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.
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.
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.
The New Zealand Bakery Association has blasted FSANZ, warning that its new requirement of iodized salt in bread "will be expensive, claiming there are not a lot of facilities to process iodised salt in the country." The bakers apparently duped foodnavigator.com writer Charlotte Eyre on that point and another: that "iodine is a nutrient commonly found in salt."
Noting that "half truths are the most insidious," the Salt Institute responded, defending the FSANZ decision and pointing out that:
1. Plain salt has 1/100th the amount of iodine of iodine-fortified salt; it may be detectable in a lab, but it's insignificant nutritionally.
2. Salt iodization is not expensive; it costs pennies per year per person.
3. New Zealand may not have "a lot of facilities to process iodised salt," but it's a small country, well-served by Salt Institute member companies Dominion Salt of New Zealand and Cheetham Salt of Australia whose few plants make virtually all the food salt in the country and which can easily accomplish the required iodization virtually with the flip of a switch.
Surely the bakers have better fights to fight.
In the October 2006 issue of Thyroid, (vol.16, no. 10) , the Public Health Committee of the American Thyroid Association stated that,
"The fetus is totally dependent in early pregnancy on maternal thyroxine for normal brain development. Adequate maternal dietary intake of iodine during pregnancy is essential for maternal thyroxine production and later for thyroid function in the fetus."
They went on to recommend a minimum of 150 µg of iodine supplementation on a daily basis. At the time they suggested that this be best accomplished through the use of vitamin/mineral supplements taken during pregnancy and lactation.
In that same issue Dr. Daniel Glinoer , professor of internal medicine at the University Hospital Saint Pierre, in Brussels, suggested that it would be very worthwhile to consider universal salt iodization as practiced in some countries, rather than the use of supplements. This debate over the best iodine delivery vehicle was highlighted by Dick in his June 12 blog, "Thyroid doctors clash over iodine nutrition for expectant mothers ."
Continuing the debate, in the most recent issue of Thyroid (May 2007, vol. 17, no. 5) , Kevin Sullivan of the department of Epidemiology at the Rollins School of Public Health, Emory University in Atlanta, GA, stresses the importance of ensuring that pregnant and lactating women receive sufficient iodine to prevent irreversible brain damage in infants. He refers to the recent NHANES data indicating that most pregnant women in the US are currently at a borderline level of iodine intake.
Sullivan goes on to make a strong recommendation that iodine fortification should be carried out on all salt concluding that used in food processing. In fact, the Salt Institute is currently discussing this matter internally and with foreign associates to ensure that there is no industry concerns about the universal iodization of salt.
The Salt Institute recently made a strong recommendation to the USDA WIC program that they make a specific effort to ensure that pregnant women and new mothers understand the importance of consuming iodized salt. Up to that point, the WIC program had made no effort to highlight the importance of consuming iodized as opposed to non-iodized salt.
As pointed out in a recent Food Technology 'Perspectives' article, in early 1924, the US salt industry produced and marketed iodized table salt for country-wide consumption. From that moment on, with a simple jiggle of the salt shaker, the US salt industry dispatched the scourges of iodine deficiency diseases - goiter, cretinism, hypothyroid coma and iodine deficiency-induced mental retardation - into the dustbin of Americans medical history. Of course, this practice ia now being adopted on a world-wide basis .
Last October, the Public Health Committee of the American Thyroid Association published recommendations on iodine supplementation for pregnant and lactating women in North America. Noting that the World Health Organization had increased its recommended daily intakes to 250 micrograms of iodine daily and that 7.3% of pregnant Americans are ingesting less than 50 micrograms -- the minimum safe level -- the ATA called for all pregnant and lactating women to take iodine supplements of 150 micrograms/day.
Not so fast, says Kevin Sullivan of Emory University, a board member of the International Council for the Control of Iodine Deficiency Disorders. Dr. Sullivan argues in a letter published in the current issue of the journal Thyroid that many women don't take supplements and, even if they started when they learned they had become pregnant, irreversible brain damage may already have been done to their unborn baby. He argued that "all household salt (as well as salt substitutes) and salt used in the food industry" should be iodized. He explained:
The Committee should be applauded for their efforts to prevent irreversible fetal brain damage as a result of iodine deficiency. While an important and useful step, the iodine supplementation during pregnancy recommendation has some limitations. First, currently the Institute of Medicine recommends multivitamins for some groups of pregnant women and the recommended vitamins and minerals do not include iodine, therefore many prenatal multivitamins do not include iodine. The Public Health Committee recommended efforts to encourage manufacturers to include iodine in all vitamin and mineral preparations for use during pregnancy and lactation. Second, many women will not use supplements on a regular basis as has been found with folic acid supplementation. Women who do not use supplements on a regular basis tend to be younger, of lower education, and of certain ethnic/racial groups. In addition, much of the damage caused by iodine deficiency occurs early in the pregnancy, therefore, by the time a woman realizes she is pregnant and seeks prenatal care, damage may have already occurred.
It would seem that the focus of preventing the negative effects of iodine deficiency in the developing fetus should focus on all women of childbearing age. Efforts should be placed on fortification of salt for human consumption as recommended by the International Council for Control of Iodine Deficiency Disorders (ICCIDD ), United Nations International Children's Emergency Fund (UNICEF ), and WHO and implemented in many countries. In the United States, all household salt (as well as salt substitutes) and salt used in the food industry should contain iodine at levels to assure an adequate iodine intake in the vast majority of the population. Through careful study of urinary iodine levels, the iodine content of salt and salt substitutes can be adjusted to assure that there is not too much or too little iodine in the diet, similar to the approach used in Switzerland. To prevent excess iodine intake, the iodine levels in other foods, such as dairy products and bread, may need to be regulated.
Iodizing salt substitutes -- like potassium chloride and "sea salt." Now, THAT's an interesting idea. For a salt industry perspective, see the Salt Institute website or that of EuSalt . The salt industry is part of a global Network for the Sustained Elimination of Iodine Deficiency .