1. OD-2011-07-Na&I1 Key Recommendations from WHO “Salt as a Vehicle of Fortification” 2007 PAHO Meeting “Improving Public Health Through the Optimal Intake of Iodine and Sodium” Key Recommendations from WHO “Salt as a Vehicle of Fortification” 2007 Omar Dary 31-March-2011 PAHO Meeting “Improving Public Health Through the Optimal Intake of Iodine and Sodium”

2. OD-2011-07-Na&I2 West Bank (Palestinian Territories) Collaboration vs. Cooperation The power of the words Salt reduction and Salt iodization initiatives Collaboration vs. Coordination COMPROMISE

3. OD-2011-07-Na&I3 Industry participation is essential, but… Cost-Effectiveness Analysis Impact Assessment Social Marketing and Education Governmental Inspection and Auditing Standards and Regulations Safe, Efficacious and Sustainable Implementation and Production Science (Efficacy trials) and Epidemiological Assessment Quality Control & Assurance - Factories Policies and National Strategies Implementation and Production of Micronutrient Premixes Nutrition and Researchers Researchers, Economists, Statisticians Bureau of Standards Food Industry/ Production Dept. Food Industry – QC/QA Department Premix manufacturers Food industry, Marketing, Government Guidance MAIN PLAYERS Nutrition Researchers, Statisticians, Laboratories Food Control from MoH, M.Economy, Food Labs Central Government Program Monitoring and Evaluation Science (Efficacy trials) and Epidemiological Assessment Cost-Effectiveness Analysis Impact Assessment Perception and separation of roles are also important.

4. OD-2011-07-Na&I4 19 recommendations emphasizing the compatibility and benefits of the two programs The WHO recommendations of 2007 Do we believe and accept all of them? Why these recommendations have not been implemented? This is a good opportunity and at the same time an important challenge

5. OD-2011-07-Na&I5 “The iodine concentration in salt should be determined considering both the level of salt consumption and median UI of the population” Analyzing only one recommendation

6. OD-2011-07-Na&I6 Situation in Guatemala in 2005* RegionsUI (µg/L) North103 North-East196 North-West119 Center167 South-East172 South-West179 * School-age children, INCAP and FANCAP data I salt (mg/kg) Positive (%) 15.359 % 27.079 % 23.366 % 16.760 % 21.891 % 26.769 % What is wrong? UI or depending on table salt?

7. OD-2011-07-Na&I7 Situation in Cambodia in 2008* ProvincesUI (µg/L) Kampot77 Koh Kong128 Phnom Penh166 Takeo182 Kampong Ch.223 Svay Rieng281 * School-age children, UNICEF-Cambodia Positive (%) 28 % 64 % 91 % 82% 54 % 29 % Is this a safe and successful program? Iodine in salt: 7.1 mg/kg (17.8 ± 23. 7 mg/kg) Iodine in fish sauce: 7.0 mg/L (5.7 ± 4.2 mg/kg) Intake of Salt: Table Salt: 10 g/d Fish Sauce: 5 g/d Total: 15 g/d

8. OD-2011-07-Na&I8 Women in Peru (2008) and USA (2001-6) RegionsUI (µg/L) Capital284 Coast302 Mount.rural227 Jungle206 Country266 Peru: Rev Peru Med Exp Salud Publica 2010; 27(2):195; USA: J Nutr 2010; doi:10.34945/jn. 109.1201147 GroupUI (µg/L) Non-pregnant130 Pregnant153 Lactating115 Only pregnant women Salt use: rare/sometimes 151/152 Dairy intake Y/N100/163 Why the difference between the two countries?

9. OD-2011-07-Na&I9 Probably salt sources Salt sourceDevelopingIn TransitionIndustrial Diet 20 %10 %10 – 15 % Processed foods 0 %16 %75 % Household salt 80 %76 %10 – 15 % Probable intake of household salt (g/d) 2 – 1010 – 201 - 3 Cases: Developing country=Uganda; in transition=Brazil; Industrial=USA. Conclusion: Salt reduction and iodine-deficiency prevention policies will vary from country to country. What is required for taking decisions?

10. OD-2011-07-Na&I10 Understanding the UI levels Group I RNI (mg/d) Urine vol. (L/d) UI (µg/L) Adj. UI (µg/L)* Women1501.4107 99 Pregnant women 2201.9115 106 Lactating women 2901.2242 223 * Assuming excretion of 92% of the intake. 7-9 year old children 90 - 1200.6150 - 200138 - 184 Conclusion: There is still many things to learn, and collaborating with programs of salt-intake reduction might accelerate progress.