1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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
Ideal iodine intake
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

11. 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 μg/l ) and more than adequate iodine intake (UIC range of μg/l ).
The Study Group suggested adopting the expanded range of optimal UIC levels for school age children (i.e 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 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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..)

29. 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

30. 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 ug/L
Women of Reproductive age ug/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

31. #commit2USI