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 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.

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.

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.

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.