presentation bioethics congress 2010

Realization of a National Strategy for the Prevention and Controlof Iodine Deficiency Disorders

Frits van der Haar, PhDEmory University, School of Public Health

Atlanta, Georgia, USA

Main Themes of Presentation

1. Progress in the Prevention of Iodine Deficiency in South-East Europe and the Commonwealth of Independent States during 2000-2009

2. Iodine Deficiency in Ukraine

3. Relationships of Dietary Iodine Supplies and Salt Iodization Strategies in Industrialized Countries

Recommended Next Steps

Progress in the RegionSE Europe and CIS during the Decade

2000 - 2009

± 2000 ± 20100%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

USI Progress in South-East Europe and the Commonwealth of Independent States, 2000-

2009

>9070-8950-6920-49<20

Prop

ortio

n of

coun

trie

s

Coverage

4 more countries have attained USI

2 more are close to the goal

4 more have coverage of 50-69%

The number of countries with coverage <50% fell by 8

A Decade of Action in National Salt Iodization Strategies in S.E. Europe and CIS

End-of-Decade situation• Plentiful iodized salt supplies and optimum iodine nutrition realized in

ARM, BEL, BiH, BUL, GEO, KAZ, KOS, MAC and TUR• Plentiful iodized salt supplies and iodine nutrition almost optimum in

AZE, KYR, MOL, MON, ROM and SER

(15 out of 20 countries = 75% success rate)

• Iodized salt supplies are facing operational challenges, and iodine nutrition improving but not yet adequate in ALB, TAJ and UZB

• No principle decision on salt iodization, dietary iodine supplies are stagnant, and persisting evidence of insufficient iodine nutrition in RUS and UKR

BUL MAC ROM BiH ALB MON SER KOS2003 2004 2005 2006 2007 2009

0

50

100

150

200

250

300

350

TUR ARM GEO BEL MOL AZE KYR TAJ2004 2005 2006 2007

BUL MAC ROM ALB MON SER BiH KOS2001 2003 2004 2006 2007 2008 2009

0

50

100

150

200

250

300

UKR* KAZ* AZE KYR TAJ2002 2006 2007 2007

Urinary Iodine Concentrations in Pregnant Women

Urinary Iodine Concentrations in School-age ChildrenBalkan Area

Balkan Area

CIS Area

CIS Area

Iodine Nutrition Achievements during the Decade 2000-2009

* Women in Ukraine and Kazakhstan were not pregnant

What are Reasons for Success?• Partnership Collaboration: Positive Common Testimony by the Key

Stakeholders on:– The need to ensure plentiful iodized salt supplies for prevention of brain

impairment in each new generation of citizens– The feasibility of national legislation/regulation to achieve optimum iodine

nutrition of the population• Evident Concern to ensure quality iodized salt supplies among the salt

industry/trade sector, the food authority/inspection and the consumer rights/interests organizations

• Regular Monitoring by public health institutions, using up-to-date methods and technology, striving for high standards in analysis and reporting, and promoting publicity of the results

• International Collaboration, including an official request for independent acknowledgment of successful national achievement

Iodine Deficiency and Salt Iodization

in Ukraine

and other Industrialized Countries

Ukraine: Surveys of Adult Women

0 20 40 60 80 1003

3.5

4

4.5

5

5.5

6

6.5

7

Percent household salt iodized

Urin

ary

Iodi

ne C

once

ntra

tion

(Log

scal

e)

Recommended range

(100 - 200µg/L)

Kravchenko V, 2005-200748 Sites covering Ukraine

Iodine from natural food: 64µg/Lfrom iodized household salt: 22µg/L

Academy Medical Sciences, 2002National Micronutrient Survey

Iodine from natural food: 66µg/Lfrom iodized household salt: 23.5µg/L

Recommended range

(100 - 200µg/L)

2002 National Iodine Survey

2005-2007 Surveys in 48 Oblasts

0

25

50

75

100

125

150

175

200

Urinary Iodine Levels in Adult Women, Ukraine

Minimum UI for non-pregnant adult women

Minimum UI for pregnant adult women

From iodinein household salt

From iodinein common foods

50% Shortfall When Women Enter Pregnancy

• Intellectual Impairment in Newborns– 33,068 Births Each Year

– Loss of IQ Points 446,418 Annually

• Future Foregone Economic Earnings– $36,586,000 Each Year

Damage Assessment Report 2006: Losses due to Iodine Deficiency

What Would a Prevention Strategy Cost? Cumulative Projections over 10 Years

3-Year Investment 1.375 million US$Break-even at 4 Years

10-Year Benefit : Cost Ratio 44.6

Would Iodized Household Salt be Adequate to Prevent Brain Damage?

Common salt Iodized salt Common salt Iodized saltSchool children Pregnant women

0

50

100

150

200

250

Net effect of iodized household salt consumption on the urinary iodine levels in school-age children and pregnant women, Donetsk

Iodized salt Dairy + sea fish Basic diet

Normal rangePregnant women

School children

Firsova N, Demina T et al, Donetsk Medical University, 2007-2008

Most of the Salt Intake is from Consuming Industrially Processed Foods

Bread & Cereals are Major Commodities in the Total Food Salt Intake

Salt Iodization Practices in Western Europe: Example of The Netherlands

Iodization Standards:Bread salt 50-65 mg iodine/kgHousehold salt 15-25 mg/kgBoth Standards are not Mandatory

Realization:Bread bakeries 93% adoptionHouseholds 65-70% coverage

Iodine supplement use 5-21%

Normal range

Salt Iodization Practices in Western Europe: Example of Denmark

Series10

20

40

60

80

100

120

140

160

Contributions to Total Iodine Intake in Adults, Denmark 2007

Bread saltHousehold saltNatural food sources

Iodi

ne in

take

µg/

d

Average requirement

Recommended intake

Iodization Standards: Bread salt 13 mg iodine/kgHousehold salt 13 mg/kgBoth standards are mandatory

Realization:Rye Bread 1.4 - 38 mg iodine/kgWheat Bread 0 – 46 mg iodine/kgHousehold salt 0.6 - 31 mg/kg

Median Increase: 63µg/d

Other Examples of Selective Salt Iodization Strategies

• Belarus

• Germany

• Australia & New Zealand

• Norway, Finland

Suggestions and Next Steps

Major Issues that may be Delaying National Decision-Making

• The Need for a Population Approach• Nutrition is not Pharmacology

• Insistence on Free Consumer Choice• The Problem is only “Mild”

• Do we Choose for Prevention or Correction?

The 3 Compelling Imperatives

Economics“The State Continues Bleeding Money”

Human Rights“Unborn Babies cannot Choose”

Ethics“The Greatest Benefit for the Greatest Number”

Suggested Next Steps

• Consider the Different Salt Supply Channels• Choose a Selective Iodization Strategy that– Benefits the Largest Possible Population Share– Focuses on Prevention of Newborn Brain Damage– Circumvents the Major Political Objections, and– Is Proven to be Safe, Effective and Low-Cost

• Adopt an Inclusive Collaborative Approach• Provide Positive Common Testimony