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Various measures were taken: large trees that prevented the entry of fresh air to villages were felled, wet streets were drained, the water tested for potability, and school hygiene improved. In addition, iodized salt was distributed and schoolchildren were given iodine tablets daily.
However, because goiter exempted young men from unpopular military service in the French army, many parents, fearing their sons would be enlisted, were against iodine prophylaxis.
This high dose of iodine was consistent with the enormous doses of iodine used to treat many diseases at the time scrofula, syphilis, arthritis. Thus, whereas French children tolerated the high doses of iodine well, it likely precipitated IIH in some adults. As a result, the program was discredited and discontinued.
Medical authorities recognized cretinism only occurred in areas of endemic goiter but were puzzled by the fact that many cretins had an atrophic or absent thyroid gland, the opposite of goiter. A clue to this apparent paradox appeared when a related disease, myxedema, was described by Ord in in London 8.
Myxedema resembled cretinism in many ways but was seen only in adults, usually women. In , Semon suggested myxedema was due to a lack of activity of the thyroid 9 after reading a report by the Swiss surgeon Kocher describing myxedemic symptoms in patients after total thyroidectomy They found this substance, termed thyroiodine, to be effective in the treatment of both myxedema and goiter.
They correctly surmised iodine itself was not therapeutically active but had to be first incorporated into an organic molecule 12 , Before its introduction, Switzerland was severely iodine deficient. For example, in , a census ordered by Napoleon reported cretins among the 70, inhabitants of the Canton Valais, in the Swiss Alps 1. In , Hunziker, in the canton of Zurich, dismissed the infection theory of goiter and stated it was not a disease but an adaptation to a diet low in iodine. He believed the addition of minute quantities of iodine to the food supply would prevent the condition and gave iodine to cure goiter in children The administration of more iodine causes it again to decrease in size.
In , the Swiss physician Bayard Fig. He did this in Grachen, an isolated village at the base of the famous Matterhorn mountain in the Zermatt valley. He gave iodized salt for 6 mo to families in the village. In , the rural Swiss general practitioner O. Bayard conducted the first dose-response trial of iodized salt to treat goiter in schoolchildren. Reproduced with permission from 1. The results of Marine and Kimball's studies of iodine prophylaxis in Akron in were not announced in Swiss medical literature until 1.
This was after Hunziker and Bayard had carried out their small-scale experiments in Switzerland. In , Klinger, noting the success of the U. He suggested the Swiss Federal Government should be responsible for the program and a Swiss Goiter Committee was formed in The Goiter Committee had no powers of decision but acted in an advisory capacity to the Federal Office of Health.
Initially, the committee cautiously advised the introduction of salt iodized at 1. However, every Swiss canton had its own salt monopoly and each cantonal government or health authority could decide whether to iodize its salt. The first canton in which iodized salt was introduced was Appenzell AR, in , thanks to the efforts of the surgeon Eggenberger Fig. He pushed the local government to allow the sale of salt iodized at 7. The birthplace of the Swiss iodized salt program: H. Eggenberger and his family iodizing salt for distribution in the Canton of Appenzell, Switzerland, in The iodine in Swiss salt was subsequently increased in a stepwise manner to 7.
This gradual increase may have avoided a widespread outbreak of IIH in the chronically iodine-deficient Swiss population In , when the salt iodine content was increased from 7. The Swiss iodized salt program today is a flexible, smooth-running program that involves a minimum of administration. Salt producers and retailers must offer both iodized and noniodized salt, as compulsory use would be perceived as unconstitutional.
At about the same time as the first Swiss iodine studies in —, Marine and Kimball were introducing iodine prophylaxis in the Midwest region of the US. David Marine Fig. According to legend, he was surprised when asked on his first day what research problem he would like to work on. He had noticed several dogs with large goiters in the neighborhood and replied without much reflection he would like to work on thyroid disease Marine subsequently confirmed Baumann's finding that large goiters contained less total iodine than healthy glands That iodine deficiency was not the only potential dietary contributor to goiter was confirmed 15 y later when Marine published his work on the goitrogenic action of certain cyanides in animals In —17, the American physician David Marine conducted the first large-scale trials of iodine supplementation to prevent goiter in children in Akron, Ohio.
From the U. Marine realized goiter was a serious public health problem in the Great Lakes region and in he planned to do an intervention with iodine in schoolchildren in Cleveland. However, the school board refused, concerned iodine could be poisonous. With the help of Kimball he received permission to do the study in neighboring Akron, Ohio 25 , The treatment group was girls in the 5th grade and above whose parents gave consent for them to be included in the trial; the controls were those girls whose parents did not consent.
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Treatment for students in the 5th—8th grades was mg NaI per school day for 10 d, equivalent to a total of mg iodine; double this amount was given to the older girls. These excessive doses are similar to those recommended a century earlier by Coindet 2. In the girls who received iodine who were not goitrous at baseline, only 0.
Based on these and other successful experiments, general prophylaxis with iodized salt was introduced in the state of Michigan in Based on an estimated per capita salt intake of 6. There were protests and at first the Bureau of Chemistry of the USDA demanded the iodized salt packages be marked with the skull and crossbones used to indicate a poison but then backed down. In , the U. Endemic Goiter Committee tried to introduce iodized salt to all the states by federal law, but the bill failed.
But although it was recognized many countries were affected by goiter, little attention was paid to iodine deficiency in public health programs. Goiter was considered a lump in the neck primarily of cosmetic concern; it generated little political attention or action and few resources were allocated for its control. This changed during the period of — Controlled studies in iodine-deficient regions showed that iodine supplementation not only eliminated the incidence of cretinism but also improved cognitive function in the remaining population.
Universal salt iodization iodized salt for both human and animal consumption also improved the viability and quality of livestock Iodine deficiency was thus shown to have social and economic consequences far greater than previously appreciated that could slow country development.
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This changing view allowed iodine deficiency and goiter to be repositioned in the development perspective. The term iodine deficiency disorders IDD was coined and IDD was repositioned as a spectrum of related disorders affecting 1. It was estimated to be the leading cause of preventable mental retardation around the world. Programs against IDD had obvious political appeal because its human, economic, and social consequences could be averted by a low-cost intervention, universal salt iodization. This message was disseminated through high-level political forums to incite attention, commitment, and actions.
Since , elimination of IDD has been an integral part of most national nutrition strategies. Today, iodine nutrition continues to be an area of active research, with recent studies focusing on the links between deficient and excess iodine intake and the epidemiology of thyroid diseases, interactions of IDD and other micronutrient deficiencies, as well as molecular mechanisms 31 — Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
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