., Dehghani , A., Afkhami , M., Galali , B. A., Ehrampush , M. H. (2005).

Goiter prevalence, urinary iodine excretion and household salt iodine after 10years of salt iodization in Yazd Province, Iran. Pak J Med Sci Jul - Sep; 21(3):298-

302.

Singh, V. Chritian, P. (2008). Trends in nutritional status of women and children in

India, Updates from the National Family Health Survey-3, Sight and Life

Magazine issue No 1/ (2008), p.19

WHO, (1995). Global prevalence of IDD. Micronutrient information system. MDIS

working paper No. 1. 1121 Geneva Switzerland.

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http://en.wikipedia.org/wiki/Indiahttp://en.wikipedia.org/wiki/Special:BookSources/0543917762http://en.wikipedia.org/wiki/Special:BookSources/0543917762http://www.ncbi.nlm.nih.gov/pubmed?term=%22Lv%20SM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Lv%20SM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Xie%20LJ%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Zhou%20RH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Chong%20ZS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Chong%20ZS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Jia%20LH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Jia%20LH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Jing%20MA%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Jing%20MA%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Zhao%20J%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Xu%20D%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Xu%20D%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/20337220http://www.ncbi.nlm.nih.gov/pubmed/20337220http://www.ncbi.nlm.nih.gov/pubmed/20337220http://www.ncbi.nlm.nih.gov/pubmed/20337220http://www.pakmedinet.com/author/Hassan+Mozaffarihttp://www.pakmedinet.com/author/Ali+Dehghanihttp://www.pakmedinet.com/author/Ali+Dehghanihttp://www.pakmedinet.com/author/Ali+Dehghanihttp://www.pakmedinet.com/author/Mohamad+Afkhamihttp://www.pakmedinet.com/author/Beman+Ali+Galalihttp://www.pakmedinet.com/author/Beman+Ali+Galalihttp://www.pakmedinet.com/author/Mohamad+Hassan+Ehrampushhttp://www.pakmedinet.com/PJMShttp://www.pakmedinet.com/PJMShttp://en.wikipedia.org/wiki/Indiahttp://en.wikipedia.org/wiki/Special:BookSources/0543917762http://www.ncbi.nlm.nih.gov/pubmed?term=%22Lv%20SM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Xie%20LJ%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Zhou%20RH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Chong%20ZS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Jia%20LH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Jing%20MA%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Zhao%20J%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Xu%20D%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Xu%20D%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/20337220http://www.ncbi.nlm.nih.gov/pubmed/20337220http://www.pakmedinet.com/author/Hassan+Mozaffarihttp://www.pakmedinet.com/author/Ali+Dehghanihttp://www.pakmedinet.com/author/Mohamad+Afkhamihttp://www.pakmedinet.com/author/Beman+Ali+Galalihttp://www.pakmedinet.com/author/Mohamad+Hassan+Ehrampushhttp://www.pakmedinet.com/PJMS


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WHO/ICCIDD/UNICEF, (2007). Assessment of the iodine deficiency disorders and

monitoring their elimination. World Health Organization. Geneva.

Zimmermann, M. B . (2009). Iodine deficiency. Endocr Rev. Jun; 30(4):376-408. EpubMay 21.

Zimmermann, M. B ., Jooste, P. L ., and Pandav, C. S . (2008). Iodine-deficiency

disorders. Lancet. Oct 4; 372(9645):1251-62.

Annexure 1:

Brochure for educating adolescents and their parents/teachers in Urdu.

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Annexure 2:

Consent of the adolescents under studyI am a student of Allama Iqbal Open University Islamabad. I am conducting a research

study for my MSc thesis. Your school/college/area is selected for this survey.

In this context I will be measuring your height and weight. You will be clinically

examined for assessment of micronutrient deficiency. For biochemical estimation your

urine will be required for urinary iodine estimation, may be your blood for

thyroglobulin, salt from your home for estimation of iodine in that. You will be asked

some questions about your dietary habits. I hope you are willing to participate in thisstudy. If you are willing please sign below.

Signature of the student: -

Name of the student: -

Class: -

School/college/area: -

Signature of the witness (class teacher/public rep): -

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Annexure 3:

Demographic profile

1 Identification #

2 School/college/area

3 Class

Name

Age in complete years

Address

Mother education

Mother profession

Father education

Father profession

Is iodized salt used atyour home Yes No

Why iodized salt isused in your home

Good for health Dont know

Who told you aboutiodized salt

Media Friends Healthworker

Why iodized salt isgood for health

For physicalgrowth

For mentalmaturity

Dont know

When your mother putiodized salt in food

Before cooking After cooking

How the iodized salt is put in your home

Tight containers Open containers

Which food containsiodine

Vegetables Fish Cereals

Source of drinkingwater

Bottled Purification tank Tape

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Annexure 4:

Dietary habits

Ser#

Food items No of times per One timeportion size

standardizedin g

Never Yr Month Days

/week

Day

1 Junk food

2 Fast food

3 Roti

4 Maize

5 Meat & itsproducts

6 Fish

7 Eggs

8 Pulses

9 Milk & itsproducts

10 DGLV

11 Fruits

13 Dry fruits

14 Iodized salt Yes No

Iodine rich foods

15 Haddock

16 Cod

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17 Condensedmilk

18 Trifle19 Eggs

20 Mayonnaise

21 Jaffa cakes

22 Cheddarcheese

23 Malt bread

24 Naan Bread

25 Yorkshirepudding

26 Cheese cake

27 Sea kelp

28 Seaweed

29 Sea foods

30 Fresh fish

31 Fish oils

32 Sea salt

33 Maraschinocherries

34 Rhubarb

35 Spanish

36 Broccoli

Iodine poor foods

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Fruits & vegetables that are fresh, frozen, canned or in the form of juices are all low in iodine.

37 Apples38 Grapes

39 Pears

40 Bananas

41 Berries

42 Pineapples

43 Peaches

44 Pears

45 Carrots

46 Celery

47 Cucumbers

48 Squash

49 Kale

50 Collardgreens

51 Sweeteners(jams, jelly,

honey, sugaretc)

52 Beverages

53 Nuts(almonds,walnuts,pistachios,hazelnuts,cashews and

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peanuts)

54 Oils (all)

55 Rice

56 Pasta

57 Legumes

58 Poultry

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Annexure 5:

Clinical examination

Cretinism

IQ level

Goiter grade 0 I II

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Annexure 6:

Biochemical tests

Test Reading

Urinary iodine

Salt iodine

Documents

Synopsis Nadir Shah Final