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GLOBAL ENDOCRINOLOGY: Global perspectives in endocrinology: coverage of iodized salt programs and iodine status in 2020.

Iodine deficiency has multiple adverse effects on growth and development. Diets in many countries cannot provide adequate iodine without iodine fortification of salt. In 2020, 124 countries have legislation for mandatory salt iodization and 21 have legislation allowing voluntary iodization. As a result, 88% of the global population uses iodized salt. For population surveys, the urinary iodine concentration (UIC) should be measured and expressed as the median, in µg/L. The quality of available survey data is high: UIC surveys have been done in 152 out of 194 countries in the past 15 years; in 132 countries, the studies were nationally representative. The number of countries with adequate iodine intake has nearly doubled from 67 in 2003 to 118 in 2020. However, 21 countries remain deficient, while 13 countries have excessive intakes, either due to excess groundwater iodine, or over-iodized salt. Iodine programs are reaching the poorest of the poor: of the 15 poorest countries in the world, 10 are iodine sufficient and only 3 (Burundi, Mozambique and Madagascar) remain mild-to-moderately deficient. Nigeria and India have unstable food systems and millions of malnourished children, but both are iodine-sufficient and population coverage with iodized salt is a remarkable 93% in both. Once entrenched, iodine programs are often surprisingly durable even during national crises, for example, war-torn Afghanistan and Yemen are iodine-sufficient. However, the equity of iodized salt programs within countries remains an important issue. In summary, continued support of iodine programs is needed to sustain these remarkable global achievements, and to reach the remaining iodine-deficient countries.

What is the availability of iodised salt in supermarkets on the Island of Ireland?

Iodine deficiency remains a global nutritional public health challenge, with evidence suggesting borderline adequate or even deficient status for UK and Irish subpopulations such as schoolgirls and pregnant women. The solution, according to the WHO, is salt iodisation, but it is not known how widely available iodised salt is in supermarkets. Iodised salt availability was determined by a shelf survey of 89 supermarket stores on the island of Ireland (n = 30 in Northern Ireland and n = 59 in the Republic of Ireland) from September 2018 to January 2019, to take into account factors such as store type, location, population density, socioeconomic status and ethnicity. Availability was calculated as the number of stores selling iodised salt as a percentage of the total. Iodised salt was only available in 11 stores (12%), of which 10 were ethnic stores. This indicates a lack of access for the majority of the Irish and Northern Irish populations.

The Science of Salt: A global review on changes in sodium levels in foods.

This review aims to summarize and synthesize studies reporting on changes in sodium levels in packaged food products, restaurant foods, and hospital or school meals, as a result of salt reduction interventions. Studies were extracted from those published in the Science of Salt Weekly between June 2013 and February 2018. Twenty-four studies were identified: 17 assessed the changes in packaged foods, four in restaurant foods, two in hospital or school meals, and one in both packaged and restaurant foods. Three types of interventions were evaluated as part of the studies: voluntary reductions (including targets), labeling, and interventions in institutional settings. Decreases in sodium were observed in all studies (n = 8) that included the same packaged foods matched at two time points, and in the studies carried out in hospitals and schools. However, there was little to no change in mean sodium levels in restaurant foods. The pooled analysis of change in sodium levels in packaged foods showed a decrease in sodium in unmatched food products (-36 mg/100 g, 95% CI -51 to -20 mg/100 g) and in five food categories-breakfast cereals, breads, processed meats, crisps and snacks, and soups. Twenty-two of the 24 studies were from high-income countries, limiting the applicability of the findings to lower resource settings.

Medico-social effectiveness of biological monitoring of iodine deficiency status (IDS) among women of reproductive age in Kazakhstan.

INTRODUCTION: Iodine deficiency is one of the most important public health problems in the world. It mostly affects pregnant women and children. The lack of iodine leads to an increase in the numbers of perinatal mortality and mental retardation. MATERIAL AND METHODS: In 2012-2014, a survey was carried out of 2,342 women, of whom 2284 were analyzed for salt to measure the content of iodine, and 2,242 women of reproductive age had their urine samples analyzed by the cerium-arsenite method based on the Sandell-Kolthoff reaction. Determination of the medical and social effectiveness of biological monitoring of IDS was carried out in 3 stages. RESULTS: The study revealed that in the eastern Kazakhstan region the relative risk (RR) of overall prevalence of iodine deficiency among women was 1.1 times higher (95% ID: 0.35-3.61; Z statistic = 0.192) among household respondents (≤15mkg/kg). In the Pavlodar region, the RR of the prevalence of total iodine deficiency is 0.5 times higher in households where the salt was not sufficiently iodized. In the Zhambyl region the RR of the iodine deficiency prevalence was about twice as high due to insufficient iodized salt. CONCLUSIONS: The introduction of biological monitoring of IDS among women, especially pregnant women, may positively affect the detection of the risk limits for the birth of infants with reduced mental abilities or other diseases during pregnancy, using timely targeted preventive measures to exclude factors that affect the spread of IDS.

Factors associated with the availability of iodized salt at household level: a case study in Bangladesh.

OBJECTIVE: The availability of iodized salt in households remains low in Bangladesh, which calls for improving the salt iodization quality and its coverage. The present study assessed the socio-economic disparity in Bangladesh to characterize the availability of iodized salt at household level. DESIGN: Associations between different socio-economic factors and availability of iodized salt at household level were explored using Bayesian mixed-effects logistic models after adjusting the district- and cluster-level random effects. SETTING: Bangladesh Multiple Indicator Cluster Survey (MICS), 2012-13.ParticipantsHouseholds (sample size, n 50981). RESULTS: Results showed that 73·15 % of household salt samples were iodized to some extent although iodization level varied. According to the regression model, houses with young (adjusted odds ratio of posterior mean (OR) = 1·31; 95 % credible interval (CI) 1·09, 1·64) and educated (OR = 3·66; 95 % CI 3·25, 4·23) household heads had significantly higher likelihood of availability of iodized salt. In addition, iodized salt was less likely be found in poor and rural households, as urban households were 2·88 times (95 % CI 2·41, 3·34) more likely have iodized salt. Moreover, the regional locations of the households were an important component that contributed to the local iodized salt coverage. As per the district-wise distribution, the north-west part of Bangladesh and Cox's Bazar in the far south seemed to lack household-level iodized salt. CONCLUSIONS: Our findings suggest that iodized salt intervention should be promoted considering the area variations, which could potentially help policy makers to design interventions in the context of Bangladesh.

Pensions and Low Sodium Salt: A Qualitative Evaluation of a New Strategy for Managing Hypertension in Rural South Africa.

BACKGROUND: This paper describes a pilot study to assess the feasibility of a novel intervention to improve the management of hypertension among older people in rural South Africa. Older South Africans have the highest rates of uncontrolled hypertension recorded for any country. Notably, South Africa has a widely-available old age grant (pension), which is delivered on a monthly basis to citizens living in rural villages. METHODS: We assessed the feasibility of engaging with older people at the point of pension delivery in the Agincourt sub-district of Mpumalanga Province. This included providing information about hypertension, measuring blood pressure, referral to primary care services, and providing a monthly supply of low sodium salt. We recruited 20 people aged 60 and over to participate in the pilot intervention, which was conducted over three months in two villages. Towards the end of the intervention, we conducted focus groups with study participants and held a meeting with local stakeholders, including the district health office and the state social security agency. RESULTS: The pilot study demonstrated (i) Sustained engagement with the original 20 participants. Of these, 19 continued to participate in the intervention during subsequent monthly pension days. (ii) A high level of acceptance of the low sodium salt product reflected in repeat usage and comments made in the focus groups. (iii) Strong support for the intervention and a willingness to collaborate with local stakeholders. (iv) A perception among participants that symptoms they associated with hypertension had abated. This is supported by blood pressure readings made over the three months of follow-up. CONCLUSION: Though limited in scope, this pilot study provided evidence of the feasibility of the intervention and justification for it to be tested on a larger and more robust basis.

Potassium iodate levels in processed edible salts available in retail shops throughout Kenya, 2013.

OBJECTIVE: Iodine-deficiency disorders, due to insufficiency of iodine in the diet, are a global public health problem. The Kenyan Food, Drugs and Chemical Substances Act stipulates that processed retail-available edible salts contain 50-84 mg of potassium iodate (KIO3) per kilogram of salt. The present study determined the status of KIO3 levels in commercial salts, for public health action.Design/Setting/SubjectsAs part of the Kenya Demographic and Health Survey 2013, field workers collected salt samples from seven different local manufacturers/packers across eight regions of the country and sent them to the National Public Health Laboratory (NPHL) for KIO3 titration analysis. RESULTS: A total of 539 samples were collected and analysed at NPHL. The samples had a mean KIO3 of 62 mg/kg. Thirty-three (6 %) samples had KIO3 of 84 mg/kg. CONCLUSIONS: The study found that 62 % of salts sampled met the Kenyan standards, 24 % were below the required limits and 13 % were above the recommended range. Continuous monitoring of edible salts at the retail level is important to detect brands not adhering to standards and trace them for remedy. However, governmental efforts should be directed to the quality control and quality assurance of the salt-manufacturing industries.

The Science of Salt: A regularly updated systematic review of the implementation of salt reduction interventions (September 2016-February 2017).

This periodic review aims to identify, summarize, and appraise studies relating to the implementation of salt reduction strategies that were published between September 2016 and February 2017. A total of 41 studies were included as relevant to the design, assessment, and implementation of salt reduction strategies, and a detailed appraisal was conducted on the seven studies that evaluated the impact of salt reduction strategies. Of these, three were national studies or included large populations and four were conducted in communities with small participant sample sizes. Each study used a different strategy for reducing salt intake varying from category-specific sodium targets for packaged food to use of a low-sodium salt substitute to behavior change interventions. Four studies found statistically significant decreases in dietary salt intake and one study showed statistically significant decreases in mean sodium density of packaged food products. Four of the seven studies used either spot or 24-hour urine samples to measure dietary salt intake and five were conducted in East or Southeast Asia-two of which were in low- and middle-income countries. Study quality varied among the seven studies and all except one had one or more risks related to bias.

Interannual study of spot urine-evaluated sodium excretion in young Japanese women.

The authors investigated interannual differences in the sodium excretion levels of young healthy Japanese women as estimated from spot urine analysis at Nakamura Gakuen University from 1995 to 2015. Participants included 4931 women aged 18 to 20 years who were classified into three time periods according to year of health check: first (1995-2001), second (2002-2007), and third (2008-2015). Estimated daily urinary sodium and potassium excretion levels and the sodium to potassium ratio were 120.6±31.9 mmol, 35.2±8.1 mmol, and 3.5±0.9, respectively. Adjusted for body weight, sodium excretion, and potassium excretion significantly decreased in the second and third period compared with the first period (P<.001). Systolic blood pressure also decreased in the same way between time periods (P<.001). Estimated urinary excretion levels of sodium and potassium in young Japanese women have decreased over the past 20 years independently of body weight.

The Science of Salt: A regularly updated systematic review of the implementation of salt reduction interventions (March-August 2016).

This review aims to identify, summarize, and appraise studies reporting on the implementation of salt reduction interventions that were published between March and August 2016. Overall, 40 studies were included: four studies evaluated the impact of salt reduction interventions, while 36 studies were identified as relevant to the design, assessment, and implementation of salt reduction strategies. Detailed appraisal and commentary were undertaken on the four studies that measured the impact of the interventions. Among them, different evaluation approaches were adopted; however, all demonstrated positive health outcomes relating to dietary salt reduction. Three of the four studies measured sodium in breads and provided consistent evidence that sodium reduction in breads is feasible and different intervention options are available. None of the studies were conducted in low- or lower middle-income countries, which stresses the need for more resources and research support for the implementation of salt reduction interventions in these countries.

Historical aspects of iodine deficiency control.

In 1895, iodine was characterized as an essential element of thyroid tissue by Baumann. The efficacy of iodine to prevent goiter was demonstrated by Marine in Northern USA in 1916-1920. Severe endemic goiter and cretinism had been almost entirely eliminated from continental Western Europe and Northern America before the 1930's; however large populations elsewhere and even some places in Western Europe (Sicily) were still affected up to the 2000's. Public health consequences of iodine deficiency are not limited to endemic goiter and cretinism. Iodine deficiency disorders include also increased neonatal death rate and decreased intellectual development, although these consequences are not included in the current estimation of the Global Burden Disease related to iodine deficiency. Severe iodine deficiency as a public health problem is now largely under control worldwide, but can still affect isolated places, in hard-to-reach and/or politically neglected populations. We emphasize the importance of maintaining international cooperation efforts, in order to monitor iodine status where iodine deficiency is now adequately controlled, and identify at-risk population where it is not. The goal should be now global eradication of severe iodine deficiency. Commercial distribution of iodized salt remains the most appropriate strategy. A randomized clinical trial in New Guinea clearly showed in the 1970's that correcting severe iodine deficiency early in pregnancy prevents endemic neurological cretinism. This supports the essential role of thyroid hormones of maternal origin on the normal fetal development, during the first trimester of pregnancy (i.e. when fetal thyroid is still not functional). A randomized clinical trial in Congo (RD) in the 1970's also showed that correcting severe iodine deficiency during pregnancy prevents myxœdematous cretinism, particularly prevalent in affected Congolese areas.

The way forward in Italy for iodine.

Italy is dealing with iodine deficiency since ancient times. In 1848 an ad hoc committee appointed by the king of Sardinia, identified extensive areas afflicted by endemic goiter and endemic cretinism in Piedmont, Liguria and Sardinia. Since then many epidemiological studies have been conducted in our country. These showed that iodine deficiency was present not only in mountain areas but also in coastal areas. In 1972 the iodization of salt at 15 mg/kg was allowed by law and iodized salt was distributed on request to selected endemic areas. Five years later the distribution was extended to the whole country. However the sale of iodized salt was not mandatory at that time and only a small fraction of the Italian population started using iodized salt. In 1991 the content of iodine in the salt was raised to 30 mg/kg and in 2005 a nationwide salt iodization program was finally implemented. Some years later a nationwide monitoring program of iodine prophylaxis was also implemented. Since 2005 the sale of iodized salt in Italian supermarkets has increased (34% in 2006, 55% in 2012), although it has been observed that the use of iodized salt is still low in the communal eating areas and in the food industry. These data are coherent with recent epidemiological studies showing that some regions in our country are still characterized by mild iodine deficiency and a high frequency of goiter and other iodine deficiency disorders. This implies that further efforts should be made to successfully correct iodine deficiency in Italy.

Access to iodized salt in 11 low- and lower-middle-income countries: 2000 and 2010.

OBJECTIVE: To describe changes in household access to iodized salt in relation to socioeconomic factors. METHODS: We extracted data on iodized household salt from Multiple Indicator Cluster Surveys conducted in 2000 and 2010. As part of the surveys, household salt samples were tested for iodization by standardized rapid-test kits that yield results to indicate whether salt is not iodized, inadequately iodized, (less than 15 parts per million, ppm), or adequately iodized (more than 15 ppm). We calculated indices of household salt iodization in 2000 and 2010, taking into account survey sampling weights. We explored associations between these indices and socioeconomic variables, both within and between countries. FINDINGS: We analysed data from 105 162 households in 2000 and 144 018 households in 2010. Between 2000 and 2010, household coverage of adequately iodized salt increased by 6.1% (from 46.3% to 52.4%) on average, but with regional differences: coverage fell by 13.0% (from 77.5% to 64.5%) in the Central African Republic but improved by 40.4% (from 22.2% to 62.6%) in Sierra Leone. Improvements in coverage were higher in rural areas and among the poorest households, but within-country socioeconomic disparities remained. There were weak associations between changes in salt iodization and national level socioeconomic indicators. CONCLUSION: Overall, the coverage of adequately iodized household salt increased over the last decade. However, the changes varied widely among countries. The goal of universal salt iodization is still distant for many countries and requires renewed efforts by governments, bilateral and multilateral agencies and civil society.

Protocol for a cluster-randomised trial to determine the effects of advocacy actions on the salt content of processed foods.

BACKGROUND: Corporate decisions affecting the composition of processed foods are a potent factor shaping the nutritional quality of the food supply. The addition of large quantities of salt to foods is incompatible with Australian Dietary Guidelines and the reformulation of processed foods to have less salt is a focus of non-governmental organisations (NGOs). There is evidence that advocacy can influence corporate behaviour but there are few data to define the effects of NGOs working in the food space. The aim of this study is to quantify the effects of advocacy delivered by a local NGO on the salt content of food products produced or marketed by companies in Australia. METHODS/DESIGN: This is a cluster-randomised controlled trial that will be done in Australia from 2013 to 2015 which includes 45 food companies. The 23 companies in the control group will receive no specific intervention whilst the 22 companies in the intervention group will receive an advocacy program based upon an established theory of change model. The primary outcome will be the mean change in sodium content (mg/100 g) of processed foods produced or marketed by intervention compared to control companies assessed at 24 months. Interim outcomes (statements of support, published nutrition policies, level of engagement, knowledge and use of technology to reduce salt, salt reduction plans, and support for national initiatives) will also be assessed and a qualitative evaluation will provide more detailed insight. DISCUSSION: This novel study will provide robust randomised evidence about the effects of advocacy on food company behaviour and the quality of the processed food supply. A finding of improved food company behaviour will highlight the potential for greater investment in advocacy whilst the opposite result will reinforce the importance of government-led initiatives for the improvement of the food supply. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02373423. 26/02/2015.

Availability of iodised table salt in the UK - is it likely to influence population iodine intake?

OBJECTIVE: Iodine deficiency has recently been found in UK young and pregnant women, which is of concern given the importance of adequate iodine intake in pregnancy for fetal brain development. The WHO recommends that iodine deficiency in a population should be corrected through salt iodisation but there is a lack of UK data on iodised-salt availability, a situation that the present study aimed to address. DESIGN: Availability of iodised salt for household use was determined by a shelf survey in five supermarket chains in each of sixteen UK areas (in Southern England, Wales and Northern Ireland) encompassing a total of seventy-seven supermarkets. All branches of a sixth supermarket chain that had 2·3% of the market share sold exclusively iodised salt. Weighted iodised-salt availability was calculated taking the market share of supermarkets into account. SETTING: The UK. SUBJECTS: Not applicable. RESULTS: Iodised salt was available in thirty-two of the seventy-seven supermarkets (41·6%). After accounting for market share and including all six UK supermarket chains, the weighted availability of iodised salt was 21·5%. The iodine concentration of the major UK brand of iodised salt is low, at 11·5 mg/kg. CONCLUSIONS: In contrast to other countries, iodised household table salt is unlikely to contribute meaningful amounts to UK iodine intake as (i) availability is low, (ii) table salt is only a small percentage of total UK salt intake and (iii) UK public-health campaigns have encouraged reduced salt consumption. As iodine intake in the UK is dependent entirely on food choices, regular monitoring of iodine status is essential.

Evolution of iodine deficiency disorders control program in India: a journey of 5,000 years.

Iodine deficiency disorders (IDD) has been documented since around 5,000 years. However, geological factors like frequent glaciations, flooding, and changing of course of rivers has led to iodine deficiency in soil. As a result everyone remains at risk of IDD, if optimum intake of iodine is not sustained. Evolution of the IDD control program in India has been a dynamic process. The model of IDD control program in India provides important lessons for successful implementation of a national health program. In formulating National Health Programs; policy environment, scientific inputs, political will, and institutional structure for decision making are necessary but not sufficient. Continuous and dynamic generation of reliable and representative state and national level data, proactive recognition of values of key stakeholders and addressing them through sustained advocacy, development of partnerships among stakeholders, institutional continuity, and mentorship are critical for achieving sustainability of results.

Reaching the poor with adequately iodized salt through the Supplementary Nutrition Programme and Midday Meal Scheme in Madhya Pradesh, India.

PROBLEM: In India, adequately iodized salt needs to be made accessible to the most marginalized. APPROACH: In an effort to provide adequately iodized salt to the most vulnerable, in 2009 Madhya Pradesh launched a state-wide initiative through two national flagship nutrition programmes: the Supplementary Nutrition Programme of the Integrated Child Development Services and the Midday Meal Scheme. Programme staff members were taught how to correctly store salt and monitor its iodine content. Field monitors assessed the iodine content of the salt in the common kitchens of participating schools and anganwadi centres monthly. LOCAL SETTING: Madhya Pradesh, a state in central India, is home to a substantial proportion of India's poor. In 2009, household coverage of adequately iodized salt in the state was nearly 90% among the richest but only about 50% among the poorest. RELEVANT CHANGES: Two hot meals prepared with adequately iodized salt were served daily for more than 21 days per month to approximately 89% of the 12,113,584 children aged 3 to 6 years enrolled in anganwadi centres (June 2011 to March 2012). One meal on school days was served to 78% of 5,751,979 primary-school children and to 79% of 2,704,692 secondary-school children (April 2011 to March 2012). Most of the kitchens visited in 2010 (79%) and 2011 (83%) were consistently using adequately iodized salt to prepare hot meals. LESSONS LEARNT: India has large-scale social safety net programmes for the poorest. Both national and state policies should mainstream the use of adequately iodized salt in these programmes.

Increase in iodine deficiency disorder due to inadequate sustainability of supply of iodized salt in District Solan, Himachal Pradesh.

Himachal Pradesh is a known endemic area for iodine deficiency disorders. A study was conducted in district Solan with the objective of assessing the prevalence of iodine deficiency disorders in school-age children. Thirty clusters were selected by using the probability-proportionate-to-size cluster sampling methodology. Clinical examination of the thyroid of 1898 children in the age-group of 6-12 years was conducted. Urine and salt samples were collected. The total goiter rate was found to be 15.4%. Median urinary iodine excretion level was 62.5 µg/l. Only 39% of the salt samples had iodine content of ≥15 ppm. Mild iodine deficiency was present in the subjects studied.