Private sector participation and engagement can benefit consolidation efforts and the implementation process. The overall quality of the available evidence for iodized salt was moderate to low for the critical outcomes of goiter (moderate), cretinism (moderate), low cognitive function (low) and urinary iodine concentration (moderate). Iodized salt should be available and used by all members of the population after 1 year of age.
Monitoring food grade salt quality is essential to ensure both the effectiveness and safety of the process of iodine fortification.
Scope and purpose
Background
Salt iodization is the preferred strategy for controlling iodine deficiency diseases and is implemented in more than 120 countries around the world (7). The most visible sign of iodine deficiency is goiter, an enlargement of the thyroid gland.
Summary of evidence
Successful and sustainable implementation of the use of iodized salt in processed foods requires awareness of the risks of iodine deficiency, appropriate legislation in accordance with a country's dietary habits and "legislative culture", regular monitoring of iodine nutritional status and dietary intake, and a collaborative effort. the role of the salt industry and food processors (39).
Recommendation
Remarks
Particular attention should be paid to identifying potential barriers to equal access for all populations in need of iodized salt. Country programs should be culturally appropriate to the target populations so that the intervention is accepted, adopted and sustained. Clear legislation should also be established for food producers and distributors, especially where the main source of dietary salt is processed foods and meals consumed outside the household.
Legislation should not only cover proper iodization of salt, but also the salt content of industrialized food products. Establishing an effective system for the ongoing and routine collection of relevant data, including measures of quality assurance and household use of iodized salt, and measures of program performance, is critical to ensuring that iodized salt programs are effective and sustainable . Regular monitoring and evaluation can identify barriers that may limit equal access to fortified salt and thus preserve health inequalities.
Implications for future research
The use of neonatal serum TSH concentration as an indicator of iodine status in pregnancy needs further validation. Findings emerging from these studies may help identify obstacles and barriers to access to iodized dietary salt.
Dissemination, adaptation and implementation Dissemination
In the United Nations system, the World Food Program is responsible for mobilizing iodized salt for selective feeding programs (61). In addition, disseminating guidelines and information on the benefits of consuming fortified dietary salt in iodine-deficient environments helps empower consumers and thus contributes to creating consumer demand. Particular attention should be paid to the acceptance of the recommendation by the various stakeholders, including salt companies, food inspectors and final consumers.
Information and advice on how women can take better care of their health before and during pregnancy is essential to encourage the consumption of iodized salt in a context where the availability of non-iodized salt is a reality. The use of data on iodine in urine can serve to adjust fortification levels in food grade salt throughout the implementation of the program. The median UIC is a rough estimate, and it depends on the person's hydration status and the climate in which he or she lives.
The Evidence and Program Guidance Unit of the Department of Nutrition for Health and Development manages the VMNIS Micronutrient Database through a network of regional and country offices, and in close collaboration with national health authorities. Monitoring both industry efforts in fortification and consumer behavior related to the consumption of food-grade salt and industrialized processed foods containing non-iodized salt is key to identifying gaps for effective scale-up and sustainability. Identifying the barriers to an efficient provision of iodized salt, and the barriers to strengthening consumer demand for iodized salt, prevents the expansion of unequal distributions of the benefits of health innovations.
Guideline development process
The WHO Nutrition (57) and SCN (58) mailing lists, which together include more than 5,500 subscribers, and the WHO Nutrition website (57) were used to identify members of the external review group. A meeting of the guideline development group – nutrition actions was held on 14–16 March 2010 in Geneva, Switzerland, to finalize the scope of the questions and rank the outcomes and populations of interest for the recommendation on fortification of food-grade salt. with iodine for the prevention and control of iodine deficiency disorders. The guideline development group discussed the relevance of the questions and adjusted them as necessary.
The procedures for decision-making are established at the beginning of the meetings, including a minimal set of rules for agreement and decision-making documentation. The members of the guideline development group secretly noted the direction and strength of the recommendation, using a form designed for this purpose, which also included a section to express their views on (i) the to document desirable and undesirable effects of the intervention; (ii) the quality of the available evidence; (iii) values and preferences related to the intervention in different settings; and (iv) the cost of options available to healthcare workers in different settings (see Annex 2). The WHO Secretariat collected the forms and released a summary of the results to the guideline development group.
If consensus was not reached, a two-thirds vote of the members of the guideline development group present was required to approve the proposed recommendation (secondary decision rule). Although there was no consensus, more than 80% of the guideline development group members decided that this was a strong recommendation. Two co-chairs with expertise in group process management and evidence interpretation were appointed at the opening of the consultation and approved by the guideline development group.
Management of competing interests
WHO personnel present at the meeting, as well as other outside technical experts involved in gathering and reviewing the evidence, were not allowed to participate in the decision-making process. Members of the WHO Secretariat were available at all times to guide the general assembly process, but did not vote or veto. All members of the guideline development group and participants in the guideline development meetings have submitted a declaration of interest with their curriculum vitae for each meeting.
The participants in the meetings of the guideline development group participated in their individual capacities and not as institutional representatives. The handling of the perceived or real conflicts of interest declared by the members of the guideline group is summarized below.1. It was decided that Dr. De-Regil could be a member of the guideline development group and would disclose his interests and those of his organization in the relevant guidelines related to micronutrient interventions, specifically salt iodization.
It was decided that dr. Neufeld may be a member of the guideline development group and that she should disclose her interests and those of her organization regarding relevant guidelines related to micronutrient interventions, particularly salt iodization. Consequently, the scope of the inquiry is any interest that is reasonably believed to affect the functions performed by the professional. It was agreed that Ms. Selamat could be a member of the guideline development group and that she declared her membership of the above mentioned national committees at the beginning of the guideline development group meeting.
Plans for updating the guideline
Rusidah Selamat declared himself as a member of a National Technical Food Fortification Committee in Malaysia. She has also published articles on iodine deficiency status and iodized salt consumption in Malaysia and the need for wider iodized salt coverage in Malaysia. All other members provided a verbal declaration of interest and were deemed not relevant to this guideline on the fortification of food grade salt with iodine.
External experts also declared their interest, but did not participate in the discussions or in the decision-making process. Follow-up to the Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases. World Health Organization, United Nations Children's Fund, International Council for the Control of Iodine Deficiency Disorders.
Assessing iodine deficiency disorders and monitoring their elimination: a guide for program managers, 3rd ed.
United Nations Children's Fund; 2008 (http://www.childinfo.org/files/idd_sustainable_elimination.pdf, accessed June 19, 2014). World Health Organization and International Council for the Control of Iodine Deficiency Disorders Global Network. Geneva: World Health Organization; 2012 (http://www.who..int/nutrition/publications/guidelines/sodium_intake_printversion.pdf, accessed June 19, 2014).
Geneva: World Health Organization; 2007 (http://www.who.int/dietphysicalactivity/Salt_Report_VC_april07.pdf, accessed 19 June 2014). Ottawa: Network for the Sustainable Elimination of Iodine Deficiency; 2007 (http://www.iccidd.org/cm_data/Salt_in_processed_foods.pdf, accessed 20 June 2014). Geneva: World Health Organization; 2007 (http://www.who.int/nutrition/.publications/WHOStatement__IDD_pregnancy.pdf, accessed 19 June 2014).
World Health Organization; 2007 (http://www.who.int/nutrition/publications/WHO_WFP_UNICEFstatement.pdf, accessed 10 September 2014). United Nations Children's Fund, Flour Fortification Initiative, International Council for Control of Iodine Deficiency Disorders (ICCIDD) Global Network, Alive&Thrive. Ha Noi: United Nations Children's Fund; 2013 (http://www.unicef.org/vietnam/UNICEF_Food_Fortification_Salt_Flour.pdf, accessed 19 June 2014).
GRADE “Summary of findings” tables
Summary of the considerations of the members of the guideline development group – nutritional actions for determining strength.
Summary of the considerations of the members of the guideline development group – nutrition actions for determining the strength
Department of Prevention of Non-Communicable Diseases Dr Eyerusalem Kebede Negussie Medical Officer, HIV Treatment and Care Department HIV/AIDS. Coordinator, Social Determinants of Health Department of Public Health, Environmental and Social Determinants of Health. US Agency for International Development Washington, DC, United States of America Dr Laurence Grummer-Strawn.
Questions in population, intervention, control, outcomes (PICO) format
USI State Setting - Non-USI State Setting Control: No iodized salt (any) Results: All ages.
