- Email: [email protected]
Iodine deficiency in pregnant women in Europe
Comment
Elizabeth N Pearce Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA 02118, USA [email protected] I declare no competing interests. 1 2
3
4
Zimmermann MB. Iodine deficiency. Endocr Rev 2009; 30: 376–408. 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: 331–37. WHO, UNICEF, and the International Council for the Control of Iodine Deficiency Disorders. Assessment of iodine deficiency disorders and monitoring their elimination, 3rd edn. Geneva: WHO, 2007. European Food Safety Authority Panel on Dietetic Products, Nutrition, and Allergies. Scientific opinion on dietary reference values for iodine. EFSA Journal 2014; 12: 3660–717.
5
6
7
8
9
Department of Health. Report on health and social subjects: 41. Dietary reference values for food, energy and nutrients for the United Kingdom. London: The Stationery Office, 1991. Bath SC, Rayman MP. A review of the iodine status of UK pregnant women and its implications for the offspring. Environ Geochem Health 2015; published online Feb 7. DOI:10.1007/s10653-015-9682-3. Monahan M, Boelaert K, Jolly K, Chan S, Barton P, Roberts TE. Costs and benefits of iodine supplementation for pregnant women in a mildly to moderately iodine-deficient population: a modelling analysis. Lancet Diabetes Endocrinol 2015; published online Aug 10. http://dx.doi. org/10.1016/ S2213-8587(15)00212-0. Food Standards Australia New Zealand. Iodine fortification. http://www. foodstandards.gov.au/consumer/nutrition/iodinefort/Pages/default.aspx (accessed June 6, 2014). Lazarus J, Brown RS, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B. 2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Eur Thyroid J 2014; 3: 76–94.
Iodine deficiency in pregnant women in Europe Published Online August 10, 2015 http://dx.doi.org/10.1016/ S2213-8587(15)00263-6
672
The adverse effects of iodine deficiency in populations (decreased IQ, goiter, hypothyroidism, and hyperthyroidism) are easily corrected with salt iodisation.1 However, these adverse effects continue to be a problem in many countries, with an estimated 1·9 billion people at risk worldwide.2 All European countries endorsed the goal of elimination of iodine deficiency at the 1992 World Health Assembly (WHA), and the 2005 WHA again called on all Member States to regularly monitor iodine nutrition. WHO recommends use of the median urinary iodine concentration in national or regional surveys to classify iodine nutrition in populations.4 Adequate iodine nutrition in the general population is shown by a median urinary iodine concentration for school-age children (aged 6–12 years) of 100–299 μg/L.4 Despite calls to monitor and eliminate Iodine deficiency, during the past decade, compared with other WHO regions, Europe has had the highest percentage of iodine-deficient schoolage children,3 despite its wealth and its high standards of health care. In 2015, in the WHO European region, only 47·9 million (66%) of the region’s 72·1 million school-age children have adequate iodine intakes.3 Iodine deficiency is especially problematic in pregnant women, who have a higher iodine requirement (250 μg per day) than non-pregnant women (150 μg per day) because they need to synthesise additional thyroid hormone to cover maternal and fetal needs, and pass iodine to the fetus for fetal thyroid hormone production.4 Iodine deficiency in utero can cause fetal hypothyroidism and irreversibly impair cognitive development, and data from observational studies in Europe suggest
that even mild-to-moderate iodine deficiency during pregnancy can have long-term adverse effects on child cognition.6 The median urinary iodine concentration in school-age children should not be used as proxy to assess iodine nutrition of pregnant women, who should be separately monitored.5 Adequate iodine nutrition in pregnant women is shown by a median urinary iodine concentration between 150 and 499 μg/L.4 To estimate the prevalence of iodine deficiency during pregnancy at the national level in the countries of the WHO European region, we searched PubMed, the WHO Vitamin and Mineral Nutrition Information System database,7 the Multiple Indicator Cluster Surveys (UNICEF) database, and the iodine deficiency disorders newsletters. To be included, studies had to have used a cross-sectional population-based sample frame and standard assay techniques to determine urinary iodine concentration. For each country, we selected the most recent national survey of pregnant women within 15 years (2000–15). For countries where a national survey was not available, we pooled all eligible subnational studies that sampled at least 100 women and presented these as a weighted national estimate. We used the median urinary iodine concentration obtained from the survey data to classify iodine nutrition in pregnant women in countries according to WHO criteria: insufficient median urinary iodine concentration less than 150 μg/L and adequate concentration between 150 and 499 μg/L.4 In 2015, 58% of pregnant women in Europe are covered by national or pooled subnational surveys; the more populous countries that still do not have data are Germany, www.thelancet.com/diabetes-endocrinology Vol 3 September 2015
Comment
Uzbekistan, Kazakhstan, Hungary, and Sweden. In ten countries, iodine intakes are adequate during pregnancy, in 21 countries intakes are deficient, and 23 have no data available (figure, appendix). Of European countries that have assessed iodine nutrition during pregnancy, twothirds have reported inadequate iodine intakes. Why has iodine deficiency, especially during pregnancy, received such little attention on the European public health agenda? Many health officials might still equate iodine deficiency with visible goitre, a disorder that has disappeared in most of Europe, and are unaware of its more subtle adverse effects on cognitive and motor development. A randomised controlled trial in European school-age children has shown moderate iodine deficiency impairs cognition.8 However, no large trials have been done in pregnant women with mild-to-moderate iodine deficiency to assess the effects of iodine repletion on infant development or post-partum maternal outcomes. This paucity of data could contribute to the reluctance of health officials to prioritise iodine nutrition during pregnancy. However, thyroid experts emphasise that, until additional physiological data are available to make a better judgment, pregnant women (and women planning a pregnancy) should ensure they are using iodised salt and should consider taking a prenatal supplement that contains 150 mcg iodine once a day.9 Several actions should be implemented to improve iodine intakes in pregnant women in Europe. WHO has repeatedly emphasised that an effective iodised salt programme with high household coverage is the best strategy to provide adequate iodine to pregnant women, partly because it ensures thyroidal iodine stores are full in women of reproductive age.4 In Europe, an increasingly smaller amount of consumed salt is added to foods in the household (eg, in the UK only about 15% of all salt consumed).10 Thus, for iodised salt programmes to be successful, processed foods need to contain iodised salt. Iodine supplementation for pregnant women might be useful when there is insufficient iodised salt, and all prenatal vitamin-mineral supplements should contain iodine. However, because most women become aware they are pregnant towards the end of the first trimester, supplementation often does not cover the first trimester, when the developing fetal brain is especially vulnerable.11 In most European countries, like in the USA,11 most prenatal vitamin supplements do not contain iodine (unpublished data). Also, supplements often do not reach www.thelancet.com/diabetes-endocrinology Vol 3 September 2015
Insufficient (<150 μg/L) Adequate (150–499 μg/L) No data Subnational or pooled
Figure: Iodine nutrition during pregnancy in the countries of the WHO European Region and Kosovo, based on urinary iodine excretion (μg/L)
poorer, less educated women, making supplementation a less equitable approach than salt fortification. Therefore, use of iodised salt by the food industry should be strongly encouraged. Denmark and Belgium have instituted compulsory iodisation of salt used in bread; however, this strategy does not seem to meet the needs of the higher iodine requirement during pregnancy.4 Iodisation of all food-grade salt is preferable, as in Croatia and Serbia, where iodised salt programmes cover the needs of pregnancy.4 In Belarus, adequate iodine intakes during pregnancy have been achieved thanks to a national strategy that combines mandatory use of iodized salt by the food industry and promotion of iodised table salt directly to consumers.12 Education of health authorities and the public on the need to prevent iodine deficiency by consuming iodised salt should take into account policies to reduce salt consumption.13 The recent Series in The Lancet on child development,14 and the World Bank,15 recommend that governments put a high priority on salt iodisation to promote health and economic development. Although this recommendation was aimed at low-income and middle-income countries in the developing world, it also applies to Europe.
See Online for appendix
Michael B Zimmermann, Małgorzata Gizak, Karen Abbott, Maria Andersson, John H Lazarus Laboratory of Human Nutrition, ETH Zürich CH-8092, Switzerland (MBZ, MG, MA); Iodine Global Network, Zurich, Switzerland (MBZ, MG, MA, JHL); Imperial College London, London, UK (KA); and Thyroid Research Group, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, Cardiff University, Cardiff, UK (JHL) [email protected]
673
Comment
We declare no competing interests. 1 2 3 4
5
6
7
Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol 2015; 3: 286–95. Zimmermann MB, Andersson M. Update on iodine status worldwide. Curr Opin Endocrinol Diabetes Obes 2012; 19: 382–87. Iodine Global Network. http://www.ign.org (accessed June 2, 2015). World Health Organization/United Nations Children’s Fund/International Council for the Control of Iodine Deficiency Disorders (WHO/UNICEF/ICCIDD). Assessment of iodine deficiency disorders and monitoring their elimination. A guide for programme managers, 3rd edition. Geneva: WHO, 2007. Wong EM, Sullivan KM, Perrine CG, Rogers LM, Peña-Rosas JP. Comparison of median urinary iodine concentration as an indicator of iodine status among pregnant women, school-age children, and nonpregnant women. Food Nutr Bull 2011; 32: 206–12. 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: 331–37. WHO, Nutrition for Health and Development. The WHO Vitamin and Mineral Nutrition Information System (VMNIS) on iodine deficiency disorders. http:// www.who.int/vmnis/iodine/data/en/index.html (accessed May 25, 2015).
8
9
10 11 12 13
14 15
Zimmermann MB, Connolly K, Bozo M, Bridson J, Rohner F, Grimci L. Iodine supplementation improves cognition in iodine-deficient schoolchildren in Albania: a randomized, controlled, double-blind study. Am J Clin Nutr 2006; 83: 108–14. Public Health Committee of the American Thyroid Association, Becker DV, Braverman LE, Delange F, et al. Iodine supplementation for pregnancy and lactation-United States and Canada: recommendations of the American Thyroid Association. Thyroid 2006; 16: 949–51. He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2014; 28: 345–52. Leung AM, Pearce EN, Braverman LE. Iodine content of prenatal multivitamins in the United States. N Engl J Med 2009; 360: 939–40. Petrenko S, Mokhort T, Gerasimov G. Belarus celebrates a superb sustained USI program. IDD Newsletter 2014; 42: 14–15. Campbell N, Dary O, Cappuccio FP, Neufeld LM, Harding KB, Zimmermann MB. Collaboration to optimize dietary intakes of salt and iodine: a critical but overlooked public health issue. Bull World Health Organ 2012; 90: 73–4. Walker SP, Wachs TD, Gardner JM, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet 2007; 369: 145–57. McGuire J, Galloway R. Enriching lives. Overcoming vitamin and mineral malnutrition in developing countries. Washington, DC: World Bank, 1994.
Zephyr/Science Photo Library
Diabetic foot disease: moving from roadmap to journey
Published Online August 4, 2015 http://dx.doi.org/10.1016/ S2213-8587(15)00252-1
For more on the IDSF see http://www.diabeticfoot.nl For more on the IWGDF see http://iwgdf.org/ For the 2015 IWGDF guidance document see http://iwgdf.org/ guidelines/
674
If you had diabetes and a foot ulcer, what would you pay to try to save your limb? Would you pay the equivalent of 5·7 years of your annual income? This amount is what it might cost in India, the country with the greatest number of people suffering from a diabetic foot ulcer.1 Even if you could afford this cost, there would be no guarantee that treatment would be successful. In a large study2 done in European specialised foot centres, 23% of patients with diabetes and a foot ulcer lost at least part of their foot, despite intensive treatment. This poor outcome reflects the fact that diabetic foot disease is both an acute and recurrent affliction that mainly affects older patients with several comorbidities. Diabetic foot disease also requires both local and systemic treatments, given by knowledgeable providers, to adherent patients. This is not a one doctor disease—it demands multidisciplinary care. Furthermore, as a notoriously unglamorous problem, the disease depends on dedicated clinicians working together in a team of health-care providers to care for a complex patient—a scenario some disparage, but we relish. The quality of life for a patient with diabetic foot disease is as poor as for one with recurrent breast cancer,3 and the burden is also borne by the patient’s family and the entire health-care system. Foot complications are now the most common and expensive diabetes-related cause of admittance to hospital in most countries in the world, and amputations are among the most feared outcomes of diabetes. What was mainly a problem in high-income countries has now gone global, with rates
of diabetic foot disease rapidly rising in India, China, the Middle East, and elsewhere. With its multifactorial pathogenesis, diabetic foot disease is in many ways a unique problem. In the past, almost nothing could be done for what was called diabetic gangrene until the discovery of antibiotics 70 years ago.4 Even then, outcomes were poor until the 1980s, when clinicians began to understand the important role of peripheral neuropathy in addition to peripheral artery disease, infection, and metabolic derangements. With this new understanding, assembling a multidisciplinary team to tackle this difficult problem emerged as a new idea.5 Findings of many subsequent studies have shown the effectiveness of this approach, which might avoid more than 45% of lower extremity amputations.6 Ideally, treatment should involve medical, surgical, podiatric, nursing, and other specialties, and use an integrated approach of expertise and technology. In May, 2015, with the goal of improving diabetic foot care, more than 1400 clinicians and researchers from 100 countries met in The Hague at the 7th International Symposium on the Diabetic Foot (ISDF). This is the largest, and perhaps most prestigious, diabetic foot meeting worldwide, bringing together health-care workers from many specialties. In addition to state-ofthe-art lectures and workshops, investigators presented more than 60 oral and 330 poster summaries of new research. The programme also included the launch of www.thelancet.com/diabetes-endocrinology Vol 3 September 2015
Elizabeth N Pearce Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA 02118, USA [email protected] I declare no competing interests. 1 2
3
4
Zimmermann MB. Iodine deficiency. Endocr Rev 2009; 30: 376–408. 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: 331–37. WHO, UNICEF, and the International Council for the Control of Iodine Deficiency Disorders. Assessment of iodine deficiency disorders and monitoring their elimination, 3rd edn. Geneva: WHO, 2007. European Food Safety Authority Panel on Dietetic Products, Nutrition, and Allergies. Scientific opinion on dietary reference values for iodine. EFSA Journal 2014; 12: 3660–717.
5
6
7
8
9
Department of Health. Report on health and social subjects: 41. Dietary reference values for food, energy and nutrients for the United Kingdom. London: The Stationery Office, 1991. Bath SC, Rayman MP. A review of the iodine status of UK pregnant women and its implications for the offspring. Environ Geochem Health 2015; published online Feb 7. DOI:10.1007/s10653-015-9682-3. Monahan M, Boelaert K, Jolly K, Chan S, Barton P, Roberts TE. Costs and benefits of iodine supplementation for pregnant women in a mildly to moderately iodine-deficient population: a modelling analysis. Lancet Diabetes Endocrinol 2015; published online Aug 10. http://dx.doi. org/10.1016/ S2213-8587(15)00212-0. Food Standards Australia New Zealand. Iodine fortification. http://www. foodstandards.gov.au/consumer/nutrition/iodinefort/Pages/default.aspx (accessed June 6, 2014). Lazarus J, Brown RS, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B. 2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Eur Thyroid J 2014; 3: 76–94.
Iodine deficiency in pregnant women in Europe Published Online August 10, 2015 http://dx.doi.org/10.1016/ S2213-8587(15)00263-6
672
The adverse effects of iodine deficiency in populations (decreased IQ, goiter, hypothyroidism, and hyperthyroidism) are easily corrected with salt iodisation.1 However, these adverse effects continue to be a problem in many countries, with an estimated 1·9 billion people at risk worldwide.2 All European countries endorsed the goal of elimination of iodine deficiency at the 1992 World Health Assembly (WHA), and the 2005 WHA again called on all Member States to regularly monitor iodine nutrition. WHO recommends use of the median urinary iodine concentration in national or regional surveys to classify iodine nutrition in populations.4 Adequate iodine nutrition in the general population is shown by a median urinary iodine concentration for school-age children (aged 6–12 years) of 100–299 μg/L.4 Despite calls to monitor and eliminate Iodine deficiency, during the past decade, compared with other WHO regions, Europe has had the highest percentage of iodine-deficient schoolage children,3 despite its wealth and its high standards of health care. In 2015, in the WHO European region, only 47·9 million (66%) of the region’s 72·1 million school-age children have adequate iodine intakes.3 Iodine deficiency is especially problematic in pregnant women, who have a higher iodine requirement (250 μg per day) than non-pregnant women (150 μg per day) because they need to synthesise additional thyroid hormone to cover maternal and fetal needs, and pass iodine to the fetus for fetal thyroid hormone production.4 Iodine deficiency in utero can cause fetal hypothyroidism and irreversibly impair cognitive development, and data from observational studies in Europe suggest
that even mild-to-moderate iodine deficiency during pregnancy can have long-term adverse effects on child cognition.6 The median urinary iodine concentration in school-age children should not be used as proxy to assess iodine nutrition of pregnant women, who should be separately monitored.5 Adequate iodine nutrition in pregnant women is shown by a median urinary iodine concentration between 150 and 499 μg/L.4 To estimate the prevalence of iodine deficiency during pregnancy at the national level in the countries of the WHO European region, we searched PubMed, the WHO Vitamin and Mineral Nutrition Information System database,7 the Multiple Indicator Cluster Surveys (UNICEF) database, and the iodine deficiency disorders newsletters. To be included, studies had to have used a cross-sectional population-based sample frame and standard assay techniques to determine urinary iodine concentration. For each country, we selected the most recent national survey of pregnant women within 15 years (2000–15). For countries where a national survey was not available, we pooled all eligible subnational studies that sampled at least 100 women and presented these as a weighted national estimate. We used the median urinary iodine concentration obtained from the survey data to classify iodine nutrition in pregnant women in countries according to WHO criteria: insufficient median urinary iodine concentration less than 150 μg/L and adequate concentration between 150 and 499 μg/L.4 In 2015, 58% of pregnant women in Europe are covered by national or pooled subnational surveys; the more populous countries that still do not have data are Germany, www.thelancet.com/diabetes-endocrinology Vol 3 September 2015
Comment
Uzbekistan, Kazakhstan, Hungary, and Sweden. In ten countries, iodine intakes are adequate during pregnancy, in 21 countries intakes are deficient, and 23 have no data available (figure, appendix). Of European countries that have assessed iodine nutrition during pregnancy, twothirds have reported inadequate iodine intakes. Why has iodine deficiency, especially during pregnancy, received such little attention on the European public health agenda? Many health officials might still equate iodine deficiency with visible goitre, a disorder that has disappeared in most of Europe, and are unaware of its more subtle adverse effects on cognitive and motor development. A randomised controlled trial in European school-age children has shown moderate iodine deficiency impairs cognition.8 However, no large trials have been done in pregnant women with mild-to-moderate iodine deficiency to assess the effects of iodine repletion on infant development or post-partum maternal outcomes. This paucity of data could contribute to the reluctance of health officials to prioritise iodine nutrition during pregnancy. However, thyroid experts emphasise that, until additional physiological data are available to make a better judgment, pregnant women (and women planning a pregnancy) should ensure they are using iodised salt and should consider taking a prenatal supplement that contains 150 mcg iodine once a day.9 Several actions should be implemented to improve iodine intakes in pregnant women in Europe. WHO has repeatedly emphasised that an effective iodised salt programme with high household coverage is the best strategy to provide adequate iodine to pregnant women, partly because it ensures thyroidal iodine stores are full in women of reproductive age.4 In Europe, an increasingly smaller amount of consumed salt is added to foods in the household (eg, in the UK only about 15% of all salt consumed).10 Thus, for iodised salt programmes to be successful, processed foods need to contain iodised salt. Iodine supplementation for pregnant women might be useful when there is insufficient iodised salt, and all prenatal vitamin-mineral supplements should contain iodine. However, because most women become aware they are pregnant towards the end of the first trimester, supplementation often does not cover the first trimester, when the developing fetal brain is especially vulnerable.11 In most European countries, like in the USA,11 most prenatal vitamin supplements do not contain iodine (unpublished data). Also, supplements often do not reach www.thelancet.com/diabetes-endocrinology Vol 3 September 2015
Insufficient (<150 μg/L) Adequate (150–499 μg/L) No data Subnational or pooled
Figure: Iodine nutrition during pregnancy in the countries of the WHO European Region and Kosovo, based on urinary iodine excretion (μg/L)
poorer, less educated women, making supplementation a less equitable approach than salt fortification. Therefore, use of iodised salt by the food industry should be strongly encouraged. Denmark and Belgium have instituted compulsory iodisation of salt used in bread; however, this strategy does not seem to meet the needs of the higher iodine requirement during pregnancy.4 Iodisation of all food-grade salt is preferable, as in Croatia and Serbia, where iodised salt programmes cover the needs of pregnancy.4 In Belarus, adequate iodine intakes during pregnancy have been achieved thanks to a national strategy that combines mandatory use of iodized salt by the food industry and promotion of iodised table salt directly to consumers.12 Education of health authorities and the public on the need to prevent iodine deficiency by consuming iodised salt should take into account policies to reduce salt consumption.13 The recent Series in The Lancet on child development,14 and the World Bank,15 recommend that governments put a high priority on salt iodisation to promote health and economic development. Although this recommendation was aimed at low-income and middle-income countries in the developing world, it also applies to Europe.
See Online for appendix
Michael B Zimmermann, Małgorzata Gizak, Karen Abbott, Maria Andersson, John H Lazarus Laboratory of Human Nutrition, ETH Zürich CH-8092, Switzerland (MBZ, MG, MA); Iodine Global Network, Zurich, Switzerland (MBZ, MG, MA, JHL); Imperial College London, London, UK (KA); and Thyroid Research Group, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, Cardiff University, Cardiff, UK (JHL) [email protected]
673
Comment
We declare no competing interests. 1 2 3 4
5
6
7
Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol 2015; 3: 286–95. Zimmermann MB, Andersson M. Update on iodine status worldwide. Curr Opin Endocrinol Diabetes Obes 2012; 19: 382–87. Iodine Global Network. http://www.ign.org (accessed June 2, 2015). World Health Organization/United Nations Children’s Fund/International Council for the Control of Iodine Deficiency Disorders (WHO/UNICEF/ICCIDD). Assessment of iodine deficiency disorders and monitoring their elimination. A guide for programme managers, 3rd edition. Geneva: WHO, 2007. Wong EM, Sullivan KM, Perrine CG, Rogers LM, Peña-Rosas JP. Comparison of median urinary iodine concentration as an indicator of iodine status among pregnant women, school-age children, and nonpregnant women. Food Nutr Bull 2011; 32: 206–12. 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: 331–37. WHO, Nutrition for Health and Development. The WHO Vitamin and Mineral Nutrition Information System (VMNIS) on iodine deficiency disorders. http:// www.who.int/vmnis/iodine/data/en/index.html (accessed May 25, 2015).
8
9
10 11 12 13
14 15
Zimmermann MB, Connolly K, Bozo M, Bridson J, Rohner F, Grimci L. Iodine supplementation improves cognition in iodine-deficient schoolchildren in Albania: a randomized, controlled, double-blind study. Am J Clin Nutr 2006; 83: 108–14. Public Health Committee of the American Thyroid Association, Becker DV, Braverman LE, Delange F, et al. Iodine supplementation for pregnancy and lactation-United States and Canada: recommendations of the American Thyroid Association. Thyroid 2006; 16: 949–51. He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2014; 28: 345–52. Leung AM, Pearce EN, Braverman LE. Iodine content of prenatal multivitamins in the United States. N Engl J Med 2009; 360: 939–40. Petrenko S, Mokhort T, Gerasimov G. Belarus celebrates a superb sustained USI program. IDD Newsletter 2014; 42: 14–15. Campbell N, Dary O, Cappuccio FP, Neufeld LM, Harding KB, Zimmermann MB. Collaboration to optimize dietary intakes of salt and iodine: a critical but overlooked public health issue. Bull World Health Organ 2012; 90: 73–4. Walker SP, Wachs TD, Gardner JM, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet 2007; 369: 145–57. McGuire J, Galloway R. Enriching lives. Overcoming vitamin and mineral malnutrition in developing countries. Washington, DC: World Bank, 1994.
Zephyr/Science Photo Library
Diabetic foot disease: moving from roadmap to journey
Published Online August 4, 2015 http://dx.doi.org/10.1016/ S2213-8587(15)00252-1
For more on the IDSF see http://www.diabeticfoot.nl For more on the IWGDF see http://iwgdf.org/ For the 2015 IWGDF guidance document see http://iwgdf.org/ guidelines/
674
If you had diabetes and a foot ulcer, what would you pay to try to save your limb? Would you pay the equivalent of 5·7 years of your annual income? This amount is what it might cost in India, the country with the greatest number of people suffering from a diabetic foot ulcer.1 Even if you could afford this cost, there would be no guarantee that treatment would be successful. In a large study2 done in European specialised foot centres, 23% of patients with diabetes and a foot ulcer lost at least part of their foot, despite intensive treatment. This poor outcome reflects the fact that diabetic foot disease is both an acute and recurrent affliction that mainly affects older patients with several comorbidities. Diabetic foot disease also requires both local and systemic treatments, given by knowledgeable providers, to adherent patients. This is not a one doctor disease—it demands multidisciplinary care. Furthermore, as a notoriously unglamorous problem, the disease depends on dedicated clinicians working together in a team of health-care providers to care for a complex patient—a scenario some disparage, but we relish. The quality of life for a patient with diabetic foot disease is as poor as for one with recurrent breast cancer,3 and the burden is also borne by the patient’s family and the entire health-care system. Foot complications are now the most common and expensive diabetes-related cause of admittance to hospital in most countries in the world, and amputations are among the most feared outcomes of diabetes. What was mainly a problem in high-income countries has now gone global, with rates
of diabetic foot disease rapidly rising in India, China, the Middle East, and elsewhere. With its multifactorial pathogenesis, diabetic foot disease is in many ways a unique problem. In the past, almost nothing could be done for what was called diabetic gangrene until the discovery of antibiotics 70 years ago.4 Even then, outcomes were poor until the 1980s, when clinicians began to understand the important role of peripheral neuropathy in addition to peripheral artery disease, infection, and metabolic derangements. With this new understanding, assembling a multidisciplinary team to tackle this difficult problem emerged as a new idea.5 Findings of many subsequent studies have shown the effectiveness of this approach, which might avoid more than 45% of lower extremity amputations.6 Ideally, treatment should involve medical, surgical, podiatric, nursing, and other specialties, and use an integrated approach of expertise and technology. In May, 2015, with the goal of improving diabetic foot care, more than 1400 clinicians and researchers from 100 countries met in The Hague at the 7th International Symposium on the Diabetic Foot (ISDF). This is the largest, and perhaps most prestigious, diabetic foot meeting worldwide, bringing together health-care workers from many specialties. In addition to state-ofthe-art lectures and workshops, investigators presented more than 60 oral and 330 poster summaries of new research. The programme also included the launch of www.thelancet.com/diabetes-endocrinology Vol 3 September 2015