Download - Presentation Bioethics Congress 2010
Realization of a National Strategy for the Prevention and Controlof Iodine Deficiency Disorders
Frits van der Haar, PhDEmory University, School of Public Health
Atlanta, Georgia, USA
Main Themes of Presentation
1. Progress in the Prevention of Iodine Deficiency in South-East Europe and the Commonwealth of Independent States during 2000-2009
2. Iodine Deficiency in Ukraine
3. Relationships of Dietary Iodine Supplies and Salt Iodization Strategies in Industrialized Countries
Recommended Next Steps
Progress in the RegionSE Europe and CIS during the Decade
2000 - 2009
± 2000 ± 20100%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
USI Progress in South-East Europe and the Commonwealth of Independent States, 2000-
2009
>9070-8950-6920-49<20
Prop
ortio
n of
coun
trie
s
Coverage
4 more countries have attained USI
2 more are close to the goal
4 more have coverage of 50-69%
The number of countries with coverage <50% fell by 8
A Decade of Action in National Salt Iodization Strategies in S.E. Europe and CIS
End-of-Decade situation• Plentiful iodized salt supplies and optimum iodine nutrition realized in
ARM, BEL, BiH, BUL, GEO, KAZ, KOS, MAC and TUR• Plentiful iodized salt supplies and iodine nutrition almost optimum in
AZE, KYR, MOL, MON, ROM and SER
(15 out of 20 countries = 75% success rate)
• Iodized salt supplies are facing operational challenges, and iodine nutrition improving but not yet adequate in ALB, TAJ and UZB
• No principle decision on salt iodization, dietary iodine supplies are stagnant, and persisting evidence of insufficient iodine nutrition in RUS and UKR
BUL MAC ROM BiH ALB MON SER KOS2003 2004 2005 2006 2007 2009
0
50
100
150
200
250
300
350
TUR ARM GEO BEL MOL AZE KYR TAJ2004 2005 2006 2007
BUL MAC ROM ALB MON SER BiH KOS2001 2003 2004 2006 2007 2008 2009
0
50
100
150
200
250
300
UKR* KAZ* AZE KYR TAJ2002 2006 2007 2007
Urinary Iodine Concentrations in Pregnant Women
Urinary Iodine Concentrations in School-age ChildrenBalkan Area
Balkan Area
CIS Area
CIS Area
Iodine Nutrition Achievements during the Decade 2000-2009
* Women in Ukraine and Kazakhstan were not pregnant
What are Reasons for Success?• Partnership Collaboration: Positive Common Testimony by the Key
Stakeholders on:– The need to ensure plentiful iodized salt supplies for prevention of brain
impairment in each new generation of citizens– The feasibility of national legislation/regulation to achieve optimum iodine
nutrition of the population• Evident Concern to ensure quality iodized salt supplies among the salt
industry/trade sector, the food authority/inspection and the consumer rights/interests organizations
• Regular Monitoring by public health institutions, using up-to-date methods and technology, striving for high standards in analysis and reporting, and promoting publicity of the results
• International Collaboration, including an official request for independent acknowledgment of successful national achievement
Iodine Deficiency and Salt Iodization
in Ukraine
and other Industrialized Countries
Ukraine: Surveys of Adult Women
0 20 40 60 80 1003
3.5
4
4.5
5
5.5
6
6.5
7
Percent household salt iodized
Urin
ary
Iodi
ne C
once
ntra
tion
(Log
scal
e)
Recommended range
(100 - 200µg/L)
Kravchenko V, 2005-200748 Sites covering Ukraine
Iodine from natural food: 64µg/Lfrom iodized household salt: 22µg/L
Academy Medical Sciences, 2002National Micronutrient Survey
Iodine from natural food: 66µg/Lfrom iodized household salt: 23.5µg/L
Recommended range
(100 - 200µg/L)
2002 National Iodine Survey
2005-2007 Surveys in 48 Oblasts
0
25
50
75
100
125
150
175
200
Urinary Iodine Levels in Adult Women, Ukraine
Minimum UI for non-pregnant adult women
Minimum UI for pregnant adult women
From iodinein household salt
From iodinein common foods
50% Shortfall When Women Enter Pregnancy
• Intellectual Impairment in Newborns– 33,068 Births Each Year
– Loss of IQ Points 446,418 Annually
• Future Foregone Economic Earnings– $36,586,000 Each Year
Damage Assessment Report 2006: Losses due to Iodine Deficiency
What Would a Prevention Strategy Cost? Cumulative Projections over 10 Years
3-Year Investment 1.375 million US$Break-even at 4 Years
10-Year Benefit : Cost Ratio 44.6
Would Iodized Household Salt be Adequate to Prevent Brain Damage?
Common salt Iodized salt Common salt Iodized saltSchool children Pregnant women
0
50
100
150
200
250
Net effect of iodized household salt consumption on the urinary iodine levels in school-age children and pregnant women, Donetsk
Iodized salt Dairy + sea fish Basic diet
Normal rangePregnant women
School children
Firsova N, Demina T et al, Donetsk Medical University, 2007-2008
Most of the Salt Intake is from Consuming Industrially Processed Foods
Bread & Cereals are Major Commodities in the Total Food Salt Intake
Salt Iodization Practices in Western Europe: Example of The Netherlands
Iodization Standards:Bread salt 50-65 mg iodine/kgHousehold salt 15-25 mg/kgBoth Standards are not Mandatory
Realization:Bread bakeries 93% adoptionHouseholds 65-70% coverage
Iodine supplement use 5-21%
Normal range
Salt Iodization Practices in Western Europe: Example of Denmark
Series10
20
40
60
80
100
120
140
160
Contributions to Total Iodine Intake in Adults, Denmark 2007
Bread saltHousehold saltNatural food sources
Iodi
ne in
take
µg/
d
Average requirement
Recommended intake
Iodization Standards: Bread salt 13 mg iodine/kgHousehold salt 13 mg/kgBoth standards are mandatory
Realization:Rye Bread 1.4 - 38 mg iodine/kgWheat Bread 0 – 46 mg iodine/kgHousehold salt 0.6 - 31 mg/kg
Median Increase: 63µg/d
Other Examples of Selective Salt Iodization Strategies
• Belarus
• Germany
• Australia & New Zealand
• Norway, Finland
Suggestions and Next Steps
Major Issues that may be Delaying National Decision-Making
• The Need for a Population Approach• Nutrition is not Pharmacology
• Insistence on Free Consumer Choice• The Problem is only “Mild”
• Do we Choose for Prevention or Correction?
The 3 Compelling Imperatives
Economics“The State Continues Bleeding Money”
Human Rights“Unborn Babies cannot Choose”
Ethics“The Greatest Benefit for the Greatest Number”
Suggested Next Steps
• Consider the Different Salt Supply Channels• Choose a Selective Iodization Strategy that– Benefits the Largest Possible Population Share– Focuses on Prevention of Newborn Brain Damage– Circumvents the Major Political Objections, and– Is Proven to be Safe, Effective and Low-Cost
• Adopt an Inclusive Collaborative Approach• Provide Positive Common Testimony