Microsoft word - perchlorate and thyroid final ehp 20sept2006 v46_clean.doc
Benjamin C. Blount, James L. Pirkle, John D. Osterloh, Liza
Valentin-Blasini and Kathleen L. Caldwell
doi:10.1289/ehp.9466 (available at http://dx.doi.org/)
Online 5 October 2006
National Institutes of Health
U.S. Department of Health and Human Services
Urinary Perchlorate and Thyroid Hormone Levels in Adolescent and Adult Men and
Benjamin C. Blount1,2, James L. Pirkle1, John D. Osterloh1, Liza Valentin-Blasini1 and
1 Division of Laboratory Sciences, National Center for Environmental Health,
Centers for Disease Control and Prevention, Atlanta, GA 30341
2Corresponding Author: Benjamin C. Blount, PhD
Division of Laboratory Sciences, National Center for Environmental Health, CDC,
4770 Buford Highway, NE, Mail Stop F47, Atlanta, GA 30341
Phone: 770.488.7894; Fax: 770.488.0181; email: firstname.lastname@example.org
*The findings and conclusions in this report are those of the authors and do not
necessarily represent the views of the Centers for Disease Control and Prevention
: Perchlorate and Thyroid Function, NHANES 2001-2002
Exposure, Iodine, NHANES, Perchlorate, Thyroid, Thyroxine, TSH
CDC: Centers for Disease Control and Prevention
NHANES: National Health and Nutrition Examination Survey
U.S. EPA: U.S. Environmental Protection Agency
We thank the staff at the National Center for Health Statistics and
Westat who were responsible for planning and conducting the National Health and
Nutrition Examination Survey (NHANES), and E. Gunter and C. Pfeiffer for managing
the National Center for Environmental Health’s involvement with NHANES. We thank
J. Morrow, J. Mauldin, S. Caudill, A. Delinsky, J. Phillips and M. Smith for technical
assistance. The authors declare they have no competing financial interests.
Perchlorate is commonly found in the environment and known to inhibit
thyroid function at high doses. Assessing the potential effect of low-level exposure to
perchlorate on thyroid function is an area of ongoing research.
Evaluate the potential relationship between urinary levels of perchlorate and
serum levels of thyroid stimulating hormone (TSH) and total thyroxine (T4) in 2299 men
and women, aged 12 and older, participating in the National Health and Nutrition
Examination Survey (NHANES) during 2001-2002.
Multiple regression models of T4 and TSH that included perchlorate and
covariates known or likely to be associated with T4 or TSH levels: age, race/ethnicity,
body mass index, estrogen use, menopausal status, pregnancy status, premenarche status,
serum C-reactive protein, serum albumin, serum cotinine, hours of fasting, urinary
thiocyanate, urinary nitrate, and selected medication groups.
Perchlorate was not a significant predictor of T4 or TSH levels in men. For
women overall, perchlorate was a significant predictor of both T4 and TSH. For women
with urinary iodine < 100 µg/L, perchlorate was a significant negative predictor of T4
(p < 0.0001) and a positive predictor of TSH (p = 0.001). For women with urinary iodine
100 µg/L, perchlorate was a significant positive predictor of TSH (p = 0.025), but not
These associations of perchlorate with T4 and TSH are coherent in
direction and independent of other variables known to affect thyroid function, but are at
perchlorate exposure levels unanticipated based on previous studies.
Perchlorate is an inorganic anion used for a variety of products such as road
flares, explosives, pyrotechnics and solid rocket propellant (Mendiratta et al. 1996).
Perchlorate can also form naturally in the atmosphere leading to trace levels of
perchlorate in precipitation (Dasgupta et al. 2005). Natural processes are considered to
concentrate perchlorate in some locations such as regions of west Texas (Dasgupta et al.
2005) and northern Chile (Urbansky et al. 2001). A combination of human activities and
natural sources has led to the widespread presence of perchlorate in the environment. As
of November 2005, perchlorate was detected in drinking water samples from 4.1% of
community water supplies in 26 different states with levels ranging from the method
detection limit of 4 µg/L to a maximum at 420 µg/L (U.S. EPA 2005). Most of this
drinking water contamination is likely due to contaminated source waters, although in
rare instances perchlorate formation has been reported to occur in water distribution
systems (Jackson et al. 2004). Additionally, perchlorate exposure from the diet is
probable, because of the contamination of milk (Kirk et al. 2005), as well as vegetables
(Sanchez et al. 2005), fruit (Sanchez et al. 2006a), grain (Sanchez et al. 2006b), and
forage crops (Jackson et al. 2005). Perchlorate contamination has also been reported in
dietary supplements and flavor enhancers (Snyder et al. 2006).
Trace levels of perchlorate in the environment leads to human exposure. Direct
measurement of perchlorate in biological samples collected from people (NAS 2005) is
considered an excellent assessment of their exposure. We recently assessed perchlorate
exposure in a nationally representative sample of 2,820 U.S. residents, ages 6 years and
older, who participated in the National Health and Nutrition Examination Survey
(NHANES) during 2001 and 2002 (Blount et al., In press).
Environmental perchlorate exposure is of potential health concern because much
larger doses of perchlorate have been shown to competitively inhibit iodide uptake (Greer
et al. 2002; Wyngaarden et al. 1953). Populations with low intake of iodine or increased
demand for iodine may be more vulnerable to inhibition of iodide uptake. Sustained
inhibition of iodide uptake can lead to hypothyroidism, although perchlorate-induced
changes to thyroid function have not been previously demonstrated in any human
population exposed to perchlorate, even at doses as high as 0.5 milligrams per kilogram
body weight per day (NAS 2005). The thyroid plays a crucial role in energy homeostasis
and neurological development. Hypothyroidism can lead to metabolic problems in adults
and abnormal development during gestation and infancy (Braverman and Utiger 2000).
Severe hypothyroidism due to iodine deficiency during pregnancy is a preventable cause
of cretinism, a permanent cognitive impairment of the developing fetus (CDC 2005;
Glinoer 2000). Mild hypothyroidism during pregnancy has been associated with subtle
cognitive deficits in children (Haddow et al. 1999; Klein et al. 2001), leading the
National Academy of Sciences to recommend that consideration be given to adding
iodide to all prenatal vitamins (NAS 2005). Therefore, we examined relationships
between urinary perchlorate, and serum thyroid hormones in men and women, 12 years
and older, who participated in NHANES 2001 – 2002.
Subjects and Methods
NHANES is conducted by the National Center for Health Statistics of the
Centers for Disease Control and Prevention (CDC). This survey is designed to assess the
health and nutrition status of the civilian, non-institutionalized U.S. population.
NHANES uses a complex multistage probability sampling designed to be representative
of the U.S. population based on age, sex, race/ethnicity and income. Data were collected
using an extensive household interview addressing health conditions and health-related
behaviors and a standardized physical examination including medical blood and urine
tests, which were conducted in mobile examination centers. NHANES 2001–2002 was
conducted in 30 locations throughout the United States. Overall, the survey interview
response rate was 83.9% and the exam response rate was 79.6%. A full description of the
NHANES survey is available at the NHANES website (CDC 2004). The study protocol
was reviewed and approved by the CDC institutional review board; additionally,
informed written consent was obtained from all subjects before they took part in the
Urinary perchlorate levels were measured by the Division of Laboratory Sciences,
National Center for Environmental Health at CDC on a representative random one-third
subsample consisting of 2,820 study participants (males and females), aged 6 years and
older (Blount et al., In press). For ages 12 and older, 2517 persons were in the random
subsample. Serum levels of thyroid stimulating hormone (TSH) and total thyroxine (T4)
were only available for 2299 participants aged 12 years and older.
Sociodemographic data was self-reported by study participants.
Race/ethnicity was derived from self-reported questionnaire data, and categorized as:
non-Hispanic white, non-Hispanic black, Mexican Americans, and Other. Each of these
race/ethnicity categories was used in the regression modeling. Non-Hispanic whites were
used as the referent group in regression analysis.
During the physical examinations, whole blood and spot urine
specimens were collected from participants, aliquoted, and stored cold (2–4°C) or frozen
until shipment. Whole blood was collected into a red top 15 ml Vacutainer tube, mixed,
allowed to clot for 30 – 45 min, centrifuged, and ~1 mL serum stored frozen in a cryovial
for future analysis for TSH and T4. Serum samples collected in 2001 were assayed for
TSH and T4 by the Coulston Foundation (Alamogordo, New Mexico) using a
microparticle enzyme immunoassay for the quantitative determination of TSH, and a
Hitachi 704 chemistry analyzer for the quantitative determination of T4 (CDC 2003).
Serum samples collected in 2002 were assayed for TSH and T4 by Collaborative
Laboratory Services (Ottumwa, Iowa) using a chemiluminescent immunoassay (Access
Immunoassay System, Beckman Instruments, Fullerton, CA) (CDC 2003). The National
Center for Health Statistics, CDC evaluated the TSH and T4 data sets from the two
laboratories and determined that the values are comparable across the 2 years.
Surplus urine samples from NHANES 2001-2002 were shipped on dry ice to the
Division of Laboratory Sciences, National Center for Environmental Health, CDC and
analyzed for perchlorate, thiocyanate and nitrate using ion chromatography tandem mass
spectrometry (Blount et al., In press; Valentin-Blasini et al. 2005). These samples were
stored frozen (-70°C) for up to 4 years before perchlorate analysis. Experiments
evaluating storage at -70°C for greater than 2 years indicate no changes in urinary levels
of this analyte. Reported results for all assays met the Division’s quality control and
quality assurance performance criteria for accuracy and precision (similar to
specifications outlined by Westgard et al. (1981)). Urine samples from the same study
participants had previously been analyzed for iodine using inductively coupled plasma
mass spectrometry (Caldwell et al. 2005).
Initial multiple regression analysis found perchlorate to be a
significant predictor of both T4 and log TSH in women, but perchlorate did not predict
either T4 or log TSH in men (data not shown). Therefore, subsequent analysis focused
on women and the analysis of women is described in this section.
Of the 1318 women aged 12 and older, 92 had missing TSH and T4 values –
leaving 1226. Of these 1226 women, 91 were excluded from analysis because they
reported a history of thyroid disease or current use of thyroid medications – leaving 1135
women. Of these 1135 women, 3 had extreme values of T4 and/or TSH and were
excluded. One of these women had a total T4 of 27 µg/dL and a TSH of 0.04 IU/L. This
woman was clearly hyperthyroid and excluded from the analysis. Two other women had
very high TSH levels of 43 and 68 and were excluded. Of the remaining 1132 women, 21
had missing perchlorate measurements, leaving a sample size of 1111 women.
The major design variables for NHANES are age, sex, race/ethnicity, and income
related to the poverty level. The values of these variables for the initial 1318 women and
the final 1111 women are: mean of age – 41.6 and 39.8 years; percent non-Hispanic
whites – 70.8% and 69.4%; percent non-Hispanic blacks – 11.8% and 12.5%; percent
Mexican Americans – 7.0% and 7.0%; and percent below the poverty level – 13.9% and
Covariates for the multiple regression analyses were chosen which are known or
likely to be associated with T4 or TSH. We selected a broad number of covariates to
evaluate the independence of the perchlorate relationship. These covariates were: age,
race/ethnicity, body mass index (BMI), serum albumin, serum cotinine (a marker of
tobacco smoke exposure), estimated total caloric intake, pregnancy status, post-
menopausal status, premenarche status, serum C-reactive protein, hours fasting before
sample collection, urinary thiocyanate, urinary nitrate, and use of selected medications.
For these covariates, Table 1 provides means (or geometric means if lognormally
distributed) for continuous variables, percent in category for categorical variables, and
number of missing results for each covariate. Thyroid function has been previously
reported to vary with the constitutional variables of age, race, sex, pregnancy, and
menopause. Serum cotinine is a marker of tobacco smoke exposure and smoking is
associated with altered thyroid function. Serum C-reactive protein was included as a
marker for inflammatory conditions that have been associated with alterations in thyroid
function. Both total caloric intake (based on a 24 hour dietary recall survey and a U.S.
Department of Agriculture database (Food and Nutrition Database for Dietary Studies
(USDA 2004)) and body mass index are related to thyroid function, but the
interrelationship as to cause or effect is unclear.
Serum albumin was included as a possible surrogate for T4 serum protein
binding. NHANES 2001-2002 included total T4 measurements but not free T4
measurements; total T4 varies with the concentrations of specific binding proteins.
Concentrations of these proteins can change with physiologic state and health conditions.
Free T4 varies less with such protein concentration changes than does total T4. Serum
albumin accounts for 15-20% of T4 binding and thyroid binding protein and prealbumin
(not measured in NHANES) account for the remaining percentage (Robbins 2000).
Thyroid autoantibody measurements were not available for 2001-2002. For
autoantibodies to affect the relationship between perchlorate and T4 or TSH, presence of
autoantibodies would have to correlate with perchlorate levels. We have found no such
correlation in the literature and we are unaware of a rationale for such an association.
Medications known to affect thyroid function were also considered. As noted
above, women taking medication containing thyroid hormone (e.g. levothyroxine) or
antithyroid drugs (e.g. methimazole or propylthiouracil) were excluded. Use of beta-
blockers, estrogen formulations, steroids, and furosemide were each modeled using an
indicator variable in the regressions. An ‘other drug’ category was also modeled by an
indicator variable. This ‘other drug’ category consisted of a heterogeneous group of
other medications that have possible effects on thyroid function, protein binding, or
measurements, including: salicylates, dopaminergics, anticonvulsants and barbiturates,
narcotic analgesics, androgenic agents, lithium, and several others (a total of 28 drug
Log of urinary creatinine was included in the models to adjust for variable water
excretion. A non-linear relationship was evaluated by adding the square of log of
perchlorate to final models, but it was not significant. Models were also checked for
significance of interaction terms involving main effects. Partial regression plots were
examined to identify any unduly influential data points. No unduly influential points
were found. Indicator variable coefficients in the models (e.g., for non-Hispanic blacks)
should be interpreted: 1 = group member and 0 = not a group member. Urine samples
were collected in three sessions of the day from 8 am through 10 pm. Mean perchlorate
levels were not statistically different across sessions (p=0.49).
Univariate statistics and distribution plots were examined for each dependent and
independent variable to look for outliers and to assess the distribution shape. TSH,
perchlorate, cotinine, body mass index, urinary thiocyanate, urinary nitrate, and C-
reactive protein were log10 transformed to normalize their distributions.
Regression models, including log of perchlorate as one of the predictor variables,
were constructed separately for thyroxine and log of TSH. The initial phase of analysis
used ordinary least squares regression (OLS) (SAS Proc Reg, SAS v. 9.0, SAS Institute,
Cary, NC) and purposefully did not adjust for the NHANES complex survey design in
order to obtain a broad group of potentially significant predictor variables. Forward
stepwise and backward elimination procedures were used on both population-weighted
and unweighted data. The entry p-value for forward elimination models was 0.10 and the
retaining p-value for backward elimination was 0.10 in order to identify significant and
borderline significant predictors. The forward stepwise and backward elimination
approaches produced models that were generally in good agreement.
This OLS analysis produced a generous list of significant and borderline
significant variables for regression analysis using SUDAAN (SUDAAN version 9.0.1,
Research Triangle Institute, Research Triangle Park, NC), which provides an analysis that
adjusts for the complex survey design. SUDAAN regression models were tested using a
manual backward elimination approach starting with the variables obtained from the OLS
regression modeling. Selected variables that were excluded in the SUDAAN backward
elimination process were added to the final model to assure they were not significant.
The stability of the perchlorate coefficient was monitored during the SUDAAN backward
The main SUDAAN regression analysis used population weights to represent
women 12 years and older in the U.S. population for the years 2001 and 2002. In
addition, we performed separate regression analyses with SUDAAN using unweighted
data and verified that regression coefficients were in good agreement with those obtained
using population weights. Reported regression model results in the tables use the
Women were categorized based on a urinary iodine cut-point of 100 µg/L and
analyzed separately. The 100 µg/L cut-point was used based on the World Health
Organization definition of sufficient iodine intake in populations. WHO noted that the
prevalence of goiter begins to increase in populations with median urinary iodine less
than 100 µg/L (WHO 1994). A urine iodine level of 100 µg/L represents about the 36th
percentile of urinary iodine concentrations in women living in the United States
(Caldwell et al. 2005). Women with lower iodine intake could be more vulnerable to
perchlorate’s effects to impair iodine uptake. From this analysis, the significance of
urinary perchlorate as a predictor of thyroid function in women was found to be largely
determined by women with urinary iodine < 100 µg/L. Consequently, we report here
results for women divided into groups based on urinary iodine levels.
Compared to use of the average of multiple spot urine measurements or use of 24
hour urine specimens, use of a single spot urine for perchlorate and iodine measurement
has more imprecision in estimating true urine levels (Andersen et al, 2001). This
imprecision is a source of random error (not bias) and therefore decreases statistical
power to detect an association between perchlorate and either TSH or T4 compared to
these other urine collection approaches.
For all women 12 years and older, multiple regression analysis found urinary
perchlorate to be a significant predictor of serum TSH and a significant predictor of
serum T4 (data not presented). Since low iodine levels had potential to affect the
relationship of perchlorate with T4 and TSH, women with urinary iodine < 100 µg/L
were analyzed separately from women with urinary iodine 100 µg/L. Results of this
analysis are presented in Tables 2 and 3 for T4 and in Tables 4 and 5 for TSH.
For women with urinary iodine < 100 µg/L, multiple regression analysis found
perchlorate to be a significant predictor (p < 0.0001) of T4 with a coefficient for log
perchlorate of -0.8917. The result of regression of T4 on perchlorate and urinary
creatinine without other covariates yielded a coefficient of -0.8604 (p < 0.0001).
Perchlorate was also a significant predictor (p = 0.0010) of log TSH with a coefficient of
0.1230. The result of regression of log TSH on perchlorate and urinary creatinine
without other covariates found a coefficient of 0.1117 (p = 0.0031). The signs of these
coefficients are coherent, with increased perchlorate associated with less production of
T4 and an increase in TSH to stimulate additional T4 production. For women with
urinary iodine 100 µg/L, perchlorate was not a significant predictor of T4 (p = 0.5503),
but remained a significant predictor of log TSH (p = 0.0249). The regression analysis
results in Tables 2 – 5 include variables that were borderline significant (0.05 p < 0.10)
to give ample opportunity for other variables to explain variance and better evaluate the
independence of the perchlorate effect.
Regression results for men (not shown) indicated that perchlorate was not a
significant predictor of either T4 or log TSH. This finding also held when examining
men with urinary iodine levels < 100 µg/L.
From the regression coefficients for women with urinary iodine < 100 µg/L, we
calculated the predicted effect size (i.e., the change in T4 and TSH) for different levels of
perchlorate exposure. We chose perchlorate levels corresponding to the 5th, 10th, 25th,
50th, 75th, 90th, and 95th percentiles of urinary perchlorate in women 12 years and older.
The minimum and maximum perchlorate values are observed results for this population
sample, they are not estimates of the 0th and 100th percentile for the U.S. population. As
such, they would be expected to change in another population sample. The effect size
was calculated from the difference between the minimum level of perchlorate measured
in women and the level of perchlorate corresponding to the specific percentile. For
example, the 50th percentile of urinary perchlorate for women is 2.9 µg/L and the
minimum level was 0.19 µg/L. Increasing exposure from 0.19 to 2.9 µg/L would result
in a predicted decrease in T4 of 1.06 µg/dL.
For TSH, one more step is needed in the calculation. Since TSH was modeled as
log TSH, the change in TSH from a given change in perchlorate depends on the starting
level of TSH. Our calculations use the approximate 50th and 90th percentiles of TSH as
starting points to estimate the predicted perchlorate effect size for TSH. Results of these
calculations for T4 and TSH are presented in Table 6. For comparison, the normal range
for T4 is 5–12 µg/dL and for TSH is 0.3–4.5 IU/L.
To search for a threshold for the perchlorate relationship with T4 and TSH,
piecewise regression models (Neter et al. 1985) were fit to the data. No inflection point
was found for the perchlorate relationship with T4 or TSH. However, statistical power is
limited to detect such a threshold, if present.
Increased urinary perchlorate was associated with increased TSH and decreased
T4 for women with urinary iodine levels < 100 µg/L, a group possibly more susceptible
to competitive inhibition of thyroid iodine uptake by perchlorate. The statistically
significant associations of urinary perchlorate with decreased serum T4 and increased
serum TSH were consistent with competitive inhibition of iodide uptake.
For women with urine iodine 100 µg/L, perchlorate was also a statistically
significant predictor for TSH but not for T4. Greater iodine intake may have diminished
the effect of perchlorate on T4 in these women. The significant association with TSH,
but not with T4, in this group may be due to the greater sensitivity of TSH to impairment
of thyroid function; that is, normal T4 levels are maintained by increasing TSH to
compensate for impaired thyroid function.
Predicted changes in serum TSH and T4 with increasing perchlorate exposure
(Table 6) can span a notable portion of the normal medical range of TSH and T4 values.
Compared to a urine level of 0.19 µg/L, perchlorate exposure at a urine level of 13 µg/L
(95th percentile) yields a predicted decrease in T4 of 1.64 µg/dL. The normal range for
T4 is 5–12 µg/dL. A similar exposure would increase TSH by 2.12 IU/L, for a woman
starting with a TSH level of 3.11 IU/L (90th percentile for TSH in women 12 years and
older). Normal range for TSH is 0.3–4.5 IU/L. Effect size estimates that start with the
90th percentile of TSH have more uncertainty than estimates starting with the 50th
percentile because the predicted TSH levels fall further from the central portions of the
The mechanism of perchlorate’s effect is competitive inhibition of iodide uptake
by the thyroid (Clewell et al. 2004; Wolff 1998). Based on this mechanism, individuals
with less iodide available to compete with perchlorate may be more vulnerable to
impaired iodide uptake. Chronically impaired iodide uptake could lead to changes in
serum thyroid hormones, consistent with the increased TSH and decreased T4 we find
associated with increased perchlorate exposure in women with urinary iodine < 100 µg/L.
WHO has identified median urinary iodine levels 100 µg/L as indicating sufficient
iodine intake for a population (WHO 1994). Based on concerns about adequate iodine
intake, the National Research Council recently recommended that consideration be given
to adding iodine to all prenatal vitamins (NAS 2005).
Perchlorate was not found to be a significant predictor of T4 or TSH in men.
Previous studies report that women have a much higher risk of goiter than do men,
especially in populations with marginal iodine intake (Laurberg et al. 2000). The
increased vulnerability of women may partially be caused by increased susceptibility to
autoimmune thyroid disease in women, the increased demands on the thyroid during
pregnancy, or the effect of estrogens on thyroid function. Estradiol has been shown to
block TSH-induced sodium/iodide symporter (NIS) expression in the FRTL5 rat
follicular cell line (Furlanetto et al. 1999). Impaired NIS expression could lead to
reduced ability of the thyroid follicular cells to import iodide, and thus an increased
vulnerability to NIS-inhibitors such as perchlorate. Also, estrogens increase thyroxine-
binding globulin and thus increase the demand for thyroxine so that free thyroxine levels
Covariates in the regression models predicted T4 and TSH levels in a manner
generally consistent with previous studies. We found that estrogen use was a significant,
independent and positive predictor of T4 in both low and sufficient iodine models of
women aged 12 and older, but was not a significant predictor in either of the TSH
models. Similar to estrogen use, pregnancy was a significant or borderline significant
predictor of T4 but not TSH. Both estrogen use and pregnancy raise estrogen levels,
increase thyroid binding proteins, and increase serum T4 concentrations (Glinoer 1997).
Menopause lowers estrogen levels and was a significant predictor of T4 in the regression
for women with urinary iodine levels < 100 µg/L.
In NHANES III (1988-94), non-Hispanic blacks were shown to have lower TSH
than other groups and Mexican Americans had higher thyroxine levels than non-Hispanic
blacks and whites (Hollowell et al. 2002). The models for TSH and T4 were consistent
with these previous findings concerning race/ethnicity. Non-Hispanic blacks have also
been shown to have lower urinary perchlorate levels than non-Hispanic whites, although
the reason for this difference is not known (Blount et al., In press). Age was positively
associated with TSH in women with urinary iodine levels 100 µg/L, but not significant
for women with urinary iodine levels < 100 µg/L. A positive association of age and TSH
was seen in NHANES III and other studies (Canaris et al. 2000; Hollowell et al. 2002).
BMI was significant in the TSH model for women with urinary iodine levels
100 µg/L and total caloric intake was significant in T4 model for women with urinary
iodine levels < 100 µg/L. Thyroid function clearly has an effect on BMI as seen
clinically and documented in populations (Nyrnes et al. 2006). The reverse is also true,
since BMI and total caloric intake can influence hypothalamic-pituitary-thyroidal axis,
though usually at the extremes of body weight and caloric intake (Acheson et al. 1984;
Burger et al. 1987; Danforth et al. 1979; Loucks et al. 1992; Loucks and Heath 1994).
Total caloric intake in NHANES is a 24 hour recall of food intake. Depending on how
well recent intake reflects long term intake, total caloric intake may parallel the effect of
BMI, which was not seen in this study. Increased caloric intake is known to increase
thyroid hormone disposition through deiodination pathways (Burger et al. 1987; Danforth
et al. 1979), increasing the conversion of T4 to the active form, T3, and increasing
conversion of T3 to inactive forms. The effect of changes in calories and carbohydrate
composition of the diet on thyroid disposition may have different short and long term
effects on T3 and T4 levels. Hours of fasting before sample collection was a borderline
significant predictor in one regression model: T4 in women with sufficient iodine.
Fasting for 60 hrs can reduce TSH in humans, but fasting for shorter periods has
unknown effects on thyroid function.
Beta-blocker drugs are commonly used to treat hypertension and other
cardiovascular conditions. Beta-blocker drugs inhibit the conversion of T4 to the more
active form, T3, and increase serum TSH (Kayser et al. 1991). Use of these drugs was
positively associated with TSH in the regression for women with urinary iodine < 100
µg/L. Serum C-reactive protein was positively associated with T4 in women in each of
the iodine groups. C-reactive protein is an acute phase reactant protein increased in many
inflammatory conditions in response to production of tissue-generated cytokines,
particularly interleukin-6; and has been used as a marker for both specific and systemic
low-level inflammation conditions. It is unclear if C-reactive protein is associated with
thyroid function other than thyroiditis (Jublanc et al. 2004; Pearce et al. 2003; Tuzcu et
al. 2005). However, the stimulus for C-reactive protein, interleukin-6, has a firm inverse
relationship with serum T3 in non-thyroidal illnesses. Also, C-reactive protein and serum
T4 binding proteins are synthesized by the liver; C-reactive protein may vary with an
unrecognized health or physiologic condition that affects the synthesis of both proteins.
The association of C-reactive protein and T4 in our study is unclear.
Other variables that are known to possibly affect thyroid function or
measurements were not significant predictors in the regression models, including the
categories of medications (other than estrogen use and beta-blockers), serum albumin,
and serum cotinine. Generally, other medication categories were small and unlikely to
have significant effects. Serum albumin did not appear in the final models. Factors such
as estrogen use that increase protein binding of thyroid hormones may have accounted for
variance in T4 due to protein binding that serum albumin may have otherwise explained.
Serum cotinine is a marker of tobacco smoke exposure and smoking is associated with
altered thyroid function (Belin et al. 2004; Bertelsen and Hegedus 1994). However,
tobacco smoke also contains other factors that can inhibit TSH secretion (Bartalena et al.
1995), and perhaps is an explanation for the absence of an association of serum cotinine
Cyanide in tobacco smoke is metabolized to thiocyanate, a competitive inhibitor
of iodide uptake (Tonacchera et al. 2004). Also, nitrate from dietary sources and from
formation by intestinal bacteria can compete with iodide. In vitro studies indicate that
perchlorate is a more potent inhibitor of human NIS, with potencies 15, 30, and 240 times
greater than thiocyanate, iodide, and nitrate, respectively (Tonacchera et al. 2004). Thus,
the ability of NIS to transport adequate amounts of iodide depends on the relative
concentrations of these competing anions. Based on the relative concentrations of
perchlorate, nitrate and thiocyanate likely to be found in human serum, several
researchers have predicted that nitrate and thiocyanate are more likely than perchlorate to
impair thyroid function (DeGroef et al. 2006; Gibbs 2006). Thiocyanate-induced NIS
inhibition is a plausible explanation of the association of smoking with goiter in
populations with low iodine intake (Knudsen et al. 2002), and is analogous to the
association of perchlorate exposure with thyroid hormones levels observed in our study.
However, in women with urinary iodine levels < 100 µg/L urinary thiocyanate was
negatively associated with serum TSH, a direction unexpected based on a mechanism of
NIS inhibition. The explanation for this is unclear. Urinary nitrate was negatively
associated with serum T4 in women with urinary iodine levels 100 µg/L, a direction
consistent with inhibition of NIS. Goitrogenic effects of nitrate intake in animal studies
have been observed, but there are few studies in humans.
Recently the National Research Council (NRC) of the National Academy of
Sciences (NAS) evaluated the potential health effects of perchlorate ingestion (NAS
2005). Based on studies of long-term treatment of hyperthyroidism and clinical studies
of healthy adults, the NRC panel estimated that a perchlorate dose of more than 0.40
mg/kg per day would be required to cause hypothyroidism in adults, although lower
doses may lead to hypothyroidism in sensitive subpopulations (NAS 2005).
Comparison of our results to previous studies requires consideration of 1) target
population group studied, 2) estimated dose of perchlorate, 3) duration of exposure to
perchlorate dose, and 4) sample size (statistical power). First, for men, our results found
no relationship with perchlorate and T4 or TSH. This finding is in general agreement
with predicted effects of this level of perchlorate exposure based on reported studies of
exposure in men. Lawrence et al administered 10 mg perchlorate daily (~ 0.14 mg/kg) to
iodine-sufficient adult males for 14 days and found a 10% decrease in radioactive iodine
uptake (RAIU), but with no change in TSH or free T4 (Lawrence et al. 2000).
Greer et al administered perchlorate to 16 male and 21 female volunteers for 14
days, and found increasing RAIU inhibition for doses between 0.02 and 0.5 mg/kg/day,
with no perchlorate-related change in TSH or free T4 (Greer et al. 2002). An unknown
number of women in the Greer study may have had urinary iodine < 100 µg/L, but if the
women were typical of the U.S. population (Caldwell et al. 2005), the predicted number
of women with low urinary iodine would be 7 to 8. Braverman et al administered
perchlorate to 13 iodine-sufficient male and female volunteers at daily doses of 0.5 mg
and 3 mg for 6 months, and found no change in RAIU, TSH or free T4 (Braverman et al.
2006). Two other studies have also found that workers exposed to perchlorate
intermittently for long periods did not have significant changes to serum TSH or T4
levels (Braverman et al. 2005; Lamm et al. 1999). These study populations were either
exclusively (Braverman et al 2005) or predominantly (Lamm et al 1999) male.
For women, only two perchlorate studies have focused on women or included a
large percentage of women. A recent study of 184 pregnant Chilean women, with mean
urinary perchlorate levels near the 99th percentile for women in NHANES 2001-2002,
found no perchlorate relationship with thyroid function (Tellez et al. 2005). Of these 184
women, 181 had mean urinary iodine levels 100 µg/L and only 3 had mean levels
< 100 µg/L. Therefore, the results of this study would compare to our results for women
with urinary iodine levels 100 µg/L. Urinary iodine levels in the Chilean study
population (median 269 µg/L) were higher than urinary iodine levels found in the
NHANES 2001 – 2002 population (median 168 µg/L, CI 159 – 178 µg/L). The Chilean
women were also pregnant, which increases the variability in T4 and TSH. This
increased variability would make an association between perchlorate and thyroid function
harder to find. The second study with a large percentage of women was the Greer study
discussed previously. These two studies are compared with the current study in Table 7.
The comparison in Table 7 indicates our study is the first to target and separately
analyze results for women with lower levels of urinary iodine, a potentially susceptible
population. A second special attribute of the current study is the much larger sample
size of women, affording more statistical power to detect a potential effect. By averaging
over many women, the current data likely represents a good approximation of a
population steady-state exposure to perchlorate that women have had for a long period of
time. If a mid- to long-term exposure is needed for perchlorate to affect thyroid function,
this data would have a better opportunity to detect that effect compared to study designs
that use short-term exposures. The influence of duration of exposure merits further
Accurate assessment of exposure is critical to detect biochemical endpoints
potentially related to exposure. Our laboratory recently developed an improved method
for measuring urinary perchlorate which enhances individual perchlorate exposure
assessment (Valentin-Blasini et al. 2005). The use of this new urinary perchlorate
measurement strengthens the ability of this study to detect potential associations with T4
This study has the general limitations of a cross-sectional analysis. Therefore, the
relationship between urinary perchlorate and thyroid function was examined with
attention to the potential influences of chance, bias, or confounding. Perchlorate (as with
any of the significant predictor variables) could be a surrogate for another unrecognized
determinant of thyroid function. We also assumed in this analysis that urinary
perchlorate correlates with levels in the thyroid stroma and tissue, a kinetically distinct
compartment. This would be the case in a population with stable, chronic exposures;
which is likely, but not certain in this population. A large sample size helps to average
such potential kinetic differences. Lastly, a measurement of free T4 would be an
Urinary perchlorate is associated with an increased TSH and decreased total T4 in
women 12 and older, who have urine iodine levels < 100 µg/L, in the U.S. population
during 2001-2002. For women with urine iodine levels 100 µg/L, urine perchlorate is a
significant predictor of TSH but not T4. These effects of perchlorate on T4 and TSH are
coherent in direction and independent of other variables known to affect thyroid function,
but are at perchlorate exposure levels unanticipated based on previous studies. Further
research is recommended to affirm these findings.
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