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Universal Salt Iodization to Prevent Iodine Deficiency Disorders

Ibu Kamudia was born on the Indonesian island of Java severely iodine deficient. She suffered from the most pronounced form of mental and physical retardation known as cretinism which was caused by a lack of iodine in the diet of her mother during the first weeks of pregnancy. Her entire life was one of virtual dependency on other family members and the extended community, although she maintained a warm playfulness.

With the support of her local religious leader, Kamudia was able to get married in a traditional Javanese wedding ceremony to a farmer who was also born with severe cretinism. During their lifetime, the Indonesian Government introduced a policy that all salt intended for human consumption be iodized, and over the course of a few short years, their iodine levels became normal, although their mental retardation (caused before they were born), was irreversible

The increased iodine intake from the locally available salt did make them more energetic and communicative, and in their mid twenties they gave birth to two sons, who were born without any signs of iodine deficiency. Although salt iodization is a cost-effective intervention for which simple appropriate technological solutions are available, there are several barriers in ensuring that all salt in the country is iodized, primarily due to the traditional customs of salt harvesting which is done by poor salt farmers. The elder son of Kumidia, Rame, now attends college in Jakarta and is studying small business administration and hopes to use his degree to work with the thousands of small farmers scattered along the coasts of Indonesia to form into cooperatives to ensure that all of their salt is adequately iodized and will help prevent iodine deficiency in future generations.

Iodine deficiency is the primary cause of preventable mental retardation and brain damage, having the most devastating impact on the brain of the developing fetus and young children in the first few years of life. Iodine deficiency also increases the chance of infant mortality, miscarriage and stillbirth. Most children born to iodine-deficient mothers appear normal but have also suffered brain damage and loss in IQ points, affecting their ability to develop to their full potential. These seemingly normal children will later have difficulty learning in school and staying in school. However, some children born to mothers whose iodine deficiency is more pronounced can suffer from extreme physical and mental retardation manifesting, and in the most extreme cases, cretinism. These children, however, represent only the tip of the iceberg; in addition, in many cases it is too late to reverse these effects.

Children who have suffered from less severe deficiencies and who appear normal, but have lost 10 to 15 intelligence quotient (IQ) points. All IDD can be prevented with just one teaspoon of iodine - consumed in tiny amounts on a regular basis over a lifetime – at very little cost.

An iodine deficient environment requires the continued addition of iodine, which is most conveniently and cheaply achieved by the addition of iodine (typically as potassium iodate) to the salt supply.Most humans eat salt in roughly the same amount each day.A decrease in salt intake can be readily met by increasing the iodine content. Where a significant amount of processed food is consumed, it is important that the salt used by the food industry in preparing such food is iodised as well as the salt used in the home.

Universal salt iodisation (USI) which ensures all salt for human and animal consumption is adequately iodised has been remarkably successful in many countries.But sustainability of this successful correction of iodine deficiency is now the challenge because iodine deficiency may recur at any time even in industrialised countries. Since 1990 there has been tremendous progress in increasing the amount of salt which is iodized in countries throughout the world, as well as the proportion of households using salt which contains adequate iodine levels to satisfy physiological requirements. At the same time, there are significant problems, and in spite of the seeming ‘simplicity’ of the intervention, there are many subtle challenges to achieving IDD elimination.

Discussion:

• Dynamics and challenges of public-private partnerships
• Role of legislation and enforcemen
• Mandatory vs. voluntary policies
• How does pubic sector provide incentives to private sector

Iodine deficiency occurs when iodine intake falls below recommended levels. Iodine deficiency is a naturally occurring ecological phenomenon that occurs in many parts of the world. The erosion of soils in riverine areas due to loss of vegetation from clearing for agricultural production, overgrazing by livestock and tree-cutting for firewood, ensures a virtual absolute loss of iodine from the soil. Consequently, the groundwater and foods grown locally in these areas lack iodine. When iodine intake falls below recommended levels, the thyroid may no longer able to synthesise sufficient amounts of thyroid hormone. The resulting low level of thyroid hormones in the blood (hypothyroidism) is the principal factor responsible for the damage done to the developing brain and the other harmful effects known collectively as the Iodine Deficiency Disorders.

The most critical period is from the twelfth week of pregnancy to the third year after birth. Normal levels of thyroid hormones are required for optimal development of the brain, and in areas of iodine deficiency, where thyroid hormone levels, brain development is impaired. In its most extreme form this results in cretinism, but of much greater public health are the more subtle degrees of brain damage which affect the entire population. As a result, the mental ability of ostensibly normal children and adults living in areas of iodine deficiency is reduced compared to what it would otherwise be.In fact, iodine deficiency is the most prevalent preventable cause of mental retardation and brain damage in the world.

Discussion:

• Global magnitude of IDD and coverage of iodized salt
• Discussion of the biology of iodine, IDD and its consequences

It is necessary to have adequate dietary iodine to prevent brain damage in the fetus and in the young infant when the brain is growing rapidly. Whether a national programme is effective in providing an adequate amount of iodine to the target population is reliably assessed by reference to measurements of salt iodine (at factory, retail and household level) and urine iodine (measured in casual samples from school children or households).

Measurements of salt and urine iodine thus provide the essential elements for monitoring whether IDD is being successfully eliminated.These measurements must be carried out regularly according to systems that include both internal and external quality control of factories in order to ensure that all edible salt being produced is iodized, and that the iodine levels are adequate.

WHO has estimated that in 1990, of its 191 Member States, 130 had a significant IDD problem, with a total of affected population of 740 million – or 13 percent of the world’s total population. While the struggle to conquer the IDD started in the early years of this century, it is the last decade that has seen the greatest progress. Progress has been particularly fast in Asia and Africa. There is an increasing number of countries in which a significant proportion of households are using adequately iodized salt, including several countries that consistently rank very low on performance of other health indicators.

Discussion:

• Indicators and tools to assess iodine status in the population
• Indicators and monitoring systems to measure the iodine content in salt
• The role of different partners in monitoring, e.g. Government, producers, civil society, etc.
• Use of information to modify program dynamics and implementation

4. How does institutional capacity affect the problem and the process?

A successful national salt iodisation programme depends on the implementation of a set of activities by various sectors:

• government ministries (legislative and justice, health, industry, agriculture, education, communication and finance);
• salt producers, salt importers and distributors, food manufactures;
• concerned civic groups;
• nutrition, food and medical scientists and other key opinion makers.

Opening the channels of communication and maintaining commitment and co-operation across these various groups is perhaps the greatest challenge to reach the goal of Universal salt Iodization (USI) and ensure the sustainable control of IDD. The salt producers and distributors are the main agents to ensure that IDD is eliminated. Protecting the consumers requires a framework to be in place that will ensure the distribution of adequately packaged, labelled, iodised salt and the setting of this framework is the main responsibility of the government.

Ensuring a demand for the product and understanding the reason to insist on only iodised salt is a shared responsibility of the private salt marketing system, the government and civic society. The establishment and maintenance of such an alliance and all of the associated programme elements will determine the success and sustainability of the programme. Two major policy questions emerge here. First, who is responsible for the marginal cost of adding iodine to salt – consumers or the Government, and secondly, is it appropriate for the Government to exert pressure on small-scale producers who are much less likely to ‘comply’ with mandatory iodization, not for a lack of commitment, but rather for a lack of adequate resources.

The multidisciplinary orientation required for a successful programme poses special difficulties in implementation. Experience indicates that particular problems often arise between health professionals and the salt industry – with their different professional orientations. There is need for mutual education about the health and development problems of IDD and the problem of the salt industry in the continued production of high quality iodised salt. Such teamwork is required for sustainability to be achieved.

There is a strong belief that the additional cost of salt iodisation to salt production (less than 5 cents [US] per person per year) should eventually be borne by an educated community. This will greatly assist sustainability, but as a public good is this the right approach among the poor and marginal segments of society who make decisions based on absolute fiscal grounds.

Discussion:

• Focus on issue of small-scale farmers
• Conflicts of interest when Government workers have financial stake in salt companies

5. Population vs. individual level outcomes

Iodine deficiency affects the entire population and if present during pregnancy may lead to permanent consequences. The treatment of thyroid disease exacerbated by iodine deficiency is extremely expensive, and imposes a major burden on the health system. Given the cost-effectiveness of IDD prevention through salt iodization, most countries (including those in the industrialized world) have opted to focus on prevention of IDD at the population level.

6. Ethical issues

The impact of iodine deficiency on a population is pronounced and in many cases, irreversible. The mental deficiency associated with IDD has an immediate effect on child learning capacity, women’s health, the quality of life of communities, and economic productivity. Thus the potential of a whole community is reduced by iodine deficiency. There is little chance of achievement, and underdevelopment is perpetuated. Indeed everybody may seem to be slow and rather sleepy. The quality of life is poor, and ambition blunted. The community becomes trapped in a self-perpetuating cycle.

One of the main issues that has been debated in the international nutrition community regarding IDD is whether the improvement of iodine status, and the prevention of IDD is a public good that should be subsidized by the Government, or whether the costs should be passed onto consumers.

A second issue which has emerged is associated with the important role of all salt producers in USI programs. There has been a particularly challenging obstacle of bringing all small-scale producers on board in countries with long coastlines, as there are literally thousands of artisanal seasonal salt producers who harvest small quantities of salt and then sell it unprocessed (and un-iodized) directly to local markets, thus creating a supply of non-iodized salt for retailers and consumers. If the Government requires these farmers to only sell iodized salt, many will not have the capacity and will be forced out of business Larger factories will come in and dominate the markets. In order to address this problem, it has been critical to identify appropriate models for ‘organizing’ small farmers, such as though co-operatives so that they can remain viable and also contribute to the progress towards USI.

Discussion:

• Who pays for a public good?
• Establishing a precedent for food fortification when adequate nutrition is considered as a basic human right

Resources:

USI Technical Links: http://www.micronutrient.org/Salt_CD/4.0_useful/4.1_fulltext/index.htm

Documentary Video: For A Few Pennies More (2000; 24min)

The importance of nutrition, and specifically iodine in the diet of poor people, is the unusual topic of this segment, set in Java , Indonesia. An estimated two billion people around the world are at risk from this medical problem. Goiters, cretinism, stillbirths, underweight babies, lower IQs-these are some of the consequences of iodine deficiency. The World Bank estimates that up to 5% of global GDP is lost because of the lack of micronutrients like iodine.

*Available through the Center for Advanced Studies in International Development (CASID) http://www.isp.msu.edu/casid/video.html

Bleichrodt N. and Born M. A Meta-analysis of Research on Iodine and Its Relationship to Cognitive Development.The Damaged Brain of Iodine Deficiency, J.-B. Stanbury (ed).Cognizant Communication Corporation, New York, 1994, pp 195-200.

WHO, UNICEF, ICCIDD. Global prevalence of iodine deficiency disorders. MDIS Working Paper # 1. 1993.