Changing landscape of IDD elimination and emerging questions Achieving Universal Salt Iodisation for Optimal Iodine Nutrition UNICEF, IGN, GAIN, MI EAP Regional Meeting 12-14 October, Bangkok #commit2USI Changing landscape of IDD elimination and emerging questions Roland Kupka UNICEF Headquarters - New York

Overview Background Salt iodization and iodine status Equity Salt iodization in wider nutrition programs Sodium intake and non-communicable chronic diseases Global architecture on salt iodization Program challenges Conclusion

110 countries iodine deficient 1993 Important to consider changing landscape to maintain the drafting of one of the most remarkable public health stories that we have begun, to complete the story, and to sustain success 110 countries iodine deficient

25 countries iodine deficient 2015 Severe Moderate Mild Adequate Excess No data 25 countries iodine deficient

Iodine status of UK schoolgirls: a cross-sectional survey mild Household iodised salt is rarely available to purchase in the UK and few if any manufacturers use iodised salt in the preparation and manufacture of foods moderate Our findings suggest that the UK is iodine deficient severe Vanderpump, Lancet 2011 Published online June 2, 2011 DOI:10.1016/S0140-6736(11)60693-4

Iodine deficiency disorders are the most common preventable cause of mental impairment globally Poor cognitive development Poor school performance Lowered earning capacity Not just goiter, but also poor cognitive development Aligns with choronic nutrition agenda Links very well with the overall Stunting can be caused by inadequate absorption or high nutrient loss due to disease. In many cases inadequate care is the factor which causes this to happen. In this UNICEF causal model there is an emphasis on the causes leading to undernutrition. We now know that there should be a much stronger emphasis on the arrow which shows the impact of undernutrition on poverty and other underlying factors. UNICEF supports programmes covering all three determinants, while avoiding overlap with other UN agencies. School : school attainment drop-out rates  Adjusted for site, sex, SES, maternal schooling, and whether participant is still attending school. tunting was associated with a reduction in schooling of 1.8 and 0.9 y before and after controlling for confounding, respectively  In our study, exposure to the atole supplement during 0–36 months of age, but not during 36–72 months, significantly increased hourly wage rates in men, though not in women. For atole supplementation during 0–24 months, the corresponding increase in the hourly wage rate was US$0·67 per h, representing an increase of 46% over average wages in the sample. Image references: Stunting: Cordero, 1993! School: sign & mortar board http://www.google.com/imgres?q=school+sign&um=1&hl=en&rls=com.microsoft:en-us:IE-SearchBox&biw=1247&bih=809&tbm=isch&tbnid=X_xWtiV_b8lC_M:&imgrefurl=http://www.highwaytrafficsupply.com/school_zone_signs.html&docid=PiSLQJyFKFkAuM&imgurl=http://www.highwaytrafficsupply.com/images/regulatory_signs.html/S4-3.jpg&w=600&h=200&ei=EgvST4W1G8eF4gTj57H5Ag&zoom=1 http://www.google.com/imgres?q=mortar+board&um=1&hl=en&rls=com.microsoft:en-us:IE-SearchBox&biw=1247&bih=809&tbm=isch&tbnid=ZYP-vON3ZAcdTM:&imgrefurl=http://puanchong2.blogspot.com/2011/12/chase.html&docid=EXzrB6gOkLrDzM&imgurl=http://1.bp.blogspot.com/- Money: http://www.google.com/imgres?q=money&hl=en&gbv=2&sig=103022112828857408389&biw=855&bih=936&tbm=isch&tbnid=RxHavGWTy_gyxM:&imgrefurl=http://www.awomansplace.org/blog/%3Fp%3D3956&docid=tt-pDER3nbvHHM&imgurl=http://www.awomansplace.org/blog/wp-content/uploads/2012/04/money-clipart71.jpg&w=630&h=575&ei=ShPST8XqAab14QTSmqiuAw&zoom=1 http://www.google.com/imgres?q=earning+money&hl=en&sa=X&gbv=2&biw=855&bih=936&tbm=isch&tbnid=xYGd-zB_0dG41M:&imgrefurl=http://tullymarket.com/how-to-make-extra-money-part-time/&docid=H4A9qBFc8dvDrM&imgurl=http://tullymarket.com/wp-content/uploads/2011/12/how-to-make-extra-money-part-time.jpeg&w=300&h=300&ei=tAvST5iSMYn74QSIwu33Ag&zoom=1&iact=hc&vpx=581&vpy=253&dur=343&hovh=225&hovw=225&tx=135&ty=90&sig=103022112828857408389&page=1&tbnh=169&tbnw=203&start=0&ndsp=14&ved=1t:429,r:9,s:0,i:128

Each dollar invested in salt iodization returns $30 in benefits EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Overview Background Salt iodization and iodine status Equity Salt iodization in wider nutrition programs Sodium intake and non-communicable chronic diseases Global architecture on salt iodization Program challenges Conclusion Take closer look at link between salt iodization and iodine status over time

Major milestones for elimination of iodine deficiency UNICEF estimates that less than one fifth of households in the developing world were using iodized salt at the time of the World Summit for Children in 1990. 1990: Widespread international support for the elimination of iodine deficiency dates from the World Summit for Children 1994: WHO and UNICEF recommended universal salt iodization as a safe, cost-effective and sustainable strategy to ensure sufficient intake of iodine by all individuals, and called on all countries to ensure access to iodized salt regardless of whether they had a documented IDD problem 2002: Pledge for progress towards the elimination of sustained iodine deficiency was renewed at the United Nations General Assembly Special Session on Children. Since 2007, focused on enhancements in program sustainability UNICEF, 2008

In 2014, WHO reaffirmed its unequivocal support for salt iodization programs by stating that all all food-grade salt, used in household and food processing should be fortified Because safe and effective strategy for IDD prevention All food-grade salt, used in household and food processing should be fortified with iodine as a safe and effective strategy for the prevention and control of iodine deficiency disorders in populations living in stable and emergency settings (strong recommendation) World Health Organization, 2014

salt is often among the few vehicles that reach poor households In many countries in the region, salt, salty condiments, such as soy sauce and fish sauce, and pickled vegetables are consumed by all segments of the population. China: High consumption of salt and salty condiments reaches all population groups independent of socioeconomic status Salt is the only vehicle that reliably reaches all population groups around the world, independent of socioeconomic status  Du et al, Am J Clin Nutr. 2014; 99: 334–343 EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Salt Iodization- Original Paradigm Coverage of Adequately Iodized Salt at Household (HHIS) Iodine Status (Urinary Iodine – UIC among school-aged children) Original paradigm: Intake of iodine through iodized salt at household level can help meet needs and eliminate deficiency. Iodine status measured among SAC Assess program sustainability Program sustainability factors

Salt Consumption United States Most salt is consumed through processed and restaurant foods (and mostly invisible) Mattes RD, et al. J AM Coll Nutr 1991;10:383–393

FNB, vol. 33, no. 4 (supplement) 2012

Program sustainability factors New Paradigm: Optimize iodine nutrition through different dietary sources of iodine fd Iodized Salt in Processed Foods & Condiments Iodized salt remains at the core of IDD control efforts Household Adequately Iodized Salt Iodine in soil & water (affects iodine in local drinking water & agricultural products) National Iodine Status (Urinary Iodine) Program sustainability factors Other targeted MN interventions (home fortification, maternal supplements..)

Overview Background Salt iodization and iodine status Equity Salt iodization in wider nutrition programs Sodium intake and non-communicable chronic diseases Global architecture on salt iodization Program challenges Conclusion Second major change is that we need to start to look at inequalities in coverage of HHIS And whether all population groups, including the most vulnerable, are covered by IS

Percentage of Households Consuming Adequately Iodized Salt 2009-2013 Not just sufficient to look at coverage at population level 75% Globally  <20%  20-49%  50-69%  70-89%  ≥ 90%  Data not presented as most recent estimate is not in accordance to the standard definition and earlier data <2009  no data Source: UNICEF Database, 2015

Household iodized salt coverage Inequities between the richest and poorest quintiles in consumption of iodized salt are evident in about two Thirds of countries Coverage lowest quintile << Coverage highest quintile Coverage lowest quintile= Coverage highest quintile But also among different at risk groups and DISPARITIES IN COVERAGE No predictable patterns of disparity are found for household consumption of iodized salt in relation to relative wealth. When recent data for 44 countries were analysed, over one third of countries showed that the richest and poorest 20 per cent of the population were roughly equal in terms of their consumption of  iodized salt (the green circles in the figure below). In another third of countries, the richest quintile was at least twice as likely as the poorest quintile to consume adequately iodized salt (red circles). Ghana showed the widest disparities: In that country, the wealthiest quintile was more than nine times more likely to consume adequately iodized salt than the poorest quintile. In Mozambique, the rich have a fourfold advantage. Five countries showed a difference of more than 40 percentage points between the richest and poorest quintiles: Algeria, Ghana, Madagascar, Senegal and the United Republic of Tanzania. The data also show that countries with higher overall coverage (circles in the top right quadrant) tend to have more equitable distribution of coverage. Some exceptions are Egypt, Lesotho and Nepal, which have high overall coverage but show stark disparities based on wealth. This calls attention to the need to identify and address barriers to the equitable use of adequately iodized salt in affected countries. - See more at: http://www.data.unicef.org/nutrition/iodine.html#sthash.xQo7hY8q.dpuf Household iodized salt coverage Highest quintile Household iodized salt coverage Lowest quintile

Overview Background Salt iodization and iodine status Equity Salt iodization in wider nutrition programs Sodium intake and non-communicable chronic diseases Global architecture on salt iodization Program challenges Conclusion

At national levels, integration of salt iodization programs in the efforts related to wider nutrition programs will be crucial At national levels, integration of salt iodization programs in the efforts related to the Scaling up Nutrition movement will be crucial. But in this new global nutrition landscape, to deliver greatest value, vertical or stand--‐alone USI programs must be Integrated into shared delivery infrastructure to achieve economies of scale. Donors are less interested in vertical programs Need to create a new sense of urgency, opportunity and vigour around iodine nutrition Continually reinforce the knowledge of iodine deficiency and promoting support for programming Reinforce the evidence-based validity of salt iodization programs in response to the changing environment Global nutrition architecture is shifting with the SUN initiative (Scaling Up Nutrition) and focus on the first 1000 days; need to better position iodine in these frameworks

Multi-stakeholder platform Salt iodization programs have successfully maintained multi-stakeholder coalitions and may therefore have a logical ‘fit’ with SUN efforts SUN multi-stakeholder platforms and networks Multi-stakeholder platform It is thus important the control of iodine deficiency can be accommodated into country-level multistakholder platform and the related networks set up to organize donor, business community, UN agencies, universityies, and the civil society. The SUN movement encourages national coalitions to implement evidence--‐based nutrition interventions and integrate nutrition Goals into health and development plans. The SUN approach shares many similarities with our time--‐tested USI approach (national ownership, multi--‐ sector partnerships, emphasis on development). Therefore, iodine programs have a logical ‘fit’ with SUN efforts And should be aligned and integrated into them. Country government Donors Civil Society FP Business Technical Community UN Agencies

Overview Background Salt iodization and iodine status Equity Salt iodization in wider nutrition programs Sodium intake and non-communicable chronic diseases Global architecture on salt iodization Program challenges Conclusion

Salt intake and noncommunicable diseases Noncommunicable diseases (NCDs) are a major contributor to mortality and morbidity globally Elevated sodium intake has been associated with a number of NCDs (including hypertension, cardiovascular disease and stroke), and decreasing sodium intake may reduce blood pressure and the risk of associated NCDs WHO recommends a reduction in sodium intake to reduce blood pressure and risk of cardiovascular disease, stroke and coronary heart disease in adults . WHO recommends a reduction to <2 g/day sodium (5 g/day salt) in adults WHO Guideline : Sodium intake for adults and children. 2012

National, Regional, and Global Sodium Intake in 1990 and 2010: A Systematic Analysis of 247 24-hour Urinary Sodium Excretion Studies and Dietary Surveys Worldwide Mean national sodium intake g/d in adult males in 2010 Recommended upper level of sodium intakes Fahimi et al. Circulation 2013; 127:A017

Coordinated programs to optimize salt and iodine intake High sodium intake Iodine deficiency ↑blood pressure→ ↑ heart disease, stroke Related to 30% of hypertension Major cause of mortality worldwide Two billion people at risk Salt iodization highly effective prevention strategy Most common cause of preventable mental impairment Optimizing salt & iodine should be global priority WHO recognizes that salt reduction and salt iodization are compatible In fact, both agendas stand to gain from close coordination and cooperation The complementarity between the salt reduction and salt iodization is insufficiently recognized Achieve consensus on importance of collaboration on optimizing salt and iodine intakes Devise tools and resources to aid in joint planning Compile reliable intake on salt intake and iodine deficiency, esp among vulnerable groups Develop harmonized message: Salt intake should be < 5g/d, but all salt should be iodized Suggested actions Campbell et al ,Rev Panam Salud Publica 32(4), 2012

Overview Background Salt iodization and iodine status Equity Salt iodization in wider nutrition programs Sodium intake and non-communicable chronic diseases Global architecture on salt iodization Program challenges Conclusion

The global iodine architecture has been harmonized with the creation of the Iodine Global Network (formerly ICCIDD Global Network) IGN plays a strong scientific and advisory role on iodine nutrition and the network of over 100 regional and national coordinators and partner agencies (GAIN, MI, and UNICEF) are at the core of its activities and global efforts to eliminate IDD. In the changing landscape of iodine nutrition, the IGN draws upon nearly 30 years of experience and expertise of academics, salt industry representatives, and partner organizations. While IGN continues to play a strong scientific and advisory role on iodine nutrition, it is the network of over 100 regional and national coordinators and partner agencies (the Global Alliance for Improved Nutrition, the Micronutrient Initiative, and UNICEF) who are at the core of its activities and global efforts to eliminate IDD.

Overview Background Salt iodization and iodine status Equity Salt iodization in wider nutrition programs Sodium intake and non-communicable chronic diseases Global architecture on salt iodization Program challenges Conclusion

Program Challenges a) Countries with scaled up programs Optimal iodine nutrition status AND scaled up USI programmes Focus is on consolidation, programme adjustments and on sustaining achievements How to ensure sustainability (sliding back, periodic oversight, commitment, mainstream iodine nutrition, functional coalition, adjust to changing national context) Dealing with external threats (media, opponent groups, complacency among policy and programme staff, changes in enabling environment) Say country teams should see where they fit

ProgramME Challenges b) Countries in scale up phase USI being scaled up with/without optimal iodine status Programme focus on a) improve the % of poorly iodized salt, b) expand capacity to suppliers with no iodization (%)  small producers; food industry Capacity (small producers, QA issues, advocacy & communication along supply value chain) Commitment (poor enforcement, illegal non-iodized salt, imported salt, disincentives to iodize salt (e.g. taxation)) Hard to reach population - IS or alternative strategies (subsidized IS, other iodine interventions)

USI not being scaled up; without optimal iodine status ProgramME Challenges c) Countries without policy/plan to scale up and achieve USI/optimal iodine Nutrition USI not being scaled up; without optimal iodine status Commitment, awareness lacking among gatekeepers (private, public, civic); and/or inadequate capacity Importance iodine nutrition/USI not recognized by policy makers or health advisers (no monitoring, issue not recognized) Confusion about presence/form of USI in combination with/without other strategies Alternative strategies promoted - compete with USI strategy, leading to reduced commitment for USI

ProgramME Challenges d) Fragile states USI (not) achieved with/without optimal iodine status Fragile environment (political, shock due to disasters) erodes USI and sliding iodine status Strategies not in place/weakening; lack of attention, priority How to ensure USI or alternative interventions are put in place short term Targeting of population, prioritization of efforts, making optimum use of resources

Overview Background Salt iodization and iodine status Equity Salt iodization in wider nutrition programs Sodium intake and non-communicable chronic diseases Global architecture on salt iodization Programme challenges Conclusion

Conclusion Salt iodization is one of the biggest public health success stories in the last two decades and remains highly relevant despite changes in programming landscape However, a quarter of the world’s population remains at risk for low iodine intakes and the job is thus not yet done IDD prevention efforts need to remain a cornerstone of global nutrition agenda Indicators address later in the year The control of iodine deficiency in all countries worldwide by 2020 is within our reach!

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