Sustainable Elimination of Iodine Deficiency: Perspectives for Lithuania ARNOLD TIMMER, UNICEF REGIONAL OFFICE 17 December 2003

Overview Central Eastern Europe & Central Asia Examples relevant to Lithuania Indicators used: Households consuming iodized salt (table salt) Iodine status: urinary iodine (table salt, other salt) TSH Newborn children protected from brain damage due to iodine deficiency I would put the first two indicators around: Iodized salt use in households 2. Iodine status (make the point that this is not only dependent on table salt but also other salt flows incl. bread, meat products, etc.) And on 3rd make the point that TSH is a wonderful indicator to CONFIRM the benefits of 1 and 2

Iodine Deficiency: The Problem Cretinism At risk of mental Impairment 10-15% IQ loss Goiter Goiter and Cretinism are the clinical manifestations that were for long the focus/trigger of control measures of IDD. In the last few decades the risk of mental impairment for a much larger group in the population was revealed by scientific studies.

East Asia follows after South Asia and Sub-Saharan Africa East Asia follows after South Asia and Sub-Saharan Africa. In East Asia, most unprotected new-born children are born in China, Indonesia, Cambodia, Philippines and Vietnam. Mild to moderate iodine deficiency has been confirmed in all countries of OUR region and in some countries, iodine deficiency is severe. Because of the absence of iodized salt in the FOOD SUPPLY around 4.5 million out of a total 5.9 million newborns in OUR region (which is 80%) are NOT protected against brain damage due to lack of iodine when the mother is pregnant. In Lithuania we estimate that only about 10% of the 30,000plus newborns are assured of brain protection from the use of iodized table salt in their households.

Lithuania + 32,000 newborns per year This means 28,800 newborns not protected With decreasing population, future generation needs to be protected! Investment in USI = better intelligence among newborn = better learning and earning = benefiting economy of the country Better intelligence among newborns means better learning and better earning, thus benefiting the economy of the country. By our decision to “invest” in brain protection from UNIVERSAL salt iodization, we prepare our children for the electronic age.

In 31 countries, > 90% households consume iodized salt In the 31 countries shown in this slide, >90% of households had iodized salt available at the time of the survey team’s last visit. Most of the countries of Latin America & Caribbean are included in this category. This group includes populous countries such as Brazil, Mexico, China and Nigeria but also small countries such as Laos, Tunisia, and Eritrea are notable among the examples of very high salt iodization rates. And countries in complex political and security situations are in this group: Dem Congo, Bolivia and Libya for example. UNICEF 2000

In 36 countries, 50-89% households consume iodized salt These are the 36 countries where salt iodization rates at the last round have been found between 50 and 89% of households. This category includes populous countries such as India, Indonesia, Bangladesh, Viet Nam, Egypt and Tanzania, but also quite a few small populations of countries such as Armenia, Botswana, Mongolia, Oman, Paraguay and Togo. Most of East and Southern Africa is in this group too. UNICEF 2000

In 38 countries, <50% households consume iodized salt And in 38 countries, the last survey found that less than 50% of households have iodized salt available. This includes many of the countries of Eastern Europe and the Newly Independent States, where under the previous centrally planned economy edible salt was expected to be iodized. This group includes populous countries such as Pakistan, The Philippines and Turkey, and it includes some countries in difficult circumstances such as Ethiopia, Angola and Sierra Leone, Mali and Senegal in Western Africa. In the Caribbean, Cuba, Haiti and the Dominican Republic are part of this group. THE REASON FOR SHOWING YOU THESE PICTURES IS TWO FOLD: (A) THE ELIMINATION OF IDD IS A GLOBAL CONCERN, (PERHAPS MENTION UNGASS) BUT SUCCESS IS DEPENDENT ON ACHIEVEMENTS IN COUNTRY AFTER COUNTRY. THUS IT IS IMPORTANT TO assure PROGRESS FROM a ***NATIONAL PERSPECTIVE***. THE SUCCESS IS NATIONALLY OWNED. AND (B) IF ENACTED NATIONALLY, THE SALT IODIZATION STRATEGY IS SUCCESSFUL IRRESPECTIVE OF THE SIZE, ECONOMIC STAGE, POLITICAL CONSTELLATION OR STRUCTURE OF THE SOCIETY, FOR INSTANCE THE SALT INDUSTRY. WE SEE TREMENDOUS PROGRESS AND SUCCESS IN COUNTRIES AS LARGE AS CHINA AND NIGERIA AND AS SMALL AS TOGO AND PANAMA, AND IN COUNTRIES AS COMPLEX AS IRAN AND CONGO AS WELL AS IN TURKMENISTAN, EAST AFRICA AND SOUTHEAST ASIA. UNICEF 2000

Production of Iodized Salt (unofficial data)

Considerations Mandatory legislation The minimum to eliminate iodine deficiency: All table salt iodized Food grade salt iodized: staple foods bread, bakery products, and others if possible Expectations from communication activities: Without mandatory law: no behaviour change of all people achievable, cost is high, not sustainable Lithuania: 20% households used iodized salt after the campaign in 2000, then dropped to 10% With mandatory law: raise awareness, inform public and main actors, use logo and slogan WHO guidelines Iodization levels: minimum 20-40 ppm iodine Iodized salt is safe - 1994 Take “yes or no” out. In advocating, we emphasize the reasons why only “yes” is acceptable. Add: WHO has published a guideline to iodize salt at least at 20-40ppm iodine. These are conservative levels, based on the collective experience in the world until the mid 1990s. Upon concerns expressed by the international community about eventual side-effects such as IIH, WHO in 1994 issued a statement that “Iodized salt is safe” (Iodine and Health).

Salt Iodization in other countries Switzerland: voluntary law since 1922 94% use of iodized salt after 60 years of public awareness raising; food producers use iodized salt Netherlands: Iodization of “all” table and bread/pasta salt (through voluntary system) 65% use iodized salt Austria: Mandatory iodization for all salt Respected by EU regulatory system In Switzerland, also food processing industry (not all, however, since the law is “voluntary”) uses iodized salt. The iodization of salt used in bread and pasta products in The Netherlands is organized in such a way that, in effect, it IS mandatory. The salt supply arrangements are such that the bread bakeries and pasta (noodles, vermicelli, macaroni, etc) industry must go to great lengths to obtain non-iodized salt. The effect is that ALL bead and pasta products supply a constant amount of small additional iodine consumption to everyone in the population. Similar examples of successful insertion in food industry are in Germany and Austria. In Austria –as the single EU country- iodization of ALL salt is mandatory. These various arrangements of USI in Europe are respected by the regulators and lawmakers of the European Union. The principle is that EU-wide agreements respect the national decisions on managing the nutritional aspects of the food supply.

Salt Iodization in other countries Denmark: 1920: voluntary iodization of table salt 1982: iodization prohibited 1998: voluntary iodization of all salt 2000: mandatory iodization of all table (retail) salt and salt for bread 100% use iodized salt today! Turkey: Mandatory law for table salt being implemented 64% use iodized salt in 2002 Iodine status not sufficient: median = 53 mcg/L None of food grade salt is iodized If you insist, the OK. But keep this short. In my view it is not an essential slide among the series.

Median Urinary Iodine levels in 28 schools Lithuania is iodine deficient! Keep it short. The norm for “adequate” iodine nutrition is between 100 and 200, and for pregnant women even more. The need for additional iodine in the common food supply in Lithuania is obvious. Median Urinary Iodine levels in 28 schools

Lithuania + 32,000 newborns per year This means 28,800 newborns not protected With decreasing population, future generation needs to be protected! Investment in USI = better intelligence among newborn = better learning and earning = benefiting economy of the country Better intelligence among newborns means better learning and better earning, thus benefiting the economy of the country. By our decision to “invest” in brain protection from UNIVERSAL salt iodization, we prepare our children for the electronic age.