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Iodine Deficiency Disorder and Knowledge about Benefit and Food Source of Iodine among Adolescent Girls in the North Shewa Zone of Amhara Region

Iodine Deficiency Disorder and Knowledge about Benefit and Food Source of Iodine among Adolescent... Hindawi Journal of Nutrition and Metabolism Volume 2021, Article ID 8892180, 9 pages https://doi.org/10.1155/2021/8892180 Research Article Iodine Deficiency Disorder and Knowledge about Benefit and Food Source of Iodine among Adolescent Girls in the North Shewa Zone of Amhara Region 1 2 3 Abayneh Birlie Zeru, Mikyas Arega Muluneh, Kassa Ketsela H Giorgis, 3 2 Mulat Mossie Menalu , and Michael Amera Tizazu Department of Public Health, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia Department of Midwifery, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia Department of Nursing, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia Correspondence should be addressed to Michael Amera Tizazu; michaelamera12@gmail.com Received 19 September 2020; Revised 30 December 2020; Accepted 7 January 2021; Published 13 January 2021 Academic Editor: Karen L. Sweazea Copyright © 2021 Abayneh Birlie Zeru et al. .is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. As the dietary iodine content depends on the iodine contents of the soil where the crop is harvested, in highland areas where the iodine content of topsoil was washed away due to erosion, iodized salt is the main source of iodine. .is study assessed the magnitude of iodine deficiency disorder and knowledge about the benefit and food sources of iodine among adolescent girls in the highland areas of the North Shewa Zone, Amhara Region, central Ethiopia. Methods. An institutional cross-sectional study was conducted from October 5, 2018, to December 30, 2019. .rough a multistage sampling technique, 625 adolescent school girls were selected from 9 schools. A pretested semistructured self-administered questionnaire was used for data collection. An- thropometric measures and thyroid gland physical examinations were performed by trained nurses. .e collected data were entered into the computer through Epi Data 3.1 software, and analysis was performed using Anthro plus and SPSS software. Results. .e total goiter rate was 317 (50.7%) with 95%CI of 46.9% to 54.6%. Grade-one and grade-two goiter accounts 226 (36.2%) and 91 (14.6%), respectively. About one-third, 428 (68.5%), had knowledge about locally available iodine source foods and 309 (72.2%) of them mentioned salt as a source of iodine. Over half, 216 (55.1%), of 392 (62.7%) participants who had knowledge about the benefit of iodine knew it prevents goiter. Diet diversity score of <5 food groups [AOR 1.487, 95%CI 1.061–2.083], stunting [AOR 1.876, 95%CI 1.079–3.257], menstruation [AOR 1.615, 95%CI 1.110–2.349], rural residence [AOR 1.412, 95%CI 1.005–1.984], and open salt storage container [AOR 2.001, 95%CI 1.044–3.833] were significantly associated with goiter. Conclusions. Total goiter rate of adolescent school girls is high in the area. Low diet diversity score, stunting, menstruation, rural residence, and using an open container for salt storage increased the risk of goiter. In addition to universal salt iodization, the emphasis has to be given on proper handling and utilization of iodized salts at the household level to avoid iodine deficiency disorder in adolescent girls. Iodine deficiency (ID) is one of those common micro- 1. Introduction nutrient deficiencies during adolescence which results in Adolescence, which is from age 10 to 19 years, is a period of enlargement of the thyroid gland known as goiter, mental rapid growth of skeletal mass, body size, and body density retardation, and physical growth retardation. .ese clinical which highlights the role of nutrients and minerals in the and subclinical abnormalities related to ID are termed as growth process. Due to gender inequality and other phys- iodine deficiency disorder (IDD) [2–6]. But, in adolescent iological needs, adolescent girls are more vulnerable for girls, the effect of ID could extend to the fetus and newborns malnutrition including micronutrient deficiency [1, 2]. during their motherhood. Mild to moderate ID during 2 Journal of Nutrition and Metabolism pregnancy impairs fetal brain development and reduces were selected using the lottery method. Second, from each child communication skill and, later, school performance selected district, 2 primary schools, rural and urban primary and IQ. In addition, it increases the risk of stillbirth, schools, were selected by the lottery method. Since all high abortions, perinatal deaths, infant mortality, and congenital schools are located in urban areas, we randomly selected one anomalies [6–8]. high school from the selected districts. .ree rural primary To prevent this intergenerational effect of ID, securing schools, 3 urban primary schools, and 3 urban high schools, adequate iodine intake for adolescent girls before pregnancy which give a total of 9 schools, were identified for the study. is an optimal strategy. Recognizing the importance of .ird, lists of adolescent girls aged from 10–19 years were preventing IDD, the World Health Organization (WHO) obtained from each selected school; then, through simple recommended universal salt iodization as the main strategy random sampling, the study participants were proportion- to achieve the elimination of IDD [9, 10]. Ethiopia started ally recruited from each school for the study. enforcing the comprehensive salt regulation which man- dates universal salt iodization in 2012 GC. Since then, io- 2.3. Data Collection Tools and Procedures. Data were collected dized salt coverage showed improvement; however, by trained female nurses through face-to-face interviews using a adequately iodized salt coverage is still low [11, 12]. Most IDD-related local studies focused on school-age semistructured questionnaire and physical examination. .e interview was conducted at school during class free time, and it (6–12 years) children, and those few studies conducted on adolescent girls revealed that goiter is a common public took, on average, 25–30 minutes. .e questionnaire was de- veloped by reviewing different kinds of literature and contex- health problem in Ethiopia. .e goiter rate among adoles- tually adapted to sociocultural norms and agroclimatic cents in Ethiopia varies from place to place ranging from conditions of the study area. .e questionnaire was divided into 25.1% to 48.9% [13–15]. Adolescent girls are over two-folds four parts: sociodemographic, dietary practices, anthropometric more at risk of goiter than adolescent boys [16]. Grade-one measurements, and thyroid examination. goiter is more prevalent in girls aged 10–14 years, and grade Diet diversity assessment: diet diversity was measured by II goiter is more common in 15–19-year-old girls [17]. adapting the Minimum Diet Diversity for Women (MDD-W) Because of topsoil erosion where iodine is usually found, questionnaire by recalling foods and beverages consumed the there is low dietary iodine content in crops cultivated in Ethiopian highland areas. .is means iodized salt is the main previous day and night. .e questionnaire was developed by the Food and Nutrition Technical Assistance (FANTA) dietary source of iodine in those areas [13, 18]. .erefore, it project to reflect the micronutrient adequacy of women’s is important to assess the magnitude of IDD and knowledge diets. It has 22 mutually exclusive food groups and categories, about the benefits and food sources of iodine among ado- of which 14 aggregated to create the MDD-W 10 food group lescent girls in the highland area of the North Shewa Zone, indicator. .e ten MDD-W food groups are grains, white central Ethiopia. roots and tubers, and plantains; pulses (beans, peas, and lentils); nuts and seeds; dairy; meat, poultry, and fish; eggs; 2. Methods and Materials dark green leafy vegetables; other vitamin A-rich fruits and vegetables; other vegetables; and other fruits. From those 10 2.1. Study Design and Setting. An institution-based cross- food groups, a minimum of 5 food groups should be con- sectional study was conducted from October 5, 2018, to sumed in 24 hours to get adequate micronutrients for women. December 30, 2019. Adolescent girls who attend public .erefore, a diet diversity score (DDS) of ≥5 was considered schools in the North Shewa Zone of Amhara Region, central adequate [19]. Ethiopia, were taken as the study population. .e North Anthropometric measurement: height was measured to Shewa Zone is one of the eleven zones found in the Amhara the nearest 0.1 cm with barefoot, and weight was measured regional state. .e North Shewa Zone is located at a latitude ° ° to the nearest 0.1 kg with light clothing. Body mass index 9 46’8.4’’N and longitude 39 40’4.8’’E with an average ele- (BMI) was obtained from WHO Anthro plus software which vation of 2840 meters above sea level. For administrative divides the weight (measured in kg) to the square of the purposes, the North Shewa Zone had been divided into 24 height (measured in meters) of study participants. Similarly, districts and 4 town administration units. the height-for-age Z score (HAZ) and BMI-for-age Z score (BAZ) were computed using WHO Anthro plus software. Adolescent girls having an HAZ of <−2 were considered as 2.2. Sample Size and Sampling Procedure. .e sample size was determined using Epi Info version 7.1.5.0 software by stunted, and those with <−3 were severely considered stunted. Adolescent girls with a BAZ of <−2 were thin, and considering 29.3% prevalence of goiter [13], 5% marginal error, 95% confidence level, and a design effect of 2. We got a those with <−3 were taken as severely thin [20, 21]. Goiter assessment: the enlargement of the thyroid gland total sample size of 636. A multistage sampling technique was employed to get related to iodine deficiency was assessed through exami- study participants. First, 3 districts (Debre-Sina, Basona nation of the thyroid gland. Goiter status was used to assess werena, and Deneda) from 14 highland districts in the zone the IDD of study participants. .ose female nurses trained Journal of Nutrition and Metabolism 3 for the data collection also examined study participants for study participants cannot write and read. .e majority of, thyroid gland enlargement. Accordingly, the level of goiter 363 (59.2%), mothers and, 435 (74.1%), fathers of study was graded as follows: participants were housewives and farmers, respectively (Table 1). Grade 0: if there is no palpable or visible goiter. Grade one: if the goiter is palpable but not visible. 3.2. Goiter Rate, Nutritional Status, and Dietary Practices. Grade two: if the goiter is visible and palpable under the .e overall prevalence of goiter was 317 (50.7%) with 95% CI normal position of the neck according to the WHO of 46.9% to 54.6%. Of those, 226 (36.2%) were grade-one and recommendation. .e total goiter rate of adolescent 91 (14.6%) grade-two goiter. Seven (1.1%) and 65 (10.4%) girls was measured by considering both grade-one and participants had severe and moderate stunting, respectively. -two goiters. A separate classroom was used for goiter .e overall prevalence of stunting was 72 (11.5%) with 95% assessment to make girls feel free to show their necks CI of 9.1% to 14.2%. From 53 (8.5%) with 95% CI of 6.3% to for examination [3, 22]. 10.6% study participants with thinness, 5 (0.8%) had severe thinness and 48 (7.7%) had moderate thinness (Table 2). 2.4. Data Quality Assurance. .e English version of the .irty-seven (5.9%) participants had a meal frequency of questionnaire was translated into the local language (Am- less than three per day. .e mean (±SD) DDS of study haric), and the consistency was checked by retranslating participants was 5.01± 1.85. Two hundred and eighty-three back to English and compared with the original version. .e (45.3%) had consumed less than the minimum required Amharic version of the questionnaire was pretested on 25 number of food groups (<5 good items) in the last 24 hours adolescent school girls to check its understandability by the (Table 2). study participant, response rate to each question, and de- From those 10 food items, grains, 564 (90.2%), were the termine the time required per questionnaire. One-day most frequently consumed food item followed by other training on the objective of the study, on data collection tool, vegetables, 508 (81.3%), and pulses, 435 (69.6%). .e chi- and procedure including how to examine the thyroid gland square test showed that dark green-leafy vegetable con- was given for three female data collectors and one super- sumption showed a significant association with goiter of visor. Daily monitoring and supervision of the data col- adolescent school girls (p value < 0.001). Grains, white roots lection and checking for completeness and consistency of and tubers, pulses, other fruits, and other vegetables also collected data were carried out by the supervisor. .e were associated with goiter. DDS was significantly associated principal investigator also examined the collected data for to goiter (p value � 0.005) (Table 3). completeness and consistency before data entry. 3.3. Knowledge of the Benefit of Iodine and Iodine Food 2.5. Data Analysis Procedures. Data were entered into Epi Sources. Four hundred and twenty-eight (68.5%) study Data 3.1 software and then exported to WHO Anthro plus participants believed they knew locally available iodine version 3.1.0 and SPSS version 24 software for analysis. HAZ source foods and the majority, 309 (72.2%), of them men- and BAZ were computed using the WHO Anthro plus tioned salt as a source of iodine. From 392 (62.7%) par- software. Descriptive statistics was made to see the socio- ticipants who knew the benefit of iodine, prevention of demographic characteristics and goiter rate of adolescent goiter, 216 (55.1%), and good health, 178 (45.4%), were more school girls. Both bivariable and multivariable binary logistic frequently mentioned. From 376 (60.2%) participants who regression analyses were used to identify factors associated had awareness of salt iodization, 148 (39.4%) mentioned with goiter. Variables with a p value of less than 0.25 on the their teachers as a primary source of information. .ough bivariable analysis and nutritionally relevant were consid- most, 568 (90.9%), households of the study participants used ered as candidate variables for further multivariable analysis. closed containers for salt storage, 432 (69.1%) had habits of Odds ratios (OR) with 95% confidence intervals (95%CI) adding salt at the beginning or middle of the food cooking were computed, and variables with a p value <0.05 on process (Table 4). multivariable analysis were considered as statistically sig- nificant risk factors for goiter. 3.4. FactorsAssociatedwithGoiter. Variables (age, residence, menstrual onset, DDS, type of salt used at the household, 3. Results and stunting) which had a p value <0.25 on bivariable analysis and nutritionally relevant variables such as wasting, 3.1. Sociodemographic Characteristics. From the total 636 sampled study participants for the study, 625 were involved meal frequency, and usual salt adding time in the cooking in the data collection, making a response rate of 98.3%. .e process were included in the multivariable analysis (Table 5). mean (±SD) age of study participants was 15.0 (±2.1) years. On the final model, DDS, stunting, menstrual onset, and Two hundred and thirty-three (37.3%) and 156 (25.0%) were residence had a statistically significant association with in the age categories of 10–14 and 17–19 years, respectively. goiter. As compared to those who had ≥5 DDS, the risk of Over half, 328 (52.5%) and 339 (54.2%), of the participants goiter was 1.49 times higher among adolescent school girls who had <5 DDS [AOR; 1.487 and 95%CI; 1.061–2.083]. were primary school attendants and rural residents, re- spectively. .e majority, 224 (37.5%), of mothers of the Stunted adolescent school girls had 87.6% higher odds of 4 Journal of Nutrition and Metabolism Table 1: Sociodemographic characteristics of participants in the Table 2: Prevalence of goiter, malnutrition, and dietary practices of North Shewa Zone, 2019. study participants, 2019. Variables Responses Frequency(%) Variables Responses Frequency (%) 10–14 233 (37.3) Grade 0 308 (49.3) Age (in years) 15–16 236 (37.8) Goiter Grade I 226 (36.2) 17–19 156 (25.0) Grade II 91 (14.6) Primary school 328 (52.5) Severe stunting (<-3SD) 7 (1.1) School High school 297 (47.5) HAZ Mild stunting (<-2SD) 65 (10.4) Rural 339 (54.2) Normal (≥-2SD) 553 (88.5) Residence Urban 286 (45.8) Severe thinness (<-3SD) 5 (0.8) Christian 603 (96.4) BAZ Mild thinness (<-2SD) 48 (7.7) Religion Muslim 16 (2.6) Normal (≥-2SD) 572 (91.5) Others 6 (1.0) <5 food groups 283 (45.3) DDS Amhara 616 (98.6) ≥5 food groups 342 (54.7) Ethnicity Others 9 (1.4) ≤2 meals per day 37 (5.9) Cannot read and write 224 (37.5) Meal frequency 3 meals per day 306 (49.0) Can read and write 219 (36.7) ≥4 meal per day 282 (45.1) Mother educational Up to grade 8 105 (17.6) Abbreviations: HAZ, height-for-age Z score; BAZ, BMI-for-age Z score; status Grade 9 to 12 24 (4.0) DDS, diet diversity score. College certificate and 25 (4.2) above Cannot read and write 85 (14.7) Zone highland districts. .is is consistent with a 48.9% total Can read and write 300 (51.7) goiter rate (36.9% grade I and 11.11.9% grade II) report in Father’s educational Up to grade 8 108 (18.6) Southern Ethiopia [14]. However, it was higher than the status Grade 9 to 12 48 (8.3) report of 39.5% goiter rate among 6–18-year-old girls in College certificate and 39 (6.7) Metekel, Northwest Ethiopia [15]. Likewise, it is higher than above the 31% total goiter rate among mothers in the highland of House wife 363 (59.2) Farmer 123 (20.1) the Amhara Region, Ethiopia [13]. .is goiter prevalence is Merchant 56 (9.1) much higher than the cutoff point of ≥5% population goiter Mother’s occupation Government employee 31 (5.1) rate recommendation of the WHO [22, 23] to define IDD as Private employee 27 (4.4) an endemic public health problem. .is higher goiter rate in Others 13 (2.1) the North Shewa Zone may be related to improper holding Farmer 435 (74.1) and utilization of iodized salt at the household level. Perhaps, Merchant 49 (8.3) it could be due to low dietary iodine intake which is related Father’s occupation Government employee 63 (10.7) to the low iodine content of common crops harvested and Private employee 27 (4.6) eaten in the area. .e highland areas of the North Shewa Others 13 (2.2) Zone are more mountainous and vulnerable for iodine- <5 206 (33.0) Family size ≥5 419 (67.0) containing topsoil erosion. As a result, common foods crops harvested and consumed by the community in the area may lack adequate iodine content. In this study, 68.5% of adolescent girls knew locally having goiter than their counterparts [AOR; 1.876; 95%CI; available iodine-rich foods which are similar to the 70% 1.079–3.257]. .e odds of goiter were 61.5% higher among report in Northwest Ethiopia [24] and higher than the 61.9% menstruating adolescent school girls compared to their report in Wellega Province of Ethiopia [25]. .is study counterparts [AOR; 1.615 and 95%CI; 1.110–2.349]. Rural revealed that 62.7% of adolescent girls knew the benefits of residents had over 41% higher odds of developing goiter iodine and 55.1% of them recognized that it is important to than urban adolescent school girls [AOR; 1.412 and 95%CI; prevent goiter. .is finding goes in line with the 2015 na- 1.005–1.984]. Using open salt storage containers at house- tional report that two-thirds of women in Ethiopia had hold increased the odds of goiter by two-folds [AOR; 2.001 awareness about goiter and 48% of them were able to as- and 95%CI; 1.044–3.833] (Table 5). sociate goiter with iodine deficiency [26]. MDD-W is one of the best indicators of micronutrient intake adequacy. .e current study revealed that the odds of 4. Discussion goiter were 1.49 times higher among adolescent school girls In this study, based on the size of thyroid gland enlargement, who consumed less than 5 food groups than their coun- 36.2% and 14.6% of adolescent school girls had grade-one terparts, which is in line with the finding of a study in the and grade-two goiter, respectively. .e overall goiter rate Dabat district of northwest Ethiopia [27]. .is is because was 50.7% which reflected that, over half of adolescent when the DDS is high, girls will get adequate nutrients such school girls were suffering from IDD in the North Shewa as iodine for the increased demand during the puberty Journal of Nutrition and Metabolism 5 Table 3: Diet diversity and its relationship with goiter among study participants, 2019. Chi-square Goiter test Responses Variables Yes No Total χ pvalue No. (%) No. (%) No. (%) 275 289 564 Yes Grains, white roots, and tubers (86.8) (93.8) (90.2) 8.892 0.003 No 42 (13.2) 19 (6.2) 61 (9.8) 208 227 435 Yes (65.6) (73.7) (69.6) Pulses (beans, peas, and lentils) 4.828 0.028 109 190 No 81 (26.3) (34.4) (30.4) 176 178 354 Yes (55.5) (57.8) (56.6) Nuts and seeds 0.328 0.567 141 130 271 No (44.5) (42.2) (43.4) Yes 64 (20.2) 68 (22.1) (21.1) Dairy 0.335 0.563 253 240 493 No (79.8) (77.9) (78.9) Yes 58 (18.3) 65 (21.2) (19.7) Meat, poultry, and fish 0.779 0.377 259 243 502 No (81.7) (78.9) (80.3) Yes 46 (14.5) 50 (16.2) 96 (15.4) Food groups consumed in the last 24 Eggs 271 258 529 0.357 0.550 No hours (85.5) (83.8) (84.6) 173 211 384 Yes (54.6) (68.5) (61.4) Dark green-leafy vegetables 12.799 0.000 144 241 No 97 (31.5) (45.4) (38.6) 104 112 216 Yes Other vitamin A-rich fruits and (32.8) (36.4) (34.6) 0.874 0.350 vegetables 213 196 409 No (67.2) (63.6) (65.4) 248 260 508 Yes (78.2) (84.4) (81.3) Other vegetables 3.924 0.048 No 69 (21.8) 48 (15.6) (18.7) Yes 59 (18.6) 78 (25.3) (21.9) Other fruits 4.113 0.043 258 230 488 No (81.4) (74.7) (78.1) 161 122 283 <5 (50.8) (39.6) (45.3) Total DDS out of 10 food groups 7.878 0.005 156 186 342 ≥5 (49.2) (60.4) (54.7) Abbreviation: DDS, diet diversity score. period. For a population with grains/cereal-based dietary of the cooking process. .e appropriate time of adding iodized salt to food during cooking is at the end or im- habits, low DDS could lead to iodine deficiency and related disorder of goiter. mediately before the end of cooking to avoid iodine loss Despite the evidence that most packed salts are ade- through evaporation which reflects the importance of proper quately iodized (≥15 ppm) than unpacked salts and salt handling utilization of iodized salts beside the universal salt iodization is the most effective interventional strategy to iodization to prevent IDD. .e level of iodine loss during prevent IDDs such as goiter [28–30], in this study, the type cooking depends upon the type of cooking procedures and of salt utilized by the household was not significantly as- time of addition of salt [31, 32]. .ough there is universal salt sociated with goiter. .is could be because of the incorrect iodization, because of improper utilization of iodized salts, timing of salt adding in the food cooking process as over foods are the main source of iodine in this study area. two-thirds, 432 (69.1%), households of adolescent girls in .is study revealed that postmenarche adolescent girls this study usually add salts at the beginning or in the middle were 61.5% more at risk of goiter than premenarche girls. 6 Journal of Nutrition and Metabolism Table 4: Knowledge about the benefits and food sources of iodine by study participants, 2019. Variables Responses Frequency (%) Yes 428 (68.5) Do you know locally available foods used as a source of iodine? (n � 625) No 197 (31.5) Salt 309 (72.2) Cereals 81 (18.9) Legumes 69 (16.1) Iodine source foods (n � 428) Fruits 29 (6.) Vegetables 57 (13.3) Others 15 (3.5) Yes 392 (62.7) Do you know the benefit of iodine-rich foods? (n � 625) No 233 (37.3) Prevents goiter 216 (55.1) Good health 178 (45.4) Prevent cretinism 84 (21.4) Benefits of iodine (n � 392) Mental development 80 (20.4) Physical growth 73 (18.6) Prevent abortion or still birth 32 (8.2) Others 21 (5.3) Yes 376 (60.2) Heard about iodized salt (n � 625) No 249 (39.8) Teachers 148 (39.4) Mass media 136 (36.2) Primary source of information (n � 376) Health workers 106 (28.2) Relatives/friends 46 (12.2) Others 22 (5.1) Packed 375 (60.0) Type of salt used (n � 625) Unpacked 205 (32.8) Both 45 (7.2) Closed container 568 (90.9) Salt storage container (n � 625) Open container 57 (9.1) At the beginning of cooking 122 (19.5) In the middle of cooking 310 (49.6) Usual time of adding salt during cooking (n � 625) Immediately before the end of cooking 153 (24.5) After cooking 40 (6.4) Table 5: Bivariate and multivariate analysis of factors associated with goiter among adolescent girls, 2019. Goiter Bivariable analysis Multivariable analysis Variables Responses Yes No COR (95%CI) p value AOR (95%CI) p value 10–14 109 124 1 1 1.771 15–16 120 116 0.378 0.828 (0.509–1.348) 0.498 Age (0.819–1.691) 1.472 17–19 88 68 0.063 0.881 (0.501–1.551) 0.938 (0.979–2.214) 1.231 Rural 180 159 0.196 1.412 (1.005–1.984) 0.049 Residence (0.898–1.687) Urban 137 149 1 1 1.639 Yes 229 189 0.04 1.615 (1.110–2.349) 0.031 Menstrual onset (1.171–2.293) No 88 119 1 1 1.573 <5 food groups 161 122 0.005 1.487 (1.061–2.083) 0.018 DDS (1.146–2.161) ≥5 food groups 156 186 1 1 1.276 ≤twice times day 21 16 0.489 1.181 (0.569–2.452) 0.614 (0.639–2.546) Meal frequency 0.972 .ree times day 153 153 0.864 0.809 (0.573–1.142) 0.280 (0.703–1.343) ≥four times day 143 139 1 1 Journal of Nutrition and Metabolism 7 Table 5: Continued. Goiter Bivariable analysis Multivariable analysis Variables Responses Yes No COR (95%CI) p value AOR (95%CI) p value 1.722 1.876 Yes 45 27 0.034 0.044 Stunted (1.039–2.854) (1.079–3.257) No 272 281 1 1 1.097 Yes 28 25 0.748 1.359 (0.720–2.563) 0.416 Wasted (0.624–1.927) No 289 283 1 1 Packed 179 196 1 1 1.399 Type of salt used at the Unpacked 115 90 0.054 1.232 (0.831–1.825) 0.081 (0.994–1.970) household 1.145 Both 23 22 0.668 0.844 (0.392–1.814) 0.421 (0.617–2.125) Closed 280 288 1 1 Type of salt storage container 1.903 Open 37 20 0.025 2.001 (1.044–3.833) 0.037 (1.078–3.359) Before cooking starts 60 62 1 1 1.117 In the middle of cooking 161 149 0.606 1.238 (0.766–2.001) 0.678 (0.734–1.699) 1.047 Usual salt adding time Immediately before the end of 77 76 0.850 1.383 (0.795–2.405) 0.607 cooking (0.651–1.685) 0.935 After cooking 19 21 0.573 0.862(0.387–1.911) 0.714 (0.457–1.911) Note: significantly associated variables at a p value <0.05. DDS, diet diversity score; COR, crude odds ratio; AOR, adjusted odds ratio. According to a study in Switzerland [33] during the mid to participants was not measured using urinary iodine concentration or iodine content of salt used at the late puberty, period girls are more susceptible to goiter even with mild iodine deficiency. .is coincidence between goiter household level; rather, we used total goiter rate which is and menarche may be related to the sex steroid hormones a less sensitive indicator of IDD. Since the goiter status of which promote modulation of the hypothalamic-pituitary- study participants was measured through observation thyroid gland axis. .e positive influence of estrogens and and physical examination, there may be nondifferential minor inhibitory effect of androgens on the circulating misclassifications during grading the level of goiter by the thyroid hormone affects thyroid function [34]. .is could data collectors. As a cross-sectional study, the observed increase the physiological demand for iodine nutrients association between those identified risk factors and during puberty, exacerbate the existing iodine deficiency, goiter should be interpreted with caution. and probably lead to the enlargement of thyroid glands in those girls with mild iodine deficiency. 5. Conclusions Nutritional status is another risk factor independently associated with goiter. Both goiter and stunting are indi- .ere was a high (50.7%) total goiter rate among adolescent cators of long-standing nutritional problems; in this study, school girls in the North Shewa Zone highland area. Adolescent stunted adolescent school girls were more likely to have school girls with low DDS, stunting, menstruation, and rural goiter than their counterparts. Likewise, studies in Nigeria residency were more likely to have goiter. In addition to showed that stunting is related to goiter [35] and low urine universal salt iodization, the emphasis has to be given on iodine levels [36]. proper handling and utilization of iodized salts at the house- Similar to the finding of a study in the Sawla district of hold level to avoid IDD on adolescent girls. .e knowledge of Southern Ethiopia [37], the residence was found to be a risk adolescent girls about the benefits of iodine-rich foods was low factor for goiter in the current study. As compared to urban (62.7%), and only half (55.1%) of them had an awareness that residents, goiter was 41.2% more likely to be observed in iodine-rich foods are important for the prevention of goiter. rural resident adolescent school girls. .e association be- tween goiter and rural residency may be because of a lack of List of Abbreviations awareness about the cause and preventive methods of goiter which may include improper storage and utilization of io- BAZ: BMI-for-age Z score dized salts at the household level. HAZ: Height-for-age Z score Despite the large sample size of adolescent girls in- IDD: Iodine deficiency disorder volved in the study as a strength, this study must have the DDS: Diet diversity score following limitations: the recent iodine level of study MDD-W: Minimum siet diversity for women 8 Journal of Nutrition and Metabolism [6] Nutrition and Physical Activity Guidelines for Adolescents, Data Availability Adolescent Nutrition, UCSF, University of California, San Francisco, CA, USA, 2013. .e datasets used and/or analyzed during the current study [7] M. Markhus, L. Dahl, V. Moe et al., “Maternal iodine status is are available from the corresponding author on reasonable associated with offspring language skills in infancy and request. toddlerhood,” Nutrients, vol. 10, no. 9, p. 1270, 2018. [8] D. Levie, T. I. M. Korevaar, S. C. Bath et al., “Association of Ethical Approval maternal iodine status with child IQ: a meta-analysis of in- dividual participant data,” 8e Journal of Clinical Endocri- A letter of ethical clearance was obtained from the Ethical nology & Metabolism, vol. 104, no. 12, pp. 5957–5967, 2019. Review Committee of Debre Berhan University. A per- [9] UNICEF-WHO Joint Committee on Health Policy, World mission letter was also obtained from the zonal health office, Summit for Children - Mid Decade Goal: Iodine Deficiency woreda health office, and each selected school. Disorders, United Nations Children’s Fund, World Health Organization, Geneva, Switzerland, JCHPSS/94/2.7), 1994. [10] WHO, UNICEF. World Health Organization, United Nations Consent Children’s Fund, Joint Statement: Reaching Optimal Iodine We obtained written consent from study participants aged Nutrition in Pregnant and Lactating Women and Young Children, World Health Organization, Geneva, Switzerland, 15 years, and for those less than 15 years of age, verbal consent from teachers and assent from participants was [11] 2017 Remarkable progress against iodine deficiency in obtained. For confidentiality purposes, the names of the Ethiopia. Idd Newsletter. participants were not included in the questionnaire. [12] T. Chuko, J. Bagriansky, and A. T. Brown, Ethiopia’s long road to USI. Idd Newsletter, 2015. Conflicts of Interest [13] C. Abuye, Y. Berhane, and T Ersumo, “.e role of changing diet and altitude on goitre prevalence in five regional states in .e authors declare that they have no conflicts of interest. Ethiopia,” East African Journal of Public Health, vol. 5, no. 3, pp. 163–168, 2008. [14] S. B. Workie, Y. G. Abebe, A. A. Gelaye, and T. C. Mekonen, Authors’ Contributions “Assessing the status of iodine deficiency disorder (IDD) and AB designed the investigation, carried out the data analyses, associated factors in Wolaita and Dawro Zones School Ad- interpreted the results, and drafted the manuscript; MA olescents, southern Ethiopia,” BMC Research Notes, vol. 10, p. 156, 2017. facilitated the data collection, interpreted the results, and [15] G. Kibatu, E. Nibret, and M. Gedefaw, “.e status of iodine reviewed and revised the manuscript. All authors read and nutrition and iodine deficiency disorders among school approved the final manuscript. children in Metekel zone, Northwest Ethiopia,” Ethiopian Journal of Health Sciences, vol. 23, no. 1, pp. 109–116, 2014. Acknowledgments [16] Y. Mezgebu, A. Mossie, P. Rajesh, and G. Beyene, “Prevalence and severity of iodine deficiency disorder among children 6- .e authors acknowledge the district education offices and 12 years of age in Shebe Senbo district, Jimma zone, Southwest school directors for their consent and assistance. .e authors Ethiopia,” Ethiopian Journal of Health Sciences, vol. 22, no. 3, are sincerely grateful to the study participants and data pp. 196–204, 2012. collectors for their full involvement in the data collection [17] R. Mushtaq, M. Ramzan, and A. Bibi, “Effects of iodine process. .e authors thank Debre Berhan University for defiency goiter on academic performance of girls,” Biomedica, material and financial support. vol. 30, no. 1, pp. 40–43, 2014. [18] M. Zimmermann, Key Barriers to Global Iodine Deficiency Disorder Control: A Summery, Human Nutrition Laboratory, References Swiss Federal Institute of technology Zurich ¨ (Ethz), Zurich, ¨ Switzerland, 2007. [1] World Health Organization, Nutrition in Adolescence: Issues [19] FaF, Minimum Dietary Diversity for Women: A Guide for and Challenges for the Health Sector: Issues in Adolescent Measurement, FAO, Rome, 2016. Health and Development, WHO, Geneva, Switzerland, 2005. [20] A. R. Masterson, P. Murakwani, and Z. Mlobane, Assessment [2] Food and Agriculture Organization, “Human vitamin and of Adolescent Girl Nutrition, Dietary Practices, and Roles in mineral requirements: report of a joint FAO/WHO expert zimbabwe, International Medical Corps, Zimbabwe, Africa, consultation bangkok, .ailand,” Food and Agriculture Or- ganization, Rome, Italy, 2001. [21] A. Sinha, H. Sharma, P. Panda, A. Chandrakar, S. Pradhan, [3] T. G. Amabye, “Knowledge of iodine deficiency disorders and and S. Dixit, “Prevalence of goitre, iodine uptake and salt intake of iodized salt in residents of mekelle tigray, Ethiopia,” iodization level in Mahasamund district of Chhattisgarh: a International Journal of Food Sciences and Nutrition, vol. 4, no. 4, pp. 208–214, 2015. baseline study in Central India,” International Journal of Research in Medical Sciences, vol. 4, no. 8, pp. 3590–3594, [4] T. Belachew, A. Gebremariam, W. Legesse et al., Micro- nutrient Deficiency: For the Ethiopian Health Center Team, 2016. [22] World Health Organization, Assessment of Iodine Deficiency Jimma University, Jimma, Ethiopia, 2005. [5] T. Khara, E. Mates, and F. Mason, Adolescent Nutrition: Policy Disorders and Monitoring 8eir Elimination: A Guide for and Programming in SUN+ Countries, Save the Children, Programme Managers, World Health Organization, Geneva, London, UK, 2015. Switzerland, 3 edition, 2007. Journal of Nutrition and Metabolism 9 [23] World Health Organization, Iodine Status Worldwide: WHO Global Database on Iodine Defifciency, Bd Benoist, M. Andersson, I. Egli, B. Takkouche, and H. Allen, Eds., World Health Organization, Geneva, Switzerland, 2004. [24] T. Demissie, “Availability and knowledge of iodized salt at household level and associated factors at Debre tabor town, northwest Ethiopia,” Journal of Nutrition and Health Sciences, vol. 6, no. 1, p. 101, 2019. [25] Z. F. Abessa and Y. J. Mashalla, “Knowledge about goitre among female school-going children in Wellega Province, Ethiopia,” Tanzania Journal of Health Research, vol. 20, no. 4, [26] A. Hailu, Ethiopian National Micronutrient Survey Report, Ethiopian Public Health Institute Ministry of Health, Addis Ababa, Ethiopia, 2016. [27] Z. Abebe, E. Gebeye, and A. Tariku, “Poor dietary diversity, wealth status and use of un-iodized salt are associated with goiter among school children: a cross-sectional study in Ethiopia,” BMC Public Health, vol. 17, p. 44, 2017. [28] World Health Organization, Goitre as a Determinant of the Prevalence and Severity of Iodine Deficiency Disorders in Populations, Vitamin and Mineral Nutrition Information System, World Health Organization, Geneva, Switzerland, 2014, http://apps.who.int/iris/bitstream/10665/133706/1/ WHO_NMH_NHD_EPG_14.5_eng.pdf?ua=1. [29] N. Aburto, M. Abudou, V. Candeias, and T. Wu, Effect and safety of salt iodization to prevent iodine deficiency disorders: a systematic review with meta-analyses, WHO eLibrary of Evi- dence for Nutrition Actions (eLENA), World Health Orga- nization, Geneva, Switzerland, 2014. [30] UNICEF, Guidance On the Monitoring of Salt Iodization Programmes and Determination of Population Iodine Status, UNICEF, NY, New York, 2015. [31] R. Rana and R. S. Raghuvanshi, “Effect of different cooking methods on iodine losses,” Journal of Food Science and Technology, vol. 50, no. 6, pp. 1212–1216, 2013. [32] K. M. Y. K. Sikdar, A. Ganguly, A. S. M. M.-A.- Hossain, and A. B. M. Faroque, “Estimation of loss of iodine from edible iodized salt during cooking of various bangladeshi food preparations,” Dhaka University Journal of Pharmaceutical Sciences, vol. 15, no. 2, pp. 161–165, 2016. [33] Y. Fleury, G. Van Melle, V. Woringer, R. C. Gaillard, and L. Portmann, “Sex-dependent variations and timing of thy- roid growth during Puberty1,” 8e Journal of Clinical En- docrinology & Metabolism, vol. 86, no. 2, pp. 750–754, 2001. [34] L. Dalla Valle, A. Ramina, S. Vianello, A. Fassina, P. Belvedere, and L. Colombo, “Potential for estrogen synthesis and action in human normal and neoplastic thyroid Tissues1,” 8e Journal of Clinical Endocrinology & Metabolism, vol. 83, no. 10, pp. 3702–3709, 1998. [35] R. A. Sanusi and N. N. 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Iodine Deficiency Disorder and Knowledge about Benefit and Food Source of Iodine among Adolescent Girls in the North Shewa Zone of Amhara Region

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Hindawi Publishing Corporation
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Copyright © 2021 Abayneh Birlie Zeru et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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2090-0732
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10.1155/2021/8892180
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Abstract

Hindawi Journal of Nutrition and Metabolism Volume 2021, Article ID 8892180, 9 pages https://doi.org/10.1155/2021/8892180 Research Article Iodine Deficiency Disorder and Knowledge about Benefit and Food Source of Iodine among Adolescent Girls in the North Shewa Zone of Amhara Region 1 2 3 Abayneh Birlie Zeru, Mikyas Arega Muluneh, Kassa Ketsela H Giorgis, 3 2 Mulat Mossie Menalu , and Michael Amera Tizazu Department of Public Health, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia Department of Midwifery, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia Department of Nursing, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia Correspondence should be addressed to Michael Amera Tizazu; michaelamera12@gmail.com Received 19 September 2020; Revised 30 December 2020; Accepted 7 January 2021; Published 13 January 2021 Academic Editor: Karen L. Sweazea Copyright © 2021 Abayneh Birlie Zeru et al. .is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. As the dietary iodine content depends on the iodine contents of the soil where the crop is harvested, in highland areas where the iodine content of topsoil was washed away due to erosion, iodized salt is the main source of iodine. .is study assessed the magnitude of iodine deficiency disorder and knowledge about the benefit and food sources of iodine among adolescent girls in the highland areas of the North Shewa Zone, Amhara Region, central Ethiopia. Methods. An institutional cross-sectional study was conducted from October 5, 2018, to December 30, 2019. .rough a multistage sampling technique, 625 adolescent school girls were selected from 9 schools. A pretested semistructured self-administered questionnaire was used for data collection. An- thropometric measures and thyroid gland physical examinations were performed by trained nurses. .e collected data were entered into the computer through Epi Data 3.1 software, and analysis was performed using Anthro plus and SPSS software. Results. .e total goiter rate was 317 (50.7%) with 95%CI of 46.9% to 54.6%. Grade-one and grade-two goiter accounts 226 (36.2%) and 91 (14.6%), respectively. About one-third, 428 (68.5%), had knowledge about locally available iodine source foods and 309 (72.2%) of them mentioned salt as a source of iodine. Over half, 216 (55.1%), of 392 (62.7%) participants who had knowledge about the benefit of iodine knew it prevents goiter. Diet diversity score of <5 food groups [AOR 1.487, 95%CI 1.061–2.083], stunting [AOR 1.876, 95%CI 1.079–3.257], menstruation [AOR 1.615, 95%CI 1.110–2.349], rural residence [AOR 1.412, 95%CI 1.005–1.984], and open salt storage container [AOR 2.001, 95%CI 1.044–3.833] were significantly associated with goiter. Conclusions. Total goiter rate of adolescent school girls is high in the area. Low diet diversity score, stunting, menstruation, rural residence, and using an open container for salt storage increased the risk of goiter. In addition to universal salt iodization, the emphasis has to be given on proper handling and utilization of iodized salts at the household level to avoid iodine deficiency disorder in adolescent girls. Iodine deficiency (ID) is one of those common micro- 1. Introduction nutrient deficiencies during adolescence which results in Adolescence, which is from age 10 to 19 years, is a period of enlargement of the thyroid gland known as goiter, mental rapid growth of skeletal mass, body size, and body density retardation, and physical growth retardation. .ese clinical which highlights the role of nutrients and minerals in the and subclinical abnormalities related to ID are termed as growth process. Due to gender inequality and other phys- iodine deficiency disorder (IDD) [2–6]. But, in adolescent iological needs, adolescent girls are more vulnerable for girls, the effect of ID could extend to the fetus and newborns malnutrition including micronutrient deficiency [1, 2]. during their motherhood. Mild to moderate ID during 2 Journal of Nutrition and Metabolism pregnancy impairs fetal brain development and reduces were selected using the lottery method. Second, from each child communication skill and, later, school performance selected district, 2 primary schools, rural and urban primary and IQ. In addition, it increases the risk of stillbirth, schools, were selected by the lottery method. Since all high abortions, perinatal deaths, infant mortality, and congenital schools are located in urban areas, we randomly selected one anomalies [6–8]. high school from the selected districts. .ree rural primary To prevent this intergenerational effect of ID, securing schools, 3 urban primary schools, and 3 urban high schools, adequate iodine intake for adolescent girls before pregnancy which give a total of 9 schools, were identified for the study. is an optimal strategy. Recognizing the importance of .ird, lists of adolescent girls aged from 10–19 years were preventing IDD, the World Health Organization (WHO) obtained from each selected school; then, through simple recommended universal salt iodization as the main strategy random sampling, the study participants were proportion- to achieve the elimination of IDD [9, 10]. Ethiopia started ally recruited from each school for the study. enforcing the comprehensive salt regulation which man- dates universal salt iodization in 2012 GC. Since then, io- 2.3. Data Collection Tools and Procedures. Data were collected dized salt coverage showed improvement; however, by trained female nurses through face-to-face interviews using a adequately iodized salt coverage is still low [11, 12]. Most IDD-related local studies focused on school-age semistructured questionnaire and physical examination. .e interview was conducted at school during class free time, and it (6–12 years) children, and those few studies conducted on adolescent girls revealed that goiter is a common public took, on average, 25–30 minutes. .e questionnaire was de- veloped by reviewing different kinds of literature and contex- health problem in Ethiopia. .e goiter rate among adoles- tually adapted to sociocultural norms and agroclimatic cents in Ethiopia varies from place to place ranging from conditions of the study area. .e questionnaire was divided into 25.1% to 48.9% [13–15]. Adolescent girls are over two-folds four parts: sociodemographic, dietary practices, anthropometric more at risk of goiter than adolescent boys [16]. Grade-one measurements, and thyroid examination. goiter is more prevalent in girls aged 10–14 years, and grade Diet diversity assessment: diet diversity was measured by II goiter is more common in 15–19-year-old girls [17]. adapting the Minimum Diet Diversity for Women (MDD-W) Because of topsoil erosion where iodine is usually found, questionnaire by recalling foods and beverages consumed the there is low dietary iodine content in crops cultivated in Ethiopian highland areas. .is means iodized salt is the main previous day and night. .e questionnaire was developed by the Food and Nutrition Technical Assistance (FANTA) dietary source of iodine in those areas [13, 18]. .erefore, it project to reflect the micronutrient adequacy of women’s is important to assess the magnitude of IDD and knowledge diets. It has 22 mutually exclusive food groups and categories, about the benefits and food sources of iodine among ado- of which 14 aggregated to create the MDD-W 10 food group lescent girls in the highland area of the North Shewa Zone, indicator. .e ten MDD-W food groups are grains, white central Ethiopia. roots and tubers, and plantains; pulses (beans, peas, and lentils); nuts and seeds; dairy; meat, poultry, and fish; eggs; 2. Methods and Materials dark green leafy vegetables; other vitamin A-rich fruits and vegetables; other vegetables; and other fruits. From those 10 2.1. Study Design and Setting. An institution-based cross- food groups, a minimum of 5 food groups should be con- sectional study was conducted from October 5, 2018, to sumed in 24 hours to get adequate micronutrients for women. December 30, 2019. Adolescent girls who attend public .erefore, a diet diversity score (DDS) of ≥5 was considered schools in the North Shewa Zone of Amhara Region, central adequate [19]. Ethiopia, were taken as the study population. .e North Anthropometric measurement: height was measured to Shewa Zone is one of the eleven zones found in the Amhara the nearest 0.1 cm with barefoot, and weight was measured regional state. .e North Shewa Zone is located at a latitude ° ° to the nearest 0.1 kg with light clothing. Body mass index 9 46’8.4’’N and longitude 39 40’4.8’’E with an average ele- (BMI) was obtained from WHO Anthro plus software which vation of 2840 meters above sea level. For administrative divides the weight (measured in kg) to the square of the purposes, the North Shewa Zone had been divided into 24 height (measured in meters) of study participants. Similarly, districts and 4 town administration units. the height-for-age Z score (HAZ) and BMI-for-age Z score (BAZ) were computed using WHO Anthro plus software. Adolescent girls having an HAZ of <−2 were considered as 2.2. Sample Size and Sampling Procedure. .e sample size was determined using Epi Info version 7.1.5.0 software by stunted, and those with <−3 were severely considered stunted. Adolescent girls with a BAZ of <−2 were thin, and considering 29.3% prevalence of goiter [13], 5% marginal error, 95% confidence level, and a design effect of 2. We got a those with <−3 were taken as severely thin [20, 21]. Goiter assessment: the enlargement of the thyroid gland total sample size of 636. A multistage sampling technique was employed to get related to iodine deficiency was assessed through exami- study participants. First, 3 districts (Debre-Sina, Basona nation of the thyroid gland. Goiter status was used to assess werena, and Deneda) from 14 highland districts in the zone the IDD of study participants. .ose female nurses trained Journal of Nutrition and Metabolism 3 for the data collection also examined study participants for study participants cannot write and read. .e majority of, thyroid gland enlargement. Accordingly, the level of goiter 363 (59.2%), mothers and, 435 (74.1%), fathers of study was graded as follows: participants were housewives and farmers, respectively (Table 1). Grade 0: if there is no palpable or visible goiter. Grade one: if the goiter is palpable but not visible. 3.2. Goiter Rate, Nutritional Status, and Dietary Practices. Grade two: if the goiter is visible and palpable under the .e overall prevalence of goiter was 317 (50.7%) with 95% CI normal position of the neck according to the WHO of 46.9% to 54.6%. Of those, 226 (36.2%) were grade-one and recommendation. .e total goiter rate of adolescent 91 (14.6%) grade-two goiter. Seven (1.1%) and 65 (10.4%) girls was measured by considering both grade-one and participants had severe and moderate stunting, respectively. -two goiters. A separate classroom was used for goiter .e overall prevalence of stunting was 72 (11.5%) with 95% assessment to make girls feel free to show their necks CI of 9.1% to 14.2%. From 53 (8.5%) with 95% CI of 6.3% to for examination [3, 22]. 10.6% study participants with thinness, 5 (0.8%) had severe thinness and 48 (7.7%) had moderate thinness (Table 2). 2.4. Data Quality Assurance. .e English version of the .irty-seven (5.9%) participants had a meal frequency of questionnaire was translated into the local language (Am- less than three per day. .e mean (±SD) DDS of study haric), and the consistency was checked by retranslating participants was 5.01± 1.85. Two hundred and eighty-three back to English and compared with the original version. .e (45.3%) had consumed less than the minimum required Amharic version of the questionnaire was pretested on 25 number of food groups (<5 good items) in the last 24 hours adolescent school girls to check its understandability by the (Table 2). study participant, response rate to each question, and de- From those 10 food items, grains, 564 (90.2%), were the termine the time required per questionnaire. One-day most frequently consumed food item followed by other training on the objective of the study, on data collection tool, vegetables, 508 (81.3%), and pulses, 435 (69.6%). .e chi- and procedure including how to examine the thyroid gland square test showed that dark green-leafy vegetable con- was given for three female data collectors and one super- sumption showed a significant association with goiter of visor. Daily monitoring and supervision of the data col- adolescent school girls (p value < 0.001). Grains, white roots lection and checking for completeness and consistency of and tubers, pulses, other fruits, and other vegetables also collected data were carried out by the supervisor. .e were associated with goiter. DDS was significantly associated principal investigator also examined the collected data for to goiter (p value � 0.005) (Table 3). completeness and consistency before data entry. 3.3. Knowledge of the Benefit of Iodine and Iodine Food 2.5. Data Analysis Procedures. Data were entered into Epi Sources. Four hundred and twenty-eight (68.5%) study Data 3.1 software and then exported to WHO Anthro plus participants believed they knew locally available iodine version 3.1.0 and SPSS version 24 software for analysis. HAZ source foods and the majority, 309 (72.2%), of them men- and BAZ were computed using the WHO Anthro plus tioned salt as a source of iodine. From 392 (62.7%) par- software. Descriptive statistics was made to see the socio- ticipants who knew the benefit of iodine, prevention of demographic characteristics and goiter rate of adolescent goiter, 216 (55.1%), and good health, 178 (45.4%), were more school girls. Both bivariable and multivariable binary logistic frequently mentioned. From 376 (60.2%) participants who regression analyses were used to identify factors associated had awareness of salt iodization, 148 (39.4%) mentioned with goiter. Variables with a p value of less than 0.25 on the their teachers as a primary source of information. .ough bivariable analysis and nutritionally relevant were consid- most, 568 (90.9%), households of the study participants used ered as candidate variables for further multivariable analysis. closed containers for salt storage, 432 (69.1%) had habits of Odds ratios (OR) with 95% confidence intervals (95%CI) adding salt at the beginning or middle of the food cooking were computed, and variables with a p value <0.05 on process (Table 4). multivariable analysis were considered as statistically sig- nificant risk factors for goiter. 3.4. FactorsAssociatedwithGoiter. Variables (age, residence, menstrual onset, DDS, type of salt used at the household, 3. Results and stunting) which had a p value <0.25 on bivariable analysis and nutritionally relevant variables such as wasting, 3.1. Sociodemographic Characteristics. From the total 636 sampled study participants for the study, 625 were involved meal frequency, and usual salt adding time in the cooking in the data collection, making a response rate of 98.3%. .e process were included in the multivariable analysis (Table 5). mean (±SD) age of study participants was 15.0 (±2.1) years. On the final model, DDS, stunting, menstrual onset, and Two hundred and thirty-three (37.3%) and 156 (25.0%) were residence had a statistically significant association with in the age categories of 10–14 and 17–19 years, respectively. goiter. As compared to those who had ≥5 DDS, the risk of Over half, 328 (52.5%) and 339 (54.2%), of the participants goiter was 1.49 times higher among adolescent school girls who had <5 DDS [AOR; 1.487 and 95%CI; 1.061–2.083]. were primary school attendants and rural residents, re- spectively. .e majority, 224 (37.5%), of mothers of the Stunted adolescent school girls had 87.6% higher odds of 4 Journal of Nutrition and Metabolism Table 1: Sociodemographic characteristics of participants in the Table 2: Prevalence of goiter, malnutrition, and dietary practices of North Shewa Zone, 2019. study participants, 2019. Variables Responses Frequency(%) Variables Responses Frequency (%) 10–14 233 (37.3) Grade 0 308 (49.3) Age (in years) 15–16 236 (37.8) Goiter Grade I 226 (36.2) 17–19 156 (25.0) Grade II 91 (14.6) Primary school 328 (52.5) Severe stunting (<-3SD) 7 (1.1) School High school 297 (47.5) HAZ Mild stunting (<-2SD) 65 (10.4) Rural 339 (54.2) Normal (≥-2SD) 553 (88.5) Residence Urban 286 (45.8) Severe thinness (<-3SD) 5 (0.8) Christian 603 (96.4) BAZ Mild thinness (<-2SD) 48 (7.7) Religion Muslim 16 (2.6) Normal (≥-2SD) 572 (91.5) Others 6 (1.0) <5 food groups 283 (45.3) DDS Amhara 616 (98.6) ≥5 food groups 342 (54.7) Ethnicity Others 9 (1.4) ≤2 meals per day 37 (5.9) Cannot read and write 224 (37.5) Meal frequency 3 meals per day 306 (49.0) Can read and write 219 (36.7) ≥4 meal per day 282 (45.1) Mother educational Up to grade 8 105 (17.6) Abbreviations: HAZ, height-for-age Z score; BAZ, BMI-for-age Z score; status Grade 9 to 12 24 (4.0) DDS, diet diversity score. College certificate and 25 (4.2) above Cannot read and write 85 (14.7) Zone highland districts. .is is consistent with a 48.9% total Can read and write 300 (51.7) goiter rate (36.9% grade I and 11.11.9% grade II) report in Father’s educational Up to grade 8 108 (18.6) Southern Ethiopia [14]. However, it was higher than the status Grade 9 to 12 48 (8.3) report of 39.5% goiter rate among 6–18-year-old girls in College certificate and 39 (6.7) Metekel, Northwest Ethiopia [15]. Likewise, it is higher than above the 31% total goiter rate among mothers in the highland of House wife 363 (59.2) Farmer 123 (20.1) the Amhara Region, Ethiopia [13]. .is goiter prevalence is Merchant 56 (9.1) much higher than the cutoff point of ≥5% population goiter Mother’s occupation Government employee 31 (5.1) rate recommendation of the WHO [22, 23] to define IDD as Private employee 27 (4.4) an endemic public health problem. .is higher goiter rate in Others 13 (2.1) the North Shewa Zone may be related to improper holding Farmer 435 (74.1) and utilization of iodized salt at the household level. Perhaps, Merchant 49 (8.3) it could be due to low dietary iodine intake which is related Father’s occupation Government employee 63 (10.7) to the low iodine content of common crops harvested and Private employee 27 (4.6) eaten in the area. .e highland areas of the North Shewa Others 13 (2.2) Zone are more mountainous and vulnerable for iodine- <5 206 (33.0) Family size ≥5 419 (67.0) containing topsoil erosion. As a result, common foods crops harvested and consumed by the community in the area may lack adequate iodine content. In this study, 68.5% of adolescent girls knew locally having goiter than their counterparts [AOR; 1.876; 95%CI; available iodine-rich foods which are similar to the 70% 1.079–3.257]. .e odds of goiter were 61.5% higher among report in Northwest Ethiopia [24] and higher than the 61.9% menstruating adolescent school girls compared to their report in Wellega Province of Ethiopia [25]. .is study counterparts [AOR; 1.615 and 95%CI; 1.110–2.349]. Rural revealed that 62.7% of adolescent girls knew the benefits of residents had over 41% higher odds of developing goiter iodine and 55.1% of them recognized that it is important to than urban adolescent school girls [AOR; 1.412 and 95%CI; prevent goiter. .is finding goes in line with the 2015 na- 1.005–1.984]. Using open salt storage containers at house- tional report that two-thirds of women in Ethiopia had hold increased the odds of goiter by two-folds [AOR; 2.001 awareness about goiter and 48% of them were able to as- and 95%CI; 1.044–3.833] (Table 5). sociate goiter with iodine deficiency [26]. MDD-W is one of the best indicators of micronutrient intake adequacy. .e current study revealed that the odds of 4. Discussion goiter were 1.49 times higher among adolescent school girls In this study, based on the size of thyroid gland enlargement, who consumed less than 5 food groups than their coun- 36.2% and 14.6% of adolescent school girls had grade-one terparts, which is in line with the finding of a study in the and grade-two goiter, respectively. .e overall goiter rate Dabat district of northwest Ethiopia [27]. .is is because was 50.7% which reflected that, over half of adolescent when the DDS is high, girls will get adequate nutrients such school girls were suffering from IDD in the North Shewa as iodine for the increased demand during the puberty Journal of Nutrition and Metabolism 5 Table 3: Diet diversity and its relationship with goiter among study participants, 2019. Chi-square Goiter test Responses Variables Yes No Total χ pvalue No. (%) No. (%) No. (%) 275 289 564 Yes Grains, white roots, and tubers (86.8) (93.8) (90.2) 8.892 0.003 No 42 (13.2) 19 (6.2) 61 (9.8) 208 227 435 Yes (65.6) (73.7) (69.6) Pulses (beans, peas, and lentils) 4.828 0.028 109 190 No 81 (26.3) (34.4) (30.4) 176 178 354 Yes (55.5) (57.8) (56.6) Nuts and seeds 0.328 0.567 141 130 271 No (44.5) (42.2) (43.4) Yes 64 (20.2) 68 (22.1) (21.1) Dairy 0.335 0.563 253 240 493 No (79.8) (77.9) (78.9) Yes 58 (18.3) 65 (21.2) (19.7) Meat, poultry, and fish 0.779 0.377 259 243 502 No (81.7) (78.9) (80.3) Yes 46 (14.5) 50 (16.2) 96 (15.4) Food groups consumed in the last 24 Eggs 271 258 529 0.357 0.550 No hours (85.5) (83.8) (84.6) 173 211 384 Yes (54.6) (68.5) (61.4) Dark green-leafy vegetables 12.799 0.000 144 241 No 97 (31.5) (45.4) (38.6) 104 112 216 Yes Other vitamin A-rich fruits and (32.8) (36.4) (34.6) 0.874 0.350 vegetables 213 196 409 No (67.2) (63.6) (65.4) 248 260 508 Yes (78.2) (84.4) (81.3) Other vegetables 3.924 0.048 No 69 (21.8) 48 (15.6) (18.7) Yes 59 (18.6) 78 (25.3) (21.9) Other fruits 4.113 0.043 258 230 488 No (81.4) (74.7) (78.1) 161 122 283 <5 (50.8) (39.6) (45.3) Total DDS out of 10 food groups 7.878 0.005 156 186 342 ≥5 (49.2) (60.4) (54.7) Abbreviation: DDS, diet diversity score. period. For a population with grains/cereal-based dietary of the cooking process. .e appropriate time of adding iodized salt to food during cooking is at the end or im- habits, low DDS could lead to iodine deficiency and related disorder of goiter. mediately before the end of cooking to avoid iodine loss Despite the evidence that most packed salts are ade- through evaporation which reflects the importance of proper quately iodized (≥15 ppm) than unpacked salts and salt handling utilization of iodized salts beside the universal salt iodization is the most effective interventional strategy to iodization to prevent IDD. .e level of iodine loss during prevent IDDs such as goiter [28–30], in this study, the type cooking depends upon the type of cooking procedures and of salt utilized by the household was not significantly as- time of addition of salt [31, 32]. .ough there is universal salt sociated with goiter. .is could be because of the incorrect iodization, because of improper utilization of iodized salts, timing of salt adding in the food cooking process as over foods are the main source of iodine in this study area. two-thirds, 432 (69.1%), households of adolescent girls in .is study revealed that postmenarche adolescent girls this study usually add salts at the beginning or in the middle were 61.5% more at risk of goiter than premenarche girls. 6 Journal of Nutrition and Metabolism Table 4: Knowledge about the benefits and food sources of iodine by study participants, 2019. Variables Responses Frequency (%) Yes 428 (68.5) Do you know locally available foods used as a source of iodine? (n � 625) No 197 (31.5) Salt 309 (72.2) Cereals 81 (18.9) Legumes 69 (16.1) Iodine source foods (n � 428) Fruits 29 (6.) Vegetables 57 (13.3) Others 15 (3.5) Yes 392 (62.7) Do you know the benefit of iodine-rich foods? (n � 625) No 233 (37.3) Prevents goiter 216 (55.1) Good health 178 (45.4) Prevent cretinism 84 (21.4) Benefits of iodine (n � 392) Mental development 80 (20.4) Physical growth 73 (18.6) Prevent abortion or still birth 32 (8.2) Others 21 (5.3) Yes 376 (60.2) Heard about iodized salt (n � 625) No 249 (39.8) Teachers 148 (39.4) Mass media 136 (36.2) Primary source of information (n � 376) Health workers 106 (28.2) Relatives/friends 46 (12.2) Others 22 (5.1) Packed 375 (60.0) Type of salt used (n � 625) Unpacked 205 (32.8) Both 45 (7.2) Closed container 568 (90.9) Salt storage container (n � 625) Open container 57 (9.1) At the beginning of cooking 122 (19.5) In the middle of cooking 310 (49.6) Usual time of adding salt during cooking (n � 625) Immediately before the end of cooking 153 (24.5) After cooking 40 (6.4) Table 5: Bivariate and multivariate analysis of factors associated with goiter among adolescent girls, 2019. Goiter Bivariable analysis Multivariable analysis Variables Responses Yes No COR (95%CI) p value AOR (95%CI) p value 10–14 109 124 1 1 1.771 15–16 120 116 0.378 0.828 (0.509–1.348) 0.498 Age (0.819–1.691) 1.472 17–19 88 68 0.063 0.881 (0.501–1.551) 0.938 (0.979–2.214) 1.231 Rural 180 159 0.196 1.412 (1.005–1.984) 0.049 Residence (0.898–1.687) Urban 137 149 1 1 1.639 Yes 229 189 0.04 1.615 (1.110–2.349) 0.031 Menstrual onset (1.171–2.293) No 88 119 1 1 1.573 <5 food groups 161 122 0.005 1.487 (1.061–2.083) 0.018 DDS (1.146–2.161) ≥5 food groups 156 186 1 1 1.276 ≤twice times day 21 16 0.489 1.181 (0.569–2.452) 0.614 (0.639–2.546) Meal frequency 0.972 .ree times day 153 153 0.864 0.809 (0.573–1.142) 0.280 (0.703–1.343) ≥four times day 143 139 1 1 Journal of Nutrition and Metabolism 7 Table 5: Continued. Goiter Bivariable analysis Multivariable analysis Variables Responses Yes No COR (95%CI) p value AOR (95%CI) p value 1.722 1.876 Yes 45 27 0.034 0.044 Stunted (1.039–2.854) (1.079–3.257) No 272 281 1 1 1.097 Yes 28 25 0.748 1.359 (0.720–2.563) 0.416 Wasted (0.624–1.927) No 289 283 1 1 Packed 179 196 1 1 1.399 Type of salt used at the Unpacked 115 90 0.054 1.232 (0.831–1.825) 0.081 (0.994–1.970) household 1.145 Both 23 22 0.668 0.844 (0.392–1.814) 0.421 (0.617–2.125) Closed 280 288 1 1 Type of salt storage container 1.903 Open 37 20 0.025 2.001 (1.044–3.833) 0.037 (1.078–3.359) Before cooking starts 60 62 1 1 1.117 In the middle of cooking 161 149 0.606 1.238 (0.766–2.001) 0.678 (0.734–1.699) 1.047 Usual salt adding time Immediately before the end of 77 76 0.850 1.383 (0.795–2.405) 0.607 cooking (0.651–1.685) 0.935 After cooking 19 21 0.573 0.862(0.387–1.911) 0.714 (0.457–1.911) Note: significantly associated variables at a p value <0.05. DDS, diet diversity score; COR, crude odds ratio; AOR, adjusted odds ratio. According to a study in Switzerland [33] during the mid to participants was not measured using urinary iodine concentration or iodine content of salt used at the late puberty, period girls are more susceptible to goiter even with mild iodine deficiency. .is coincidence between goiter household level; rather, we used total goiter rate which is and menarche may be related to the sex steroid hormones a less sensitive indicator of IDD. Since the goiter status of which promote modulation of the hypothalamic-pituitary- study participants was measured through observation thyroid gland axis. .e positive influence of estrogens and and physical examination, there may be nondifferential minor inhibitory effect of androgens on the circulating misclassifications during grading the level of goiter by the thyroid hormone affects thyroid function [34]. .is could data collectors. As a cross-sectional study, the observed increase the physiological demand for iodine nutrients association between those identified risk factors and during puberty, exacerbate the existing iodine deficiency, goiter should be interpreted with caution. and probably lead to the enlargement of thyroid glands in those girls with mild iodine deficiency. 5. Conclusions Nutritional status is another risk factor independently associated with goiter. Both goiter and stunting are indi- .ere was a high (50.7%) total goiter rate among adolescent cators of long-standing nutritional problems; in this study, school girls in the North Shewa Zone highland area. Adolescent stunted adolescent school girls were more likely to have school girls with low DDS, stunting, menstruation, and rural goiter than their counterparts. Likewise, studies in Nigeria residency were more likely to have goiter. In addition to showed that stunting is related to goiter [35] and low urine universal salt iodization, the emphasis has to be given on iodine levels [36]. proper handling and utilization of iodized salts at the house- Similar to the finding of a study in the Sawla district of hold level to avoid IDD on adolescent girls. .e knowledge of Southern Ethiopia [37], the residence was found to be a risk adolescent girls about the benefits of iodine-rich foods was low factor for goiter in the current study. As compared to urban (62.7%), and only half (55.1%) of them had an awareness that residents, goiter was 41.2% more likely to be observed in iodine-rich foods are important for the prevention of goiter. rural resident adolescent school girls. .e association be- tween goiter and rural residency may be because of a lack of List of Abbreviations awareness about the cause and preventive methods of goiter which may include improper storage and utilization of io- BAZ: BMI-for-age Z score dized salts at the household level. HAZ: Height-for-age Z score Despite the large sample size of adolescent girls in- IDD: Iodine deficiency disorder volved in the study as a strength, this study must have the DDS: Diet diversity score following limitations: the recent iodine level of study MDD-W: Minimum siet diversity for women 8 Journal of Nutrition and Metabolism [6] Nutrition and Physical Activity Guidelines for Adolescents, Data Availability Adolescent Nutrition, UCSF, University of California, San Francisco, CA, USA, 2013. .e datasets used and/or analyzed during the current study [7] M. Markhus, L. Dahl, V. Moe et al., “Maternal iodine status is are available from the corresponding author on reasonable associated with offspring language skills in infancy and request. toddlerhood,” Nutrients, vol. 10, no. 9, p. 1270, 2018. [8] D. Levie, T. I. M. Korevaar, S. C. Bath et al., “Association of Ethical Approval maternal iodine status with child IQ: a meta-analysis of in- dividual participant data,” 8e Journal of Clinical Endocri- A letter of ethical clearance was obtained from the Ethical nology & Metabolism, vol. 104, no. 12, pp. 5957–5967, 2019. Review Committee of Debre Berhan University. A per- [9] UNICEF-WHO Joint Committee on Health Policy, World mission letter was also obtained from the zonal health office, Summit for Children - Mid Decade Goal: Iodine Deficiency woreda health office, and each selected school. Disorders, United Nations Children’s Fund, World Health Organization, Geneva, Switzerland, JCHPSS/94/2.7), 1994. [10] WHO, UNICEF. World Health Organization, United Nations Consent Children’s Fund, Joint Statement: Reaching Optimal Iodine We obtained written consent from study participants aged Nutrition in Pregnant and Lactating Women and Young Children, World Health Organization, Geneva, Switzerland, 15 years, and for those less than 15 years of age, verbal consent from teachers and assent from participants was [11] 2017 Remarkable progress against iodine deficiency in obtained. For confidentiality purposes, the names of the Ethiopia. Idd Newsletter. participants were not included in the questionnaire. [12] T. Chuko, J. Bagriansky, and A. T. Brown, Ethiopia’s long road to USI. Idd Newsletter, 2015. Conflicts of Interest [13] C. Abuye, Y. Berhane, and T Ersumo, “.e role of changing diet and altitude on goitre prevalence in five regional states in .e authors declare that they have no conflicts of interest. Ethiopia,” East African Journal of Public Health, vol. 5, no. 3, pp. 163–168, 2008. [14] S. B. Workie, Y. G. Abebe, A. A. Gelaye, and T. C. Mekonen, Authors’ Contributions “Assessing the status of iodine deficiency disorder (IDD) and AB designed the investigation, carried out the data analyses, associated factors in Wolaita and Dawro Zones School Ad- interpreted the results, and drafted the manuscript; MA olescents, southern Ethiopia,” BMC Research Notes, vol. 10, p. 156, 2017. facilitated the data collection, interpreted the results, and [15] G. Kibatu, E. Nibret, and M. Gedefaw, “.e status of iodine reviewed and revised the manuscript. All authors read and nutrition and iodine deficiency disorders among school approved the final manuscript. children in Metekel zone, Northwest Ethiopia,” Ethiopian Journal of Health Sciences, vol. 23, no. 1, pp. 109–116, 2014. Acknowledgments [16] Y. Mezgebu, A. Mossie, P. Rajesh, and G. Beyene, “Prevalence and severity of iodine deficiency disorder among children 6- .e authors acknowledge the district education offices and 12 years of age in Shebe Senbo district, Jimma zone, Southwest school directors for their consent and assistance. .e authors Ethiopia,” Ethiopian Journal of Health Sciences, vol. 22, no. 3, are sincerely grateful to the study participants and data pp. 196–204, 2012. collectors for their full involvement in the data collection [17] R. Mushtaq, M. Ramzan, and A. Bibi, “Effects of iodine process. .e authors thank Debre Berhan University for defiency goiter on academic performance of girls,” Biomedica, material and financial support. vol. 30, no. 1, pp. 40–43, 2014. [18] M. Zimmermann, Key Barriers to Global Iodine Deficiency Disorder Control: A Summery, Human Nutrition Laboratory, References Swiss Federal Institute of technology Zurich ¨ (Ethz), Zurich, ¨ Switzerland, 2007. 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