Introduction Iodine deficiency is likely to be common in New Zealand (NZ), as a consequence of low soil iodine levels (and consequently low iodine levels in crop vegetables and animal products), a decline in the use of iodised salt, and a decline in the practice of washing milk storage vats with iodine containing cleaning agents.Iodine levels fall during pregnancy, and recent NZ surveys have confirmed high rates of iodine deficiency in pregnant NZ women and amongst breast fed children.1-3 Iodine is a prerequisite for the synthesis of thyroid hormone. Therefore maternal hypothyroidism which is clearly associated with neurological defects in the foetus (although the effect of milder degrees of maternal hypothyroidism remains uncertain) may result from low maternal iodine levels.4-6Controlled interventional studies to delineate the effect of iodine deficiency per se (in the absence of objective thyroid dysfunction) are lacking, although numerous international case controlled studies support the notion that iodine supplementation in areas of endemic iodine deficiency is associated with improved childhood developmental performance.7Thus, many countries now recommend the routine supplementation of iodine during pregnancy and whilst breastfeeding although specific recommendations differ. In 2010, the NZ Ministry of Health provided a series of recommendations on the use of iodine supplementation by these groups.8We wished to study general awareness of these recommendations amongst healthcare workers and non-healthcare worker groups.Method We produced a paper-based questionnaire incorporating 14 questions focusing on iodine status in New Zealanders, and awareness of current recommendations for iodine supplementation. The questions were designed to minimise the leading of responders to specific answers based on previous questions.Subjects were canvassed by one of the authors (VN) through visits to the antenatal and postnatal wards, and outpatient units in Wellington Regional Hospital, and local community pharmacies. Subjects were asked to complete the questionnaire on the spot without reference to guidance texts.Results 72 subjects were recruited in April 2013 of whom 25 were healthcare workers (10 pharmacists, 9 midwifes, 6 hospital nurses) and 47 women who were not (37 pregnant, 10 breastfeeding). No person approached declined to be interviewed, and no major issues with questionnaire completion were encountered.Forty-six percent of responders felt that New Zealanders were deficient in Iodine, possibly reflective of recent discussion in the media (36% stated that levels were adequate and 17% felt iodine excess had been documented). Responses from healthcare workers were not significantly different from non-healthcare workers, although clear differences in knowledge of dietary supplementation practices in NZ were evident.100% of pharmacists and 80% of other healthcare workers were aware of dietary iodine supplementation, and with the exception of one responder, all were aware that this was achieved via the fortification of commercially produced bread.Whilst 72% of non-healthcare professional responders were also aware of iodine fortification in NZ, a broader group of fortified food products were identified (incorrectly including meat, locally produced vegetables, and dairy products).Reassuringly, 87% and 76% of responders were aware of the recommendation that iodine is supplemented in pregnancy and whilst breastfeeding respectively (see figure 1 for ministry of health recommendations). However, specific knowledge on these recommendations varied markedly; 65% of those who were aware of pregnancy iodine supplementation felt that iodine supplementation should commence once pregnancy is confirmed whilst the remainder felt pre-conception commencement was the recommendation.Once commenced, 56% felt that supplementation should continue throughout the entire pregnancy, with the remainder stating that supplementation should either stop as soon as pregnancy is confirmed (6%) or at 3 or 6 months gestation (21 and 16% respectively). 76% of responders were aware of the recommendation to use iodine supplementation when breastfeeding, with the majority (54%) stating that this should continue until the child is weaned from breast milk.Whilst the majority of those aware of iodine supplementation guidelines were also aware that commercially available iodine supplements (Neurokare etc) were most suitable, 54% of responders also felt that supplementation could be achieved through dietary changes only. Only 11% of responders felt that Kelp based products were an appropriate option.Healthcare workers were further questioned on the specifics of iodine supplementation whilst pregnancy or breastfeeding. Knowledge amongst this group was generally very good with all pharmacists questioned correctly acknowledging the recommendations for iodine supplementation during these stages. Furthermore, the correct iodine dose (150mcg daily) was identified by all with the exception of one pharmacist who incorrectly stated a lower dose for those who are breastfeeding.Every responder stated that they would ask women with known thyroid dysfunction to consult their doctor prior to commencing iodine supplementation.Summary This brief questionnaire-based survey provides reassurance that knowledge of current ministry of health recommendations for iodine supplementation in pregnancy and breastfeeding is generally good, although this study does of course not address the question of whether this knowledge is acted upon by NZ women.Future public health messages should further strengthen this awareness, whilst also focus on the choice of appropriate modalities for optimal and safe supplementation. Figure 1 Vithusia Nithiananthan Medical Student Imperial College School of Medicine London, United Kingdom Richard W Carroll Consultant Endocrinologist Endocrine, Diabetes and Research Centre, Wellington Regional Hospital University of Otago, Wellington, New Zealand Jeremy D Krebs Consultant Endocrinologist Endocrine, Diabetes and Research Centre, Wellington Regional Hospital University of Otago, Wellington, New Zealand

Introduction Iodine deficiency is likely to be common in New Zealand (NZ), as a consequence of low soil iodine levels (and consequently low iodine levels in crop vegetables and animal products), a decline in the use of iodised salt, and a decline in the practice of washing milk storage vats with iodine containing cleaning agents.Iodine levels fall during pregnancy, and recent NZ surveys have confirmed high rates of iodine deficiency in pregnant NZ women and amongst breast fed children.1-3 Iodine is a prerequisite for the synthesis of thyroid hormone. Therefore maternal hypothyroidism which is clearly associated with neurological defects in the foetus (although the effect of milder degrees of maternal hypothyroidism remains uncertain) may result from low maternal iodine levels.4-6Controlled interventional studies to delineate the effect of iodine deficiency per se (in the absence of objective thyroid dysfunction) are lacking, although numerous international case controlled studies support the notion that iodine supplementation in areas of endemic iodine deficiency is associated with improved childhood developmental performance.7Thus, many countries now recommend the routine supplementation of iodine during pregnancy and whilst breastfeeding although specific recommendations differ. In 2010, the NZ Ministry of Health provided a series of recommendations on the use of iodine supplementation by these groups.8We wished to study general awareness of these recommendations amongst healthcare workers and non-healthcare worker groups.Method We produced a paper-based questionnaire incorporating 14 questions focusing on iodine status in New Zealanders, and awareness of current recommendations for iodine supplementation. The questions were designed to minimise the leading of responders to specific answers based on previous questions.Subjects were canvassed by one of the authors (VN) through visits to the antenatal and postnatal wards, and outpatient units in Wellington Regional Hospital, and local community pharmacies. Subjects were asked to complete the questionnaire on the spot without reference to guidance texts.Results 72 subjects were recruited in April 2013 of whom 25 were healthcare workers (10 pharmacists, 9 midwifes, 6 hospital nurses) and 47 women who were not (37 pregnant, 10 breastfeeding). No person approached declined to be interviewed, and no major issues with questionnaire completion were encountered.Forty-six percent of responders felt that New Zealanders were deficient in Iodine, possibly reflective of recent discussion in the media (36% stated that levels were adequate and 17% felt iodine excess had been documented). Responses from healthcare workers were not significantly different from non-healthcare workers, although clear differences in knowledge of dietary supplementation practices in NZ were evident.100% of pharmacists and 80% of other healthcare workers were aware of dietary iodine supplementation, and with the exception of one responder, all were aware that this was achieved via the fortification of commercially produced bread.Whilst 72% of non-healthcare professional responders were also aware of iodine fortification in NZ, a broader group of fortified food products were identified (incorrectly including meat, locally produced vegetables, and dairy products).Reassuringly, 87% and 76% of responders were aware of the recommendation that iodine is supplemented in pregnancy and whilst breastfeeding respectively (see figure 1 for ministry of health recommendations). However, specific knowledge on these recommendations varied markedly; 65% of those who were aware of pregnancy iodine supplementation felt that iodine supplementation should commence once pregnancy is confirmed whilst the remainder felt pre-conception commencement was the recommendation.Once commenced, 56% felt that supplementation should continue throughout the entire pregnancy, with the remainder stating that supplementation should either stop as soon as pregnancy is confirmed (6%) or at 3 or 6 months gestation (21 and 16% respectively). 76% of responders were aware of the recommendation to use iodine supplementation when breastfeeding, with the majority (54%) stating that this should continue until the child is weaned from breast milk.Whilst the majority of those aware of iodine supplementation guidelines were also aware that commercially available iodine supplements (Neurokare etc) were most suitable, 54% of responders also felt that supplementation could be achieved through dietary changes only. Only 11% of responders felt that Kelp based products were an appropriate option.Healthcare workers were further questioned on the specifics of iodine supplementation whilst pregnancy or breastfeeding. Knowledge amongst this group was generally very good with all pharmacists questioned correctly acknowledging the recommendations for iodine supplementation during these stages. Furthermore, the correct iodine dose (150mcg daily) was identified by all with the exception of one pharmacist who incorrectly stated a lower dose for those who are breastfeeding.Every responder stated that they would ask women with known thyroid dysfunction to consult their doctor prior to commencing iodine supplementation.Summary This brief questionnaire-based survey provides reassurance that knowledge of current ministry of health recommendations for iodine supplementation in pregnancy and breastfeeding is generally good, although this study does of course not address the question of whether this knowledge is acted upon by NZ women.Future public health messages should further strengthen this awareness, whilst also focus on the choice of appropriate modalities for optimal and safe supplementation. Figure 1 Vithusia Nithiananthan Medical Student Imperial College School of Medicine London, United Kingdom Richard W Carroll Consultant Endocrinologist Endocrine, Diabetes and Research Centre, Wellington Regional Hospital University of Otago, Wellington, New Zealand Jeremy D Krebs Consultant Endocrinologist Endocrine, Diabetes and Research Centre, Wellington Regional Hospital University of Otago, Wellington, New Zealand