Salt for Freedom
and
Iodized Salt for
Freedom from Preventable Brain Damage
The All India Institute of Medical Sciences, New Delhi
ICCIDD
June 2005
* The All India Institute of Medical Sciences, New Delhi* The All India Institute of Medical Sciences, New Delhi
##
Indian Coalition for Control of Iodine Deficiency Disorders (ICIndian Coalition for Control of Iodine Deficiency Disorders (ICCIDD)CIDD)
Dr. Chandrakant
S. Pandav*#
Dr. Anil Kumar#
Dr. Denish
Moorthy#
Dr. K. Anand*
Dr. R. Sankar#
Dr. M. G. Karmarkar#
Ensuring freedom from preventable brain damage
Sustainable Elimination of Iodine Deficiency Disorders
in India
Ensuring freedom from preventable brain damage
Towards Sustainable Elimination of
Iodine Deficiency Disorders in India
Vision for the Nation
“With our resources and the money we spend,
we could easily accomplish three times what we do,
in half the time we normally take,
if we were to operate in mission mode with a vision for the nation”
-Dr. A. P. J. Abdul Kalam
President of India
(“Ignited Minds”)
Outline of presentation1.
What is iodine & what is iodine deficiency?
2.
What are the consequences of iodine deficiency?
3.
How do we eliminate iodine deficiency?
4.
The Kangra Valley Study (1956 –
1972)
5.
New Evidence: From Endemic Goiter to IDD (1962 –
1983)
6.
What is the status of iodized salt coverage in India? (1998-99; 2002)
7.
Changing status of legislation (1968-2005)
8.
Key issues in IDD
9.
Do we need Universal Salt Iodization?
10.
Why did consumption of iodized salt decrease?
11.
The way forward
1. What is iodine &
what is iodine deficiency?
What is iodine? -
1• Nutrient needed in a
minute quantity daily. Recommended daily intake:
150 μg (Micronutrient)
• Total quantity present in body
is (15-20 mg) mostly in thyroid gland
What is iodine? -
2
• Iodine: Essential component of
thyroid hormones,
which are needed for:
-
Optimal mental & physical development
-
Regulation of body metabolism
(Generation & utilization of body energy)
Iodine : Daily requirements
Age Group Iodine Requirement (µg/day)
0 –
11 months 50
12 –
59 months 90
6 –
12 years 120
>
12 years 150
Pregnant & Lactating Women 200
[WHO, UNICEF, ICCIDD: Recommended iodine levels in salt and guidelines for monitoring their adequacy and effectiveness. WHO/NUT/96.13. Geneva. 1996 ]
Sources of iodine
• Food is the main source of iodine– Meat, fish & dairy products
– Vegetables, cereals
• High amounts in sea fish & seaweeds
• Sea salt is a poor source of iodine
Iodine deficiency –
Disease of the soil
Melting of Glaciers
Floods
Rivers changing course
Gradual leaching of iodine from soil due to:
Iodine deficiency : A disease of the soil
SOIL EROSION
: WATER, SOIL
Environmental iodine deficiency
Low Availability : PLANTS Iodine poor feeds & of iodine
fodders, goitrogens
Effect on animals
: LIVESTOCK Clinical & Reproductive disorders,
Decreased productivity
Effect on people
: HUMANS
Health & Socio - economic impact
2. What are the consequences of iodine deficiency?
1. What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
Goiter has been known since the days of Lord Buddha and before
Earliest evidence of goiter: 3000 BC
Importance of iodine in brain development -
1
• 50,000 brain cells produced/second
in developing fetal brain
• 100 billion brain cells in adult
• One million billion connections between these brain cells:
Determine IQ
Importance of iodine in brain development -
2
100 billion brain cells in adult human
Comparable to the number of stars in the sky
Brain cell branching
• Diminished brain cell branching due to iodine deficiency• Diminished branching Less connections Lower IQ
Importance of iodine in brain development -
4
90 % of human brain development occurs between 3rd
month of pregnancy & 3rd
year of life (Critical period)
Importance of iodine in brain development -
5
• Deficiency of iodine during this critical period of development results in permanent brain damage
• This brain damage can primarily be prevented by correcting iodine deficiency before & during pregnancy
• This makes it vital that all expectant
& lactating mothers get their
daily requirement of iodine
Importance of iodine in brain development -
6
• Iodine deficiency is single most common cause of mental handicap worldwide
• It is totally preventable
Spectrum of IDDGoiter
Loss of 13 IQ points,
Leading Cause of Mental handicap
Cretinism
Spontaneous Abortions,
Stillbirths,
Birth Defects
Defects of Speech & Hearing,
Squint,
Psychomotor defects
Iceberg of IDD
1% - 10%
Cretinism
5% - 30%
Some brain damage
30% - 70%
Loss of energy due to hypothyroidism
Effects on humans: Fetus
Mortality
• Spontaneous abortions & stillbirths• Increased perinatal
mortality
Disability• Birth defects• Defects of speech & hearing• Psychomotor defects• Cretinism
Effects on humans: Neonate
Mortality
• Increased neonatal mortality
Morbidity
• Neonatal Goiter• Neonatal Hypothyroidism
(Decreased production of thyroid hormones at birth)
Effects on humans: Children & adolescents
• Goiter• Hypothyroidism• Retarded physical development• Impaired mental function (13 IQ points)
LOSS OF IQ : IMPLICATIONS
The Intelligence Quotient (IQ) score of children living in an iodine deficient environment is nearly 13 IQ points less than those living in iodine sufficient environments
IMPLICATIONS OF LOSS OF IQ
Poor scholastic performance
Frequent failures / grade repetitions
Absenteeism / Dropouts
Impact : Retarded social & economic growth
Effects on humans: Adults
• Goiter & its complications
• Hypothyroidism
• Impaired mental function
• Iodine induced hyperthyroidism (IIH)
Effects on all age groups: Iodine deficiency & nuclear radiation
• Iodine deficiency leads to increased susceptibility to nuclear radiation
• When there is iodine sufficiency, the thyroid gland does not take up
radioactive iodine
• Therefore, in iodine deficient
populations, it is critical to have
effective universal salt iodization
Effects on livestock
• Goiter
• Hypothyroidism
• Reproductive disorders
• Decreased productivity
(Milk, meat, wool, eggs)
• Lower work outputGoiter in animal
3. How do we eliminate iodine deficiency?
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock
Iodine deficiency disorders: A public health problem -
1
Worldwide distribution
Iodine deficiency disorders: A public health problem -
2
• High risk groups: -
Pregnant & lactating women
-
Pre-school children
• Elimination of IDD: -
is an important developmental &
social goal for governments (UNGASS 2002; MDG –
2015)
-
is possibleUNGASS: United Nations General Assembly Special Session on Children
MDG: Millennium Development Goals
Our primary concern
To ensure that:
• Every population should&
• Every mother & child mustGet their daily supply of iodine
Iodine consumption on daily basis for all times to come
• Daily requirement of iodine per person is 150 µg –
fits on the tip of hair !
• Lifetime requirement for 70 years is 5 gms – one teaspoonful !
• However, this daily requirement has to be met daily, for all times to come
• “Daily consumption of adequately iodized salt is a healthy habit”
Vehicle for iodine : Salt• One food item consumed every day,
by everybody in fixed quantities
• Rich or poor, urban or rural area, man or woman, child or adult
• Average daily consumption in India per person is 10 gm
• Iodization of salt is a simple process
• Cost of salt iodization is : 10 paise/person/year
Iodized salt –
The panacea for iodine deficiency
Salt production and iodization
(Supply)
Promotion of Iodized Salt Consumption
(Demand)
4. The Kangra Valley Study (1956 –
1972)
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock
3.
How do we eliminate iodine deficiency?
-
By daily consumption of adequately iodized salt
Prof. V. Ramalingaswami8 August 1921 –
28 May 2001
Legacy of The LegendScience & Society
Kangra
Kangra Valley StudyPioneer study conducted in
Kangra District of
Himachal
Pradesh, by
Prof. V. Ramalingaswami
Himachal
Pradesh
From evidence to program –
1 The Kangra Valley study (1956-1972)
Study design Community based Prospective controlled trial
Study area Kangra Valley, Himachal
Pradesh Divided into 3 zones –A , B , C
Study period 1956 -
1972
Study duration 16 years
Study population 1,00,000 School age children
Outcome variable
Goiter prevalence among school age children
From evidence to program –
2 The Kangra Valley study (1956-1972)
• Baseline survey in 1956
• Salt distributed to three zones– Zone A : Salt + Potassium iodide– Zone B : Plain salt– Zone C : Salt + Potassium iodate
• 15 gms of salt/person/day– So as to ensure 200 µg of iodine/person/day
• Salt produced by Hindustan Salts Ltd. at Sambhar lake (Rajasthan)
with UNICEF assistance
Kangra Valley study area
From Pathankot
To Kulu
Dharamsala
Zone A
KI Salt Zone B
Plain Salt Zone C
KIO3
Salt
From evidence to program –
3 The Kangra Valley study (1956-1972)
Administrative Interventions
– Legislation (ban on sale of non-
iodized salt in study area)
– Iodized salt distributed through government shops
– No price difference between iodized and non-iodized salt
From evidence to program –
4.1 The Kangra Valley study (1956-1972)
10%
20%
30%
40%
Prevalence of goiter in zone A (KI salt)
1956 1962 1968
40%
19%
8%Goi
ter
prev
alen
ce in
%
Intervention
From evidence to program –
4.2 The Kangra Valley study (1956-1972)
Prevalence of goiter in zone B (Plain salt till 1962, then KI salt)
10%
20%
30%
40%
1956 1962 1968
40%
15%
Goi
ter
prev
alen
ce in
%
Intervention
42%
From evidence to program –
4.3 The Kangra Valley study (1956-1972)
10%
20%
30%
40%
Prevalence of goiter in zone C (KIO3
salt)
1956 1962 1968
40%
15%
5%Goi
ter
prev
alen
ce in
%
Intervention
From evidence to program –
5 The Kangra Valley study (1956-1972)
Conclusions
• Iodine supplementation in the form of adequately iodized salt on a regular and continuous basis reduces goiter prevalence
Recommendations
• Establish a National Goiter Control Programme (NGCP)
As a result, National Goiter Control Program established in 1962
5. New evidence: From goiter to IDD (1962 –
1983)
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock
3.
How do we eliminate iodine deficiency?
-
By daily consumption of adequately iodized salt
4.
The Kangra Valley Study: 1956 –
1972
-
Provided scientific basis for NGCP
Scenario after Kangra Valley studyNational Goiter Control Program (NGCP)
launched at the end of Second Five Year Plan (1962)
Aims
: 1) Initial survey to identify endemic areas
2) Production & Supply of iodized salt to endemic areas
3) Impact assessment surveys after five years
Approach
: District specific program
NGCP activities (1962-1983)
Salt iodization plants established in public sector
Rajasthan:
5
Gujarat:
3
West Bengal:
4
Estimated need/year 1.00 million tons (100%)
Production Capacity / year 0.38 million tons ( 38%)
Actual production / year 0.15 million tons ( 15%)
}12
NGCP: Low priority
• Goiter: -
is painless
-
not a cause of death -
has been perceived as a
cosmetic problem only -
socio-cultural norm
in some groups
• Therefore, NGCP received low priority from the viewpoint of government as a national public health program,
and also from the population
New epidemiological evidence: 1962-1983
• Delhi study : Endemic goiter in Delhi, 1980• Extra Himalayan foci of IDD reported• 1984 –
86 : ICMR multicentric study
- 14 districts in 9 states
(outside traditional “goiter belt”)- Goiter Prevalence : 21%- Endemic cretinism: 0.7%
Iodine Deficiency Disorders : A public health problem
in all states/UTs of India
• Subsequent surveys carried all over India
Iodine deficiency & learning disabilities
Global studies
School age children living in iodine deficient
environment, on an average, have 13 I.Q.points less than those living in iodine sufficient
environment(Bleichrodt N, Born M Ph. A meta-analysis of research on iodine and its relationship to cognitive
development. In: Stanbury JS (ed). The damaged brain of iodine deficiency – Cognitive behavioral,
neuromotor, educative aspects. New York: Cognizant Communication Corporation, 1994:195-200 )
Meta-analysis of 21 studies, 8 countries
Iodine deficiency & learning disabilities
Indian studies
1.
Intellectual assessment of school children from
severely iodine deficient villages
Mehta M, Pandav CS, Kochupillai N. Indian Pediatr 1987;24:467.
2.
Developmental lag in pre-school children of
goitrous
mothers.
Upadyaya SK et al. Indian Pediatr 1983;20:259
3.
Intellectual and motor development in school children from severely iodine deficient region -
Sikkim
Sankar R, Pandav CS, et al. Indian J Pediatr 1994;61:407-414
All studies point to impaired intellectual and physical development, and reduced psychomotor performance due to iodine deficiency
Iodine Deficiency = Goiter = Visible Swelling
No Pain, Cosmetic problem
Cretinism: A rare event= LOW PRIORITY
Brain DamageLack of Energy - hypothyroidism
Learning Disability, ↑Deaths
Child Development & Child Survival
Human Resource Development
= HIGH PRIORITY
The hourglass of IDD
Historic view
1962-1983
Current view
1984 onwards
Universal Salt Iodization
• In 1983, Government of India took policy decision to iodize all salt meant for
human consumption –
Universal Salt Iodization (USI)
• Private sector was permitted and encouraged to produce iodized salt
• “Elimination of goiter”
was included in Prime Minister’s 20-point National Development Program
6. What is the status of iodized salt coverage in India?
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock
3.
How do we eliminate iodine deficiency?
-
By daily consumption of adequately iodized salt
4.
The Kangra Valley Study: 1956 –
1972
-
Provided scientific basis for NGCP
5.
New evidence: From endemic goiter to IDD (1962-1983)
Salt iodization -
1 Progress after declaration of USI *
Variables 1962 –
1983 1984 –
2003
No. of Salt iodization plants 12 859
Production Capacity(in million tons)
0.038 12.2
Estimated requirement/year(in million tons)
0.1 5.0
Actual Production(in million tons)
0.015 4.1
Actual ProductionRequired Production
15% 82%
Production: in Public Sector 100% 2.5%
Production: in Private Sector,including cooperatives
0% 97.5%
* Universal salt iodization (USI) proposed by Government of India in 1983
Salt iodization -
2 Progress from 1985 –
2003
Production of iodized salt in India (Million Tons)
0.3
1985
2.5
1990
3.7
1995
4.7
2000
4.5
2001 2002
4.2
2003
4.1
1
2
3
4
5
Ban lifted
Salt production in India (2003)
StateSalt produced
(% of total)
Gujarat 71
Tamilnadu 16
Rajasthan 9
Andhra Pradesh 2
Maharashtra 1
Others 1
Total 100
Source: Annual Report (2003 –
2004), Salt Department, Govt. of India
}96
Production of Refined Iodized Salt
0
20
40
60
80
100
Gujarat
Tam
ilnadu
Rajasthan
Others
Refineries Refined IodizedSalt
RefineriesRefined Iodized Salt
Gujarat Tamilnadu Rajasthan Others Total
Number of refineries 26 (65%) 7 (17%) 2 (5%) 5 (13%) 40 (100%)
Production of refined iodized salt
1083 (81%) 182 (14%) 60 (4.5%) 6 (0.5%) 1331 (100%)
%
Production of Unrefined Iodized Salt
010203040506070
Gujarat
Tam
ilnadu
Rajasthan
Others
Salt Iodizationunits
UnrefinedIodized Salt
Salt IodizationunitsUnrefinedIodized Salt
Gujarat Tamilnadu Rajasthan Others Total
Number of iodization units
300 (36.6%) 74 (9%) 297 (36.2%) 148 (15.2%) 819 (100%)
Production of unrefined iodized salt
1722 (61.7%) 392 (14%) 550 (19.7%) 125 (4.6%) 2789 (100%)
State wise production of refined & unrefined iodized salt
State Refined salt production
Unrefined salt production
Gujarat 1083 (81%) 1722 (61.7%)
Rajasthan 60 (4.5%) 550 (19.7%)
Tamilnadu 182 (14%) 392 (14%)
Others 6 (0.5%)125 (4.6%)
Total 1331 (100%) 2789 (100%)
Indian Scenario: Use of iodized salt National Family Health Survey –
2
(1998-1999)
Iodized Salt Consumption at Household Level % Value
Adequate iodine in salt 49
Inadequate iodine in salt 22
No iodine in salt 29
Total 100
} 71%
Adequately iodized salt: contains 15 mg iodine/kg salt at household level (15 ppm)
Consumption of adequately iodized salt according to socio -
economic status
in India (NFHS-II, 1998-99)
LOW SES MEDIUM SES HIGH SES
36%50%
78%
64%50%
22%Inadequate InadequateInadequate
Adequate
Adequate
Adequate
Use of Iodized SaltUse of Iodized Salt at Household Level at Household Level ––
North EastNorth East
Meg
halay
a
63%55%
Naga
land
67%70%NFHS –2, 1998-99
DLHS - RCH, 2002
Mizo
ram
91%
52%
Man
ipur
88%
59%
Arun
acha
l
84%
57%
80%
59%
Assa
m
Sikk
im
79%
47%
Delhi
89%80%
J & K
53%
24%
Punjab
75%
64%NFHS – 2, 1998-99
DLHS - RCH, 2002
Use of Iodized SaltUse of Iodized Salt at Household Level at Household Level ––
NorthNorth
Himac
hal
91%87%
Harya
na
71%
53%
Bihar
47%
25%
Chhati
sgarh
57%
36%
47%
Jhark
hand
32%
NFHS – 2, 1998-99
DLHS - RCH, 2002
Use of Iodized SaltUse of Iodized Salt at Household Level at Household Level ––
HeartlandHeartland
57%
42%
M.P.
U.P.
49%
5%
49%
5%Uttra
ncha
l
27%
A. P
.
28%35%
Orissa
30%
Kera
la*39%
56%
Tamil N
adu*
21% 22%
NFHS – 2, 1998-99
DLHS - RCH, 2002
Use of Iodized SaltUse of Iodized Salt at Household Level at Household Level --
SouthSouth
Karn
ataka
43%
23%
Goa*
42%
54%56%
Gujara
t
38%
Rajasth
an
46%
24%
NFHS – 2, 1998-99
DLHS - RCH, 2002
60%
45%
Mah
aras
htra
Use of Iodized Salt at Household Level -
West
Progress with salt iodization in Iran
90
50
72
88
0
10
20
30
40
50
60
70
80
90
100
1994 1995 1996 1997
Progress with salt iodization in Vietnam
2532
83
49
61
73 75 78 79 80
0
10
20
30
40
50
60
70
80
90
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Progress with Salt Iodization in China
9080
70
40
0
20
40
60
80
100
1995 1997 1999 2002
Coverage rate of Iodized Salt meeting standards
Estimated percentage of households consuming adequately iodized salt
Bhut
an95%
China
93%
Vietn
am
77%
Thail
and
74%
Bang
lades
h
70%
Indo
nesia
65%
Nepa
l
63%
India
50%
Myanm
ar
48%UNICEF-2003
Burden in India & China
Country Newborns Unprotected in millions (%) per year
India 13.0 (50%)
China 1.3 ( 7 %)
India & China
Iodized salt coverage <80%
Iodized salt coverage >80%
Summary: Use of Iodized Salt at Household Level
1) India is performing poorly as compared to other countries in South East Asia Region
2) In general, there has been a gradual decrease in iodized salt coverage at the household level
3) Alarming situation in UP, Uttaranchal
4) * Kerala
& Goa
–
improvement after
state-level partnership activities5)
Poor performance by salt producing states: National Repercussions
(Gujarat, Tamilnadu, Rajasthan)
7. Changing status of legislation (1968 –
2005)
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock
3.
How do we eliminate iodine deficiency?
-
By daily consumption of adequately iodized salt
4.
The Kangra Valley Study: 1956 –
1972
-
Provided scientific basis for NGCP
5.
New evidence: From Endemic Goiter to IDD (1962-1983)
6.
What is the status of iodized salt coverage in India?
(1998-99; 2002)
Changing status of legislation
Iodized Salt brought under revised PFA Act1987
Sale & storage of non-iodized salt banned1997
Central Government decides to lift ban on
sale of non-iodized saltMay 2000
Ban on sale of non-iodized salt liftedSeptember 2000
Policy decision taken for Universal Salt Iodization1983
Iodized salt brought under PFA Act1968
Withdrawal of the ban
• Government of India withdraws ban on sale of non – iodized salt for human consumption (13th
September 2000)
• Reason given by Government of India: “Matters of public health should be left to
the informed choice, and not enforced through compulsion”
Before May 2000: All States (29) & UT (6) had the ban in place except
Andhra Pradesh & Maharashtra (Partial ban) Kerala (No ban)
Scenario after lifting of the ban
After lifting of the ban,
large quantities of non-iodized salt available
for human consumption
in Gujarat -
the major salt producing state
Ban remained in place 27 states & UTs
Ban partially remained in place
Andhra Pradesh, Maharashtra
Ban lifted & then reinstated Orissa
Ban lifted Gujarat, Arunachal
Pradesh
No ban Kerala
8. Key issues in IDD
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock
3.
How do we eliminate iodine deficiency?
-
By daily consumption of adequately iodized salt
4.
The Kangra Valley Study: 1956 –
1972
-
Provided scientific basis for NGCP
5.
New evidence: From Endemic Goiter to IDD (1962 –
1983)
6.
What is the status of iodized salt coverage in India?
(1998-99; 2002)
7.
Changing status of legislation (1968 –
2005)
Key issues in IDD
• National vs. Multinational
• Consequences of excess iodine
• Cost of iodine
• Cost of iodized salt
IDD control program is a national effort
Contribution Made For Assessment & Tracking Progress:
- By national institutions
- With national support
- By national scientists
- Using national laboratories & equipments
Issue 1:National vs
Multinational -
1
National vs. Multinational -
2
• India is self-sufficient in production of common salt
• High quality salt iodization plants -
manufactured in India,
-
exported to other countries
• Technical assistance by national agencies
National vs. Multinational -
3
• Conversion of iodine to potassium iodate done in India
• Iodine imported: -
Less than 0.005% of all imports
-
Only 20% of total iodine imported is used for iodizing salt
-
Rest (80%) goes to industries (pharmaceuticals, medicare, dyes)
• Reason for import: No natural source of iodine in India
• Japan: -
Average intake is 3,000 g/day
-
Seaweed soup -
20 times the required amount
-
No side effects reported
• Pharmacological dose of iodine:
-
200,000
g/day
-
1300 times required amounts
-
can cause iodide goiter.
Issue 2: Consequences of excess iodine –
1
Iodide goiter has not beenreported from salt iodization programs
Issue 2: Consequences of excess iodine –
2
• Increased incidence of IIH (Iodine Induced Hyperthyroidism)
– Place: Severe iodine deficiency of long duration
– Intervention: Introduction of salt with high iodine content (100 ppm) in a short period of time
– Predisposing conditions: Pre-existing autonomous thyroid nodule or latent Graves Disease
– People: Commonly affects older age group (>40 years)
Increased incidence of IIH is Increased incidence of IIH is transient, minimal and self limitingtransient, minimal and self limiting
Issue 3: Cost of iodine for salt iodization
Total annual requirement of iodized salt in India for 1,000 million population @5kg/person/year 5 million tons
Iodine required for salt iodisation@30ppm (30gm/ton)
150,000 kg(150 tons)
Price of iodine @ Rs. 666/Kg,
Therefore total price for 150 tons Rs. 10 million
Cost of iodine/person/year 10 paise
Cost of iodine for salt iodization is 10 paise/person/year
(¼
cents/person/year)
Elimination of Iodine Deficiency Disorders YES -
A Worthwhile Investment in Health
This work was conducted as part of the INCLEN Training of Dr. Pandav at McMaster University, Canada, 1990-1991
Cost of iodine/person/year 10 paise
Cost benefit ratio(only health benefits)
1:3
If benefits related to education (13 I.Q points) & livestock (increased productivity & yield of eggs, milk, wool, etc) included, then:Cost benefit ratio
1:10
Issue 4: Price of iodized salt
Acts and Rules for Salt
• “Salt”
is declared as an item of food under Essential Commodities Act, 1955
• State governments have been authorized to administer the Act for
– Fixing the prices of salt– Its movement within their States,
if necessary
Community perception about iodized salt
Iodized Salt
Refined Salt
Packaged Salt
Branded Salt
High Priced SaltIodized Salt =
The reality
Phoda
salt 0.25 0.25 ––
1.00 1.00 RsRs./Kg./Kg
Crystal salt 1.50 1.50 ––
2.00 2.00 RsRs./Kg./Kg
Powdered salt 2.00 2.00 ––
4.00 4.00 RsRs./Kg./Kg
Refined salt > 4.00 > 4.00 RsRs./Kg./Kg
I
O
D
I
Z
A
T
I
O
N
State / UT PDS selling price/ kg.
Chhattisgarh Rs. 0.25
Gujarat Rs. 0.50
Tamilnadu Rs. 2.50
Rajasthan Rs. 2.50
Sikkim Rs. 2.90 (Loose iodized)
Price of iodized salt through Public Distribution System (PDS)
in some Indian states -
1
Source: Annual Report (2003-2004), Salt Department, Govt. of India
Price of iodized salt through Public Distribution System (PDS)
in some Indian states -
2
State / UT PDS selling price/ kg.
Arunachal
Pradesh Rs. 3.15
Tripura Rs. 3.50
Orissa Rs. 2.00 –
7.00
Goa Rs. 6.00 –
7.00
Himachal
Pradesh Rs. 7.50
Source: Annual Report (2003-2004), Salt Department, Govt. of India
Total Monthly Per Capita Consumer Expenditure (MPCE) on salt per person *
*Reference period of 30 days
Source: National Sample Survey Round 55; NSS Report No. 545,
Household Consumer Expenditure in India: 1999-2000 –
Key Results
Variable Rural Urban (In Rs.)
Salt Rs. 1.09 Rs. 1.38
All Food items Rs. 289 Rs. 411
Salt as a % of
All Food Items0.37% 0.34%
Total Consumer Expenditure
Rs. 486 Rs. 855
Salt as a % of Total Consumer Expenditure
0.22% 0.16%
Consumer expenditure on salt is negligible : <0.5%
Universal salt iodization – Myths & facts -1
Issues Myth Fact
MultinationalMultinational companies have a stronghold on iodized salt
• All the salt in India is produced, iodized, packaged and sold by national companies• All research on iodine and iodized salt is done by national scientists in national institutions
MonopolyThe large companies have a monopoly over the salt production
Most of the salt in India is produced by the medium and small-scale producers
Universal salt iodization – Myths & facts -
2
Issues Myth Fact
PriceIodization has lead to an increase in the price of salt
• Cost of iodine per person per year is 10 paise!• Iodization increases the price by about 50 paise!• Increased price is due to costs of packaging, branding & advertisement etc.
Packaged vs non-packaged
salt
Iodized salt sold loose is not effective
• Loose iodized salt is equally effective• Over 70 percent of total iodized salt produced is sold loose
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock
3.
How do we eliminate iodine deficiency?
-
By daily consumption of adequately iodized salt
4.
The Kangra Valley Study: 1956 –
1972
-
Provided scientific basis for NGCP
5.
New evidence: From Endemic Goiter to IDD (1962-1983)
6.
What is the status of iodized salt coverage in India?
(1998-99; 2002)
7.
Changing status of legislation (1968 –
2005)
8.
Key issues in IDD
9. Do we need universal salt iodization?
Do we need Universal Salt Iodization?
• Yes, USI is required for all times to come!• Because iodine deficiency is a disease of soil
• IDD is a public health problem Therefore, it requires public health solution
• The serious irreversible consequences of iodine deficiency (mental handicap)
may not be visible grossly
• Prevention (including health promotion & specific protection)
is better than cure (including early diagnosis & treatment,
disability limitation & rehabilitation)
“I would be hard-hearted enough to let the sick die if you can tell me how to
prevent others from falling sick”
-
Mahatma Gandhi
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil
2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock
3.
How do we eliminate iodine deficiency?
-
By daily consumption of adequately iodized salt
4.
The Kangra Valley Study: 1956 –
1972
-
Provided scientific basis for NGCP
5.
New evidence: From Endemic Goiter to IDD (1962-1983)
6.
What is the status of iodized salt coverage in India?
(1998-99; 2002)
7.
Changing status of legislation (1968 –
2005)
8.
Key issues in IDD
9.
Do we need Universal Salt Iodization?
-
Yes, for all times to come
10. Why did consumption of adequately iodized salt decrease?
Why did consumption of adequately iodized salt decrease? -
1
Government of India lifts ban on sale of Non-iodized salt :
13 Sept., 2000
As a result, sense of complacency at State level
Increase in Rail Tariff –1st
April 2002
• Consequently, increase in movement of
iodized salt by road (especially from Rajasthan)
• Currently, No mechanism in place for monitoring quality of iodized salt transported by road
Why did consumption of adequately iodized salt decrease? -
2
Disappearance of most common
visible effect of iodine deficiency i.e. goiter
Perception in people that :
-
iodized salt consumption is
NOT required anymore
Why did consumption of adequately iodized salt decrease? -
3
Why did consumption of adequately iodized salt decrease? -
4
Communication strategy
– DID NOT focus on mental handicap as a
consequence of iodine deficiency
– WAS NOT commensurate with seriousness of problem
both in terms of scale & frequency
1.
What is iodine & what is iodine deficiency?
-
Iodine is a micronutrient
-
Iodine deficiency is a disease of the soil2.
What are the consequences of iodine deficiency?
-
Brain damage & impaired physical growth in humans
-
Decreased productivity in livestock3.
How do we eliminate iodine deficiency?
-
By daily consumption of adequately iodized salt4.
The Kangra Valley Study: 1956 –
1972
-
Provided scientific basis for NGCP5.
New evidence: From Endemic Goiter to IDD (1962-1983)6.
What is the status of iodized salt coverage in India?
(1998-99; 2002)
7.
Changing status of legislation (1968 –
2005)8.
Key issues in IDD9.
Do we need Universal Salt Iodization?
-
Yes, for all times to come10. Why did the consumption of iodized salt decrease?
11. The way forward
The Dandi
March
FREEDOM FROM PREVENTABLE BRAIN DAMAGE
THROUGH DAILY CONSUMPTION OF
ADEQUATELY IODIZED SALT
Platinum jubilee of Dandi March(12th March – 6th April 1930-2005)
Towards the Elimination of Iodine Deficiency Disorders in India
The way forward : Sustained Political Commitment
• NIDDCP should be a priority National Health Program
of the Govt. of India
• Strategy for IDD elimination is universal salt iodization
• Increase & sustain 100% coverage of adequately iodized salt
Action:
1) Revitalize the National IDD Task Force
2) National Level meeting of Secretaries,
Directors of Health & Family Welfare &
Programme Officers in charge of IDD
3) Followed by State & District level
sensitization meetings
IDD Control Programme : MultiIDD Control Programme : Multi--pronged Strategypronged Strategy
Promotion of Consumption of
Adequately Iodized Salt Forever
Demand Pull
Supply Push
Regular
Reliable
Representative
State-level
Scientific Data
Data For Decision Makers
Sustained Political
Commitment
The way forward
IDD Control Programme : Multi-pronged Strategy
Promotion of Consumption of
Adequately Iodized Salt Forever
Supply Push
The way forward: Supply (Push)
Need to reinstate ban
Iodized Salt brought under revised PFA Act1987
Sale & storage of non-iodized salt banned1997
Ban on sale of non-iodized salt liftedSeptember 2000
Policy decision taken for Universal Salt Iodization1983
Iodized salt brought under PFA Act1968
Central Government drafts proposal to ban
sale of non-iodized salt
April
2005
Supply (Push)
Salt producers
Economic
incentives
Technical
Support
Social
incentives
Rail transport
Cheaper than road
Category B:
High priority
Exemption from
duty & tax
Social profit:
Welfare of children
Welfare of society
Quality
assurance
Better
iodization
techniques
Increased
yield of
quality salt
• Continue with Priority for Rail movement for Iodized Salt :
Category B
• Reduce rail tariff for iodized salt
Supply (Push) –
Government -
1
Supply (Push) –
Government -
2
• Exempt Iodine for iodized salt
from import duty and sales tax
“Vaccine for optimum brain development”
Iodized salt exempted from VAT : Empowered Committee taken decision
Final notification to be issued
•Efforts to reduce price differentials between iodized & non-iodized salt
•More cost effective targeting of the PDS to address macro and micronutrient deficiencies
…Iodized Salt
Supply (Push) –
Government -
3
• Alliance with salt producers
– Good Manufacturing Practices
– Low Price , High Quality
– Active Assistance in obtaining International
ISO 9002 accreditation
(To be ready for WTO after Year 2005)
• External Independent Quality Assurance
Program
Supply (Push) –
Salt Industry
Consumption of adequately iodized salt according to socio -
economic status
in India (NFHS-II, 1998-99)
LOW SES MEDIUM SES HIGH SES
36%50%
78%
64%50%
22%Inadequate InadequateInadequate
Adequate
Adequate
Adequate
Consumption of adequately iodized salt according to socio -
economic status
in India (NFHS-II, 1998-99)
LOW SES MEDIUM SES HIGH SES
36%50%
78%
64%50%
22%Inadequate InadequateInadequate
Adequate
Adequate
Adequate
Adequately iodized salt production• Primarily from large scale producers•Remaining contribution from medium & small scale producers
Consumption of adequately iodized salt according to socio -
economic status
in India (NFHS-II, 1998-99)
LOW SES MEDIUM SES HIGH SES
36%50%
78%
64%50%
22%Inadequate InadequateInadequate
Adequate
Adequate
Adequate
Adequately iodized salt production
Primarily from large scale producers
Remaining contribution from medium & small scale producers
The challenge:
To adequately iodize 100% of salt
To sustain iodization of 100% of salt
Focus: Small & Medium scale salt producers
Supply (Push) –
Salt Industry Support Small scale salt producers
• Need to focus on small scale salt producers (Suppliers to Low Socio-economic Status)
• Potassium iodate subsidy in kind for 3 yrs -
Form revolving fund for purchase of
potassium iodate within this time• Initial assistance for repair and maintenance of
salt iodization plants• Technical & training support for:
-
Improving quantity & quality of common salt -
Maintenance of salt iodization plants
-
Establishing iodine monitoring laboratories• Ongoing external quality assurance for
iodized salt
Small Scale Salt Producers: Supply of Iodized Salt
Small scale salt producers / Traders
Traders
No Iodization Iodized SaltManufacturers
KIO3 Subsidyfor 3 years
MicrocreditFinancing
Iodized Salt
MarketPublic Distribution System
Common Salt
Common Salt
Distribution
“Respond to Market Signal”
Non-iodized Salt
IDD Control Programme : Multi-pronged Strategy
Promotion of Consumption of
Adequately Iodized Salt Forever
Demand Pull
Supply Push
The way forward: Demand (Pull)
Demand (Pull)
Community PerceptionMedia Education Legislation
(PFA Act, 1954)
Schools Physicians
Professional
OrganizationsAgriculture &
livestock
Traders
Consumer
Organizations
Disability
Groups
Demand (Pull)
• Intensify IEC with renewed focus on iodine & brain development
:
Iodine Quota & Intelligence Quotient• Education for All : Knowledge Power• India as a developed country• Regular Partnership with Media
Action
1)
Engage the services of a professional communication agency
2)
Consortium of Private iodized salt manufacturers to participate actively in this campaign
Personal meetings to promote use of adequately iodized salt
• People’s Representatives
• Political Party Office Bearers
• Policy Makers
• Producers of Salt & I-Salt
• Physicians
• Brochure (4 pages) -
Fact Sheet
-
Importance of IDD -
Current Status & Relevance of USI
Participation of frontline workers
Department of Education
School Principals
IEC,Mid Day Meals
Ministry of Health &
Family Welfare
ANM
IEC
Department of Women & Child Development
Anganwadi
Worker
IEC,Food
Supplement
Motivational Letter,20 Questions booklet on IDD,Flip Charts,Salt Testing Kits for Iodine
IEC Package:
Communication Challenges -
1Penetrate the system with key messages
• Schools : Loss of IQ, poor school performance, school drop out rates, employment opportunity
• Physicians : Daily consumption of adequately iodized salt is a healthy habit
• Professional associations’ advocacy• Agriculture & livestock :
giving iodized salt to livestock increases productivity
(milk, meat, eggs, wool & work output)
Communication Challenges -
2
Value Addition
1)
Traders: Iodized salt -
a value added product
2)
Consumer organizations: value for money
3)
Disability Groups : Mental disability -
Totally preventable
(IMPACT, Other groups)
Communication Challenges -
3
Communication Themes
• Iodine is important
• It prevents things we may not see: -
Mental handicap
-
Loss of 13 I.Q. points
• These are serious & irreversible
• IDD retards social & economic development
Communication Challenges -
4
Community Perception
Why is the daily consumption of adequately iodized salt a good thing ?
• Things we are asking people to do…• They have to do for all times to come…• As a result of daily consumption of
adequately iodized salt, discussions on preventable brain damage will be
a lesson of history
IDD Control Programme : Multi-pronged Strategy
Promotion of Consumption of
Adequately Iodized Salt Forever
Demand Pull
Supply Push
Regular
Reliable
Representative
State-level
Scientific Data
The way forward: Regular Reliable Representative Scientific Data
Regular, Reliable, Representative Scientific Data
• Surveys conducted by respective state governments in collaboration with AIIMS, UNICEF, MI, ICCIDD
• Kerala, Tamilnadu, Orissa, Bihar, Goa, Rajasthan
• Quantitative component: 30 Cluster Methodology
• Qualitative component: K A B P
(Knowledge, Attitude, Beliefs, Practices)
• Need for tracking progress to achieve sustainability
NFHS-3 (2005-2006)
• National Family Health Survey (NFHS-3) under process
• 110,000 families will be visited from all over the country
• Iodine in salt will be detected by salt testing kit (STK)
Our suggestion: Analyze 10% of salt samples by titration method
AIIMS / NIN can analyze these 11,000 samples by titration method
IDD Control Programme : Multi-pronged Strategy
Promotion of Consumption of
Adequately Iodized Salt Forever
Demand Pull
Supply Push
Regular
Reliable
Representative
State-level
Scientific Data
Data For Decision Makers
Sustained Political
Commitment
The way forward: Sustained Political Commitment
Tracking Progress Towards Sustainable Elimination of IDD in
Kerala (2001)
Tracking Progress Towards Sustainable Elimination of IDD in
Tamil Nadu (2002 - 2003)
Dissemination Workshop5th June 2003, Chennai
AdvocacyDemand Creation
Monitoring
Health Minister
Secy. Health
Panchayat Raj
Members
District Magistrates
AwarenessMonitoring
Activities Related to Supply Side
Increase in Iodized Salt Production
Capacity of TNSC
Salt & Iodized Salt Producers Meeting
Ensuring Quality, Accessibility. Availability, Affordability, Acceptability
of Iodized Salt
Linking Research to Policy & Program:
The Tamilnadu experience -
1
Linking Research to Policy & Program: The Tamilnadu experience -
2
• Quality iodized crystal salt distributed at Rs. 2.50/Kg through PDS
• Increase in distribution of iodized salt by ten folds through PDS
Year 2000 : 4,200 tons Year 2004 : 42,829 tons
• Distribution of iodized salt to Below Poverty Line (BPL) population:
Tamilnadu
: 3.5 million people Karnataka
: 2.0 million people
Andhra Pradesh
: 1.5 million people
Why should government facilitate the process of elimination of IDD?
• Health is socially desirable and better for people
than they realize
• Health is a ‘merit good’
– Government has the responsibility to protect
population health
– Individuals do not always make good choices,
especially when benefits are in the future
• Government’s intervention on iodized salt producers
(who are small in number as compared to the
entire population) benefits the entire population
• 1,000 iodized salt producers : 1,000 million people benefited
( ‘positive externalities’)
Tenth Five Year Plan (2002-2007) Annual Health Expenditure Outlays (approx.)
Program Rs. Crores
(%)
Pulse Polio (revised) 322 (25)
Immunization and its Routine Strengthening
286 (22)
Social Marketing and Free distribution of contraceptives
341 (26)
NACO 254 (20)
NPCB 89 (7)
National IDDCP 7 (0.5)
TOTAL 1298 (100)
* Source: Health Information of India 2003, CBHI, DGHS, MoHFW, GoI
AIDS
NPCB
Pulse Polio
Immunization
Contraception
IDD
and} (47)
Presently, NO consultant for IDD.
Express need to have full-time consultants under NIDDCP
to accelerate the program
Consultants in health programs
Pulse Polio303 consultants
Tuberculosis100 Consultants
Leprosy18 Consultants
• In the field of nutrition as in politics, the task is to do what is possible without
forgetting to do what is necessary
• Achieving optimal iodine nutrition through USI, provides this opportunity –
“Never before so much can be done For so many, For all times to come For so little, in such a short time”
Consumption of adequately iodized salt for all times to come
IDD Control Programme : Multi-pronged Strategy
Promotion of Consumption of
Adequately Iodized Salt Forever
Demand Pull
Supply Push
Regular
Reliable
Representative
State-level
Scientific Data
Data For Decision Makers
Sustained Political
Commitment
To Reiterate the Next Steps
In summary…1.
What is iodine & what is iodine deficiency?
2.
What are the consequences of iodine deficiency?3.
How do we eliminate iodine deficiency?
4.
The Kangra Valley Study (1956 –
1972)5.
New Evidence: From Endemic Goiter to IDD
(1962 –
1983)6.
What is the status of iodized salt coverage
in India? (1998-99; 2002)7.
Changing status of legislation (1987 –
2005)
8.
Key issues in IDD9.
Do we need Universal Salt Iodization?
10.
Why did consumption of iodized salt decrease?11.
The way forward
How Simple is Simple?
The Story of Iodine Deficiency &
Preventable Brain Damage
Sustainable Elimination of Iodine Deficiency Disorders in India
“Simple Goitre is the easiest of all known diseases to prevent…
It may be excluded from the list of human diseases
as soon as the society determines to make the effort.”
- Dr. David Marine, 1920(Pioneer in mass prophylaxis of endemic goiter)
Thus, The Story of iodine deficiency continues…
How Simple is Simple?How Simple is Simple?
Even man finds it difficult to be human !Even man finds it difficult to be human !
MirzaMirza GhalibGhalib
18th Century Poet18th Century Poet
" We ourselves sometimes feel that what we do is just a drop in the ocean,
But the ocean would be less because of that missing drop.“
- Mother Teresa
" We ourselves sometimes feel that what we do is just a drop in the ocean,
But the ocean would be less because of that missing drop.“
- Mother Teresa
Acknowledgements -
1
To the Global PartnershipDedicated to the Sustainable Elimination of
Iodine Deficiency DisordersAn Ancient Scourge of Mankind
The People of the affected countriesThe Governments of the affected countries
The Salt Producers of each country
Acknowledgements -
2
The International Agencies –
especially
The United Nations Children’s Fund
The World Health Organization
The World Bank
The Micronutrient Initiative
Kiwanis International
Acknowledgements -
3
The Bilateral Agencies –
especially
The Australian Agency for International Development
The Canadian International Development Agency
The Netherlands Ministry for Development Cooperation
The Swedish International Development Agency
The United States Agency for International Development
Acknowledgements -
4
The Global Network for Sustained Elimination of Iodine Deficiency
The International Council for Control of Iodine Deficiency Disorders
Thank You!
For further details, correspondence is invited at:For further details, correspondence is invited at:
Dr. C. S. PandavDr. C. S. Pandav Professor & Head, Professor & Head,
Center for Community MedicineCenter for Community Medicine All India Institute of Medical SciencesAll India Institute of Medical Sciences
AnsariAnsari NagarNagar New Delhi New Delhi –– 110029110029
Email: Email: [email protected]@iqplusin.org
Daily consumption of adequately iodized salt is a healthy habit
Towards Sustainable Elimination of IDD
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