IDDNEWSLETTERIn this Issue:

VOLUME 23 NUMBER 1 FEBRUARY 2007

INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS

THE INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS (ICCIDD) is a nonprofit, nongovernmental organizationdedicated to sustained optimal iodine nutrition and the elimination of iodine deficiency throughout the world. Its activities have been supported bythe international aid programs of Australia, Canada, Netherlands, USA, and also by funds from UNICEF, the World Bank and others.

ICCIDD

The Consultation, which metin Geneva, Switzerland in2005, reached a general con-sensus on several importantissues.

Universal salt iodization(USI) remains the key strategyto eliminate IDD

Where USI has been effec-tive for at least two years, withsalt adequately iodized andconsumed by more than 90percent of the population, itcan be reasonably expectedthat the iodine needs of women ofchild-bearing age and pregnant andlactating women are covered by theirdiet, and that the iodine stored in thethyroid gland is sufficient to ensureadequate hormone synthesis andsecretion.Thus, supplementation isnot recommended.

Iodized salt may not provideenough iodine to meet a child’sneeds during complementary fee-ding, especially if the mother is onlymarginally iodine sufficient, unlesscomplementary foods are fortifiedwith iodine. It may be necessary therefore to give additional iodine

to make sure that require-ments are met until such timeas the child starts to eat thenormal family food.

Monitoring of both iodizedsalt quality and iodine nutriti-on are important to ensurethat an optimal state of iodinenutrition is reached and thensustained.

The Consultation made seve-ral specific recommendationsconcerning requirements and

indicators to control iodine deficien-cy disorders in pregnant and lactatingwomen, and in children less than 2years old.The complete results of theConsultation will be published in aspecial issue of the journal PublicHealth Nutrition in 2007.

Iodine requirements inpregnancy and infancy

Ethiopia 8Unicef report 10

Kazakhastan 12Pregnancy 1Moldova 3Thyroglobulin 6

Tuva 17

China 18Meetings and Announcements 19Abstracts 19

Cameroon

15

A WHO Technical Consultation has produced new guidelines on iodine requirements andmonitoring in these vulnerable age groups.

Recommended iodine intake

PregnancyThe Technical Consultation proposedto increase the current FAO/WHORecommended Nutrient Intake foriodine during pregnancy from 200µg/day to 250 µg/day (Table 1). Adaily intake greater than this is notnecessary and preferably should notexceed 500 µg/day, as such an intakemay be associated with impaired thy-roid function.

LactationDuring lactation the physiology ofthyroid hormone production and urinary iodine excretion returns tonormal, but iodine is concentrated inthe mammary gland for excretion inbreast milk.Thus using the urinaryiodine concentration to estimateintake may lead to an underestimateof requirements. But because of theneed to ensure that the infant getsenough iodine from breast milk tobuild reserves in the thyroid gland, itwas recommended that lactatingwomen should continue to consume250 µg/day of iodine.This alsorepresents an increase in the recom-mended intake of iodine by 50µg/day compared with the previousRecommended Nutrient Intake.Theintake preferably should also notexceed 500 µg/day.

Children less than two years ofageFor children less than twoyears of age the previouslyrecommended iodine intakeof 90 µg/day remains thesame. There was no attemptto propose a recommendediodine intake for preterminfants because of the lack of data.

Median urinary iodineconcentration as an indi-cator of iodine status The Consultation proposedthat the median urinary iodine concentration was the best indicator to use in populationsurveys to assess the iodinenutrition of pregnant and lac-tating women, and of youngchildren less than two years.However, further studies arerequired to provide bettersupport for this statement.Moreover this indicatorshould not be used for thepurposes of individual diagno-sis and treatment. As an indi-cator of iodine intake, medianurinary iodine concentrationdoes not provide direct infor-mation about thyroid functi-on. However, a low medianurinary iodine concentration

indicates that a population is at riskof developing thyroid disorders.

The Technical Consultation recom-mended that iodine status should beassessed in urinary iodine surveysconducted every 3 – 5 years usingestablished methods.Table 2 showsthe median urinary iodine concen-trations proposed to classify pregnantwomen, lactating women and chil-dren aged 0 – 2 years old into cate-gories of iodine intake.

2 IDD NEWSLETTER FEBRUARY 2007 PREGNANCY

Table 1: The daily recommended nutrient intakefor iodine proposed for pregnant and lactatingwomen and children less than 2 years old, andthe daily intake that was considered should notto be exceeded.

Population Recommended Excessivea

Group nutrient intake iodine (µg/d)for intake (µg/d)

Pregnant women 250 > 500

Lactating women 250 > 500

Children < 2 years 90 > 180

a The term “excessive” means in excess of the amountrequired to prevent and control iodine deficiency.

Table 2: The median or range in urinary iodineconcentrations used to categorise the iodineintake of pregnant women, lactating womenand children less than two years of age.

Population Median urinary Category ofGroup iodine concen- iodine intake

tration (µg/L)

Pregnant women < 150 Insufficient150 – 249 Adequate250 – 499 More than adequate >_ 500 Excessivea

Lactating womenb < 100 Insufficient>_ 100 Adequate

Children less < 100 Insufficientthan 2 years old >_ 100 Adequate

a The term “excessive” means in excess of the amountrequired to prevent and control iodine deficiency.b In lactating women, the figures for median urinary iodi-ne are lower than the iodine requirements because ofthe iodine excreted in breast milk.

IDD NEWSLETTER FEBRUARY 2007 MOLDOVA 3

According to WHO criteria, Mol-dova is currently mildly iodine defi-cient.The first epidemiological sur-vey carried out in children between1996 and 1998 found high levels ofiodine deficiency, with a median uri-nary iodine level of 78 µg/L andgoiter prevalence rates ranging from27% in the south of the country to41% in the central zone.The govern-ment of Moldova is committed tothe World Fit for Children goal forthe sustainable elimination of IDDthrough USI.A national decree man-dates the iodization of all table andanimal salt without including saltused for processed foods. Eventhough the governmental decreerequires all table salt to be iodized,

the enforcement of this regulationremains problematic. Recent dataindicate an increase in the householduse of iodized salt -from 32% in2000 to 60% in 2005.

The importance of food producers using iodized salt

Although being part of USI, the useof iodized salt in food manufacturingindustries is frequently overlooked,even though a large proportion ofthe daily salt (and potentially iodine)intake is derived from processedfoods, especially in industrializedcountries.This is of particularimportance for pregnant women,whose table salt intake may havedecreased following the advice ofhealth care providers, and who arethe primary target group for the pre-vention of the irreversible conse-quences of iodine deficiency on thebrain of the unborn child. UNICEFin CEE/CIS has therefore emphasi-zed the importance of the use ofiodized salt by food industries.

In order to ensure that iodized salt isused in commonly consumed foodssuch as bread, cheese, meat, meatproducts and pickles, both thegovernment and the food industryneed to agree and commit to its

introduction. Until 2006, only onelarge bread producer in Moldova wasusing iodized salt in its production,moreover, this was only on a tempo-rary basis.The use of iodized salt infood is hindered by the belief thatiodized salt could have an impact onthe quality of the final product’scolor, taste, texture or smell.Moreover, in many countries thecompetition between food manufac-turers is strongly related to foodprice. Due to the poor economicconditions in Moldova, convincingfood producers therefore was all themore difficult.

Convincing food producers inMoldova to use iodized salt:a study tour in Switzerland

Alexandra Eriksson, Arnold Timmer, Lilia TurcanUNICEF Regional Office for Central and Eastern Europe & Commonwealth of Independent States and UNICEF Country Office Moldova

The Republic of Moldova, a country between Romania and Ukraine with a populati-on of about 4.2 million, is one of the poorest nations in the Commonwealth ofIndependent States (CIS). Less than 2/3rds of households use iodized salt and thecountry remains iodine deficient.

This Moldovan infant needs adequate iodine for normal development

Additionally, food producers hesitateto use iodized salt because they fearit will increase prices of their pro-ducts, and worry that if the productsare exported, they will be subject toinspection in the importing country.UNICEF focuses its support toincrease the use of iodized salt by thefood industry in three ways: a) provi-ding scientific studies on the effectsof iodized salt use in food processing;b) obtaining and sharing testimonialsand practices from food producersthat safely use iodized salt; c) expo-sing food industry members to suc-cessful practices in other countries.

A learning experience: a studytour to Switzerland

The UNICEF Regional Office forCEE/CIS and the UNICEFCountry Office in Moldova collabo-rated with the Government ofMoldova, Swiss food producers andICCIDD Switzerland to organize astudy tour. Switzerland was thoughtto be an ideal example for Moldova,with its long history in the struggleagainst IDD and its successful imple-mentation of the use of iodized saltin cheese, bread, meat and pickles.The Moldovan delegation composedof government officials, food scien-tists and food producers arrived inGeneva in March 2006 for a visit toselected Swiss food industries.

The objective was to convince theMoldovan delegation of the feasibili-ty and the safety of using iodized saltin their products by an exposure toSwiss practices. Even though theimportance of adequate iodine nutri-tion was fully accepted by the studytour members, the use of iodized saltmet resistance prior to the visit.Thestudy tour started in Geneva atUNICEF with a briefing on the suc-cessful elimination of IDD inSwitzerland by Dr. Hans Bürgi(ICCIDD Focal Point forSwitzerland), and a presentation of

the global situation by Dr. Bruno deBenoist (Chief, Micronutrient Unit,WHO Geneva).This was followedby a visit to three food companies inSwitzerland: la Maison du Gruyère,producer of the famous Swiss hardcheese, BAER AG a family-ownedsoft cheese producer and PoullyTradition SA, a Geneva based indu-strial bakery.

The legal situation in Moldova

It was of great interest to theMoldovan delegation to understandthe legal process in Switzerland; howthe framework ensures a systemwhich should be flexible and not tooresource-consuming and finally howit guarantees the adequate iodineintake of the population. InMoldova, three major institutionalbodies regulate the food production,which is not optimal. During thetour it became increasingly clear thatthe legal process had to be simplifiedin Moldova in order to implementthe mandatory use of iodized salt inthe food industry and to create anefficient system in the long run.

Resistance by the food industry

One main issue stressed by theMoldovan delegation was the percei-ved need to monitor the iodine con-tent in the final food products.During the briefing and discussionswith the food producers, the delega-tion asked questions concerning theprocedures to measure the iodinecontent in processed foods. Dr. Bürgiassured delegation,“although thereare ways to assess the level of iodinein food, it is not part of our surveil-lance program, because it is verycumbersome - it has been performedonly twice in Switzerland in the pasttwenty-five years.”“Periodic assess-ments of the iodine status in thepopulation offer reliable and conclu-sive data on the functioning and ade-quacy of the salt iodization effort”.

To ensure that food producers com-ply with the law in Moldova, ran-dom checks of the type of salt usedin food processing companies couldbe included in the regulatory inspec-tion.

This type of question reflects the fearthat the iodine levels in processedfoods could present a risk to thepopulation, even though the amountsof iodine added to the salt are minu-te and the quantity of salt in recipesare very small. Moreover, it showsthat the shift from non-iodized saltto iodized salt is still perceived asunnecessary risk-taking.Throughoutthe discussions it became increasinglyclear to the Moldovans that it ismuch more efficient to monitor thetype of salt used in food factoriesthan to test iodine in the final pro-ducts.

The second issue emphasized by thedelegation was the effect of iodizedsalt on the quality of the product.This is a recurring question, but stu-dies have repeatedly shown that theuse of iodized salt in processed foodhas no impact on the flavor, taste,texture or the color of products.The amount of iodine added to saltis infinitely small and the potentialnegative impact of iodized salt onfood quality is only a myth.Interestingly, a small scale study onthe impact of iodized salt on thequality of pickles was done inMoldova (before the study tour toSwitzerland), which found no effect,but this was not convincing for thedelegation.The experts tasted thefood products at the Swiss factoriesmade with iodized salt to observeany possible difference in the taste,color or smell, but could not identifyany changes.

4 IDD NEWSLETTER FEBRUARY 2007 MOLDOVA

IDD NEWSLETTER FEBRUARY 2007 MOLDOVA 5

The outcomes of the tour

The visits and discussions persuadedthe Moldovan delegation of the valueof using iodized salt in the foodindustry and led the experts to makeimportant statements at the end ofthe tour. It was agreed that the legalframework surrounding the use ofiodized salt should be simplified, thatiodized salt has no negative impacton the quality of food products towhich it is added and that the mea-surement of the iodine content inthe final product is not necessary.

The tour had strong persuasiveeffects because it showed that proces-sed foods produced with iodized saltare consumed by the entire populati-on of Switzerland without any sideeffects and that they are exported aswell. Moreover, another key convin-cing argument is that these productsare world-famous and even conside-red as national symbols, like theGruyère cheese.

Ion Cretu, head of the departmentof food industry and regulations inMoldova, concluded the study tourwith these revealing words: “…thebarrier to the introduction of iodi-zed salt in processed foods inMoldova is not a technical one buta mental one. We have lost a lot oftime and much could have beendone to reduce IDD”.

The Poully Bakery in Geneva, where iodized salt is used in all baked goods

Cheese making with iodized salt in the Gruyere cheese factory

The Moldovan delegation discusses iodized salt during their visit to the Poully Bakery in Geneva

6 IDD NEWSLETTER FEBRUARY 2007 THYROGLOBULIN

Lessons learned

From the Moldovan experience andthe other study tours organized inthe CEE/CIS region such as thestudy tours in 2005 by a Latviandelegation to the Netherlands and aTurkish delegation to Bulgaria in2006, Unicef is convinced that suchstudy visits offer an effective way ofdealing with the psychological blocksurrounding the use of iodized saltin food. Concerns can be dealt withthrough dialogue with other produ-cers, observation of the productionprocess and tasting the products.When Andrei Ciburciu, leading spe-

cialist at the Moldovan Departmentof Food Hygiene, admitted,“thestudy tour in Switzerland savedmoney in the long run”, it was clearthat it produced a real change intheir way of thinking.

Food producers in Switzerland play-ed an important role in transferringexperience and knowledge on theuse of iodized salt in the food indu-stry in Moldova. Even though it tooksome effort to convince Swiss com-panies to host the study tour, thethree food producers that were visi-ted enjoyed the exchange of infor-mation and generally were interested

to renew their knowledge on iodinerelated issues.The IDD situation inSwitzerland would be a major healthproblem if the use of iodized salt wasnot widespread in the food industry.However new pressures by Swissconsumers who debate the use ofadditives, like iodine, in their food,could lead one day to a change inpractices on the use of iodized salt.Therefore, not only could Moldovabe an example for other countries of their region but it could one dayturn out to be an example forSwitzerland.

Assessment of iodine status usingdried blood spot thyroglobulinDried blood spot thyroglobulin may be a valuable new indicator of iodine nutrition in children

Michael Zimmerman ICCIDD Deputy Regional Coordinator for Western Europe

Background

Despite significant global progressagainst the iodine-deficiency disor-ders (IDD), one in three school-agechildren remain iodine-deficient.Iodine deficiency is the single mostimportant preventable cause of men-tal retardation worldwide.Threemeasures – urinary iodine (UI),goiter rate, and serum thyrotropin(TSH) – are recommended forassessment of iodine nutrition inpopulations (1), but each has limitati-ons. UI is an indicator of recent iodi-ne intake, but not of thyroid functi-on. Because thyroid size decreasesonly slowly after iodine repletion, thegoiter rate may remain high for seve-ral years after introduction of iodizedsalt (1,2).TSH is a sensitive measure

of iodine status only in the newbornperiod (1,3).Thus, an additional indi-cator of thyroid function, sensitive torecent changes in iodine nutritionand applicable in children, would bevaluable in monitoring iodine statusin populations.

Thyroglobulin (Tg), a thyroid-speci-fic protein that is a precursor in thesynthesis of thyroid hormone, has noknown physiological role outside thethyroid (4,5). If a sensitive assay isused,Tg can be detected in theserum of all healthy individuals (6,7).In the absence of thyroid damage,the major determinants of serum Tgare thyroid cell mass and TSH stimu-lation (7).Thus, serum Tg is elevatedin iodine-deficient areas due to TSHhyperstimulation and thyroid hyper-

plasia. In 1994,WHO/ICCIDDrecommended using serum Tg toassess iodine nutrition, and proposedthat a median Tg concentration of<10 µg/L in a population indicatediodine sufficiency (8). However, datato support this Tg cut-off value werelimited, and the recommendationwas not included in the revised 2001WHO/ICCIDD guidelines (1).Awidely-used serum Tg assay has beenadapted for use on dried wholeblood spots (DBS) (9). But use of Tgfor monitoring iodine status is limi-ted by large interassay variability andlack of reference data for Tg in heal-thy, iodine-sufficient school-age chil-dren.

Objectives

Therefore, in a study coordinated byICCIDD and WHO (10), the objec-tives were to:1) develop standard reference materi-al for the DBS-Tg assay using theCRM-457 Tg reference preparation2) using this material, establish aninternational reference range forDBS-Tg in iodine-sufficient childrenthat could be used for monitoringiodine nutrition3) evaluate the standardized DBS-Tgassay and reference range in a longi-tudinal study of goitrous childrenbefore and after introduction of iodi-zed salt.

Methods

Serum Tg reference material of theEuropean Community Bureau ofReference (CRM-457) was adaptedfor DBS and its stability tested overone year. DBS-Tg was determined inan international sample of 5-14 y-oldchildren (n=700).The children wereeuthyroid, antiTg antibody-negative,and residing in areas of long-termiodine sufficiency in South America,Central Europe, the EasternMediterranean,Africa, and theWestern Pacific.The sample includedchildren from five major ethnicgroups: Lima, Peru (Hispanic);Zürich, Switzerland (White);Manama, Bahrain (Arabic); CapeTown, South Africa (Black); andDalian, China (Asian). Subsequently,in a 10-month trial in iodine-defi-cient children, DBS-Tg and otherindicators of iodine status were mea-sured before and after introductionof iodized salt.

Results

Stability of the CRM-457 Tg refe-rence standard on DBS over 1 y ofstorage at -20° and -50°C wasacceptable.Although there were smalldifferences in dried blood spot thyro-globulin between the sites and bet-ween younger and older children,these differences were minimal, andthere were no gender differences.Overall, the data indicate age-, site-or gender-adjusted reference rangesfor dried blood spot thyroglobulinare unnecessary for children in theage range of 5-14 yrs. It is thereforerecommended to use a single refe-rence range for screening and moni-toring of iodine nutrition in this agegroup.The dried blood spot thyro-globulin reference interval for iodi-ne-sufficient school-age children is4-40 µg/L.

In the intervention, before introduc-tion of iodized salt, median DBS-Tgwas 49 µg/L and over 2/3rds of chil-dren had DBS-Tg values >40 µg/L.After 5 and 10 mo of iodized saltuse, median DBS-Tg decreased to 13and 8 µg/L, and only 7% and 3% ofchildren had values >40 µg/L. DBS-Tg correlated well at baseline and 5months with urinary iodine and thy-roid volume.

Conclusions

The availability of reference materialand an international reference rangefacilitates the use of DBS-Tg formonitoring of iodine nutrition inschool-age children.WHO is cur-rently preparing a statement recom-mending this test to monitor iodine

status in children. DBS-Tg, used inconjunction with UI to measurerecent iodine intake and thyroidvolume to assess long-term anatomicresponse, may be a useful biologicalindicator for monitoring thyroidfunction in children after introducti-on of iodized salt (10).

References1. WHO, UNICEF, ICCIDD. 2001 Assessementof iodine deficiency disorders and monitoringtheir elimination: a guide for programme mana-gers, 2nd ed.,WHO/NHD/01.1, Geneva.2. Zimmermann MB, Hess SY,Adou P,Torresani T,Wegmüller R, Hurrell RF. 2003Thyroid size and goiter prevalence after intro-duction of iodized salt: a 5-year prospectivestudy using ultrasonography in schoolchildren inCôte d’Ivoire.Am J Clin Nutr 77:663-667 3. Zimmermann MB,Aeberi I,Torresani T,Bürgi H. 2005 Increasing the iodine concentra-tion in the Swiss iodized salt program markedlyimproves iodine status in pregnant women andchildren: a 5-yr prospective national study.Am JClin Nutr 88:388-392.4. Tórrens JI, Burch HB. 2001 Serum thyroglo-bulin measurement. Endocrinol Metab ClinNorth Am 30:429-467.5. De Vijlder JJM, Ris-Stalpers C,Vulsma T.1999 On the origin of circulating thyroglobulin.Eur J Endocrinol 140:7-86. Dunn JT, Dunn AD. 2000 Thyroglobulin:chemistry, biosynthesis and proteolysis. In:Braveman LE, Utiger RD eds.Werner andIngbar’s The Thyroid:A Fundamental andClinical Text, 8th ed., Lippincott Williams andWilkins, Philadelphia.7. Spencer CA. 1995 Thyroglobulin measure-ment: techniques, clinical benefits, and pitfalls.Endocrinol Metab Clin North Am 24:841-863.8. WHO/ICCIDD/UNICEF. 1994 Indicatorsfor assessing Iodine Deficiency Disorders andtheir control through salt iodization. Geneva,WHO/NUT/94.6.9. Zimmermann MB, Moretti D, Chaouki N,Torresani T. 2003 Development of a driedwhole blood spot thyroglobulin assay and itsevaluation as an indicator of thyroid status ingoitrous children receiving iodized salt.Am JClin Nutr 77:1453-1458.10. Zimmermann MB, de Benoist B,Corigliano S, Jooste PL, Molinari L, Moosa K,Pretell EA,Al-Dallal ZS,Wei Y, Zu-Pei C,Torresani T. 2006 Assessment of iodine statususing dried blood spot thyroglobulin: develop-ment of reference material and establishment ofan international reference range in iodine-suffi-cient children. J Clin Endocrinol Metab.2006;91(12):4881-7.

IDD NEWSLETTER FEBRUARY 2007 THYROGLOBULIN 7

8 IDD NEWSLETTER FEBRUARY 2007 ETHIOPIA

Ethiopia remains severelyiodine deficient

One third of the population ofEthiopia survive on less than 1 USDa day. Children in particular arehighly affected by malnutrition.Forty per cent of children are sever-ely and moderately underweight, 52per cent are stunted and 11 per centare wasted. Malnutrition is theunderlying cause for more than 50per cent of deaths of children underfive years of age. Currently, only28% of households have access toiodized salt.

Although IDD is a major publichealth problem in Ethiopia, there arerecent signs of progress. In 2003,steps were made toward increasingpopulation access to iodized saltthrough training of 18 salt producingcompanies and quality control labo-ratory technicians located in 4 regi-ons on salt iodization. In 2004,agreements were signed between theFederal Ministry of Health and theEthiopian salt producing companiesand salt iodization machines were

distributed.As Ethiopia scales upproduction of iodized salt, morework needs to be done on technicalissues like quality control and packa-ging before being able to get most ofthe Ethiopian salt production iodi-zed.

A soldier turns salt producer

Just three years ago,WoldayTeklemicheal was a soldier. Now, healong with 26 of his old army bud-dies, have been demobilized, and for-med a co-operative that is producingiodized salt. Shiwott, as they havecalled their cooperative, operates outof a recently constructed tin factory,in Mekelle, the regional capital ofTigray in Northern Ethiopia.“Wechose a donkey piled with iodizedsalt for our logo,” explains Wolday,“as the donkey is what carries the salthere from the distant salt mines anddonkeys are what people use to carrythe iodized salt back to the commu-nity.”

UNICEF, working in partnershipwith the Regional Health Bureau,

helped to set up the business by pro-viding the salt crusher, the iodinemixer and supplies of iodine, as wellas training. Unfortunately, previously,all salt iodization was done inEritrea, and now along with theother legacies of the war, Ethiopiahas very limited capacity to produceiodized salt. UNICEF’s investment inShiwott is part of a larger effortacross the country to increase theavailability and use of iodized salt.

While large segments of the popula-tion are at risk of iodine deficiencies,yet not aware of the advantages ofiodized salt, the challenges to createmore of a local market are considera-ble. Not far from the Shiwott factoryand their whole sale store, is Mekele’smain salt market. Haji KahsayAhmed, 75 years old, has been in thesalt business for more than 20 years.Sitting with his business partner,behind a massive wall of salt bricks,they buy direct from the salt miners in the remote parts of Tigray andAfar and then resell to buyers inAddis.With little profit margin, it is atough and competitive business. Heunderstands the benefit but thinks alot more will need to be done to getmore salt iodized.

The members of Shiwott Coopera-tive agree.“The main problem is thecommunity is not yet aware of all theadvantages” explains Wolday.“Theyknow the taste of salt but they donot know what it includes.” Shiwotthas the potential to produce morethan 200 quintals of iodized salt aday but is producing under capacitybecause of the limited market.

With a population of 70 million suffering from drought, flooding and armed conflict,only 28% of Ethiopian households have access to iodized salt.

Wolday Teklemicheal, salt producer in Mekelle

IDD NEWSLETTER FEBRUARY 2007 ETHIOPIA 9

It was December 28, 2004, and theflight from the capital city of AddisAbaba to Lalibela in northernEthiopia was spectacular: overhead,bright blue skies and below, themagnificent hills and valleys of theAbyssinian Massif (the Ethiopiancentral plateau). Soon after findingour hotel, my colleagues and I setout for a mountain range northeastof Lalibela to find the beautifulchurch of Ymrehanna Krestos, a12th-century church built within a cave.

However, to get there requires along, hot, dusty drive, followed by along, hot, dusty hike.When we start-ed up the rocky path to YmrehannaKrestos, we first caught sight of chil-dren, barefoot and skinny.Then wecame across the women, sitting in

the dust with their palms up, beggingfor food, water, or anything we couldgive. Initially, their eyes held my gaze,but then I looked down and saw thegoiters, massive goiters unlike any Ihad ever seen. Similar images were toconfront me later in Lalibela, then inthe cities of Gondar in the north andArbe Minch in the south.Theimages continue to haunt me today.

Outside the capital city of AddisAbaba, goiters (also called “sicknessof the thick neck”) are endemic inEthiopia, illustrating the persistenceof severe iodine deficiency even in2005.The country’s civil war withEritrea in the late 1990s permanentlydisrupted its supply of Eritrean iodi-zed salt and now over 70% ofEthiopian households use noniodizedsalt from the neighboring country of

Djibouti. Not surprisingly, surveyshave shown a resurgence of IDDthroughout Ethiopia. Of course,endemic goiters are the most blatantmanifestations of IDD; much moreinsidious are stunted growth, mentaland psychomotor retardation, andsignificantly lower IQ among chil-dren with IDD, as well as higherrates of infertility, miscarriage, birthdefects, and stillbirths in adultwomen with IDD. Iodine deficiencyrepresents a major threat to thesocioeconomic health of Ethiopiaand a moral challenge to us all.

The good news: in Ethiopia, 10 newsalt iodizing plants have recentlybeen built. On my next trip toEthiopia, I hope to visit them all.

An eye-opening trip to Ethiopia

Many youngEthiopian womensuffer from severeiodine deficiencyand endemic goi-ter. This increasestheir risk for com-plications duringpregnancy andmay impair mentaldevelopment oftheir offspring.

To remedy the problem, they areworking with UNICEF and theRegional Health Bureau to streng-then community awareness about theadvantages of iodized salt.Already

they have initiated activities inschools, churches and through theradio. ‘It is crucial the community seethe value it can make to their life,”says Wolday, who like most of his

coop members had no idea beforethey starting their business that it wasso important,“We are happy that weare helping to improve the health ofour people.”

Personal stories Carolyn Becker, M.D Division of Endocrinology, Columbia University Medical Center, NY, USA

An eye-opening trip to Ethiopia

In the 2007 report,“The State of theWorld’s Children 2007:Women andChildren:The Double Dividend ofGender Equality”, Unicef providescurrent global figures on the percen-tage of households with access toiodized salt.As shown in the Table 1,global progress toward universal saltiodization, which was rapid duringthe 1990’s, has slowed over the pastdecade. Only about half of house-holds in the least developed coun-tries have access to iodized salt.Thedata for individual countries is givenin Table 2.These findings argue forrenewed efforts to reach the remai-ning one-third of the global popula-tion not covered by iodized salt.

10 IDD NEWSLETTER FEBRUARY 2007 UNICEF REPORT

2007 Unicef report suggestsglobal progress against iodinedeficiency is slowing

Table 1: From the Unicef Reports 1997-2007 on the State of the World's Children: percentage of households using iodized salt over the last decade, by region

2007 2006 2003 2000 1997

Sub-Saharan Africa 67 64 67 62 47

Eastern and Southern Africa 60 60 – – –

West and Central Africa 73 68 – – –

Middle East and North Africa 65 58 53 48 75

South Asia 54 49 53 65 58

East Asia and Pacific 85 85 80 74 48

Latin America and Caribbean 86 86 81 89 80

CEE/CIS 50 47 39 25 26

Developing countries 71 69 68 68 55

Least developed countries 53 53 54 57 33

World 70 68 67 66 54

IDD NEWSLETTER FEBRUARY 2007 UNICEF REPORT 11

Countries and % of householdsterritories using iodized salt

Afghanistan 28

Albania 62

Algeria 69

Angola 35

Argentina 90

Armenia 97

Azerbaijan 26

Bangladesh 70

Belarus 55

Belize 90

Benin 72

Bhutan 95

Bolivia 90

Bosnia and Herzegovina 62

Botswana 66

Brazil 88

Bulgaria 98

Burkina Faso 45

Burundi 96

Cambodia 14

Cameroon 88

Cape Verde 0

Central African Republic 86

Chad 56

Chile 100

China 93

Colombia 92

Comoros 82

Congo, DR 72

Costa Rica 97

Côte d'Ivoire 84

Croatia 90

Cuba 88

Dominican Republic 18

Ecuador 99

Egypt 78

El Salvador 62

Equatorial Guinea 33

Eritrea 68

Ethiopia 28

Fiji 31

Countries and % of householdsterritories using iodized salt

Gabon 36

Gambia 8

Georgia 68

Ghana 28

Guatemala 67

Guinea 68

Guinea-Bissau 2

Haiti 11

Honduras 80

India 57

Indonesia 73

Iran 94

Iraq 40

Jamaica 100

Jordan 88

Kazakhstan 83

Kenya 91

Korea (DPR) 40

Kyrgyzstan 42

Lao (PDR) 75

Lebanon 92

Lesotho 91

Libyan Arab Jamahiriya 90

Madagascar 75

Malawi 49

Maldives 44

Mali 74

Mauritania 2

Mauritius 0

Mexico 91

Moldova 59

Mongolia 75

Morocco 59

Mozambique 54

Myanmar 60

Namibia 63

Nepal 63

New Zealand 83

Nicaragua 97

Niger 15

Nigeria 97

Countries and % of householdsterritories using iodized salt

Oman 61

Palestinian Territory 64

Pakistan 17

Panama 95

Paraguay 88

Peru 91

Philippines 56

Romania 53

Russian Federation 35

Rwanda 90

Saint Kitts and Nevis 100

Sao Tome and Principe 74

Senegal 41

Sierra Leone 23

South Africa 62

Sri Lanka 94

Sudan 1

Swaziland 59

Syrian Arab Republic 79

Tajikistan 28

Tanzania (United Republic of) 43

Thailand 63

Macedonia 94

Timor-Leste 72

Togo 67

Trinidad and Tobago 1

Tunisia 97

Turkey 64

Turkmenistan 100

Uganda 95

Ukraine 32

Uzbekistan 57

Venezuela 90

Viet Nam 83

Yemen 30

Zambia 77

Zimbabwe 93

Source: MICS, DHS and UNICEF.

Table 2: Unicef State of the World’s Children 2007. Percentage of households using iodized salt, by country

12 IDD NEWSLETTER FEBRUARY 2007 KAZAKHASTAN

Valentina Sivryukova knew herpublic service messages were hittingthe mark when she heard how oneKazakh schoolboy called another stupid.“What are you,” he sneered,“iodine-deficient or something?” Ms.Sivryukova, president of the nationalconfederation of Kazakh charities,was delighted. It meant that the yearsspent trying to raise public awarenessthat iodized salt prevents brain dama-ge in infants were working. If thecampaign bore fruit, Kazakhstan’snational I.Q. would be safeguarded.In fact, Kazakhstan has become anexample of how even a vast and still-developing nation like this CentralAsian country can achieve a remar-kable public health success. In 1999,only 29 percent of its householdswere using iodized salt. Now, 94 percent are. Next year, the UnitedNations is expected to certify it offi-cially free of iodine deficiency disor-ders.

That turnabout was not easy.TheKazakh campaign had to overcomewidespread suspicion of iodization,common in many places, eventhough putting iodine in salt, publichealth experts say, may be the sim-plest and most cost-effective healthmeasure in the world. Each ton ofsalt needs about two ounces of potas-sium iodate, which costs about $1.15.“Find me a mother who wouldn’tpawn her last blouse to get iodine ifshe understood how it would affecther fetus,” said Jack C. S. Ling, thechair of ICCIDD.

The 1990 World Summit for Child-ren called for the elimination ofiodine deficiency by 2000, and the subsequent effort was led byProfessor Ling’s organization alongwith Unicef, the WHO, KiwanisInternational, the World Bank andthe foreign aid agencies of Canada,Australia, the Netherlands, theUnited States and others. Largely outof the public eye, they made terrificprogress: 25 percent of the world’shouseholds consumed iodized salt in1990. Now, about 66 percent do.

But the effort has been faltering late-ly.When victory was not achieved by2005, donor interest began to flag asAIDS, avian flu and other threats gotmore attention. And, like all such

drives, it cost more than expected. In1990, the estimated price tag was $75million – a bargain compared with,for example, the fight against polio,which has consumed about $4 billi-on. Since then, according to David P.Haxton, ICCIDD executive director,about $160 million has been spent,including $80 million from Kiwanisand $15 million from the GatesFoundation, along with unknownamounts spent on new equipment bysalt companies.“Very often, I’ll talkto a salt producer at a meeting, andhe’ll have no idea he had this powerin his product,” Mr. Haxton said.“He’ll say ‘Why didn’t you tell me?Sure, I’ll do it. I would have done itsooner.’ ”

The cheap part, experts say, is spray-ing on the iodine.The expense isalways for the inevitable public relati-ons battle. In some nations, iodizati-on becomes tarred as a governmentplot to poison an essential of life –salt experts compare it to the furiousopposition by 1950s conservatives tofluoridation of American water.In others, civil libertarians demand aright to choose plain salt, with theresult that the iodized kind rarelyreaches the poor. Small salt makerswho fear extra expense often lobbyagainst it. So do makers of iodinepills who fear losing their market.

The Kazakhastan salt iodizationprogram: a remarkable publichealth successOn December 16, 2006, a front-page story in the New York Times (later reprinted inthe Times of India and other major newspapers worldwide) by Donald McNeil Jr.entitled “On the Brink: In Raising the World’s I.Q., the Secret’s in the Salt” descri-bed the success of Kazakhstan’s iodized salt campaign. The story and photographsare excerpted below.

Breaking down that resistance takesboth money and leadership. “For 5cents per person per year, you canmake the whole population smarterthan before,” said Dr. Gerald N.Burrow, a former dean of Yale’smedical school and ICCIDD vicechairman.“That has to be good for acountry. But you need a governmentwith the political will to do it.”

In the 1990s, when the campaign foriodization began, the world’s greatestconcentration of iodine-deficientcountries was in the landlocked for-mer Soviet republics of Central Asia.All of them – Kazakhstan,Turkmeni-stan,Tajikistan, Uzbekistan, Kyrgh-

zstan – saw their economies breakdown with the collapse of the SovietUnion.Across the region, only 28percent of all households used iodi-zed salt.“With the collapse of thesystem, certain babies went out withthe bathwater, and iodization wasone of them,” said Alexandre Zouev,chief Unicef representative inKazakhstan.

Dr.Toregeldy Sharmanov, who wasthe Kazakh Republic’s health mini-ster from 1971 to 1982, when it wasin the Soviet Union, said the pro-blem was serious even then. But he

had been unable to fix it becausepolicy was set in Moscow.“Kazakh children were stunted com-pared to the same-age Russian chil-dren,” he said.“But they paid noattention. It was a scandal.” In 1996,Unicef, which focuses on the healthof children, opened its first office inKazakhstan and arranged for a surveyof 5,000 households. It found that 10percent of the children were stunted,opening the way for internationalaid. (Stunting can have many causes,but iodine deficiency is a prime cul-prit.) In neighboring Turkmenistan,President Saparmurat Niyazov solvedthe problem by simply declaringplain salt illegal in 1996 and ordering

shops to give each citizen 11 poundsof iodized salt a year at state expense.

In Kazakhstan, President NursultanA. Nazarbayev, was supportive. Buteven so, as soon as Parliament begandebating mandatory iodization in2002, strong lobbies formed againstthe measure.The country’s biggestsalt company was initially reluctantto cooperate, fearing higher costs, aUnicef report said. Cardiologistsargued against iodization, fearing itwould encourage people to use moresalt, which can raise blood pressure.More insidious, Dr. Sharmanov said,

were private companies that soldiodine pills.“They promoted theirproducts in the mass media, sayingiodized salt was dangerous,” he said,shaking his head. So Dr. Sharmanov,the national Health Ministry, Ms.Sivryukova and others devised amarketing campaign. Comic stripsstarring a hooded crusader, IodineMan, rescuing a slow-witted studentfrom an enraged teacher were hand-ed out across the country.A logo wasdesigned for food packages certifiedto contain iodized salt: a red dot anda curved line in a circle, meant torepresent a face with a smile so bigthat the eyes are squeezed shut.Also,Ms. Sivryukova’s network of localcharity women stepped in. Hervolunteers approached schools, askingteachers to create dictation exercisesabout iodized salt and to have stu-dents bring salt from home to test itfor iodine in science class.

Ms. Sivryukova described one child’stears when he realized he was theonly one in his class with noniodizedsalt.The teacher, she said, reassuredhim that it was not his fault.“Children very quickly start tellingtheir parents to buy the right salt,”she said. One female volunteer wentto a bus company and rerecorded its“next-stop” announcements inter-spersed with short plugs for iodizedsalt.“She had a very sexy voice, andmen would tell the drivers to play itagain,” Ms. Sivryukova said. Even theformer world chess championAnatoly Karpov, who is a herothroughout the former Soviet Unionfor his years as champion, joined thefight.“Eat iodized salt,” he advisedschoolchildren in a television appea-rance,“and you will grow up to begrandmasters like me.”

IDD NEWSLETTER FEBRUARY 2007 KAZAKHASTAN 13

Salt, excavated from a field at the Aral Tuz salt processing plant, in train carriages

14 IDD NEWSLETTER FEBRUARY 2007 KAZAKHASTAN

Mr. Karpov, in particular, handledhostile journalists adeptly, Mr. Zouevsaid, deflecting inquiries as to why hedid not advocate letting peoplechoose iodized or plain salt by com-paring it to the right to have twotaps in every home, one for cleanwater and one for dirty. By late2003, the Parliament finally madeiodization mandatory.

Today in central Kazakhstan, aminiature mountain range rises overAral, a decaying factory town onwhat was once the shore of the AralSea, a salt lake that has steadilyshrunk as irrigation projects begununder Stalin drained the rivers thatfeed it. Drive closer and the sharpwhite peaks turn out to be a smallAlps of salt – the Aral Tuz Companystockpile. Salt has been dug here forcenturies. Nowadays, a great rail-mounted combine chews away at a10-foot-thick layer of salt in the oldseabed, before it is towed 11 milesback to the plant, and washed andground. Before it reaches the packa-ging room, as the salt falls through achute from one conveyor belt toanother, a small pump sprays iodineinto the grainy white cascade.Thestep is so simple that, if it were notfor the women in white lab coats

scooping up samples, it would bemissed.The $15,000 tank and sprayerwere donated by Unicef, which alsoused to supply the potassium iodate.Today Aral Tuz and its smaller rival,Pavlodar Salt, buy their own.

Asked about the Unicef report sayingthat Aral Tuz initially resisted iodiza-tion on the grounds that it would eat

up 7 percent of profits, the compa-ny’s president, Ontalap Akhmetov,seemed puzzled.“I’ve only been pre-sident three years,” he said.“But thatmakes no sense.”The expense, hesaid, was minimal.“Only a few centsa ton.” Kazakhstan was lucky. It hadjust the right mix of political andeconomic conditions for success:political support, 98 percent literacy,an economy helped along by risingprices for its oil and gas. Mostimportant, perhaps, one company,Aral Tuz, makes 80 percent of theedible salt.

That combination is missing in manynations where iodine deficiencyremains a health crisis. In nearbyPakistan, for instance, where 70 per-cent of households have no iodizedsalt, there are more than 600 smallsalt producers.

“If a country has a reasonably well-organized salt system and only a cou-ple of big producers who get on thebandwagon, iodization works,” saidVenkatesh Mannar, a former salt pro-ducer in India who now heads theMicronutrient Initiative in Ottawa,which seeks to fortify the foods ofthe world’s poor with iodine, ironand other minerals.“If there are a lotof small producers, it doesn’t.”Now that Kazakhstan has its law, Ms.Sivryukova’s volunteers have not letup their vigilance.They help enforceit by going to markets, buying saltand testing it on the spot.Thegovernment has trained customsagents to test salt imports and fencedsome areas where people dug theirown salt. Children still receive boo-klets and instruction.

Experts agree the country is unlikelyto slip back into neglect. Surveys findconsumers very aware of iodine, andthe red-and-white logo is such a hitthat food producers have asked forpermission to use it on foods withadded iron or folic acid, said Dr.Sharmanov, the former KazakhRepublic health minister.And thesalt is working. In the 1999 surveythat found stunted children, a smallersampling of urine from women ofchild-bearing age found that 60 per-cent had suboptimal levels of iodi-ne.“We just did a new study, whichis not released yet,” said Dr. FeruzaOspanova, head of the nutrition aca-demy’s laboratory.“The number waszero percent.”

In Kzyl-Orda, seventh graders passing information booklets to one another about the importanceof iodized salt.

IntroductionIodine deficiency in westernCameroon was first observed in1973-74 (1). Endemic IDD was laterdescribed in this district by Lantumand collaborators in 1991 (2, 3).Afterthis, universal salt iodization (USI)was introduced into Cameroon as acorrective intervention. In 2002, in astudy by the Ministry of Health, amedian UI of 190 µg/L was reported(4). Because Bamoungoum inwestern Cameroon is one of the 20Sentinel Zones for monitoring theeffectiveness of the national USI pro-gram, ICCIDD carried out animpact evaluation there in 2006.

School surveyIn May 2006, a team led by ProfessorDan Lantum (ICCIDD Focal Pointfor Anglophone West Africa) survey-ed six primary schools of the district.The research team explained thehealth problems of IDD and goiter.The school children were happy andexcited that goiters were no longerseen in the community, but theywere not aware of the importance of iodized salt in their mothers’ kit-chens.The age range of the partici-pating children (n=646) was 9-14years.All the children were asked tobring to school a sample of salt col-lected from their mother’s kitchenfor testing for iodine.The next day,

the children lined up in the openfield in front of the school and theresearch team went round testingtheir salt samples using a Rapid TestKit. Each was asked to loudly pro-claim the color change after the testand what it signified. Cries of:“Thecolour is violet/blue! My salt samplecontains iodine!” filled the school-yard.

A subsample of salt collected fromthe children was also analyzed bytitration for iodine content. Goiterwas palpated in the children and spoturine samples (n=183) were collec-ted and were tested titrimetrically.Since all iodized salt consumed inCameroon is produced by three refineries at the Douala Port, in addi-tion to iodized salt imported fromSenegal, salt samples were collectedfrom these sources and analyzed foriodine content.

Surprising resultsIn 1991, the total goiter rate (TGR)in this region was 53% (3), while themedian UI was 30 µg/L, indicatingmoderate-to-severe IDD. By 2006,the TGR was 2%, but the median UIwas high, at 389 µg/L, and the rangewas 270-735 µg/L (Table 1).Twentypercent of children showed adequateiodine nutrition (UI 100-300 µg/L),while 80% had UIs in the excessrange (UI >300 µg/L) (Table 2).

In the samples of iodized salt fromthe refineries, although the regulati-on in force stipulates a concentrationof 100 ppm (5), the values in foursources ranged from 28-225 ppm;one sample had salt iodized at 878ppm (6) (Table 3). However, theiodine content of salt samples inhouseholds showed a range of 15-40ppm.

IDD NEWSLETTER FEBRUARY 2007 CAMEROON 15

D.N. Lantum, E.L. Monyuytaa, and J.N. BonglaisinWest and Central Africa Region, ICCIDD; and the University of Yaounde, Cameroon

Dan Lantum testing household salt for iodine in schools in Bamougoum, Cameroon, May 2006

Sentinel screening of iodinestatus in western Cameroonfinds excess iodine intake

16 IDD NEWSLETTER FEBRUARY 2007 CAMEROON

DiscussionThe results suggest iodized salt pro-ducers were not strictly followingthe level of iodization stipulated bythe regulation in force (5).This is anindication that quality control oftheir product needs to be improved.Proper training of technicians at therefineries is therefore indicated, aswell as frequent inspections by theMinistries of Health and Commerce.There was a marked difference iniodine content of iodized salt at pro-duction and at household levels.Thisis due to the losses (evaporation) ofiodine during the salt distributionchain - which can take months oreven years between the factory atDouala and a household atBamoungoum.

The median UI of 389 µg/L and thefinding that 80% of children wereexcreting iodine in the excess rangeis of concern and raises the issue ofpossible iodine toxicity.This empha-sizes the urgent need for carefulmonitoring of iodized salt producti-on and IDD status. Excess iodizationof salt is expensive and unnecessarilyinflates the cost of USI programs.High intakes of iodine in childrenare associated with increased thyroidvolume, suggesting adverse effects onthyroid function (8).

RecommendationsThe IDD control program inwestern Cameroon, in place for 15years, demonstrates the effectivenessof USI in eliminating IDD. But asBamoungoum is only one sentinelzone out of 20, this raises the questi-on: is Bamoungoum representative ofthe entire country? Similar impactstudies should be conducted in othersentinel zones or a new national sur-vey should be done. More frequentmonitoring of the USI/IDD pro-gram in Cameroon is needed, and,specifically, a revision of salt iodizati-on regulations to the recommended

range, that is, 25-45 ppm as iodine or35-65 ppm as potassium iodate (9).

References1. Aquaron R. et al (1976-1978; report oniodine in drinking water in Noun,Bamoungoum, Upper Sanaga and Kribbi);cited in Lantum et al. a Base-Line Survey ofIDD In Cameroon (1990-1991).2. Lantum D. N., Bailey K.V.,Thilly J. C.,Benmiloud M. and Ngum J.W. (1991); GoitreSurvey in Bamoungoum – West Province ofCameroon in March – April 1991.3. Lantum D. N. et al (1990-1991); Base-lineSurvey of Iodine Deficiency Disorders inCameroon: Public Health Unit, UCHS,University of Yaounde.4. Siebetcheu D. et al (2003); ImpactEvaluation of Salt Iodization in Cameroon, in

IDD NEWSLETTER ,Vol. 19, N° 2, May2003 pp 26-27.5. Arrêté 0133/A/MSP/SG/DSFM/SDSF/

SN (29 Mai 1991)Portant utilization dusel iodé dans la pro-phylaxie des Troublesdûs à une carence eniode (TDCI).Ministère de la Santé.6. Monyuytaa E. L.,Bonglaisin J. N.,Lantum D. N. (2006) ;Report of ICCIDDMission to SaltRefineries at DoualaPort in LittoralProvince on 28-30thMarch 2006.7. Delange F., deBenoist B., Pretell E.,and Dunn J.T,ICCIDD and WHO(2001), IodineDeficiency in theWorld:Where do westand at the turn ofthe Century? IDDNEWSLETTER,August 17(3).8. Zimmermann MB,Ito Y, Hess SY, FujiedaK, Molinari L. (2005)High thyroid volumein children withexcess dietary iodineintakes.Am J ClinNutr. 81:840-4.9. WHO/UNICEF/ICCIDD (1996);RecommendedIodine Levels in Saltand Guidance for

Monitoring their Adequacy and Effectiveness.WHO; Geneva, Document WHO/NUT/96.13.

Table 1: Median urinary iodine concentration by school inBamoungoum, western Cameroon in 2006

School n UI (µg/L)

Ecole Publique de Mbi A 39 387

Ecole Publique de Mbi B 40 327

Ecole Publique Mbi 2 13 339

Ecole Catholique St Antoine de Doumelong 27 340

Ecole Publique de Chefferie Bamoungoum 32 600

Ecole Publique Camp Militaire 32 345

Total 183 389

Table 2: Distribution of urinary iodine concentrations in chil-dren in Bamoungoum in 2006

UI (µg/L) % Iodine intake

0-20 0 Severe Deficiency

20-<50 0 Moderate

50-<100 0 Mild

100-<300 20.2 Adequate

300 and above 79.8 Excess

Table 3: Iodine concentrations salt samples at productionpoint in Douala, March 2006

Brand n Iodine (ppm)

Socapursel 12 28

Sotrasel 12 38

Aigle 10/8 41/52

SSS/SOREPCO 28/14 144/879

IDD NEWSLETTER FEBRUARY 2007 TUVA 17

Two Kiwanians travel to Siberiato test the effect of iodine onanimal productivity

In 1999 Dr. Robert DeLong,ICCIDD Board Member from DukeUniversity, USA, was invited to eva-luate IDD in Tuva. He examinedchildren in remote villages and foundhigh rates of IDD.As an interimsolution, Dr. DeLong proposedadding iodine to salt blocks for ani-mals. He felt this would bring iodineto the local people through meat andrelated products like milk, cheese andbutter. His proposal was based onsimilar work done in the UK in the1920s. Dr. DeLong met with thePresident of Tuva and an agreementwas reached. If salt processing andiodination equipment were providedto the government of Tuva, then thegovernment of Tuva would furnishsalt, iodine and funding for the pro-ject.

With the agreement in hand, Dr.DeLong ordered the processingmachinery and submitted a grantrequest to Kiwanis/UNICEF formoney to cover the equipment and

to conduct follow-up medical stu-dies. The grant request was turneddown: it was felt Tuva was so remotethat monitoring would be too diffi-cult. Since the salt processing machi-nery was already ordered, and almostready for shipment, two Kiwaniansfrom New Jersey, USA, John Greenand Jerry Brenner convinced theKiwanis Foundation to adopt theproject and raise funds; living up totheir motto:“Young Children –Priority One!”

The equipment finally arrived inTuva in September 2002 and wasinstalled and tested. Further talkswith government officials indicatedthe equipment would be operatedand funded by the Republic of Tuva.The equipment was placed under thecontrol of the Ministry of Agricul-ture because its interim use wasaimed at livestock. Unfortunately,since then there has been very littleprogress in salt iodination in Tuva.

However, John and Jerry were deter-mined to get iodine to children inremote areas of Tuva.They madeseveral trips to Tuva in an effort toprovide iodized salt blocks to far-mers, and to determine the effects ofiodized salt on the productivity ofthe livestock.They worked closelywith a local doctor, Dr. RimmaChubarova. Dr. Chubarova, whosupervised all the local study work,from the manufacture of the saltblocks to the selection of farms andthe recording of all results, didn’tspeak English. John and Jerry can notspeak Russian. But somehow theymanaged.

A study was done in 2005-2006.TheTuvan Ministry of Agriculture pro-duced iodized salt blocks that weredistributed to three “test” farms andthree other farms served as controls.The farms were similar in the num-ber of animals maintained and theirgeneral care and conditions (feed,water and housing).All farmersreceived free block salt for a periodof six months and all were compen-sated for their participation (3000Rubles or a little more than $100).

“…if we can demonstrate increa-sed livestock productivity due toiodine, all farmers will want to usesalt with iodine and that may getmore iodine to the citizens ofTuva.” John Green

John Green and Jerry Brenner Kiwanis Chapter, New Jersey, USA

The Republic of Tuva, population about 350,000, belongs to the Russian Federation.It lies next to Mongolia at the geographic center of Asia, and mountain ranges isolateit from the rest of Siberia. It has long been affected by severe IDD.

Tuvans in traditional dress

Personal stories

Manufacture of the iodized salt blocks in Tuva

18 IDD NEWSLETTER FEBRUARY 2007 CHINA

During the study, in addition to livebirths, information was gathered onthe amounts of iodine contained inthe milk and urine of the animalsbefore and after 6 months of iodinesupplementation. In the iodine sup-plemented farms, all types of live-

stock – cows, ewes and does – show-ed increases in productivity. Overall,animal productivity doubled in thefarms receiving iodine.

In a poor country like Tuva, increa-sing animal productivity by iodinesupplementation could provide aneconomic boost.The participatingfarmers recognized the clear diffe-rences between “test” and “control”farm productivity.They have discus-sed iodized salt at their local mee-tings and will insist on iodized saltblocks in the future. Prof. RobertDelong, commenting on the resultsof the study, said:“This type of datafor animals is not unprecedented, butit is of great importance, to my

mind. It demonstrates that iodinesupplementation can have importanteconomic advantages for animal hus-bandmen. Milk and meat from sup-plemented animals benefits humans.Probably iodization of animalsshould have greater attention in allareas of severe iodine deficiency.”

Prof Chen Zu-Pei was surprised tofind several young cretins during arecent field study in July 2006 inAkesu Prefecture of SouthernXinjiang. He identified 16 cretinsaged less than 15 years, with theyoungest being 3 years old.Responding to his report of severeiodine deficiency in this region, theChinese Ministry of Health imme-diately sent a team to confirm thefindings and expand the investigationto three counties located in Akesuand Hetian Prefectures.

The team, led by Prof. Sun Dianjunand Prof. Chen Zupei, worked fortwo weeks and then held a 3-dayworkshop.Thirty six cretins less than10 years old were identified (mainlyneurological cretins); of these, 14cases were aged less than 6 years.Thecretins were found in villages wheremainly non-iodized rock salt is used.In the local primary schools, it wasestimated that 10 IQ points were lost(measured by the China Ravens’Test)

and 16% of school children exhibitedmild mental retardation (IQ in therange of 50-69).

The MOH decided on the followingurgent measures:

To implement an iodized oil pro-gram in the three counties where

endemic cretins were identified.Thisprogram is planned to last until iodi-zed salt can be made available.

To expand the investigation to theentire region of southern Xinjiang.The total population of this region is8 million living in 5 prefectures, inwhich there are 3 prefectures withpotential new cretins.

The government of Xinjiang wasto hold a Teleconference AdvocacyMeeting

To expand the investigation intothe Western areas of China wherethe coverage of iodized salt is below70%; these provinces include Tibet,Xinjiang, Qinhai, Gansu, Ningxia,Sichuan. Chongqing and Yunnan.This program will start in early 2007.

A monitoring plan will be develo-ped for identifying high-risk areas.

National Training Courses will beorganized for health workers in theregion on identifying endemic creti-nism.

New cretins discovered in southern Xinjiang, ChinaChen Zu-Pei ICCIDD Reginal Coordinator for China and East Asia

John and Jerry examining salt iodizationmachinery in Tuva

Canada Supports Salt Iodization forAfghan ChildrenThe Government of Canada has announced a$500,000 contribution to the MicronutrientInitiative to provide salt iodization programsfor 10 million Afghans. Iodine deficiency--prevalent in Afghanistan--causes many infantsto be born mentally impaired, and lessens theability of children and youth to learn andwork.This initiative in Afghanistan is expec-ted to prevent over 100,000 children frombeing born mentally impaired. "We are plea-sed that the Canadian government continuesto invest in cost-effective micronutrient pro-grams that have the power to reach millionsof children in the world's poorest countries,"said Venkatesh Mannar, President of theMicronutrient Initiative. "In Afghanistan,where the prevalence of iodine deficiency isamong the highest in the world, eliminatingvitamin and mineral deficiencies is critical forpeople's health and well-being as well as tonational economic development."

ICCIDD Annual Board MeetingThe ICCIDD Annual Board Meet-ing was held in Manila, Philippines,on February 3-4, 2006.The meetingwas graciously hosted by Dr.TheoSan Luis, ICCIDD Focal Point forthe Philippines.The meeting beganwith Reports of the Chair, ExecutiveDirector, Secretary and Treasurer.Discussions on resource developmentfor ICCIDD included the changingdevelopment aid environment, newbilateral aid potential, the role offoundations, and the potential of

advertising and product endorsements.Organizational goals that were discussedincluded the work plan, a vision statement,dealing with national programs, improvingregional relations, the Global Network andcollaborations on country monitoring.Committee reports were given by ResourceDevelopment, the Salt Committee, theScience Committee, as well as reports on the

Newsletter and new ICCIDD Website.Theworking budget for 2007 was approved, andlifetime service awards were distributed.Themeeting was immediately followed by the 8thCongress of the Asia-Oceania ThyroidAssociation, February 4-6, 2007, at the WestinPhilippine Plaza Hotel in Manila.

The 2007 Micronutrient ForumMeetingThe first international meeting of the Micro-nutrient Forum will take place on 16-18April 2007 in Istanbul.The theme of theconference is,“Consequences and Control ofMicronutrient Deficiencies: Science, Policy,and Programs – Defining the Issues.”

Thyroid Disease in Older Adults:Diagnosis, Management, and ClinicalImpactThe American Thyroid Association will holdthis meeting on Friday, May 18, 2007, inWashington, DC. It is endorsed by theAmerican Geriatrics Society. For informati-

on: website: www.thyroid.org; orcontact: thyroid@thyroid.org.

The 60th World HealthAssemblyThe 60th World Health Assemblywill take place on 14-23 May 2007,at the Palais des Nations in Geneva,Switzerland.

IDD NEWSLETTER FEBRUARY 2007 MEETINGS AND ANNOUNCEMENTS ABSTRACTS 19

Meetings and Announcements

AbstractsEffect of a mandatory iodization pro-gram on thyroid gland volume basedon individuals' age, gender, and pre-ceding severity of dietary iodine defi-ciency: a prospective, population-based study.Vejbjerg P et al. J Clin EndocrinolMetab.2007 Jan 30; [Epub ahead of print]The authors aimed to prospectively evaluatethe effect of four years' mandatory iodizationof salt (13 ppm iodine) on thyroid volume intwo regional areas in Denmark with mild ormoderate iodine deficiency.Two separatecross-sectional studies were performed before(n=4649) and after (n=3570) salt iodization.Women aged 18-65 years, and men aged 60-65 years were examined, and thyroid ultraso-nography was performed.A lower medianthyroid volume was seen in all age groups

after iodization.The largest relative declinewas found among the younger females fromthe area with previous, moderate iodine defi-ciency.After iodization there were no regio-nal differences in median thyroid volume inthe age groups less than 45 years of age.

Iodine nutrition status of exclusivelybreast-fed infants and their mothers inNew Delhi, India.Gupta R et al. J Pediatr Endocrinol Metab.2006;19(12):1429-35.The authors assessed the iodine nutrition ofexclusively breast-fed infants and theirmothers. Spot urinary iodine (UI) and serumTSH levels were measured in 175 infants andtheir mothers. Iodine content of salt used byparticipants was also analyzed.The medianUI levels in mothers and infants was 124

µg/L and 162 µg/L, respectively. Serum TSHwas elevated in 29% of mothers and 2% ofinfants. No correlation was observed betweenindividual mother-infant UI or serum TSHlevels. Over 90% of the salt samples testedhad adequate iodine concentration.

Iodine status of Tasmanians followingvoluntary fortification of bread withiodine.Seal JA et al. Med J Aust. 2007;186(2):69-71.The aim of this study was to describe iodinestatus of Tasmanians following voluntary for-tification of bread with iodine in October2001. Cross-sectional UI surveys ofTasmanian schoolchildren aged 8-11 yearswere done. Median UI was 75 µg/L in 1998,72 µg/L in 2000, 105 µg/L in 2003,

ICCIDD Board members at their2007 meeting inManila

Prof. Chandrakant Pandav (l) receiving anappreciation award for longstanding servicefrom the ICCIDD Chair, Jerry Burrow

109 µg/L in 2004 and 105 µg/L in 2005.Median UI in post-intervention years (2003-2005) was significantly higher than in pre-intervention years. Switching to iodized saltin bread appears to have resulted in a signifi-cant improvement in iodine status inTasmania. Given iodine deficiency has beenidentified in other parts of Australia and inNew Zealand, mandatory iodine fortificationof the food supply in both countries is wort-hy of consideration.

Child development: risk factors for adverse outcomes in developing countries.Walker SP et al. Lancet.2007;369(9556):145-57.Poverty and associated health, nutrition, andsocial factors prevent at least 200 millionchildren in developing countries from attai-ning their developmental potential.The aut-hors reviewed the evidence linking compro-mised development with modifiable risks inchildren from birth to 5 years of age. Iodinedeficiency was one of four key risk factorswhere the need for intervention is urgent:the others were stunting, inadequate cogniti-ve stimulation and iron deficiency anemia.The risks often occur together or cumulati-vely, with concomitant increased adverseeffects on the development of the world'spoorest children.

Iodine deficiency persists in the Zanzibar Islands of Tanzania.Assey VD et al. Food Nutr Bull.2006;27(4):292-9.The authors aimed to establish the prevalenceof iodine-deficiency disorders in twoZanzibar Islands, a community assumed tohave ready access to iodine-rich seafoods. Inschoolchildren, goiter prevalence was 21.3%for Unguja and 32.0% for Pemba.The overallmedian UI was 128 µg/L. For Unguja themedian was 186 µg/L, a higher value thanthe median of 53 µg/L for Pemba.The household availability of iodated salt was63.5% in Unguja and 1.0% in Pemba.Thecommunity was not aware of IDD or iodatedsalt.These findings contradict the commonassumption that an island population withaccess to seafood is not at risk for IDD.

Efficacy of daily and weekly multiplemicronutrient food-like tablets for thecorrection of iodine deficiency inIndonesian males aged 6-12 mo.Wijaya-Erhardt M et al. Am J Clin Nutr.2007;85(1):137-43.The authors aimed to compare the efficacyof daily and weekly multiple micronutrientfood-like tablets (foodLETs) on iodine statusin infants. In a double-blind, placebo-control-led trial, 133 Indonesian males aged 6-12 mowere randomly assigned to 1 of 4 groups: adaily multiple-micronutrient foodLET provi-ding the Recommended Nutrient Intake(RNI)(DMM), a weekly multiple-micronu-trient foodLET providing twice the RNI(WMM), a daily 10-mg Fe foodLET (DI), orplacebo.At baseline, only 31% of subjects hada UI <100 µg/L.At 23 wk, the DMM grouphad the highest increment in UI; however,after adjustment for initial UI, the changes inUI were not different between the 4 groups.The DMM group had the greatest reductionin the proportion of iodine-deficient infants.The authors concluded that daily consumpti-on of a foodLET providing the RNI duringinfancy can improve iodine status.

Urine iodine measurements, creatinineadjustment and thyroid deficiency inan adult United States population.Haddow JE et al. J Clin Endocrinol Metab.2007 Jan 2; [Epub ahead of print]The aim of the study was to determine if lowurine iodine was associated with thyroid defi-ciency in the US. Using the NHANES IIIdata set, median TSH and total T4 valueswere examined according to deciles of urineiodine (with and without creatinine correcti-on).Among the 5,963 men and 5,722women, median UI did not vary with increa-sing age, while median creatinine levelsdecreased. UI and creatinine concentrationswere lower among women.TSH increasedwith age, while total T4 decreased. NeitherTSH nor total T4 median values were asso-ciated with UI.A multivariate regression ana-lysis revealed only a weak association bet-ween UI and markers of thyroid function.The authors concluded that in the UnitedStates, the non-pregnant, adult population isiodine sufficient.

Selenium and goiter prevalence in borderline iodine sufficiency. Brauer VF et al. Eur J Endocrinol.2006;155(6):807-12.The authors investigated the influence ofselenium (Se) on thyroid volume in 172 sub-jects from area with borderline selenium andiodine sufficiency.The mean urinary Se(USe) and UI concentrations were 24 µgSe/L or 27 µg Se/g creatinine, and 96 µg I/Lor 113 µg I/g creatinine. Subjects with goiter(n=89) showed significantly higher USelevels than probands with normal thyroidvolume.The authors concluded that USe isnot an independent risk factor for the deve-lopment of goiter in borderline iodine suffi-ciency.

Thyroid hormone synthesis and secretion in humans after 80 milli-grams of iodine for 15 days and subsequent withdrawal.Theodoropoulou A et al. J Clin EndocrinolMetab. 2007;92(1):212-4.The study aim was to determine whether, inhuman thyroid, administration of large dosesof iodine for a relatively long time results inalterations of intrathyroidal hormonal (HI),T4 and T3, and total iodine (TI) content, aswell as whether changes in serum concentra-tion of thyroid hormones and TSH wouldoccur after iodine administration or disconti-nuation. In 33 euthyroid patients, Lugol solu-tion (80 mg iodine) was administered for 15d. Groups of six to eight patients underwentoperation 0, 5, 10, and 15 d after iodinewithdrawal. Intrathyroidal HI content andserum T4 and T3 were unchanged duringand after iodine discontinuation.TI wasincreased during iodine administration andreturned to control values 5 d after disconti-nuation of iodine. Serum TSH was increasedduring iodine administration and returned tocontrol values 10 d after iodine withdrawal.The authors concluded that administration ofhigh doses of iodine increased intrathyroidalTI, but did not change HI or serum T4 andT3.

THE IDD NEWSLETTER is published quarterly by ICCIDD and distributed free of charge in bulk by international agencies and by individual mailing.The Newsletter also appears on ICCIDD’s website (www.iccidd.org). The Newsletter welcomes comments, new information, and relevant manuscriptson all aspects of iodine nutrition, as well as human interest stories on IDD elimination in countries.

For further details about the IDD Newsletter, please contact:Michael B. Zimmermann, M.D., the editor of the Newsletter, at the Human Nutrition Laboratory, Swiss Federal Institute of Technology Zürich, ETHZentrum, Schmelzbergstrasse 7, LFW E19, CH-8092 Zürich, Switzerland, phone: +41 44 632 8657, fax: +41 44 632 1470,iccidd.newsletter@ilw.agrl.ethz.ch.

ICCIDD gratefully acknowledges the support of UNICEF and the Swiss Federal Institute of Technology Zürich for the IDD Newsletter.

© Copyright 2007 by International Council for Control of Iodine Deficiency Disorders

Des

ign:

Urs

Im

holz

8706

Fel

dmei

len,

Sw

itzer

land

20 IDD NEWSLETTER FEBRUARY 2007