Monday, June 10, 2013

Iodine part 3: Factors affecting iodine status, testing and supplementiation

Over the previous two parts of this blog series we've discussed the roles of iodide/iodine in the body as well as how changes to the food system have negatively impacted iodine status.  In the final blog in this series we will discuss how certain things impact iodine status, how you can test your iodine status, and what you need to know about supplementing with iodine.  This information is directly from the protocol used in the Iodine Project and is the work of Dr. Abraham, Dr. Flechas, and Dr. Brownstein.  If you are considering iodine supplementation and have any sort of thyroid issues you should use iodine under the care of a doctor of integrative medicine.

At the end of the last blog we discussed the removal of iodine from bread back in the 70s.  As a result, Americans are excreting 50% less iodine than they did back then.  To make matters worse, they replaced iodine with something called bromine.  Bromine, iodine, fluorine, chlorine, and astatine belong to a class of chemical elements called halogens.  The halogens are highly reactive elements that can react with other compounds by stealing an electron.  When they do this they are called halides and can interchangeably bind to the receptors on your cells.  Chloride and iodide are both important for health, fluoride is often used to prevent cavities, and bromide doesn't appear to be necessary and can be potentially harmful.  Whether bromide is toxic or not, I believe it is, it is certainly problematic for people low in iodide, as is fluoride.  While there is no hard evidence to indict bromide at very low levels, high levels are certainly toxic.

Where do we find bromide?

As mentioned above, you can find bromide in bread and other bakery products since iodine was replaced with bromide.  You can also find brominated vegetable oil(BVO) in citrus flavored soft drinks like Mountain Dew, some energy drinks, and formerly in Gatorade.  In 2013, an online petition asked PepsiCo to stop putting BVO in Gatorade.  The impetus for the petition was that Europe, India, and Japan do not allow BVO for use as a food additive as they regard it as unsafe.  Since Gatorade is sold in those countries, there is already a formula without BVO so there is no reason to put a potentially toxic substance in it.  The petition was successful and Pepsi removed the BVO from the citrus Gatorade flavors in 2013.  Bromide-based pesticides are also used on the food supply, mostly in strawberries.

Despite there being some uses in the food supply, bromide is primarily an environmental toxin.  Bromide can be found in plastics, certain medications(Atrovent and some anesthetics), bromine pool and hot tub treatments, and as a fire retardant in mattresses, carpets, and upholstery/car upholstery.  Adding evidence that bromide is primarily an environmental toxin, a study performed in 1997 found that in healthy adults living in Beijing, the lungs had the highest tissue levels of bromine(1).  Furthermore, the authors stated that the tissue levels of bromine in subjects from this study were significantly lower than people from other countries.  While it is certainly possible that the lungs just happen to be an area where bromine accumulates, it seems unlikely that an ingested substance would specifically accumulate in the lungs, especially one that can interchangeably bind to iodide receptors in the body.  Since Asian cultures tend to eat high levels of iodide in the form of seaweed, iodide may "boot" bromide from the body with the exception of bromide's point of entry or areas where the sodium iodide symporter(NIS) is lacking.

Bromide toxicity

Bromide was used over the counter as a sedative and remedy for headaches until 1975 when it was removed from over the counter use as well as prescription medicine due to chronic toxicity(2).  Bromide's extremely long half life in the blood of 12 days causes levels to build up in the body over time and makes it difficult to dose.  Most of the acute side effects associated with bromide use are neurological in nature, but chronic toxicity affects the endocrine and reproductive systems in animals(3).  In rats and mice, bromide toxicity has been shown to effect the pituitary gland, adrenal gland, thyroid gland, prostate gland, testes, and ovaries with very high doses.  Probably the most important gland to look at in regard to bromide toxicity is the thyroid gland given bromide's classification as a goitrogen.


Goitrogens are substances that interfere with thyroid function and can lead to goiter.  In the case of bromide and the other halides, low intake of iodide causes the other halides to take up space on the NIS, blocking iodide uptake.    Studies in rats have shown bromide to take the place of iodide in the thyroid with a concomitant drop in thyroid hormones with high bromide intakes(4, 5) as well as reducing the half-life of iodine by 2/3rds(5).  Cruciferous vegetables such as broccoli, kale, and cauliflower are also considered goitrogens.  Their effects are mediated by glucosinolates that can form thiocyanates that compete with iodide at receptors on the symporter or goitrins that directly interfere with thyroid hormone synthesis(6). In addition to competing with iodide at the thyroid, bromide also causes elimination of iodide from the skin(7), but there is no evidence cruciferous vegetables do the same.  Cooking inactivates some of the goitrogens found in cruciferous vegetables.

One has to be careful to not put the horse before the cart when looking at the goitrogenic effects of food.  There are many beneficial effects to eating cruciferous vegetables including cancer prevention(8) as well as meeting your nutrient needs for the day.  High exposure to goitrogens merely means your iodine needs increase and that low to moderate iodine intake is not sufficient(9, 10, 11).  Since there are no beneficial effects to being exposed to bromide, it should be avoided altogether and your exposure to elements that may contain it(Pools, plastics in computers, and fire retardant materials in furniture and upholstery) should be considered when calculating your daily need for iodide.  In addition, while fluoride appears to be beneficial when applied to the teeth, there is no evidence of it being beneficial when ingested.  This is a problem because most of the water supply in the United States is fluoridated.

Testing for iodine sufficiency

All of this evidence points to the importance of determining whether you are iodine sufficient or not.  There are far too many factors to make a blanket recommendation for an RDA for iodine.  People who eat high levels of goitrogenic foods, work in in the furniture industry, work with bromide-based chemicals, use Atrovent, or spend a lot of time in their car probably have a higher iodine requirement than people who don't fit any of that criteria.  One of the least effective ways to measure iodine is in the serum.  Iodine, like magnesium, is primarily found inside cells.  Measuring your iodine levels by measuring the amount of iodine in your blood would be like measuring the amount of gas in your car by how much is in your fuel line.  Your fuel line will be full up until the point your gas tank becomes empty, at which point your fuel line will empty almost immediately.  The current standard for measuring iodine sufficiency is the urinary iodine spot and 24 hour loading test.

The urinary iodine spot test measures the iodine level in your urine upon awakening and is used as a reference value.  The 24 hour urinary iodine loading test involves taking 50mg of Iodoral after the spot test and collecting your urine for 24 hours, including the first urination on the next day.  The amount of iodine in your urine is used to determine what percentage of the iodine you retained in your body.  Healthy people excrete 90% of ingested iodine in the urine, so people with levels lower than that are said to be deficient in iodine as their body attempts to retain more.  In addition, you can also measure bromide and fluoride levels in the urine to identify whether or not you have high levels of either halide.  There are no randomized clinical studies supporting the use of this test to determine iodine sufficiency.  However, the physicians in the Iodine Project who have been using this test as well as treating patients with iodine find that the level of iodine excreted in the urine is inversely related to the severity of symptoms and that the test and symptoms improve over time with proper supplementation iodide/iodine(12, 13, 14,) (Note: Dr. Abraham, referenced in 12 & 13, makes Iodoral and therefore has a financial interest in both iodine supplementation and the test, which uses 50mg Iodoral as the iodine load).  You can order the 24 hour urinary iodine lading test from FFP laboratories and do not need a doctor's prescription.

Supplementing with iodine

Seaweed, fish, eggs, dairy and iodized salt are the primary sources of iodine in the diet.  The iodine content of seaweed varies by the type of seaweed and the iodine content of dairy depends on the diet of the animal was well as the type of teat cleanser the farmer uses as iodine based teat dips cleansers absorb in to the udder and get in to the milk.  However, chlorine can also be used and may increase competition with iodine as it is also a halogen.  While I think seaweed is probably sufficient for getting your iodine needs, the other foods are probably not going to get you to an adequate intake.  If you don't eat seaweed, the only way you are going to meet your iodine needs is through supplementation.  If you are deficient in iodine, supplementation is probably your only option.  I tend to recommend food over supplementation in most cases; magnesium, fish oil, and iodine are the only exceptions.  Let's take a look at supplementing with iodine.  (Note:This information is taken from the recommendations of Dr. Abraham and Dr. Brownstein of the Iodine Project. This is from their practical experience working with thousands of patients, there are no randomized clinical trials supporting this protocol.  I have experience with it and will discuss that in part 4)


The dosage of iodine you choose is dependent on many factors including exposure to goitrogens.  There are iodine deficient people supplementing with 150mg of iodine(3 orders of magnitude higher than the RDA) with no ill effects.  This level of intake is pretty severe and more than likely unsafe unless doing so under the supervision of a physician.  The smartest approach to determining your dosage of iodine is to start a little above the RDA(200mcg) and double it every couple of weeks.  As long as you also take the companion supplements that will be discussed later you can probably start safely at double this number.  Since you will be starting at such a low dosage, it will probably not be possible for you to use Iodoral until you reach 4mg of iodine(1/4 of a 12.5mg Iodoral).  You can use any brand of potassium iodide until then, just make sure you determine your dose by the amount of iodide and not the total amount of potassium iodide.

Research by Eskin et al, found that iodide and iodine each seem to accumulate more in different tissues with iodide accumulating more in the thyroid and iodine accumulating more in the breast tissue of rats(15).  Because of these findings and the fact that so may tissues seem to require iodine/iodide, the best course of action is to supplement with both as soon as possible.  The only products I know of that contain both are Lugol's solution and Iodoral, but there are more than likely other options or combinations you can use to get both in supplement form.  As always, you should discuss supplementation with your doctor and if you have a thyroid condition you should be using iodine supplementation under their supervision.

One of the primary determinants of the dosage that is best for you is the presence of bromine related detoxification symptoms.  The bromine related detoxification symptoms can be found here.  If you experience any of these symptoms, you are clearing bromine from your tissues faster than your detoxification system can remove them.  Many people ignore these symptoms if they are minor(I did) and work up to a dosage of 50mg over time.  At a dosage of 50mg, the doctors of the Iodine Project state that most people will reach iodine sufficiency in 3 months.  Of course, there will be variability in this number and that will be dependent on your score on the 24 hour iodine excretion test.  Taking this test at regular intervals is a good idea to make sure iodine supplementation is working.  In some instances there are other issues such as a defective symporter that can increase the time it takes to reach iodine sufficiency.  There are companion supplements to take that cover these issues and some of the other issues that may arise.

Companion supplements

Selenium plays an important role in the thyroid.  It supports efficient thyroid hormones synthesis and is also needed to convert T4 to the active T3.  Supplementing with iodine while deficient in selenium can make a thyroid problem worse and vice versa.  Chris Kresser wrote a terrific article covering the use of selenium that can be found here.  You will want to get approximately 200mcg of selenium.  It's best to get a selenium complex that contains multiple forms of selenium.

Vitamin C
Vitamin C is a powerful antioxidant and is very useful in supporting the liver while the body detoxes.  Based on case reports and the experience from physicians in the Iodine Project, vitamin C also helps improve a defective sodium iodide symporter(16).  Aim for 3000mg or more of vitamin C per day depending on the severity of your detox symptoms and be sure to spread the dosage out throughout the day as much as possible.  If you take too much vitamin C at one time you could experience loose stools.  It is also important to taper down your dosage slowly if you decide to stop taking it as a sharp drop in vitamin C intake can simulate the symptoms of vitamin C deficiency.

Magnesium helps the body detox and is used in over 300 enzymatic reactions.  Since most people are probably deficient in magnesium it is a good idea to take it in supplement form.  Aim for 500mg of elemental magnesium per day of a more time released form of magnesium.  I use Jigsaw Magnesium w/SRT which is dimagnesium malate but other people have gotten good results from magnesium glycinate or citrate.  Magnesium oxide often causes loose stools so use it at your discretion.  If you have any sort of kidney pathology you should discuss magnesium supplementation with your doctor.

Vitamins B2 & B3
The doctors in the Iodine Project have found that supplementing with vitamins B2 and B3 help increase the absorption of iodine.  Aim for 100mg of B2 as riboflavin and 500mg of B3 (Not niacinamide) in a time released form per 50mg of iodine.  The doctors of the Iodine Project have a formula called ATP cofactors that they use with their patients.  This dosage of B2 and B3 will definitely turn your urine bright yellow.

Salt is used to help support the adrenals and speed up the excretion of bromide.  The doctors of the Iodine Project have found that supplementing with 1/2 tsp of unrefined celtic sea salt dissolved in to a glass of water 2 times a day has helped with bromide detox symptoms.  In addition, bromide half-life has been shown to be dependent on sodium intake in rats(17).  The sodium in salt is also used to increase iodide uptake by powering the sodium iodide symporter.


Over the course of this three part series on iodine we have discussed why the RDA for iodine is low, how environmental exposure to bromide increases iodine needs, how factors in the diet can contribute to low iodine status, how changes to the food system have decreased the amount of iodine we consume, and how to safely supplement with iodine.  The protocol used by the doctors in the Iodine Project is based off their practical experience treating thousands of people as well as the experience of thousands more from the Curezone and Yahoo Iodine groups.  I am currently halfway through using this protocol and will give my personal take in part 4 of this blog series once I have completed the high dose phase and enter a maintenance dose.  The results thus far have been pretty amazing.  If you decide to implement an iodine protocol it's wise to consult a physician familiar with using high dosage iodine.

Part 1    Part 2