Balancing Iodine Policy in the Maldives: Insights from a Literature Review

Balancing Iodine Policy in the Maldives: Insights from a Literature Review

By: RN. Ali Bassam

Abstract

Iodine nutrition requires moving beyond deficiency-focused frameworks to also consider risks of excess. Using the Maldives as a case study, this review shows how compounded exposure from seafood, iodized salt, water, and processed foods challenges one-size-fits-all policies. By synthesizing dietary, environmental, and health evidence, it emphasizes the need for context-specific strategies to anticipate unintended outcomes, such as rising thyroid disorders, and to guide more balanced approaches that protect public health while avoiding oversimplified interventions.

Introduction

Iodine is a micronutrient essential for thyroid hormone synthesis, and both deficiency and excess can lead to thyroid dysfunction. While global health efforts have historically focused on eliminating iodine deficiency, growing evidence shows that excessive iodine intake may also contribute to thyroid disorders, particularly autoimmune hypothyroidism (Leung et al., 2012; Sun, Shan, & Teng, 2014). In the Maldives, where tuna is consumed daily and iodized salt is widely used, the risk of iodine excess is a pressing concern that requires careful contextual examination (Khudair et al., 2025).

Iodine Nutrition in the Maldives

The Maldives has implemented universal salt iodization for decades, ensuring that nearly all salt consumed is iodized (Iodine Global Network, 2023). At the same time, Maldivians have a naturally high intake of iodine-rich foods, especially tuna, which is eaten once or twice daily (Banna, 2024). This combination creates a compounded intake scenario where iodine levels may exceed what the body requires. Rising reports of thyroid dysfunction in the country suggest that excess iodine exposure may already be contributing to health problems (Khudair et al., 2025). Importantly, most studies on iodine in the Maldives have focused only on salt coverage and urinary iodine levels, without considering the broader dietary and environmental context that shapes iodine intake (Krishnan, 1999; Maharjan & Timmer, 2023). Furthermore, Maldivians consume a very high amount of salt, with WHO STEP survey data showing that over 70% of the population exceeds recommended daily limits (HPA, 2024; WHO, 2022). Since nearly all salt in the country is iodized, this excessive salt consumption directly translates into higher iodine intake, compounding the risk of iodine excess and thyroid dysfunction.

Dietary Patterns and Multiple Iodine Sources

The Maldivian diet is unique in its reliance on tuna, which is naturally rich in iodine (Banna, 2024). Cooking practices further increase exposure, as tuna is often prepared using well water from coral islands, which may itself contain iodine (Krishnan, 1999), and iodized salt is routinely added during cooking (Iodine Global Network, 2023). Beyond seafood and salt, mineral waters consumed in the Maldives also contain iodine (Maharjan & Timmer, 2023), and many processed foods imported into the country are fortified or naturally high in iodine (Khudair et al., 2025). With high salt consumption patterns and the exclusive use of iodized salt imports, the daily diet of Maldivians—tuna cooked in iodine-rich water with added iodized salt—creates a situation where excessive iodine intake is highly likely.

Rising Thyroid Concerns

Thyroid disorders, including hypothyroidism and autoimmune thyroiditis, are increasingly reported in the Maldives (Ministry of Health Maldives, 2024). Historically, iodine deficiency was the primary concern, but growing evidence shows that excess iodine can also trigger thyroid dysfunction (Leung, Braverman, & Pearce, 2012). In genetically susceptible populations, high iodine exposure may worsen autoimmune thyroid disease, creating new public health challenges (Pearce, Lazarus, Moreno-Reyes, & Zimmermann, 2016). The Maldivian context is particularly complex, with overlapping iodine sources from seafood, iodized salt, drinking water, and processed foods, making the risk of thyroid-related problems significant and requiring careful monitoring (Iodine Global Network, 2023).

Rethinking Salt Strategy

The Maldives faces a distinctive nutritional challenge where iodine exposure is shaped by both dietary habits and environmental factors. While iodized salt programs have historically been crucial in combating iodine deficiency disorders, the current situation reveals a more complex reality. The heavy reliance on seafood, particularly tuna, provides naturally high levels of iodine, and when combined with fortified salt, this can lead to excessive intake. Such compounded exposure raises concerns about thyroid health, including risks of hyperthyroidism and autoimmune conditions, which are increasingly being reported in the region (Iodine Global Network, 2023). This highlights the limitations of a uniform iodine policy, which may inadvertently shift the population from deficiency to excess, underscoring the need for a recalibrated approach that better reflects the Maldives’ unique dietary and environmental context (Banna, 2024).

Developing a more nuanced iodine strategy requires integrating evidence from multiple sources, including dietary intake surveys, environmental monitoring, and health surveillance data. Policymakers must consider the diversity of consumption patterns across different communities, as not all groups have equal access to seafood or share the same dietary practices. Tailored interventions—such as adjusting iodization levels, promoting alternative sources of micronutrients, or implementing targeted supplementation—could help balance the risks of deficiency and excess (Khudair et al., 2025). Furthermore, rising thyroid concerns demand closer collaboration between nutrition experts and healthcare providers to ensure early detection and management of iodine-related disorders (Ministry of Health Maldives, 2024). By aligning public health measures with local realities, the Maldives can move toward a more sustainable and context-sensitive iodine policy that safeguards population health without compromising nutritional security.

Conclusion

Maldivians are not iodine-deficient by default. On the contrary, their daily diet and environment expose them to multiple sources of iodine: tuna, iodized salt, well water, mineral water, and processed foods. This creates a high likelihood of excessive intake, which may contribute to the growing burden of thyroid disorders in the country. Current research has not adequately addressed these contextual factors, highlighting the urgent need for population-specific strategies that balance iodine intake and protect thyroid health.

 

 

References

·         Banna, K. (2024, October 22). Tuna fish: How much iodine is in this iodine-rich food for thyroid health? Fishing and Fish. https://fishingandfish.com/how-much-iodine-in-tuna-fish/

·         Health Protection Agency. (2024). National survey on noncommunicable disease risk factors: Maldives STEPS survey 2023. Malé: Health Protection Agency, Ministry of Health.

·         Iodine Global Network. (2023, July). Status of the iodine nutrition and salt iodization program in Maldives: Country brief. UNICEF Regional Office for South Asia. https://ign.org/app/uploads/2023/10/Maldives_Country-Brief.pdf

·         Khudair, A., Khudair, A., Niinuma, S. A., Habib, H., & Butler, A. E. (2025). Beyond thyroid dysfunction: The systemic impact of iodine excess. Frontiers in Endocrinology, 16, Article 1568807. https://doi.org/10.3389/fendo.2025.1568807

·         Krishnan, A. (1999). Iodine deficiency disorders in the Maldives: A public health problem. Academia.edu.. https://www.academia.edu/59735123/Iodine_deficiency_disorders_in_the_Maldives_A_public_health_problem

·         Leung, A. M., Braverman, L. E., & Pearce, E. N. (2012). Iodine-induced thyroid dysfunction. Current Opinion in Endocrinology, Diabetes and Obesity, 19(5), 414–419. https://doi.org/10.1097/MED.0b013e328357f93b

·         Maharjan, M. R., & Timmer, A. (2023). Status of the iodine nutrition and salt iodization program in Maldives. Iodine Global Network. https://ign.org/app/uploads/2023/10/Maldives_Country-Brief.pdf

·         Ministry of Health Maldives. (2024). Annual health bulletin 2024. Malé: Government of Maldives.

·         Pearce, E. N., Lazarus, J. H., Moreno-Reyes, R., & Zimmermann, M. B. (2016). Consequences of iodine excess. Endocrine Reviews, 37(2), 106–132. https://doi.org/10.1210/er.2015-1090

·         Sun, X., Shan, Z., & Teng, W. (2014). Effects of increased iodine intake on thyroid disorders. Endocrinology and Metabolism, 29(3), 240–247. https://doi.org/10.3803/EnM.2014.29.3.240

·         World Health Organization. (2022). STEPwise approach to noncommunicable disease risk factor surveillance (STEPS): Maldives country report. Geneva: World Health Organization.