Factors Associated with Iodine Deficiency Disorders (IDD)

in Elementary School 4 Krebet, Ponorogo, East Java

Nadiyah, Mahdian and Laras Sitoayu

Department of Nutrition Science, Universitas Esa Unggul, Jl. Arjuna Utara No.9, Jakarta, Indonesia

Keywords: IDD, Jambon, Krebet, Iodine, Protein.

Abstract: One of the problems being faced in Ponorogo district is the phenomenon of Idiot Village. One of the

villages known by the nickname is the Krebet Village in Jambon sub-district. Jambon is an endemic area

due to Iodine Deficiency Disorders (IDD). The purpose of this study is to examine the factors associated

with IDD in Elementary School 4 Krebet. This cross-sectional study was conducted from February to June

2016. The population is all students in Elementary School 4 Krebet. The total sample was 72 students. IDD

status was identified using the palpation. Salt iodine content was measured using the iodine test. The

frequency of food consumption from outside the village (FFCO) was collected by a food frequency

questionnaire. Energy and protein intake were assessed using food recall. Nutritional status was measured

using a height for age (HFA) index. The results of multiple logistic regression tests showed that significant

factors associated with the incidence of IDD were iodine salt content (OR=8.7; p=0.003), protein intake

level (OR=6.7; p=0.004), and FFCO (OR=5.8; p=0.009). It is very important for the Government of the

Ponorogo Regency to ensure that used salt truly contains iodine.

1 INTRODUCTION

Iodine deficiency (ID) causes poor school

performance, decreased resistance to infection, lack

of physical strength of children (WHO, 2013),

preventable mental retardation (Egli et al., 2004),

and inhibits the socio-economic growth of the nation

in general (Andersson, Karumbunathan and

Zimmermann, 2012).

The most vulnerable groups to ID are school

children and pregnant women, compared to other

population segments (Benoist et al., 2008).

According to the International Council for Control

of Iodine Deficiency Disorders (ICCIDD), there

were 32 countries with iodine deficiency in 2011,

declined from 54 countries in 2003 (World Health

Organization, 2013).

Iodine Deficiency Disorders (IDD) is still a

public health problem in Indonesia. National

prevalence was still above 5% in 2010 and varied

between provinces. There were still found sub-

districts with a prevalence of IDD above 30%. It was

estimated that around 18.16 million people live in

moderate and severe endemic areas, and 39.24

million people live in mild endemic areas (National

Institute of Health Research and Development,

2010).

According to the Basic Health Research 2013.,

urine iodine concentration (UIC) with a risk of

iodine deficiency among children aged 6-12 years as

14.9μg/L. Classified as endemic when it is observed

that population suffering from goiter enlargement

with the following classification, severe if the Total

Goiter Rate/TGR is or greater than 30%, moderate

if TGR ranges from 20% to 29.9%, mild if TGR

ranges from 5 to 19.9%, and non-endemic if TGR is

less than 5% (Ministry of Health, 2001).

Based on the result of the IDD survey in East

Java, it was found that TGR as 24.8%, classified as

mild endemic. One of the endemic areas in East Java

is Ponorogo Regency, it has a TGR of 12.27%. (East

Java Provincial Health Office, 2009).

Nutrition mapping 2008, which was conducted in

Ponorogo Regency to a sample of 6300 elementary

school children using the palpation, found that 9.7%

of children with grade I goiter, and 0.9% of children

with grade II goiter, as a result, Total Goiter Rate

(TGR) is 10.6% (Ponorogo Regency Health Office,

2010).

One of the endemic areas in the Ponorogo

Regency is Jambon Sub-district. The population in

Nadiyah, ., Mahdian, . and Sitoayu, L.

Factors Associated with Iodine Deﬁciency Disorders (IDD) in Elementary School 4 Krebet, Ponorogo, East Java.

DOI: 10.5220/0009573001730178

In Proceedings of the 1st International Conference on Health (ICOH 2019), pages 173-178

ISBN: 978-989-758-454-1

173

Jambon suffering from IDD as 315 people, the most

are found in Krebet and Sidoharjo Village

(Ponorogo Regency Health Office, 2015). Sidoharjo

Village is located at the end of Jambon Sub-district

and is area expansion from Krebet Village since

September 2007.

Sidoharjo Village is often known as the idiot

village. Out of 6257 total population of Sidoharjo

Village, approximately 249 people have mental

disabilities. It is caused by many factors, including

the location of the village on the slopes of the

limestone mountains with barren land so that it only

can be planted cassava as a staple food that is daily

consumed. Second, the lack of iodine content, even

none, contained in the salt consumed every day

(Ponorogo Regency Health Office, 2014).

Elementary School 4 Krebet is a public primary

school located in Dusun Sidowayah, Sidoharjo

Village, Jambon Sub-district, Ponorogo Regency.

This school accepts all children either normal or

with special needs. Although the Ministry of Health

has developed regulations and guidelines for the

availability of iodized salt, IDD prevalence is still a

significant public health problem. Therefore, this

study aims to examine factors related to IDD among

school children in Elementary School 4 Krebet,

Sidoharjo Village, Jambon, Ponorogo, East Java.

2 METHOD

2.1 Study Design, Time and Location

A school-based cross-sectional study was conducted

in Elementary School 4 Krebet, Dusun Sidowayah,

Sidoharjo Village, Jambon Sub-District, from

February to June 2016. The sub-district is found in

Ponorogo Regency, 20 km from the Ponorogo City.

The village, which is located at the end of Jambon

Sub-district, is area expansion from Krebet Village

since September 2007. Sidoharjo Village is located

at an altitude of 325 meters above sea level, in a

barren land and gets an average rainfall of 2000-

2500 mm once a year, with temperatures of 21-23ºC

(Ponorogo Regency Health Office,2014).

2.2 Sampling Procedure

The sample size was calculated by G-Power

software 3.1.9.2 considering the following

assumptions: 50% expected prevalence of IDD, a

5% error margin and at a 95% confidence level.

After adding a non-response rate of 10%, a sample

size of 72 was obtained. To select study participants,

this study used a systematic sampling technique. The

number of children from each class was divided by

the total number of samples to get the sampling

fraction. In addition, the total number of children

who meet the criteria chosen from each class was

proportional to the population size.

Study participants should meet the inclusion and

exclusion criteria. The inclusion criteria are the child

has lived in the village at least for the last year and

able to communicate. The exclusion criteria are the

child consumed iodine supplement for the last six

months and not present during data collection.

2.3 Data Collection and Procedure

The palpation method of the thyroid gland indicates

the enlargement, surface, and consistency of the

thyroid (Benoist et al., 2008). The palpation was

performed by trained health officers to assess the

size of the thyroid gland. According to the WHO

criteria, goiter was clinically defined: grade-0 when

there is no palpable goiter and categorized as not

suffering from IDD, grade-1 when there is palpable

and visible goiter with extended neck, and grade-2

when visible goiter with the head in normal position

is found (WHO, UNICEF, ICCIDD, 2001). In this

study, grade-1 and grade-2 were categorized as

suffering from IDD.

To specify the iodine content of salt, the

enumerators took the used salt for cooking at the

participant home. Iodine test was used to assess the

iodine content of the salt. Compared with the chart

color, the iodine content of salt was ensured. Iodine

concentration in salt is classified eligible or meet the

requirement when ranging between 30-80 ppm and

ineligible when less than 30 ppm (Ministry of

Health, 2001).

Information on food frequency from outside the

village was collected using a 30 items-Food

Frequency Questionnaire (FFQ). The questionnaire

was completed in the presence of skilled

enumerators. The tool was previously developed and

validated in a preliminary study. Each sample was

asked to answer the details of food in the

considerations column. At first, the reported answer

in FFQ was changed to a frequency score. Score 50

when consumed more than once a day, score 25

when consumed once a day, score 15 for four to six

times a week, score 10 for two to three times a week,

score 1 when consumed once a week, and score 0

when never consumed. Then, the total score from

each sample was divided by total sample to find the

average score, the average is 316.27. Classified to

frequently consumed when the sample’s score is or

ICOH 2019 - 1st International Conference on Health

174

greater than the average score and infrequently

consumed when the sample’s score is less than the

average score (Nadimin, 2011).

Energy and protein intake level was collected by

a 24-hour food recall to record the information of all

foods and beverages consumed by study participant

for two in consecutive days. Energy and protein

intake level was measured by percentage to the

Recommended Dietary Allowance (RDA) 2013.

Good when the intake level is or greater than 80%

RDA and poor when the level is less than 80%

RDA.

The used nutritional status is the Height for Age

(HFA) index, which is used to identify chronic

malnutrition. Z-score was calculated by WHO

Anthroplus software. Classified to stunted when the

HFA index is below -2SD value of z-scores and

normal when the index is or above -2SD (World

Health Organization, 2015).

2.4 Data Analysis

Frequencies and proportions were used to describe

variables as descriptive statistics. A bivariate

analysis using the chi-square test was used to show

the crude odds ratio of each independent variable on

IDD (grade I and II of a goiter). In multivariate

analysis, multiple logistic regression was applied

using a backward method to overcome the presence

of multicollinearity (Santoso et. al., 2005). With the

backward method, the best model is obtained by

eliminating insignificant variables. With a

corresponding 95% confidence interval, crude odds

ratio and adjusted odds ratio were calculated to

exhibit the power of the relationship. A p-value of

<0.05 was chosen to assert statistical significance.

3 RESULTS

More than half (51.4%) of the children were male

and aged ranging between 11-16 years. Nearly half

(41.7%) of the children were stunted and had IDD

(grade 1 and 2 goiter). About three-fourth (76.4%)

of the children had poor energy intake levels. More

than half (56.9%) of children had poor protein intake

levels. Almost one-third (27.8%) of the household

used ineligible iodized salt. About two-thirds

(63.9%) of children infrequently consumed food

from outside the village (Table 1).

The proportion of children who frequently

consumed food from outside the village in the last

week as following, most (94.4%) of them frequently

consumed rice and 76.4% ate tempeh and tofu,

followed by egg (65.3%) as their common animal

food source, then vegetables (46.9 %) and banana

(36.1 %) as the major fruit source. About one-third

(30.5%) of them frequently ate chicken. However,

the consumption of animal food products was low,

in which 17.0, and 9.7 %, respectively of children

ate dairy products and meat such as beef (Figure 1).

The prevalence of goiter was 41.7 %, in which

about 33.4 and 8.3 %, were found with grade 1 and

grade 2 goiter, respectively. The result of the

bivariate logistic regression analysis showed that

energy and protein intake level, iodine concentration

in salt and frequency of food consumption from

outside the village were significantly associated with

IDD. In the multivariate logistic regression analysis,

protein intake level, iodine concentration in salt and

frequency of food consumption from outside the

village remained significantly associated with IDD.

The odds of IDD among children with poor protein

intake level 6.7 times [AOR = 6.7; 95% CI: 1.8,

24.7] higher as compared to children with good

protein intake level. Those used ineligible salt 8.7

times [AOR = 8.7; 95% CI: 2.1, 35.7] higher as

compared to those used eligible iodized salt.

Likewise, the likelihood of IDD among children

infrequently consumed food from outside the village

was 5.9 times [AOR = 5.9; 95% CI: 1.5, 22.3] higher

than that of frequent counterparts (Table 2).

4 DISCUSSION

In this study, the prevalence of IDD or goiter was

41.7%, showed that there is a severe public health

problem. According to the World Health

Organization (WHO), the total goiter rate above 5%

reflects a public health problem (World Health

Organization, 2001).

This study also showed that the application of

iodized salt (72.2%) was lower than the WHO

recommendation (>90%) (World Health

Organization, 2013). Iodine concentration in salt

was found as the most dominant associated factor to

IDD [AOR = 8.7; 95% CI: 2.1, 35.7]. It is known

that the provision of iodine intake through daily

consumption of salt is the most commonly used

method. It has proven its success and has been

recommended by WHO and UNICEF. To accelerate

the achievement of IDD elimination, an agreement

was reached that iodized salt is the best tool to

increase iodine consumption in the effort to

eliminate IDD problems (WHO, UNICEF, ICCIDD,

2001).

Factors Associated with Iodine Deﬁciency Disorders (IDD) in Elementary School 4 Krebet, Ponorogo, East Java

175

Table 1: Characteristics of school children in Elementary School 4 Krebet, Jambon sub-district, Ponorogo, East Java, 2016.

Characteristics Frequency Percent

Sex

Male 37 51.4

Female 35 48.6

Age (in years)

5-10 35 48.6

11-16 37 51.4

Nutritional status (height for age)

Normal (-2SD to +2SD) 42 58.3

Stunted (<-2SD) 30 41.7

Energy intake level

Good (≥ 80% RDA) 17 23.6

Poor (<80% RDA) 55 76.4

Protein intake level

Good (≥ 80% RDA) 31 43.1

Poor (<80% RDA) 41 56.9

Iodine concentration in salt

Eligible (30-80 ppm) 52 72.2

Ineligible (< 30 ppm) 20 27.8

Frequency of food consumption from outside the

village

Frequent(≥ mean score) 26 36.1

Infrequent (<mean score) 46 63.9

Iodine Deficiency Disorders (IDD)

Yes (grade I and II goiter) 30 41.7

No (grade 0) 42 58.3

Figure 1: Proportion of respondents frequently consumed food from outside the village in the last week.

The majority of children have poor energy and

protein intake levels. Poor energy intake causes

protein anabolism to produce energy and inhibit the

metabolism of the thyroid hormone (Hetzel, 1989).

Poor protein intake level among children is a

significantly associated factor to IDD [AOR = 6.7;

95% CI: 1.8, 24.7]. Based on the dietary survey in

this study, the common dietary protein sources are

tempeh and tofu. Animal sources were not

frequently consumed because it is expensive and the

traditional market is far away.

According to Sauberlich (1999), protein

deficiency inhibits the production of thyroid

hormones, both triiodothyronine (T3) and thyroxine

(T4) are bound to serum proteins. In the production

of thyroid hormone, the initial step is the merger of

ICOH 2019 - 1st International Conference on Health

176

Table 2: Factors associated with iodine deficiency disorder/IDD (grade 1 and 2 goiters) among school children in

Elementary School 4 Krebet, Jambon Sub-District, Ponorogo Regency, East Java, 2016 (n =72).

Charactersitic

Iodine deficiency

disorders

COR

(95 % CI)

AOR

(95 % CI)

Yes No

Nutritional status

Stunted 10 20 0.5 (0.1, 2.5)

Normal 20 22 1

Energy intake level

Poor 27 28 4.5 (1.3, 9.6)*

Good 3 14

Protein intake level

Poor 23 18 4.4 (1.9, 25.1)* 6.7 (1.8, 24.7)*

Good 7 24

Iodine concentration in salt

Ineligible 14 6 5.2 (2.2, 35.8)* 8.7 (2.1, 35.7)*

Eligible 16 36 1 1

Frequency of food

consumption from outside the

village

Infrequent 25 21 5.0 (1.6, 22.6)* 5.9 (1.5, 22.3)*

Frequent 5 21 1 1

*p< 0.05,

Crude Odds Ratio,

Adjusted Odds Ratio

iodide into a large protein. In a state of decreased

protein will cause total hormone levels to decrease.

A decrease in released hormones from the thyroid

gland (especially T4) will cause feedback barriers in

the pituitary gland to produce Thyroid Stimulating

Hormone (TSH). The role of protein is also to

neutralize the effect of thiocyanate (Brody, 1993).

The frequency of food consumption from outside

the village was observed as a significantly associated

factor [AOR =5.9; 95% CI: 1.5, 22.3]. Iodine

content in the soil used in agriculture associated with

the incidence of iodine deficiency. Serious

deficiencies still take place in certain regions, even

though iodine supplementation programs have been

able to combat iodine deficiency in many regions of

the world (Brody, 1993).

As located in the highlands, Sidoharjo village has

a lack of food diversity. In order to get other

foodstuffs than local foodstuffs commonly grown,

they should go to traditional markets in other

regions. In addition, the large amount of local food

that commonly can be planted and grown have

goitrogenic substances such as spinach, cassava,

cabbage, and corn.

As research by Ningtyas et al., (2014), another

cause of iodine deficiency disorders (IDD) in Jember

Regency that was identified is the thiocyanate

goitrogenic factor. Papaya leaves, cassava leaves,

cabbage, and bamboo shoot are vegetables with

goitrogenic substances that were consumed daily.

The consumption of foods containing goitrogens

aggravates the development of goiter among children

with iodine deficiency (Brody, 1993). Goitrogens are

substances interfering with the incorporation of iodine

into a protein in the thyroid gland thus disrupt the

production of thyroid hormones.

Lack of food diversity consumed in Sidoharjo

causes a lack of nutrients intake such as selenium

that is important for thyroid metabolism. The

deiodinases are enzymes containing selenium that

are important for the activation of thyroid hormones.

These enzymes catalyze the deiodination of T4 and

produce the active form of thyroid hormone (T3) to

the bloodstream (Brody, 1993).

The study has some limitations. First, this study

used only school children as respondents. Second,

the study used a cross-sectional design thus the

results may not demonstrate the causality.

Factors Associated with Iodine Deﬁciency Disorders (IDD) in Elementary School 4 Krebet, Ponorogo, East Java

177

5 CONCLUSIONS

The prevalence of iodine deficiency disorders was

high, showing a severe public health problem. The

application of iodized salt in this study was lower

than the WHO recommendation. Moreover, The

dominant associated factor of IDD was ineligible

iodized salt. Hence, there is a necessity to strengthen

the application of salt iodization by the Government

of the Ponorogo Regency and concern must be

directed to schoolchildren to eradicate IDD

efficiently.

ACKNOWLEDGMENTS

The authors would like to deliver their gratefulness

to the study respondents for their participation and

Elementary School 4 Krebet for the study location

support.

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