Achieving Universal Salt Iodisation for Optimal Iodine Nutrition UNICEF, IGN, GAIN, MI EAP Regional Meeting 12-14 October, Bangkok #commit2USI New guidance on evaluation & surveillance of IDD elimination and salt iodisation Jonathan Gorstein USI Partnership Project/ Iodine Global Network

Original paradigm for tracking progress towards USI OUTLINE Original paradigm for tracking progress towards USI Interpretation of national survey data on Household Iodized Salt (HHIS) coverage and iodine intake Other issues in evaluation and surveillance Revised paradigm for tracking progress towards USI – improved program guidance EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Transport, Distribute, Wholesale MONITORING OF USI PROGRAMS Monitoring at strategic points in the value chain   Processed Foods Imported Salt Salt Producer Process & Pack Transport, Distribute, Wholesale Retail Sale Household A framework for assessing the salt distribution network in any country in order to identify new opportunities for USI advocacy and communications. We don’t have the resources or the time to intervene everywhere and with every possible strategy. Strategic ( leverage points) Focus on consumer demand without working salt supply side is futile effort Internal Monitoring External Monitoring Surveillance and Evaluation of coverage and impact Regulatory Monitoring EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Transport, Distribute, Wholesale MONITORING OF USI PROGRAMS Monitoring at strategic points in the value chain   Processed Foods Imported Salt Salt Producer Process & Pack Transport, Distribute, Wholesale Retail Sale Household A framework for assessing the salt distribution network in any country in order to identify new opportunities for USI advocacy and communications. We don’t have the resources or the time to intervene everywhere and with every possible strategy. Strategic ( leverage points) Focus on consumer demand without working salt supply side is futile effort Internal Monitoring External Monitoring Surveillance and Evaluation of coverage and impact Regulatory Monitoring EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Original paradigm for tracking progress towards USI OUTLINE Original paradigm for tracking progress towards USI Interpretation of national survey data on HHIS coverage and iodine intake Other issues in evaluation and surveillance Revised paradigm for tracking progress towards USI – improved program guidance 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) Intake of iodine through iodized salt at household level can help meet needs and eliminate deficiency. Iodine status measured among SAC Assumption – physiological requirement for iodine can be provided in salt, consumed on a daily basis Intake of iodine through iodized salt at household level can help meet needs and eliminate deficiency Measure two key performance indicators: HHIS – adequately iodized salt at household level UIC – iodine status of populations Assess program sustainability Program sustainability factors

Salt Iodization- Original Paradigm Coverage of Adequately Iodized Salt at Household (HHIS) Iodine Status (Urinary Iodine – UIC among school-aged children) Intake of iodine through iodized salt at household level can help meet needs and eliminate deficiency. Iodine status measured among SAC Assumption – physiological requirement for iodine can be provided in salt, consumed on a daily basis Intake of iodine through iodized salt at household level can help meet needs and eliminate deficiency Measure two key performance indicators: HHIS – adequately iodized salt at household level UIC – iodine status of populations Assess program sustainability Original goal of USI : >90% coverage of HHIS Implication: Eliminate IDD Program sustainability factors

Original paradigm for tracking progress towards USI OUTLINE Original paradigm for tracking progress towards USI Interpretation of national survey data on HHIS coverage and iodine intake Other issues in evaluation and surveillance Revised paradigm for tracking progress towards USI – improved program guidance EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

INTERPRETATION OF NATIONAL SURVEY DATA Key questions: Why is there a disconnect between HHIS coverage and iodine status? Based on changing program landscape (Roland), how to improve indicators for program monitoring? How to enhance analysis and presentation of data Need to double check numbers Ref: ICCIDD/GN Global Scorecard (UNICEF and WHO Data) EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

CRITERIA for classification of iodine status in sac Population IDD Status WHO, UNICEF, ICCIDD (2007) Median value Iodine Status < 20 g/l Severe iodine deficiency 20-49 Moderate iodine deficiency 50-99 Mild iodine deficiency 100-199 Ideal iodine intake 200-299 More than adequate intake  300 Excessive iodine intake Need to double check numbers EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

CRITERIA for classification of iodine status in sac In 2013, Zimmerman et al. published data from multiple study sites that measured Urinary Iodine and thyroid function in SAC Multi-center study found no adverse function consequences across the WHO ranges of adequate (UIC range of 100-199 μg/l ) and more than adequate iodine intake (UIC range of 200-299 μg/l ). The Study Group suggested adopting the expanded range of optimal UIC levels for school age children (i.e. 100-299 μg/l) WHO is currently reviewing Need to double check numbers Zimmerman et al. Thyroglobulin is a sensitive measure of both deficient and excess iodine intakes in children and indicates no adverse effects on thyroid function in the UIC range of 100-299 μg/l: A UNICEF/ICCIDD Study Group Report. J Clin Endocrin Metab. 2013 Ref: ICCIDD/GN Global Scorecard (UNICEF and WHO Data) EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Regional achievements: household iodised salt coverage and iodine status EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Regional achievements: household iodised salt coverage and iodine status Blue box represents USI goal Blue box represents range of optimal status EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Regional achievements: household iodised salt coverage and iodine status 1/9 countries reached USI goal 7/9 counties with ‘optimal iodine status Blue box represents USI goal Blue box represents range of optimal status EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Regional achievements: household iodised salt coverage and iodine status 1/9 countries reached both program goals EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

INTERPRETATION OF NATIONAL SURVEY DATA National data hides sub-national variations Many countries have ‘adequate’ iodine status but <90% HHIS, but there are sub-populations with inadequate iodine status - unprotected Other sources of iodine may be contributing to iodine status, in particular iodised salt used in food processing EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Iodine status vs. HHIS: stratification by iodine content Nepal 2005/6 Vietnam 2005/6 HHIS coverage 58% 93% National MUIC 188 ug/L 130 ug/L Iodine Content in HH Salt Median UIC SAC (ug/L) No Iodine (<5ppm) 71 78 Inadequate iodine (5-15ppm) 131 136 Adequate iodine (15ppm) 252 155 This is supposed to be an illustration of point 1 in slide 5 – need real stratified data from a country in the yellow zone of slide 4. Ideally it would be compared with stratified data from a country in the green zone of slide 4. Do you have such data? This VN data is untrue. MUIC of SAC is “optimal” in both countries although Nepal only had HHIS of 58% Stratification of MUIC by salt iodine content indicates HH’s consuming non-iodized salt were deficient and those consuming inadequately iodized salt had lower MUIC than those consuming adequately iodized salt Refs: Nepal: National Micronutrient Survey 2005/6; Viet Nam: National IDD Survey 2005/6 EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Philippines: inequity in iodine status and HHIS Blue box represents range of optimal status Blue box represents range of optimal status EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Assess Other sources of iodine in the diet - indonesia This is supposed to be an illustration of point 1 in slide 5 – need real stratified data from a country in the yellow zone of slide 4. Ideally it would be compared with stratified data from a country in the green zone of slide 4. Do you have such data? This VN data is untrue. Indonesia analysis has revealed that, on average, 75% of total iodine intake is from HHIS, while 15% is from iodized salt used in instant noodles and 10% is from iodine in drinking water, but some areas where water is a major source Refs: 2013 Indonesia Riskedas (Litbang Kesehatan) EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Original paradigm for tracking progress towards USI OUTLINE Original paradigm for tracking progress towards USI Interpretation of national survey data on HHIS coverage and iodine intake Other issues in evaluation and surveillance Revised paradigm for tracking progress towards USI – improved program guidance EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

PERFORMANCE OF RTK TO ASSESS SALT WITH ANY IODINE EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

PERFORMANCE OF RTK TO ASSESS SALT WITH ADEQUATE IODINE EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Use of rtk to assess iodine in salt RTK only appropriate to distinguish salt with no iodine from salt without iodine To measure content of iodine in salt, quantitative tools are required New tools are available in addition to titration - I-Reader and the iCheck—appear to be the most reliable in terms of analytical performance (Comparative Validation of Five Quantitative Rapid Test Kits for the Analysis of Salt Iodine Content: Laboratory Performance, User-and Field-Friendliness) This is supposed to be an illustration of point 1 in slide 5 – need real stratified data from a country in the yellow zone of slide 4. Ideally it would be compared with stratified data from a country in the green zone of slide 4. Do you have such data? This VN data is untrue. EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Use medians to present uic data In the presentation of UIC data, only medians are appropriate Cut-off points are based on population classification, so median UIC in SAC < 100 ug/l reflects sub-optimal iodine status, but should not be used to estimate the proportion with sub-optimal intake Daily variation that will result in many individual days when a UIC value will be less than adequate Even in populations in which iodized salt ensures adequate thyroid stores, there will be individuals with a UIC<100mg/L on the day of the survey, but are not truly iodine deficient This is supposed to be an illustration of point 1 in slide 5 – need real stratified data from a country in the yellow zone of slide 4. Ideally it would be compared with stratified data from a country in the green zone of slide 4. Do you have such data? This VN data is untrue. EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Use medians to present uic data An example from Switzerland: Median UIC of 120 ug/l and TGR < 3% – Population classified as ‘optimal’ 36% of the values < 100 ug/L – but this not indicate that one third of the population has sub-optimal intakes This is supposed to be an illustration of point 1 in slide 5 – need real stratified data from a country in the yellow zone of slide 4. Ideally it would be compared with stratified data from a country in the green zone of slide 4. Do you have such data? This VN data is untrue. EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Original paradigm for tracking progress towards USI OUTLINE Original paradigm for tracking progress towards USI Interpretation of national survey data on HHIS coverage and iodine intake Other issues in evaluation and surveillance Revised paradigm for tracking progress towards USI – improved program guidance 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) Intake of iodine through iodized salt at household level can help meet needs and eliminate deficiency. Iodine status measured among SAC Assumption – physiological requirement for iodine can be provided in salt, consumed on a daily basis Intake of iodine through iodized salt at household level can help meet needs and eliminate deficiency Measure two key performance indicators: HHIS – adequately iodized salt at household level UIC – iodine status of populations Assess program sustainability Program sustainability factors

National vs subnational New Paradigm: Optimize iodine nutrition through different dietary sources of iodine fd Iodized Salt in Processed Foods & Condiments Household Adequately Iodized Salt School age vs pregnant National vs subnational Iodine in soil & water (affects iodine in local drinking water & agricultural products) National Iodine Status (Urinary Iodine) Program sustainability factors Other MN interventions (home fortification, maternal supplements..)

Improved Program Monitoring Iodine intake Measure major sources of iodine in the diet (HH, PF) Use titration to assess actual iodine content in salt Iodine status in the population (UIC) Focus on WRA and PW Presentation of Median only, for now Link monitoring of USI to sodium reduction Measure salt (per capita consumption) and sources in the diet Measure sodium from same urine panel as iodine Data interpretation Sub-group analysis by SES, poverty risk, HH salt iodine content to identify program challenges Use of data (iodine intake, iodine status , salt consumption) to adjust iodine standards EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Use of program data to revise iodine standards and improve programs Feedback to adjust iodization level (every 5-10 yrs) If MUIC >300 --> reduce If MUIC <100 --> increase or focus on program strengthening Start up program: set approximate iodization level Iodization level Assess Household Iodized Salt Assess Iodized salt in Processed Foods Make sure the program is in place and scaled up , then assess coverage and then iodine status Measure Iodine status (Urinary Iodine) School children 100- 299 ug/L Women of Reproductive age 100-199ug/L Make sure both groups have adequate iodine If not, then consider modifying standards EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

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