Iodine

Fact Sheet for Health Professionals

Introduction
Iodine is a trace element that is naturally present in some foods, is
added to some types of salt, and is available as a dietary
supplement. Iodine is an essential component of the thyroid
hormones thyroxine (T4) and triiodothyronine (T3). Thyroid
hormones regulate many important biochemical reactions,
including protein synthesis and enzymatic activity, and are critical
determinants of metabolic activity [1,2]. They are also required for
proper skeletal and central nervous system development in fetuses
and infants [1].

Thyroid function is primarily regulated by thyroid-stimulating

hormone (TSH), also known as thyrotropin. It is secreted by the
pituitary gland to control thyroid hormone production and
secretion, thereby protecting the body from hypothyroidism and
hyperthyroidism [1]. TSH secretion increases thyroidal uptake of
iodine and stimulates the synthesis and release of T3 and T4. In
the absence of sufficient iodine, TSH levels remain elevated,
leading to goiter, an enlargement of the thyroid gland that reflects
the body’s attempt to trap more iodine from the circulation and
produce thyroid hormones. Iodine may have other physiological
functions in the body as well. For example, it appears to play a role
in immune response and might have a beneficial effect on
mammary dysplasia and fibrocystic breast disease [2].

The earth’s soils contain varying amounts of iodine, which in turn

affects the iodine content of crops. In some regions of the world,
iodine-deficient soils are common, increasing the risk of iodine
deficiency among people who consume foods primarily from those
areas. Salt iodization programs, which many countries have
implemented, have dramatically reduced the prevalence of iodine
deficiency worldwide [2,3].
Iodine in food and iodized salt is present in several chemical forms
including sodium and potassium salts, inorganic iodine (I2), iodate,
and iodide, the reduced form of iodine [4]. Iodine rarely occurs as
the element but rather as a salt; for this reason, it is referred to as
iodide and not iodine. Iodide is quickly and almost completely
absorbed in the stomach and duodenum. Iodate is reduced in the
gastrointestinal tract and absorbed as iodide [2,5]. When iodide
enters the circulation, the thyroid gland concentrates it in
appropriate amounts for thyroid hormone synthesis and most of
the remaining amount is excreted in the urine [2]. The iodine-replete
healthy adult has about 15–20 mg of iodine, 70%–80% of which is
contained in the thyroid [6].

Median urinary iodine concentrations of 100–199 mcg/L in

children and adults, 150–249 mcg/L in pregnant women and >100
mcg/L in lactating women indicate iodine intakes are adequate [3].
Values lower than 100 mcg/L in children and nonpregnant adults
indicate insufficient iodine intake, although iodine deficiency is not
classified as severe until urinary iodine levels are lower than 20
mcg/L.

Recommended Intakes
Intake recommendations for iodine and other nutrients are
provided in the Dietary Reference Intakes (DRIs) developed by the
Food and Nutrition Board (FNB) at the Institute of Medicine of the
National Academies (formerly National Academy of Sciences) [2].
DRI is the general term for a set of reference values used for
planning and assessing nutrient intakes of healthy people. These
values, which vary by age and gender [2], include the following:

Recommended Dietary Allowance (RDA): Average daily level

of intake sufficient to meet the nutrient requirements of
nearly all (97%–98%) healthy individuals; often used to plan
nutritionally adequate diets for individuals

Adequate Intake (AI): Intake at this level is assumed to ensure

nutritional adequacy; established when evidence is
insufficient to develop an RDA

Estimated Average Requirement (EAR): Average daily level of

intake estimated to meet the requirements of 50% of healthy
 individuals; usually used to assess the nutrient intakes of
groups of people and to plan nutritionally adequate diets for
them; can also be used to assess the nutrient intakes of
individuals

Tolerable Upper Intake Level (UL): Maximum daily intake

unlikely to cause adverse health effects

Table 1 lists the current RDAs for iodine [2]. For infants from birth
to 12 months, the FNB established an AI for iodine that is
equivalent to the mean intake of iodine in healthy, breastfed infants
in the United States.

Table 1: Recommended Dietary Allowances (RDAs) for Iodine [2]

Age Male Female Pregnancy Lactation
Birth to 6 months 110 mcg* 110 mcg*
7–12 months 130 mcg* 130 mcg*
1–3 years 90 mcg 90 mcg
4–8 years 90 mcg 90 mcg
9–13 years 120 mcg 120 mcg
14–18 years 150 mcg 150 mcg 220 mcg 290 mcg
19+ years 150 mcg 150 mcg 220 mcg 290 mcg

* Adequate Intake (AI)

The World Health Organization (WHO), United Nations Children’s

Fund, and the International Council for the Control of Iodine
Deficiency Disorders recommend a slightly higher iodine intake for
pregnant women of 250 mcg per day [3,7].

Sources of Iodine
Food

Seaweed (such as kelp, nori, kombu, and wakame) is one of the

best food sources of iodine [5]. Other good sources include fish
and other seafood as well as eggs (see Table 2). Iodine is also
present in human breast milk [2,5] and infant formulas [8].

Dairy products contain iodine. However, the amount of iodine in

dairy products varies by whether the cows received iodine feed
supplements and whether iodophor sanitizing agents were used to
clean the cows and milk-processing equipment [9]. For example, an
analysis of 59 samples of nonfat milk found a range of 38 to 159
mcg per cup (with an average of 84 mcg/cup used for Table 2) [8].
Plant-based beverages used as milk substitutes, such as soy and
almond beverages, contain relatively small amounts of iodine.

Most commercially prepared bread contains very little iodine

unless the manufacturer has used potassium iodate or calcium
iodate as a dough conditioner [10,11]. Manufacturers list dough
conditioners as an ingredient on product labels but are not required
to include iodine on the Nutrition Facts label [12], even though
these conditioners provide a substantial amount of iodine.
According to 2019 data from the U.S. Department of Agriculture
(USDA) Branded Food Products Database, approximately 20% of
ingredient labels for white bread, whole-wheat bread, hamburger
buns, and hot dog buns listed iodate [13]. Pasta is not a source of
iodine unless it is prepared in water containing iodized salt
because it absorbs some of the iodine [11].

Most fruits and vegetables are poor sources of iodine, and the
amounts they contain are affected by the iodine content of the soil,
fertilizer use, and irrigation practices [2,10]. This variability affects
the iodine content of meat and animal products because of its
impact on the iodine content of foods that the animals consume
[14]. The iodine amounts in different seaweed species also vary
greatly. For example, commercially available seaweeds in whole or
sheet form have iodine concentrations ranging from 16 mcg/g to
2,984 mcg/g [15]. For these reasons, the values for the foods listed
in Table 2 are approximate but can be used as a guide for
estimating iodine intakes.

Table 2: Iodine Content of Selected Foods [8]

Micrograms
(mcg) Percent
Food per serving DV*
Bread, white, enriched, made with 296 197
iodate dough conditioner, 2 slices**
Bread, whole-wheat, made with iodate 273 182
dough conditioner, 2 slices**
Cod, baked, 3 ounces 146 97
 Micrograms
(mcg) Percent
Food per serving DV*
Seaweed, nori, dried, 2 tablespoons, 116 77
flaked (5 g)
Oysters, cooked, 3 ounces 93 62
Yogurt, Greek, plain, nonfat, ¾ cup 87 58
Milk, nonfat, 1 cup 84 56
Iodized table salt, ¼ teaspoon 78 52
Fish sticks, cooked, 3 ounces 57 38
Egg, hard boiled, 1 large 31 21
Pasta, enriched, boiled in water with 30 20
iodized salt, 1 cup
Ice cream, chocolate, ⅔ cup 28 19
Cheese, cheddar, 1 ounce 14 9
Liver, beef, cooked, 3 ounces 14 9
Shrimp, cooked, 3 ounces 13 9
Tuna, canned in water, drained, 3 8 5
ounces
Fruit cocktail in light syrup, canned, ½ 5 3
cup
Fish sauce, 1 tablespoon 4 3
Beef, chuck, roasted, 3 ounces 3 2
Soy beverage, 1 cup 3 2
Chicken breast, roasted, 3 ounces 1 1
Apple juice, 1 cup 1 1
Bread, whole-wheat, made without 1 1
iodate dough conditioner, 2 slices**
Bread, white, enriched, made without 1 1
iodate dough conditioner, 2 slices**
Sea salt, noniodized, ¼ teaspoon 1 1
Rice, brown, cooked, ¾ cup 0 0
Corn, canned, ½ cup 0 0
Broccoli, boiled, ½ cup 0 0
Banana, 1 large 0 0
Soy sauce, 1 tablespoon 0 0
Lima beans, boiled, ½ cup 0 0
 Micrograms
(mcg) Percent
Food per serving DV*
Green peas, boiled, ½ cup 0 0
Pasta, enriched, boiled in water without 0 0
iodized salt, 1 cup

*DV = Daily Value. The U.S. Food and Drug Administration (FDA)
developed DVs to help consumers compare the nutrient contents
of foods and dietary supplements within the context of a total diet.
The DV for iodine is 150 mcg for adults and children age 4 years
and older [12]. FDA does not require food labels to list iodine
content unless iodine has been added to the food. Foods providing
20% or more of the DV are considered to be high sources of a
nutrient, but foods providing lower percentages of the DV also
contribute to a healthful diet.
**About 20% of bread products in the United States list iodate
dough conditioners on their labels. Products made without these
conditioners contain very little iodine.

The USDA, FDA, and ODS-NIH Database for the Iodine Content of
Common Foods (http://www.ars.usda.gov/northeast-area/beltsville-md-
bhnrc/beltsville-human-nutrition-research-center/methods-and-application-
of-food-composition-laboratory/mafcl-site-pages/iodine/) [8] lists the
iodine content of numerous foods and beverages.

Iodized salt

The United States, Canada, and dozens of other countries have

salt-iodization programs [3,16,17]. In the United States, salt
manufacturers have been adding iodine to table salt since the
1920s, although this practice is still voluntary [18]. FDA has
approved the use of potassium iodide and cuprous iodide for salt
iodization [19], whereas the WHO recommends the use of
potassium iodate due to its greater stability, particularly in warm,
damp, or tropical climates [3]. According to its label, iodized salt in
the United States contains 45 mcg iodine/g salt (between 1/8 and
1/4 teaspoon); measured salt samples have an average of 47.5–
50.7 mcg iodine/g salt [8,18]. However, most salt intake in the
United States comes from processed foods, and food
manufacturers almost always use noniodized salt in these foods. If
they do use iodized salt, they must list the salt as iodized in the
ingredient list on the food label [9]. Specialty salts, such as sea salt,
kosher salt, Himalayan salt, and fleur de sel, are not usually iodized.
Product labels will indicate if the salt is iodized or provides iodide.
As shown in Table 2, noniodized sea salt provides virtually no
iodine [8].

Dietary supplements

In dietary supplements, iodine is often present as potassium iodide

or sodium iodide [20]. Supplements containing kelp, a seaweed
that contains iodine, are also available. A small study found that
people absorb potassium iodide almost completely (96.4%) [21].

Many multivitamin/mineral supplements contain iodine, often at a

dose of 150 mcg [20], and some, but not all, prenatal supplements
contain iodine [22]. Dietary supplements containing only iodine are
also available, and many contain high doses, sometimes above the
UL [20]. Many dietary supplements that contain iodine are listed in
the Dietary Supplement Label Database from the NIH [20]. This
database contains label information from tens of thousands of
dietary supplement products on the U.S. market.

Iodine Intakes and Status

Iodine intakes

The Total Diet Study (TDS), an FDA monitoring program, provides

estimated iodine intakes of the U.S. population [23]. Through the
TDS program, foods that represent the average U.S. diet are
purchased and analyzed for several components, including iodine.
Based on analytical results from TDS food samples collected
between 2008 and 2012, combined with food consumption
estimates, the average daily iodine intake in the United States was
216 mcg/day, with a range from 141 to 296 mcg/day across all age
and gender groups [24]. These intakes meet or exceed the EAR for
all groups.

TDS data do not include iodine that people obtain from the
discretionary use of iodized salt [25,26]. Because many U.S.
households use iodized salt, TDS data likely underestimate the true
iodine intake of most U.S. residents. Data from the National Health
and Nutrition Examination Survey (NHANES) collected between
1999 and 2004 indicate that 28–29% of adults use iodine-
containing dietary supplements [27]; this use also adds to the
population’s total iodine intake.

Iodine status of the general U.S. population

Iodine status is typically assessed using urinary iodine

measurements. Urinary iodine reflects dietary iodine intake directly
because people excrete more than 90% of dietary iodine in the
urine [4]. Spot urine iodine measurements are a useful indicator of
iodine status within populations [28,29]. However, multiple 24-hour
urinary iodine or multiple spot urine measurements are more
accurate for individuals [4,30].

Median urinary iodine concentrations, from spot samples collected

as part of a large survey, can be used to characterize the iodine
status of populations [31]. However, because spot samples are not
a suitable indicator of individual iodine status [30], these
measurements cannot be used to diagnose individual cases of
iodine deficiency or to identify the proportion of a population with
iodine deficiency or with excessive iodine intakes [31]. For a
population of school-age children or nonpregnant adults to be
iodine sufficient, median urinary iodine concentrations should be
greater than 100 mcg/L and no more than 20% of the population
should have values lower than 50 mcg/L [3].

Urinary iodine measurements from NHANES have been used since

1971 to monitor the iodine status of the U.S. population [32]. Since
the inception of the NHANES monitoring program, urinary iodine
measurements have shown that the general U.S. population is
iodine sufficient. This is despite the fact that urinary iodine levels
decreased by more than 50% between 1971–1974 and 1988–1994
[2,33]. Much of this decline was a result of decreased levels of
iodine in milk due to the reduced use of iodine-containing feed
supplements and iodophor sanitizing agents in the dairy industry
[34] as well as the reduced use of iodate dough conditioners by
commercial bakers. The use of erythrosine, an iodine-containing
food dye commonly used in fruit-flavored breakfast cereals, also
decreased during this time [34] though it is unclear to what extent
this change actually affected urinary iodine levels because the
bioavailability of iodine from erythrosine has been found to be low
[35]. This sharp decline in urinary iodine levels caused some
concern during the late 1990s that the iodine sufficiency of the U.S.
population could be at risk if this trend continued [33].

More recent NHANES measurements indicate that urinary iodine

levels have stabilized in the general U.S. population. During 2007–
2008, NHANES participants age 6 years and older had a median
urinary iodine concentration of 164 mcg/L [36]. Among women of
reproductive age, the median urinary iodine concentration in
NHANES 2007–2014 was 119 mcg/L [37]. These values have
essentially remained unchanged in the last three NHANES surveys,
indicating that the dietary iodine intake of the general U.S.
population has remained stable since 2000 [36].

Iodine status of U.S. pregnant women

According to the WHO, a median urinary iodine concentration of

150–249 mcg/L indicates adequate iodine nutrition during
pregnancy, while values less than 150 mcg/L are considered
insufficient [3,7]. Analyses of NHANES datasets from 2003 to 2014
indicate that a substantial portion of pregnant women in the United
States are iodine insufficient. Median urinary iodine concentrations
for pregnant women participating in NHANES surveys were 181
mcg/L in 2003–2004, 153 mcg/L in 2001–2006, 125 mcg/L in
2005–2008, and 144 mcg/L in 2007–2014 [32,36-38]. Suboptimal
iodine status during pregnancy has also been observed in Australia
[39].

Pregnant women who do not consume dairy products may be

particularly at risk of iodine insufficiency. According to NHANES
2001–2006 data, pregnant women who consumed no dairy
products in the previous 24 hours had a median urinary iodine
concentration of only 100 mcg/L, compared with 163 mcg/L
among consumers of dairy [38]. Women who restrict their dietary
salt intake also have lower urinary iodine concentrations and might
be more likely to be iodine deficient than women who don’t restrict
salt intake [40].

Overall, it appears that the general U.S. population has adequate

iodine intake but that some pregnant women may be at risk for
iodine deficiency. Continued national iodine monitoring is needed
with more emphasis on population subgroups that are most
susceptible to iodine deficiency disorders.

Iodine Deficiency
Iodine deficiency has multiple adverse effects on growth and
development and is the most common cause of preventable
intellectual disability in the world [41]. Iodine deficiency disorders
result from inadequate thyroid hormone production secondary to
insufficient iodine [5]. During pregnancy and early infancy, iodine
deficiency can cause irreversible effects.

Under normal conditions, the body tightly controls thyroid hormone

concentrations via TSH. Typically, TSH secretion increases when
iodine intake falls below about 100 mcg/day [5]. TSH increases
thyroidal iodine uptake from the blood and the production of
thyroid hormone. However, very low iodine intakes can reduce
thyroid hormone production even in the presence of elevated TSH
levels. In addition, it is important to note that TSH concentration
may remain within the normal range when iodine intake is low, so
TSH is not a sensitive indicator of iodine deficiency [5].

If a person’s iodine intake falls below approximately 10–20

mcg/day, hypothyroidism occurs [1], a condition that is frequently
accompanied by goiter. Goiter is usually the earliest clinical sign of
iodine deficiency [2]. In pregnant women, iodine deficiency of this
magnitude can cause major neurodevelopmental deficits and
growth retardation in the fetus as well as miscarriage and stillbirth
[5]. Chronic, severe iodine deficiency in utero causes cretinism, a
condition characterized by intellectual disability, deaf mutism,
motor spasticity, stunted growth, delayed sexual maturation, and
other physical and neurological abnormalities [5].

In infants and children, less severe iodine deficiency can also

cause neurodevelopmental deficits such as somewhat lower than
average intelligence as measured by IQ [1,42,43]. Mild to moderate
maternal iodine deficiency has also been associated with an
increased risk of attention deficit hyperactivity disorder in children
[44]. In adults, mild to moderate iodine deficiency can cause goiter
as well as impaired mental function and work productivity
secondary to hypothyroidism. Chronic iodine deficiency may be
associated with an increased risk of the follicular form of thyroid
cancer [45].

Groups at Risk of Iodine Inadequacy

Historically, iodine deficiency was endemic in mountainous regions
of the United States and Mexico, and in the so called goiter belt
around the Great Lakes [46]. Thanks to a more national food
supply, iodized salt, and other factors, overt iodine deficiency is
now uncommon in North America. International efforts since the
early 1990s have dramatically reduced the incidence of iodine
deficiency worldwide, but some groups of people are still at risk of
inadequate iodine intake. Iodine insufficiency remains a public
health problem in 25 countries with a total population of about 683
million people [47]. The following groups are among those most
likely to have inadequate iodine status.

People who do not use iodized salt

The use of iodized salt is the most widely used strategy to control
iodine deficiency. Currently, about 88% of households worldwide
use iodized salt, but iodine insufficiency is still prevalent in certain
regions, particularly Southeast Asia, sub-Saharan Africa, and
Eastern Europe [47,48].

Pregnant women

During pregnancy, the RDA for iodine increases from 150 to 220
mcg/day [2]. Surveys indicate that many pregnant women in the
United States might consume insufficient amounts of iodine even if
they do not have signs or symptoms of overt iodine deficiency [36].
The impact, if any, of this insufficient intake on fetal development is
not known.

Vegans and people who eat few or no dairy products,

seafood, and eggs

Seafood, eggs, milk, and milk products are among the best sources
of iodine. Vegans, people with certain food allergies or lactose
intolerance, and others who consume no or minimal amounts of
these foods might not obtain sufficient amounts of iodine [49,50].
People living in regions with iodine-deficient soils

Iodine-deficient soils produce crops that have low iodine levels.

Mountainous areas (e.g., Himalayas, Alps, and Andes regions) and
river valleys prone to flooding (especially in South and Southeast
Asia) are among the most iodine-deficient regions in the world [5].
People living in these areas are at risk of iodine deficiency unless
they consume iodized salt or foods produced outside the iodine-
deficient area.

People with marginal iodine status who eat foods

containing goitrogens

Consumption of foods that contain goitrogens, substances that

interfere with the uptake of iodine in the thyroid, can exacerbate
iodine deficiency [2]. Foods high in goitrogens include soy, cassava,
and cruciferous vegetables (e.g., cabbage, broccoli, and
cauliflower). Deficiencies of iron and/or vitamin A may also be
goitrogenic [51]. These issues are of concern primarily for people
living in areas prone to iodine deficiency [6]. For most people,
including most of the U.S. population, who have adequate iodine
intakes and eat a variety of foods, the consumption of reasonable
amounts of foods containing goitrogens is not a concern.

Iodine and Health

Due to its important role in fetal and infant development and
thyroid hormone production, iodine is a critical nutrient for proper
health at all life stages. This section focuses on four areas of
biomedical research examining iodine’s role in health and disease:
fetal and infant development, cognitive function during childhood,
fibrocystic breast disease, and radiation-induced thyroid cancer. It
also includes a section on low iodine diets, which are usually
recommended for patients preparing to undergo radioactive iodine
treatment.

Fetal and infant development

Iodine sufficiency during pregnancy is extremely important for

proper fetal development. During early pregnancy, when fetal
thyroid gland development is incomplete, the fetus depends
entirely on maternal T4 and, therefore, on maternal iodine intake
[52]. Production of T4 increases by approximately 50% during
pregnancy [53], requiring a concomitant increase in maternal iodine
intake. Sufficient iodine intake after birth is also important for
proper physical and neurological growth and maturation.

Research suggests that infants are more sensitive to the effects of

iodine deficiency than other age groups, as indicated by changes in
their TSH and T4 levels in response to even mild iodine deficiency
[54]. Although severe iodine deficiency disorders are uncommon in
the United States, mild to moderate iodine insufficiency during
pregnancy may subtly affect fetal development [4,55-59]. A meta-
analysis of 6,180 mother-child pairs from three birth cohorts in the
Netherlands, Spain, and the United Kingdom found that verbal IQ
assessed in children at 1.5 to 8 years of age was lower if their
mothers had lower iodine status in their first trimester of
pregnancy [43]. To accommodate increased iodine needs during
pregnancy and lactation, the iodine RDA is 220 mcg/day for
pregnant women and 290 mcg/day for lactating women [2].
Similarly, the WHO recommends 250 mcg/day during pregnancy
and lactation [3].

Despite the importance of iodine for proper fetal development, the

effects of iodine supplements during pregnancy on infant and child
neurodevelopment in particular are inconclusive. Two randomized
clinical trials had a similar study design in which iodine was
provided from early pregnancy to delivery (150 or 200 mcg/day
iodine as potassium iodide) and assessed child cognition using the
same tool at age 1.5 or 2 years [60,61]. Iodine supplementation had
no effect on child cognitive, language, or motor scores [62]. One of
these trials also assessed children at age 5–6 years and continued
to find no benefit on child neurodevelopment from the mother’s use
of iodine [60].

Breast milk contains iodine, although concentrations vary based on

maternal iodine levels. Infants who are exclusively breastfed
depend on maternal iodine sufficiency for optimal development. In
a study of 57 healthy lactating women from the Boston area,
median breast milk iodine content was 155 mcg/L [63]. Based on
reported infant iodine needs and the typical volume of breast milk
consumed, the authors calculated that 47% of the women may
have been providing their infants breast milk containing insufficient
amounts of iodine. During the weaning period, infants not receiving
iodine-containing complementary foods may also be at risk of
iodine deficiency, even in countries with iodized salt programs
[64,65].

To ensure that adequate amounts of iodine are available for proper

fetal and infant development, several national and international
groups recommend iodine supplementation during pregnancy,
lactation, and early childhood. For women living in countries with
weak, sporadic, or uneven iodized salt distribution, the WHO
recommends iodine supplementation for all women of childbearing
age to achieve a total iodine intake of 150 mcg/day. For pregnant
and lactating women in these countries, iodine intakes of 250
mcg/day from both supplements and dietary sources are
recommended [3,7]. WHO recommendations for these countries
also include breastfeeding through 24 months of age, combined
with complementary foods fortified with iodine for children
between the ages of 7–24 months [7].

The American Thyroid Association recommends that women who

are planning a pregnancy, currently pregnant, or lactating should
supplement their diet with 150 mcg/day iodine in the form of
potassium iodide [66]. Similarly, the American Academy of
Pediatrics recommends that women who are pregnant, planning to
become pregnant, or lactating take a daily supplement providing at
least 150 mcg iodine and use iodized salt [67].

The use of iodine-containing dietary supplements by pregnant and

lactating women in the United States appears to be low compared
to current recommendations. Of 59 best-selling prenatal
multivitamin supplements on the market in 2016–2017, only 34
contained iodine [22]. The median iodine content was 150 mcg per
daily serving, with a range of 25 to 290 mcg; 25 of the 34 provided
iodine as potassium iodide. According to 2011–2014 NHANES
data, 72.2% of pregnant woman took any dietary supplement, but
only 17.8% of them took an iodine-containing product [68]. Among
lactating women, 75% took a dietary supplement, but only 19% of
them took an iodine-containing product.

Results from a 2010 study, however, raise some questions as to the

safety of widespread iodine supplementation in areas of relative
iodine sufficiency. In this cross-sectional study, pregnant women
living in Spain had a significantly increased risk of
hyperthyrotropinemia (TSH >3 microU/mL) if they consumed iodine
supplements in doses ≥200 mcg/day compared with those who
consumed doses <100 mcg/day [69]. These findings suggest that
taking higher doses of supplemental iodine during pregnancy could
induce thyroid dysfunction in some women and underscore the
need for additional research into the effects on maternal thyroid
function of iodine supplementation during pregnancy.

Taken as a whole, these findings indicate that increased public

awareness of iodine’s importance during pregnancy and lactation
is warranted and that further research into the effects of iodine
supplementation during pregnancy is needed. Many researchers,
as well as the American Thyroid Association, stress the importance
of continued iodine status monitoring among women of
reproductive age [1,4,32,38,56,70,71].

Cognitive function during childhood

The effects of severe iodine deficiency on neurological

development are well documented. Results from several studies
suggest, for example, that chronic, moderate to severe iodine
deficiency, particularly in children, reduces IQ by about 12–13.5
points [53]. A 2004 Cochrane Review concluded that iodine
supplementation in children living in areas of iodine deficiency
appears to both positively affect physical and mental development
and decrease mortality with only minor and transient adverse
effects [72].

The effects of mild iodine deficiency during childhood are more

difficult to quantify. Some research suggests that mild iodine
deficiency is associated with subtle neurodevelopmental deficits
and that iodine supplementation might improve cognitive function
in mildly iodine-deficient children [52].

In a 2009 randomized, placebo-controlled study, 184 children age

10–13 years in New Zealand with a median urinary iodine
concentration of 63 mcg/L received iodine supplements (150
mcg/day) or placebo for 28 weeks [73]. Iodine supplementation
improved iodine status (median urinary iodine concentration after
supplementation was 145 mcg/L) and significantly improved
measures of perceptual reasoning and overall cognitive score
compared with children taking a placebo. These findings suggest
that correcting mild iodine deficiency in children could improve
certain components of cognition. Additional research is required to
fully understand the effects of mild iodine deficiency and iodine
supplementation on cognitive function.

Fibrocystic breast disease

Fibrocystic breast disease is a benign condition characterized by

lumpy, painful breasts and palpable fibrosis. It commonly affects
women of reproductive age, but it can also occur during
menopause, especially in women taking estrogens [74]. Breast
tissue has a high concentration of iodine, especially during
pregnancy and lactation [4,75]. Some research suggests that iodine
supplementation might be helpful for fibrocystic breast disease,
although a specific mechanism of action has not been established
[76] and data are limited.

In a double-blind study, researchers randomly assigned 56 women

with fibrocystic breast disease to receive daily supplements of
iodine (70 to 90 mcg I2/kg body weight) or placebo for 6 months
[74]. At treatment completion, 65% of the women receiving iodine
reported decreased pain compared with 33% of women in the
placebo group. A more recent randomized, double-blind, placebo-
controlled clinical trial had similar findings. In this study,
researchers randomly assigned 111 women (18–50 years of age)
with fibrosis and a history of breast pain to receive tablets
containing 0 mcg, 1,500 mcg, 3,000 mcg, or 6,000 mcg of iodine
per day [76]. After 5 months of treatment, women receiving doses
of 3,000 or 6,000 mcg iodine had a significant decrease in breast
pain, tenderness, and nodularity compared with those receiving
placebo or 1,500 mcg iodine. The researchers also reported a
dose-dependent reduction in self-assessed pain. None of the
doses was associated with major adverse events or changes in
thyroid function test results.

Although the results of these studies are promising, more research

is needed to clarify iodine’s role in fibrocystic breast disease.
Moreover, the doses used in these studies (approximately 1,500–
6,000 mcg per day) are several times higher than the iodine UL of
1,100 mcg for adults. Doses of this magnitude should only be used
under the guidance of a physician [2].

Radiation-induced thyroid cancer

Nuclear accidents can release radioactive iodine into the

environment, increasing the risk of thyroid cancer in exposed
individuals, especially children [77,78]. Thyroidal uptake of
radioactive iodine is higher in people with iodine deficiency than in
people with iodine sufficiency. For this reason, iodine-deficient
individuals have a particularly high risk of developing radiation-
induced thyroid cancer when exposed to radioactive iodine.

FDA has approved potassium iodide as a thyroid-blocking agent to

reduce the risk of thyroid cancer in radiation emergencies involving
the release of radioactive iodine [77]. FDA recommends that
exposed people take a daily pharmacological dose (16–130 mg
potassium iodide, depending on age) until the risk of significant
radiation exposure ends [77,78]. Potassium iodide was widely used
in Poland following the 1986 Chernobyl accident and childhood
thyroid cancer rates did not increase substantially in subsequent
years [79]. In areas where iodide prophylaxis was not used, such as
Belarus and Ukraine, where many children were mildly iodine
deficient, the incidence of thyroid cancer sharply increased among
children and adolescents [77].

Low iodine diets for radioactive iodine treatment

Patients preparing to undergo radioactive iodine treatment for

differentiated thyroid cancer are usually instructed to follow a low
iodine diet prior to treatment. The rationale behind this guidance is
to deplete iodine levels in the body and increase thyroidal uptake of
the radioactive iodine (iodine–131) [80-82].

A low iodine diet typically limits iodine intake to 50 mcg/day or less

for 1 to 2 weeks before treatment [80-83]. Specific
recommendations vary, however, and research is ongoing to define
optimal guidelines for low iodine diets. For example, one study in
an area of the Netherlands with sufficient iodine status found that
following a low iodine diet for 4 days might adequately prepare
patients for radioactive iodine treatment [84]. This study examined
24-hour urinary iodine excretion in 65 patients with differentiated
thyroid cancer who followed a low iodine diet (less than 50
mcg/day) for 7 days. Iodine excretion on day 4 of the low iodine
diet was not significantly different than that on day 7. However, the
authors noted that following a low iodine diet for only 4 days might
not be sufficient for people living in iodine-rich areas.

People following a low iodine diet should avoid many foods,

including iodized salt, fish and other seafood, seaweed, milk and
milk products, liver, and eggs. They should also avoid bread and
other grain products made with iodate dough conditioners, as well
as maraschino cherries and some red or pink beverages because
these products are often made with iodine-containing red dyes
[8,82,85]. Foods that are relatively low in iodine include noniodized
salt (including many sea salts), fruits and fruit juices, vegetables,
plant-based milk substitutes (such as soy and almond beverages),
rice, pasta, oatmeal, beans, nuts, poultry, pork, beef (except liver),
and bread that does not contain iodate dough conditioners.

Nutrition Facts labels on foods do not usually list iodine unless the
manufacturer has added iodine to the food. Therefore, Nutrition
Facts labels cannot be relied upon to identify foods that naturally
contain iodine, such as seaweed, fish, and other seafood.

Iodine is also present in some dietary supplements, including

products containing kelp and many multivitamin/mineral
supplements [20]. The Supplement Facts labels on dietary
supplement products will indicate whether iodine is present and at
what dose.

Patients preparing for radioactive iodine treatment may develop

hyponatremia, especially if they are undergoing thyroid hormone
withdrawal [86]. To reduce the risk of hyponatremia, the American
Thyroid Association notes that noniodized salt use should not be
restricted when following a low iodine diet [83] . Other groups at
risk for hyponatremia include people who are over 65 years of age,
females, and those taking thiazide diuretics [82]. Noniodized salt is
available in grocery stores. In addition, almost all salt used in
processed foods in the United States is noniodized; product labels
will indicate if the manufacturer used salt that is iodized or
provides iodine [9].
The following resources may be helpful for clinicians and patients
when planning low iodine diets to prepare for radioactive iodine
treatment:

“Low Iodine Diet (https://www.thyroid.org/low-iodine-diet/)” from

the American Thyroid Association provides guidelines and
menu options for meals and snacks.

The USDA, FDA, and ODS-NIH Database for the Iodine

Content of Common Foods (https://www.ars.usda.gov/northeast-
area/beltsville-md-bhnrc/beltsville-human-nutrition-research-
center/methods-and-application-of-food-composition-
laboratory/mafcl-site-pages/iodine/) lists the iodine content per
serving and per 100-gram amounts of hundreds of foods and
beverages. Includes food descriptions, as well as means,
standard deviations, value ranges, sample sizes, and
supporting documentation.

“Thyroid Cancer Treatment

(https://www.cancer.gov/types/thyroid/hp/thyroid-treatment-pdq)”
from the National Cancer Institute includes information on
radioactive iodine therapy.

“Childhood Thyroid Cancer Treatment

(https://www.cancer.gov/types/thyroid/hp/child-thyroid-treatment-
pdq)” from the National Cancer Institute provides information
about risk factors, clinical presentation, diagnosis, and
treatment of different types of childhood thyroid cancer.

Despite widespread recommendations to follow a low iodine diet

prior to radioactive iodine treatment, results from studies
examining the impact of this practice on treatment success are
inconsistent [80,82,83]. The authors of a 2022 systematic review
and meta-analysis of 56 quantitative and 3 qualitative studies
concluded that low iodine diets reduce iodine status [87]. However,
results were unclear on whether this improves the success of
radioactive iodine treatment. In addition, studies have not
examined whether following a low iodine diet to prepare for
radioactive iodine treatment affects long-term disease recurrence
or mortality [83].

Health Risks from Excessive Iodine

High intakes of iodine can cause some of the same symptoms as
iodine deficiency—including goiter, elevated TSH levels, and
hypothyroidism—because excess iodine in susceptible individuals
inhibits thyroid hormone synthesis and thereby increases TSH
stimulation, which can produce goiter [2,88]. Iodine-induced
hyperthyroidism can also result from high iodine intakes, including
when iodine is administered to treat iodine deficiency. Studies have
also shown that excessive iodine intakes cause thyroiditis and
thyroid papillary cancer [2,88]. Cases of acute iodine poisoning are
rare and are usually caused by doses of many grams. Acute
poisoning symptoms include burning of the mouth, throat, and
stomach; fever; abdominal pain; nausea; vomiting; diarrhea; weak
pulse; and coma [2].

Responses to excess iodine and the doses required to cause

adverse effects vary [89]. Some people, such as those with
autoimmune thyroid disease and iodine deficiency, may experience
adverse effects with iodine intakes considered safe for the general
population [2,5].

The FNB has established iodine ULs for food and supplement
intakes (Table 3). In most people, iodine intakes from foods and
supplements are unlikely to exceed the UL [2]. Long-term intakes
above the UL increase the risk of adverse health effects. The ULs
do not apply to individuals receiving iodine for medical treatment,
but such individuals should be under the care of a physician [2].

Table 3: Tolerable Upper Intake Levels (ULs) for Iodine [2]

Age Male Female Pregnancy Lactation
Birth to 6 Not possible to Not possible to
months establish* establish*
7–12 Not possible to Not possible to
months establish* establish*
1–3 years 200 mcg 200 mcg
4–8 years 300 mcg 300 mcg
9–13 600 mcg 600 mcg
years
14–18 900 mcg 900 mcg 900 mcg 900 mcg
years
19+ years 1,100 mcg 1,100 mcg 1,100 mcg 1,100
mcg
* Formula and food should be the only sources of iodine for
infants.

Interactions with Medications

Iodine supplements have the potential to interact with several types
of medications. A few examples are provided below. Individuals
taking these medications on a regular basis should discuss their
iodine intakes with their health care providers.

Antithyroid medications

Antithyroid medications, such as methimazole (Tapazole), are used

to treat hyperthyroidism. Taking high doses of iodine with
antithyroid medications can have an additive effect [89] and could
cause hypothyroidism.

Angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme (ACE) inhibitors, such as

benazepril (Lotensin), lisinopril (Prinivil and Zestril), and fosinopril
(Monopril), are used primarily to treat high blood pressure. Taking
potassium iodide with ACE inhibitors can increase the risk of
hyperkalemia (elevated blood levels of potassium) [89].

Potassium-sparing diuretics

Taking potassium iodide with potassium-sparing diuretics, such as

spironolactone (Aldactone) and amiloride (Midamor), can increase
the risk of hyperkalemia [89].

Iodine and Healthful Diets

The federal government’s 2020–2025 Dietary Guidelines for
Americans notes that “Because foods provide an array of nutrients
and other components that have benefits for health, nutritional
needs should be met primarily through foods. … In some cases,
fortified foods and dietary supplements are useful when it is not
possible otherwise to meet needs for one or more nutrients (e.g.,
during specific life stages such as pregnancy).”
For more information about building a healthy dietary pattern, refer
to the Dietary Guidelines for Americans
(https://www.dietaryguidelines.gov) and the USDA’s MyPlate.
(https://www.choosemyplate.gov/)

The Dietary Guidelines for Americans describes a healthy dietary

pattern as one that

Includes a variety of vegetables; fruits; grains (at least half

whole grains); fat-free and low-fat milk, yogurt, and cheese;
and oils.
Milk and milk products contain iodine.

Includes a variety of protein foods such as lean meats;

poultry; eggs; seafood; beans, peas, and lentils; nuts and
seeds; and soy products.
Some fish contain high amounts of iodine. Eggs are
also good sources of iodine.

Limits foods and beverages higher in added sugars, saturated

fat, and sodium.

Limits alcoholic beverages.

Stays within your daily calorie needs.

References

1. National Research Council, Committee to Assess the Health

Implications of Perchlorate Ingestion. Health Implications of
Perchlorate Ingestion (http://www.nap.edu/openbook.php?
record_id=11202&page=1). Washington, DC: The National
Academies Press, 2005.

2. Institute of Medicine, Food and Nutrition Board. Dietary

Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron,
Chromium, Copper, Iodine, Iron, Manganese, Molybdenum,
Nickel, Silicon, Vanadium, and Zinc
(http://www.nap.edu/openbook.php?record_id=10026&page=1).
Washington, DC: National Academy Press, 2001.