In Focus
Hypothyroidism in India: more to be done The incidence of thyroid disorders in India is high, with hypothyroidism a particular problem that is not adequately controlled in the country at present. Sanjeet Bagcchi reports on this important public health issue. For the advanced management of thyroid disorders workshop see http://www. newindianexpress.com/cities/ chennai/42-Million-Suffer-fromThyroid-Disorders/2014/06/06/ article2265599.ece For the hyperthyroidism survey see http://timesofindia. indiatimes.com/city/mumbai/ One-in-10-adults-suffers-fromhypothyroidism-finds-survey/ articleshow/23841203.cms For the hypothyroidism 2013 study see http://www.ijem.in/ article.asp?issn=2230-8210;year =2013;volume=17;issue=4;spage =647;epage=652;aulast=Unnikri shnan For the iodine deficiency disorder newsletter see http:// www.iccidd.org/newsletter/idd_ aug13_india.pdf For the iodized salt coverage study see http://pib.nic.in/ newsite/erelease. aspx?relid=93253
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On June 5, 2014, delegates at a national workshop on the advanced management of thyroid disorders held in Chennai, India, heard that 42 million people in India have thyroid disorders. Hypothyroidism, specifically, is the most common of thyroid disorders in India, affecting one in ten adults. However, despite this dismal situation, the country does not have an effective and scientifically crafted policy to control the disease. The prevalence of hypothyroidism in India is 11%, compared with only 2% in the UK and 4·6% in the USA. Compared with coastal cities (eg, Mumbai, Goa, and Chennai), cities located inland (eg, Kolkata, Delhi, Ahmedabad, Bangalore, and Hyderabad) have a higher prevalence (11·7% vs 9·5%). According to Ambrish Mithal, chairman of the Medanta Division of Endocrinology and Diabetes (Gurgaon, India), the reason behind the higher mean thyroid -s timulatin g hormon e concentration and range in India compared with western countries is possibly linked to long-standing iodine deficiency in the country, which has only been partly corrected over the past 20 years. The highest prevalence of hypothyroidism (13·1%) is noted in people aged 46–54 years, with people aged 18–35 years being less affected (7·5%). “Although an easy-to-detect and inexpensive-to-treat disease, patients with hypothyroidism in India often remain undetected and untreated, and thus the disease impairs the work performance and economic productivity of Indian people”, says Swapan Jana, a public health expert and secretary of Society for Social Pharmacology (Kolkata, India). He
adds: “In the past, iodine deficiency was blamed for the occurrence of hypothyroidism in India, but the disease is still prevalent in this country, despite the promotion of iodised salt since 1983”. Production of iodised salt in India has increased by almost nine times in the past two decades—from 0·7 million metric tons per year in 1985–86 to about 6·2 million nowadays. Despite an increase in iodised salt consumption (national coverage was 51% in 2005–06 and 71% in 2009), a 2013 study showed that 42·2% of households consumed inadequately iodised salt and 10·5% consumed salt with no iodine. “Even now, there are two major factors— poverty and inability of consumers to assess the quality of salt they purchase—that hinder iodised salt consumption in India, thereby putting a large number of people at risk of iodine deficiency”, says Jana. “Iodine supplementation can also induce or aggravate autoimmunity, resulting in goitre and thyroid dysfunction”, says Mithal. According to Sanjay Kalra, consultant endocrinologist at the Bharti Hospital (Haryana, India), “India has just completed its transition from iodine deficiency to iodine replete status. This transition is followed by a spurt in autoimmune thyroid disorders.” Ambika Gopalakrishnan Unnikrishnan, chief endocrinologist at the Chellaram Diabetes Institute (Pune, India), notes: “Across the world, with the advent of iodisation, autoimmune thyroid disease has become the most common cause of hypothyroidism.” Environmental factors other than iodine deficiency might play a part in hypothyroidism in India. “Goitrogens
and exposure to cyanogenic compounds have an adverse impact on iodine metabolism”, says Mithal. “The unregulated use of pesticides and exposure to endocrine disruptors could be a reason”, he suggests, adding that “Unclean drinking water and exposure to industrial pollutants like resorcinol and phthalic acid have also been suggested as causes.” According to Mithal, the programme to eradicate iodine deficiency has had “tremendous impact”; however, the two so-called hot spots that need to be addressed as a matter of priority are hypothyroidism in neonates and pregnant women. “Hypothyroidism in pregnant women if untreated or inadequately treated can compromise fetal neurocognitive development”, he points out. “A nationwide screening programme for congenital hypothyroidism should be very high on the agenda”, Mithal urges. He adds: “Early treatment will prevent irreversible mental retardation in a large number of newborns. Screening and treatment of pregnant women in the first trimester for thyroid disorders could also have a significant impact on brain health of the neonate. These two areas need to be taken up by the government on a high priority.” According to Kalra, broadscale measures are needed to control hypothyroidism in India. He thinks that it is important to spread awareness in the population and do targeted screening and early management of the disease. “India has impressive policies to deal with non-communicable diseases. The non-communicable disease prevention programme needs to include thyroid disorders in its ambit”, Kalra adds.
Sanjeet Bagcchi
www.thelancet.com/diabetes-endocrinology Vol 2 October 2014
Hypothyroidism in India: more to be done The incidence of thyroid disorders in India is high, with hypothyroidism a particular problem that is not adequately controlled in the country at present. Sanjeet Bagcchi reports on this important public health issue. For the advanced management of thyroid disorders workshop see http://www. newindianexpress.com/cities/ chennai/42-Million-Suffer-fromThyroid-Disorders/2014/06/06/ article2265599.ece For the hyperthyroidism survey see http://timesofindia. indiatimes.com/city/mumbai/ One-in-10-adults-suffers-fromhypothyroidism-finds-survey/ articleshow/23841203.cms For the hypothyroidism 2013 study see http://www.ijem.in/ article.asp?issn=2230-8210;year =2013;volume=17;issue=4;spage =647;epage=652;aulast=Unnikri shnan For the iodine deficiency disorder newsletter see http:// www.iccidd.org/newsletter/idd_ aug13_india.pdf For the iodized salt coverage study see http://pib.nic.in/ newsite/erelease. aspx?relid=93253
778
On June 5, 2014, delegates at a national workshop on the advanced management of thyroid disorders held in Chennai, India, heard that 42 million people in India have thyroid disorders. Hypothyroidism, specifically, is the most common of thyroid disorders in India, affecting one in ten adults. However, despite this dismal situation, the country does not have an effective and scientifically crafted policy to control the disease. The prevalence of hypothyroidism in India is 11%, compared with only 2% in the UK and 4·6% in the USA. Compared with coastal cities (eg, Mumbai, Goa, and Chennai), cities located inland (eg, Kolkata, Delhi, Ahmedabad, Bangalore, and Hyderabad) have a higher prevalence (11·7% vs 9·5%). According to Ambrish Mithal, chairman of the Medanta Division of Endocrinology and Diabetes (Gurgaon, India), the reason behind the higher mean thyroid -s timulatin g hormon e concentration and range in India compared with western countries is possibly linked to long-standing iodine deficiency in the country, which has only been partly corrected over the past 20 years. The highest prevalence of hypothyroidism (13·1%) is noted in people aged 46–54 years, with people aged 18–35 years being less affected (7·5%). “Although an easy-to-detect and inexpensive-to-treat disease, patients with hypothyroidism in India often remain undetected and untreated, and thus the disease impairs the work performance and economic productivity of Indian people”, says Swapan Jana, a public health expert and secretary of Society for Social Pharmacology (Kolkata, India). He
adds: “In the past, iodine deficiency was blamed for the occurrence of hypothyroidism in India, but the disease is still prevalent in this country, despite the promotion of iodised salt since 1983”. Production of iodised salt in India has increased by almost nine times in the past two decades—from 0·7 million metric tons per year in 1985–86 to about 6·2 million nowadays. Despite an increase in iodised salt consumption (national coverage was 51% in 2005–06 and 71% in 2009), a 2013 study showed that 42·2% of households consumed inadequately iodised salt and 10·5% consumed salt with no iodine. “Even now, there are two major factors— poverty and inability of consumers to assess the quality of salt they purchase—that hinder iodised salt consumption in India, thereby putting a large number of people at risk of iodine deficiency”, says Jana. “Iodine supplementation can also induce or aggravate autoimmunity, resulting in goitre and thyroid dysfunction”, says Mithal. According to Sanjay Kalra, consultant endocrinologist at the Bharti Hospital (Haryana, India), “India has just completed its transition from iodine deficiency to iodine replete status. This transition is followed by a spurt in autoimmune thyroid disorders.” Ambika Gopalakrishnan Unnikrishnan, chief endocrinologist at the Chellaram Diabetes Institute (Pune, India), notes: “Across the world, with the advent of iodisation, autoimmune thyroid disease has become the most common cause of hypothyroidism.” Environmental factors other than iodine deficiency might play a part in hypothyroidism in India. “Goitrogens
and exposure to cyanogenic compounds have an adverse impact on iodine metabolism”, says Mithal. “The unregulated use of pesticides and exposure to endocrine disruptors could be a reason”, he suggests, adding that “Unclean drinking water and exposure to industrial pollutants like resorcinol and phthalic acid have also been suggested as causes.” According to Mithal, the programme to eradicate iodine deficiency has had “tremendous impact”; however, the two so-called hot spots that need to be addressed as a matter of priority are hypothyroidism in neonates and pregnant women. “Hypothyroidism in pregnant women if untreated or inadequately treated can compromise fetal neurocognitive development”, he points out. “A nationwide screening programme for congenital hypothyroidism should be very high on the agenda”, Mithal urges. He adds: “Early treatment will prevent irreversible mental retardation in a large number of newborns. Screening and treatment of pregnant women in the first trimester for thyroid disorders could also have a significant impact on brain health of the neonate. These two areas need to be taken up by the government on a high priority.” According to Kalra, broadscale measures are needed to control hypothyroidism in India. He thinks that it is important to spread awareness in the population and do targeted screening and early management of the disease. “India has impressive policies to deal with non-communicable diseases. The non-communicable disease prevention programme needs to include thyroid disorders in its ambit”, Kalra adds.
Sanjeet Bagcchi
www.thelancet.com/diabetes-endocrinology Vol 2 October 2014
