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1.  Iodisation of Salt in Slovenia: Increased Availability of Non-Iodised Salt in the Food Supply 
Nutrients  2016;8(7):434.
Salt iodisation is considered a key public health measure for assuring adequate iodine intake in iodine-deficient countries. In Slovenia, the iodisation of all salt was made mandatory in 1953. A considerable regulatory change came in 2003 with the mandatory iodisation of rock and evaporated salt only. In addition, joining the European Union’s free single market in 2004 enabled the import of non-iodised salt. The objective of this study was to investigate the extent of salt iodising in the food supply. We examined both the availability and sale of (non-)iodised salt. Average sales-weighted iodine levels in salt were calculated using the results of a national monitoring of salt quality. Data on the availability and sales of salts were collected in major food retailers in 2014. Iodised salt represented 59.2% of the salt samples, and 95.9% of salt sales, with an average (sales-weighted) level of 24.2 mg KI/kg of salt. The average sales-weighted KI level in non-iodised salts was 3.5 mg KI/kg. We may conclude that the sales-weighted average iodine levels in iodised salt are in line with the regulatory requirements. However, the regulatory changes and the EU single market have considerably affected the availability of non-iodised salt. While sales of non-iodised salt are still low, non-iodised salt represented 33.7% of the salts in our sample. This indicates the existence of a niche market which could pose a risk of inadequate iodine intake in those who deliberately decide to consume non-iodised salt only. Policymakers need to provide efficient salt iodisation intervention to assure sufficient iodine supply in the future. The reported sales-weighting approach enables cost-efficient monitoring of the iodisation of salt in the food supply.
doi:10.3390/nu8070434
PMCID: PMC4963910  PMID: 27438852
salt; sodium; iodine; sales; food supply; Slovenia
2.  Adequate Iodine Status in New Zealand School Children Post-Fortification of Bread with Iodised Salt 
Nutrients  2016;8(5):298.
Iodine deficiency re-emerged in New Zealand in the 1990s, prompting the mandatory fortification of bread with iodised salt from 2009. This study aimed to determine the iodine status of New Zealand children when the fortification of bread was well established. A cross-sectional survey of children aged 8–10 years was conducted in the cities of Auckland and Christchurch, New Zealand, from March to May 2015. Children provided a spot urine sample for the determination of urinary iodine concentration (UIC), a fingerpick blood sample for Thyroglobulin (Tg) concentration, and completed a questionnaire ascertaining socio-demographic information that also included an iodine-specific food frequency questionnaire (FFQ). The FFQ was used to estimate iodine intake from all main food sources including bread and iodised salt. The median UIC for all children (n = 415) was 116 μg/L (females 106 μg/L, males 131 μg/L) indicative of adequate iodine status according to the World Health Organisation (WHO, i.e., median UIC of 100–199 μg/L). The median Tg concentration was 8.7 μg/L, which was <10 μg/L confirming adequate iodine status. There was a significant difference in UIC by sex (p = 0.001) and ethnicity (p = 0.006). The mean iodine intake from the food-only model was 65 μg/day. Bread contributed 51% of total iodine intake in the food-only model, providing a mean iodine intake of 35 μg/day. The mean iodine intake from the food-plus-iodised salt model was 101 μg/day. In conclusion, the results of this study confirm that the iodine status in New Zealand school children is now adequate.
doi:10.3390/nu8050298
PMCID: PMC4882711  PMID: 27196925
iodine; iodised salt; fortification; deficiency; children; New Zealand
3.  Dietary sodium and iodine in remote Indigenous Australian communities: will salt-reduction strategies increase risk of iodine deficiency? A cross-sectional analysis and simulation study 
BMC Public Health  2015;15:1318.
Background
Excess salt intake is a global issue. Effective salt-reduction strategies are needed, however, as salt is a vehicle for iodine fortification, these strategies may also reduce iodine intake. This study examines the case of the remote Indigenous Australian population; we employed an innovative, objective method to assess sodium and iodine intakes against requirements and modelled the potential effects of salt-reduction strategies on estimated sodium and iodine intakes.
Design
Store-sales data were collected from 20 remote Indigenous community stores in 2012–14 representing the main source of food for 2 years for ~8300 individuals. Estimated average sodium and iodine intakes were compared against recommendations (nutrient reference values weighted to age and gender distribution). Linear programming was employed to simulate potential effects of salt-reduction strategies on estimated sodium and iodine intakes.
Results
Estimated average sodium intake was 2770 (range within communities 2410–3450) mg/day, far exceeding the population-weighted upper limit (2060 mg/day). Discretionary (added) salt, bread and processed meat were the biggest contributors providing 46 % of all sodium. Estimated average iodine intake was within recommendations at 206 (186–246) μg/day. The following scenarios enabled modelling of estimated average salt intake to within recommendations: 1) 67 % reduction in sodium content of bread and discretionary salt intake, 2) 38 % reduction in sodium content of all processed foods, 3) 30 % reduction in sodium content of all processed foods and discretionary salt intake. In all scenarios, simulated average iodine intakes remained within recommendations.
Conclusions
Salt intakes of the remote Indigenous Australian population are far above recommendations, likely contributing to the high prevalence of hypertension and cardiovascular mortality experienced by this population. Salt-reduction strategies could considerably reduce salt intake in this population without increasing risk of iodine deficiency at the population-level. These data add to the global evidence informing salt-reduction strategies and the evidence that these strategies can be synergistically implemented with iodine deficiency elimination programmes.
Trial registration
Australian New Zealand Clinical Trials Registry: ACTRN12613000694718.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-015-2686-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12889-015-2686-1
PMCID: PMC4696303  PMID: 26714467
4.  Iodine Status and Prevalence of Goitre in School Going Children in Rural Area 
Introduction: Iodine deficiency disorder (IDD) is one of the preventable major public health problems in India. It has been always thought that goitre was only found in the Himalayan goitre belt. Recent surveys outside the conventional goitre belt have identified foci of iodine deficiency in other parts of India.
Aim: 1) To assess the prevalence of goitre among school-going children in the age group of 6-15 years. 2) To find out the relationship of goitre prevalence with the salt intake and urinary iodine excretion. 3) To unfold the iodine nutritional status of the study population.
Material and Methods: The study was conducted from January 2005 to July 2006 in school children of 6-15 years of age, attending the 55 schools of Bellur hobli in the southern part of India. The clinical examination of all the 1600 children of the selected schools was done to detect and grade goitre. Urine and salt samples were collected from sub-samples (n = 400) to estimate the urinary iodine excretion level and iodine content in the salt respectively.
Results: The goitre prevalence in the study population was found to be 0.125%. Urinary iodine excretion (UIE) level of ≥ 100 mcg / l was found in 361 children (90.25%) and < 100 mcg/ l in 39 children (9.75%). Estimation of iodine content of the salt samples revealed that 363 (90.75%) consumed adequately iodised salt (> 15ppm) and 37 (9.25%) consumed inadequately iodised salt (< 15ppm).
Conclusion: Bellur Hobli is not an endemic area for goitre and there is no biochemical iodine deficiency in this population due to effective implementation of Universal iodization programme (UIP). It is reasonable to conclude that by achieving the universal iodisation of salt, IDD can be successfully eliminated from the community.
doi:10.7860/JCDR/2013/6311.4732
PMCID: PMC4190768  PMID: 25302243
Goitre; Iodine deficiency; Iodised salt; Urinary iodine excretion
5.  A cross-sectional comparison study on the iodine nutritional status between rural and urban residents in Zhejiang Province, China 
BMJ Open  2014;4(6):e005484.
Objectives
To evaluate the difference of iodine nutritional status between rural and urban residents under the universal salt iodisation policy.
Setting
A multistage cluster sampling technique was employed in the present cross-sectional study. In total, 3300 rural and 3300 urban households were selected where the investigation was conducted.
Participants
A total of 8553 rural and 8909 urban residents participated in this provincial survey.
Primary and secondary outcome measures
Spot urine samples were collected and the iodine concentration in urine was determined by the modified acid-digestion method.
Results
The median urinary iodine concentration of rural residents was 170.1 μg/L, which was higher than that of urban residents with 153.5 μg/L. For school-aged children, middle-aged people and older people, the median urinary iodine concentration of rural residents was 191.2, 160.2 and 154.0 μg/L, respectively, which was higher than that of urban residents with 166.2, 153.8 and 129.5 μg/L, respectively. Risk factors for urinary concentration of rural residents were age (OR=0.99), terrain (OR=0.83), usual intake of pickled products (OR=1.45) and non-iodised salt intake (OR=0.39), while those for urban residents were age (OR=0.99), terrain (OR=0.83), usual intake of aquatic products (OR=1.24) and non-iodised salt intake (OR=0.27) compared with iodised table salt intake.
Conclusions
The median urinary iodine concentration of rural residents was higher than that of urban residents although they were both falls in optimal iodine status as recommended by WHO/UNICEF/International Council for the Control of Iodine Deficiency Disorders. Iodised salt intake is the major factor which influences the iodine nutritional status mostly for rural and urban residents. The ongoing monitoring of population iodine status remains crucially important.
doi:10.1136/bmjopen-2014-005484
PMCID: PMC4078769  PMID: 24969785
NUTRITION & DIETETICS; PUBLIC HEALTH; EPIDEMIOLOGY
6.  Dietary Iodine Intake of the Australian Population after Introduction of a Mandatory Iodine Fortification Programme 
Nutrients  2016;8(11):701.
To address mild iodine deficiency in Australia, a mandatory fortification program of iodised salt in bread was implemented in 2009. This study aimed to determine factors associated with achieving an adequate dietary iodine intake in the Australian population post-fortification, and to assess whether bread consumption patterns affect iodine intake in high-risk groups. Using nationally representative data of repeated 24-h dietary recalls from the 2011–2012 Australian National Nutrition and Physical Activity Survey, dietary iodine intakes and food group contributions were compared by age, socioeconomic status (SES), and geographical remoteness (N = 7735). The association between fortified bread intake and adequacy of iodine intake (meeting age and sex-specific Estimated Average Requirements) was investigated using logistic regression models in women of childbearing age 14–50 years (n = 3496) and children aged 2–18 years (n = 1772). The effect of SES on bread consumption was further investigated in a sub group of children aged 5–9 years (n = 488). Main sources of iodine intake at the time of the survey were cereal and cereal products, followed by milk products and dishes. Differences in iodine intake and dietary iodine habits according to age, SES and location were found (p < 0.001) for women of child-bearing age. Fortified bread consumption at ≥100 g/day was associated with five times greater odds of achieving an adequate iodine intake (OR 5.0, 95% CI 4.96–5.13; p < 0.001) compared to lower bread consumption in women and 12 times in children (OR 12.34, 95% CI 1.71–89.26; p < 0.001). Disparities in dietary iodine intake exist within sectors of the Australian population, even after mandatory fortification of a staple food. On-going monitoring and surveillance of iodine status is required.
doi:10.3390/nu8110701
PMCID: PMC5133088  PMID: 27827915
iodine; fortification; Australia; dietary intake; bread; monitoring
7.  Post-production Losses in Iodine Concentration of Salt Hamper the Control of Iodine Deficiency Disorders: A Case Study in Northern Ethiopia 
Iodine is essential for good function of the thyroid, and its deficiency is of public-health importance in Ethiopia. Iodization of salt is an effective and sustainable strategy to prevent and control iodine deficiency in large populations. The effectiveness of salt-iodization programmes depends on the conservation of iodine concentration in salt at various stages of the supply-chain. The overall objective of the study was to assess the loss of iodine in salt from production to consumption and to estimate the proportion of adults, especially pregnant women, at risk of dietary iodine insufficiency. A cross-sectional study was conducted during February-April 2007 in northern Ethiopia. Iodine concentrations of salt samples from producers (n=41), retailers (n=7), and consumers (n=32) were determined using iodiometric titration. A risk assessment was conducted for dietary iodine insufficiency among adults, including pregnant women, using a semi-probabilistic approach. The concentration of iodine in the sampled salts decreased by 57% from the production site to the consumers. The assessment of exposure showed that adults in 63% (n=20) of the households, including 90% (n=29) with pregnant women, were at risk of insufficient iodine intake. A monitoring and evaluation system needs to be established to ensure adequate supply of iodine along the distribution chain. Special attention is needed for the retailers and consumers. At these levels, dissemination of information regarding proper storage and handling of iodized salt is necessary to address the reported loss of iodine from salt.
PMCID: PMC2980888  PMID: 20635634
Cross-sectional studies; Iodine; Iodine deficiency; Salt; Ethiopia
8.  Iodine nutritional status and risk factors for goitre among schoolchildren in South Tajikistan 
Background
Iodine deficiency affects nearly 1.9 billion people worldwide, but it can be prevented by salt iodization. This cross-sectional survey assessed current iodine status, iodized salt coverage and risk factors for goitre among schoolchildren in South Tajikistan.
Methods
Ten primary schools in four districts in South Tajikistan were randomly selected. In schoolchildren aged 7 to 11 years, a spot urine sample was collected for measurement of urinary iodine, dried blood spots were collected for measurement of thyroglobulin, and goitre was assessed by palpation. Iodine content of salt samples and local selling points was determined by coloration using rapid test kits and titration method.
Results
Of 623 schoolchildren enrolled, complete data was obtained from 589. The overall median urinary iodine concentration (UIC) was 51.2 μg/L indicating mild-to-moderate iodine deficiency. Among all children, 46.6% (95% Confidence Interval (CI) = 42.4%-50.6%) of children were found to be goitrous (grade 1 goitre: 30.6%, 95% CI = 26.9%-34.5%; grade 2 goitre: 16.0%, 95% CI = 13.1%-19.2%). The risk factor for goitre remaining significant in the multivariable logistic regression model was 'buying salt once a month’ (OR = 2.89, 95% CI = 1.01-8.22) and 'buying salt once every six months’ (OR = 2.26, 95% CI = 1.01-5.04) compared to 'buying salt every one or two weeks’. The overall median thyroglobulin concentration was elevated at 13.9 μg/L. Of the salt samples from households and selling points, one third were adequately iodised, one third insufficiently and one third were not iodised.
Conclusion
Iodine deficiency remains a serious health issue among children in southern Tajikistan. There is a persisting high prevalence of goitre, elevated thyroglobulin and low UIC despite interventions implemented by Tajikistan and international partners. Quality control of salt iodine content needs to be improved. Continued efforts to raise awareness of the health effects of iodine deficiency are needed to increase consumer demand for iodised salt.
doi:10.1186/1472-6823-13-50
PMCID: PMC4175091  PMID: 24180470
Iodine status; Goitre; Risk factors for goitre; Urinary iodine concentration; Thyroglobulin concentration; Salt iodization; Schoolchildren; Tajikistan
9.  Iodine in commercial edible iodized salts and assessment of iodine exposure in Sri Lanka 
Background
Iodine is an essential micronutrient used by the thyroid gland in the production of thyroid hormones. Both excessive and insufficient iodine intakes can cause thyroid diseases thus harmful to the human body. Inadequate iodine intake by human body causes Iodine Deficiency Disorders (IDD) and hypothyroidism. Excessive iodine intake causes Iodine Induced Hyperthyroidism (IIH). Universal Salt Iodization (USI) is the most effective way of preventing IDD. This study determined the concentrations of iodine species in commercial edible salt products, the stability of iodine at different conditions and iodine exposure at the consumer level.
Methods
The iodine contents of six commercial edible iodized salts were determined qualitatively and quantitatively for both iodide and iodate. Thereafter, the first three products of highest iodine contents, the stability of iodide at exposed to air and heat was measured after 24 hours. Risk assessment of exposure was done at four levels considering the WHO estimation.
Results
Results revealed that all of the salt products have excess iodine that is above the fortification level of 15–30 mg kg−1 level in Sri Lanka. Iodide stability was reduced at the average percentages of 13.1, 10.7 and 11.3. The iodate loss percentages were 0, 5.7 and 0 at open air. The iodide loss percentages at the temperature of 50 °C were 4.6, 7.8 and 8.6 while at 100 °C, loss percentages were 11.1, 11.4 and 15.9 for the same salt products. The iodine exposure at lower consumption during cooking ranged 244.4–432.2 μg/day while 325.9–576.3 μg/day for medium consumption, 407.4–720.4 μg/day for moderate high salt consumptions and 488.8–864.4 μg/day for high salt consumptions. As a total 95.8 % cases can cause IIH and only 4.1 % of them can provide optimal iodine nutrition in a population. Iodine exposure without cooking ranged 305.5–540.3 μg/day for low salt consumption, 407.4–720.4 μg/day for medium consumption and 509.2–900.5 μg/day for moderate high consumption and 611.1–1080.6 μg/day for high salt consumptions.
Conclusions
All of the incidents (100 %) of consumption without cooking at the household level can cause excessive iodine intake and IIH in a population.
doi:10.1186/s13690-016-0133-0
PMCID: PMC4885120  PMID: 27242918
Hypothyroidism; Iodine Deficiency Disorders (IDD); Iodine Induced Hyperthyroidism (IIH); Universal Salt Iodization (USI); Edible salts; Fortification level; Nutrition; Iodide; Iodate; Risk assessment; Exposure
10.  Iodine status in the Nordic countries – past and present 
Food & Nutrition Research  2016;60:10.3402/fnr.v60.31969.
Background
Adequate iodine nutrition is dependent on ground water content, seafood, and, as many countries use iodized cow fodder, dairy products. In most countries, salt fortification programs are needed to assure adequate iodine intake.
Objectives
The objectives are threefold: 1) to describe the past and present iodine situation in the Nordic countries, 2) to identify important gaps of knowledge, and 3) to highlight differences among the Nordic countries’ iodine biomonitoring and fortification policies.
Design
Historical data are compared with the current situation. The Nordic countries’ strategies to achieve recommended intake and urine iodine levels and their respective success rates are evaluated.
Results
In the past, the iodine situation ranged from excellent in Iceland to widespread goiter and cretinism in large areas of Sweden. The situation was less severe in Norway and Finland. According to a 1960 World Health Organization (WHO) report, there were then no observations of iodine deficiency in Denmark. In Sweden and Finland, the fortification of table salt was introduced 50–75 years ago, and in Norway and Finland, the fortification of cow fodder starting in the 1950s helped improve the population's iodine status due to the high intake of milk. In Denmark, iodine has been added to household salt and salt in bread for the past 15 years. The Nordic countries differ with regard to regulations and degree of governmental involvement. There are indications that pregnant and lactating women, the two most vulnerable groups, are mildly deficient in iodine in several of the Nordic countries.
Conclusion
The Nordic countries employ different strategies to attain adequate iodine nutrition. The situation is not optimal and is in need of re-evaluation. Iodine researchers, Nordic national food administrations, and Nordic governmental institutions would benefit from collaboration to attain a broader approach and guarantee good iodine health for all.
doi:10.3402/fnr.v60.31969
PMCID: PMC4901513  PMID: 27283870
iodine; goiter; history; thyroid; fortification; Iceland; Norway; Sweden; Denmark; Finland
11.  Food Group Intakes as Determinants of Iodine Status among US Adult Population 
Nutrients  2016;8(6):325.
Adequate intake of iodine is essential for proper thyroid function. Although dietary reference intakes for iodine have been established, iodine intake cannot be estimated due to the lack of data on iodine contents in foods. We aimed to determine if food group intakes can predict iodine status assessed by urinary iodine concentration (UIC) from spot urine samples of 5967 US adults in the National Health and Nutrition Examination Survey (NHANES) 2007–2012. From an in-person 24-h dietary recall, all foods consumed were aggregated into 12 main food groups using the individual food code of the US Department of Agriculture (USDA); dairy products, meat/poultry, fish/seaweed, eggs, legumes/nuts/seeds, breads, other grain products, fruits, vegetables, fats/oils, sugars/sweets, and beverages. Chi-square test, Spearman correlation, and multiple linear regression analyses were conducted to investigate the predictability of food group intakes in iodine status assessed by UIC. From the multiple linear regressions, the consumption of dairy products, eggs, and breads, and iodine-containing supplement use were positively associated with UIC, whereas beverage consumption was negatively associated with UIC. Among various food group intakes, dairy product intake was the most important determinant of iodine status in both US men and women. Subpopulation groups with a high risk of iodine deficiency may need nutritional education regarding the consumption of dairy products, eggs, and breads to maintain an adequate iodine status. Efforts toward a better understanding of iodine content in each food and a continued monitoring of iodine status within US adults are both warranted.
doi:10.3390/nu8060325
PMCID: PMC4924166  PMID: 27240399
iodine status; urinary iodine concentration; food group intake; National Health and Nutrition Examination Survey
12.  Urinary Iodine Excretion In Pregnancy: A Pilot Study in The Region of Nepal 
Background: Pregnancy is accompanied by profound alterations in the thyroid economy and the relative iodine deficiency. The median Urinary Iodine Excretion (UIE) is the most reliable indicator of the population’s iodine nutrition. The physiological alterations in normal pregnancy, such as an increased glomerular filtration rate, potentially invalidate UIE as an assessment tool in pregnancy.
Objectives: To assess the Urinary Iodine Excretion (UIE) in pregnant mothers and to enquire about the current status of their iodised salt intake.
Methods: We carried out a cross-sectional study in which urine samples were collected from 45 pregnant mothers who were admitted to the antenatal ward. The iodine level in the urine was analysed by a method which was provided by Singh and Ali, to determine the Urinary Iodine Excretion (UIE). A questionnaire was introduced to document the status of the dietary intake of iodised salt. The UIE was expressed in median (interquartile) and the other data are expressed in frequency and percentage. Fisher Exact test was applied to compare between UIE and iodine intake.
Results: Thirteen (28.88%) pregnant mothers had UIEs of <150 μg/L, which were below the cut-off point of the UIE for pregnant mothers. Overall, 33 mothers were from the Terai region; among them, one third had UIEs of <150 μg/L. Among the 45 pregnant women, 15 (33.34%) were not using iodised salt and the rest were using iodised salt. Among those who were using iodised salt (30 out of 45), 8 pregnant women had UIEs of <150 μg/L and among those who were not using iodised salt, 5 pregnant women had UIEs of < 150 μg/L.
Conclusion: The UIE was below 150μg/L in a substantial percentage (28.89%) of pregnant women of the Terai region, regardless of their intake of iodised salt.
doi:10.7860/JCDR/2013/6040.3136
PMCID: PMC3749625  PMID: 23998055
Iodine deficiency disorder; Urinary iodine excretion; Pregnancy
13.  Effect of salt reduction on iodine status assessed by 24 hour urinary iodine excretion in children and their families in northern China: a substudy of a cluster randomised controlled trial 
BMJ Open  2016;6(9):e011168.
Objective
To study the effect of salt reduction on iodine status and to determine whether iodine consumption was still adequate after salt reduction in a population where universal salt iodisation is mandatory.
Design
A substudy of a cluster randomised controlled trial, with schools randomly assigned to either the intervention or the control group.
Setting
28 primary schools in Changzhi, northern China.
Participants
279 children in grade 5 of primary school (mean age: 10.1); 553 adults (age: 43.8).
Intervention
Children were educated about the harmful effects of salt and how to reduce salt intake using the schools' usual health education lessons. Children then delivered the message to their families. The duration was 1 school term (≈3.5 months).
Main outcome measure
Difference between the intervention and control groups in the change of iodine intake as measured by repeat 24 hour urinary iodine from baseline to the end of the trial.
Results
At baseline, the mean salt intake was 7.0±2.5 g/day in children and 11.7±4.4 g/day in adults and the median iodine intake was 165.1 μg/day (IQR: 122.6–216.7) and 280.7 μg/day (IQR: 205.1–380.9) in children and adults, respectively. At the end of the study, salt and iodine decreased in the intervention compared with control group. The mean effect on salt for intervention versus control was −1.9 g/day (95% CI −2.6 to −1.3) in children and −2.9 g/day (95% CI −3.7 to −2.2) in adults. The mean effect on iodine was −19.3% (95% CI −29.4% to −7.7%) in children and −11.4% (95% CI −20.3% to −1.5%) in adults.
Conclusions
With ≈25% reduction in salt intake, there was a significant reduction in iodine consumption in northern China where salt is iodised. Despite this, iodine intake was still adequate, and well above the estimated average requirement. Our findings indicate that reducing salt to the WHO's target—30% reduction by 2025—will not compromise iodine status.
Trial registration number
ClinicalTrials.gov NCT01821144.
doi:10.1136/bmjopen-2016-011168
PMCID: PMC5051323  PMID: 27670515
Salt reduction; Iodine status; 24h urine collections; Cluster randomised trial
14.  Variable Iodine Intake Persists in the Context of Universal Salt Iodization in China123 
The Journal of Nutrition  2012;142(9):1728-1734.
Iodine deficiency disorders were prevalent in China until the introduction of universal salt iodization in 1995. Concerns have recently arisen about possible excess iodine intake in this context. To document iodine intake and the contribution from iodized salt in China, we surveyed dietary iodine intake during China’s nationally representative 2007 total diet study (TDS) and during an additional TDS in 4 coastal provinces and Beijing in 2009. Iodine intake was broken down by age and sex in 2009. Mean daily iodine and salt intake and the contribution from different food and beverage groups (and in 2009, individual items) was measured. The iodine in food cooked with iodized and noniodized salt was also assessed. The mean calculated iodine intake of a standard male in China was 425 μg/d in 2007 and 325 μg/d in coastal areas in 2009, well below the upper limit (UL) in all provinces. In 2009, iodine intake was above the UL in only 1–7% of age-sex groups, except among children (18–19%). A concerning number of individuals consumed less than the WHO-recommended daily allowance, including 31.5% of adult women. Salt contributed 63.5% of food iodine, and 24.6% of salt iodine was lost in cooking. Overall salt consumption declined between the surveys. Salt iodization assures iodine nutrition in China where environmental iodine is widely lacking. The risk of iodine excess is low, but planned decreases in salt iodization levels may increase the existing risk of inadequate intake. Regular monitoring of urinary iodine and more research on the impact of excess iodine intake is recommended.
doi:10.3945/jn.112.157982
PMCID: PMC3417834  PMID: 22810983
15.  Reducing salt in food; setting product-specific criteria aiming at a salt intake of 5 g per day 
Background/Objectives:
There is an increasing public health concern regarding high salt intake, which is generally between 9 and 12 g per day, and much higher than the 5 g recommended by World Health Organization. Several relevant sectors of the food industry are engaged in salt reduction, but it is a challenge to reduce salt in products without compromising on taste, shelf-life or expense for consumers. The objective was to develop globally applicable salt reduction criteria as guidance for product reformulation.
Subjects/Methods:
Two sets of product group-specific sodium criteria were developed to reduce salt levels in foods to help consumers reduce their intake towards an interim intake goal of 6 g/day, and—on the longer term—5 g/day. Data modelling using survey data from the United States, United Kingdom and Netherlands was performed to assess the potential impact on population salt intake of cross-industry food product reformulation towards these criteria.
Results:
Modelling with 6 and 5 g/day criteria resulted in estimated reductions in population salt intake of 25 and 30% for the three countries, respectively, the latter representing an absolute decrease in the median salt intake of 1.8–2.2 g/day.
Conclusions:
The sodium criteria described in this paper can serve as guidance for salt reduction in foods. However, to enable achieving an intake of 5 g/day, salt reduction should not be limited to product reformulation. A multi-stakeholder approach is needed to make consumers aware of the need to reduce their salt intake. Nevertheless, dietary impact modelling shows that product reformulation by food industry has the potential to contribute substantially to salt-intake reduction.
doi:10.1038/ejcn.2015.5
PMCID: PMC4493648  PMID: 25690867
16.  Sodium content of processed foods in the United Kingdom: analysis of 44,000 foods purchased by 21,000 households123 
Background: In the United Kingdom, sodium reduction targets have been set for a large number of processed food categories. Assessment and monitoring are essential to evaluate progress.
Objectives: Our aim was to determine whether household consumer panel food-purchasing data could be used to assess the sodium content of processed foods. Our further objectives were to estimate the mean sodium content of UK foods by category and undertake analyses weighted by food-purchasing volumes.
Design: Data were obtained for 21,108 British households between October 2008 and September 2009. Purchasing data (product description, product weight, annual purchases) and sodium values (mg/100 g) were collated for all food categories known to be major contributors to sodium intake. Unweighted and weighted mean sodium values were calculated.
Results: Data were available for 44,372 food products. The largest contributors to sodium purchases were table salt (23%), processed meat (18%), bread and bakery products (13%), dairy products (12%), and sauces and spreads (11%). More than one-third of sodium purchased (37%) was accounted for by 5 food categories: bacon, bread, milk, cheese, and sauces. For some food groups (bread and bakery, cereals and cereal products, processed meat), purchase-weighted means were 18–35% higher than unweighted means, suggesting that market leaders have higher sodium contents than the category mean.
Conclusion: The targeting of sodium reduction in a small number of food categories and focusing on products sold in the highest volumes could lead to large decreases in sodium available for consumption and therefore to gains in public health.
doi:10.3945/ajcn.110.004481
PMCID: PMC3561609  PMID: 21191142
17.  Increasing Awareness and Use of Iodised Salt in a Marginalised Community Setting in North-West Pakistan 
Nutrients  2015;7(11):9672-9682.
Iodine deficiency is still prevalent in parts of Pakistan, despite the introduction of a national Iodine Deficiency Disorder Control Programme in 1994. The purpose of this study was to gain an understanding of the knowledge, attitudes and practice regarding the use of iodised salt in a brick kiln community, and to use this information to design an intervention to increase its consumption. A cross-sectional survey was used to assess the use of iodised salt and focus group discussions explored the attitudes and barriers to its use. Thematically analysed transcripts informed the design of a 4-month intervention. Iodised salt sales and urine iodine concentration (UIC) were monitored to assess the effectiveness of the intervention. At baseline, 2.6% of households reported use of iodised salt and barriers included its higher cost and belief about a negative impact on reproduction. During the intervention, sales of salt labelled as iodised increased by 45%, however this was not reflected in an increase in UIC. This study highlighted the positive impact of education and awareness raising on iodised salt consumption in a hard to reach, marginalised community. However, issues regarding adequate iodisation by local producers and appropriate storage also need to be urgently addressed at a provincial level.
doi:10.3390/nu7115490
PMCID: PMC4663618  PMID: 26610563
iodine deficiency; goitre; urinary iodine concentration; community engagement; iodised salt; Pakistan; Khyber Pakhtunkhwa
18.  Assessment of Iodine Status in Children, Adults, Pregnant Women and Lactating Women in Iodine-Replete Areas of China 
PLoS ONE  2013;8(11):e81294.
Background
Iodine deficiency disorders (IDD) are widespread in China. Presently, IDD have been put under control by Universal Salt Iodisation (USI) in China; however, there is a lack of evidence on whether the iodine status in adults, pregnant women and lactating women is optimal. This study was therefore conducted to assess the iodine nutrition and thyroid function of children, adults, pregnant women and lactating women residing in areas where the USI program is fully established.
Design
Six areas were selected according to the geographical regions in China. In each of these areas, we selected 4 distinct groups of subjects (children, adults, pregnant women and lactating women) in regions where the coverage rate of iodised salt was more than 95% and the levels of iodine and fluoride in drinking water were less than or equal to 10 µg/L and 1 mg/L, respectively. We tested the iodine content of salt, urinary iodine (UI), free thyroxin (FT4), thyrotropin (TSH), thyroglobulin (Tg), thyroglobulin antibody (Tg-Ab) and antimicrosomal antibody (TM-Ab) in the 4 groups, and examined the thyroid volume in children.
Results
The median urinary iodine (MUI) concentrations were 271.4 μg/L, 260.2 μg/L, 205.9 μg/L and 193.9 μg/L in children, adults, pregnant women and lactating women, respectively; MUI in children and adults were more than adequate. The goitre prevalence (GP) in children was 6.70%. The odds ratios (OR) of subclinical hypothyroidism in the Tg-Ab- or TM-Ab-positive groups were 3.80, 7.65, 2.01 and 7.47 for children, adults, pregnant women and lactating women, respectively, compared with the negative groups.
Conclusions
The iodine status in children and adults is above the requirement, we should reduce their iodine intake. Subclinical hypothyroidism easily occurs in the Tg-Ab or TM-Ab positive groups.
doi:10.1371/journal.pone.0081294
PMCID: PMC3840003  PMID: 24282581
19.  Adequate iodine levels in healthy pregnant women. A cross-sectional survey of dietary intake in Turkey 
Saudi Medical Journal  2016;37(6):698-702.
Objectives:
To assess current iodine levels and related factors among healthy pregnant women.
Methods:
In this cross-sectional, hospital-based study, healthy pregnant women (n=135) were scanned for thyroid volume, provided urine samples for urinary iodine concentration and completed a questionnaire including sociodemographic characteristics and dietary habits targeted for iodine consumption at the Department of Obstetrics and Gynecology, School of Medicine, Muğla Sıtkı Koçman University, Muğla, Turkey, between August 2014 and February 2015. Sociodemographic data were analyzed by simple descriptive statistics.
Results:
Median urinary iodine concentration was 222.0 µg/L, indicating adequate iodine intake during pregnancy. According to World Health Organization (WHO) criteria, 28.1% of subjects had iodine deficiency, 34.1% had adequate iodine intake, 34.8% had more than adequate iodine intake, and 3.0% had excessive iodine intake during pregnancy. Education level, higher monthly income, current employment, consuming iodized salt, and adding salt to food during, or after cooking were associated with higher urinary iodine concentration.
Conclusion:
Iodine status of healthy pregnant women was adequate, although the percentage of women with more than adequate iodine intake was higher than the reported literature.
doi:10.15537/smj.2016.6.13887
PMCID: PMC4931654  PMID: 27279519
20.  Maternal urinary iodine concentration in pregnancy and children's cognition: results from a population-based birth cohort in an iodine-sufficient area 
BMJ Open  2014;4(6):e005520.
Objective
Reports from populations with an insufficient iodine intake suggest that children of mothers with mild iodine deficiency during pregnancy are at risk for cognitive impairments. However, it is unknown whether, even in iodine-sufficient areas, low levels of iodine intake occur that influence cognitive development in the offspring. This study investigated the association between maternal low urinary iodine concentration (UIC) in pregnancy and children's cognition in a population-based sample from a country with an optimal iodine status (the Netherlands).
Setting and participants
In 1525 mother–child pairs in a Dutch multiethnic birth cohort, we investigated the relation between maternal UIC<150 μg/g creatinine, assessed <18 weeks gestation and children's cognition.
Outcomes measures
Non-verbal IQ and language comprehension were assessed during a visit to the research centre using Dutch test batteries when the children were 6 years.
Results
In total, 188 (12.3%) pregnant women had UIC<150 μg/g creatinine, with a median UIC equal to 119.3 μg/g creatinine. The median UIC in the group with UIC>150 μg/g creatinine was 322.9 μg/g and in the whole sample 296.5 μg/g creatinine. There was a univariate association between maternal low UIC and children's suboptimum non-verbal IQ (unadjusted OR=1.44, 95% CI 1.02 to 2.02). However, after adjustment for confounders, maternal low UIC was not associated with children's non-verbal IQ (adjusted OR=1.33, 95% CI 0.92 to 1.93). There was no relation between maternal UIC in early pregnancy and children's language comprehension at 6 years.
Conclusions
The lack of a clear association between maternal low UIC and children's cognition probably reflects that low levels of iodine were not frequent and severe enough to affect neurodevelopment. This may result from the Dutch iodine fortification policy, which allows iodised salt to be added to almost all processed food and emphasises the monitoring of iodine intake in the population.
doi:10.1136/bmjopen-2014-005520
PMCID: PMC4067856  PMID: 24928597
EPIDEMIOLOGY
21.  Iodine source apportionment in the Malawian diet 
Scientific Reports  2015;5:15251.
The aim of this study was to characterise nutritional-I status in Malawi. Dietary-I intakes were assessed using new datasets of crop, fish, salt and water-I concentrations, while I status was assessed for 60 women living on each of calcareous and non-calcareous soils as defined by urinary iodine concentration (UIC). Iodine concentration in staple foods was low, with median concentrations of 0.01 mg kg−1 in maize grain, 0.008 mg kg−1 in roots and tubers, but 0.155 mg kg−1 in leafy vegetables. Freshwater fish is a good source of dietary-I with a median concentration of 0.51 mg kg−1. Mean Malawian dietary-Iodine intake from food, excluding salt, was just 7.8 μg d−1 compared to an adult requirement of 150 μg d−1. Despite low dietary-I intake from food, median UICs were 203 μg L−1 with only 12% defined as I deficient whilst 21% exhibited excessive I intake. Iodised salt is likely to be the main source of dietary I intake in Malawi; thus, I nutrition mainly depends on the usage and concentration of I in iodised salt. Drinking water could be a significant source of I in some areas, providing up to 108 μg d−1 based on consumption of 2 L d−1.
doi:10.1038/srep15251
PMCID: PMC4621511  PMID: 26503697
22.  Salt Reduction Initiatives around the World – A Systematic Review of Progress towards the Global Target 
PLoS ONE  2015;10(7):e0130247.
Objective
To quantify progress with the initiation of salt reduction strategies around the world in the context of the global target to reduce population salt intake by 30% by 2025.
Methods
A systematic review of the published and grey literature was supplemented by questionnaires sent to country program leaders. Core characteristics of strategies were extracted and categorised according to a pre-defined framework.
Results
A total of 75 countries now have a national salt reduction strategy, more than double the number reported in a similar review done in 2010. The majority of programs are multifaceted and include industry engagement to reformulate products (n = 61), establishment of sodium content targets for foods (39), consumer education (71), front-of-pack labelling schemes (31), taxation on high-salt foods (3) and interventions in public institutions (54). Legislative action related to salt reduction such as mandatory targets, front of pack labelling, food procurement policies and taxation have been implemented in 33 countries. 12 countries have reported reductions in population salt intake, 19 reduced salt content in foods and 6 improvements in consumer knowledge, attitudes or behaviours relating to salt.
Conclusion
The large and increasing number of countries with salt reduction strategies in place is encouraging although activity remains limited in low- and middle-income regions. The absence of a consistent approach to implementation highlights uncertainty about the elements most important to success. Rigorous evaluation of ongoing programs and initiation of salt reduction programs, particularly in low- and middle- income countries, will be vital to achieving the targeted 30% reduction in salt intake.
doi:10.1371/journal.pone.0130247
PMCID: PMC4511674  PMID: 26201031
23.  Iodine Intake in Somalia Is Excessive and Associated with the Source of Household Drinking Water123 
The Journal of Nutrition  2014;144(3):375-381.
Few data on iodine status in Somalia are available, but it is assumed that deficiency is a public health problem due to the limited access to iodized salt. We aimed to describe the iodine status of the population of Somalia and to investigate possible determinants of iodine status. A national 2-stage, stratified household cluster survey was conducted in 2009 in the Northwest, Northeast, and South Central Zones of Somalia. Urinary iodine concentration (UIC) was determined in samples from women (aged 15–45 y) and children (aged 6–11 y), and examination for visible goiter was performed in the Northwest and South Central strata. A 24-h household food-frequency questionnaire was conducted, and salt samples were tested for iodization. The median UICs for nonpregnant women and children were 329 and 416 μg/L, respectively, indicating excessive iodine intake (>300 μg/L). The prevalence of visible goiter was <4%. The coverage of salt iodization was low, with a national average of 7.7% (95% CI: 3.2%, 17.4%). Spatial analysis revealed localized areas of relatively high and low iodine status. Variations could not be explained by food consumption or salt iodization but were associated with the main source of household drinking water, with consumers of borehole water having a higher UIC (569 vs. 385 μg/L; P < 0.001). Iodine intake in Somalia is among the highest in the world and excessive according to WHO criteria. Further work is required to investigate the geochemistry and safety of groundwater sources in Somalia and the impact on human nutrition and health.
doi:10.3945/jn.113.176693
PMCID: PMC3927550  PMID: 24500936
24.  Iodine Status of Women of Reproductive Age in Sierra Leone and Its Association with Household Coverage with Adequately Iodized Salt 
Nutrients  2016;8(2):74.
Salt iodization programs are a public health success in tackling iodine deficiency. Yet, a large proportion of the world’s population remains at risk for iodine deficiency. In a nationally representative cross-sectional survey in Sierra Leone, household salt samples and women’s urine samples were quantitatively analyzed for iodine content. Salt was collected from 1123 households, and urine samples from 817 non-pregnant and 154 pregnant women. Household coverage with adequately iodized salt (≥15 mg/kg iodine) was 80.7%. The median urinary iodine concentration (UIC) of pregnant women was 175.8 µg/L and of non-pregnant women 190.8 µg/L. Women living in households with adequately iodized salt had higher median UIC (for pregnant women: 180.6 µg/L vs. 100.8 µg/L, respectively, p < 0.05; and for non-pregnant women: 211.3 µg/L vs. 97.8 µg/L, p < 0.001). Differences in UIC by residence, region, household wealth, and women’s education were much smaller in women living in households with adequately iodized salt than in households without. Despite the high household coverage of iodized salt in Sierra Leone, it is important to reach the 20% of households not consuming adequately iodized salt. Salt iodization has the potential for increasing equity in iodine status even with the persistence of other risk factors for deficiency.
doi:10.3390/nu8020074
PMCID: PMC4772038  PMID: 26848685
iodine status; salt iodization; salt iodine levels; household equity; Sierra Leone
25.  Developing a national salt reduction strategy for Mongolia 
Background
The increase in prevalence of risk factors such as hypertension has contributed to an incremental rise in non-communicable diseases (NCDs) in Mongolia over recent decades, such that they now account for 80% of all deaths in the country. Salt reduction is one of the most cost-effective interventions to reduce the burden of NCDs.
Methods
In 2011, the Ministry of Health (MOH) instigated the development of a national salt reduction strategy for Mongolia. As part of a 2-week national consultation and training program on salt reduction, it established an inter-sectoral working party and organized a series of bilateral meetings and visits to factories. Actions arising included a baseline survey of population salt consumption patterns and the implementation of a series of pilot salt reduction initiatives.
Results
The results of the baseline assessment revealed that average daily intake of salt, based on 24 hour urine samples from a representative national sample (n=1,027), was 11.06±5.99 g in 2011, more than double the World Health Organization (WHO) five grams recommendation. Moreover, while most participants knew that salt was bad for health, few were taking efforts to reduce intake, and many were consuming highly salty meals and tea; salt in tea alone was estimated to contribute 30% of daily salt intake. A pilot Pinch Salt intervention to reduce salt consumption of factory workers was undertaken in Ulaanbaatar (UB) city between 2012 and 2013, and was associated with a reduction of 2.8 g of salt intake. Ongoing food industry initiatives have led to significant reductions in salt levels in bread, and companies producing processed meat have indicated a willingness to reduce salt. Relevant stakeholders have also supported the campaign by participating in annual World Salt Awareness Week events. The activities to date have demonstrated the potential for action and there is now a need scale these up to a national level to ensure that Mongolia is in a strong position to achieve a 30% reduction in population salt intake by 2025. The main goal of the Mongolian national salt reduction strategy is to create a social, economic and legal environment that supports salt reduction, including by influencing food supply, increasing partnerships between government and relevant stakeholders, and creating an enabling environment to support improved consumer choices. The strategy will be implemented from 2015 to 2025, with an interim review of progress in 2020.
Conclusions
Given that Mongolia has one of the highest rates of stroke in the world, which is strongly associated with population-wide blood pressure (BP) levels, the addition of a population-based stroke surveillance program would provide a reliable direct assessment of the impact of these salt reduction initiatives on the health of the Mongolian people. The results from this research would likely be widely generalizable to other populations experiencing similar lifestyle transitional changes.
doi:10.3978/j.issn.2223-3652.2015.04.11
PMCID: PMC4451311  PMID: 26090334
Sodium; salt intake; 24-hour urine; economic region; population; Mongolia

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