Harold Alderman of the World Bank estimates the payback for investments in iodizing salt to return between $12 and $30 for every dollar invested. The study was just published in the Journal of Developmental Origins of Health and Disease . Iodizing salt was judged superior to supplementing vitamin A and zinc, doing general community nutrition education or doing iron fortification.

Alderman laments the fact that "economic investments often fail to follow from evidence...Quite possibly economists believe that rapid economic growth will, by itself, will eliminate undernutrition. If so, they are mistaken in that belief." Growth, he documents has only a "modest impact."

Investment patterns are politically-determined and over-invest in HIV/AIDS and injuries "while non-communicable disease as well as maternal and perinatal health and nutrition along with non HIV/AIDS communicable diseases receive less than they should according to calculated health benefits.

India is the country with the world's largest population of newborns who are unprotected by iodized salt from the mental impairment caused by Iodine Deficiency Disorders. At the India-International Salt Summit 2010, I was invited to share my views on whether there is any conflict between government advocacy of salt reduction and its pursuit of universal salt iodization.

Short answer: no conflict at all. As I told the international delegates (pdf 75.57 kB) :

Two public health challenges inhere in dietary salt, both with major public health implications. First, conclusive research, broad experience and consensus organizational endorsement support fortification of salt with potassium iodate or potassium iodide to protect against Iodine Deficiency Disorders. Second, inconsistent research, ineffective experience, yet broad endorsements have mired implementation of advisories for population salt intake reduction intended to improve human cardiovascular health outcomes.

I noted a series of efforts by salt reduction activists questioning whether portraying salt as a public health benefactor and the fact that the issue has been dismissed whenever it has been raised, adding:

Let’s hope this is the end of this false “debate.” We need to unite and put our energies into achieving universal salt iodization. We cannot be distracted by those who would blame their lack of success reducing dietary salt on our achievements in advancing salt iodization.

If salt reductionists want to argue in favor of reducing overall salt intakes, we should make them offer evidence, not excuses. We should remind them that while the hypothesized benefits of salt reduction may fuel contentious debate, there is global consensus that salt iodization is the most cost-effective and sustainable strategy to prevent iodine deficiency disorders. It is imperative that we promote iodized salt to help every expectant mother enjoy optimal iodine nutrition and every child be born protected from iodine deficiency. Optimal iodine nutrition will protect the entire population from the loss of intellectual and physical resources through this easily preventable cause of mental retardation.

At a Washington, D.C. panel hosted by the Pan American Health Organization (PAHO) November 3rd, panelists representing the International Council for the Control of Iodine Deficiency Disorders (ICCIDD), US Agency for International Development (US AID), Health Canada, PAHO, US Food and Drug Administration (FDA) and the International Life Sciences Institute (ILSI) affirmed unanimously that there is no conflict between the global campaign to iodize salt and efforts in many countries to moderate salt intake levels.

Representing ICCIDD Americas Regional Coordinator Eduardo Pretell, former minister of health from Peru, explained that as salt intake levels may vary, or as the iodine contribution of iodized salt changes within the overall diet, salt iodization programs have proved they can simply and easily adjust the level of iodine fortification. He emphasized the necessity of systematic monitoring of iodine sufficiency either through measuring the household use of iodized salt or, better, through regular population surveys of urinary iodine excretion.

Pretell also pointed out that there is no evidence that countries which iodize salt consume different amounts of salt from those that have inadequate iodization, nor has salt consumption changed when a country achieves salt iodization. He emphasized that special care must be taken to ensure adequate iodine intakes for pregnant and lactating women and educational efforts directed to these groups urging use of iodized salt as part of any population salt reduction effort.

He reminded the group that iodine deficiency is a perpetual threat for persons living in areas with iodine-deficient soils and that, for those areas, universal salt iodization is the consensus strategy to improve iodine nutrition because fortifying salt with iodine is the easiest and least expensive option.

Pretell’s comments were amplified by Dr. Omar Dary from US AID who spoke generally on micronutrient fortification, but chose virtually all his examples from salt iodization initiatives. Dary explained that salt is the ideal carrier for iodine and other vital nutrients because its intake is consistent and predictable. He warned that the U.S. is at risk of iodine deficiency, urged American food processors to use iodized salt and reiterated Dr. Pretell’s insistence that monitoring is the key to success in salt iodization.

The importance of Dr. Dary’s advocacy for food processors to use iodized salt was brought home by Dr. Eric Hentges, president of ILSI, who presented new data confirming that, in the U.S., about three-fourths of salt is consumed as part of processed foods (none of which is iodized).

The other speakers confined their remarks to advocacy of salt reduction, but all affirmed the importance of successful salt iodization.

The UN Development Program (UNDP) recently published its fifth Arab Human Development Report reviewing the state of affairs in the Arab world. Recently returned from a global meeting on salt iodization in Cairo, I eagerly plumbed the report, particularly Chapter 6 which described nutrition challenges. In that discussion, I found the pattern of the entire report -- and, I hope, a lesson for the rest of the world about the value of competitive ideas.

Chapter 6 on nutrition references iodine deficiency, but fails to make the iodine/brain development connection. It says lack of iodine and other vital nutrients "weaken children's bodies and impair their immune systems" and "reduces productivity." A missed opportunity.

The "missed opportunity" theme pervades the report. Fouad Ajami , professor at the School of Advanced International Studies at Johns Hopkins University, calls the report an "autopsy of the Arab condition," adding:

The first of these reports, published in 2002, was treated with deference. A group of Arab truth-tellers, it was believed, had broken with the evasions and the apologetics to tell of the sordid condition of Arab society—the autocratic political culture, the economic stagnation, the cultural decay. So all Arabs combined had a smaller manufacturing capacity than Finland with its five million people, and a vast Arabic-speaking world translated into Arabic a fifth of the foreign books that Greece with its 11 million people translates. With all the oil in the region, tens of millions of Arabs were living below the poverty line. Little has altered in the years separating the first of these reports from the most recent.

Ajami commends Iranians contesting the announced results of that country's recent presidential election. He would probably find joy in the purple-inked fingers of Iraqi voters as well. But he condemns (democratic, surely, not Islamist) activists in other countries for the ineffective opposition to authority. The lessons he draws are about truth-telling and free public discourse. While lamenting that the powers-that-be have eradicated dissent, he goes one step further, which struck me as instructive in our public health nutrition debate elsewhere in the world, particularly in the US and the UK. He declared:

The simple truth is that the Arab world has terrible rulers and worse oppositionists.

Let me use the contentious salt and health debate to illustrate this transference. In our instant debate, there are those who contend that because salt is related to blood pressure (lowering salt will reduce the blood pressure of some -- and more than the number for whom low-salt diets increase BP) and because populations with lower BP have lower risk of cardiovascular events like heart attacks and strokes, that this "proves" the efficacy of universal salt reduction. Opponents of a population intervention argue that studies of heart attack rates and cardiovascular mortality don't show those on low-salt diets fare better -- often they are placed at additional risk. Moreover, no amount of behavior modification has worked and the latest strategy, coercing the food industry into lowering the sodium density of its products, is untested and flies in the face of research showing that the unconscious brain sets the appetite for sodium.

The "rulers" here embrace the "sodium hypothesis" and endorse sodium reduction. Unfortunately, like the entrenched rulers of the Middle East, they are trying to stifle dissent and deny the legitimacy of the scientific debate. No matter that a recent presidential address to the International Society of Hypertension described the fundamentally-flawed basis for U.S. policy. No matter that the prestigious Cochrane Collaboration , inventors of "evidence-based medicine" finds no basis for the U.S. policy. No matter, even, that the government's own U.S. Preventive Services Task Force agrees that no evidence supports the strategy, the "rulers" press forward. In this regard, they are "terrible rulers," to use Ajami's term.

Worse, where is the opposition? If "the Arab world has terrible rulers and worse oppositionists," are we any better? True, some have decried the assault on sound science (see Taubes, "The (Political) Science of Salt ") and others lament the "nanny state " and "food police " second-guessing individual food choices and steamrolling the food industry on the salt content of its food. But until Kellogg's (html 54.86 kB) recently raised the prospect that the emperor had no clothes, the food industry has largely been content to ignore the science and pump pricier low-sodium foods into the marketplace, fellow-travelers willing to claim the government-bestowed "health" claim in return for their silence on issues of quality science.

Too often we point with disdain at the failings of others when what's needed is a harder look in the mirror. If we want science to guide health policy, we must become "truth-tellers" too.

Basil S. Hetzel, AC, MD, FRCP, emeritus professor of medicine at the University of Adelaide, Australia and the first/founding Executive Director of International Council for the Control of Iodine Deficiency Disorders (ICCIDD ), has been honored to receive the 2009 Pollin Prize . The award ceremony was held in New York City this week.

ICCIDD, The Network for the Sustained Elimination of Iodine Deficiency and other global health agencies (WHO , UNICEF , UN World Food Program , and Gates Foundation-funded GAIN ) agree that iodizing salt is the most sustainable solution to global IDD problems .

The Pollin Prize has only six previous winners (it is not awarded annually; only when contributions are judged outstanding). It is comforting that a second salt-related winner has also been recognized. The inaugural winners in 2002 were three Americans (Norbert Hirschorn, MD, David R. Nalin, MD and Nathiel F. Pierce) and one Indian, MD Dilip Mahalanabis,MD, who were honored for their contributions promoting Oral Rehydration Therapy . ORT uses salt/sugar solutions to combat diarrhea.

The award recognizes Dr. Hetzel for:

His pioneering work led to our understanding of the effects of iodine deficiency on brain development – and the importance of incorporating iodized salt in the diet to prevent brain damage in newborns.

Dr. Hetzel's research team in Papua New Guinea (1964-1972) established that brain damage could be prevented by correction of iodine deficiency before pregnancy. This groundbreaking research led him to begin a worldwide campaign to incorporate iodized salt into the diets of more than two billion people in some 130 countries where iodine is lacking.

The World Health Organization now recognizes that iodine deficiency is the most common preventable cause of brain damage in the world today.

Dr. Hetzel's efforts have prevented brain damage in millions of children. We honor his vision, leadership and discovery.

In 2002, the Pollin Prize committee pronounced ORT "The most important medical discovery of the 20th Century." It's hard to name any more significant -- unless it is iodizing salt!

The American Dietetic Association has reaffirmed its support for "functional foods," issuing this statement this week:

All foods are functional at some physiological level, but it is the position of the American Dietetic Association that functional foods that include whole foods and fortified, enriched or enhanced foods have a potentially beneficial effect on health when consumed as part of a varied diet on a regular basis, at effective levels. ADA supports research to further define the health benefits and risks of individual functional foods and their physiologically active components. Health claims on food products, including functional foods, should be based on the significant scientific agreement standard of evidence and ADA supports label claims based on such strong scientific substantiation. Food and nutrition professionals will continue to work with the food industry, allied health professionals, the government, the scientific community and the media to ensure that the public has accurate information regarding functional foods and thus should continue to educate themselves on this emerging area of food and nutrition science.

ADA also reminds us, pointedly:

The American Dietetic Association defines functional foods as those that “move beyond necessity to provide additional health benefits that may reduce disease risk and/or promote optimal health. Functional foods include conventional foods, modified foods (fortified, enriched or enhanced), medical foods and foods for special dietary uses.”

Curiously missing from the list of examples of functional foods is the first functional food and, arguably, the most important among them: iodized salt . The U.S. began iodizing salt in 1924 and has virtually eliminated the scourge of Iodine Deficiency Disorders, the most preventable cause of mental retardation.

European salt makers and the iodine nutrition community breathed a collective sigh of relief when the European Commission published its latest draft proposal on nutrient profiles used in nutrition label claims. Article 2, paragraph 3 exempts "salt (bearing) nutrition or health claims related to the addition of iodine and/or fluorine."

Somewhat surprisingly to some, Europe as slipped into iodine insuffiency, necessitating increased promotion for the use of iodized salt. The World Health Organization had warned against backsliding on use of iodized salt.

EuSalt led the charge preserving iodized and fluoridated salt and forecasts that the draft will be finalized on April 27.

A study just published in Hypertension documents that continuous activation of the renin-angiotensin system impairs cognitive function in mice. In humans, low-salt diets reliably predict increased activity of the renin-angiotensin system. The body produces these neurohormones when it senses inadequate salt intake -- and that "inadequacy" is far, far above the IOM's "adequate intake" level for sodium. Low-salt dieters can be assumed to have continuously high renin-angiotensin activity levels.

Other studies have suggested low-salt diets may produce mental impairment. This could be the mechanism.

All this is in addition to the contributions of iodized salt, the consensus solution to overcoming the most easily-prevented, but still-widespread cause of mental retardation: iodine deficiency

Salt is so basic to our existence we often forget its life-saving role as an essential nutrient; consider oral rehydration therapy which has saved millions of lives, particularly in Africa. But salt is not only essential to life, it plays a key role combatting mental retardation; consider the enormous achievement of iodized salt.

New York Times columnist Nicholas D. Kristof does just that. In today's paper, he reviews the enormous paybacks of salt iodization, "Raising the World's I.Q ."

Salt does have a real downside, Kristof admits -- "it's so numbingly boring, few people pay attention to it or invest in it. (Or dare write about it!)." I guess we here at the Salt Institute are so insensate we didn't realize that salt was boring or unworthy of attention so count us among the few.

Thankfully, Kristof is one of the few as well. With his proselytizing, perhaps the few will become many.

Columbo, Sri Lanka's Sunday Times has an informative review of the salt industry in that country showing how the privatization and modernization of the industry leads to progress in iodizing salt. The country's salt production is in transition as the photo above depicts, but more modern facilities are coming on line.

Many consumers continue in ignorance about the primary reason for consuming iodized salt: fetal and infant brain development. This isn't an aesthetic issue. For example, as my comment to this blogger notes, iodine deficiency for an expectant mother can penalize her child 10-15 IQ points.

A new study in The Journal of Clinical Endocrinology & Metabolism found that "Prolonged iodized salt significantly improves maternal thyroid economy and reduces the risk of maternal thyroid insufficiency during gestation, probably because of a nearly restoring intrathyroidal iodine stores."

Women who used salt for at least two years before becomng pregnant avoided thyroid failure during pregnancy. The Italian research team found in its study of 100 women, 62 of whom were "long-term" users of iodized salt and 38 of whom were not. The short-term group had a six-fold greater incidence on thyroid failure.

Thanks to a global campaign by UNICEF and its partners (which include the Salt Institute) about 70% of households around the world are now receiving iodine through iodized salt, and 34 countries have universal salt iodization, according to a new UNICEF report, Sustainable Elimination of Iodine Deficiency ,issued June 26. As recently ago as two decades, only 20% of households were receiving sufficient levels of iodine.

In 1990, IDD was a public health problem affecting an estimated 2 billion people. Today, that number has been pared to about 400 million, half of them in India. Each year, 38 million children are born at risk of iodine deficiencies that can penalize them 10-15 IQ points in mental capacity.

For the past two years, more than 50 economists under the aegis of the Copenhagen Consensus have been studying the 30 most promising public health interventions to help policy-makers prioritize public health investments. They filed their report today and issued a news release summarizing their findings.

The top three:

1. Combatting micronutrient malnutrition by fortifying foods with vitamin A and zinc.

2. Completing the Doha round of international trade liberalization.

3. Iodizing salt and fortifying foods with iron.

Micronutrient malnutrition ("hidden hunger") is the clear winner with two of the top three "solutions." Fortifying with vitamin A and zinc return $17 for every dollar invested. The benefits of iodizing salt are $9 for every dollar invested.

With the candidates for the Democratic US presidential nomination competing to bash free trade, #2 may gain some political salience. But investing in micronutrient fortification -- including universal salt iodization -- should be high on the public health agenda.

In the article, "Technological issues associated with iodine fortification of foods ," authors Winger, Konig and House describe some of the potential interactions of iodine compounds with foods. This article is of considerable interest because it goes into a range of possible problems associated with high-level iodine fortification - that is, the addition of iodine compounds directly to the finished foods.

Although the authors attempt to make it clear that the negative consequences of iodine fortification of foods would only occur at high levels of fortification and would never be the result of using iodized salt, they do not unequivocally state that, for all intents and purposes, whole formulated food products would never be iodized at levels that would impact the color, flavor or functionality of those foods.

If whole, formulated foods will never be iodized to those levels which can impact on the quality of the food, then the whole issue becomes moot and should not be confused with the use of iodized salt in food products.

Iodized salt can be used in formulating all food products without any fear of reducing quality.

Perhaps it would have been useful for the authors to have made that simple statement of fact.