Comparison of Salt Iodization Requirements in National Standards with Global Guidelines.

Background: Food fortification is the addition of 1 or more micronutrients to commonly consumed foods and is utilized by many countries as a public health intervention to prevent and control micronutrient deficiencies. As iodine deficiency was a major public health issue globally, the WHO developed evidence-based guidelines for the fortification of salt with iodine. The implementation of salt iodization has been highly successful in reducing iodine deficiency disorders worldwide and is recommended as the main strategy to prevent iodine deficiency. Objectives: This analysis compared salt iodization requirements specified in countries' salt standards with WHO 2014 Guidelines on salt fortification. Methods: For countries with mandatory salt iodization legislation, data from the Global Fortification Data Exchange regarding iodine amounts and iodine compounds, to be added to salt per the country standard and corresponding national salt intake quantities, were compared with 2014 WHO Guidelines. Results: As of 4 September 2021, 110 countries with mandatory salt iodization legislation had national salt standards that specified iodine amounts and compounds and salt intake data. All but 1 specified at least 1 recommended iodine compound, but the majority specified higher iodine amounts in salt standards than indicated in the guidelines, taking salt consumption levels into account. Our analysis did not find excess iodine intake as a result; however, we did not have data on the extent of compliance with national salt standards. Conclusions: Existing iodization requirements in salt standards appear to be appropriate for most countries. Countries in which iodine amounts in salt standards are significantly higher than those recommended in the 2014 Guidelines, in particular those with low compliance with national standards or excess iodine intake, may wish to review program process and output indicators and assess whether current iodine amounts in standards would result in excessive intake if implementation was improved.

Four years after implementation of a national micronutrient powder program in Kyrgyzstan, prevalence of iron deficiency and iron deficiency anemia is lower, but prevalence of vitamin A deficiency is higher.

BACKGROUND/OBJECTIVES: In 2009, the Ministry of Health of Kyrgyzstan launched a national Infant and Young Child Nutrition (IYCN) program which included point-of-use fortification of foods with micronutrient powders (MNP) containing iron, vitamin A, and other micronutrients. Caretakers of children aged 6-23 months were given 30 sachets of MNP every 2 months. Micronutrient surveys were conducted in 2009 and 2013. The objective of the study was to compare the prevalence of anemia and deficiencies of iron and vitamin A among children aged 6-29 months prior to the MNP program (2009) with those after full implementation (2013). SUBJECTS/METHODS: Cross-sectional national surveys were conducted in 2009 (n = 666) and 2013 (n = 2150). Capillary blood samples were collected to measure hemoglobin, iron (ferritin and soluble transferrin receptor [sTfR]) and vitamin A (retinol binding protein [RBP]) status, and inflammation status (C-reactive protein [CRP] and α-1-acid glycoprotein [AGP]). Ferritin, sTfR, and RBP were adjusted for inflammation; hemoglobin was adjusted for altitude. RESULTS: The prevalence of anemia was non-significantly lower in 2013 compared to 2009 (32.7% vs. 39.0%, p = 0.076). Prevalence of inflammation-adjusted iron deficiency (54.8% vs. 74.2%, p<0.001) and iron deficiency anemia (IDA, 25.5% vs. 35.1%, p = 0.003) were lower and the prevalence of inflammation-adjusted vitamin A deficiency was higher (4.3% vs. 2.0%, p = 0.013) in 2013 compared to 2009. CONCLUSIONS: Four years after the initiation of a national Infant and Young Child Nutrition program including the introduction of point-of-use fortification with MNP, the prevalence of iron deficiency and IDA is lower, but the prevalence of vitamin A deficiency is higher.

Universal Salt Iodization Provides Sufficient Dietary Iodine to Achieve Adequate Iodine Nutrition during the First 1000 Days: A Cross-Sectional Multicenter Study.

Background: Dietary iodine requirements are high during pregnancy, lactation, and infancy, making women and infants vulnerable to iodine deficiency. Universal salt iodization (USI) has been remarkably successful for preventing iodine deficiency in the general population, but it is uncertain if USI provides adequate iodine intakes during the first 1000 d. Objective: We set out to assess if USI provides sufficient dietary iodine to meet the iodine requirements and achieve adequate iodine nutrition in all vulnerable population groups. Methods: We conducted an international, cross-sectional, multicenter study in 3 study sites with mandatory USI legislation. We enrolled 5860 participants from 6 population groups (school-age children, nonpregnant nonlactating women of reproductive age, pregnant women, lactating women, 0-6-mo-old infants, and 7-24-mo-old infants) and assessed iodine status [urinary iodine concentration (UIC)] and thyroid function in Linfen, China (n = 2408), Tuguegarao, the Philippines (n = 2512), and Zagreb, Croatia (n = 940). We analyzed the iodine concentration in household salt, breast milk, drinking water, and cow's milk. Results: The salt iodine concentration was low (<15 mg/kg) in 2.7%, 33.6%, and 3.1%, adequate (15-40 mg/kg) in 96.3%, 48.4%, and 96.4%, and high (>40 mg/kg) in 1.0%, 18.0%, and 0.5% of household salt samples in Linfen (n = 402), Tuguegarao (n = 1003), and Zagreb (n = 195), respectively. The median UIC showed adequate iodine nutrition in all population groups, except for excessive iodine intake in school-age children in the Philippines and borderline low intake in pregnant women in Croatia. Conclusions: Salt iodization at ∼25 mg/kg that covers a high proportion of the total amount of salt consumed supplies sufficient dietary iodine to ensure adequate iodine nutrition in all population groups, although intakes may be borderline low during pregnancy. Large variations in salt iodine concentrations increase the risk for both low and high iodine intakes. Strict monitoring of the national salt iodization program is therefore essential for optimal iodine nutrition. This trial was registered at clinicaltrials.gov as NCT02196337.

Determinants of stunting reduction in Ethiopia 2000 - 2011.

The prevalence of stunting in Ethiopia declined from 57% in 2000 to 44% in 2011, yet the factors producing this change are not fully understood. Data on 23,999 children 0-59 months of age from three Demographic and Health Surveys (DHS) from 2000, 2005, and 2011 were analyzed to assess the trends in stunting prevalence, mean height-for-age z-scores (HAZ) and the associations between potential factors and HAZ. Associations were determined separately using three separate generalized linear models for children age less than 6 months, 6-23 months, and 24-59 months of age. Significant variables were then analyzed to determine if they showed an overall trend between the 2000 and 2011 surveys. In children < 6 months of age, only mother's height was both a significant predictor of HAZ and showed a progressive, albeit non-significant, increase from 2000 to 2011. In children 6-23 months of age, only mother's use of modern contraception showed substantial changes in a direction consistent with improving HAZ, but improvements in maternal nutrition status were observed from 2000 to 2005. For children 24-59 months of age a consistent and progressive change is seen in child's diarrhea, fever, mother's education, and the occurrence of open defecation. Our analysis demonstrated that factors associated with HAZ vary by child's age and the dominant livelihood practice in the community. Variables that could have contributed to the decline of stunting in Ethiopia in children less than 5 years of age include markers of child health, mother's nutritional status, mother's educational level, and environmental hygiene.

Performance of rapid test kits to assess household coverage of iodized salt.

OBJECTIVE: The main indicator adopted to track universal salt iodization has been the coverage of adequately iodized salt in households. Rapid test kits (RTK) have been included in household surveys to test the iodine content in salt. However, laboratory studies of their performance have concluded that RTK are reliable only to distinguish between the presence and absence of iodine in salt, but not to determine whether salt is adequately iodized. The aim of the current paper was to examine the performance of RTK under field conditions and to recommend their most appropriate use in household surveys. DESIGN: Standard performance characteristics of the ability of RTK to detect the iodine content in salt at 0 mg/kg (salt with no iodine), 5 mg/kg (salt with any added iodine) and 15 mg/kg ('adequately' iodized salt) were calculated. Our analysis employed the agreement rate (AR) as a preferred metric of RTK performance. Setting/Subjects Twenty-five data sets from eighteen population surveys which assessed household iodized salt by both the RTK and a quantitative method (i.e. titration or WYD Checker) were obtained from Asian (nineteen data sets), African (five) and European (one) countries. RESULTS: In detecting iodine in salt at 0 mg/kg, the RTK had an AR>90 % in eight of twenty-three surveys, while eight surveys had an AR90 %. CONCLUSIONS: The RTK is not suited for assessment of adequately iodized salt coverage. Quantitative assessment, such as by titration or WYD Checker, is necessary for estimates of adequately iodized salt coverage.

Thyroglobulin is a sensitive measure of both deficient and excess iodine intakes in children and indicates no adverse effects on thyroid function in the UIC range of 100-299 µg/L: a UNICEF/ICCIDD study group report.

CONTEXT: The median urinary iodine concentration (UIC) is a biomarker of iodine intake. According to the World Health Organization, a median UIC in the range 100-199 µg/L indicates adequate and 200-299 µg/L more than adequate intake. Thyroglobulin (Tg) may be a promising functional biomarker of both iodine deficiency and excess. OBJECTIVES: Using a standardized dried blood spots-Tg assay in children, we evaluated the Tg response to both low- and high-iodine intake and estimated the population cutoff point for iodine deficiency or excess. Also, we compared thyroid functions within the UIC ranges of 100-199 vs 200-299 µg/L. DESIGN AND SETTING: We conducted a cross-sectional study in primary schools in 12 countries. SUBJECTS: SUBJECTS were 6 to 12 years old (n = 2512). MAIN OUTCOME MEASURES: We measured UIC, TSH, total T4, Tg, and thyroid antibodies. RESULTS: Over a range of iodine intakes from severely deficient to excessive, Tg concentrations showed a clear U-shaped curve. Compared with iodine-sufficient children, there was a significantly higher prevalence of elevated Tg values in children with iodine deficiency (UIC <100 µg/L) and iodine excess (UIC >300 µg/L). There was no significant change in the prevalence of elevated Tg, TSH, T4, or thyroid antibodies comparing children within the UIC ranges of 100-199 vs 200-299 µg/L. CONCLUSIONS: In school-aged children, 1) Tg is a sensitive indicator of both low and excess iodine intake; 2) a median Tg of <13 µg/L and/or <3% of Tg values >40 µg/L indicates iodine sufficiency in the population; 3) the acceptable range of median UIC in monitoring iodized salt programs could be widened to a single category of sufficient iodine intake from 100 to 299 µg/L.

UNICEF-CDC global assessment of home fortification interventions 2011: current status, new directions, and implications for policy and programmatic guidance.

BACKGROUND: Micronutrient powders (MNP) reduce anemia and improve iron status in children aged 6 to 23 months. Little is known about home fortification interventions in low-income and middle-income countries. OBJECTIVE: To describe highlights of the Global Assessment of Home Fortification Interventions 2011, new directions, and needed policy and programmatic guidance. METHODS: A cross-sectional survey ofhomefortification interventions was conducted. Staff at UNICEF and regional focal points at Home Fortification Technical Advisory Group partner agencies sent questionnaires to representatives in 152 low-income and middle-income countries. Included interventions met the following criteria: they were for prevention and used MNP lipid-based nutrient supplements (LNS), or complementary food supplements (CFS); one recommended mode of use was mixing into food; they were implemented or planning to start within 12 months; and research interventions were directly linked to programs. RESULTS: This study identified 63 implemented interventions (36 countries) and 28 planned interventions (21 countries), including 34 implemented interventions (22 countries) and 25 planned interventions (20 countries) that used MNP These interventions were expected to reach 17.2 million people in 2011, including 14.1 million participants in MNP interventions. Among implemented interventions, 16% distributed nationally. Most interventions used integrated approaches targeting young children. Recently, there was increasing expansion of interventions in Africa. The main challenges identified were monitoring and evaluation, adherence, product funding, and procurement. CONCLUSIONS: Home fortification interventions, especially those that use MNP, are increasing and scaling up rapidly in regions with widespread problems of micronutrient deficiencies and stunting. Home fortification interventions contribute to global initiatives to reduce undernutrition.

Processed foods as an integral part of universal salt iodization programs: a review of global experience and analyses of Bangladesh and Pakistan.

BACKGROUND: Despite the reference to salt for food processing in the original definition of universal salt iodization (USI), national USI programs often do not explicitly address food industry salt. This may affect program impact and sustainability, given the increasing consumption of processed foods in developing countries. OBJECTIVE: To review experience of the use of iodized salt in the food industry globally, and analyze the market context in Bangladesh and Pakistan to test whether this experience may be applicable to inform improved national USI programming in developing countries. METHODS: A review of relevant international experience was undertaken. In Bangladesh and Pakistan, local rural market surveys were carried out. In Bangladesh, structured face-to-face interviews with bakers and indepth interviews with processed food wholesalers and retailers were conducted. In Pakistan, face-to-face structured interviews were conducted with food retailers and food labels were checked. RESULTS: Experience from industrialized countries reveals impact resulting from the use of iodized salt in the food industry. In Bangladesh and Pakistan, bread, biscuits, and snacks containing salt are increasingly available in rural areas. In Bangladesh, the majority of bakers surveyed claimed to use iodized salt. In Pakistan, 6 of 362 unique product labels listed iodized salt. CONCLUSIONS: Successful experience from developed countries needs to be adapted to the developing country context. The increasing availability of processed foods in rural Bangladesh and Pakistan provides an opportunity to increase iodine intake. However, the impact of this intervention remains to be quantified. To develop better national USI programs, further data are required on processed food consumption across population groups, iodine contents of food products, and the contribution of processed foods to iodine nutrition.

The process of setting micronutrient recommendations: a cross-European comparison of nutrition-related scientific advisory bodies.

OBJECTIVE: To examine the workings of the nutrition-related scientific advisory bodies in Europe, paying particular attention to the internal and external contexts within which they operate. DESIGN: Desk research based on two data collection strategies: a questionnaire completed by key informants in the field of micronutrient recommendations and a case study that focused on mandatory folic acid (FA) fortification. SETTING: Questionnaire-based data were collected across thirty-five European countries. The FA fortification case study was conducted in the UK, Norway, Denmark, Germany, Spain, Czech Republic and Hungary. RESULTS: Varied bodies are responsible for setting micronutrient recommendations, each with different statutory and legal models of operation. Transparency is highest where there are standing scientific advisory committees (SAC). Where the standing SAC is created, the range of expertise and the terms of reference for the SAC are determined by the government. Where there is no dedicated SAC, the impetus for the development of micronutrient recommendations and the associated policies comes from interested specialists in the area. This is typically linked with an ad hoc selection of a problem area to consider, lack of openness and transparency in the decisions and over-reliance on international recommendations. CONCLUSIONS: Even when there is consensus about the science behind micronutrient recommendations, there is a range of other influences that will affect decisions about the policy approaches to nutrition-related public health. This indicates the need to document the evidence that is drawn upon in the decisions about nutrition policy related to micronutrient intake.

Universal salt iodization in the Central and Eastern Europe, Commonwealth of Independent States (CEE/CIS) Region during the decade 2000-09: experiences, achievements, and lessons learned.

BACKGROUND: By 2000, the global track record on universal salt iodization (USI) indicated 26% access to adequately iodized salt in the Central and Eastern Europe, Commonwealth of Independent States (CEE/ CIS) Region. OBJECTIVE: Aimed at extracting lessons learned, this study examined experiences, achievements, and outcomes of USI strategies in CEE/CIS countries during the subsequent decade. METHODS: Information from the design, timing, execution, outputs, multi-sector management and results of actions by national stakeholders yielded 20 country summaries. Analysis across countries used a LogFrame Analysis typical for public nutrition development. RESULTS: By 2009, USI strategies had reached the target and population iodine nutrition shown adequate levels in 9 countries, while in 6 others, USI was close and/or population iodine status showed only minor imperfection. True USI, i.e., iodization of salt destined both for the food industry and the household, had been made mandatory in 13 of these 15 countries. In the Balkan area, USI and iodine nutrition advanced more than in CIS. Of the 20 sample countries, 17 (85%) had exceeded the mark of 50% adequate access, while the overall regional score reached 55% by 2010. CONCLUSIONS: Experience from this region suggests that strong partnership collaboration, a new concept in post-Soviet societies, was a major success factor. Voluntary iodization or focusing on household salt alone was less likely conducive for success. Achieving optimum iodine nutrition required the setting of proper iodine standard Weak political leadership insistence in the Russian Federation and Ukraine to embrace USI is the main factor why the region remains behind in the global progress.

The challenges of iodine supplementation: a public health programme perspective.

An adequate iodine intake during pregnancy, lactation and early childhood is particularly critical for optimal brain development of the foetus and of children 7-24 months of age. While the primary strategy for sustainable elimination of iodine deficiency remains universal salt iodisation, the World Health Organization and the United Nations Children's Fund recommend a complementary strategy of iodine supplements as a temporary measure when salt iodisation could not be implemented. This article aims to review current evidence on efficacy and implications of implementing iodine supplementation as a public health measure to address iodine deficiency. Iodine supplementation seems unlikely to reach high coverage in a rapid, equitable and sustained way. Implementing the programme requires political commitment, effective and efficient supply, distribution and targeting, continuous education and communication and a robust monitoring system. Thus, universal salt iodisation should remain the primary strategy to eliminate iodine deficiency.

Child nutrition in countries of the Commonwealth of Independent States: time to redirect strategies?

BACKGROUND: Countries in the Commonwealth of Independent States made little progress in child nutrition and mortality between 1990 and 2005. The present paper assesses the nutritional status of children <5 years of age and discusses possible strategies for improvement. METHODS: Data on low birth weight, infant and young child feeding, underweight, overweight and micronutrient deficiencies were compiled from available reports and databases, complemented through questionnaires to UNICEF Country Offices, and analysed by country, age, gender, urban/rural residence, maternal education and wealth quintiles. RESULTS: Exclusive breast-feeding in the first 6 months and continuing breast-feeding up to 2 years fall short of WHO and UNICEF recommendations. Complementary foods are introduced too early and may be poor in protein and micronutrients. Stunting and underweight are prevalent, especially in children aged 12 to 35 months; overweight is even more prevalent. Vitamin A and I deficiencies are still present in some countries, despite current control efforts. Anaemia ranges between 20 % and 40 %. Higher rates of malnutrition are found in rural areas, children of less educated mothers and lower-income families. DISCUSSION: Current public health strategies should be redirected to address: (i) overall protection, promotion and support of infant and young child feeding, in addition to breast-feeding; (ii) overweight, in addition to underweight and stunting; and (iii) malnutrition as a whole, in addition to micronutrient deficiencies. An equity lens should be used in developing policies and plans and implementing and monitoring programmes. Capacity building, cross-sectoral action, improved data collection within adequate legal frameworks and community engagement should be the pillars of redirected strategies.