To,
Professor Dr. Aziz Ahmad,
Chief Editor,
Journal of Saidu Medical College,
Sawat.
Subject:-
PUBLICATION OF ORIGINAL ARTICLE.
It is certified that my research titled, “To Assess the effect of pineapple on
Goiter size and TSH level” is an original research, conducted by me and which is
approved by the Ethical review committee of P.G.M.I. Lahore. It is further submitted
that I have not sent this article for publication to any Journal.
Dr. Abdul Rehman Khokhar
Assistant Professor of Physiology
D.G Khan Medical College
Dera Ghazi Khan
TO ASSESS THE EFFECT OF PINEAPPLE ON
GOITER SIZE AND TSH LEVEL
ABDUL REHMAN KHOKHAR1, MUHAMMAD SHAHID FARQUI2,
MUHAMMAD ARSHAD QURESHI3 , TANVIR ALI KHAN SHIRWANY4
QURRAT UL AIN REHMAN5.
1. Assistant Professor Physiology D.G Khan Medical College Dera Ghazi Khan
2. Assistant Professor Physiology P.G.M.I Lahore
3. Assistan Professor Pharmacology Sahiwal Medical College Sahiwal
4. Principal/Professor of Physiology Red Crescent Medical College Lahore
5. P.A.E.C. Science College Dera Ghazi Khan
ABSTRACT
INTRODUCTION
Endemic goiter is a major world wide problem and is a preventable disease. More than 12%
of world population is affected. Ananas Comosus is a good source of iodine and vitamin c.
Which reduce the size of goiter.
OBJECTIVES
1.To measure the goiter size reduction between study and control groups at 4, 8, and
ten weeks of intervention
2.Suppression of TSH level up to 25% from base line
STUDY DESIGN Randomsized control Trial.
SAMPLE SIZE 7o, study group 35, control group 35.
SAMPLING TECHNIQUE Simple Random sampling.
DOSE STANDARDIZATION was done by P.C.S.I.R laboratories complex Lahore.
EXCLUSION CRITERIA.
Subjects suffering from bleeding disorder, liver disease and thyrotoxicosis. History of
thyroid surgery, solitary nodular goiter with history of pain and regional
lymphadenopathy. Diabetes mellitis, History of use of iodized salt, contracting
marriage. Goitrogenic food/marine foods intake, change in bowel habits
DATA COLLECTION
Subjects suffering from endemic goiter were selected from teaching hospital D.G Khan.
Goiter size measurement and TSH estimation was done at 0, 4, 8 and 10 weeks of study.
DATA ANALYSIS
Goiter size reduction from baseline 4.41±0.86cm to 2.00±1.02 after eight week of intervation
was highly significant among study group P<0.000, and TSH suppresses from baseline
2.63±0.95 to 0.94±0.84 after eight week P< 0.000. While changes in control group were non
significant.
CONCLUSION
Ananas Comosus is good alterneture remely for endemic goiter patients and a valuable goiter
shrinkage agent.
KEY WORDS:





PCSIR
Goiter
Ananas Comosus
PEI
TRIAC
TSH
Pakistan Council of Scientific & Industrial Research
enlarged Thyroid gland
Pineapple
Percutaneous Ethanol injection
Thri-iodo thyro acetic acid
Thryoid Stimulating hormone
INTRODUCTION:
World Health Organization has declared endemic goiter a major world-wide problem and
public health priority1. It is a preventable disease, and threat to social and economic
development of poor countries. More than 12% of world population is affected2. Endemic
goiter is more prevalent in hilly areas3. The fact that iodine deficiency plays a major role in
the genesis of endemic goiter4 . In Pakistan an alarming high prevalame of endemic goiter
has been reported from Northern Areas of country in laps of Himalyas5.
Unreliable assessment of iodine deficiency, poor iodine supplementation, inadequate
education, publicity, cost affective are deadly sins, to be avoided in order to achieve
sustainable elimination of iodine deficiency1. National Utilization level of iodized salt is only
17% as projected in the Econmic Servey of Pakistan. Which is drastically lower than W.H.O
recommending level > 90% level due to non availability and high priece6.
People residing in goitrous areas can only obtain enough iodine by consuming sustainable
protion of their food in form of marine food, foods from iodine rich regions and using iodized
salt7. Iodine is unstable and has largely been replaced by iodate due to sublimation8. Effects
of iodine deficiency are worsened if selenium level is low9.
Ananas comosm has been used for its medicinal properties for hundred of years. It has broad
specturm of actions and a good source of iodine and vitamin C10.
Bromelain is an enzyme complex, present in fruit and stem of pineapple, which is key to
pineapple medicinal use11. Bromelain is an effective anti-inflammatory agent. Pineapple juice
is used to treat morning sickness and sea sickness. Two slices of fresh pineapple (25mg)
contain 1 mg of iodine and 100 mg of vitamin C is a recommended adult dose per day12. It
enhances the absorption and permeability of Amoxicallin and Tetracycline in diseased tissue
so it is synergistic effect is documented13.
Contact dermatitis is reported side effect of prolong use of pineapple. Safety during
pregnancy and lactation is not documented yet14.
Data Collection Procedure
Planned visits were made to subjects homes, along with a female nurse, to explain
criteria/requirements of study. Lists of foods/fruits of high iodine content was
provided to subjects and advised not to consume these foods during study period.
Seventy female were selected from medical outpatient department of teaching hospital
D.G. Khan. After selection, subjects were randomized and divided into 2 groups,
study and control groups. 5 ml of blood was drawn aseptically for base-line, Hb and
TSH estimation from all subjects and was allowed to clot for 15-20 minutes. Then it
was centifuged for ten minutes at 5,000 rpm. Serum was sucked and stored , at -20 C
in serum cups. Microlab-300 Analyzer was used for serum TSH estimation by ELISA
kits Human Germany. All subjects of study group had taken 27 gm of fresh. Ananas
comosus daily for period of eight weeks. Control group was given Placebo to be eaten
during study period
Blood samples were drawn aseptically from both study and control group for TSH
estimation at 04, 08 and ten weeks of study Goiter size was measured with vernier
caliper at onset of study and subsequently at four, eight and ten weeks. Findings were
recorded on evaluation proforma.
RESULTS
Seventy female subjects with newly diagnosed endemic goiter were randomized.
Eleven subjects dropped out during follow up. At onset of study no significant
difference was noted between TSH, T3, T4 levels and goiter size of both groups.
(Table 1).
After four and eight weeks of pineapple ingestion goiter size reduction was 2.38% and
2-98% respectively. Within control group changes in goiter size were non significant
P=0.06, (Table 2). While highly significant goiter size reduction was noted among
study group, P=0.000, (Table 3). Serum TSH level comparison by paired sample t test,
with in control group, resulted no significant suppression of TSH level. P> .704,
which was 0.94% and 4.3% only at four and eight weeks (Table 4). While TSH
suppression was high significant at four and eight weeks of pineapple ingestion among
study group P=0.000, (Table 5). When compared between two group by Independent
sample t test, highly significant goiter size reduction was noted P=0.000, (Table 6)
and TSH suppression was also highly significant P=0.000, (Table 7) which indicates
that pineapple is a good goiter size reducing agant.
Table 1 Baseline Characteristic on 1st day
No. of females
Age in years
Goiter size
T3
T4
TSH
Hb%
Study group
n = 29 (82.9%)
19.86 + 3.96
4.41 + 0.86 cm
1.29 + 0.46 ng/ml
7.78 + 1.96 ug/dl
2.63 + 0.95 miu/l
11.10±2.19gm%
Control group
n =30 (85.7%)
19.27 + 3.17
4.33 + 1.05 cm
1.45 + 0.46 ng/ml
6.84 + 2.17 ug/dl
2.74 + 1.44 miu/l
10.91±2.35gm%
Results are expressed as mean ± SD
Table 2 Comparison of goiter size within control group (non-treated) by paired samples t-test
Control group (n=30)
Time
Base line
4 week
8 week
10 week
Goiter size (cm)
4.33 ± 1.05
4.23 ± 1.09
4.22 ± 1.04*
4.21 ± 1.15
p-value
Reduction
0.066
0.018
0.097
2.38%
2.47%
2.98%
Results are expressed as mean ± SD
Table 3 Comparison of goiter size within study group (treated) by paired samples t-test
study group (n=29)
Time
Base line
4 week
8 week
10 week
goiter size
4.41 ± 0.86
2.99 ± 0.53***
2.00 ± 1.02***
2.17 ± 1.09***
p-value
Reduction
0.000
0.000
0.000
31.25%
54.83%
50.03%
Table 4 Comparison of serum TSH within control group (non-treated) by paired samples t-test
Control group (n=30)
Time
Base line
4 week
8 week
10 week
TSH (miu/l)
2.74 ± 1.44
2.73 ± 1.37
2.72 ± 1.30
2.69 ± 1.57
p-value
Reduction
0.704
0.735
0.259
0.945%
2.447%
4.363%
Table 5 Comparison of serum TSH within study group (treated) by paired samples t-test
study group (n=29)
Time
Base line
4 week
8 week
10 week
TSH (miu/l)
2.63 ± 0.95
0.41 ± 0.19***
0.94 ± 0.84***
2.44 ± 0.70
p-value
Reduction
0.000
0.000
0.353
82.31%
56.61%
3.17%
Table 6 Comparison of Goiter size (cm) between control group (non-treated) versus study group
(treated) by Independent Samples t-test
Time
Base line
4 week
8 week
10 week
Control group
Mean ± SD
4.33 ±1.05
4.23 ±1.09
4.22 ±1.04*
4.21 ±1.15
Study group
Mean ± SD
4.41 ± 0.86
2.99 ± 0.53***
2.00 ± 1.02***
2.17 ± 1.09***
p-value
0.750
0.000
0.000
0.000
Table 7 Comparison of serum TSH between control group (non treated) versus study group
(treated) by Independent Samples t-test
Time
Base line
4 week
8 week
10 week
Control group
Mean ± SD
2.74 ± 1.44
2.73 ± 1.37
2.72 ± 1.30
2.69 ± 1.57
Study group
Mean ± SD
2.63 ± 0.95
0.41 ± 0.19***
0.94 ± 0.84***
2.44 ± 0.70
p-value
.720
.000
.000
.433
DISCUSSION
Visible goiter causes cosmetic disfigurement of neck. Iodine deficiency results
decrease serum T3, T4, which leads to high TSH level, which resulting in hyperactivity
of thyroid leading to goiter15. Fresh pineapple, ingestion (fresh) resulted significant
goiter size reduction within eight weeks, while no significant change in goiter size was
reported in control group.
Numerous studies have been carried out, using various chemical substances to
determine their effects on thyroid goiters. But evidently no study appears to evaluate
effects of natural substance especially fruits like pineapple and strawberries on
development or otherwise of goiters.
Guglielmi et al (2004) established the role and efficiency of per-cutaneous Ethanol
injection(PEI) in benign thyroid lesions. Fifty eight recurrent cystic nodules and soft
autonomous functioning nodules were treated by PEI for six years16 while in our study
seventy female patents having goiter were studied. Iqbal et al concluded that
significant TSH suppression was noted with thyroxin supplementation for one year
which was given 50-100 ug/day among interventional group which was highly
significant while in Placebo group TSH level remain persistent till the end of study17.
While in our study significant TSH suppression was noted in study group just after
four weeks of intervention. No TSH suppression was observed in control group.
Brenta et al (2003) described comparison of therapeutic efficacy between L- Thyroxin and
Tri-iodo-Thyro acetic acid (TRIAC) in non toxic and nodular goiters. Thirty six women were
studies for eleven month after randomization. While in our study endemic goiters females
were treated with fresh pineapple for short period. Goiter volume was assessed by Three
dimensional sonography, while we used vernier caliper for goiter size measurements and
patients were evaluated a four, eight and ten weeks of intervention. After II months thereby
goiter size was reduced – 42% in TRIAC group, while in our study goiter size reduction was
more than 50% of initial size.
Our findings like goiter size reduction and TSH Suppression are in accordance with those of
Brenta et al18, but more effective with less duration.
Finding of our study also confirm to recommendation of Food and Drug Administration
(2013) for TSH monitoring at 6-8 weeks interval unit normalization19. While our study
showed significant improvement in serum T3 T4 and TSH levels and highly significant goiter
size reduction with 8 weeks of intervention.
Anderson et al concluded after double blind household base interventional study of 5-15
years old, randomly assigned in Three groups; Intervention was iodized salt, dual fortified
salt with iron as micronized ground ferric pyrophosphate (MGFEPP) or iron as ferrous
fumarate both at 2mg/gm of salt. Dual fortification improved, serum ferritin, Hemoglobin,
urinary iodine, status first day, five and ten month were estimated20, while in our study we
estimated Hemoglobin level only at first day of study and comparatively lesser goiter size
reduction was reported among anemic patients.
Loss of iodine in salt with 1.8% moisture were high, which caused colour changes in some
local foods, while no iodine loss or any sort of color changes was not noted in our study.
Zimmermann et-al reported that goiter size reduction was poor among anemic children after
oral iodine supplementation. Goiter rate was persistent even after iodine supplementation.
Our study results are in accordance with Zimmermann et al regarding comparatively less
goiter size reduction was noted among anemic females21.
Zimmermann MB (2008) While tracing history various studies during last century or so,
referred to a study of Marine and Kimball involving iodine intervention in school children of
Akren and Ohio, USA
They treated young girls by 200 mg of sodium iodide for 10 days, equivalent to 1700 mg of
iodine in total, while double dose was given to older girls, while in our study 26.64 gm / day
of fresh pineapple containing 1 mg iodine was ingested by young females for eight weeks. No
case of goiter was reported from treated group, while control group show +25% goiter at final
examination22. In our study goiter size was reduced significantly with a given safe dose.
Zimmernnann et-al reported That iodine intake for short period in doses 500-1000mg/day
have inhibitory effect on Thyroid function. In our study safe but effective dose of iodine (1
mg/day) as fresh pineapple was given for short period of eight weeks, which resulted
significant goiter size reduction and significant TSH inhibition23.
Fresh pineapple, which is a food item and cost effective in quantity required for therapeutic
use. It act as a good therapeutic agent for endemic goiter patients. Our study has some
limitations, because it is contraindicated in pregnancy, lactation and bleeding disorders etc.
Address for correspondence:Dr. Abdul Rehman Khokhar
Assistant Professor of Physiology
D.G. Khan Medical College
Dera Ghazi Khan
Email: drarkhokhar@yahoo.com
Cell # 0323-7877375
Certain Explanation
 Females were selected, became endemic goiter is more common among females.
 Pineapple is freely available but people are ignorant about its health benefits,
solicits not commonly used.
 Tables shows different comparisons, within group and between two groups so
cannot be combined.
 Reason for increase in size/TSH elevation, at ten weeks. Because pineapple
ingestion was withheld two weeks before.