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Fulltext Iodine deficiency disorders in Sarawak, Malaysia

Kiyu A, Tambi Z, Ahmad Y

Asia Pac J Clin Nutr, 1998 Dec;7(3/4):256-61.
PMID: 24393680

The state of Sarawak in Malaysia has a high prevalence of iodine deficiency disorders (IDD). This has been revealed through a review of goitre surveys that were carried out in the State from the early 1970s to the 1990s. The primary cause was low iodine intake. Contributory factors were low iodine content in the soil and water as well as high cassava consumption. Virtual elimination of IDD is one of the nutritional goals of the IDD prevention and control programs. The strategies adopted include the iodination of coarse salt, which is sold in the market by shopkeepers and also provided free from government health clinics; legislation requiring that salt sold in IDD-gazetted areas must be iodised; and the use of iodinators to iodise water supplied by the gravity-feed system to villages and boarding schools in rural areas. The indicators used in the monitoring and evaluation of the program include the availability of iodised salt in the market and households, iodine levels in water supply that had been fitted with iodinators, goitre volume measured by ultrasound, and urinary iodine excretion among school children.

Matched MeSH terms: Iodine/deficiency
Fulltext Endemic Goitre: A preventable and yet highly prevalent disease in Sarawak

Chen PCY

Med J Malaysia, 1981 Jun;36(2):67-9.
PMID: 7343820

Comment in: Tan YK. Endemic goitre: a preventable and yet highly prevalent disease in
Sarawak. Med J Malaysia. 1982 Mar;37(1):96-7

Matched MeSH terms: Iodine/deficiency*
Measurement of thyroid volume in children using a portable ultrasound machine: a technical note

Mahmud N

Asia Pac J Public Health, 2001;13(1):36-9.
PMID: 12109259

The data on thyroid volume measurements that determines prevalence of goitre in children is very important for public health consideration as the presence of goitre in children effectively reflects the status of iodine deficiency disorders (IDD) in the general population. Ultrasound is an excellent modality to evaluate thyroid size. Local experience in using a portable ultrasound machine to measure thyroid volume is presented. The thyroid anatomy and techniques of ultrasound assessment are highlighted. Proper training of public health doctors to perform thyroid gland ultrasonography is crucial to ensure that the thyroid volume data collected would be more accurate and reliable for the planning of health programmes to eliminate IDD in the particular areas.

Matched MeSH terms: Iodine/deficiency
Does the use of mean or median Z-score of the thyroid volume indices provide a more precise description of the iodine deficiency disorder status of a population?

Foo LC, Mafauzy M

Eur. J. Endocrinol., 1999 Dec;141(6):557-60.
PMID: 10601955

Endemic iodine deficiency is largely an environmental problem affecting whole populations. Currently, thyroid volume data from a population are analyzed with the sole objective of obtaining an estimate of goitre prevalence using +97th percentile or +2 standard deviations of an appropriate reference as cut-off. This paper proposes an alternative approach to the analysis and presentation of thyroid volume data using Z-scores (standard deviation scores) of the thyroid volume indices such as thyroid volume-for-age or thyroid volume-for-body surface area. The calculation of the summary statistics of the Z-scores, such as mean or median, provides an alternative to the prevalence-based approach for expressing severity of iodine deficiency disorders (IDD). An advantage of the mean or median Z-score is that it describes the thyroid volume profile (and therefore the IDD status) of the entire population directly, unlike goitre prevalence which gives information only about the extremes of distribution. The frequency curve or histogram of the Z-scores provides a complete picture of the whole distribution. Although qualitatively similar conclusions on IDD severity can be drawn from both analytical approaches, only the Z-score system is able to capture adequately the trends or changes in thyroid size over time, and to establish whether a previously iodine-deficient community's thyroid volume profile has returned to 'normal' (as indicated by a distribution that is not significantly different from that of the reference) following intervention. As a continuous variable, Z-scores are particularly useful for the analysis of data from populations where the sample size is relatively small, or where many individuals lie outside the extreme percentiles of the reference population. In view of its advantages in the context of activities based on single and multiple measurements, the Z-score system is to be preferred for the reporting and use of thyroid volume indices. A desirable consequence of this preference is that national goals will be oriented towards an improvement of the overall thyroid volume profile of the population, rather than just a reduction of the number of individuals at the extremes.

Matched MeSH terms: Iodine/deficiency*
Iodine deficiency disorders: a public health challenge in developing countries

Ali O

Nutrition, 1995 Sep-Oct;11(5 Suppl):517-20.
PMID: 8748212

Iodine as a trace element is an essential nutrient for human growth and development. Its potential impact on manpower development in third world countries are of special concern, primarily due to iodine deficiency disorders (IDD) such as goiter, hypothyroidism, and cretinism. IDD of mild to moderate severity are still found in Malaysia. The prevalence ranges from almost zero in many developed urban areas to more than 90% in some rural parts of Malaysia, especially in Sabah and Sarawak. The endemias were associated with low urinary excretion of iodine among the population, indicating poor iodine intake and low iodine content in the environment. Water and salt iodination strategies are being planned to eradicate the disease by the year 2000.

Matched MeSH terms: Iodine/deficiency*
Fulltext Iodine deficiency disorders among pregnant women in Sarawak, Malaysia

Lim KK, Chan YY, Mahmud NA, Ismail H, Tan BC, Chua BK, et al.

Int J Public Health Res, 2018;8(2):980-986.
MyJurnal

Introduction Iodine deficiency disorders (IDD) during pregnancy may impair the neurological development of the fetus. The aim of this study is to determine the iodine status among pregnant women (PW) in Sarawak after introduction of mandatory universal salt iodisation (USI) for seven years.
Methods A total of 508 first trimester PW attending government Maternal and Child Health Care clinics in all 11 divisions in Sarawak between 1st April and 15th June 2015 were recruited. Urine samples were obtained and analysed for urinary iodine concentration (UIC) using the modified Sandell-Kolthoff reaction method. For pregnant women, an adequate iodine intake was defined as a median UIC between 150-249 µg/L according to the WHO/UNICEF/ICCIDD’s criterion. For further analyses, the 11 divisions were then combined into 3 regions, namely Northern (Miri, Bintulu, Limbang), Central (Kapit, Mukah, Sibu, Sarikei, Betong) and Southern (Kota Samarahan, Kuching, Sri Aman).
Results TThe median UIC of the PW in Sarawak was 105.6 µg/L, indicating iodine deficiency. A total of 330 (65.0%) PW had UIC<150 µg/L. In terms of urinary iodine levels by region, the median UIC in Northern, Central and Southern regions were 136.3 µg/L, 85.5 µg/L and 97.4 µg/L respectively. The differences in median UIC between regions were significant. In addition, the Northern region (p = 0.001), Malay/Melanau ethnicity (p = 0.015) and parous parity (p = 0.014) were significantly associated with higher median UIC. No significant association was found for locality, age nor gravida.
Conclusions This study indicates inadequate iodine status among PW in Sarawak despite seven years of mandatory USI. In fact, the majority of PW appear not to be protected against IDD and its consequences. In future, a comprehensive study should be carried out to determine the levels of iodine in salt at the retail outlets, villages and households in Sarawak.
Keywords Iodine deficiency disorders - Pregnant women - Mandatory USI - Sarawak

Matched MeSH terms: Iodine/deficiency*
Fulltext A Review of Published Literature Regarding Health Issues of Coastal Communities in Sabah, Malaysia

Azzeri A, Ching GH, Jaafar H, Mohd Noor MI, Razi NA, Then AY, et al.

Int J Environ Res Public Health, 2020 Feb 27;17(5).
PMID: 32120949 DOI: 10.3390/ijerph17051533

Several of the coastal zones in Sabah, Malaysia, are isolated and inaccessible. This study aimed to review the published literature on the health status of the coastal communities in Sabah. The following four main health issues were found: (i) malaria, (ii) tuberculosis (TB), (iii) seafood poisoning, and (iv) antenatal problems. Factors associated with the risk of acquiring malarial infection in the studied coastal area were advanced age, male sex, farming as an occupation, history of travel outside the village, and rainy seasons. TB infection was primarily observed in adult men. Seafood poisoning was significantly common in Sabah. Studies have reported that tetrodotoxin and paralytic shellfish poisoning were commonly reported (30-60 cases annually). Several pregnant women in the coastal community had insufficient knowledge of the national antenatal care programme. Nonetheless, 99% of them received antenatal care at public healthcare facilities with 92% of them undergoing safe delivery. Nevertheless, a majority of the pregnant women had iodine deficiency due to low iodised salt intake. Findings from this review highlighted that the coastal communities in Sabah are experiencing significant health problems. Specific attention is required to significantly enhance the health and well-being of the individuals living in the coastal communities in Sabah.

Matched MeSH terms: Iodine/deficiency
Socioeconomic correlates of iodine status among school children in Sarawak, Malaysia

Wah-Yun Low, Siti Norazah Zulkifli, Rajeswari Karuppiah

Asia Pac J Public Health, 2002;14(2):110-7.
PMID: 12862416 DOI: 10.1177/101053950201400210

Iodine deficiency is recognized as a public health problem. This paper assesses iodine status by socioeconomic factors in school children in Sarawak, East Malaysia. Kuching, Bau and Simunjan districts were chosen based on advice from the Sarawak's Medical and Health Authority. 803 school children, aged eight years, were selected from 19 schools via proportionate systematic sampling. About half the proportion of the school children were from Kuching, 24% from Simunjan and 22% from Bau. Almost all were equally distributed by sex. By mother's race, almost half were Malays, followed by Bidayuh, Iban, Chinese and other races. Mean urinary iodine concentration was 3.36 microg/ 100ml, mean creatinine level was 111.10 mg/100ml and mean creatinine/iodine ratio was 39.45 microg/ gram. Four female children (0.5%) were found to have enlarged thyroid. Urinary iodine levels were significantly different by district, mother's race and household income. It was highest in Kuching, among children with Malay mothers, and with household incomes more than RM500 per month. Conversely, it was lowest in Bau, among children of Iban/Dayak and Chinese mothers, and incomes of RM500 or less per month. Based on the WHO/UNICEF/ICCIDD classification, the Sarawak school children in the present study fall into the moderate IDD category. The low prevalence of goitre is a positive finding indicating that iodine deficiency is corrected over time.

Matched MeSH terms: Iodine/deficiency*
Local versus WHO/International Council for Control of Iodine Deficiency Disorders-recommended thyroid volume reference in the assessment of iodine deficiency disorders

Foo LC, Zulfiqar A, Nafikudin M, Fadzil MT, Asmah AS

Eur. J. Endocrinol., 1999 Jun;140(6):491-7.
PMID: 10366404

Iodine deficiency endemia is defined by the goitre prevalence and the median urinary iodine concentration in a population. Lack of local thyroid volume reference data may bring many health workers to use the European-based WHO/International Council for Control of Iodine Deficiency Disorders (ICCIDD)-recommended reference for the assessment of goitre prevalence in children in different developing countries. The present study was conducted in non-iodine-deficient areas in Malaysia to obtain local children's normative thyroid volume reference data, and to compare their usefulness with those of the WHO/ICCIDD-recommended reference for the assessment of iodine-deficiency disorders (IDD) in Malaysia.

Matched MeSH terms: Iodine/deficiency*
Thyroid volumes in a national sample of iodine-sufficient swiss school children: comparison with the World Health Organization/International Council for the control of iodine deficiency disorders normative thyroid volume criteria

Hess SY, Zimmermann MB

Eur. J. Endocrinol., 2000 Jun;142(6):599-603.
PMID: 10822222

The determination of goiter prevalence in children by thyroid ultrasound is an important tool for assessing iodine deficiency disorders. The current World Health Organization/International Council for the Control of Iodine Deficiency Disorders (WHO/ICCIDD) normative values, based on thyroid volume in iodine-sufficient European children, have recently been questioned, as thyroid volumes in iodine-sufficient children from the USA and Malaysia are smaller than the WHO/ICCIDD reference data. Our objective was to describe ultrasonographic thyroid volumes in a representative national sample of iodine-sufficient Swiss school children, and to compare these with the current reference data for thyroid volume.

Matched MeSH terms: Iodine/deficiency*
Fulltext Urinary iodine excretion in the northeast of Peninsular Malaysia

Mafauzy M, Mohamad WB, Anum MY, Musalmah M

Southeast Asian J. Trop. Med. Public Health, 1995 Mar;26(1):138-42.
PMID: 8525401

A total of 2,034 subjects aged 15 years and above from different parts of the State of Kelantan were studied to determine goiter size and urinary iodine excretion. The State was divided into 2 areas - area 1 consisting of localities in the districts near the coast and area 2 consisting of localities in the inland districts. There were 1,050 subjects in area 1 and 984 subjects in areas 2. The mean age (+/- SE) of subjects in areas 1 and 2 were 38.2 + 0.5 and 37.1 +/- 0.5 years, respectively. The prevalence of goiter was 31.4% in area 1 and 45.0% in area 2; the difference was statistically significant (p < 0.05). However, the prevalence of large and visible goiters (grades II and III) was only 2.0% in area 1 and 3.3% in area 2; the difference was not statistically significant. The mean (+/- SD) urinary iodine excretion in areas 1 and 2 was 57.1 +/- 2.1 and 56.8 +/- 2.1 micrograms I/g Cr, respectively. The values were below those recommended by WHO. There was no significant difference in urinary iodine excretion between those with and without goiters in both areas and also between the grades of goiters. There were significantly more females with goiters than males in both areas but there was no significant difference in the urinary iodine excretion between the 2 sexes. Thus based on urinary iodine excretion, the iodine intake of the population in this area, was suboptimal and this was associated with a high prevalence of goiter.

Matched MeSH terms: Iodine/deficiency
Fulltext The prevalence of endemic goitre in the Keningau Division of Sabah

Chen PC, Wong ML, Ong FP

Asia Pac J Public Health, 1989;3(1):78-81.
PMID: 2719877 DOI: 10.1177/101053958900300111

Four areas of differing remoteness were studied to determine the prevalence of goitre in the Keningau Division of Sabah. These areas were Keningau town, the Biah Resettlement Scheme, the Dalit subdistrict and the Pagalunggan subdistrict. The predominant ethnic group in these areas is the Murut. The overall endemicity of goitre for the study population was 76.5% for females aged 15 years and above. There was a significant correlation between the incidence of goitre and the remoteness of an area. The Dalit subdistrict has the highest incidence of goitre (82.6%) followed by the Pagalunggan subdistrict (77.8%), the majority of these goitre cases being classified as grade 2 (visible goitres). These were the two most remote areas in the study. In contrast, Keningau town, the least remote area has the lowest incidence of goitre (62.5%) with most of the goitres being relatively small. With regards to salt usage in the Dalit subdistrict, only 3.0% used iodised salt; 28.0% used fine salt; 3.6% used coarse salt and 65.5% used both fine and coarse salt. In the Pagalunggan subdistrict, all females used uniodised salt with 17.6% using fine salt, 20% using coarse salt and the remainder using both fine and coarse salt. As yet, there is no legislation for the iodisation of salt in Sabah. It is clear that all types of salt need to be iodised and adequately distributed to deprived areas, particularly inland areas.

Matched MeSH terms: Iodine/deficiency
Iodization of village water supply in the control of endemic iodine deficiency in rural Sarawak, Malaysia

Foo LC, Zainab T, Goh SY, Letchuman GR, Nafikudin M, Doraisingam P, et al.

Biomed Environ Sci, 1996 Sep;9(2-3):236-41.
PMID: 8886337

A simple water iodizing system, which incorporates the Venturi principle in combination with the controlled release mechanism of a silicone-sodium iodide elastomer, for the iodization of rural piped-water supply in the control of endemic iodine deficiency has been developed and its effectiveness evaluated in three Iban longhouse villages in the iodine-deficient district of Lubok Antu, Sarawak. Urines were collected for iodine assays from women aged 15-40 years before and at 6 and 12 months after the connection of the iodinating device; goiter assessment was performed on the women at the start and end of the 1-year study. Water samples were collected for iodine assays at 2-weekly intervals. In all three villages, significant and sustained increases in median urinary iodine excretions, reaching levels recommended for an iodine-sufficient population, were observed; goitre prevalences were reduced in all the villages (by 22.6% to 35.8%). The iodine levels in the water ranged from 34 micrograms/l to 212 micrograms/L. In the control village, median urinary iodine excretions remained essentially unchanged but a small increase in goiter prevalence was observed. The iodized water was well received by the villagers and no adverse effects of water iodization were observed. The system functioned unattended throughout the one year period. The cost of providing supplemental iodine via the iodizing device is approximately 60 cents (U.S.) per family per year which is affordable by either the Government or the villagers. It is concluded that the iodizing system offers a new cost-effective strategy for the control of endemic iodine deficiency in Sarawak and may have applications in other areas with similar water sources.

Matched MeSH terms: Iodine/deficiency*
Fulltext An evaluation of the effectiveness of water iodinator system to supply iodine to selected schools in Terengganu, Malaysia

Lim KK, Siti Rohana D, Zawiah A, Wan Nazaimoon WM

Trop Biomed, 2006 Dec;23(2):172-8.
PMID: 17322819 MyJurnal

This is a cross-sectional study conducted from January to September 2004 in a group of school children aged 8 -10 years old. The schools and study subjects were selected using stratified systematic sampling technique. A total of 44 schools and 1100 subjects were selected from schools with iodinator and schools without iodinator. Samples collected were spot urine and drinking water. Dietary and iodised water consumption data were obtained from interviews. A total of 931 subjects (84.6%) responded; 558 (50.7%) from schools with iodinator and 373 (33.9%) from schools without iodinator. Results showed that in more than half (53.8%) of the schools with iodinators, mean water iodine level was below 25 microg/L. The study population in Terengganu was found to be mildly iodine deficient with an overall median urine iodine concentration (uIC) of 74 microg/L. Based on WHO criteria, 4.1% with uIC <20 microg/L (severe), 19.5% with uIC between 20-49 microg/L (moderate), 49.2% with uIC between 50-99 microg/L (mild) and 27.2% was iodine sufficient with uIC >100 microg/L. Majority of the study subjects were found to have high seafood intake (> 90%) and low in goitrogen food intake. This study suggests water iodinator system may not be a suitable method of supplying iodine and an alternative is needed in order to eradicate the iodine deficiency problem seen in some parts of Malaysia.

Matched MeSH terms: Iodine/deficiency*
Fulltext Iodine status among pregnant women in rural Sabah, Malaysia

Lim KK, Chan YY, Teh CH, Ismail H, Yusof R, Muhi J, et al.

Asia Pac J Clin Nutr, 2017 8 15;26(5):861-866.
PMID: 28802296 DOI: 10.6133/apjcn.092016.06

BACKGROUND AND OBJECTIVES: In 2000, legislation on mandatory universal salt iodisation was enacted in Sabah, Malaysia, to reduce the incidence of iodine deficiency disorders among its population. To evaluate the iodine levels among pregnant women from selected rural divisions in Sabah 13 years after the enactment of the universal salt iodisation programme.
METHODS AND STUDY DESIGN: This cross-sectional study was conducted from 1 May to 30 June, 2013, in three rural divisions of Sabah (the Interior, the West Coast, and Kudat). Data regarding domestic iodised salt use and iodine-containing supplement consumption were obtained from respondents through face-to-face interviews; goitre enlargement was examined through palpation and graded according to the World Health Organization classification. Spot urine samples were also obtained to assess urinary iodine levels by using an in-house modified micromethod.
RESULTS: In total, 534 pregnant women participated. The prevalence of goitre was 1.0% (n=5), noted only in the West Coast and Kudat divisions. Although all pregnant women consumed iodised salt, overall median urinary iodine concentration was only 106 μg/L, indicating insufficient iodine intake, with nearly two-thirds of the women (60%) having a median urinary iodine concentrations of <150 μg/L.
CONCLUSIONS: Pregnant women from the rural divisions in Sabah still exhibit iodine deficiency disorder despite the mandatory universal salt iodisation programme. Iodine supplementation programmes targeting pregnant women are warranted.

Matched MeSH terms: Iodine/deficiency
Eliminating iodine deficiency in rural Sarawak, Malaysia: the relevance of water iodization

Foo LC, Mahmud N, Satgunasingam N

Am J Public Health, 1998 Apr;88(4):680-1.
PMID: 9551019
Matched MeSH terms: Iodine/deficiency*
Levels of thyroxine, TSH, thyroid volume and mental performance among Orang Asli in selected settlements in Malaysia

Osman A, Zaleha MI, Iskandar ZA, Tan TT, Ali MM, Roslan I, et al.

East Afr Med J, 1996 Apr;73(4):259-63.
PMID: 8706612

A significant difference in the levels of thyroxine (T4), thyroid stimulating hormone (TSH) and thyroid volume among settlements at various selected Orang Asli locations is reported. The levels improved according to the level of socio-economic development. No significant difference was found in mental performance by location.

Matched MeSH terms: Iodine/deficiency*
Fulltext Update on the prevalence of malnutrition among children in Asia

Khor GL

Nepal Med Coll J, 2003 Dec;5(2):113-22.
PMID: 15024783

Approximately 70.0% of the world's malnourished children live in Asia, resulting in the region having the highest concentration of childhood malnutrition. About half of the preschool children are malnourished ranging from 16.0% in the People's Republic of China to 64.0% in Bangladesh. Prevalence of stunting and underweight are high especially in South Asia where one in every two preschool children is stunted. Besides protein-energy malnutrition, Asian children also suffer from micronutrient deficiency. Iron deficiency anaemia affects 40.0-50.0% of preschool and primary school children. Nearly half of all vitamin A deficiency and xeropthalmia in the world occurs in South and Southeast Asia, with large numbers of cases in India (35.3 million), Indonesia (12.6 million) and China (11.4 million). Another major micronutrient problem in the region is iodine deficiency disorders, which result in high goiter rates as manifested in India, Pakistan and parts of Indonesia. While under-nutrition problem persists, overweight problem in children has emerged in Asia, including Taiwan, Singapore and urban China and Malaysia. The etiology of childhood malnutrition is complex involving interactions of multiple determinants that include biological, cultural and socio-economic influences. Protein-energy malnutrition and micronutrient deficiency leading to early growth failure often can be traced to poor maternal nutritional and health care before and during pregnancy, resulting in intrauterine growth retardation and children born with low birth weight. While significant progress has been achieved over the past 30 years in reducing the proportion of malnourished children in developing countries, nonetheless, malnutrition persists affecting large numbers of children. The socio-economic cost of the malnutrition burden to the individual, family and country is high resulting in lower cognitive outcomes in children and lower adult productivity. Interventions that are cost-effective and culturally appropriate for the elimination of childhood malnutrition deserve the support of all.

Matched MeSH terms: Iodine/deficiency
Effects of iodine deficiency on insulin-like growth factor-I, insulin-like growth factor-binding protein-3 levels and height attainment in malnourished children

Wan Nazaimoon WM, Osman A, Wu LL, Khalid BA

Clin Endocrinol (Oxf), 1996 Jul;45(1):79-83.
PMID: 8796142

The expression and synthesis of IGF-I and IGFBP-3 have been shown to be regulated by hormones and nutrition. We study the effects of malnutrition and iodine deficiency on these growth factors and the height attainment of a group of children.

Matched MeSH terms: Iodine/deficiency*
Fulltext Iodized salt supplementation and its effects on thyroid status amongst Orang Asli in Hulu Selangor, Malaysia

Lim KK, Wong M, Mohamud WN, Kamaruddin NA

Asia Pac J Clin Nutr, 2013;22(1):41-7.
PMID: 23353609 DOI: 10.6133/apjcn.2013.22.1.02

BACKGROUND: This research was performed to determine the prevalence of iodine deficiency disorder (IDD) and the effects of iodized salt supplementation on thyroid status amongst Orang Asli in Hulu Selangor, Malaysia.
METHODS: Study respondents were from three target groups, i.e. pre-school children (PSC), primary school-going children (SGC) and adult women. Each household was supplied with iodized salt fortified with iodate fortificant for a period of 12 months and the iodine levels in the salt ranged from 20 to 30 μg/L. Samples collected before and after 6 and 12 months of introduction to iodized salt were urine from all groups, as well as serum samples from adult women.
RESULTS: A total of 200 respondents were recruited; 58 (29.0%) PSC, 65 (32.5%) SGC and 77 (38.5%) adult women. The median urine-iodine concentration (mUIC) in all groups were of moderately low before the iodized salt intervention, but increased significantly in all study groups after 6 and 12 months of intervention. However, at the end of the study, there was an increase in severe iodine deficiency (mUIC <20 μg/L) from 7.5% to 12% and about 9% of PSC and SGC respondents had mUIC level of more than 300 μg/L while the adult women showed a significant increase in free triiodothyronine (fT3) levels.
CONCLUSION: The study demonstrated that iodized salt supplementation was able to show an improvement in iodine level amongst Orang Asli. However, an increase in severe iodine deficiency and iodine excess indicated that the iodized salt programme needs to be carefully monitored.

Matched MeSH terms: Iodine/deficiency

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