-

Supervised by Dr. Al Anoud Al-Thani

Prepared ByProf. Izzeldin HusseinDr. Walaa Fattah Al-ChetachiMr. Shamseldin Ali KhalifaMr. Rami YassoubMr. Benjamin Vinodson Poovelil

Foreword from the Minister of Public Health

The past two years have witnessed an array of demographic and economic changes in the State of Qatar, in part due to a fluctuating hydrocarbon economy, but more importantly as a result of the country’s steadfast commitment to achieve its nationally set vision and aspirations to realize a knowledge-based economy. Despite these changes and fluctuating financial resources, our efforts remain steadfast to achieving a world-class healthcare system equipped with the capacities to not only treat disease, but prevent the initiation and pervasiveness of infirmity amongst the country’s entire population as well.

Our ongoing endeavors come at a time when we are concluding the first phase of our National Health Strategy 2011 – 2016 and transitioning to a new stage of plans and developments to continue fulfilling the State of Qatar’s commended health goals and objectives. Amongst these developments will be the emphasis of community assessments and needs-based approaches to concentrate our strengths and resources on the country’s most demanding health matters.

By following this comprehensive methodology to identify persistent disease risk factors, we will be reaching out to all segments of the population in all their settings of work and rest. This further allows us to target the most affected persons, in the hope of building their capacities to manage their own health by promoting the uptake of basic health recommendations in the most mundane activities, including the purchasing and preparation of food products.

This is not the country' s first assessment of iodine deficiency. However, significant progress has been made since the State of Qatar' s last iodine deficiency assessment to advance and maintain the health of our country' s residents and nationals. This survey is evidence of the exemplary progress and health achievements made, revealing the State of Qatar to be free of Iodine Deficiency Disorders ( IDD). The assessment is the result of months of data collection and analysis, along with deliberations and collaboration amongst the State of Qatar’s Ministry of Public Health (MoPH) and Ministry of Education and Higher Education (MEHE), the International Council for Control of Iodine Deficiency Disorders (ICCIDD) Global Network and the World Health Organization (WHO). The reach of the survey was not limited by the boundaries of the school premises. It extended to include the households of the participating students in the aim of fostering community involvement and self-management of health, while determining the consumption and impact of iodide-fortified salts as the principle means to ensure adequate iodine levels in the population.

I

The following report elaborates on the above endeavors and concludes that the State of Qatar is free of IDD.

Aside from influencing public health policy-making, the report provides a set of recommendations for attaining optimal iodine intake levels at the community-wide level. Achieving these recommendations requires nothing less than a multisectoral, multidisciplinary approach.

From that aspect, I call on involved stakeholders to reflect on the findings and recommendations of this survey and identify solutions and best practices on how we, as a health authority, the government as a whole, and public health professionals at large can pursue health promoting decisions and activities that emphasize community engagement in matters, such as maintaining the recommended levels of iodine intake. Following such an undertaking serves as a strong means to address the most imminent public health concerns from a preventive and collaborative approach, and through it, we can work to ensure the development of effective and sustainable health solutions for the people of the State of Qatar.

Her ExcellencyDr. Hanan Al Kuwari

Minister of Public Health

II

Foreword from the Director of Public Health

The current regional and global economic constraints and capricious health demands of a highly unstable population in the State of Qatar, due to the constant movement of the working expatriate population, require public health initiatives that are capable of regularly assessing community needs and designing tailored health promotion programs and projects accordingly.

In fulfillment of this understanding and principle, the public health department at the Ministry of Public Health (MoPH) has been implementing surveys and research projects to accurately and regularly identify the prevalence and causes of disease risk factors, such as, yet not limited to, improper nutrition and dietary habits. Major advancements in this regard were realized after the launching of the State of Qatar’s National Nutrition and Physical Activity Project as part of the National Health Strategy 2011 – 2016.

Since its establishment, the project has implemented various studies in collaboration with regional and international bodies in its attempts to develop effective and tailored health promotion programs that cover the largest portions of society. One of the project’s most recent successes has been the implementation of an IDD survey. Although the survey’sprinciple target included children ages 6 to 12 at the State of Qatar’s independentschools, its methodology expanded to include obtaining samples of household salt products for examining their iodine fortification levels. This, along with a series of physic-al and laboratory examinations carried out on the participating students, allowed us toidentify where we stand, what actions need to be taken based on the survey’s findings,and the stakeholders that would need to be involved to ensure the success of such actions.

The elimination of IDD is considered a critical developmental issue, and therefore, it has been given top priority by governments and international agencies. Accordingly, the conduction of prevalence surveys is essential for the prevention of iodine deficiency and related IDD, especially as the associated public health measures are considered to be amongst the simplest and least expensive nutrition enhancing initiatives. Solutions simply entail the addition of a small and constant amount of iodine to commercial salt products. In recognition of the importance of preventing IDD, in 1991, the World Health Assembly (WHA) adopted the goal of eliminating iodine deficiency worldwide. More recently, in 2005, WHA called on all national governments to report on their iodine status every three years as a means to periodically measure the population iodine levels.

III

In consideration of the above public health significance o f iodine levels and in response and adherence to the WHA resolutions, the State of Qatar has taken several steps in the past

to assess the salt iodization and IDD levels in the country. The origins and drive behind the

current survey go back to December 8 and 9, 2010, when the State of Qatar hosted a two-

day workshop on the sustainable elimination of IDD in partnership with the International

Council for Control of Iodine Deficiency Disorders (ICCIDD) Global Network and the

World Health Organization Eastern Mediterranean Regional Office (WHO-EMRO). The

workshop marked the beginning of the State of Qatar’s efforts to promote and achieve

Universal Salt Iodization (USI) and an IDD free status. Following the workshop and

also in response to WHA’s resolutions and the recommendations of the Gulf Cooperation

Council (GCC) Health Ministers’ Executive Board and the Gulf Nutrition Committee, plans

were put in place to conduct a national survey aimed at evaluating the intake and status of

iodine among schoolchildren in the State of Qatar.

The survey was implemented in March 2014 under the lead of the MoPH and in collaboration

with the Ministry of Education and Higher Education (MEHE). Technical assistance was

provided by the ICCIDD Global Network and WHO, in particular, the Nutrition Department

at WHO-EMRO.

The IDD survey has provided essential data on the situation of USI and IDD prevalence in the

country. As a result, it is anticipated to contribute to establishing an effective system for the

sustainable elimination of IDD in the State of Qatar.

Completion of the iodine deficiency survey marks another milestone in the public health

department’s agenda to systematically develop a national health surveillance system capable

of providing representative and timely population data.

The conduction of the survey has also served as a vehicle for enhancing internal capacities

within the public health department. This comes at a time when the department is in the

stages of building on the development of a Public Health Strategy that holds improved

community health activities as one of its main objectives.

Shk. Dr. Mohammed Bin Hamad AL-Thani Director of Public Health Ministry of Public Health

IV

Contributing Authors and Investigators

Ministry of Public Health, Public

Dr. Al-Anoud Bint Mohamed Al-Thani -

Dr. Walaa Fattah Al- Chetachi - Supervisor,

Dr. Badria Al-Malki - Public Health Specialist

Dr. Ahmed Omar Haj Bakri - Supervisor,

Mr. Shamseldin Ali Khalifa - Acting Head

Mr. Benjamin Vinodson Poovelil -

Mr. Rami Yassoub - Supervisor, Health

Ministry of Education and Higher

Dr. Abdelaziz Al- Saadi - Director, Policy

Ms. Latifa Mohammed Ali - First Policies Analysis Researcher, Policy Analysis and

Ms. Layla Ahmad Al-Sulati - Secretarial

ICCIDD Global Network and World Health Organization

Prof. Izzeldin Hussein - ICCIDD Global Network Regional Coordinator for the Gulf and Eastern Mediterranean Region; Research Coordinator at the Lipidomics and Human Nutrition Research Centre in London Metropolitan University

Prof. Michael Zimmermann - ICCIDD Global Network Executive Director; Department of Health Sciences and Technology at the Swiss Federal Institute of Technology (ETH) in Zürich, Switzerland

Prof. Maria Anderson - Department of Health Sciences and Technology at the Swiss Federal Institute of Technology (ETH) in Zürich, Switzerland

Dr. Salah Elbadawi - ICCIDD Global Network/ National Coordinator, Ministry of Health, United Arab Emirates

Dr. Abdulrahim Mutwakel - Gizan Medical School, Kingdom of Saudi Arabia (KSA)

Mr. Saleh Al Shamakhi - Nutrition and Statistical Department, Ministry of Health, Oman

Dr. Ayoub Al Jawaldeh - Nutrition Regional Adviser to WHO-EMRO

Manager Health Promotion and Non-

Cardiovascular diseases, Diabetes, Nutrition

of Health Intelligence and Information

Health Intelligence Unit

Information and Data Collection

and Analysis and Research Office

Specialist, Policy Analysis and Research

Research Office

Office

Education Health Department

Communicable Diseases Division

and Blindness Prevention Unit

Section

Biostatistician

V

The preparations for and implementation of the Iodine Deficiency Disorders (IDD)

survey/ assessment, along with the development of this report, required the concerted

efforts and technical input of a group of experts and public health professionals from

different local, regional and international organizations. We take the opportunity to

express our gratitude to the different persons and organizations whom are recognized

for their support at the level of different stages in the survey’s implementation. Special

acknowledgment and full recognition is given to Dr. Mohammed Bin Hamad Al-Thani,

Director of Public Health at the Ministry of Public Health (MoPH), for his ongoing

guidance and supervision that ensured the successful completion of the assessment.

Moreover, this survey would not have been possible without the firm commitment and

logistical support of our main partner, the State of Qatar’s Ministry of Education and

Higher Education.

Additionally, the World Health Organization’s Eastern Mediterranean Regional Office, through the International Council for Control of Iodine Deficiency Disorders Global Network, provided the technical assistance necessary for the development and implementation of the survey by way of making available to MoPH facilitators that helped in the organization and supervision of the survey’s design and field activities. For their contribution and efforts, we convey our sincere appreciation. The survey’s national team, consisting of members from MoPH’s Public Health Department, also provided tremendous efforts at the levels of survey design and data collection.

This acknowledgement cannot be concluded without expressing our sincere appreciation to the survey’s field team members that were involved in the extensive data collection activities. The field team diligently coordinated amongst the participating schools and the schoolchildren themselves, along with their parents, the school principals, teachers and nurses that, in turn, supported and satisfied the survey’s core information needs; to each of them we extend our gratitude and appreciation. This national IDD assessment would not have been possible without their vital contribution.

We strongly hope that the indispensable efforts of the above persons and organizations and the survey’s results prove fruitful by helping to draw a national strategy for maintaining an IDD free status within the State of Qatar.

Acknowledgements

VI

Table of Contents

I

III

V

VI

IX

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2

3

4

6

7

7

8

9

10

10

11

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Foreword from the Minister of Public Health

Foreword from the Director of Public Health

Contributing Authors and Investigators

Acknowledgements

EXECUTIVE SUMMARY

1.0 INTRODUCTION

2.0 IODINE DEFICIENCY DISORDERS (IDD)..

2.1 Iodine Requirements

2.2 Epidemiological Criteria for Assessing Iodine Nutrition

2.3 Iodine Supplementation

2.4 Biological Features of Urinary Iodine

2.5 Forms of Iodine Fortification

3.0 STATE OF QATAR NATIONAL IODINE DEFICIENCY DISORDERS SURVEY

3.1 Survey Aim and Objectives

3.2 Materials and Methods

3.2.1 Preliminary Preparations

3.2.2 Study Settings

3.2.3 Sample Size and Sampling

3.2.4 Personnel Training

3.2.5 Data Collection Tools

3.2.6 Data Collection Process and Duration

3.2.7 Salt Sample Analysis

3.2.8 Data Management and Cleaning

3.2.9 Statistical Analysis

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19

193.3 Ethical Considerations

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VII

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25

31

32

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4.0 RESULTS

4.1 Description of the Study Sample

4.2 Total Goiter Prevalence

4.3 Urinary Iodine Concentrations

4.4 Household Salt Sample

4.5 Knowledge, Attitudes and Practices towards Iodized Salt

5.0 DISCUSSION

5.1 Excessive Urinary Iodine Concentration

5.2 Household Use of Iodized Salt in the State of Qatar

5.3 Knowledge, Attitudes and Practices

6.0 CONCLUSION

7.0 RECOMMENDATIONS

REFERENCES

ANNEXES

Annex I

Annex II

Annex III

Annex IV

Annex

26

V

34

35

38

39

42

44

46

47

VIII

IX

EXECUTIVE SUMMARY

11

Iodine is a vital nutrient for thyroid hormone synthesis and optimal fetal brain development during pregnancy and early childhood.

Globally, iodine deficiency is considered one of the most prevalent micronutrient deficiencies and the main cause of potentially preventable mental retardation during childhood. It is also the cause of a spectrum of other morbidities referred to as iodine deficiency disorders (IDD). Salt iodization is recommended to prevent and treat many of these disorders; however, excessive iodine intake may give rise to yet another health complication known as iodine-induced hyperthyroidism (IIH). Fortunately, this can be prevented through ongoing and careful monitoring of the iodization levels of food products. Therefore, a periodic measurement of the population iodine status is important to ensure the absence of both deficient and excess iodine levels.

The World Health Assembly has advised national governments to report on their iodine status every three years. Consistent with this recommendation, and in reason of the aforementioned factors, the State of Qatar conducted a national survey in 2014 to evaluate iodine intake and its levels among schoolchildren (an age group that is vulnerable to IDD and suitable for determining the population iodine status). To ensure a consistent methodology in data collection, processing and analysis for later national, regional, and international comparisons in IDD rates, the survey tools were developed by the International Council for Control of Iodine Deficiency Disorders (ICCIDD) Global Network.

In total, 1020 schoolchildren agreed to participate in the survey, yielding a response rate of 85.4%. Data on the socio-demographic characteristics of students were collected, and information on the knowledge, attitudes and practices of the participating children and their parents towards iodized salt was obtained with the use of a specially designed questionnaire. Students’ height and weight were measured using standard anthropometric techniques. Samples of the salt used in households were also collected.

The overall assessment of the iodine status by the survey relied on indicators

recommended by WHO/UNICEF/ICCIDD*. Accordingly, the urinary iodine

concentration (UIC) and iodine content of household salt were considered as the

objective markers of iodine status and intake, respectively. Moreover, urinary

iodine excretion was analyzed by following the ammonium persulfate method, while titration

*WHO: World Health Organization

*UNICEF: United Nations International Children’s Emergency Fund

X

and rapid test kits (RTK) were used for household salt analyses. In adherence to the stated methods, the urine samples of the surveyed school children were collected from 967 participants ages 6 to 12 years, yielding a another response rate of 95% (out of the participating 1020 schoolchildren). Another, second (repeat), urine sample was collected from a random sub-sample of 288 students on the subsequent days of the first urine sample collection to measure the UIC and assess for habitual iodine intake.

Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, while means, medians and standard deviations presented quantitative variable data and results.

The median UIC of the involved schoolchildren was determined to be 333.2µg/l. This value falls in the “excessive intake” category (the recommended optimal range is 100–199 µg/l according to the WHO/UNICEF/ICCIDD UIC assessment criteria). However, the repeat sample collected on the following days for the purposes of determining an “adjusted distribution” showed that the habitual iodine intake of schoolchildren in the State of Qatar fell within the recommended range. The results also showed that 74.9% of households are using adequately iodized salt and 56.7 % of students consume fish at least once weekly.

In conclusion, iodine intake amongst schoolchildren in the State of Qatar falls above the recommended range. Therefore, national efforts are needed to bring iodine intake and concentration levels within the cut-off value for the concerned survey population’s age group. This could potentially be achieved by reducing the daily salt intake at the population level and/or revising the salt iodine content specification. In addition to determining the iodine intake and concentration levels and the prevalence of IDD in the State of Qatar, this initiative will contribute to ongoing efforts aimed at developing a national and sustainable IDD elimination strategy. Within this strategy lies the urgent need to establish a surveillance system for the continuous monitoring of iodine content and salt intake at the population level in the State of Qatar.

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1

Iodine deficiency is a major worldwide public health concern, constituting a threat to the social and economic development of all countries. The most devastating outcomes of iodine deficiency are increased perinatal mortality and mental retardation. It results mainly from a low dietary supply of iodine, the leading cause of preventable brain damage. This has been the primary and motivating force behind the current, worldwide drive for its elimination (WHO, UNICEF & ICCIDD, 2007).

Salt is the most commonly used means/medium for iodization, mostly because of its low-cost and widespread availability. Salt iodization is also relatively easy to implement, regulate and monitor. Although it was first introduced in 1920 in the United States (Marine & Kimball, 1920) and Switzerland (Bürgi, Supersaxo & Selz, 1990), the global expansion of this strategy did not take place until the 1990s when the World Health Assembly (WHA) adopted universal salt iodization (USI) (i.e. the iodization of all salt for human and livestock consumption) as the main strategy to eliminate iodine deficiency disorders (IDD) (WHO, 2001). Currently, the World Health Organization (WHO) recommends adding 20 - 40 milligrams of iodine per kilogram of salt in order to meet the required iodine amounts, assuming that the average consumption of salt per capita is 10 grams/day (WHO, UNICEF & ICCIDD, 1996).

In May 2005, the WHA enacted resolution (WHA 58.24), “Sustaining the elimination of iodine deficiency disorders”, thus renewing efforts to eradicate IDD and requiring governments to submit national progress reports to the WHO triennially (WHO, 2005). Following this, during WHA’s 60th session, WHO adopted the WHA resolution (WHA 60.21) regarding iodine deficiency (WHA, 2007). All assembly delegates have taken note of the progress report on the elimination of IDD and have welcomed the progress made under WHO Resolution 60.21. Presently, USI remains the preferred strategy for WHO to control IDD (UNICEF, 2012). As such, countries are called on to continuously recognize the importance of iodized salt in preventing IDD, while they work on reducing total salt intake in the population as a measure to reduce population blood pressure. All the more, the International Council for Control of Iodine Deficiency Disorders (ICCIDD) Global Network will continue to promote collaboration across the public and private sectors to accelerate IDD elimination.

INTRODUCTION 1.0

13

2

IDD has long been a worldwide health burden, ranking 77 amongst the global leading causes of death in 1990, thus contributing to 0.1% of the total disability adjusted life years lost (DALYs) (Murray & Lopez, 1996). When iodine requirements are not met, the resulting iodine deficiency causes hypothyroidism and a number of other physiological and growth complications grouped under the term IDD (WHO, UNICEF & ICCIDD, 2007). The spectrum of IDD that was adapted from Hetzel (1983) is represented in (Table 1).

IODINE DEFICIENCY DISORDERS (IDD) 2.0

Table 1: Spectrum of iodine deficiency disorders

Physiological Groups Health Consequences of Iodine Deficiency

All ages GoiterHypothyroidism

Increased susceptibility to nuclear radiation

Fetus

Spontaneous abortionStillbirthCongenital anomaliesPerinatal mortality

Neonate

Endemic cretinism including mental deficiency with a mixture ofmutism

Spastic diplegia, squinting, hypothyroidism and short statureInfant mortality

Child and adolescentImpaired mental functionDelayed physical developmentIodine-induced hyperthyroidism (IIH)

AdultsImpaired mental functionIodine-induced hyperthyroidism (IIH)

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3

Iodine Requirements 2.1

Adequate iodine is required for thyroid hormone synthesis. In turn, thyroid hormones ensure regular “neuronal migration, myelination, synaptic transmission and plasticity during fetal and early post-natal life”. Fetal hypothyroidism, due to iodine deficiency, can result in permanent neurocognitive impairment (Hetzel, Dunn & Stanbury, 1987).

Prevention and control efforts aim primarily at ensuring adequate iodine intake in order to maintain normal thyroid function. Increased iodine intake can be achieved through iodine supplementation and/or food fortification.

Iodine requirements not only differ depending on age, but for women, pregnancy and, more specifically, the stage of pregnancy also affects the needed iodine levels. Physiologic and metabolic changes increase the average maternal iodine requirement during pregnancy, as compared to pre-pregnancy, for three reasons. First, there is the increase of approximately 50% in maternal thyroxin (T4) production to maintain maternal euthyroidism and transfer the thyroid hormone to the fetus early in the first trimester, before the fetal thyroid becomes functional. Second, is the needed transfer of iodine to the fetus, particularly in the later stages of gestation, and, lastly, the increase in renal iodine clearance during pregnancy also increases women’s iodine requirements (WHO, UNICEF & ICCIDD, 2007).

If iodine deficiency occurs during the critical period of brain development, from fetal life up to the third month after birth, the resulting thyroid failure will lead to irreversible alterations in brain function. Under severe conditions, iodine deficiency may be responsible for an average Intelligence Quotient (IQ) loss of 13.5 points among children (Bleichrodt & Born, 1994).As such, in 2007, the WHO, the United Nations International Children’s Emergency Fund (UNICEF) and the ICCIDD Global Network developed guidelines that included indicators for assessing iodine nutrition based on urinary iodine concentration (UIC), amongst other indicators and measures, as is shown in the below tables (Tables 2-6).

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4

Epidemiological Criteria for Assessing Iodine Nutrition

In areas where IDD affects the entire population, a school-based sampling technique is recommended. In such a situation, UIC is considered as the most efficient and practical approach to monitor IDD (Andersson, Takkouche, Egli & de Benoist, 2003).

Table 2 shows the epidemiological criteria for assessing the iodine status in schoolchildren according to their median UIC. The UIC levels are based on WHO/UNICEF/ICCIDD Guidelines (2007).

2.2

Table 2: Epidemiological criteria for assessing iodine nutrition based on median urinary iodine concentrations iodine concentrations in school-age children, WHO/UNICEF/ICCIDD (2007)

Median Urinary Iodine (µg/l)*

Iodine Intake Iodine Status

20 > Insufficient Severe iodine deficiency

20 - 49 Insufficient Moderate iodine deficiency

50 - 99 Insufficient Mild iodine deficiency

100 - 199 Adequate Adequate iodine nutrition

200 - 299 Aboverequirements

Likely to provide adequate intake for pregnant/lactating women, but may pose a slight risk of more than adequate intake in theoverall population

300≤ Excessive Risk of adverse health consequences (iodine-inducedhyperthyroidism, autoimmune thyroid diseases)

*µg/l: micrograms per liter

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5

Table 3: Simplified classification of goiter by palpation, WHO/UNICEF/ICCIDD (2007)

Goiter Grade Goiter Examination

Grade 0 No palpable or visible goiter

Grade 1 A goiter that is palpable but not visible when the neck is in the normal position (i.e.,the thyroid is not visibly enlarged)

Thyroid nodules in a thyroid, which is otherwise not enlarged, fall into this category

Grade 2

A swelling in the neck that is clearly visible when the neck is in the normal position

and is consistent with an enlarged thyroid when the neck is palpated

Table 4: Epidemiological criteria for assessing the severity of IDD based on the prevalence of goiter in school-age children, WHO/UNICEF/ICCIDD Guidelines (2007)

Total Goiter Rate (TGR) None Mild Moderate Severe

Prevalence of goiter 0.0 - 4.9% 5.0 -19.9% 20.0- 29.9% 30% ≤

Overall, UIC levels falling below 100µg/l and a goiter prevalence of more than 5% amongst school-aged children are indicators of an iodine deficiency that has escalated into a public health problem.

Other epidemiological criteria for assessing the severity of IDD in school-age children include the simplified classification of goiter by palpation and the prevalence of goiter. These criteria are detailed in Tables 3 and 4 based on WHO/UNICEF/ICCIDD Guidelines (2007).

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6

Iodine Supplementation

The recommended dosages of daily and annual iodine supplementation according to WHO/UNICEF/ICCIDD Guidelines (2007) are illustrated in Table 5.

Table 5: The recommended dosages of daily and annual iodine supplementation, WHO/UNICEF/ICCIDD (2007)

Population Groups Daily Dose of Iodine Supplement (µg/d)

Single Annual Dose of Iodized Oil Supplement (µg/y)

Pregnant women 250 400

Lactating women 250 400

Women of reproductive age (15–49 y) 150 400

Children < 2 y 90 200 µg/d: micrograms per day

µg/y: milligrams per year

2.3

The criteria for monitoring progress made towards ensuring the effectiveness of the above illustrated iodine supplementation amounts and the sustainable elimination of IDD according to WHO/UNICEF/ICCIDD Guidelines (2007) are summarized in Table 6.

Table 6: Summary of criteria for monitoring progress towards the sustainable elimination of IDD as a public health problem, WHO/ UNICEF/ICCIDD (2007)

Indicators Goals

Salt iodization

Proportion of households using adequately iodized salt >90%

Urinary iodine

Median in population 100 - 199 µg/l

Median in pregnant women 150 - 249 µg/l

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Biological Features of Urinary Iodine

Most of the iodine absorbed by the body will eventually be expelled through the urine. Considering this fact, urinary iodine excretion is a representative indicator (marker) of the recently consumed iodine amount, but it can vary from day to day and even within a single day. Nevertheless, this variation tends to even out at the population level, and studies have confirmed that UIC samples (for children and adults) collected in the morning, and in sufficient numbers, are enough to assess a population’s iodine nutrition levels (Dunn et al., 1993; WHO, UNICEF & ICCIDD, 2007).

Forms of Iodine Fortification

There are two forms of iodine fortificant, iodate and iodide. These two forms are usually added either as potassium iodate (KIO3) or potassium iodide (KI) to salt. The iodate is more stable under adverse climatic conditions; therefore, it is preferred in countries with a tropical climate (Mannar & Dunn 1995; WHO, 1991). It is important to ensure that all salt for human consumption is effectively iodized, including table salt and salt added to processed foods. This excessive caution is due to the current trend in industrialized countries, and developing ones as well, to reduce the consumption of salt in the form of table salt, and instead increase it through processed foods consumption (Andersson, Takkouche, Egli & de Benoist, 2003).Before the salt iodization strategy was adopted in the 1990s, the main approach to correcting iodine deficiency in developing countries was through the iodine supplementation of oil (iodized oil). This method of iodine supplementation is now also being recommended for population groups living in severely affected endemic areas that are not using iodized salt (Delange, 1996).

2.4

2.5

Encouragingly enough, most countries have begun implementing IDD control programs and a growing number of them are even monitoring and controlling for iodine status using the universal iodization strategy.

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8

For years, the extent of IDD in the State of Qatar has been unidentified, with the last study to determine the prevalence of IDD in the country being conducted in 1996. Based on that study, the median UIC was determined to be below 100 µg/l among 30% of children ages 6 to 16 years old (WHO Database on Iodine Deficiency, 2007). Considering the above, and in order to endorse the WHA resolutions, the State of Qatar’s then Supreme Council of Health (SCH) – now Ministry of Public Health (MoPH)– organized a training workshop in collaboration with the ICCIDD Global Network. Accordingly, in December 2010, MoPH invited a team of senior experts from the ICCIDD Global Network to elaborate on the IDD/USI issue, promote USI and train the national task force for the IDD prevention program.

The workshop was co-chaired by Dr. Mohammed Bin Hamad Al-Thani, Director of the Public Health Department, and Professor David Haxton, Executive Director of ICCIDD Global Network. Experts from ICCIDD Global Network facilitated the workshop as well, including:

• Prof. Izzeldin Hussein: ICCIDD Global Network Regional Coordinator for the Gulf andEastern Mediterranean Region; Research Coordinator at the Lipidomics and HumanNutrition Research Centre in London Metropolitan University

• Prof. Chandrakant S. Pandav: ICCIDD Global Network Regional Coordinator for Asia

• Prof. Gregory A. Gerasimov: ICCIDD Global Network expert in Russia, and

• Dr. Salah Elbadawi: ICCIDD Global Network National Coordinator, Ministry of Health,United Arab Emirates.

The team of experts trained more than 40 persons, including health care providers, public health professionals and nurses on the IDD prevention and control program. The training focused on aspects related to monitoring and evaluation, a national assessment system, promotion of USI, and increasing awareness at the community level. The training workshop also provided basic information about the methods of updating data on IDD prevalence in the State of Qatar.

Recently (in 2014), in order to update the available data on IDD prevalence and track the progress of IDD prevention and control in the State of Qatar, MoPH conducted a national survey in collaboration with the then Supreme Education Council (SEC) – now Ministry of Education and Higher Education (MEHE) – and with technical assistance from the ICCIDD

STATE OF QATAR NATIONAL IODINE DEFICIENCY DISORDERS SURVEY 3.0

Global Network and the WHO Eastern Mediterranean Regional Office (EMRO), particularly, their Nutrition Department.

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9

To keep up with WHO/UNICEF/ICCIDD requirements, the State of Qatar has legalized importing iodized salt for human consumption, and since then iodized salt has been made available to the public. Moreover, the State of Qatar, similar to other Gulf Cooperation Council (GCC) countries, is committed to the recent recommendation of the GCC Standardization Organization (2012), which states that iodine content must be 15-40 mg/kg of all table salt (GSO, 2012).

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Survey Aim and Objectives

The survey was designed to assess the iodine nutrition status among schoolchildren ages 6 to 12 in the State of Qatar. Based on this aim, the study’s objectives were the following:

1. To determine the iodine nutrition status among schoolchildren ages 6 to 12 in the Stateof Qatar by measuring their UIC and determining total goiter prevalence.

2. To identify the iodine content of salt samples collected from the respective school children’shouseholds.

3. To assess the knowledge, attitudes and practices of schoolchildren and their parentsregarding iodine deficiency and its associated health consequences as well as therecommended iodized salt consumption.

3.1

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Following is a description of the methods and resources used in conducting this survey:

Materials and Methods

Preliminary Preparations

Communication between MoPH and the ICCIDD Global Network on conducting a survey to assess the iodine status and IDD in the State of Qatar started in the fourth quarter of 2013. A team of experts from the ICCIDD Global Network was subsequently assigned to assist MoPH in this endeavor.

Accordingly, a survey protocol under the name of ‘Qatar National IDD Survey’ was prepared by the ICCIDD Global Network experts according to WHO/UNICEF/ICCIDD guidelines (2007), with schoolchildren ages 6 to 12 being the survey’s prime target. The study protocol was then reviewed and approved by a national team at MoPH, led by Dr. Al-Anoud bint Mohammed Al-Thani, Manager of Health Promotion & Non-Communicable Diseases. The team included experts from multiple disciplines and backgrounds, including public health, epidemiology and statistics.

3.2

3.2.1

Meanwhile, official meetings were held between the two main stakeholders concerned with IDD in the State of Qatar, the MoPH and MEHE. This resulted in the survey plan, along with its related activities and timelines, being arranged and shared with MEHE for its review and approval. MEHE responded and assisted the national endeavor by providing official data and detailed information on primary independent schools that included information segregated to the sub-levels of grades and classes. Following this milestone achievement, all needed print materials and equipment were purchased and prepared.

Study Settings

Schoolchildren are the most suitable target group for IDD surveillance, mainly because of their high vulnerability to the health issue and applicability to a variety of surveillance activities (compatible for exposure to consistent monitoring and follow up). This is intrinsically due to the fact that schoolchildren may be readily accessed, examined and easily assessed for UIC, as one example, directly on the school premises, the setting of this study’s implementation.

3.2.2

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Sample Size and Sampling

The survey conducted back in 1996 revealed that %30 of children ages 6 to16 had a median UIC below 100 µg/l (WHO Database on Iodine Deficiency, 2007). Based on these results, the sample size of the present national IDD survey was calculated according to the following equation:

3.2.3

n The required sample size

n=Z2 * P(1-P) e2

Z The p robability value associated with the confidence levelP The prevalence rate of IDD in the country (determined e The desired margin of error

n

n

n

3.84*(0.0025/0.21)

322.5; hence, approximately

323

from the previous survey)

Accordingly,

Z

P

e

Using these values, the initial calculation comes out to:

1.96 (95% confidence interval, as recommended)0.3 (the IDD prevalence rate)0.05 (as recommended by the relied upon and mentioned guidelines)

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Based on the sampling techniques of WHO/UNICEF/ICCIDD guidelines (2007) and the WHO/ICCIDD/UNICEF Manual (2008), the design effect recommended for this study is three, and the predicted response rate is 80%. Therefore, to achieve the desired precision for students of both sexes and accommodate for the mentioned factors, the sample size was inflated, which resulted in an adjusted value of:

n= ( 323*3) /0. 80 n= 1209

12

Since the target population consists of 6 to 12 year old children at primary independent schools (grades 1 to 6), respondents were recruited from an original sample consisting of all independent primary schools in the country to ensure representativity. From each selected school, one entire class (all students in the class) had to be selected and included in the survey sample. This was all done in accordance to WHO/UNICEF/ICCIDD guidelines (2007). Hence, a two-stage cluster sampling technique was used, where the school was the cluster that was selected at the first stage, while the school grade/class was the unit that was selected at the second stage.

Moving on, a list of all independent primary schools in the State of Qatar was provided by MEHE, which came out to a total of 98 schools. The average number of students in each class was 25, and according to the estimated sample size needed, the total number of schools that needed to be included in the sample was 49. Systematic sampling proceeded with a sampling interval for identifying the schools of two.

Based on this approach and the total number of students in each school, all independent primary schools were listed and numbered from one to 98. The schools were then systematically selected with a consistent sequence interval of two. The first school was randomly selected. In total, out of the 98 primary independent schools, 49 were selected and included in the survey. The distribution of schools between all-girls and all-boys schools was 22 and 27, respectively.

Following, MEHE provided a list of all classes within each primary grade (1 to 6) in all independent schools, and accordingly, all classes in each school were listed sequentially from one to N (the total number of classes in each school). Finally, one class was randomly selected from each school. Ultimately, this provided the list of all classes selected, from which a sub-list of all participating/targeted students was obtained.

This resulted in a total of 1213 primary independent school students from both sexes being the selected sample.

Each selected school student was allocated a four-digit identification code. The first two digits corresponded to the school number and the last two digits indicated the student’s number in the class list. This code was printed on eight sticker labels, which were then placed on all data collection forms and samples (salt and urine) to anonymously identify each student’s information during the data collection process.

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13

Moreover, from the same school cohort, 16 schools, amounting to 391 students, were then randomly chosen to provide the second spot urine samples on the subsequent days of the first urine sample. This subsample constituted 32.2% of the original survey sample.

Personnel Training

Two workshops on IDD were organized and conducted by MoPH. As previously mentioned, the first was an orientation workshop that took place in Doha in December 2010. The main aim of this workshop was to build the State of Qatar national team’s capacity on the elimination techniques of IDD and monitoring of USI as well as to prepare for the assessment and determination of IDD prevalence in the State of Qatar.

Shortly afterwards, a task force led by the Manager of Health Promotion & Non-communicable Diseases was established at MoPH to oversee the related IDD survey planning and implementation. An international team of experts technically supported the task force, and, as such, both teams were responsible for the successful implementation of the IDD survey in the State of Qatar.

Additionally, a total of 30 field workers were selected from MoPH staff, alongside a group of volunteers, to participate in the data collection process. This resulted in six field survey teams being formed, with each team consisting of three healthcare professionals (a physician, nurse and survey assistant). The remaining number of field workers on the teams were considered as backup (replacements/substitutes, as needed) for the healthcare professionals.

3.2.4

25

In order to ensure that data collection was correctly performed, an intensive three-day training was provided to field workers. This was the second training workshop that took place from the 25th to 27th of February 2014. In fact, this workshop was held just a few days before the actual fieldwork to train all field workers on the survey’s methodology and tools. The role of each team member was also explained and discussed thoroughly to ensure that everyone on the team was well acquainted with her/his duties and responsibilities during the fieldwork.

In preparation for the different trainings, the ICCIDD Global Network regional coordinator developed a manual entitled, “Training program to conduct a national survey for assessment of iodine deficiency prevalence among primary school students in the State of Qatar” in both Arabic and English. The manual was carefully edited by the national team, and was then discussed and used to guide the second training workshop (Annex 1).

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Data Collection ToolsData collection forms were developed to collect information about the schoolchildren participating in the survey. These forms included the consent form, the survey questionnaire and the school record (Annexes 2-4).

Each school record was prepared to include the data collection date and the name and code number of the selected school. The record also contained student information, such as the code number, name, sex, and date of birth to ensure that the child was within the targeted age group and eligible for the survey. This form also collected other student information related to the provision of household salt samples and urine samples. Data on goiter examination and weight and height measurements were also required by and reported in this form (Annex 4).

The survey questionnaire was divided into three sections. The first section contained a set of questions on the socio-demographic profile of each student participating in the survey, such as the date of birth, sex, nationality, family size, and total number of people living within their household. The second section collected information on the use of iodized salt for cooking within households, its type of packaging, and the frequency of salt product purchases (monthly, etc.). The salt product’s weight and brand name were also collected by the second set of questions.

3.2.5

26

The last section consisted of questions needed to evaluate parents’ level of awareness about goiter as well as their attitudes and behavior towards using iodized salt in their households. Other information regarding the presence of a food label on the salt product’s package and inquiries as to whether or not the person routinely responsible for buying the household salt pays attention to and reads the label on the salt package were also presented in the last section. Worthy of noting, the questionnaire also gathered information on the frequency of fish consumption in the week and the overall seafood intake in the day immediately preceding the time (day) of urine sample collection (Annex 3).

15

Data Collection Process and Duration Prior to the launching of any activities related to the State of Qatar’s IDD Survey, MoPH initiated communication with and obtained full approval from MEHE for the implementation of the survey at the level of a pre-identified sample of independent schools.

In turn, MEHE provided an official letter of approval to access the identified school sample for the necessary data collection procedures. MEHE then proceeded to inform all relevant school principals and administrators of the study’s objectives and the expected visit of the surveyors.

Upon receiving MEHE approval, six teams were assembled to oversee the survey’s operations. Each team consisted of three members, including a survey assistant, a physician and a nurse (one of whom was designated as the team leader). Each team was assigned to eight schools, with the exception of one team that was responsible for overseeing survey activities at nine schools.

Prior to conducting any school visit, the teams communicated with the respective school nurses and principals, informing them about the study’s methods and purpose and assuring them of the strict confidentiality of all results and involvement that would be maintained throughout and after the survey’s duration. Convenient dates for conducting the needed data collection activities were also arranged between the teams and school administrators.

3.2.6

Accordingly, the teams planned for and visited the concerned schools with a copy of the MEHE approval letter and a roster of the schools’ grades, classes and students to be surveyed. This list of students to be surveyed from each school had already (previously, prior to the school visit) been identified and reviewed with school administrators that had also provided, on their part, all needed information on the selected students, including their names, genders and dates of birth, amongst other demographics.

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16

During the first school visit, the teams first approached the concerned school administrators, who, in turn, assigned to each team a school coordinator. The assigned coordinator assisted the team by accompanying them to the concerned class and informing students and teachers alike of the survey and its details. Once all the necessary instructions had been conveyed, each student was provided with her/his own identified (named) envelope that had enclosed the following:

• Information sheet: containing all the details and methods needed by the students’parents to consent to their children’s participation in the survey (Annex 5)

• Informed consent

• Questionnaire: one of the IDD survey’s main data collection tools

• Ziploc bag: for returning samples of the salt used by the students’ respectivehouseholds

All students were carefully instructed to have their parents read the information and instructions provided and sign the corresponding consent form, upon which they (the parents) would complete the questionnaire and provide a five-tablespoon (50 mg) sample of their household salt in the Ziploc bag afforded to them.

During the second prearranged school visit, students presented the teams with the items they were originally instructed to complete and provide (questionnaire and salt sample, respectively). Team members, in turn, checked all questionnaires and samples and made sure that all identifiers (sticker labels) were accurate and in place.

The second visit also consisted of two essential data collection procedures that included physicians examining students for the presence of a goiter and students receiving the necessary instructions (via a short video shown only to boys and verbal instructions provided separately to girls) on the proper method for providing a urine sample. These procedures had already received the necessary parental consent via the original consent form signed by the parents prior to their having completed the questionnaire and provided the required salt sample.

Once all urine samples were collected (children returning with the urine samples), the code number (sticker label) was verified. Team nurses then transferred the urine samples by disposable pipettes from the originally used cups to special recommended tubes arranged in racks inside iceboxes in preparation for being received by the laboratory. The code number on the tube corresponded with that on the collection cup and the code number assigned to the child. This task began at the schools, but it was completed at MoPH.

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17

Other onsite data collection included measuring students’ height and weight, which was carried out during the second visit in adherence to WHO (1995) recommendations. Each team had one set of height and weight measurement devices. This was also in accordance to WHO recommendations. Weight and height were measured with participants wearing light clothing and without shoes. Height measurements were performed using the height scale Seca 213 and were rounded to the nearest millimeter. On the other hand, weight measurements were obtained by using the 813 Seca digital weight floor scale with high capacity and recorded to the nearest 100 grams. The scale was placed on a firm and flat surface to ensure accurate and precise measurements. Daily calibration of the weight measuring devices (by relying on a known reference weight) was also carried out to further ensure the accuracy and precision of measurements.

Lastly, the team and school administrators scheduled a third and final visit on the subsequent days of the second visit for the collection of the second urine sample from a subsample of the originally identified and sampled students. Similar to the first collection, all urine samples were transferred from their original containers into laboratory tubes and refrigerated at four

degrees Celsius at MoPH premises before being shipped to a WHO accredited laboratory in Tanzania for analysis. However, only a specific, limited, amount from each urine sample was sent to Tanzania for analysis. All remaining urine samples and amounts were kept and maintained in the refrigerator at MoPH for further quality control purposes, as and if needed.

As for the school records, each record was filled, first, by the survey task force members with the official school and student information, and then by the survey team members during the fieldwork. Fieldwork recorded information included the data collection date, weight and height measurements, goiter examination results, and whether or not the student provided a urine sample and household salt sample.

The data collection process of the national IDD survey required three weeks to be completed (14 working days – considering five working days per week). It endured from March 5 – 24, 2014. During this period, each team conducted at least three visits to each school assigned to it in order to complete the necessary fieldwork and data collection requirements.

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18

3.2.7Salt Sample Analysis The iodine content of salt was determined quantitatively by the titration method and using spectrophotometry that was conducted at a WHO accredited lab in Tanzania, and qualitatively through the use of the rapid test kits (RTK) – placing two to three drops on each salt sample. Samples with no change in color were recorded as ‘0’, indicating no iodine in the salt; whereas, salt samples that turned blue were recorded as ‘1’, indicating the presence of iodine. The results were then recorded in the data collection form (Refer to Figure 1 for a depiction of the process).

Figure (1): Rapid Test Kits (RTK) for qualitative assessment of iodine in salt

Data Management and Cleaning

Double independent data entry was carried out using the Epi-Info 6.04 computer software package. A QES file for the questionnaire data was prepared with specific checks set for appropriate fields using the CHECK program, thus minimizing data entry errors. Upon receipt by the data management team at MoPH, quality checks were also done to ensure the completeness of the forms. Coding was done for certain variables. For the yes and no questions, the digits “1” and “0” were used, respectively, and consistently throughout the form. Missing data were coded as “99.” After completion of data entry, the two independent files were compared using the Epi-Info VALIDATE program. In case of any discrepancies between the two files, the original forms were revised and data entry was corrected accordingly.

3.2.8

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19

The Department of Health Sciences and Technology at the Swiss Federal Institute of Technology (Switzerland) was responsible for data cleaning upon completion of all data entry. This task involved creating summary tables with minimum and maximum values, frequencies and cross tabulation. All outlying values detected were examined and verified from the original data collection forms.

Statistical AnalysisQualitative variable data were presented using descriptive statistics in the form of frequencies and percentages. Means, medians and standard deviations were used for quantitative variables. Tabular and graphic presentations were also provided for further clarification and representation of the study’s results. Moreover, for non-normally distributed quantitative continuous data, the non-parametric Mann-Whitney test was used to compare two groups. Statistical significance was set at P-value < 0.05.

UIC data was extrapolated to indicate iodine intake, adjusted for intra-individual variation to obtain the habitual iodine intake, and, lastly, interpreted using the estimated average requirement (EAR) cut-point model.

3.2.9

31

Ethical Considerations 3.3

Ethical principles and guidelines for the conduction of research on human subjects were adhered to throughout the survey’s implementation and were an intrinsic part of the study’s design and implementation stages. All required information on the study’s content, procedures and objectives was provided to the participating schoolchildren and their parents prior to their involvement in any of the study’s research related activities. In fulfillment of this, an information sheet clarifying the aim and objectives of the survey was prepared and distributed to each student included in the survey sample (Annex 5). A written consent form that was provided to the participating students’ parents for their own review and signature, thus confirming their approval of their children’s participation, complemented the information sheet (Annex 2). The above was completed in collaboration with the schools’ principals, teachers and nurses. The concerned documents and consent forms informed parents and students of their right to refuse participation in the survey and that all information provided will be treated with strict confidentiality and used for scientific purposes only.

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RESULTS

Out of the 98 primary independent schools, 49 were randomly selected and surveyed, out of which 22 schools were for girls only, while 27 were boys-only schools. This amounted to a total of 1213 schoolchildren (43% girls and 57% boys) being randomly selected to participate in the survey based on a sample frame provided by MEHE and the selected schools. The sampling method resulted in approximately two thirds (61%) of the selected schoolchildren coming from independent primary schools located in the Al- Rayyan and Doha municipalities, the biggest residential areas/municipalities in the State of Qatar.

During the first field visit by the field team members to their assigned schools, it was discovered that 18 students, who had been originally included in the survey sample during the planning stage, had been transferred to other schools; hence, the total sample number was reduced to 1195 schoolchildren from the 49 randomly selected schools.

Out of the 1195 targeted schoolchildren, a total of 1020 agreed to participate in the survey, yielding a response rate of 85.4%; however, the data of 8 respondents were later excluded from the study as their ages fell outside the survey’s targeted age group/inclusion criteria (seven 13-year-old students and one 14-year-old student). Thus, a total of 1012 students were considered as respondents in the survey, by fulfilling one or more of the following:

• Completing the questionnaire with their parents and/or

• Providing the household salt sample (998 students, 98.6 %) and/or

• Providing the first urine sample (967 students, 95.5%).

For the repeat spot urine analysis, 288 children out of a subsample of 391 of the same/original students’ cohort (original survey sample) provided a second spot urine sample on the subsequent days, yielding a response rate of 73.7% (29.8% of the total number of students [967] that provided the first urine sample).

4.0

4.1Description of the Study Sample

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As for sex and age distributions amongst the participating school children, boys exceeded females and constituted 56.6% of the survey’s respondents, while schoolchildren ages 9 and 10 years were the largest age groups, subsiding at 20.9% and 20.2%, respectively (refer to Table 7). Accordingly, the mean age of the respondents was 8.8 years ±SD 1.6 years (9.1±1.7 years and 8.7±1.5 years for girls and boys, respectively).

Table 7: Age and sex distribution of survey respondents ages 6 to 12 years

Category Girls Boys Total

Age in Years No. % No. % No. %

6 67 15.3 36 6.3 103 10.2

7 18 4.1 118 20.6 136 13.4

8 58 13.2 122 21.3 180 17.8

9 93 21.2 119 20.7 212 20.9

10 101 23.0 103 18.0 204 20.2

11 85 19.4 63 11.0 148 14.6

12 17 3.8 12 2.1 29 2.9

Total Students Ages 6 to 12 439 100.0 573 100.0 1012 100.0

Mean Age ± SD 9.1±1.7 8.7±1.5 8.8±1.6

Total Goiter Prevalence

During the physical examination of the participating students, a palpable/visible goiter (grade1 & grade 2) was recorded as positive in the school data record, and the absence of or a non-palpable goiter was recorded as negative (WHO, UNICEF & ICCIDD, 2007). Based on this employed method, Table (8) shows that the total goiter prevalence was found to be 0.4% amongst the surveyed students, with more boys affected than girls, 0.53% vs 0.23%, respectively.

Table 8: Total goiter rate among survey respondents ages 6 to 12 years

Total Goiter Rate Over All Boys Girls

No. % No. % No. % Positive 4 0.40 3 0.53 1 0.23

Negative 992 99.6 561 99.47 431 99.77

Total 996 100.0 564 100.0 432 100.0

4.2

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22

Urinary Iodine Concentrations 4.3

Urinary Iodine Concentration (UIC)µg/L Iodine Status

1stUrine Sample

No. %

20> Severe iodine deficiency 6 0.6

20 - 49 Moderate iodine deficiency 22 2.3

50 - 99 Mild iodine deficiency 34 3.5

100 - 199 Adequate iodine nutrition 121 12.5

200 - 299 Slight risk 207 21.4

300 - 399Risk of adverse health consequences

224 23.2

400 - 499 149 15.4

≤ 204 21.1

Total 967 100

All the more, the UIC of students was not normally distributed; therefore, the geometric and arithmetic means and median values of UIC were estimated (Refer to Table 10). The median UIC values were estimated at 333.2µg/L and 360.4µg/L for the first and repeat (sub) samples (UIC-2nd paired measurements), respectively, while the adjusted distribution median value for both samples was 341.6µg/L (Refer to table10).

Table 10: First and second spot urine sample (2nd paired) measurements of survey respondents

CategoryUrinary Iodine Concentration (UIC-1st Sample)

Urinary Iodine Concentration(1st Sample UIC –First Day Measurements of Sub-Sample participants) )

Urinary Iodine Concentration(UIC- SubSample Paired to 1st Sample

Adjusted Distribution

N 967 288 288 1255

Median 333.2 345.1 360.4 341.6

Mean 379.2 391.9 404.4 385.0

Geometricmean 308.4 332.6 356.6 318.9

Standarddeviation 234.8 224.8 212.8 230.1

Minimum 1.4 26.4 39.2 1.4

Maximum 1833.0 1430.6 1640.8 1833.0

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500

According to the cut-off points of the WHO/UNICEF/ICCIDD guidelines (2007), only 12.5% of students have a UIC falling within the optimal recommended range of 100-199 µg/L (recognized as having an adequate iodine nutrition), while the majority (81.1%) of students were determined to be exceeding this favored range (Refer to Table 9 for more details).

Table 9: Distribution of urinary iodine concentration amongst school students according to the WHO cut-off points

23

However, when looking at variations based on sex, a highly significant difference was detected in the first sample overall median UIC level between male and female students, as is shown in Table (11).

Table 11: Distribution of median urinary iodine concentration amongst survey respondents by age and sex

Age(Years)

Indicator Overall UIC-1st Urine Sample

Boys UIC-1st Urine Sample

Girls UIC-1st Urine Sample

6N 94 36 58

Median (IQR) 371.6 (289.8) 385.9 (308.4) 358.7 (291.1)

7N 131 114 17

Median (IQR) 377.4 (262.6) 391.3 (265.9) 307.6 (263.3)

8N 173 117 56

Median (IQR) 324.2 (217.0) 328.6 (221.2) 300.4 (179.3)

9N 200 115 85

Median (IQR) 328.3 (214.0) 353.6 (238.8) 282.2 (208.5)

10N 197 101 96

Median (IQR) 341.8 (220.1) 373.8 (255.3) 317.4 (176.0)

11N 145 62 83

Median (IQR) 315.8 (231.0) 299.9 (181.8) 355.4 (271.4)

12N 27 11 16

Median (IQR) 320.0 (262.6) 309.0 (256.4) 335.4 (245.8)

OverallN 967 556 411

Median (IQR)* (228.6) 333.2 (245.7) 351.1 316.0 (212.0)**

* IQR = Interquartile Range**Mann-Whitney U test was used for comparing the Overall Median UIC levels between boys and girls (p = 0.003).

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Other anthropometric measurements taken included weight and height that were measured for 991 students (boys and girls), constituting 97.9% of respondents. Students’ weight ranged between 15.1 and 94.6 kg with a mean of 34.6kg ± SD 12.7kg, while the median weight was computed to be 31.5kg (Refer to Table 12).

Table 12: Weight parameters of surveyed school students

Category OverallWeight (kg)

GirlsWeight (kg)

BoysWeight (kg)

N 991 430 561Median 31.5 32.4 30.5Mean 34.6 35.6 33.9

Standard deviation 12.7 12.9 12.5

Minimum 15.1 15.1 16.0

Maximum 94.6 89.0 94.6

As for the urine sub-samples (the final onsite collection of anthropometric data), they were adjusted for intra-individual variation to obtain the habitual iodine intake and then interpreted using the EAR cut-off point model. Based on the students’ median weight (31.5 kg), the UIC cut-off values were calculated, which corresponded to an iodine EAR of 73 µg/day and a tolerable upper level of iodine intake of 600 µg/day, as is illustrated in (Figure 2). Although the median UIC falls in the “excessive intake” category, according to WHO/UNICEF/ICCIDD guidelines (2007), the adjusted distribution clearly shows that the habitual iodine intake of schoolchildren in the State of Qatar lies within the recommended range, thus confirming that none of the surveyed students suffer from neither low nor excessive habitual iodine intake (refer to Figure 2).

Figure (2): The Adjusted Distribution

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Household Salt Sample

Regarding the use and iodization of household salt, 998 respondents provided the requested samples, of which 48.7 % showed positive results when using RTK. Titration method data was available for 992 salt samples and revealed a median iodine content of 25.30 ppm with a mean of 27.1 ppm ± SD 13.6 ppm. As for iodized salt usage amongst households, the study revealed that 74.9% of households used adequately iodized salt, while 12.5% and 12% used excessively and insufficiently iodized salt, respectively, also according to WHO/UNICEF/ICCIDD criteria (2007) (refer to Table 13).

Table 13: Iodine content of the household salt samples collected from respondents

Iodine Content in Household Salt No. Percentage (%)

No iodine 6 0.6

Inadequate (<15 ppm) 119 12.0

Adequate (15-40 ppm) 743 74.9

Excessive (>40 ppm) 124 12.5

Total 992 100.0

4.4

Total salt intake was measured to be quite high. Based on the median UIC (333.2 µg/L) and salt iodine content (25.3 ppm), the current salt intake of the surveyed households is 13.2 grams/day, which is approximately three times greater than the latest WHO recommendation of 5 grams/day (WHO Global action plan for the prevention and control of NCDs 2013-2020).

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A set of questions were designed to assess the level of awareness, attitudes and practices of households towards iodized salt.

Figure (3) shows that schoolchildren’s parents (either their fathers [49.3%] or mothers [48.4%]) are the main persons in the households responsible for purchasing salt products

Figure (4): Commercial Outlets Accessed for Salt Purchasing

Figure (3): Salt Purchasing Distribution and Frequency amongst Household Members

Furthermore, figure (4) indicates that salt is more frequently purchased from large commercial outlets rather than small shops, 83.6% vs. 14.8%, respectively. This reality suggests focusing related monitoring and inspection activities on large commercial malls and other major food outlets.

Knowledge, Attitudes and Practices towards Iodized Salt 4.5

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0.7

27

Moreover, the study revealed that the majority (56.3%) of respondents purchase 1000-750 gram salt packages, and just over one-fourth (27.3%) purchase salt packages weighing anywhere from 500-250 grams (refer to Figure 5).

Figure (5): Weight (grams) of Purchased Salt Products/Packages

As for the frequency of salt purchases, 64.0% of respondents claimed that they purchase salt on a monthly basis, while another 26.8% purchase salt twice per month, and the remainder purchase salt three or more times per month (refer to Table 14). The study also revealed that plastic containers and paper bags were the preferred types of packaging for purchased salt at 49.2% and 46.6% of all purchased salt, respectively. In fact, this is a significant public health practice, since plastic containers decrease iodine losses that would otherwise occur as a result of excessive exposure to heat, light and humidity (WHO, UNICEF & ICCIDD, 2007).

Table 14: Frequency of Salt Purchasing per Month and Package Types

Indicator

Frequency of Purchasing Salt/Month No. %

One Time 632 64.0

Two Times 265 26.8

Three Times and More 91 9.2

Total Respondents 988 100.0

Type of Salt Packaging

Plastic Containers 484 49.2

Paper Bags 459 46.6

Nylon Bags 22 2.2

Unpacked Salt 5 0.5

Others 14 1.4

Total Respondents 984 100.0

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At the level of public awareness towards iodized salt, the study showed that 55.1% of respondents are aware of iodine’s health benefits, and more than two thirds, 68.0%, have heard about goiter. Moreover, it was also found that 57.8% of respondents claim to read the salt packaging information/label before purchasing the product. It is worth noting, as well, that the majority (86.8%) of respondents asserted that their household salt packages are labeled with the iodine content (see Table 15).

Table 15: Awareness of Health Benefits of Iodized Salt and Reading of Salt Packaging Labels

Indicator No. %

Knowledge of Iodized Salt Health Benefits

Yes 530 55.1

No 432 44.9

Total Respondents 962 100.0

Respondents Claimed They Heard Bbout Goiter

Yes 663 68.0

No 312 32.0

Total Respondents 975 100.0

Reading the Salt Package Label

Yes 566 57.8

No 413 42.2

Total Respondents 979 100.0

Availability of Salt Packages Labeled with Iodine Content at Household

Yes 794 86.8

No 121 13.2

Total Respondents 915 100.0

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When it comes to the availability and variety of salt products in the State of Qatar, local consumers have a wide array of salt brands to choose from; however, Nezo was found to be the most popular amongst households, accounting for 51.3% of all purchases/use, as is shown in Table (16).

Iodized salt 17 1.8

Al Majed 13 1.4

Solty 12 1.3

koral 9 1.0

Risa 7 0.7

Lulu 7 0.7

Al meurha 5 0.5

Foodys 5 0.5

Others 51 5.4

Unknown 232 24.6

Total respondents 944 100.0

Table 16: Brand names of Cooking and Household Salt

Brand Name No. of Household %

Nezo 484 51.3

Mezo 46 4.9

Azzurro 32 3.4

Dhuha 24 2.5

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Fish is also a good alternative source of iodine, and regular consumption does assist in maintaining adequate iodine levels (WHO & FAO, 2004). Encouragingly enough, the study did reveal that about one-third (30.7%) of respondents consume one fish-containing meal weekly, and another 17.9% have fish twice a week (refer to Table 17 for more figures).

Table 17: Fish Consumption Frequency amongst Respondents’ Families

Indicator

Frequency of Consuming Fish-Containing Meal No. %

Every 2 Weeks or More 373 37.9

Once Weekly 303 30.7

Twice Weekly 176 17.9

Thrice Weekly 53 5.4

≥ Four Times Weekly 27 2.7

Never 53 5.4

Total Respondents 985 100.0

More specifically, the study also provided information about students’ consumption of fish- and seafood-containing meals on the day immediately preceding the urine sample collection; the figure for such consumption stood at 29.8% of students (see Table 18).

Table 18: Consumption of Fish- and Seafood-containing Meals One Day Prior to Urine Samples

Indicator

No. %Students Who Consumed Fish and Seafood Containing Meals on the Day Preceding Urine Samples Collection

Yes 293 29.8

No 691 70.2

Total Respondents 984 100.0

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Iodine Deficiency Disorders have been a public health problem in the State of Qatar for many years. This is based on the WHO Vitamin and Mineral Nutrition Information System and the national data of 1996 on UIC, where IDD prevalence in the State of Qatar was estimated to be 30% (WHO database on iodine deficiency 2007).

This, amongst other factors, encouraged conducting the existing study, which is the first nationally representative survey to assess the prevalence of IDD among schoolchildren in the State of Qatar.

According to WHO/UNICEF/ICCIDD (2007) criteria for tracking progress of IDD elimination, UIC levels less than 100µg/L and 50µg/L should not exceed prevalence rates of 50% and 20% in a population, respectively. For the State of Qatar, the present survey shows that only 6.4% of the studied population has a UIC less than 100 µg/L and only 2.9% falls less than 50 µg/L. The study also revealed a median UIC of 333.2µg/L, which denotes a more than adequate intake of iodine. According to WHO/UNICEF/ICCIDD criteria (2007) on UIC, this falls in the “excessive intake” category, although, the adjusted distribution of iodine intake amongst schoolchildren was within the recommended intake range. Furthermore, the adjusted distribution showed that none (0%) of the students have neither low nor excessive habitual iodine intake.

DISCUSSION 5.0

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Excessive Urinary Iodine Concentration 5.1

Excessive iodine intake may result in iodine-induced hyperthyroidism (IIH). Fortunately, this habit can be prevented by careful monitoring (Delange, de Benoist & Alnwick, 1999). As such, the WHA has called on national governments to report on their iodine nutrition status on a regular three year period.

Although a healthy thyroid can adjust to a wide range of iodine intake by regulating the synthesis and release of thyroid hormones, even modest increases in iodine intake can

precipitate thyroid disorders in individuals with past or present thyroid abnormalities. More concerning are the detrimental consequences that excess iodine has on thyroid functions during childhood, a vulnerable and determining stage in life. Excess dietary iodine has been associated with goiter and thyroid dysfunction amongst children. Evidence comes from coastal Japanese children, where consumption of iodine-rich seaweed, which equates/compares to an intake of about >20 mg of iodine per day, was associated with a prevalence of visible goiter of 3%–9% (Suzuki, Higuchi, Sawa, Ohtaki & Horiuchi, 1965).

All the more, one significant international study of 6 to 12 year-old children found that chronic dietary iodine intake (UIC >detected by ultrasonography (Zimmermann, Ito, Hess, Fujieda & Molinari, 2005). The onset of mild thyroid hyper-stimulation has also been detected by increased thyroglobulin in the

emphasize the importance of avoiding excess iodine intake, denoted by a median UIC of

et al., 2013).

The median UIC and salt iodine content in this survey were shown to be 333.2µg/l and 25.3 ppm, respectively. This implies that the current daily salt intake is 13.2 grams per surveyed schoolchild, while WHO recommends a daily salt intake of 5 grams, which is also to help prevent the risk of high blood pressure (WHO Global action plan for the prevention and control of NCDs 2013-2020). As such, a more precise and carefully designed survey to measure sodium levels in a 24-hour urine sample is needed.

44

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5.2Household Use of Iodized Salt in the State of Qatar

The goal of USI can be achieved when 90% or more of households use adequately iodized salt. According to this survey, the majority of households, 74.9%, use adequately iodized salt. Only 12.0% of households consume insufficiently iodized salt, while another 12.5% use excessively iodized salt.

The study revealed that the responsibility of purchasing salt rests mainly with the parents. Therefore, it would be effective to educate parents about the importance and benefits of iodized salt on their health and the health of their family members as well as the recommended iodine content level of household salt products.

Knowledge, Attitudes and Practices 5.3

The survey revealed a median concentration of urinary iodine of 333.2µg/l. This value is in excess of the level recommended by WHO/UNICEF/ICCIDD (2007). However, the adjusted distribution showed that the habitual iodine intake assessment was within the recommended range. Based on the WHO/UNICEF/ICCIDD (2007) recommendation, iodine intake amongst school children in the State o f Qatar should be reduced to bring UIC levels to <300 µg/l, especially as the risk of adverse health consequences due to excessive iodine intake starts when UIC levels begin to exceed this amount. This can be achieved by red-ucing the salt intake at the population level to 5 grams per day and revising the specification for salt iodine content in the country.

CONCLUSION 6.0

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1. A surveillance system is required to regularly monitor salt reduction and iodine intake.Periodic collection of data and regular reporting would facilitate efforts to prevent excessivesalt intake. The proposed surveillance system should follow a systematic approach in thesupervision and regular monitoring of salt at three critical settings, including the entrypoints of imported salt, retail shops and households. To ensure a sustainable approach tothe elimination of IDD, it is recommended that the surveillance system also be an integralcomponent of the national salt iodization program.

2. Comprehensive national public awareness and advocacy program and social marketingcampaigns should be developed and implemented to improve community awareness onthe importance and use of iodized salt and the harmful effects of noncompliance as wellas promote the uptake of best practices.

3. Planning and implementation of a survey to determine the sodium intake levels inthe country should be considered. Additionally, it would be of much added value toundertake an assessment survey for iodine nutrition among mothers, pregnant womenand young children in order to determine their iodine intake, and, consequently, guidefuture strategies that would promote best practices for adhering to recommended iodineintake levels.

4. Community health promotion efforts need to give special attention to schoolchildrenand encourage them to consume more seafood, fruits and vegetables. One approachto assist in such promotion efforts is to increase the availability of these food groups andproducts in school canteens.

RECOMMENDATIONS 7.0

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1. Andersson M, Takkouche B, Egli I, and de Benoist B. The WHO Global Database on iodinedeficiency disorders: the importance of monitoring iodine nutrition. Scandinavian Journal ofNutrition 166- 162 :(4) 47 ;2003.

2. Bleichrodt N, Born MP. A metaanalysis of research on iodine and its relationship to cognitivedevelopment. In: Stanbury JB, ed. The damaged brain of iodine deficiency.New York:

Cognizant Communication Publ; 1994. p. 200-195.

3. Bürgi H, Supersaxo Z, Selz B. Iodine deficiency diseases in Switzerland one hundred yearsafter Theodor Kocher’s survey: A historical review with some new goiter prevalence data.

Acta Endocrinol (Copenh) 590 -577 :123 ;1990.

4. Delange F. Administration of iodized oil during pregnancy: a summary of the publishedevidence. Bull World Health Organization 8-101 :74 ;1996.

5. Delange F, de Benoist B, Alnwick D. Risks of iodine induced hyperthyroidism after correctionof iodine deficiency by iodized salt. Thyroid 556 -545 :9 ;1999.

6. Dunn JT, CrutchfieldHE, Gutekunst R, et al. Assessment of Iodine Deficiency Disorders andMonitoring their Elimination. Methods for measuring iodine in urine. The Netherlands,ICCIDD, 1993.

7. GCC Standardization Organization (GSO). GSO 2007/1843/Amd 1:2012.

8. Hetzel BS. Iodine deficiency disorders (IDD) and their eradication. Lancet1129–2:1126 ;1983.

9. Hetzel BS, Dunn JT, Stanbury JS, eds. The Prevention and Control of Iodine DeficiencyDisorders. Amsterdam, The Netherlands: Elsevier; 1987.

10. Mannar V and Dunn JT. Salt iodization for the elimination of iodine deficiency. The Netherlands,International Council for Control of Iodine Deficiency Disorders, 1995.

11. Marine D, Kimball OP. Prevention of simple goiter in man. Arch Intern Med 72-661 :25 ;1920.

12. Murray CJ, Lopez AD. The Global Burden of Disease: a comprehensive assessment ofmortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020.Cambridge, MA, Harvard School of Public Health, (Global Burden of Disease and InjurySeries, vol. I), 1996.

13. Suzuki H, Higuchi T, Sawa K, Ohtaki S, Horiuchi Y. “Endemic coast goiter” in Hokkaido, Japan.Acta Endocrinol (Copenh) 176–50:161;1965.

14. United Nations Children’s Fund, World Health Organization. World Summit for Children – MidDecade Goal: Iodine Deficiency Disorders. UNICEF–WHO Joint Committee on Health Policy.Geneva, United Nations Children’s Fund, World Health Organization,1994 (JCHPSS/2.7/94).

15. United Nations Children’s Fund. The State of the World’s Children 2012: Children in an UrbanWorld. New York: United Nations Children’s Fund (UNICEF); 2012.

16. WHO, FAO. Vitamin and Mineral Requirements in Human Nutrition, Second Edition. WorldHealth Organization and Food and Agriculture Organization of the United Nations, Rome,Italy 2004.

17. World Health Assembly (60.21). Sustaining the elimination of iodine deficiency disorders.The Sixtieth World Health Assembly, Eleventh plenary meeting, 23 May 2007– Committee A,fifth report. http://apps.who.int/gb/ebwha/pdf_files/WHASSA_WHA-60Rec1/E/reso-60-en.pdf .

18. World Health Organization, United Nations Children’s Fund, International Council for theControl of Iodine Deficiency Disorders. Recommended iodine levels in salt and guidelinesfor monitoring their adequacy and effectiveness. Geneva: WHO; 1996.

19. World Health Organization. Physical status: the use and interpretation of anthropometry-report of a WHO expert committee (WHO Tech Rep Ser;854) Geneva.1995.

20. World Health Organization, United Nations Children’s Fund, International Council for theControl of Iodine Deficiency Disorders. Assessment of the Iodine Deficiency Disorders andmonitoring their elimination. Geneva: WHO; 2001.

21. World Health Organization, United Nations Children’s Fund, and the International Councilfor the Control of Iodine Deficiency Disorders. Assessment of Iodine Deficiency Disordersand Monitoring their Elimination: A Guide for Programme Managers. 3rd ed. Geneva,Switzerland: World Health Organization; 2007. ISBN: 9789241595827.

22. World Health Organization. Evaluation of certain food additives and contaminants. Thirty-seventh report of the Joint FAO/WHO Expert Committee on Food Additives. Geneva, WorldHealth Organization,1991(WHO Technical Series No. 806).

23. World Health Organization. Global action plan for the prevention and control of non-communicable diseases 2020-2013. World Health Organization, Geneva, Switzerland .

24. World Health Organization, United Nations Children’s Fund, and the International Councilfor the Control of Iodine Deficiency Disorders. Elimination of iodine deficiency disorders:a manual for health workers, World Health Organization. Regional Office for the EasternMediterranean, ICCIDD, UNICEF (EMRO Technical Publications Series; 2008 ,(35.

36

25. World Health Organization. Sustaining the elimination of iodine deficiency disorders.Resolution WHA58.24. In: Fifty-eighth World Health Assembly, Geneva, 25 May 2005. Geneva:World Health Organization; 101–2005:100. Publication no. 1. WHA2005/58/REC/1.

26. World Health Organization. WHO Global Database on Iodine Deficiency Geneva,Switzerland: 2007. http://who.int/vmnis/iodine/data/database/countries/qat_idd.pdf?ua=1.The database on iodine deficiency includes data by country on goiter prevalence and/orurinary iodine concentration.

27. Zimmermann M B, Ito Y, Hess SY, Fujieda K, and Molinari L. High thyroid volume in childrenwith excess dietary iodine intakes. Am J Clin Nutr. Am J Clin Nutr.844-840 :(4)81 ;2005.

28. Zimmermann MB, Aeberli I, Andersson M, Assey V, Yorg JA, Jooste P, etal. Thyroglobulinis a sensitive measure of both deficient and excess iodine intakes in children and indicates

group report. J Clin Endocrinol Metab.80-1271:(3)98;2013. study

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الملحقاتANNEXES

39

Annex I

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2..

3. .

4.

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I ملحق

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4407016444070737

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Annex III

12-6

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III ملحق

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