IODINE FACT SHEET FOR HEALTH PROFESSIONALS – Patriotic Strong Lugol’s Iodide

INFORMATION FROM

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES – NATIONAL INSTITUTES OF HEALTH (NIH)

INTRODUCTION

Iodine is a trace element that is naturally present in some foods, added to others, and available as a dietary supplement. Iodine is an essential component of the thyroid hormones thyroxine (T4) and triiodothyronine (T3). Thyroid hormones regulate many important biochemical reactions, including protein synthesis and enzymatic activity, and are critical determinants of metabolic activity [1,2]. They are also required for proper skeletal and central nervous system development in fetuses and infants [1].

Thyroid function is primarily regulated by thyroid-stimulating hormone (TSH), also known as thyrotropin. It is secreted by the pituitary gland to control thyroid hormone production and secretion, thereby protecting the body from hypothyroidism and hyperthyroidism [1]. TSH secretion increases thyroidal uptake of iodine and stimulates the synthesis and release of T3 and T4. In the absence of sufficient iodine, TSH levels remain elevated, leading to goiter, an enlargement of the thyroid gland that reflects the body’s attempt to trap more iodine from the circulation and produce thyroid hormones.

Iodine may have other physiological functions in the body as well. For example, it appears to play a role in immune response and might have a beneficial effect on mammary dysplasia and fibrocystic breast disease [2].
The earth’s soils contain varying amounts of iodine, which in turn affects the iodine content of crops. In some regions of the world, iodine-deficient soils are common, increasing the risk of iodine deficiency among people who consume foods primarily from those areas. Salt iodization programs, which many countries have implemented, have dramatically reduced the prevalence of iodine deficiency worldwide [2,3].

Iodine in food and iodized salt is present in several chemical forms including sodium and potassium salts, inorganic iodine (I2), iodate, and iodide, the reduced form of iodine [4]. Iodine rarely occurs as the element, but rather as a salt; for this reason, it is referred to as iodide and not iodine. Iodide is quickly and almost completely absorbed in the stomach and duodenum. Iodate is reduced in the gastrointestinal tract and absorbed as iodide [2,5]. When iodide enters the circulation, the thyroid gland concentrates it in appropriate amounts for thyroid hormone synthesis and most of the remaining amount is excreted in the urine [2]. The iodine-replete healthy adult has about 15–20 mg of iodine, 70%–80% of which is contained in the thyroid [6].

Median urinary iodine concentrations of 100–199 mcg/L in children and adults, 150–249 mcg/L in pregnant women and >100 mcg/L in lactating women indicate iodine intakes are adequate [3]. Values lower than 100 mcg/L in children and non-pregnant adults indicate insufficient iodine intake, although iodine deficiency is not classified as severe until urinary iodine levels are lower than 20 mcg/L.

Recommended Intakes
Intake recommendations for iodine and other nutrients are provided in the Dietary Reference Intakes (DRIs) developed by the Food and Nutrition Board (FNB) at the Institute of Medicine of the National Academies (formerly National Academy of Sciences) [2]. DRI is the general term for a set of reference values used for planning and assessing nutrient intakes of healthy people. These values, which vary by age and gender [2], include:

• Recommended Dietary Allowance (RDA): Average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%–98%) healthy individuals; often used to plan nutritionally adequate diets for individuals.
• Adequate Intake (AI): Intake at this level is assumed to ensure nutritional adequacy; established when evidence is insufficient to develop an RDA.
• Estimated Average Requirement (EAR): Average daily level of intake estimated to meet the requirements of 50% of healthy individuals; usually used to assess the nutrient intakes of groups of people and to plan nutritionally adequate diets for them; can also be used to assess the nutrient intakes of individuals.
• Tolerable Upper Intake Level (UL): Maximum daily intake unlikely to cause adverse health effects.

Table 1 lists the current RDAs for iodine [2]. For infants from birth to 12 months, the FNB established an AI for iodine that is equivalent to the mean intake of iodine in healthy, breastfed infants in the United States.

Table 1: Recommended Dietary Allowances (RDAs) for Iodine[2]
Age                                           Male                 Female              Pregnancy           Lactation
Birth to 6 months                      110 mcg*           110 mcg*
7–12 months                            130 mcg*           130 mcg*
1–3 years                                   90 mcg               90 mcg
4–8 years                                   90 mcg               90 mcg
9–13 years                               120 mcg             120 mcg
14–18 years                             150 mcg             150 mcg            220 mcg               290 mcg
19+ years                                 150 mcg             150 mcg            220 mcg                290 mcg
* Adequate Intake (AI)

The World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and the International Council for the Control of Iodine Deficiency Disorders (ICCIDD) recommend a slightly higher iodine intake for pregnant women of 250 mcg per day [3,7].

Sources of Iodine
Food
Seaweed (such as kelp, nori, kombu, and wakame) is one of the best food sources of iodine, but it is highly variable in its content (Table 2) [5]. Other good sources include seafood, dairy products (partly due to the use of iodine feed supplements and iodophor sanitizing agents in the dairy industry [8]), grain products, and eggs. Dairy products, especially milk, and grain products are the major contributors of iodine to the American diet [9]. Iodine is also present in human breast milk [2,5] and infant formulas.

Fruits and vegetables contain iodine, but the amount varies depending on the iodine content of the soil, fertilizer use, and irrigation practices [2]. Iodine concentrations in plant foods can range from as little as 10 mcg/kg to 1 mg/kg dry weight [5]. This variability in turn affects the iodine content of meat and animal products because it affects the iodine content of foods that the animals consume [10]. The iodine content of different seaweed species also varies greatly [11]. For these reasons, the values in Table 2 are approximate.

Table 2: Selected Food Sources of Iodine [10,11,12]
Approximate
Micrograms (mcg)
Food                                                                                           per serving                                     Percent DV*
Seaweed, whole or sheet, 1 g                                                    16 to 2,984                                    11% to 1,989%
Cod, baked,                                                                                3 ounces                                              9966%
Yogurt, plain, low-fat,                                                                   1 cup                                                    7550%
Iodized salt,                                                                     1.5 g (approx. ¼ teaspoon)                              7147%
Milk, reduced fat,                                                                         1 cup                                                     5637%
Fish sticks,                                                                                3 ounces                                                  5436%
Bread, white, enriched,                                                              2 slices                                                    4530%
Fruit cocktail in heavy syrup, canned,                                        ½ cup                                                      4228%
Shrimp,                                                                                    3 ounces                                                    3523%
Ice cream, chocolate,                                                                ½ cup                                                       3020%
Macaroni, enriched, boiled,                                                       1 cup                                                         2718%
Egg,                                                                                        1 large                                                         2416%
Tuna, canned in oil, drained,                                                    3 ounces                                                    1711%
Corn, cream style, canned,                                                       ½ cup                                                         149%
Prunes, dried,                                                                          5 prunes                                                      139%
Cheese, cheddar,                                                                     1 ounce                                                       128%
Raisin bran cereal,                                                                     1 cup                                                          117%
Lima beans, mature, boiled,                                                     ½ cup                                                             85%
Apple juice,                                                                                1 cup                                                            75%
Green peas, frozen, boiled,                                                       ½ cup                                                           32%
Banana,                                                                                  1 medium                                                         32%
*DV = Daily Value. The U.S. Food and Drug Administration (FDA) developed DVs to help consumers compare the nutrient contents of foods and dietary supplements within the context of a total diet. The DV for iodine is 150 mcg for adults and children aged 4 years and older [13]. FDA does not require food labels to list iodine content unless iodine has been added to the food. Foods providing 20% or more of the DV are considered to be high sources of a nutrient, but foods providing lower percentages of the DV also contribute to a healthful diet.

The U.S. Department of Agriculture’s (USDA’s) FoodData Central [14] does not list the iodine content of foods or provide lists of foods containing iodine.

Iodized Salt
The United States, Canada, and dozens of other countries have salt iodization programs [3,15,16]. In the United States, salt manufacturers have been adding iodine to table salt since the 1920s, although it is still a voluntary program [12]. The U.S. Food and Drug Administration (FDA) has approved potassium iodide and cuprous iodide for salt iodization [17] while the WHO recommends the use of potassium iodate due to its greater stability, particularly in tropical climates [3]. According to its label, iodized salt in the United States contains 45 mcg iodine/g salt (between 1/8 and 1/4 teaspoon); measured salt samples have an average level of 47.5 mcg iodine/g salt [12]. However, the majority of salt intake in the United States comes from processed foods, and food manufacturers almost always use non-iodized salt in processed foods. If they do use iodized salt, they must list the salt as iodized in the ingredient list on the food label [8].

Dietary supplements
Many multivitamin/mineral supplements contain iodine in the forms of potassium iodide or sodium iodide. Dietary supplements of iodine or iodine-containing kelp (a seaweed) are also available. A small study found that potassium iodide is almost completely (96.4%) absorbed in humans [18].

Iodine Intakes and Status
Iodine Intakes
The Total Diet Study (TDS), an FDA monitoring program, provides estimated iodine intakes of the U.S. population [9]. Through the TDS program, foods that represent the average U.S. diet are purchased and analyzed for several components, including iodine. Based on analytical results from TDS food samples collected between 2008 and 2012, combined with food consumption estimates, the average daily iodine intake in the United States was 216 mcg/day, with a range from 141 to 296 mcg/day across all age and gender groups [19]. These intakes meet or exceed the EAR for all groups.

TDS data do not include iodine that people obtain from the discretionary use of iodized salt [20,21]. Because many U.S. households use iodized salt, TDS data likely underestimate the true iodine intake of most U.S. residents. Data from the National Health and Nutrition Examination Survey (NHANES) collected between 1999 and 2004 indicate that 28–29% of adults use iodine-containing dietary supplements [22]; this use also adds to the population’s total iodine intake.

Iodine status of the general U.S. population
Iodine status is typically assessed using urinary iodine measurements. Urinary iodine reflects dietary iodine intake directly because people excrete more than 90% of dietary iodine in the urine [4]. Spot urine iodine measurements are a useful indicator of iodine status within populations [23,24]. However, multiple 24-hour urinary iodine or multiple spot urine measurements are more accurate for individuals [4,25]. For a population of school-aged children or non-pregnant adults to be iodine sufficient, median urinary iodine concentrations should be greater than 100 mcg/L and no more than 20% of the population should have values lower than 50 mcg/L [3].

Urinary iodine measurements from NHANES have been used since 1971 to monitor the iodine status of the U.S. population [26]. Since the inception of the NHANES monitoring program, urinary iodine measurements have shown that the general U.S. population is iodine sufficient. This is despite the fact that urinary iodine levels decreased by more than 50% between 1971–1974 and 1988–1994 [2,27]. Much of this decline was a result of decreased levels of iodine in milk due to the reduced use of iodine-containing feed supplements and iodophor sanitizing agents in the dairy industry [28], as well as the reduced use of iodate dough conditioners by commercial bakers. The use of erythrosine, an iodine-containing food dye commonly used in fruit-flavored breakfast cereals, also decreased during this time [28], though it is unclear to what extent this change actually affected urinary iodine levels because the bioavailability of iodine from erythrosine has been found to be low [29]. This sharp decline in urinary iodine levels caused some concern during the late 1990s that the iodine sufficiency of the U.S. population could be at risk if this trend continued [27].

More recent NHANES measurements indicate that urinary iodine levels have stabilized in the general U.S. population. During 2007–2008, NHANES participants aged 6 years and older had a median urinary iodine concentration of 164 mcg/L [30]. Among women of reproductive age, the median urinary iodine concentration in NHANES 2007–2014 was 119 mcg/L [31]. These values have essentially remained unchanged in the last three NHANES surveys, indicating that the dietary iodine intake of the general U.S. population has remained stable since 2000 [30].

Iodine Status of U.S. Pregnant Women
According to the WHO, a median urinary iodine concentration of 150–249 mcg/L indicates adequate iodine nutrition during pregnancy, while values less than 150 mcg/L are considered insufficient [3,7]. Analyses of NHANES datasets from 2003 to 2014 indicate that a substantial portion of pregnant women in the United States are iodine insufficient. Median urinary iodine concentrations for pregnant women participating in NHANES surveys were 181 mcg/L in 2003–2004, 153 mcg/L in 2001–2006, 125 mcg/L in 2005–2008, and 144 mcg/L in 2007–2014 [26,30-32]. Suboptimal iodine status during pregnancy has also been observed in Australia [33].

Pregnant women who do not consume dairy products may be particularly at risk of iodine insufficiency. According to NHANES 2001–2006 data, pregnant women who consumed no dairy products in the previous 24 hours had a median urinary iodine concentration of only 100 mcg/L, compared with 163 mcg/L among consumers of dairy [32]. Women who restrict their dietary salt intake also have lower urinary iodine concentrations and might be more likely to be iodine deficient than women who don’t restrict salt intake [34].

Overall, it appears that the general U.S. population has adequate iodine intake but that some pregnant women may be at risk for iodine deficiency. Continued national iodine monitoring is needed with more emphasis on population subgroups that are most susceptible to iodine deficiency disorders.

Iodine Deficiency
Iodine deficiency has multiple adverse effects on growth and development, and is the most common cause of preventable intellectual disability in the world [35]. Iodine deficiency disorders result from inadequate thyroid hormone production secondary to insufficient iodine [5]. During pregnancy and early infancy, iodine deficiency can cause irreversible effects.

Under normal conditions, the body tightly controls thyroid hormone concentrations via TSH. Typically, TSH secretion increases when iodine intake falls below about 100 mcg/day [5]. TSH increases thyroidal iodine uptake from the blood and the production of thyroid hormone. However, very low iodine intakes can reduce thyroid hormone production even in the presence of elevated TSH levels.

If a person’s iodine intake falls below approximately 10–20 mcg/day, hypothyroidism occurs [1], a condition that is frequently accompanied by goiter. Goiter is usually the earliest clinical sign of iodine deficiency [2]. In pregnant women, iodine deficiency of this magnitude can cause major neurodevelopmental deficits and growth retardation in the fetus, as well as miscarriage and stillbirth [5]. Chronic, severe iodine deficiency in utero causes cretinism, a condition characterized by intellectual disability, deaf mutism, motor spasticity, stunted growth, delayed sexual maturation, and other physical and neurological abnormalities [5].

In infants and children, less severe iodine deficiency can also cause neurodevelopmental deficits such as somewhat lower-than-average intelligence as measured by IQ [1,36,37]. Mild to moderate maternal iodine deficiency has also been associated with an increased risk of attention deficit hyperactivity disorder in children [38]. In adults, mild-to-moderate iodine deficiency can cause goiter as well as impaired mental function and work productivity secondary to hypothyroidism. Chronic iodine deficiency may be associated with an increased risk of the follicular form of thyroid cancer [39].

Groups at Risk of Iodine Inadequacy
Historically, iodine deficiency was endemic in mountainous regions of the United States and Mexico, and in the so called “goiter belt” around the Great Lakes [40]. Thanks to a more national food supply, iodized salt, and other factors, iodine deficiency is now uncommon in North America. International efforts since the early 1990s have dramatically reduced the incidence of iodine deficiency worldwide, but some groups of people are still at risk of inadequate iodine intake. Iodine insufficiency remains a public health problem in 25 countries with a total population of about 683 million people [41].

People living in regions with iodine-deficient soils
Iodine-deficient soils produce crops that have low iodine levels. Mountainous areas, such as the Himalayas, Alps, and Andes regions, and river valleys prone to flooding, especially in South and Southeast Asia, are among the most iodine-deficient regions in the world [5]. Populations in these areas are at risk of iodine deficiency unless they have access to iodized salt or foods produced outside the iodine-deficient area.

People with marginal iodine status who eat foods containing goitrogens
Consumption of foods that contain goitrogens, substances that interfere with the uptake of iodine in the thyroid, can exacerbate iodine deficiency [2]. Foods high in goitrogens include soy and cassava, cabbage, broccoli, cauliflower, and other cruciferous vegetables. Deficiencies of iron and/or vitamin A may also be goitrogenic [42]. These issues are of concern primarily for people living in areas prone to iodine deficiency [6]. For most people, including most of the U.S. population, who have adequate iodine intakes and eat a variety of foods, the consumption in reasonable amounts of foods containing goitrogens is not a concern.

People who do not use iodized salt
The use of iodized salt is the most widely used strategy to control iodine deficiency. Currently, about 88% of households worldwide use iodized salt, but iodine insufficiency is still prevalent in certain regions, particularly Southeast Asia, sub-Saharan Africa, and Eastern Europe [41,43].

Pregnant women
During pregnancy, the RDA for iodine increases from 150 to 220 mcg/day [2]. Surveys indicate that many pregnant women in the United States, while not showing signs of overt iodine deficiency, may obtain insufficient amounts of iodine [30]. The impact of this, if any, on fetal development is not known at this time.

Iodine and Health
Due to its important role in fetal and infant development and thyroid hormone production, iodine is a critical nutrient for proper health at all life stages. This section focuses on four areas of biomedical research examining iodine’s role in health and disease: fetal and infant development, cognitive function during childhood, fibrocystic breast disease, and radiation-induced thyroid cancer.

Fetal and infant development
Iodine sufficiency during pregnancy is extremely important for proper fetal development. During early pregnancy, when fetal thyroid gland development is incomplete, the fetus depends entirely on maternal T4 and therefore, on maternal iodine intake [44]. Production of T4 increases by approximately 50% during pregnancy [45], requiring a concomitant increase in maternal iodine intake. Sufficient iodine intake after birth is also important for proper physical and neurological growth and maturation.

Research suggests that infants are more sensitive to the effects of iodine deficiency than other age groups, as indicated by changes in their TSH and T4 levels in response to even mild iodine deficiency [46]. Although severe iodine deficiency disorders are uncommon in the United States, mild-to-moderate iodine insufficiency during pregnancy may subtly affect fetal development [4,47,48,49,50,51]. A meta-analysis of 6,180 mother-child pairs from three birth cohorts in the Netherlands, Spain, and the United Kingdom found that verbal IQ assessed in children at 1.5 to 8 years of age was lower if their mothers had lower iodine status in their first trimester of pregnancy [37]. To accommodate increased iodine needs during pregnancy and lactation, the iodine RDA is 220 mcg/day for pregnant women and 290 mcg/day for lactating women [2]. Similarly, the WHO recommends 250 mcg/day during pregnancy and lactation [3].

Despite the importance of iodine for proper fetal development, the effects of iodine supplements during pregnancy on infant and child neurodevelopment in particular are inconclusive. Two randomized clinical trials had a similar study design in which iodine was provided from early pregnancy to delivery (150 or 200 mcg/day iodine as potassium iodide) and assessed child cognition using the same tool at ages 1.5 or 2 years [52,53]. Iodine supplementation had no effect on child cognitive, language, or motor scores [54]. One of these trials also assessed children at age 5‒6 years and continued to find no benefit on child neurodevelopment from the mother’s use of iodine [52].

Breast milk contains iodine, although concentrations vary based on maternal iodine levels. Infants who are exclusively breastfed depend on maternal iodine sufficiency for optimal development. In a study of 57 healthy lactating women from the Boston area, median breast milk iodine content was 155 mcg/L [55]. Based on reported infant iodine needs and the typical volume of breast milk consumed, the authors calculated that 47% of the women may have been providing their infants breast milk containing insufficient amounts of iodine. During the weaning period, infants not receiving iodine-containing complementary foods may also be at risk of iodine deficiency, even in countries with iodized salt programs [56,57].

To ensure that adequate amounts of iodine are available for proper fetal and infant development, several national and international groups recommend iodine supplementation during pregnancy, lactation, and early childhood. For women living in countries with weak, sporadic, or uneven iodized salt distribution, the WHO recommends iodine supplementation for all women of childbearing age to achieve a total iodine intake of 150 mcg/day. For pregnant and lactating women in these countries, iodine intakes of 250 mcg/day from both supplements and dietary sources are recommended [3,7]. WHO recommendations for these countries also include breastfeeding through 24 months of age, combined with complementary foods fortified with iodine for children between the ages of 7–24 months [7].
The American Thyroid Association recommends that women who are planning a pregnancy, currently pregnant, or lactating should supplement their diet with 150 mcg/day iodine in the form of potassium iodide [58]. Similarly, the American Academy of Pediatrics recommends that women who are pregnant, planning to become pregnant, or lactating take a daily supplement providing at least 150 mcg iodine and use iodized salt [59].

The use of iodine-containing dietary supplements by pregnant and lactating women in the United States appears to be low compared to current recommendations. Of 59 best-selling prenatal multivitamin supplements on the market in 2016–2017, only 34 contained iodine [60]. The median iodine content was 150 mcg per daily serving, with a range of 25 to 290 mcg; 25 of the 34 provided iodine as potassium iodide. According to 2011–2014 NHANES data, 72.2% of pregnant woman took any dietary supplement, but only 17.8% of them took an iodine-containing product [61]. Among lactating women, 75% took a dietary supplement, but only 19% of them took an iodine-containing product.

Results from a 2010 study however, raise some questions as to the safety of widespread iodine supplementation in areas of relative iodine sufficiency. In this cross-sectional study, pregnant women living in Spain had a significantly increased risk of hyperthyrotropinemia (TSH >3 microU/mL) if they consumed iodine supplements in doses ≥200 mcg/day compared with those who consumed doses <100 mcg/day [62]. These findings suggest that taking higher doses of supplemental iodine during pregnancy could induce thyroid dysfunction in some women and underscore the need for additional research into the effects on maternal thyroid function of iodine supplementation during pregnancy.
Taken as a whole, these findings indicate that increased public awareness of iodine’s importance during pregnancy and lactation is warranted and that further research into the effects of iodine supplementation during pregnancy is needed. Many researchers, as well as the American Thyroid Association, stress the importance of continued iodine status monitoring among women of reproductive age [1,4,26,32,48,64,63].

Cognitive function during childhood
The effects of severe iodine deficiency on neurological development are well documented. Results from several studies suggest, for example, that chronic, moderate-to-severe iodine deficiency, particularly in children, reduces IQ by about 12–13.5 points [45]. A 2004 Cochrane review concluded that iodine supplementation in children living in areas of iodine deficiency appears to both positively affect physical and mental development and decrease mortality with only minor and transient adverse effects [65].

The effects of mild iodine deficiency during childhood are more difficult to quantify. Some research suggests that mild iodine deficiency is associated with subtle neurodevelopmental deficits and that iodine supplementation might improve cognitive function in mildly iodine-deficient children [44].

In a 2009 randomized, placebo-controlled study, 184 children aged 10–13 years in New Zealand with a median urinary iodine concentration of 63 mcg/L received iodine supplements (150 mcg/day) or placebo for 28 weeks [66]. Iodine supplementation improved iodine status (median urinary iodine concentration after supplementation was 145 mcg/L) and significantly improved measures of perceptual reasoning and overall cognitive score compared with children taking a placebo. These findings suggest that correcting mild iodine deficiency in children could improve certain components of cognition. Additional research is required to fully understand the effects of mild iodine deficiency and iodine supplementation on cognitive function.

Fibrocystic breast disease
Fibrocystic breast disease is a benign condition characterized by lumpy, painful breasts and palpable fibrosis. It commonly affects women of reproductive age, but it can also occur during menopause, especially in women taking estrogens [67]. Breast tissue has a high concentration of iodine, especially during pregnancy and lactation) [4,68]. Some research suggests that iodine supplementation might be helpful for fibrocystic breast disease, although a specific mechanism of action has not been established [69] and data are limited.

In a double-blind study, researchers randomly assigned 56 women with fibrocystic breast disease to receive daily supplements of iodine (70 to 90 mcg I2/kg body weight) or placebo for 6 months [70]. At treatment completion, 65% of the women receiving iodine reported decreased pain compared with 33% of women in the placebo group. A more recent randomized, double-blind, placebo-controlled clinical trial had similar findings. In this study, researchers randomly assigned 111 women (18–50 years of age) with fibrosis and a history of breast pain to receive tablets containing 0 mcg, 1,500 mcg, 3,000 mcg, or 6,000 mcg of iodine per day [69]. After 5 months of treatment, women receiving doses of 3,000 or 6,000 mcg iodine had a significant decrease in breast pain, tenderness, and nodularity compared with those receiving placebo or 1,500 mcg iodine. The researchers also reported a dose-dependent reduction in self-assessed pain. None of the doses was associated with major adverse events or changes in thyroid function test results.

Although the results of these studies are promising, more research is needed to clarify iodine’s role in fibrocystic breast disease. Moreover, the doses used in these studies (approximately 1,500–6,000 mcg per day) are several times higher than the iodine UL of 1,100 mcg for adults. Doses of this magnitude should only be used under the guidance of a physician [2].

Radiation-induced thyroid cancer
Nuclear accidents can release radioactive iodine into the environment, increasing the risk of thyroid cancer in exposed individuals, especially children [71,72]. Thyroidal uptake of radioactive iodine is higher in people with iodine deficiency than in people with iodine sufficiency. For this reason, iodine-deficient individuals have a particularly high risk of developing radiation-induced thyroid cancer when exposed to radioactive iodine.

The FDA has approved potassium iodide as a thyroid-blocking agent to reduce the risk of thyroid cancer in radiation emergencies involving the release of radioactive iodine [71]. The FDA recommends that exposed people take a daily pharmacological dose (16–130 mg potassium iodide, depending on age) until the risk of significant radiation exposure ends [71,72]. Potassium iodide was widely used in Poland following the 1986 Chernobyl accident and childhood thyroid cancer rates did not increase substantially in subsequent years [73]. In areas where iodide prophylaxis was not used, such as Belarus and Ukraine, where many children were mildly iodine-deficient, the incidence of thyroid cancer sharply increased among children and adolescents [71].

Health Risks from Excessive Iodine
High intakes of iodine can cause some of the same symptoms as iodine deficiency—including goiter, elevated TSH levels, and hypothyroidism—because excess iodine in susceptible individuals inhibits thyroid hormone synthesis and thereby increases TSH stimulation, which can produce goiter [2,74]. Iodine-induced hyperthyroidism can also result from high iodine intakes, including when iodine is administered to treat iodine deficiency. Studies have also shown that excessive iodine intakes cause thyroiditis and thyroid papillary cancer [2,74]. Cases of acute iodine poisoning are rare and are usually caused by doses of many grams. Acute poisoning symptoms include burning of the mouth, throat, and stomach; fever; abdominal pain; nausea; vomiting; diarrhea; weak pulse; and coma [2].

Responses to excess iodine and the doses required to cause adverse effects vary [74]. Some people, such as those with autoimmune thyroid disease and iodine deficiency, may experience adverse effects with iodine intakes considered safe for the general population [2,5].

The FNB has established iodine ULs for food and supplement intakes (Table 3). In most people, iodine intakes from foods and supplements are unlikely to exceed the UL [2]. Long-term intakes above the UL increase the risk of adverse health effects. The ULs do not apply to individuals receiving iodine for medical treatment, but such individuals should be under the care of a physician [2].

Table 3: Tolerable Upper Intake Levels (ULs) for Iodine [2]
Age                                        Male                           Female                             Pregnancy                       Lactation
Birth to 6 months                  Not possible to establish*                                   Not possible to establish*
7–12 months                        Not possible to establish*                                    Not possible to establish*
1–3 years                               200 mcg                         200 mcg
4–8 years                               300 mcg                         300 mcg
9–13 years                             600 mcg                         600 mcg
14–18 years                            900 mcg                       900 mcg                             900 mcg                        900 mcg
19+ years                             1,100 mcg                    1,100 mcg                          1,100 mcg                     1,100 mcg
* Formula and food should be the only sources of iodine for infants.

Interactions with Medications
Iodine supplements have the potential to interact with several types of medications. A few examples are provided below. Individuals taking these medications on a regular basis should discuss their iodine intakes with their healthcare providers.

Anti-thyroid medications
Anti-thyroid medications, such as methimazole (Tapazole®), are used to treat hyperthyroidism. Taking high doses of iodine with anti-thyroid medications can have an additive effect [75] and could cause hypothyroidism.

Angiotensin-converting enzyme (ACE) inhibitors
ACE inhibitors, such as benazepril (Lotensin®), lisinopril (Prinivil® and Zestril®), and fosinopril (Monopril®), are used primarily to treat high blood pressure. Taking potassium iodide with ACE inhibitors can increase the risk of hyperkalemia (elevated blood levels of potassium) [75].

Potassium-sparing diuretics
Taking potassium iodide with potassium-sparing diuretics, such as spironolactone (Aldactone®) and amiloride (Midamor®), can increase the risk of hyperkalemia [75].

Iodine and Healthful Diets
The federal government’s 2015-2020 Dietary Guidelines for Americans notes that “Nutritional needs should be met primarily from foods. … Foods in nutrient-dense forms contain essential vitamins and minerals and also dietary fiber and other naturally occurring substances that may have positive health effects. In some cases, fortified foods and dietary supplements may be useful in providing one or more nutrients that otherwise may be consumed in less-than-recommended amounts.”

For more information about building a healthy diet, refer to the Dietary Guidelines for Americans and the U.S. Department of Agriculture’s MyPlate.
The Dietary Guidelines for Americans describes a healthy eating pattern as one that:

• Includes a variety of vegetables, fruits, whole grains, fat-free or low-fat milk and milk products, and oils.
  Milk is an excellent source of iodine. Fruits, vegetables, and bread also provide small quantities of iodine.
• Includes a variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), nuts, seeds, and soy products.
  Some fish contain high amounts of iodine. Eggs are also good sources of iodine.
• Limits saturated and trans fats, added sugars, and sodium.
• Stays within your daily calorie needs.

References

1. National Research Council, Committee to Assess the Health Implications of Perchlorate Ingestion. Health Implications of Perchlorate Ingestion. Washington, DC: The National Academies Press, 2005.
2. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press, 2001.
3. World Health Organization. United Nations Children’s Fund & International Council for the Control of Iodine Deficiency Disorders. Assessment of iodine deficiency disorders and monitoring their elimination. 3rd ed. Geneva, Switzerland: WHO, 2007.
4. Patrick L. Iodine: deficiency and therapeutic considerations. Altern Med Rev. 2008 Jun;13(2):116-127. [PubMed abstract]
5. Zimmermann MB. Iodine deficiency. Endocr Rev. 2009 Jun;30(4):376-408. [PubMed abstract]
6. Zimmermann MB, Jooste PL, Pandav CS. Iodine-deficiency disorders. Lancet. 2008 Oct 4;372(9645):1251-1262. [PubMed abstract]
7. WHO Secretariat, Andersson M, de Benoist B, Delange F, Zupan J. Prevention and control of iodine deficiency in pregnant and lactating women and in children less than 2-years-old: conclusions and recommendations of the Technical Consultation. Public Health Nutr. 2007 Dec;10(12A):1606-1611. [PubMed abstract]
8. Pennington JA, Young B. Iron, zinc, copper, manganese, selenium, and iodine in foods from the United States Total Diet Study. J Food Compost Anal. 1990 June;3(2):166-184.
9. Murray CW, Egan SK, Kim H, Beru N, Bolger PM. US Food and Drug Administration’s Total Diet Study: dietary intake of perchlorate and iodine. J Expo Sci Environ Epidemiol. 2008 Nov;18(6):571-580. [PubMed abstract]
10. Pennington JAT, Schoen SA, Salmon GD, Young B, Johnson RD, Marts RW. Composition of Core Foods of the U.S. Food Supply, 1982-1991. III. Copper, Manganese, Selenium, and Iodine. J Food Comp Anal. 1995;8(2):171-217.
11. Teas J, Pino S, Critchley A, Braverman LE. Variability of iodine content in common commercially available edible seaweeds. Thyroid. 2004 Oct;14(10):836-841. [PubMed abstract]
12. Dasgupta PK, Liu Y, Dyke JV. Iodine nutrition: iodine content of iodized salt in the United States. Environ Sci Technol. 2008 Feb 15;42(4):1315-1323. [PubMed abstract]
13. U.S. Food and Drug Administration. Food Labeling: Revision of the Nutrition and Supplement Facts Labels. 2016.
14. U.S. Department of Agriculture, Agricultural Research Service. FoodData Central, 2019.
15. Global Fortification Data Exchange. Fortification Legislation.
16. UNICEF Data. Iodized salt data.
17. U.S. Food and Drug Administration, Code of Federal Regulations, CFR 21, Sections 184.1634 and 184.1265. Revised April 1, 2009.
18. Aquaron R, Delange F, Marchal P, Lognoné V, Ninane L. Bioavailability of seaweed iodine in human beings. Cell Mol Biol (Noisy-le-grand). 2002 Jul;48(5):563-569. [PubMed abstract]
19. Abt E, Spungen J, Pouillot R, Gamalo-Siebers M, Wirtz M. Update on dietary intake of perchlorate and iodine from U.S. food and drug administration’s total diet study: 2008-2012. J Expo Sci Environ Epidemiol 2018;28:21-30. [PubMed abstract]
20. Pennington JA, Young BE, Wilson DB. Nutritional elements in U.S. diets: results from the Total Diet Study, 1982 to 1986. J Am Diet Assoc. 1989 May;89(5):659-664. [PubMed abstract]
21. Pennington JA, Young BE. Total diet study nutritional elements, 1982-1989. J Am Diet Assoc. 1991 Feb;91(2):179-183. [PubMed abstract]
22. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Accessed 11/14/2009.
23. Ristic-Medic D, Piskackova Z, Hooper L, Ruprich J, Casgrain A, Ashton K, Pavlovic M, Glibetic M. Methods of assessment of iodine status in humans: a systematic review. Am J Clin Nutr. 2009 Jun;89(6):2052S-2069S. [PubMed abstract]
24. Zimmermann MB. Methods to assess iron and iodine status. Br J Nutr. 2008 Jun;99 Suppl 3:S2-9. [PubMed abstract]
25. König F, Andersson M, Hotz K, Aeberli I, Zimmermann MB. Ten repeat collections for urinary iodine from spot samples or 24-hour samples are needed to reliably estimate individual iodine status in women. J Nutr 2011;141:2049-54. [PubMed abstract]
26. Caldwell KL, Miller GA, Wang RY, Jain RB, Jones RL. Iodine status of the U.S. population, National Health and Nutrition Examination Survey 2003-2004. Thyroid. 2008 Nov;18(11):1207-1214. [PubMed abstract]
27. Hollowell JG, Staehling NW, Hannon WH, Flanders DW, Gunter EW, Maberly GF, Braverman LE, Pino S, Miller DT, Garbe PL, DeLozier DM, Jackson RJ. Iodine nutrition in the United States. Trends and public health implications: iodine excretion data from National Health and Nutrition Examination Surveys I and III (1971-1974 and 1988-1994). J Clin Endocrinol Metab. 1998 Oct;83(10):3401-3408. [PubMed abstract]
28. Pennington JA, Schoen SA. Total diet study: estimated dietary intakes of nutritional elements, 1982-1991. Int J Vitam Nutr Res. 1996;66(4):350-362. [PubMed abstract]
29. Poulsen E. Case study: erythrosine. Food Addit Contam. 1993 May-Jun;10(3):315-323. [PubMed abstract]
30. Caldwell KL, Makhmudov A, Ely E, Jones RL, Wang RY. Iodine Status of the U.S.Population, National Health and Nutrition Examination Survey, 2005-2006 and 2007-2008. Thyroid. 2011 Feb 16. [PubMed abstract]
31. Perrine CG, Herrick KA, Gupta PM, Caldwell KL. Iodine status of pregnant women and women of reproductive age in the United States. Thyroid 2019;29:153-4. [PubMed abstract]
32. Perrine CG, Herrick K, Serdula MK, Sullivan KM. Some subgroups of reproductive age women in the United States may be at risk for iodine deficiency. J Nutr. 2010 Aug;140(8):1489-1494. [PubMed abstract]
33. Charlton KE, Gemming L, Yeatman H, Ma G. Suboptimal iodine status of Australian pregnant women reflects poor knowledge and practices related to iodine nutrition. Nutrition. 2010 Oct;26(10):963-8. [PubMed abstract]
34. Tayie FA, Jourdan K. Hypertension, dietary salt restriction, and iodine deficiency among adults. Am J Hypertens. 2010 Oct;23(10):1095-1102. [PubMed abstract]
35. Iodine Global Network.
36. Santiago-Fernandez P, Torres-Barahona R, Muela-Martínez JA, Rojo-Martínez G, García-Fuentes E, Garriga MJ, León AG, Soriguer F. Intelligence quotient and iodine intake: a cross-sectional study in children. J Clin Endocrinol Metab. 2004 Aug;89(8):3851-3857. [PubMed abstract]
37. Levie D, Korevaar TIM, Bath SC, Murcia M, Dineva M, Llop S, Espada M, van Herwaarden AE, de Rijke YB, Ibarluzea JM, Sunyer J, Tiemeier H, Rayman MP, Guxens M, Peeters RP. Association of maternal iodine status with child IQ: A meta-analysis of individual participant data. J Clin Endocrinol Metab 2019;104:5957-67. [PubMed abstract]
38. Vermiglio F, Lo Presti VP, Moleti M, Sidoti M, Tortorella G, Scaffidi G, Castagna MG, Mattina F, Violi MA, Crisà A, Artemisia A, Trimarchi F. Attention deficit and hyperactivity disorders in the offspring of mothers exposed to mild-moderate iodine deficiency: a possible novel iodine deficiency disorder in developed countries. J Clin Endocrinol Metab. 2004 Dec;89(12):6054-6060. [PubMed abstract]
39. Zimmermann MB, Galetti V. Iodine intake as a risk factor for thyroid cancer: A comprehensive review of animal and human studies. Thyroid Res 2015;8:8. [PubMed abstract]
40. Cooper LF, Barber EM, Mitchell HS. Nutrition in Health and Disease, 9th ed. J.B. Lippincott Co, Philadelphia. 1943, pg 66.
41. The Iodine Global Network. Global scorecard of iodine nutrition in 2019.
42. Hess SY. The impact of common micronutrient deficiencies on iodine and thyroid metabolism: the evidence from human studies. Best Pract Res Clin Endocrinol Metab. 2010 Feb;24(1):117-132. [PubMed abstract]
43. UNICEF. The State of the World’s Children 2019.
44. Melse-Boonstra A, Jaiswal N. Iodine deficiency in pregnancy, infancy and childhood and its consequences for brain development. Best Pract Res Clin Endocrinol Metab. 2010 Feb;24(1):29-38. [PubMed abstract]
45. Zimmermann MB. Iodine deficiency in pregnancy and the effects of maternal iodine supplementation on the offspring: a review. Am J Clin Nutr. 2009 Feb;89(2):668S-672S. [PubMed abstract]
46. Delange F. Iodine requirements during pregnancy, lactation and the neonatal period and indicators of optimal iodine nutrition. Public Health Nutr. 2007 Dec;10(12A):1571-1580. [PubMed abstract]
47. Pearce EN, Bazrafshan HR, He X, Pino S, Braverman LE. Dietary iodine in pregnant women from the Boston, Massachusetts area. Thyroid. 2004 Apr;14(4):327-328. [PubMed abstract]
48. Hollowell JG, Haddow JE. The prevalence of iodine deficiency in women of reproductive age in the United States of America. Public Health Nutr. 2007 Dec;10(12A):1532-1539; discussion 1540-1541. [PubMed abstract]
49. Bath SC, Steer CD, Golding J, Emmett P, Rayman MP. Effect of inadequate iodine status in UK pregnant women on cognitive outcomes in their children: Results from the Avon Longitudinal Study of Parents and Children (ALSPAC). Lancet 2013;382:331-7. [PubMed abstract]
50. Hynes KL, Otahal P, Burgess JR, Oddy WH, Hay I. Reduced educational outcomes persist into adolescence following mild iodine deficiency in utero, despite adequacy in childhood: 15-year follow-up of the gestational iodine cohort investigating auditory processing speed and working memory. Nutrients 2017;9:1354. [PubMed abstract]
51. Abel MH, Brandlistuen RE, Caspersen IH, Aase H, Torheim LE, Meltzer HM, Brantsaeter AL. Language delay and poorer school performance in children of mothers with inadequate iodine intake in pregnancy: Results from follow-up at 8 years in the Norwegian Mother and Child Cohort Study. European Journal of Nutrition 2019;58:3047-58. [PubMed abstract]
52. Gowachirapant S, Jaiswal N, Melse-Boonstra A, Galetti V,Stinca S, Mackenzie I, et al. Effect of iodine supplementation in pregnant women on child neurodevelopment: A randoised, double-blind, placebo-controlled trial. Lancet Diabetes Endocrinol 2017;5:853-63. [PubMed abstract]
53. Zhou SJ, Skeaff SA, Ruan P, Doyle LW, Anderson PJ, Komman L, et al. The effect of iodine supplementation in pregnancy on early childhood neurodevelopment and clinical outcomes: Results of an aborted randomised placebo-controlled trial. Trials 2015;16:563. [PubMed abstract]
54. Dineva M, Fishpool H, Rayman MP, Mendis J, Bath SC. Systematic review and meta-analysis of the effects of iodine supplementation on thyroid function and child neurodevelopment in mildly-to-moderately iodine-deficient pregnant women. Am J Clin Nutr. 2020. Published online ahead of print.
55. Pearce EN, Leung AM, Blount BC, Bazrafshan HR, He X, Pino S, Valentin-Blasini L, Braverman LE. Breast milk iodine and perchlorate concentrations in lactating Boston-area women. J Clin Endocrinol Metab. 2007 May;92(5):1673-1677. [PubMed abstract]
56. Andersson M, Aeberli I, Wüst N, Piacenza AM, Bucher T, Henschen I, Haldimann M, Zimmermann MB. The Swiss Iodized Salt Program Provides Adequate Iodine for School Children and Pregnant Women, but Weaning Infants Not Receiving Iodine-Containing Complementary Foods as well as Their Mothers Are Iodine Deficient. J Clin Endocrinol Metab 2010;95:5217-24. [PubMed abstract]
57. Fallah R, Du L, Braverman LE, He X, Segura-Harrison M, Yeh MW, et al. Iodine nutrition in weaning infants in the United States. Thyroid 2019;29:573-6. [PubMed abstract]
58. Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, et al. 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid 2017;27:315-89. [PubMed abstract]
59. Council on Environmental Health, Rogan WJ, Paulson JA, Baum C, Brock-Utne AC, Brumberg HL, et al. Iodine deficiency, pollutant chemicals, and the thyroid: New information on an old problem. Pediatrics 2014;133:1163-6. [PubMed abstract]
60. Patel A, Lee SY, Stagnaro-Green A, MacKay D, Wong AW, Pearce EN. Iodine content of the best-selling United States adult and prenatal multivitamin preparations. Thyroid 2019;29:124-7. [PubMed abstract]
61. Gupta PM, Gahche JJ, Herrick KA, Ershow AG, Potischman N, Perrine CG. Use of iodine-containing dietary supplements remains low among women of reproductive age in the United States: NHANES 2011-2014. Nutrients 2018, 10, 422; doi: 10.3390/nu10040422. [PubMed abstract]
62. Rebagliato M, Murcia M, Espada M, Alvarez-Pedrerol M, Bolúmar F, Vioque J, Basterrechea M, Blarduni E, Ramón R, Guxens M, Foradada CM, Ballester F, Ibarluzea J, Sunyer J. Iodine intake and maternal thyroid function during pregnancy. Epidemiology. 2010 Jan;21(1):62-69. [PubMed abstract]
63. Pearce EN. What do we know about iodine supplementation in pregnancy? J Clin Endocrinol Metab. 2009 Sep;94(9):3188-3190. [PubMed abstract]
64. Public Health Committee of the American Thyroid Association, Becker DV, Braverman LE, Delange F, Dunn JT, Franklyn JA, Hollowell JG, Lamm SH, Mitchell ML, Pearce E, Robbins J, Rovet JF. Iodine supplementation for pregnancy and lactation-United States and Canada: recommendations of the American Thyroid Association. Thyroid. 2006 Oct;16(10):949-951. [PubMed abstract]
65. Angermayr L, Clar C. Iodine supplementation for preventing iodine deficiency disorders in children. Cochrane Database Syst Rev. 2004;(2):CD003819. [PubMed abstract]
66. Gordon RC, Rose MC, Skeaff SA, Gray AR, Morgan KM, Ruffman T. Iodine supplementation improves cognition in mildly iodine-deficient children. Am J Clin Nutr. 2009 Nov;90(5):1264-1271. [PubMed abstract]
67. Ghent WR, Eskin BA, Low DA, Hill LP. Iodine replacement in fibrocystic disease of the breast. Can J Surg. 1993 Oct;36(5):453-460. [PubMed abstract]
68. Azizi F, Smyth P. Breastfeeding and maternal and infant iodine nutrition. Clin Endocrinol (Oxf). 2009 May;70(5):803-809. [PubMed abstract]
69. Kessler JH. The effect of supraphysiologic levels of iodine on patients with cyclic mastalgia. Breast J. 2004 Jul-Aug;10(4):328-336. [PubMed abstract]
70. Center for Drug Evaluation and Research, Food and Drug Administration. Guidance. Potassium iodide as a thyroid blocking agent in radiation emergencies. December 2001.
71. Ghent WR, Eskin BA, Low DA, Hill LP. Iodine replacement in fibrocystic disease of the breast. Can J Surg. 1993 Oct;36(5):453-460. [PubMed abstract]
72. World Health Organization. Guidelines for Iodine Prophylaxis following Nuclear Accidents. 1999.
73. Nauman J, Wolff J. Iodide prophylaxis in Poland after the Chernobyl reactor accident: benefits and risks. Am J Med 1993;94:524-532. [PubMed abstract]
74. Pennington JA. A review of iodine toxicity reports. J Am Diet Assoc. 1990 Nov;90(11):1571-1581. [PubMed abstract]
75. Natural Medicines Comprehensive Database. Iodine. Accessed 10/13/2009.

Disclaimer
This fact sheet by the Office of Dietary Supplements (ODS) provides information that should not take the place of medical advice. We encourage you to talk to your healthcare providers (doctor, registered dietitian, pharmacist, etc.) about your interest in, questions about, or use of dietary supplements and what may be best for your overall health. Any mention in this publication of a specific product or service, or recommendation from an organization or professional society, does not represent an endorsement by ODS of that product, service, or expert advice.