Sustainable Elimination of Iodine Deficiency (Disorders): Perspective for Central & Eastern Europe and Central Asia ARNOLD TIMMER, UNICEF REGIONAL OFFICE April 2004

Iodine Deficiency: The Problem At risk of mental Impairment 10-15% IQ loss Goiter Cretinism

Iodine Deficiency Lowers IQ (10-15%) and Productivity Endocrinology Center, Moscow, 2002 Irreversible!

The network of connections are less dense Iodine Sufficient Brain Iodine Deficient Brain Source: From Legrand, 1967.

IDD … A Reminder From affected individuals to deficient populations: iodine deficiency affects the whole population Iodine = mental performance intelligence Iodine deficiency decreases IQ of newborns by % of ALL individuals and all population groups In an iodine deficient population, goiter, cretinism, and mental or cognitive deficits coexist

IDD … A Challenge IDD is a medical problem and should be solved by public health sector versus IDD is a nutritional problem and requires involvement of food sector Prevention of iodine deficiency versus Ensuring adequate iodine nutrition

Newborns unprotected against loss of IQ due to iodine deficiency Moldova: 67% unprotected or 26,000 Georgia: 33% unprotected or 15,000 Ukraine: 70% unprotected or 263,000 Kosovo: 16% unprotected or … CEE/CIS Region: 52% unprotected or 2.6 million

From the individual … to the population

A Public Health Problem that Affects the Whole Population requires a Solution that reaches the Whole Population!

Impact of Iodine Deficiency on the Nation Health care cost for treatment of thyroid diagnosis and treatment: –Germany: 700 million Euro per year Newborns with lower IQ is a loss of future productivity for the country: –Russia: 600,000 newborns unprotected: 1.4 billion US$ over next 5 years

Iodine Deficiency - The Solution Universal Salt Iodization Essential!

Why Salt? Possible: technologically easy to add iodine to salt Cheap: 0.02 US$ per person per year Safe: salt consumption 5-15 gr/day; iodine added does not exceed maximum limit and is still enough to meet daily requirement Available to all: salt is everywhere Affordable for all: salt is cheap

Types of salt Human: –Table (used at home for cooking and home-based food processing) –Food grade (used by food processing industry) Animal Technical (all salt not used for consumption: de-icing roads, tanning,..) Minimum to eliminate IDD: –Table + food grade (minimum: few staple foods like bread, pasta) Ideal: –Table + Food + Animal

IDD Elimination through USI Goal: sustainable elimination of ID by 2005 Strategy: Universal Salt Iodization (USI) Key issues: –Smart start for next generation –Iodine needs to be provided to the entire population regularly and forever –USI: 90% of households use iodized salt (IS) –All salt for human and animal consumption –Not to increase salt use but to use iodized salt

The Agreement: IDD Elimination through USI Special Session January 1994: Joint UNICEF-WHO Committee on Health Policy UN Special Session on Children A World Fit for Children- Your governments signed the goal to eliminate IDD by 2005!

79 million newborns protected from losses in learning ability in the developing world Source: SOWC 2004

Household use of iodized salt (by UNICEF region )

Household levels of iodized salt consumption (as of 2001) (countries for which data are available) Source: UNICEF MICS/DHS surveys

Production of Iodized Salt (unofficial data)

Realizing USI Phases: 1.Building commitment among partners, creating alliances, USI legislation development 2.Increasing iodized salt supply (production/import) and supporting activities 3.Fine-tuning of the programme, assessing impact, focus on sustainability

The Market Production of IS Enforcement of Laws Government Legislation The Black Market Uniodized Salt The Household Iodized Salt : From the Law to the Table Adequate iodine nutrition

Programme Cycle ASSESSMENT of the problem & means for resolution ANALYSIS of the cause of the problem ACTION Based on the analysis & available resources ASSESSMENT of the problem & means for resolution ANALYSIS of the cause of the problem ACTION Based on the analysis & available resources

Action Components Communication and Advocacy Interventions Monitoring and Evaluation Management, Training, Technical support, Capacity development

The Main Components of a National Iodine Nutrition Programme Communications High-level Advocacy Mobilization Consumer Education Salt Iodization Production & Quality Assurance Packaging & labeling Marketing Retailing Pricing Monitoring Legislation/Regulation Standards & Inspection Manufacturing Practice Impact Assessments Reporting IDD Slide courtesy of Emory University

Production Quality Assurance Awareness raising Coverage Monitoring Legislation Regulations Laboratory Impact Advocacy Policy Management Universal Salt Iodization

Role of Communication Difficult to convince behavior Different scenarios: –legislation (+) enforcement (+) –legislation (+) enforcement (-) –legislation (-) enforcement (-) Purpose short term is to increase immediate use: –Mass media campaign –Package and shops Purpose long term is to sustain basic level of awareness: –Curriculum in schools –Package

The Market Production of IS Enforcement of Laws Government Legislation The Black Market Uniodized Salt The Household Iodized Salt : From the Law to the Table Supportive Environment Advocacy for USI legislation  Creation of IDD coalitions and monitoring bodies  Engagement of IS producers in advocacy and IS agenda Increasing ImmediateUse  IS marketing to consumers  Branding and packaging with IS producers  Point of sale promotion Adequate iodine nutrition Ensuring Sustained Use  IS promotion by medical professionals  IDD education and IS promotion in schools and civil society groups  Engaging private sector salt production in marketing

Universal Salt Iodization Program Management Policy/Advocacy Ensuring Adequate Supply Ensuring Awareness and Use Production/Importation Quality assurance Packaging/labeling Legislation/Regulation Price Awareness Logo/ product recognition Behavior change Coverage Monitoring Impact Assessment