1. Meeting: Iodine Villages Across Thailand to Honor Her Royal Highness Princess Maha Chakri Sirindhorn, Nutritional Princess: Overcoming the Challenges to Sustainability 25 June 2015, Bangkok Sustaining the Prevention and Control of Iodine Deficiency in the Southeast Asia and Pacific Region Karen Codling Regional Coordinator South East Asia and the Pacific

2. 1993 110 countries iodine deficient Ref: IGN

3. 2014 30 countries remain iodine deficient Ref: IGN

4. HH use of adequately iodized salt globally and by region UNICEF SOWC 2015

5. Household use of iodised salt in the EAP Region Ref: National surveys such as DHS, MICS, Living Standards, National Nutrition or IDD. Surveys assessing adequately of iodine with a quantitative methodology, such as titration, shown with an asterix *

6. Lessons learnt in increasing coverage with iodised salt and sustaining IDD elimination achievements

7. The importance of mandatory legislation  Equalizes costs for producers  Provides more equitable access to fortified foods  public health impact  Can be more easily monitored than voluntary fortification  Does not require consumer behavior change  Sets appropriate fortification standards

8. Reasons for mandatory legislation Analysis of salt iodisation programmes has found that in one decade, countries with mandatory legislation had a greater increase in household coverage (from 49% to 72%, compared with the increases in countries with voluntary iodisation (from 40% to 49%) Ref: Horton, Mannar & Wesley. Micronutrient Fortification (Iron and Salt Iodisation) Copenhagen Best Practice Paper 2008

9. Ref: National IDD Surveys and Multiple Cluster Indicator Survey in 2011 Decline in coverage of adequately iodized salt in Viet Nam following the end of mandatory legislation End of mandatory legislation

10. Malaysia  Legislation 1999  Peninsular Malaysia – Voluntary  Sarawak – Mandatory in some districts  Sabah – Mandatory  2010 survey - UIC and HHIS

11. Salt iodisation in Malaysia Ref: Selamat et al. Iodine deficiency status and iodised salt consumption in Malaysia: findings from a national iodine deficiency disorders survey. Asia Pac J Clin Nutr. 2010

12. The importance of enforcement  Weak point of most fortification programmes  Enforcement of food fortification should be integrated into routine food control systems  Industry/enterprises must fortify  Government must create safe, fair environment  Best way govt can support mandatory salt iodisation is ensure all enterprises comply with law – create an even playing field

13. The importance of use of iodised salt in processed foods & animal feed  WHO recommendations for scope of salt iodization  “universal salt iodization calls for fortification with iodine of all food-grade salt for human and animal consumption, including salt for food processing” Ref: WHO, 2014 and WHO, UNICEF, ICCIDD, 2007

14. Iodised salt for food processing and animals  Why iodised salt for food processing? – A significant amount of salt is consumed through processed foods – As countries develop, proportion of salt consumed through processed foods increases  Why iodised salt for animal? – Animals also suffer from iodine deficiency; iodised salt improves health and increases productivity  If salt for food processing and animal feed is iodised, there can be no leakage of non-iodised to the market

15. Estimates of proportion of salt consumed as household salt or through processed food  WHO: “in many countries, about 80% of salt in the diet comes from processed foods” Country Processed Food United Kingdom77 United States75 South Africa60 Philippines57 Indonesia46 China45 Ref: WHO, 2014 and various country references (see notes)

16. Sources of sodium intake in Thanh Oai district of Hanoi Ref: National Institute of Nutrition. Investigation of dietary sodium intake and sources in adults, aged 25-64 years. 2010

17. The importance of monitoring and evaluating the impact  Coverage sub-nationally to identify unreached populations  Urinary iodine status of different population groups to ensure adequate iodine for whole population (school age children, pregnant women, reproductive age women)  Urinary iodine status to adjust iodization levels  Use of iodized salt in processed foods  Salt intake from household salt and processed foods

18.  Iodized salt has a large effect on reducing the risk of goitre, cretinism, low cognitive function, and iodine deficiency.  Robust monitoring of salt iodization programmes is important to ensure safe and effective levels of iodine consumption, especially as countries implement programmes to reduce population salt intake 2014

19. For more information: Web: http://www.ign.org Twitter: @ign_iccidd Email: kcodling@ign.org