respect to prevalence of undernutrition. The authors suggested that fluoride or an associated goitrogen might be responsible for the goiters seen in the two towns with the highest fluoride concentrations but that some other factor(s) was involved in development of goiter in the other towns.

Several studies have compared various aspects of thyroid status in populations with different fluoride intakes (for details, see Appendix E, Table E-4). Leone et al. (1964) and Baum et al. (1981) reported no significant differences in thyroid status between populations with low (0.09-0.2 mg/L) and high (3-3.5 mg/L) fluoride concentrations in the drinking water. Leone et al. (1964) looked only at protein-bound iodine and physical examination of the thyroid in adults; Baum et al. (1981) measured a number of parameters in teenagers, including T4, T3, and TSH. Neither study reported iodine status of the groups. Baum et al. (1981) showed but did not explain a decrease in thyroglobulin in girls in the high-fluoride group.

Bachinskii et al. (1985) examined 47 healthy persons, 43 persons with hyperthyroidism, and 33 persons with hypothyroidism. Prolonged consumption of “high-fluoride” drinking water (2.3 mg/L, as opposed to “normal” concentrations of 1 mg/L) by healthy persons was associated with statistically significant changes in TSH concentrations (increased), T3 concentrations (decreased), and uptake of radioiodine (increased), although the mean values for TSH and T3 were still within normal ranges (see Appendix E, Table E-6). The mean value of TSH for the healthy group (4.3 ± 0.6 milliunits/L; Table E-6) is high enough that one expects a few individuals to have been above the normal range (typically 0.5-5 milliunits/L; Larsen et al. 2002). These results were interpreted as indicating disruption of iodine metabolism, stress in the pituitary-thyroid system, and increased risk of developing thyroidopathy (Bachinskii et al. 1985).

Lin et al. (1991) examined 769 children (7-14 years old) for mental retardation in three areas of China, including an area with “high” fluoride (0.88 mg/L) and low iodine, an area with “normal” fluoride (0.34 mg/L) and low iodine, and an area where iodine supplementation was routine (fluoride concentration not stated). Ten to twelve children in each area received detailed examinations, including measuring thyroid 131I uptake and thyroid hormone concentrations. Children in the first area had higher TSH, slightly higher 131I uptake, and lower mean IQ than children in the second area. Children in the first area also had reduced T3 and elevated reverse T3, compared with children in the second area. The authors suggested that high fluoride might exacerbate the effects of iodine deficiency. In addition, the authors reported a difference in T3/rT3 (T3/reverse-T3) ratios between high- and low-fluoride areas and suggested that excess fluoride ion affects normal deiodination.

A recent study by Susheela et al. (2005) compared thyroid hormone status (free T4, free T3, and TSH) of 90 children with enamel fluorosis

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