Public Health Nutrition: 13(3), 424–429 doi:10.1017/S1368980009990280 Persistence of severe iodine-deficiency disorders despite universal salt iodization in an iodine-deficient area in northern India Subhash Yadav 1 , Sushil Kumar Gupta 1 , Madan M Godbole 1, *, Manoj Jain 2 , Uttam Singh 3 , Praveen V Pavithran 1 , Raman Boddula 1 , Anand Mishra 4 , Ashutosh Shrivastava 1 , Ashwani Tandon 1 , Manish Ora 5 , Amit Chowhan 2 , Manoj Shukla 1 , Narendra Yadav 1 , Satish Babu 4 , Manoj Dubey 1 and Pradeep K Awasthi 1 1 Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India: 2 Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India: 3 Department of Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India: 4 Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India: 5 Department of Nuclear Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India Submitted 28 May 2008: Accepted 29 April 2009: First published online 11 June 2009 Abstract Objective: The aim of the present study was to determine the impact of universal salt iodization (USI) on the prevalence of iodine deficiency in the population of an area previously known to have severe iodine deficiency in India. Design: In a cross-sectional survey, a total of 2860 subjects residing in fifty-three villages of four sub-districts of Gonda District were examined for goitre and urinary iodine concentration. Free thyroxine and thyroid-stimulating hormone levels were also measured. Salt samples from households were collected for estimation of iodine content. Results: A reduction in goitre prevalence was observed from 69 % reported in 1982 to 27?7 % assessed in 2007. However, 34 % of villages still had very high ende- micity of goitre (goitre prevalence .30 %). Twenty-three per cent of households consumed a negligible amount (,5 ppm) and 56 % of households consumed an insufficient amount (5–15 ppm) of iodine from salt. Conclusions: Although there was an overall improvement in iodine nutrition as revealed by decreased goitre prevalence and increased median urinary iodine levels, there were several pockets of severe deficiency that require a more targeted approach. Poor coverage, the use of unpackaged crystal salt with inadequate iodine and the washing of salt before use by 90 % of rural households are the major causes of persisting iodine-deficiency disorders. This demonstrates lapses in USI imple- mentation, lack of monitoring and the need to identify hot spots. We advocate strengthening the USI programme with a mass education component, the supply of adequately iodized salt and the implementation of complementary strategies for vulnerable groups, particularly neonates and lactating mothers. Keywords Iodine-deficiency disorders Universal salt iodization Goitre prevalence Urinary iodine concentration Endemic goitre Iodine-deficient area Eighty-four per cent of the 130 countries affected by iodine-deficiency disorders (IDD) have either national legislation or a draft on salt iodization in place (1) . Worldwide, the sustainability of IDD control programmes has become a major focus. In several countries in which IDD was eliminated by universal salt iodization (USI), control programmes faltered, IDD recurred (2,3) and new cases of cretinism have also appeared (4,5) . On recommendations of the Central Council of Health in 1984, the Government of India took a policy decision with the goal of ‘universal iodization of salt’. Despite remarkable progress in the control of IDD, it remains a significant public health problem in India (6–8) . It has been estimated that 200 million people in India are exposed to the risk of iodine deficiency and more than 71 million suffer from goitre and other IDD (9) . The central notification restricting the sale of non-iodized salt was relaxed in late 2000 by removing the punitive clause. Although the restriction on the sale of non- iodized salt was re-imposed in November 2005, it did not take effect until May 2006 (10) . Assessing the severity of IDD and monitoring the progress of salt iodization programmes remains the cornerstone of any control strategy. The National Family Health Survey-III revealed that 51 % of households were using adequately iodized salt *Corresponding author: Email madangodbole@yahoo.co.in r The Authors 2009