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Prevalence of Thyroid Disease In Malaysia
Mohammad Arif Shahar Diabetes and Endocrine Unit (DEU)
International Islamic University Malaysia (IIUM)
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Why do we need to know about prevalence?
• Burden of the disease (epidemiological point of view)
• Screening (public health point of view)
• Making a diagnosis (clinical point of view)
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Morbidity related to thyroid disorders
Hyperthyroidism
• Cardiomyopathy
• Osteoporosis
Hypothyroidism
• Cardiovascular disease
• Obesity
• Dyslipidemia
• Pregnancy outcome
• Cognitive function
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Thyroid Cancer
• Morbidity and mortality
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Outline
• Previous studies on thyroid disorders in Malaysia
• The MyENDO-Thyroid study
• Clinical implications
• Unanswered questions
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Prevalence of thyroid disorders
• Thyroid dysfunction
– Thyroid status rather than actual diagnosis
• Goitre and thyroid nodules
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Previous studies on thyroid disorders in Malaysia
Author N Disease of interest
Hypothyroid Hyperthyroid Goitre Thyroid nodule
Chen et al (1988)
343 Penan population, Sarawak
Endemic goitre
- - 60.6% -
Tan et al (1989)
180 from a single centre
Graves disease
- 0.2-1.4% - -
Mafauzy et al (1993)
2450 Kelantan population
Endemic goitre
- - 36.8% -
Foo et al (1994)
974 population in Sarawak
Endemic goitre
- - 31.8% -
Osman et al (1995)
1419 Orang Asli vs Malay
Endemic goitre
28.4% vs 5.3%
- 20-70% -
Yazmin et al (2014)
98 patients with depression
Subclinical thyroid dysfx
4% (subclinical)
11% (subclinical)
- -
Ong et al (2014)
174 SLE patients AITD 54.5% 45.5% - - 5/8/2017 1100-1125 6
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Endocrine Disorders in Malaysia: Thyroid (MyENDO:Thyroid) Study
• Initiated by The Malaysian Endocrine Metabolic Society (MEMS)
• Objectives:
– Determine the prevalence of:
• Thyroid dysfunction
• Goitre and thyroid nodules;
– In the Malaysian adult population
• Completed end of 2016
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Inclusion and exclusion criteria
• Inclusion criteria:
– Age ≥ 18 years
– Malaysian citizen
• Exclusion criteria:
– Pregnancy
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Malaysian Map, Source: Google Map
North
West Coast
South
East Coast
Central
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Results
Figure 1: Subjects enrolled
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Analysis
Figure 2: Definitions of sub-population in this cohort
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Results
• Demography
• Measurement of TSH, FT4, FT3, antiTPO and antiTG in the population – The effect of age
• Prevalence of thyroid dysfunction
• Prevalence of goitre and thyroid nodule – Goitre vs age
– Goitre vs ethnicity
– Goitre vs geographical location
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Demography % of Subjects
Characteristics Study Population
(N=2,190)
Malaysian Population*
(N=30,995,700)
Age distribution
18-24 9.8 19.4
25-34 9.9 18.7
35-44 13.7 13.0
45-54 23.5 10.6
55-64 26.6 7.4
65-74 12.9 3.9
>74 3.7 2.0
Median age 52.0 27.8
Male:Female Ratio 58.1:100 106.6:100
Ethnicity
Malay 69.1 61.8
Chinese 23.7 21.4
Indian 6.3 6.4
Others 0.9 0.9
Non-Malaysian 0.0 9.6
*Current Population Estimate 2015, Department of Statistics Malaysia
Table 1: Comparison between the study cohort and Malaysian population 5/8/2017 1100-1125 13
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Results
• Demography
• Measurement of TSH, FT4, FT3, antiTPO and antiTG in the population – The effect of age
• Prevalence of thyroid dysfunction
• Prevalence of goitre and thyroid nodule – Goitre vs age
– Goitre vs ethnicity
– Goitre vs geographical location
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TSH, FT4, FT3, antiTPO, antiTG in the adult Malaysian population (Total
Population)
Median 25th Centile 75th Centile 97.4th Centile
TSH 1.16 0.81 1.63 3.55
fT4 12.98 11.99 13.97
fT3 4.10 3.71 4.48
antiTPO 12.8 <10.0 20.4
antiTG <20.0 <20.0 250.7
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TSH, FT4 and FT3 in the adult Malaysian population (Reference
Population)
Median 25th Centile 75th Centile 97.5th Centile
TSH 1.14 0.83 1.55 3.55
fT4 12.95 11.95 13.94
fT3 4.12 3.71 4.50
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TSH
Lower limit = 0.32 uIU/mL Upper limit (97.5th centile) = 3.55
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Results
• Demography
• Measurement of TSH, FT4, FT3, antiTPO and antiTG in the population – The effect of age
• Prevalence of thyroid dysfunction
• Prevalence of goitre and thyroid nodule – Goitre vs age
– Goitre vs ethnicity
– Goitre vs geographical location
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12
13
14
18-24 25-34 35-44 45-54 55-64 65-74 >74
fT4
(p
mo
l/L)
*p<0.05 **p<0.001
*
**
1
1.2
1.4
18-24 35-44 55-64 >74
TSH
(u
IU/m
L)
Age (Years)
Relationship between TSH, fT4, fT3 and age (Total population)
3.5
3.9
4.3
18-24 35-44 55-64 >74
fT3
(p
mo
l/L)
Age (Years)
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12
12.6
13.2
13.8
18-24 25-34 35-44 45-54 55-64 65-74 >74
fT4
(p
mo
l/L)
*p<0.05
*
*
1
1.5
2
2.5
18-24 35-44 55-64 >74
TSH
(u
IU/m
L)
Age (Years)
Relationship between TSH, fT4, fT3 and age (Reference population)
3.5
3.9
4.3
18-24 35-44 55-64 >74
fT3
(p
mo
l/L)
Age (Years)
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8
12
16
18-24 25-34 35-44 45-54 55-64 65-74 >74
anti
TPO
(IU
/mL)
Age (years)
Relationship between antiTPO and age (Total population)
*p<0.05
*
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Results
• Demography
• Measurement of TSH, FT4, FT3, antiTPO and antiTG in the population – The effect of age
• Prevalence of thyroid dysfunction
• Prevalence of goitre and thyroid nodule – Goitre vs age
– Goitre vs ethnicity
– Goitre vs geographical location
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0.5%
3.8%
0.3%
1.6%
8.3%
1.1% 0.6%
8.3%
0.0%
2.8%
15.4%
2.0%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Total population Known thyroid disorders Disease free population
Hypothyroid Subclinical Hypothyroid Hyperthyroid Subclinical Hyperthyroid
Prevalence of thyroid dysfunction in Malaysia
Shahar et al (2017)
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57.1%
48.0%
70.9%
3.6%
8.0%
2.5%
28.6%
4.0% 20.0%
7.6%
10.7%
20.0%
16.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Patients on L-thyroxine
Patients on anti-thyroid drugs
Patients not onany medication
Euthyroid Hypothyroid Subclinical Hypothyroid Hyperthyroid Subclinical Hyperthyroid
2.5%
Prevalence of thyroid dysfunction among those with known thyroid disorders
Shahar et al (2017)
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2.10%
9.40%
4.60%
1.10%
5.30% 4.90%
1.40%
6.50%
3.90%
11.40%
3.40%
2.20%
1.30% 1.60%
4.30%
1.70%
0.60%
2.80%
1.30%
4.40%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
MyENDO Canaris (2000) Hallowell(2002)
Tunbridge(1977)
Vanderpump(1995)
Madariaga(2002)
Konno (1993) Kasagi (2009) Usha Menon(2009)
Gopaliah R(2016)
Hypothyroidism
Hyperthyroidism
Comparison of prevalence (%) of thyroid dysfunction of with selected studies
Shahar et al (2017)
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The burden of newly diagnosed thyroid dysfunction
Thyroid Status Known thyroid
disorders
Previously
undiagnosed
thyroid dysfunction
Total
Hypothyroid 5 (45.0) 6 (55.0) 11 (100.0)
Subclinical
hypothyroid
11 (32.0) 23 (68.0) 34 (100.0)
Hyperthyroid 11 (92.0) 1 (8.0) 12 (100.0)
Subclinical
hyperthyroid
21 (34.0) 40 (66.0) 61 (100.0)
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55%
68%
8%
66%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Hypothyroid
Subclinicalhypothyroid
Hyperthyroid
Subclinicalhyperthyroid
Known thyroid disorders Previously undiagnosed thyroid dysfunction
The burden of newly diagnosed thyroid dysfunction
Shahar et al (2017)
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Results
• Demography
• Measurement of TSH, FT4, FT3, antiTPO and antiTG in the population – The effect of age
• Prevalence of thyroid dysfunction
• Prevalence of goitre and thyroid nodule – Goitre vs age
– Goitre vs ethnicity
– Goitre vs geographical location
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5
15
4 4
27
3 4
18
3
0 2
0 0
17.5
35
Total PopulationKnown thyroiddisorders
Disease freePopulation
Prevalence (%) of goitre and thyroid nodule in Malaysian adult population
Goitre grade 1
Goitre grade 2
Thyroid nodule
Totalthyroidectomy
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9.3
15.5
7
15.4
12 11.6
7.6
0
2
4
6
8
10
12
14
16
18
MyENDO Tunbridge(1977)
Vanderpump(1995)
Kasagi (2009) Usha Menon(2009)
Zhang Z(2002)
Yu XH (2008)
Pe
rce
nt
(%)
Comparison of Prevalence of Goiter between Selected Studies
Goitre
Shahar et al (2017)
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3.6 3.2
11 10
0
2
4
6
8
10
12
MyENDO Tunbridge (1977) Yu XH (2008) Yang YX (2011)
Pe
rce
nt
(%)
Comparison of Prevalence of Thyroid Nodule between Selected Studies
Thyroid nodule
Shahar et al (2017)
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Known thyroid
disorders
Previously
undiagnosed
goitre/thyroid
nodules
Total
Goitre
Grade 1 21 (20.0) 89 (81.0) 110 (100.0)
Grade 2 36 (38.0) 59 (62.0) 95 (100.0)
Total thyroidectomy 2 (100.0) 0 (0.0) 2 (100.0)
Thyroid nodule
Palpable 25 (32.0) 53 (68.0) 78 (100.0)
The burden of newly diagnosed goitre and thyroid nodule
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81.0%
62.0%
0.0%
68.0%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Grade 1
Grade 2
Total thyroidectomy
Palpable
Go
itre
Thyr
oid
no
du
le
Known thyroid disorders Previously undiagnosed goitre/thyroid nodules
The Burden Of Newly Diagnosed Goitre And Thyroid Nodule
Shahar et al (2017)
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Results
• Demography
• Measurement of TSH, FT4, FT3, antiTPO and antiTG in the population – The effect of age
• Prevalence of thyroid dysfunction
• Prevalence of goitre and thyroid nodule – Goitre vs age
– Goitre vs ethnicity
– Goitre vs geographical location
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12 8
88 92
0
25
50
75
100
125
age < 45 age >/= 45
Perc
ent
Prevalence Of Goitre According To Age
No goitre Goitre
*P = 0.008
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Results
• Demography
• Measurement of TSH, FT4, FT3, antiTPO and antiTG in the population – The effect of age
• Prevalence of thyroid dysfunction
• Prevalence of goitre and thyroid nodule – Goitre vs age
– Goitre vs ethnicity
– Goitre vs geographical location
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5 5.2
4.3
5.3
3.8 3.1
15.1
5.3
0.1 0 0 0
3.2
4.4 3.6
10.5
0
2
4
6
8
10
12
14
16
Malay Chinese Indian Others
Pe
rce
nt
(%)
Prevalence of goitre and thyroid nodule by ethnicity (Total population)
Goutre Grade 1 Goitre Grade 2 Total thyroidectomy Thyroid nodule
* P < 0.001
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4.1 4.9
4
5.3
2.5
1.6
12
5.3
2.3
3.3
1.6
10.5
Malay Chinese Indian Others
Pe
rce
nt
(%)
Prevalence of goitre and thyroid nodule according to ethnicity (Disease Free Population)
Goitre Grade 1 Goitre Grade 2 Thyroid nodule
* P < 0.001
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18.7
9.7 7.1
24.2 25.8
42.9
2.2 0 0
16.5
22.6 21.4
0
5
10
15
20
25
30
35
40
45
50
Malay Chinese Indian
Pe
rce
nt
(%)
Prevalence of goitre and thyroid nodule by ethnicity (Population with known thyroid disease)
Goitre Grade 1
Goitre Grade 2
Total thyroidectomy
Palpable thyroid nodule
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Results
• Demography
• Measurement of TSH, FT4, FT3, antiTPO and antiTG in the population – The effect of age
• Prevalence of thyroid dysfunction
• Prevalence of goitre and thyroid nodule – Goitre vs age
– Goitre vs ethnicity
– Goitre vs geographical location
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Prevalence of Goitre
Shahar et al (2017)
Positive antiTPO
Positive antiTG
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Region
West (5) East (9) North (4) Central South (8)
Location Tanjung Karang and
Kuala Selangor
Kuantan Bidor Subang Jaya Johor Bahru
Designation Rural Urban Rural Urban Urban
Location Coastal Coastal In-land In-land Coastal
Median urinary iodine (ug/L) (by
State)*
126.0 76.5 77.8 131.0 118.0
Median urinary iodine (ug/L) (by
rural/urban)**
94 (59,145) 121 (74,180) 94 (59,145) 121 (74,180) 121 (74,180)
* WM Wan Nazaimoon et al, 2010 ** Rusidah Selamat et al, 2010 5/8/2017 1100-1125 44
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Who are those with goitre? Total population
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Clinical implications
• Exercise caution when interpreting thyroid function and antibodies (esp. TSH and antiTPO) in the elderly population – treat or not treat?
• Majority of patients with hypothyroidism and subclinical thyroid dysfunction was unaware of their condition – active case detection
• Goiter found in rural-inland areas are associated with previous reported low urinary iodine level, while those found in urban-coastal areas are associated with high titre of thyroid antibodies – areas of different etiologies
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Unanswered questions
• Presence of pockets of iodine deficiency may be related to increase prevalence of goitre? – especially in rural in-land areas (Need actual measurement of iodine)
• Is there thyroid cancer among those with goitre and thyroid nodule (more in those aged < 45 years)? (Requires ultrasound examination and cytological/tissue diagnosis)
• The effectiveness of treatment given for patients with thyroid disorders (requires analysis at individual centre)
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Take home messages
• Our prevalence of thyroid dysfunction are compatible most studies world wide (2.1% for hypothyroidism and 3.4% hyperthyroidism)
• Prevalence of goitre is 9.3% and thyroid nodule is 3.6%
• There may be pockets of iodine deficiency which contributes to goitre in rural areas
• Goitre in the coastal areas are likely autoimmune
• Large proportion of the population may be unaware that they have some sort of thyroid problems especially hypothyroidism and subclinical thyroid dysfunction
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Acknowledgement
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AP Dr Ahmad Marzuki Omar Prof Dr Nor Azmi Kamaruddin
Dr Azura Dina Muhayiddin AP Dr Norasyikin Ab Wahab
Dr Chong Kuck Meng Dr Norhaliza Mohd Ali
Dr Hanita Othman Prof Dr Norlela Shukor
Prof Dr Kwa Siew Kim Dr Ooi CP
Dr G R Letchuman A/K Ramanathan Dr Subashini Selvarajoo
Dr Loh Huai Heng Dr Wan Juani Wan Seman
Dr Luqman Ibrahim Dr Yusniza Yusoff
Dr Zanariah Hussien Supporting staff Endocrinology Laboratory, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) Department of Internal Medicine, UKMMC Department of Internal Medicine, International Islamic University Malaysia (IIUM) Medical Graduates, International Islamic University Malaysia, Class of 2015 and 2016. Year 2/2015 Medical Students, Quest International University, Perak
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Thank you for your kind attention
International Islamic University Malaysia
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