DMSc

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• ?????? ?????
• 23 ??????? 2557

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Location
Department of Medical Sciences Nonthaburi
DMSc
Regional Medical Science Centers
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WHO National Influenza Center, From
1972-present, Regional Influenza Reference
Laboratory (RIRL) in SEAR 2010 , NIH Thailand WHO
Global Influenza Surveillance Network
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?????????

• ?????????????????????????? ???????????????????????
  ???? ?? 2552
• ??????????????????????? 91 ??? ???????????????????
  ??????? 90-110 ???
• ????????????? ??????????? 60 ?????????????????????
  ????????? 150 ?????????/???? ??????????????????
  60 ???????????????????????????????????????????????
  ????????? 50

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New European recommendations on iodine intake

• The European Food Safety Authority (EFSA) has
  proposed an adequate intake (AI) level of 70-130
  µg for infants and children, 150 µg for adults
  and 200 µg for pregnant and lactating women.
• ??????? 250 µg
• An AI is the average observed daily level of
  intake by a population group (or groups) of
  apparently healthy people that is assumed to be
  adequate.
• This Scientific Opinion is now open for public
  comment, and stakeholders can give input until
  February 26, 2014.

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• ????????????

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Thyroid Hormones

• There are two biologically active thyroid
  hormones
• - tetraiodothyronine (T4 usually called
  thyroxine)
• - triiodothyronine (T3)
• Derived from modification of tyrosine.

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Thyroid Follicles
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One Major Advantage of this System

• The thyroid gland is capable of storing many
  weeks worth of thyroid hormone (coupled to
  thyroglobulin).
• If no iodine is available for this period,
  thyroid hormone secretion will be maintained.

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Actions of Thyroid Hormones

• Thyroid hormones are essential for normal growth
  of tissues, including the nervous system.
• Lack of thyroid hormone during development
  results in short stature and mental deficits
  (cretinism).
• Thyroid hormone stimulates basal metabolic rate.
• What are the specific actions of thyroid hormone
  on body systems?

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Actions of Thyroid Hormone

• Required for GH and prolactin production and
  secretion
• Required for GH action
• Increases intestinal glucose reabsorption
  (glucose transporter)
• Increases mitochondrial oxidative phosphorylation
  (ATP production)
• Increases activity of adrenal medulla
  (sympathetic glucose production)
• Induces enzyme synthesis
• Result stimulation of growth of tissues and
  increased metabolic rate. Increased heat
  production (calorigenic effect)

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Effects of Thyroid Hormone on Nutrient Sources

• Effects on protein synthesis and degradation
• increased protein synthesis at low thyroid
  hormone levels (low metabolic rate growth)
• increased protein degradation at high thyroid
  hormone levels (high metabolic rate energy)
• Effects on carbohydrates
• low doses of thyroid hormone increase glycogen
  synthesis (low metabolic rate storage of energy)
• high doses increase glycogen breakdown (high
  metabolic rate glucose production)

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Recommendations for iodine intake (µg/day) by age
or population group
Age or population groupa U.S. Institute of Medicine Age or population groupc World Health Organization
Infants 012 months b 110-130 Children 0-5 years 90
Children 1-8 years 90gt Children 6-12 years 120
Children 9-13 years 120gt
Adults 14 years 150 Adults gt12 years 150
Pregnancy 220 Pregnancy 250
Lactation 290 Lactation 250
a Recommended Daily Allowance. b Adequate Intake.
c Recommended Nutrient Intake.
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The spectrum of iodine deficiency disorders, IDD
Fetus MiscarriageStillbirthsCongenital anomaliesIncreased perinatal morbidity and mortalityEndemic cretinism
Neonate Neonatal goiterNeonatal hypothyroidismEndemic mental retardationIncreased susceptibility of the thyroid gland to nuclear radiation
Child and adolescent Goiter(Subclinical) hypothyroidismImpaired mental functionRetarded physical developmentIncreased susceptibility of the thyroid gland to nuclear radiation
Adult Goiter with its complicationsHypothyroidismImpaired mental functionSpontaneous hyperthyroidism in the elderlyIodine-induced hyperthyroidismIncreased susceptibility of the thyroid gland to nuclear radiation
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?????????????????????????????????????????????????
???????????????

• 1. ???????????
• ??????????????????????????????????? 20 ?????????
  ?????????? 40 ????????? ?????????????? 1 ????????
  (?????????????????????? ?????????????????
  ???????? 16 ?????? 2554)
• 2. ???/??????
• ??????????????????????????????????? 2 ?????????
  ?????????? 3 ???????????? 1 ????
  (?????????????????????? ???? 202, 203 ?????????
  2)
• 3.?????????????????
• ??????????????????????????????????? 2 ?????????
  ?????????? 3 ???????????? 1 ????

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?????????

1. ?????????????????????????????????????? ??????
   ????????????????? ???????????????????????????????
   ???????????????????
2. ??????????????????????????????????????????????????
   ?????????????
3. ???????????????????????????????????? ??????
   ?????????????????? ???????????????????????????????
   ?????? ?????? ?????????????????? (?????????????
   19 ?????)
4. ??????????????????????????????????????????????????
   ? ??????????????????????????????????????? ?????
   ??????????? ???????????????? ?????????????????????
   ?????????????????????????

???????????? ?????? ?????????????
??????????? Titration WHO2007. Assessment of iodine deficiency disorders and monitoring their elimination. EUSalt/AS 002-2005. LOD3.5 mg/kg
?????? ????????? ????????? ICP-MS Journal of Analytical Atomic Spectrometry, September 1998. V 13.
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??????

• ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ????? ???????????? ?????????????????????????????
  (WHO)
• ??????????????????????????????????????????????????
  ?? (DRI) ?????? ?????????????????? 1 ????
  ????????????????? 150 ????????? ????????????
  potassium iodide ????????? 60 ????????????????????
  ? ferrous fumarate 185 ????????? ???????? 400
  ????????? (Triferdine 150) ???????????????????
  (?????????????????????????????????????????)
  ???????? 1 ???? ????????????????
  ???????????????????????? 6 ?????
• ?????????????????????? ???????????????????????????
  ????? ????????????????????????????????????????????
  ????????????????????????????????
  ??????????????????????????????????????????????????
  ??????????????????????????????

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???????????
?? ????????????? ??????????? (??./????????) ?????????????? ?????????????? ??????????????
?? ????????????? ??????????? (??./????????) lt 20 ??./???????? gt 40 ??./???????? ??????
2555 77 ???????? 3 - 70.5 15 9 31.2
2556 51 4.4 -75.5 4 4 15.7
2557 82 ???????? 3 -153 5 2 8.5
??????????????????????????????????? 20 ?????????
?????????? 40 ????????? ?????????????? 1 ????????
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??????????????? 2557
???????????? ????????????? ??????????? (??./????) ?????????????? ?????????????? ??????????????
???????????? ????????????? ??????????? (??./????) lt 2 ??./???? gt 3 ??./???? ??????
????????? 48 ????? 81.4 11 8 39.6
????????? 26 ????? - 5.30 8 2 38.5
????????? 15 ????? -4.09 3 1 26.7
????????? ????????????? 12 0.40 5.73 3 1 33.3
???????????? 2 ????? 5.60 1 1
??? 103 ?????????????? 26 ???????? ??????????? 13 ???????? ?????????????? ????????????? 37.9
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2555 vs 2557
???????????? ????????????? ????????????? ?????????????? (??????) ?????????????? (??????)
???????????? ?? 2555 ?? 2557 ?? 2555 ?? 2557
????????? 43 48 35 (81.4) 19 (39.6)
????????? 44 26 26 (59.1) 10 (38.5)
????????? 20 15 13 (65) 4 (26.7)
????????? ????????????? 19 12 15 (79) 4 (33.3)
??? 126 101 89 (71) 37 (36.6)
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Neonatal TSH
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Newborn screening

• TSH gt 12.5 mU/L

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• ???????????????????????????????????????
• ????????????????????????????

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?????????????????????????????????????

• J Clin Endocrinol Metab. 2013 May98(5)1954-62.
  doi 10.1210/jc.2012-4249. Epub 2013 Apr 30.
• Mild iodine deficiency during pregnancy is
  associated with reduced educational outcomes in
  the offspring 9-year follow-up of the
  gestational iodine cohort.
• Hynes KL, Otahal P, Hay I, Burgess JR
• CONCLUSIONS
• This study provides preliminary evidence that
  even mild iodine deficiency during pregnancy can
  have long-term adverse impacts on fetal
  neurocognition that are not ameliorated by iodine
  sufficiency during childhood.
• ???????????????????????????????????????????????
  ??????????????????????????????????
  ?????????????????????????????????????????

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WHO/UNICEFF/ICCIDD criteria for assessing
population iodine status using population median
urinary iodine concentration
Iodine Status General Population (mg/L) Pregnant and lactating women (mg/L) School children 6 years old (mg/L)
Excessive 300 500 300
Above requirements 200-299 250-499 200-299
Iodine Sufficient 100-199 150-249 100-199
Mild Iodine Deficiency 50-99 lt150 50-99
Moderate Iodine Deficiency 20-49 lt20-49 20-49
Severe Iodine Deficiency lt20 lt20 lt20
The term excessive means in excess of the
amount required to prevent and control
iodine deficiency. Values in this table are
sourced from WHO/UNICEF/ICCIDD (2007a)
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??????? 2554 2554 2554 2554 2555 2555 2555 2555
??????? ????????????? median lt150 µg/L lt150 µg/L ????????????? median lt150 µg/L lt150 µg/L
??????? ????????????? median ????? ?????? ????????????? median ????? ??????
?????????? 392 205.8 131 33.4 216 76.4 160 74.1
???????? 298 127.4 175 58.7 298 80 225 75.5
??????? 294 103.8 205 69.7 241 86.6 178 73.9
?????? 241 94.4 176 73 251 87.9 188 74.9
??? 296 101.5 215 72.6 304 90.9 225 74
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?????????????????????????????????????????????????
???????

• ?????????????????????????? (median urine iodine)
• ????????????????????????????????????? (population
  based)
• ??????????????????????????????????????????????????
  ?????? ???????????????????????????????????????????
  ???????????????????

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???????????? (Secondary indicator)

• lt 3 frequency of Nonatal TSH values gt 5
  mlU/l (whole blood)
• ??????????? 11.25 mU/L (serum)

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???????????????????????????????????

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• ????
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????????????

• ?????????????????????????????????????????????????
  ????????????????????????????? ??????????????????
  ??? ???????????????????????????
  ??????????????????????? 3 ????? ???????????????
  ??????????????????????????????????????????????????
  ?????????? ???????

?????????????????????? ????????????? 3rd party
?????????????????????????????????????????????????
?????????
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????????????????

• ???????????? spot urine ??????????????????????????
  ??????????????????????????????????????????????????
  ????????????????? ???????????????????????????????
  ?????????????????? 10 ???? ?????????????????????
  30 ??? ??? 300 ????????
• ???????????????????? 10 ???? ??????????????????
  300 ????????
• ?????????????? ???????????????????????????????????
  ????????????? ??????????????????????????
  ????????????

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