Sustainable Elimination of
Iodine Deficiency (Disorders):
Perspective for
Central & Eastern Europe and Central
Asia
ARNOLD TIMMER,
UNICEF REGIONAL OFFICE
April 2004
Iodine Deficiency: The Problem
Cretinism
Goiter
At risk of
mental
Impairment
10-15% IQ loss
Endocrinology Center, Moscow, 2002
Iodine Deficiency Lowers IQ (10-15%)
and Productivity
The network of connections are less dense
Iodine Sufficient Brain
Iodine Deficient Brain
Source: From Legrand, 1967.
IDD … A Reminder
• From affected individuals to deficient
populations: iodine deficiency affects the
whole population
• Iodine = mental performance intelligence
• Iodine deficiency decreases IQ of newborns
by 10-15 % of ALL individuals and all
population groups
• In an iodine deficient population, goiter,
cretinism, and mental or cognitive deficits
coexist
IDD … A Challenge
IDD is a medical problem and should be
solved by public health sector
versus
IDD is a nutritional problem and requires
involvement of food sector
Prevention of iodine deficiency
versus
Ensuring adequate iodine nutrition
41 million newborns still unprotected:
113.000 per day!
Middle East/
North Africa
Latin America/
Caribbean
2 million
3 million
South Asia
17 million
CEE/CIS
4 million
East Asia/
Pacific
7 million
Sub-Saharan
Africa
8 million
Newborns unprotected against loss
of IQ due to iodine deficiency
•
•
•
•
Moldova: 67% unprotected or 26,000
Georgia: 33% unprotected or 15,000
Ukraine: 70% unprotected or 263,000
Kosovo: 16% unprotected or …
• CEE/CIS Region: 52% unprotected or
2.6 million
From the individual …
population
to the
A Public Health Problem
that Affects the Whole
Population requires a
Solution that reaches the
Whole Population!
Impact of Iodine Deficiency on
the Nation
• Health care cost for treatment of thyroid
diagnosis and treatment:
– Germany: 700 million Euro per year
• Newborns with lower IQ is a loss of
future productivity for the country:
– Russia: 600,000 newborns unprotected:
1.4 billion US$ over next 5 years
Iodine Deficiency - The Solution
Universal Salt Iodization
Why Salt?
• Possible: technologically easy to add
iodine to salt
• Cheap: 0.02 US$ per person per year
• Safe: salt consumption 5-15 gr/day;
iodine added does not exceed
maximum limit and is still enough to
meet daily requirement
• Available to all: salt is everywhere
• Affordable for all: salt is cheap
Types of salt
• Human:
– Table (used at home for cooking and home-based
food processing)
– Food grade (used by food processing industry)
• Animal
• Technical (all salt not used for consumption:
de-icing roads, tanning,..)
• Minimum to eliminate IDD:
– Table + food grade (minimum: few staple foods
like bread, pasta)
• Ideal:
– Table + Food + Animal
IDD Elimination through USI
Goal: sustainable elimination of ID by
2005
Strategy: Universal Salt Iodization (USI)
Key issues:
– Smart start for next generation
– Iodine needs to be provided to the entire
population regularly and forever
– USI: 90% of households use iodized salt (IS)
– All salt for human and animal consumption
– Not to increase salt use but to use iodized salt
The Agreement:
IDD Elimination through USI
• Special Session January 1994: Joint
UNICEF-WHO Committee on Health
Policy
• UN Special Session on Children 2002
-A World Fit for ChildrenYour governments signed the goal to
eliminate IDD by 2005!
79 million newborns protected
from losses in learning ability in
the developing world
Source: SOWC 2004
Household use of iodized salt (by
UNICEF region - 2003)
CEE/CIS
39
South Asia
49
Middle East/North Africa
51
Sub-Saharan Africa
66
Latin America/Caribbean
84
China
93
East Asia/Pacific (w ithout China)
53
East Asia/Pacific
82
Developing countries
66
World
66
0
20
40
60
80
100
Household levels of iodized
salt consumption (as of 2001)
100
Macedonia
Turkmenistan
90
Croatia
90
Yugoslavia
73
Armenia
84
56
Albania
41
Azerbaijan
37
Belarus
Moldova
33
Kyrgyzstan
27
Tajikistan
20
Kazakhstan
20
19
Uzbekistan
Georgia
8
Ukraine
5
0
20
40
(countries for which data are available)
Source: UNICEF MICS/DHS surveys
60
80
100
120
Production of Iodized Salt
(unofficial data)
100
90
80
70
60
50
40
30
20
10
Uk
ra
in
e
Ru
ssi
Uz
a
be
ki
sta
n
Be
lar
us
M
ol
Ka dova
za
kh
sta
n
Ar
m
en
i
Ge a
or
Ta gia
jik
Tu
ist
an
rk
m
en
ist
an
0
IS production in 1999
or 2000, % of total
IS production in 2001
or 2002, % of total
Realizing USI
Phases:
1. Building commitment among partners,
creating alliances, USI legislation
development
2. Increasing iodized salt supply
(production/import) and supporting
activities
3. Fine-tuning of the programme, assessing
impact, focus on sustainability
Iodized Salt:
From the
Law to the Table
Government Legislation
Enforcement of Laws
Production of IS
The Black
Market
Uniodized
Salt
The Market
The Household
Adequate iodine nutrition
Programme Cycle
ASSESSMENT
of the problem & means
for resolution
ACTION
ANALYSIS
Based on the analysis &
available resources
of the cause of the
problem
Action Components
Communication and
Advocacy
Interventions
Monitoring and
Evaluation
Management, Training, Technical support, Capacity
development
The Main Components of a
National Iodine Nutrition
Programme
Communications
IDD
• High-level Advocacy
• Mobilization
• Consumer Education
Salt Iodization
• Production & Quality Assurance
Monitoring
• Packaging & labeling
• Legislation/Regulation • Marketing
• Standards & Inspection • Retailing
• Manufacturing Practice • Pricing
• Impact Assessments
• Reporting
Slide courtesy of Emory University
Production
Policy
Universal Salt
Iodization
Impact
Role of Communication
• Difficult to convince behavior
• Different scenarios:
– legislation (+)
– legislation (+)
– legislation (-)
enforcement (+)
enforcement (-)
enforcement (-)
• Purpose short term is to increase immediate
use:
– Mass media campaign
– Package and shops
• Purpose long term is to sustain basic level of
awareness:
– Curriculum in schools
– Package
Iodized Salt:
From the
Law to the Table
Government Legislation
Enforcement of Laws
Production of IS
The Black
Market
Uniodized
Salt
The Market
Supportive Environment
•Advocacy for USI legislation
Creation of IDD coalitions and
monitoring bodies
Engagement of IS producers in
advocacy and IS agenda
Increasing ImmediateUse
IS marketing to consumers
Branding and packaging with IS
producers
Point of sale promotion
Ensuring Sustained Use
IS promotion by medical
professionals
IDD education and IS promotion
in schools and civil society groups
Engaging private sector salt
production in marketing
The Household
Adequate iodine nutrition
Production/Importation
Quality assurance
Packaging/labeling
Legislation/Regulation
Price
Monitoring
Awareness
Logo/
product recognition
Behavior change
Coverage
Ensuring
Adequate
Supply
Program Management
Policy/Advocacy
Ensuring
Awareness and
Use
Universal Salt
Iodization
Impact
Assessment