FORTIFICATION OF SALT – PAST, PRESENT AND FUTURE. S. Ranganathan and B. Sesikeran. National Institute of Nutrition. Introduction. Iodine deficiency. For estimating the soluble iron, a sample of fortified salt was dissolved in The percentage absorption of 55Fe salt was computed from the ratio of 55Fe to 59Fe . WHO I Guideline: Fortification of food-grade salt with iodine for the prevention . guideline is produced in response to a request for guidance in relation to a change example. Sometimes, evidence-based and proven interventions fail to be.
Moreover, the other susceptible group is women providing breast milk to their children, as this may be the only source of iodine for an infant during the first 6 months of life 4. It is estimated that about 1. Approximately one third of the world's population lives in areas where natural sources of iodine are low, and therefore they require the permanent presence of iodine-supplying interventions.
Salt iodization is the preferred strategy for control of iodine deficiency disorders and is implemented in more than countries around the world 7. Many countries worldwide have successfully eliminated iodine deficiency disorders or made substantial progress in their control, largely as a result of salt iodization and dietary diversification. Dairy products are also a good source of iodine if cattle are fed with iodine-enriched feed, and therefore including milk and other dairy products as part of promotion of dietary diversification is important to prevent iodine deficiency disorders.
The most visible sign of iodine deficiency is goitre, an enlargement of the thyroid gland.
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Individuals living in areas affected by severe iodine deficiency may have an intelligence quotient IQ of up to When iodine intake is inadequate, the thyroid gland may no longer be able to synthesize sufficient amounts of thyroid hormones. Low levels of thyroid hormones in the blood, referred to as hypothyroidism, are responsible for damage to the developing brain and for the whole spectrum of iodine deficiency disorders.
The spectrum of iodine deficiency disorders includes goitre; hypothyroidism; increased susceptibility to nuclear radiation; spontaneous abortion; stillbirths; congenital anomalies; perinatal mortality; endemic cretinism, including mental deficiency with a mixture of mutism, spastic dysplegia, squint, hypothyroidism and short stature; infant mortality; impaired mental function; delayed physical development; and iodine-induced hyperthyroidism 11 These can be prevented by ensuring that the population has an adequate intake of iodine.
Both insufficient and excess iodine can have negative effects on thyroid functioning. Excessive intake of iodine may be associated with complications such as iodine-induced hyperthyroidism in some cases 13 or hypothyroidism in others Data indicate a small increase in the risk for iodine-induced hyperthyroidism with increasing iodine intakes in older adults, mainly those with pre-existing nodular goitre 14 On a population basis, iodine-induced hyperthyroidism represents a transient increase in the incidence of hyperthyroidism that occurs when there is an increase in iodine intake in severely iodine-deficient populations.
The number of people at risk of iodine-induced hyperthyroidism is directly proportional to the number of individuals with nodular goitre. This condition will disappear with the correction of iodine deficiency 16 Sea fish and some seaweeds are good sources of dietary iodine.
Iodine can also be found in vegetables and cereals if they are produced in iodine-sufficient soils, poultry or meat and milk, if the animals consume foods grown in iodine-sufficient soils or are given iodine-containing feed supplements.
At all intake levels, a proportionate amount of iodine is excreted in the urine, so the urinary iodine excretion UIE using h urine collections is the ideal biochemical indicator for assessing iodine status. However, owing to the difficulties associated with using this indicator for assessing populations and monitoring programmes, the simple urinary iodine concentration UIC has been used 18although this may not reflect the intake distribution of individuals and populations as well as measurement of h UIE.
However, because of the lower urinary volume in children, the UIC may be higher in that age group than in adults. As ofthere were 57 million school-age children who were not attending school 20which may affect the interpretation of the results. In the past, the prevalence of goitre was also a commonly used indicator for the assessment of iodine deficiency in a population, although it has little practical usefulness now because goitre has nearly disappeared in many countries.
Goitre is also not recommended for assessing the response to an intervention, as it can take months or years for goitre to regress after the normalization of iodine intake 11 However, it remains useful in countries or regions that have not yet introduced iodised salt programmes.
However, these indicators are usually not recommended for monitoring iodine nutrition, because they are more expensive and less sensitive Measurement of serum or dried blood spot thyroglobulin Tg in school-age children appears to be a sensitive indicator of iodine status in a population and it may be used to monitor improving thyroid function after iodine repletion However, further validation is required for standardization of collection and measurement techniques for Tg, and for establishment and interpretation of cut-off values Recognizing the importance of preventing iodine deficiency disorders, in the World Health Assembly adopted the goal of eliminating iodine deficiency as a public health problem.
Inworld leaders endorsed this goal when they met at the World Summit for Children at the United Nations, and it was reaffirmed by the International Conference on Nutrition in Insoluble iron compounds, such as elemental iron powders or iron phosphate compounds, cause fewer sensory changes but may be so poorly absorbed as to be of little nutritional value 7. The ideal iron compound for a DFS would be one with high bioavailability that causes no sensory changes or losses of iodine when the iron compound is added to salt.Double Fortified Salt -- Commercial -- [Full - HD]
In animals, bioavailability of ferrous sulfate encapsulated with partially hydrogenated vegetable oil is comparable to that of nonencapsulated ferrous sulfate Encapsulated iron is used in infant formulas and infant cereals, and it has excellent potential for overcoming unwanted sensory changes and iodine losses in salt, while maintaining high bioavailability 7.
Therefore, we developed a new DFS, with iodine added as potassium iodide and iron added as ferrous sulfate encapsulated with hydrogenated vegetable oil. We tested the stability of the DFS under local conditions and evaluated its organoleptic effects when added to traditional northern Moroccan meals. To set the fortification concentration of the DFS, we measured salt and iron intake and estimated iron bioavailabilty from the local diet. Finally, we compared the efficacy of the DFS to iodized salt IS in a randomized, double-blind trial in iodine-deficient Moroccan schoolchildren with a high prevalence of anemia.
The population is of mixed Berber and Arab descent.
This region is isolated from commercial routes, and most foods consumed are produced locally Measurement of salt intake and iron bioavailability To establish the optimal fortification concentration for the DFS, we needed to know the daily salt intake and iron bioavailability from the local diet.
Three-day weighed food records were kept in 50 households randomly selected from local census rolls. Households were asked to continue in their usual food choices and habits and their traditional ways of cooking and serving foods. To account for seasonal variations, 24 households were studied in the damp season and 26 in the dry season. In this region, meals consist of 1 or 2 communal dishes placed in the center of the table from which all family members eat with their hands.
We therefore estimated individual food consumption by using the unit of consumption UC formula of the Department of Agriculture of Morocco Nutrient intakes were calculated by using the Moroccan food composition table 16 and the Food and Agriculture Organization food composition table for Africa In addition, local legumes, cereals, and vegetables were directly analyzed for iron and phytic acid content.
The algorithms of Tseng et al 18 and Reddy et al 19 were used to estimate iron bioavailability. To estimate iron absorption for a range of body iron, results of the algorithms were adjusted 20 for high, medium, and low body iron stores. Salt preparation Nearly all of the salt used in this region is supplied by a local cooperative; the salt is produced in drying ponds of water from a salty spring. Morocco legislated mandatory salt iodization inbut because of financial constraints, this cooperative has not yet begun iodization.
First, concentrated mixes were made by adding mg KI alone or mg KI and g encapsulated ferrous sulfate to 2-kg batches of salt by using a small electric rotating-drum mixer MINI 80; Engelsmann, Ludwigshafen, Germany for mixing at 26 rpm for 10 min. The 2-kg mixes were then added to kg batches of salt in a large electric rotating-drum mixer ELTE ; Engelsmann at 30 rpm for 10 min.
Stability testing The IS and DFS were stored as 2-kg batches in closed low-density transparent polyethylene sacks under local ambient conditions during both the dry and damp seasons.
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Colorimetry was used to measure color stability; in addition, a panel of 12 local adults aged 24—52 y visually inspected unmarked samples that were placed side-by-side on white backgrounds. First, during the summer season, in preparation for the efficacy study, village households were randomly selected from census rolls. At each household, a local interviewer showed unmarked g samples of IS and DFS in identical clear polyethylene bags placed side-by-side on white backgrounds and asked 2 forced-choice questions: Fifty-two households were randomly selected from each of the 2 study groups.
Both the interviewer and the head of household were blind to group assignment. The head of household answered 8 forced-choice questions on patterns of salt use, acceptability of color and taste, and overall satisfaction with the salt. Organoleptic testing To evaluate potential color, odor, and taste changes when the IS and DFS were added to local foods, sensory testing was done in both the dry and damp seasons.
IS and DFS, after storage in closed low-density transparent polyethylene sacks for 2—3 wk, were added to northern Moroccan meals prepared by local women in their kitchens according to traditional recipes. Each type of salt was added in identical amounts in parallel to separate portions of 4 common foods: Their flavor, odor, and color were then compared by the local panel with the use of triangle tests During the triangle test, 3 coded samples of each of the 4 foods were given in random order in a private setting.
The panelists were asked to determine which sample of each food differed from the other 2 samples and to describe how the samples differed Efficacy study The subjects were 6—y-old children from 2 neighboring primary schools. Informed written consent was obtained from the chief medical officer and the school director, and informed oral consent was obtained from the parents of the children. At baseline, weight and height were measured and a spot urine sample was collected for measurement of urinary iodine UI.
Ultrasound examination was performed on subjects sitting upright with the neck extended.