Iodine Network Bulletin
Volume 1 Issue 5, September 2005

In this issue:

1. News from Network Secretariat: Iodine Network Web site

The website of the Network has been restructured and recently moved to a new site www.IodineNetwork.net . The redesign of our Web site was done to improve access to the Network and iodine deficiency/ universal salt iodization related information and activities. In improving access, we've also improved our readiness to respond to news and emerging issues through our Web site.

We have made a lot of changes in our Web site that will make it easier and faster to surf our site. The new web site uses the left-side navigation on every page. Among the many changes we have made, the most significant include About Us, Resources and Publication. These recent changes have been a significant undertaking and we hope to continue the momentum with continued improvements. Through Nutrition Bulletin, you will be informed when new information is available on the Network web site.

Overall, we hope to offer more engaging and interactive content on issues that are the most relevant to Network members. If you have a question or comment about the new site, please contact the Secretariat at Info@IodineNetwork.net or visit our website at www.IodineNetwork.net .

2. Welcome to Dr Martin Bloem, New Chief Nutrition Service World Food Programme.

WFP has appointed Dr. Martin W. Bloem as a Chief, Nutrition  Service (PDPN), Policy, Strategy and Programme Support Division. Dr. Bloem, trained as a public health physician and held previous leadership positions at Helen Keller International as Senior Vice President, Chief Medical Officer, Asia-Pacific Regional Director, Bangladesh and Indonesia Country Directord. He is also an Associate Professor - Adjunct at John Hopkins Bloomberg School of Public Health. Dr. Bloem has extensive r esearch and professional experiences in m icronutrient deficiencies, especially vitamin A and iron. His contact information at the WFP Nutrition Service, Policy, Strategy and Programme Support Division, Rome , Italy is ( 39)-06-6513-2565 , email martin.bloem@wfp.org

3. Country Assessment in Bulgaria

A team of experts consisted of Dr. Frits van der Haar, Mr. Jan W.F. van Ingen and Prof Peter M. Laurberg visited Bulgaria from April 26 to May 5 to assess country achievement toward the national goal of sustainable elimination of iodine deficiency disorders (IDD). The team reviewed records and documentation, held interviews and discussions with the government, academia, salt industry and food processing industry, the media and consumer organizations concerned with the national efforts. The review was coordinated by the Ministry of Health, together with the UNICEF, UNDP and WHO offices in Bulgaria . In anticipation of the review, the Bulgarian MOH prepared a detailed report, which in the team's view presented a truthful and accurate history and situation analysis.

In the 2003 survey, the Urinary Iodine Concentration (UIC) of 809 schoolchildren aged 7-11 years and a sub sample of pregnant women were measured. The survey found that median UIC of schoolchildren was around 200µg/L and for pregnant women was 165µg/L. The goitre prevalence as evaluated using ultrasound was less than 3% and the visible goitre was below 5%. Thus, the team is of the opinion that in Bulgaria , IDD has presently been reduced below the level of public health importance. It was also noted that the 2003 survey significantly over-sampled children in previously endemic areas. Therefore, the actual national goitre prevalence in 2003 among schoolchildren was lower than the estimates given in the report.

The team used the list of criteria recommended by the 1999 ICCIDD/UNICEF/WHO expert panel for a judgment on the likelihood that the success of IDD elimination through USI in Bulgaria will be permanent. At the end of the mission, the team concluded that Bulgaria has succeeded in tackling a historically significant and severe IDD problem by bringing the dietary iodine intake in the population within the generally acceptable range. The underlying factors of this success is a well-organized and conscientiously applied universal salt iodization strategy that adds a small and regular amount of iodine to the common diet of the population by the iodization of all household (edible) and food industry (food-grade) salt. The team found that USI strategy in Bulgaria is effective. Based on the results and further analysis of recent national survey data, and on a review of ongoing activities and existing documentation, the team also concludes that at present IDD has fallen below public health significance. The team concluded that IDD has been eliminated in Bulgaria and this achievement is likely to be sustained. The team also provided some recommendations to improve efficiency, save costs, reduce the likelihood of future failure and sharpen the focus in impact assessments of the national IDD elimination policy:

•  Focus on pregnant women as most meaningful and vulnerable target group

•  Discontinue the policy of KI tablet distribution to pregnant women

•  Adopt an improvement of the range of mandated salt iodine levels

•  Effectuate the current plans for improved national oversight

•  Consider using the neonatal TSH data for regular population monitoring

4. Double Fortified Salt: Potential for salt as a vehicle to deliver iron along with iodine

Annie Wesley, Micronutrient Initiative Ottawa

The only true example of a food that is globally fortified is salt. Within a span of two decades, a major proportion of the world's salt has been iodized. That makes salt an attractive food vehicle to carry multiple nutrients.

In theory, the combination of iodine and iron in salt can simultaneously combat the deficiencies of these two nutrients, which together affect more than one-third of the world's population. However, when scientists and food engineers attempted to accomplish this seemingly simple task, they were faced to address a broad array of chemical, technical, and organoleptic problems.

The technology recently finalized by the Micronutrient Initiative ( MI ) in collaboration with the University of Toronto involves coating of iron compound with stabilizing ingredients through agglomeration and encapsulation. This successfully prevents the iron from chemical interaction with iodine and from contact with moisture in the salt.

The new Double Fortified Salt (DFS) premix for iron can be easily blended with locally produced dry refined iodized salt to produce DFS. There is no disruption to the existing salt iodization process. At a salt consumption level of 10 g/day, the iron from DFS meets an average of 30% of the daily iron requirements in the diet.

Tests conducted in selected countries in Africa and Asia show that the DFS is:

•  Stable during storage and transportation

•  Biologically available

•  Acceptable when blended with local salt

•  Acceptable to consumers

Pilot projects further confirmed that Double Fortified Salt has potential to be used as part of emergency feeding programs as well as programs such as school midday meal schemes and public food distribution systems. To understand the commercial channels for DFS, market testing is being coordinated in collaboration with the industry.

Through recent transfer of technology, the DFS premix is now produced in India for a much lower price than in North America . The cost of fortifying salt with iron in addition to iodine comes to only about 18 to 20 US cents per person per year. National health systems could save millions of dollars a year in costs associated with treating iron and iodine deficiencies. This amount can be attained by a combination of commercial marketing and government-funded programs. It is an opportunity for the salt industry to play a crucial role by working together with national governments towards reaching the global goal of reducing all forms of iron deficiency by one third by 2010.

5. Origins and evolution of the Western diet: implications of iodine and seafood intakes for the human brain
(Letter to the Editor)

Stephen C Cunnane , American Journal of Clinical Nutrition, Vol. 82, No. 2, 483, August 2005

Dear Sir:
Cordain et al ( 1 ) are to be congratulated on a succinct and topical overview, recently published in the Journal, of the perils of a Westernized diet with respect to the risk of chronic degenerative diseases in humans. Indeed, there is widespread support for reinstituting several aspects of the so-called Paleolithic diet, especially higher fiber and lower content of refined, adulterated, or synthetic constituents. However, the authors do not seem to have made reference in their article to the effect of diet on a defining feature of modern humans-namely, the brain-whether that effect is related to brain development, advanced brain function, or risk of degenerative brain disease. Several micronutrients are discussed, but iodine seems to have been overlooked, despite the fact that it is 1 of the 2 nutrients (the other is iron) from which humans globally are considered to suffer the most common deficiency ( 2 ).

The most serious consequence of iodine deficiency is impaired neurologic development, a problem that most developed countries have avoided only by legislating the use of iodized table salt; commonly preferred food choices that exclude seafood simply do not provide enough iodine. Indeed, publications from Australia, the United States, and Europe during the past decade show that mild-to-moderate iodine deficiency is reemerging as people in developed countries consume less table salt, dairy products, meat, fish, and seafood ( 3 - 5 ).

Cordain et al gave an overview of the nutrient density in various major food groups in Table 4 of their article, but they made no mention of the relatively poor bioavailiability of micronutrients, especially minerals, from some of these food groups. The concentration in plants of zinc or iron, without consideration of the phytate content of those plants, exaggerates the true value of plants as sources of these nutrients. Although iodine is not shown in Table 4, goitrogens in many cultivated plants greatly reduce the availability of iodine from plant-based diets. Hence, the overall ranking in Table 4 of seafood second to vegetables as a source of micronutrients underestimates the true value of seafood in protecting against the risk of the major nutrient deficiencies that affect humans. Among the food groups shown in the table, seafood actually has the highest available content of several minerals needed for brain development, including iodine, iron, zinc, copper, and selenium ( 6 ).

The focusing of some attention on the human health implications of declining iodine and seafood intakes is warranted because those declining intakes are directly linked to brain development. The modern-day vulnerability of the developing human brain to inadequate intakes of iodine, iron, docosahexaenoic acid, and several other brain-selective nutrients shows that, if seafood had not been a significant component of the Paleolithic diet, the modern human brain probably would not have evolved in the first place ( 6 , 7 ).

REFERENCES

1. Cordain L, Eaton SB, Sebastian A, et al. Origins and evolution of the Western diet: health implications for the 21st centery. Am J Clin Nutr 2005;81:341-54.

2. Ramkrishnan U. Prevalence of micronutrient malnutrition worldwide. Nutr Rev 2002;60:S45-52.

3. Weetman AP. Hypothyroidism. Screening and subclinical disease. BMJ 1997;314:1175-8.

4. Morris MS, Boston AG, Jacques PF, Selhub J, Rosenberg IH. Hyperhomocysteinemia and hypercholesterolemia associated with hypothyroidism in the third US National Health and Nutrition Examination Survey. Atherosclerosis 2001;155:195-200.

5. Gunton JE. Iodine deficiency in ambulatory participants at a Sydney teaching hospital: is Australia truly iodine replete? Med J Aust 1999;171:467-70.

6. Cunnane SC. Survival of the fattest: the key to human brain evolution. Hackensack , NJ : World Scientific, 2005.

7. Cunnane SC, Crawford MA. Survival of the fattest: fat babies were the key to evolution of the large human brain. Comp Biochem Physiol 2003;136A:17-26.

8. Loren Cordain , S Boyd Eaton, Anthony Sebastian, Neil Mann, Staffan Lindeberg, Bruce A Watkins, James H O'Keefe, and Janette Brand-Miller. American Journal of Clinical Nutrition, Vol. 82, No. 2, 483-484, August 2005 ( Authors Response , Letter to the Editor)

Dear Sir:
We thank Dr Cunnane for his congratulatory words about our recent article in the Journal ( 1 ). Clearly, in a review article of a somewhat limited nature, it would not be possible to comprehensively document all diseases and maladies of civilization that have been linked to the typical Western diet. Instead, we referred interested readers to Cordain's earlier, more exhaustive review of the numerous health problems and illnesses associated with the consumption of cereal grains, a food introduced in the relatively more recent Neolithic period ( 2 ). We agree with the notion that normal human brain development and function require a diet adequate in iron, iodine, and long-chain polyunsaturated fatty acids (PUFAs) of both the n-3 and n-6 families. Moreover, there is little doubt that animal foods, which were the dietary staples for historically studied hunter-gatherers ( 3 , 4 ), are rich sources of these nutrients ( 1 , 5 , 6 ).

With respect to iodine and the brain's development and function, it should be pointed out that a wide variety of staple foods domesticated during the Neolithic period and later (ie, millet, maize, soy, cassava, sweet potatoes, lima beans, turnips, cabbage, cauliflower, rapeseed, mustard, onion, garlic, bamboo shoots, and palm tree fruit) contain a variety of goitrogens ( 7 , 8 ) that may elicit symptoms of iodine deficiency despite adequate iodine intakes ( 7 , 9 ). Hence, plant food-dominated diets containing goitrogens, which were adopted by humanity after the agricultural revolution, may play a significant role in impairing thyroid function and thereby adversely influencing human brain development ( 10 ). In contrast, iodine deficiency is rare among traditional societies that consume animal-based diets ( 11 ).

For reasons we outlined previously ( 6 , 12 ), we respectfully disagree with Cunnane's suggestion that seafood would have represented the primary source of long-chain PUFAs (22:6n-3 and 20:4n-6) and other micronutrients necessary to the relaxation of the selective pressure previously constraining encephalization in hominins. Exploitation of the marine environment is first documented in the archaeologic record during the Middle Paleolithic period ( 110 000 y BP), and stable isotope data show that inland aquatic foods were not utilized by hominins living in Europe until the mid-Upper Paleolithic period ( 28 000-20 000 y BP) ( 13 ). Hence, aquatic animal foods, whether ocean- or inland-derived, would have played a minor role in providing nutrients that were crucial to the rapid hominin brain expansion that occurred during the Early Paleolithic period ( 2.5-2.0 million y BP). Rather, terrestrial animal foods (including muscle, brain, marrow, thyroid gland, and other organs) would have represented the primary source of long-chain PUFAs, iron, zinc, iodine, and other nutrients that were necessary for encephalization and normal brain development ( 6 , 12 , 14 ).

REFERENCES

1. Cordain L, Eaton SB, Sebastian A, et al. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr 2005;81:341-54.

2. Cordain L. Cereal grains: humanity's double-edged sword. World Rev Nutr Diet 1999;84:19-73.

3. Cordain L, Brand Miller J, Eaton SB, Mann N, Holt SHA, Speth JD. Plant-animal subsistence ratios and macronutrient energy estimations in worldwide hunter-gatherer diets. Am J Clin Nutr 2000;71:682-92.

4. Cordain L, Eaton SB, Miller JB, Mann N, Hill K. The paradoxical nature of hunter-gatherer diets: meat based, yet non-atherogenic. Eur J Clin Nutr 2002;56(suppl):S42-52.

5. Andersen S, Hvingel B, Laurberg P. Iodine content of traditional Greenlandic food items and tap water in East and West Greenland . Int J Circumpolar Health 2002;61:332-40.

6. Cordain L, Watkins BA, Mann NJ. Fatty acid composition and energy density of foods available to African hominids: evolutionary implications for human brain development. World Rev Nutr Diet 2001;90:144-61.

7. Gaitan E. Goitrogens in food and water. Annu Rev Nutr 1990; 10:21 -39.

8. Doerge DR , Sheehan DM. Goitrogenic and estrogenic activity of soy isoflavones. Environ Health Perspect 2002;110(suppl):349-53.

9. Lakshmy R, Rao PS, Sesikeran B, Suryaprakash P. Iodine metabolism in response to goitrogen induced altered thyroid status under conditions of moderate and high intake of iodine. Horm Metab Res 1995;27:450-4.

10. Rao PS, Lakshmy R. Role of goitrogens in iodine deficiency disorders and brain development. Indian J Med Res 1995;102:223-6.

11. Andersen S, Hvingel B, Kleinschmidt K, Jorgensen T, Laurberg P. Changes in iodine excretion in 50-69-y-old denizens of an Arctic society in transition and iodine excretion as a biomarker of the frequency of consumption of traditional Inuit foods. Am J Clin Nutr 2005;81:656-63.

12. Cordain L, Miller JB, Eaton SB, Mann N. Reply to SC Cunnane. Am J Clin Nutr 2000;72:1585-6 (letter).

13. Richards MP, Pettitt PB, Stiner MC, Trinkaus E. Stable isotope evidence for increasing dietary breadth in the European mid-Upper Paleolithic. Proc Natl Acad Sci U S A 2001;98:6528-32.

The Network BUlletin is prepared by the Network for Sustained Elimination of Iodine Deficiency and posted on its website, www.iodinenetwork.net . If you have any information to share or queries please contact Dr. Juliawati Untoro , IDD Network Secretary at info@iodinenetwork.net