A cross-sectional study of the Evaluation of Iodine Deficiency among Pregnant Women Attending Antenatal Clinic at a Community Health Centre

doi:10.21203/rs.3.rs-4944748/v1

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Research Article

A cross-sectional study of the Evaluation of Iodine Deficiency among Pregnant Women Attending Antenatal Clinic at a Community Health Centre

https://doi.org/10.21203/rs.3.rs-4944748/v1

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Background

Iodine deficiency is a critical global health issue, especially among pregnant women. Iodine is essential for producing thyroid hormones, which are vital for metabolic regulation and the development of the nervous system, bones, and muscles during pregnancy and early childhood. Pregnancy increases the maternal thyroid gland's iodine requirement, and severe deficiency can cause hypothyroidism in both mother and fetus. This can lead to preterm birth, low birth weight, miscarriage, and impaired cognitive development in children.

Methods

This cross-sectional study aimed to evaluate the dietary habits and iodine levels among pregnant women was conducted from January to December 2021. It included 158 pregnant women who provided informed consent. Data were collected using a pretested questionnaire on sociodemographic characteristics and dietary intake, alongside urine samples for urinary iodine concentration (UIC) analysis.

Results

Participants had a mean age of 29.37 years and an average household size of 3.552. Dietary analysis through a modified food frequency questionnaire (FFQ) showed infrequent consumption of iodine-rich foods. Urine samples analyzed using the Sandell-Kolthoff reaction revealed a mean UIC of 200.24 µmol/L, with 50.6% of participants having levels below the recommended threshold for pregnant women.

Conclusions

The study revealed high prevalence of iodine deficiency among the participants, highlighting the need for improved public health interventions to boost iodine intake during pregnancy. The findings stress the urgent need for better dietary education and supplementation programs to ensure adequate iodine levels among pregnant women, particularly in Sub-Saharan Africa, to mitigate the adverse effects of iodine deficiency.

Iodine

Pregnancy

Fetus

Dietary Habits

Iodine deficiency which mainly affect pregnant women, is one of the main public health concerns with a worldwide distribution [1]. Iodine is an essential component used in the formation of thyroid hormones which include triiodothyronine (T3) and thyroxine (T4) [2]. Thyroid hormones control various physiological and growth processes like metabolic rate and neurological, bone and muscle development particularly during the gestational period and early childhood [3].

Among physiological changes which occur in the body of a pregnant woman is alteration in the thyroid physiology, due to a rise in demand on the maternal thyroid gland [4]. It has been postulated that the more severe the iodine shortage during pregnancy, the more severe the repercussions for both the maternal and foetal thyroid glands and may result in hypothyroidism [5]. Again, maternal and fetal hypothyroidism caused by a lack of iodine in the mother's diet throughout pregnancy leads to increased risks of early birth, low birth weight, pregnancy loss, and poorer child cognitive quotient [5].

The vast majority of dietary iodine (> 90%) is excreted through urine which is primarily a passive process that is influenced by the glomerular filtration rate (GFR). In fact, the urine iodine secretion (UIE) is a dynamic equilibrium between food intake, thyroidal iodine extraction, the whole-body thyroid hormone pool, and GFR in a non-pregnant individual on a stable diet. Due to increased iodine demand naturally during pregnancy, the World Health Organization (WHO) recommends a higher iodine requirement for women who are pregnant (250ug/day) than for normal adults (150ug\day), still iodine deficiency is experienced by some pregnant women [1, 6, 7].

Even though adequate documentation on global iodine status of pregnant women exists, pregnant and lactating women in Sub-Saharan African countries have little to no knowledge of their iodine status and those in Ghana are not in exemption [8, 9]. It is based on the above that this study aimed at determining the dietary habits and iodine level among pregnant women is being carried out.

Aim, Design and Setting of the Study.

The aim of this study was to determine the iodine level and dietary habits among pregnant women. This was a cross-sectional study which was conducted from January to December 2021 at the Pentecost hospital Madina, Accra, Ghana.

Characteristics of Participants.

The study population involved one hundred and fifty-eight (158) pregnant women attending antenatal clinic (ANC) at the hospital.

Research Ethics and Patient Consent.

Ethical approval was obtained from the ethical and protocol review committee of the School of Biomedical and Allied Health Science (SBAHS/AA/MLAB/10673670/2020–2021) as well as the institutional ethical committee of the Pentecost hospital and the Noguchi Memorial Institute for Medical Research. All the participants gave their informed written consent before the commencement of the study. All methods were carried out in accordance with relevant guidelines and regulations.

Data Collection Procedure.

After consent was taken from the participants, they were interviewed with a questionnaire for information on their social demographic characteristics and dietary intake with regards to foods containing iodine. The questionnaire was pretested at the Mamprobi polyclinic ANC. Afterwards, the participants were given clean, tightly sealed urine containers to collect on-the-spot urine which were used for the determination of urine iodine concentration.

Social Demographic Characteristics.

The social demographic characteristics were the first part of the questionnaire. In this section, participants were asked questions which are believed to affect their dietary habit to an extent and as such their iodine concentration. The questions covered their age, week of gestation/trimester, blood pressure, nationality, marital status, residency, household number or size, household income per month, occupation, and their level of education.

Determination of Dietary Habits.

A modified quantitative food frequency questionnaire (QFFQ) which had foods containing iodine from all parts of the country to cater for the diverse people from different ethnic groups and background was used. With the QFFQ, the participants were made to answer questions on food/dish and how often they take in each of the food/dish, be it once a day, more than once a day, 1–2× a week, 3–4× a week, 5–6× a week, 1–2× a month, rarely or never, after which they were asked to estimate the amount eaten at a sitting (servings/portions) with the use of food modules and their amount estimated in grams. The food/dishes were categorized into beverages/porridges, milk and milk products, bread, vegetables, fish and seafood, salt and salted foods, meat and meat products, starches, legumes, soups, stews and fruits.

Sample Collection and Determination of Urinary Iodine Concentration.

The participants were given clean tightly sealed urine containers with demarcations in millimeters. They were then instructed to let the first drop of urine out into the toilet bowl and direct the remaining urine into the container to about the 10ml mark. The urine samples collected were immediately immersed in ice for preservation and transported to the micronutrient laboratory certified by ICCID at the Noguchi Memorial Institute for Medical Research for analysis.

Sample Analysis.

Principle

Urine is digested with Ammonium persulfate. Iodide is a catalyst in the reduction of Ceric ammonium sulfate (yellow) to the cerous form (colorless) and is detected by the rate of color disappearance (Sandell-Kolthoff reaction).

Procedure

Urine was allowed to reach room temperature and then mixed to suspend sediment.
250µl of urine was pipetted from each urine sample, working standards ranging from 0 to 300µg/l and internal urine controls, into 13×100mm test tubes. Duplicate iodine standard and a set of internal urine controls were included in the batch.
1ml of Ammonium persulfate was added to each tube and heated to 45mins at 95 ^oC.
Tubes were cooled to room temperature.
3.5ml Arsenious acid solution was added and mixed by vortex and left to stand for 15minutes.
400µl of Ceric ammonium sulfate solution was added to each tube at 30seconds intervals with mixing and vortexing after each addition.
The tubes were allowed to sit at room temperature for exactly 30minutes after the addition of Ceric ammonium sulfate to the first tube and absorbance read at 420nm. They were read in succession at the same time intervals as when adding the Ceric ammonium sulfate.
Since the digestion procedure had no specific endpoint, blanks and standards were run for each assay to allow for variation in heating time.

• Data Analysis

The data obtained was analyzed using the Statistical Program for Social Sciences (SPSS) version 20.0. To evaluate if there is a substantial difference between dietary habits and iodine levels or concentration, a T-test was used with a probability value of 0.05. In addition, descriptive figures such as means and percentages were used to present the data.

Socio-Demographic Characteristics of Participants

One hundred and fifty-eight (158) pregnant women participated in the study and 25.9%, 39.2% and 34.8% were in their first, second and third trimesters respectively. Mean age was 29.37 with standard deviation of 5.866. About 69.6% of subjects were married and 15.8% were in cohabitation. Also, the mean household number was 3.552 with standard deviation of 1.699. In terms of education, 41% of the study subjects had formal education out of which 29.7% were of secondary and 31% tertiary form (Table 1).

Insert Table 1 here

Table 1

A table of the social demographic variables of the participants with their frequencies and percentages.
Variable	Number (N)	Percentage (%)
Week Of Gestation
• 1st Trimester	41	25.9
• 2nd Trimester	62	39.2
• 3rd Trimester	55	34.8
First Visit To ANC for this pregnancy
• Yes	72	45.6
• No	86	54.6
Marital Status
• Married	110	69.6
• Cohabitation	25	15.8
• Divorced	1	0.6
• Single	22	13.9
Occupation
• Formal	28	17.7
• Informal (Self-employed)	107	67.7
• Unemployed	23	14.6
Level Of Education
• Basic	65	41.1
• SHS	47	29.7
• Tertiary	31	19.6
• No formal education	15	9.5
Medical History
• Thyroid disease	2	1.3
• Gastrointestinal disease	1	0.6
• Kidney disorders	0	0.0
• Nausea	68	43.0
BMI • 17–18.5 (Mild thinness) • 18.5–25 (Normal) • 25–30 (Overweight) • 30–35 (obese class I) • 35–40 (obese class II)	29 91 17 8 3	18.4 57.6 17.1 5.0 1.9

Assessment of Dietary Habits among the Pregnant Women

From the analysis of the food intake of the participants using FFQ, it was observed that, food or dishes high in iodine such as seaweeds were not being consumed by the pregnant women at all. Food rich in iodine such as Yoghurt, Brukina (made with cow milk), cheese, Milk, Cabbage, Canned fish, Shrimps, iodated salts, salted meat, salted fish, eggs, and bouillon were also rarely taken (Table 2).

Table 2

A table showing the dietary habits of the participants.
FOOD/DISH	ONCE A DAY n (%)	MORE THAN ONCE A DAY n (%)	5–6 TIMES A WEEK n (%)	3–4 TIMES A WEEK n (%)	1–2 TIMES A WEEK n (%)	1–2 TIMES A MONTH n (%)	RARELY n (%)	NEVER n (%)
MILO/COCOA POWDER ETC.	22(13.9)	5(3.2)	1(0.6)	16(10.1)	43(27.2)	21(13.3)	14(8.9)	36(22.8)
CORN PORRIDGE	5(3.2)	---	2(1.3)	3(1.9)	37(23.4)	19(12.0)	27(17.1)	65(41.1)
OATS	16(10.1)	---	2(1.3)	10(6.3)	35(22.2)	16(10.1)	23(14.6)	56(35.4)
YOGHURT	6(3.8)	---	1(0.6)	9(5.7)	---	---	30(19.0)	59(37.3)
MILLET PORRIDGE	11(7.0)	---	3(1.9)	6(3.8)	40(25.3)	22(13.9)	18(11.4)	58(36.7)
BRUKINA	2(1.3)	1(0.6)	1(0.6)	7(4.4)	14(8.9)	20(12.7))	23(14.6)	90(57.0)
CHEESE	1(0.6)	---	1(0.6)	2(1.3)	12(7.6)	8(5.1)	16(10.1)	118(74.7)
MILK	19(12.0)	3(1.9)	2(1.3)	17(10.8)	50(31.6)	10(6.3)	18(11.4)	39(24.7)
CABBAGE	6(3.8)	2(1.3)	---	6(3.8)	47(29.7)	15(9.5)	19(12.0)	63(39.9)
VEGIES	8(5.1)	1(0.6)	2(1.3)	15(9.5)	57(36.1)	18(11.4)	12(7.6)	45(28.5)
CANNED FISH	5(3.2)	2(1.3)	6(3.8)	11(7.0)	38(24.1)	21(13.3)	21(13.3)	54(34.2)
SHRIMPS	2(1.3)	2(1.3)	1(0.6)	2(1.3)	5(3.2)	8(5.1)	23(14.6)	115(72.8)
CRABS	2(1.3)	2(1.3)	2(1.3)	3(1.9)	12(7.6)	10(6.3)	27(17.1)	100(63.3)
OCTOPUS	---	---	---	---	1(0.6)	3(19)	1(0.6)	152(96.2)
SEAWEED	---	---	---	---	---	---	---	158(100.0)
IODATED SALT	36(22.8)	61(38.6)	2(1.3)	5(3.2)	2(1.3)	1(0.6)	12(7.6)	39(24.7)
SALTED MEAT	1(0.6)	2(1.3)	---	6(3.8)	2(12.7)	9(5.7)	17(10.8)	103(65.2)
BOUILON	65(41.1)	37(23.4)	7(4.4)	8(5.1)	6(3.8)	4(2.5)	4(2.5)	24(15.2)
SALTED FISH	26(16.5)	3(1.9)	6(3.8)	9(5.7)	44(27.8)	15(9.5)	13(8.2)	42(26.6)
POULTRY	14(8.9)	1(0.6)	1(0.6)	19(12)	51(32.3)	22(13.9)	16(10.1)	34(21.5)
OFFAL	2(1.3)	---	---	3(1.9)	19(12)	16(10.1)	30(19)	88(55.7)
SAUSAGE	---	---	1(0.6)	6(3.8)	30(19.0)	24(15.2)	21(13.3)	76(48.1)
EGGS	39(24.7)	3(1.9)	13(8.2)	44(27.8)	29(18.4)	7(4.4)	10(6.3)	13(8.2)
TURKEY	---	---	---	---	5(3.2)	6(3.8)	18(11.4)	129(81.6)
PLANTAIN	4(2.5)	---	5(3.2)	17(10.8)	64(40.5)	20(12.7)	18(11.4)	30(19.0)
SPAG	4(2.5)	---	4(2.5)	12(7.6)	51(32.3)	17(10.8)	13(8.2)	57(36.1)
BAKED BEANS	---	---	---	1(0.6)	8(5.1)	5(3.2)	12(7.6)	131(82.9)
SOYBEANS OR FLOUR	---	1(0.6)	---	1(0.6)	8(5.1)	3(1.9)	5(3.2)	138(87.3)
BANANA	12(7.6)	1(0.6)	3(1.9)	22(13.9)	62(39.2)	12(7.6)	16(10.1)	27(17.1)
FRUIT JUICES	5(3.2)	---	4(2.5)	6(3.8)	24(15.2)	9(5.7)	18(11.4)	89(56.3)

Insert Table 2 here

Descriptive Statistics from the FFQs

The outcome of the study shows the descriptive statistics of the food/dish from the FFQs when given scores of 8,7,6,5,4,3,2 and 1 which represents, More than once a day, once a day, 5-6x a week, 3-4x a week, 1-2x a week, 1-2x a month, rarely and never respectively (Table 3).

Table 3

A table of the descriptive statistics of the food intake of participants.
Food/dish	N	Mean	Std. Deviation
Milo/cocoa powder, etc.	158	3.68	2.082
corn porridge	158	2.44	1.566
Oats porridge	158	2.94	1.947
Millet porridge	158	2.82	1.805
Yoghurt	158	2.56	1.618
Cheese/wagashie	158	1.55	1.132
Evaporated milk	158	3.54	2.024
Cabbage	158	2.67	1.732
Vegetable salad/coleslaw	158	3.18	1.739
Canned fish	158	2.87	1.785
Shrimps	158	1.59	1.317
Crabs	158	1.84	1.491
Octopus	157	1.06	.370
Seaweeds	158	1.00	.000
Iodated salt	158	5.39	2.996
Bouillon cubes	155	3.30	2.985
Salted meat	158	1.88	1.473
Salted fish	158	3.65	2.171
Poultry	158	3.11	1.740
Turkey	158	1.28	.687
Spaghetti noodles	158	2.85	1.667
Offal (Liver, tripe, etc.)	158	1.91	1.276
Sausage	158	2.06	1.406
Banana	157	3.60	1.735
Eggs	158	4.76	1.950
Plantain	158	3.32	1.520
Baked beans	157	1.32	.817
Soybeans or flour	158	1.29	.946
Fruit juices	157	2.16	1.670

Assessment of Iodine Level of the Pregnant Women

From the analysis of the urine iodine concentration (UIC), the minimum UIC was 24.48µmol and the maximum UIC was 859.73µmol. The mean UIC was 200.24µmol with a standard deviation of 161.787µmol (Table 4).

Table 4

A table showing the iodine levels of the participants in the study.
Range	Frequency	Percentage	Interpretation
< 150	80	50.6%	Deficient
> 500	12	7.6%	Excessive
150–250	44	27.8%	Adequate
250–499	22	13.9%	More than adequate

Figure 1 shows the relationship between the various food types taken by the participants and their iodine levels. Here, the participants were grouped into low and high intake in terms of consumption and whether they were deficient in iodine or not.

Insert Fig. 1 here

Figure 1

The figure looked at the number of participants who are deficient in iodine and those not under A – age, trimester, and size of household. Then from B to D under the consumption of the various food items. In Fig. 1B, we see the foods that gave low deficiency which is not the case for the foods consumed in Fig. 1C and D.

Correlation between Dietary Habits and Iodine Levels of the Study Participants.

The relationship or association of the food/dish taken by the pregnant women to their UIC using the Pearson rank correlation and the p-value to determine their significance was carried out. The Pearson correlation showed no association between the dietary intake of the participants and UIC. Evaporated milk had an appreciable level of positive correlation which though not negligible but was also not quite as strong with an insignificant P-value (p = 0.36, r = 0.65) (Table 5).

Table 5

The table shows the various food/dish and their correlation or relation with the measured iodine levels.
Food	P-Value	Pearson correlation
Milo/Cocoa powder	0.307	-0.802
Corn porridge	0.271	0.088
Oats porridge	0.012	0.200
Millet porridge	0.611	-0.041
Yoghurt	0.024	0.180
Brukina	0.151	-0.115
Cheese/wagashie	0.526	-0.051
Evaporated milk	0.36	0.654
Cabbage	0.362	0.073
Vegetable salad/Coleslaw	0.439	0.062
Canned fish	0.628	-0.039
Shrimp	0.306	0.082
Crabs	0.487	0.056
Octopus	0.138	0.119
Seaweeds	---	---
Iodated salt	0.754	0.025
Bouillon cubes	0.164	0.112
Salted meat	0.012	0.200*
Salted fish	0.009	0.207**
Poultry	0.711	0.030
Turkey	0.929	0.007
Offal (Liver, tripe, etc.)	0.569	-0.046
Sausages	0.884	0.012
Eggs	0.108	0.128
Plantain	0.203	0.102
Spaghetti, noodles	0.715	0.029
Baked beans	0.608	0.041
Soybeans or flour	0.098	0.132
Banana	0.395	0.068
Fruit juices	0.780	-0.022

Insert Table 5 here

Association between UIC and the Week of Gestation.

Given the odds ratio and the p-value. First trimester had insignificant p-value but no odds ratio as well. Second trimester had statistically insignificant p-value but a relevant odds ratio showing association between second trimester of pregnancy and UIC. Again, third trimester showed a statistically significant p-value and a stronger association with UIC as compared with second trimester.

This study reports on the iodine status of one hundred and fifty-eight pregnant women visiting the anti-natal clinic (ANC) at an urban hospital in Accra, Ghana. The mean age of the participants was 29.37 years with a standard deviation of 5.866. This is in line with Simpson et al., (2016) who reported an age group of 25–29 as being more willing to take regular iodine supplementation in their diet in the Central Region of Ghana [8]. Again, the majority of the participants had informal occupation without a stable monthly income or salary. Also, when compared to higher income households, participants from lower income households purchased foods of lower nutritional quality which may contribute to the lower diet quality observed among some of the participants [10]. Furthermore, most of the women only had basic education which may affect their food choices. This is because other authors have shown that better educated pregnant women are more likely to consume food with a higher dietary quality index [11].

With the iodine analysis, the study also revealed the median urine iodine concentration (UIC) of the participants to be 200.24µmol and 80 (50.6%) of them had a UIC below 150µmol which falls below the recommended WHO UIC for pregnant women [6]. However, 27.8% of them had satisfactory values with 7.6% having levels above normal. These findings are in line with the findings of Bath et al., (2013) who also posited that mild iodine deficiency during pregnancy led to abnormal neurodevelopment [12]. Again, it collaborated with the findings of Ainy et al., (2017) who indicated that median UIC in pregnant women decreased from adequate to inadequate levels as the pregnancy ages that is from adequate levels in the first trimester to inadequate levels in the third trimester of pregnancy [13]. Furthermore, in the current study, there was a significant relationship between women in their third trimester and low iodine levels.

With regards to participants' dietary intake, the results showed that most of the participants do not incorporate a daily intake of iodine-rich sources of food into their diet which is consistent with the UIC found in the study population (Fig. 1). However, those who took iodine rich foods such as eggs, Banana, poultry, and evaporated milk had a low level of deficiency (Fig. 1B). From the information gathered, it appears that a lot more of the participants incorporated bouillon cubes (which is known to be fortified with iodine) in their daily meals but not all of them showed significant increase in their iodine levels. This can be explained by a study by Murcia et al., (2010) which concluded that iodine from dietary supplement may not be completely absorbed [14].

The decrease in UIC seen in this study could also be attributed to not taking meals with the right quantity of iodine in it (Fig. 1C – D), especially with the use of iodated salts where the WHO estimates a 20% loss of iodine from production, with an additional 20% loss during cooking [15]. Also, according to WHO, in order to meet an average daily requirement of 150g iodine from a daily salt intake of 10g of salt, iodine concentration in salt at the point of production should be between 20ppm and 40ppm but most salts in Ghana do not achieve this level [15, 16].

The study also found an association between milk intake and UIC which can be related to the findings of a study which demonstrated the critical role of cow's milk as an iodine source during pregnancy [17]. This finding is also consistent with data gathered primarily from school children in several European countries [18]. Dahl et al., (2004) also discovered that milk and other dairy products contributed approximately 55% and 70% of the dietary iodine intake in adults and children respectively from Norway, and that this varies with geographical location and season, as it is dependent on the iodine content of the soil [19].

The study identified a significant prevalence of iodine deficiency among pregnant women attending the PHM in Ghana's Greater Accra Region. This highlights the need to revitalize health education programs that promote universal salt iodization (USI) and the fortification of foods with iodine. During antenatal care (ANC) education, it is crucial to stress the importance of incorporating iodine into the diet. These efforts are vital to ensuring sufficient iodine levels, particularly among vulnerable groups. One limitation of the study was the exclusion of nutritional supplement intake in the questionnaire, as well as the lack of quantification of various foods to accurately assess iodine intake. Future research could address this by conducting a similar study that investigates whether pregnant women are supplementing their dietary intake with iodine through nutritional supplements.

ANC Antenatal Care

FFQ Food Frequency Questionnaire

FT4 Free thyroxine

GFR Glomerular filtration rate

ID Iodine deficiency

IDD Iodine deficiency disorders

IMR Infant mortality rate

MMN Multi-micronutrient

NMIMR Noguchi Memorial Institute for Medical Research

PHM Pentecost hospital Madina

SPSS Statistical Program for Social Sciences

TBG Thyroid binding globulin

TPO Thyroperoxidase

TRH Thyrotropin-releasing hormone

TSH Thyroid stimulating hormone

UIC Urine iodine concentration

UIE Urine iodine excretion

USI Universal Salt Iodization

WHO World Health Organization

Ethics approval and consent to participate.

Ethical clearance was obtained from the ethical and protocol review committee of the College of Health Sciences (CHS-Et/M.1-P5.3/2018-2019) as well as the institutional ethical committees of the Pentecost hospital and the Noguchi Memorial Institute for Medical Research. All the study details were explained to the participants, and informed consent was obtained before the commencement of the study.

Consent for publication.

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The Authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors’ contributions: SAB - Conceptualized the study, prepared the original draft, and supervised the project. BTM - Conceptualized the study, curated the data, developed the methodology, and supervised the project. NYAA - Conducted the investigation, developed the methodology, curated the data, and performed formal analysis. DNOA - Curated the data, developed the methodology, and performed formal analysis. LA - Reviewed and edited the manuscript.

Acknowledgements

We are grateful to the directors and managers of the Pentecost hospital and the Noguchi Memorial Institute for Medical Research for their assistance in carrying out this study.

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No competing interests reported.

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A cross-sectional study of the Evaluation of Iodine Deficiency among Pregnant Women Attending Antenatal Clinic at a Community Health Centre

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Abstract

Background

Methods

Results

Conclusions

Figures

BACKGROUND

METHODS

Procedure

• Data Analysis

RESULTS

Socio-Demographic Characteristics of Participants

Assessment of Dietary Habits among the Pregnant Women

Descriptive Statistics from the FFQs

Assessment of Iodine Level of the Pregnant Women

DISCUSSION

CONCLUSION

List of abbreviation

Declarations

References

Additional Declarations

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