Efficacy and safety of long-term universal salt iodization on thyroid disorders: epidemiological evidence from 31 provinces of mainland China.
Abstract
Background: Mandatory universal salt iodization (USI) has been implemented in China for 20 years. Although iodine deficiency disorders are effectively controlled, the risk of excess iodine have been debated. Methods: A nationally representative cross-sectional study with 78,470 enrolled participants, aged 18 years or older, from all 31 provincial regions of mainland China was performed. The participants were given a questionnaire and underwent B-mode ultrasonography of the thyroid. Serum concentrations of thyroid hormones, thyroid antibodies, and urine iodine concentration (UIC) were measured. Results: The median UIC of the adult population was 177.89 μg/L. The weighted prevalence of thyroid disorders in adults were as follows: 0.78% of overt hyperthyroidism, 0.44% of subclinical hyperthyroidism, 0.53% of Graves' disease, 1.02% of overt hypothyroidism, 12.93% of subclinical hypothyroidism, 14.19% of positive thyroid antibodies, 10.19% of positive thyroid peroxidase antibodies, 9.70% of positive thyroglobulin antibodies, 1.17% of goiter, and 20.43% of thyroid nodules. Iodine excess was only associated with higher odds of overt hyperthyroidism and subclinical hypothyroidism, while iodine deficiency was significantly associated with higher odds of most thyroid disorders. In addition, increased iodine intake was significantly associated with elevated serum thyrotropin levels but was inversely associated with thyroid antibodies and thyroid nodules. Conclusions: The long-term mandatory USI program with timely adjustments is successful in preventing iodine deficiency disorders, and it appears to be safe. The benefits outweigh the risks in a population with a stable median iodine intake level of up to 300 μg/L.
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Following iodine prophylaxis in China, the incidence of thyroid autoantibodies decreased to similar levels as before iodine prophylaxis was implemented, indicating that the effect of early iodine-induced thyroid autoimmunity was transient.
“The results showed that following iodine prophylaxis, the incidence of thyroid autoantibodies decreased to similar levels as before iodine prophylaxis was implemented, indicating that the effect of early iodineinduced thyroid autoimmunity was transient.67”
From Hypothyroidism (2024) · cites this paper as [67]
Hypothyroidism may affect up to 12% of the population, primarily as subclinical hypothyroidism, with higher prevalence in areas with inadequate nutritional iodine levels.
“The prevalence in North America and Europe ranges from 0.3%to2%, 3-5 but may affect up to 12% of the population, primarily as subclinical hypothyroidism,withhigherprevalenceinareaswith inadequate nutritional iodine levels. 2,6”
From Hypothyroidism: A Review (2025) · cites this paper as [6]
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He, J., Li, G.-A., Zhu, Z.-Y., Hu, M., Wu, H., Zhu, J., Zhao, H., Zhang, H., & Huang, F. (2021) · Environmental Pollution · doi:10.1016/j.envpol.2021.117739 · Cited by 16 · see citing works
The Association of Thyroid Nodules With Blood Trace Elements Identified in a Cross-Section Study
Zeng, H., Hu, Y., Luo, Y., Ye, Y., Song, C., Yu, G., Chen, Z., Liu, S. M., Liang, Y., Liu, L., et al. (2022) · Frontiers in Nutrition · doi:10.3389/fnut.2022.870873 · Cited by 16 · see citing works
Han, Y., Wang, C., Zhang, L., Zhu, J., Zhu, M. J., Li, Y., Teng, D., Teng, W., & Shan, Z. (2022) · Frontiers in Endocrinology · doi:10.3389/fendo.2022.853889 · Cited by 15 · see citing works
Zhao, S., Tang, L., Fu, J., Yang, Z., Su, C., & Rao, M. (2022) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgac458 · Cited by 15 · see citing works
Xie, J., Wang, J., & Cui, X. (2025) · Autoimmunity Reviews · doi:10.1016/j.autrev.2025.103803 · Cited by 15 · see citing works
Wang, X., Wang, H., Yan, L., Yang, L., Xue, Y., Yang, J., Yao, Y., Tang, X., Tong, N., Wang, G., et al. (2021) · Endocrinology and Metabolism · doi:10.3803/enm.2021.1101 · Cited by 17 · see citing works
“Inclusion and exclusion criteria In inclusion criteria, the entire initial data in the present study were equal to the data of the TIDE survey [8,14].”
MethodResultInfluentialAn iodine balance study to explore the recommended nutrient intake of iodine in Chinese young adults
Yang, L., Wang, J., Yang, J., Zhang, H., Liu, X., Mao, D., Lu, J., Gu, Y., Li, X., Wang, H., et al. (2020) · British Journal Of Nutrition · doi:10.1017/s0007114520002196 · Cited by 15 · see citing works
“However, it is doubted that there is some correlation between the high prevalence of thyroid disease and long-term USI policy (7,8) .”
Associations of metal profiles in blood with thyroiditis: a cross-sectional study
Luo, Y., Zeng, H., Ye, Y., Yu, G., Song, C., Liu, S. M., Chen, X., Jiang, Y., Duan, H., Li, Y., et al. (2022) · Environmental Science and Pollution Research · doi:10.1007/s11356-022-23625-1 · Cited by 14 · see citing works
Yan, Y., Wang, X., Wu, H., Chen, C., Li, X., Yang, R., Li, F., Yan, L., Mu, M., & Xu, M. (2022) · Postgraduate Medicine · doi:10.1080/00325481.2022.2139485 · Cited by 14 · see citing works
Zhang, M., Ni, W., Zhang, L., Fan, K., Sun, Y., Liu, C., & Xu, S. (2023) · Frontiers in Endocrinology · doi:10.3389/fendo.2023.1216308 · Cited by 14 · see citing works
Iodine-induced thyroid dysfunction: a scientometric study and visualization analysis
Gong, B., Wang, X., Wang, C., Yang, W., Shan, Z., & Lai, Y. (2023) · Frontiers in Endocrinology · doi:10.3389/fendo.2023.1239038 · Cited by 14 · see citing works
Prevalence of thyroid dysfunction among Iranian older adults: a cross-sectional study
Mirahmad, M., Mansour, A., Moodi, M., Safkhani, E., Haghpanah, V., Asili, P., Fakhrzadeh, H., Payab, M., Ebrahimpur, M., Khorashadi, M., et al. (2023) · Scientific Reports · doi:10.1038/s41598-023-49085-2 · Cited by 17 · see citing works
“Previous studies reported that as the population age, the prevalence of thyroid disorders increased, mainly due to the increase in subclinical hypo-and hyperthyroidism 8,9 .”
BackgroundZhao, W., Lu, R., Li, Y., & Guo, R. (2021) · Clinical Hemorheology and Microcirculation · doi:10.3233/ch-211235 · Cited by 14 · see citing works
“In our country, the prevalence of thyroid nodules in high-resolution ultrasound examination is about 20% – 35% [1–3].”
Wang, S., Jin, J., Guo, C., Li, Z., Xu, T., Wen, X., Hu, J., Wang, Y., Wei, Y., & Jin, J. (2021) · The Science of The Total Environment · doi:10.1016/j.scitotenv.2021.150546 · Cited by 14 · see citing works
Liu, Z., Lin, Y., Wu, J., Chen, D., Wu, X., Lan, Y., & Chen, Z. (2022) · Nutrition & Metabolism · doi:10.1186/s12986-022-00656-6 · Cited by 14 · see citing works
“99% among the excessive iodine intake people, respectively) [6].”
BackgroundYang, K., Lu, C., Chen, K., Shan, Z., Teng, W., Li, Y., & on behalf of the Thyroid Disorders, I. S. A. D. E. S. G. (2024) · Thyroid · doi:10.1089/thy.2024.0286 · Cited by 13 · see citing works
Zhang, Y., Sun, Y., He, Z., Xu, S., Liu, C., Li, Y., Shan, Z., & Teng, W. (2021) · Clinical Endocrinology · doi:10.1111/cen.14589 · Cited by 13 · see citing works
“11 The coexistence of iodine excess and an ageing society further complicates the assessment of hypothyroidism in clinical practice.”
Preconception TSH and Adverse Pregnancy Outcomes in China: A Nationwide Prospective Cohort Study
Du, H., Wu, D., Zhou, X., Yang, H., Zhu, H., Chen, S., & Pan, H. (2022) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgac208 · Cited by 13 · see citing works
Liu, X., Yuan, J., Zhou, H., Wang, Y., Tian, G., Liu, X., Wang, X., Tang, M., Meng, X. Z., Kou, C., et al. (2022) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgac614 · Cited by 13 · see citing works
The Prevalence and Risk Factors Associated with Iodine Deficiency in Canadian Adults
Mathiaparanam, S., de Macedo, A. N., Mente, A., Poirier, P., Lear, S. A., Wielgosz, A. T., Teo, K. K., Yusuf, S., & Britz‐McKibbin, P. (2022) · Nutrients · doi:10.3390/nu14132570 · Cited by 12 · see citing works
“Nonetheless, remarkable progress has been made in expanding universal salt iodization programs to reduce the prevalence of iodine deficiency disorders worldwide [9,10].”
BackgroundLi, A., Zhou, Q., Mei, Y., Zhao, J., Zhao, M., Xu, J., Ge, X., Li, Y., Li, K., Yang, M. J., et al. (2023) · Journal of Hazardous Materials · doi:10.1016/j.jhazmat.2023.132115 · Cited by 12 · see citing works
The burden of iodine deficiency
Wu, Z., Liu, Y., & Wang, W. (2024) · Archives of Medical Science · doi:10.5114/aoms/178012 · Cited by 12 · see citing works
“The implementation of salt iodization programs such as universal salt iodization (USI) have led to decreases in the iodine deficiency rate worldwide, such that the current global iodine nutritional status has significantly improved compared to before such efforts were instigated [9, 16–18].”
BackgroundMa, C., Zhong, J., Zou, Y., Liu, Z., Li, H., Pang, J., Liu, X., Zejipuchi, Tian, L., Hou, L., et al. (2022) · Frontiers in Endocrinology · doi:10.3389/fendo.2022.816970 · Cited by 12 · see citing works
Yao, J., Zhang, W., Wang, J., Wang, K., Lv, C., Zhang, Z., Chen, X.-Z., Chen, Y., Jiang, W., Niu, J., et al. (2021) · Biological Trace Element Research · doi:10.1007/s12011-021-02727-w · Cited by 12 · see citing works
Herbal medicine for Hashimoto's thyroiditis: A systematic review and network meta-analysis
Luo, J., Zhou, L., Sun, A., Yang, H., Zhang, P., Liu, K., Yu, X., Lin, Y., Huang, Y., & Han, L. (2024) · Journal of Ethnopharmacology · doi:10.1016/j.jep.2023.117663 · Cited by 11 · see citing works
Han, B., Wang, L., Wang, X., Huang, K. J., Shen, Y., Wang, Z., & Jing, T. (2024) · Environmental Research · doi:10.1016/j.envres.2024.118781 · Cited by 11 · see citing works
Cui, Y., Wang, Y., Hou, C., Zhang, D., Zheng, P., Chen, Z., Li, W., Duan, Y., Li, F., Liu, H., et al. (2022) · European Journal of Nutrition · doi:10.1007/s00394-021-02792-w · Cited by 11 · see citing works
Hydrogen Sulfide Promotes Thyroid Hormone Synthesis and Secretion by Upregulating Sirtuin-1
Zhao, X., Cao, Y., Jin, H., Wang, X., Zhang, L., Zhang, Y., Yu, Y., Huang, Y., Gao, Y., & Zhang, J. (2022) · Frontiers in Pharmacology · doi:10.3389/fphar.2022.838248 · Cited by 11 · see citing works
“Various diseases can be caused by hypothyroidism, such as heart failure (Biondi, 2012), hypertension (Tiller et al., 2016), reversible dementia (Muangpaisan et al., 2012).”
BackgroundChen, H., Lü, J., & Li, Y. (2022) · Frontiers in Nutrition · doi:10.3389/fnut.2022.754351 · Cited by 11 · see citing works
Xu, Y., Wang, C., Li, X., Guo, W.-L., Liu, G., Zhang, H., Sun, Y., Zhu, D.-F., & Xu, Q. (2022) · Biomedicine & Pharmacotherapy · doi:10.1016/j.biopha.2022.113495 · Cited by 11 · see citing works
Study on the Relationship Between Serum Iodine and Thyroid Dysfunctions: a Cross-Sectional Study
Xu, T., Guo, W., Ren, Z., Wei, H., Tan, L., & Zhang, W. (2022) · Biological Trace Element Research · doi:10.1007/s12011-022-03459-1 · Cited by 11 · see citing works
“The main reason is that their subjects are from regions in China where iodine is adequate, sufficient, and in excess, while our subjects were from non-high water iodine areas in Tianjin, China.”
BackgroundResultInfluentialApplication of oral inorganic iodine in the treatment of Graves’ disease
Huang, Y., Xu, Y., Xu, M., Zhao, X., & Chen, M. (2023) · Frontiers in Endocrinology · doi:10.3389/fendo.2023.1150036 · Cited by 12 · see citing works
Zhong, F., Guan, Q., Zhang, H., Zhang, X., Zhao, M., Yuan, Z., Fan, X., Han, J., Li, Q., Wang, Z., et al. (2022) · EClinicalMedicine · doi:10.1016/j.eclinm.2022.101629 · Cited by 10 · see citing works
Mi, J., Wang, R., Feng, Q., Han, L., Zhuang, Y., Chen, K., Chen, Z., Hua, Z., Luo, Y., & Lin, J. (2024) · BioMedical Engineering OnLine · doi:10.1186/s12938-024-01215-1 · Cited by 10 · see citing works
“In China, a nationwide cross-sectional study conducted by the Chinese Society of Endocrinology and the Chinese Thyroid Association revealed that 20.43% of patients had thyroid nodules [2].”
BackgroundInfluentialZhao, Y., Wang, P., Dionigi, G., Kou, J., Li, C., Li, F., Wang, T., Tian, W., Jiang, K., Wang, P., et al. (2024) · International Journal of Surgery · doi:10.1097/js9.0000000000002084 · Cited by 10 · see citing works
Systemic Lupus Erythematosus Patients With Related Organic Damage Are at High Risk of Hypothyroidism
Ni, J., Li, J., Wang, Y., Guan, L., Lin, H., Zhang, L., & Zhang, H. (2022) · Frontiers in Endocrinology · doi:10.3389/fendo.2022.920283 · Cited by 10 · see citing works
- Authors
- Li, Y., Teng, D., Ba, J., Chen, B., Du, J., He, L., Lai, X., Teng, X., Shi, X., Li, Y., Chi, H., Liao, E., Liu, C., Liu, L., Qin, G., Qin, Y., Quan, H., Shi, B., Sun, H., Tang, X., Tong, N., Wang, G., Zhang, J.-A., Wang, Y., Xue, Y., Yan, L., Yang, J., Yang, L., Yao, Y., Ye, Z., Zhang, Q., Zhang, L., Zhu, J., Zhu, M., Ning, G., Mu, Y., Zhao, J., Shan, Z., & Teng, W.
- Affiliations
- Harbin Medical University (CN)
- First Hospital of China Medical University (CN)
- Chinese PLA General Hospital (CN)
- Army Medical University (CN)
- First Affiliated Hospital of Dalian Medical University (CN)
- Ningxia Medical University (CN)
- Second Affiliated Hospital of Nanchang University (CN)
- Hohhot First Hospital (CN)
- Central South University (CN)
- Nanjing University of Chinese Medicine (CN)
- Fujian Medical University (CN)
- Zhengzhou University (CN)
- First Affiliated Hospital of GuangXi Medical University (CN)
- Hainan General Hospital (CN)
- First Affiliated Hospital of Xi'an Jiaotong University (CN)
- Wuhan Union Hospital (CN)
- First Hospital of Lanzhou University (CN)
- Sichuan University (CN)
- First Hospital of Jilin University (CN)
- Shanghai University of Medicine and Health Sciences (CN)
- Anhui Medical University (CN)
- First People's Hospital of Yunnan Province (CN)
- Sun Yat-sen University (CN)
- Shanxi Medical University (CN)
- Tibet Autonomous Region People's Hospital (CN)
- Qinghai Provincial Peoples Hospital (CN)
- Zhejiang Center for Disease Control and Prevention (CN)
- Guiyang Medical University (CN)
- Second Hospital of Hebei Medical University (CN)
- First Affiliated Hospital of Xinjiang Medical University (CN)
- Tianjin Medical University General Hospital (CN)
- Shanghai Jiao Tong University (CN)
- Shandong University (CN)
- Corresponding author
- Shan, Zhongyan
- Teng, Weiping
- ORCID
- Li, Yongze
- Chen, Bing
- Du, Jianling
- Lai, Xiaoyang
- Teng, Xiaochun
- Shi, Xiaoguang
- Li, Yanbo
- Liu, Chao
- Liu, Libin
- Qin, Guijun
- Qin, Yingfen
- Quan, Huibiao
- Shi, Bingyin
- Sun, Hui
- Tang, Xulei
- Tong, Nanwei
- Wang, Guixia
- Zhang, Jin-an
- Wang, Youmin
- Yan, Li
- Yang, Jing
- Yang, Lihui
- Ye, Zhen
- Zhang, Qiao
- Zhang, Lihui
- Zhu, Jun
- Zhu, Mei
- Ning, Guang
- Mu, Yiming
- Zhao, Jiajun
- Shan, Zhongyan
- Teng, Weiping
- Venue
- Thyroid
- Publisher
- SAGE Publications
- Published
- 2020-04-01
- Volume
- 30
- Issue
- 4
- Pages
- 568-579
- ISSN
- 1050-7256 (ISSN-L)
- 1557-9077
- OpenAlex
- W3007310873
- Cited by
- 359
- References
- 25
- Citations by year
- 2026: 40 · 2025: 60 · 2024: 80 · 2023: 59 · 2022: 57 · 2021: 50 · 2020: 12 · 2013: 1
- FWCI
- 33.94
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Thyroid (publishedVersion)
- PubMed (publishedVersion)
- Lanzhou University Institutional Repository (submittedVersion)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Cancer Diagnosis and Treatment
- Health Sciences › Medicine › Surgery › Thyroid and Parathyroid Surgery
- Keywords
- universal salt iodization, iodine excess, iodine deficiency disorders, thyroid dysfunction, urinary iodine, overt hyperthyroidism, subclinical hypothyroidism, Graves' disease, thyroid autoantibodies, thyroid peroxidase antibodies, thyroglobulin antibodies, thyroid nodules, goiter, thyroid-stimulating hormone, iodine intake, China
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, China, Cross-Sectional Studies, Female, Humans, Hyperthyroidism, Hypothyroidism, Iodine, Male, Middle Aged, Thyroid Gland, Ultrasonography, Prevalence, Sodium Chloride, Dietary, Young Adult
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