INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS THE INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS (ICCIDD) is a nonprofit, nongovernmental organization dedicated to sustained optimal iodine nutrition and the elimination of iodine deficiency

s 20 United States 5 Bosnia 7 Serbia 2 New Zealand 9 Italy 10 Iodized salt and UI 11 Iodine deficiency during pregnancy Over the past decade, there has been increasing focus on iodine deficiency during pregnancy. Iodine is critical for optimal fetal development. Yet 38 million newborns in developing countries every year remain unprotected from the lifelong consequences of brain damage associated with iodine deficiency. How can we ensure adequate iodine intake in this vulnerable group? This issue of the IDD Newsletter highlights efforts in countries as diverse as Bosnia and Herzegovina, New Zealand, Italy, Serbia and the United States. Distribution of infants born in developing countries annually who are unprotected against IDD, by region, 2000-2006 2 IDD NEWSLETTER AUGUST 2010 SERBIA Historically, goiter and cretinism were significant public health problems in Yugoslavia. The first regulations on salt iodization were introduced in 1937 at a low level of 5mg KI/kg for household salt directed to the high goiter areas. During a Congress of Preventive Medicine in 1950, the iodization level was increased to 10mg KI/kg in 1954 and expanded to all the salt for human and animal consumption. Ten years later, epidemiological surveys found a 4-fold reduction in the goiter prevalence among school children (1). The present legislation in Serbia mandates that all edible salt should be iodized at 12-18 mg iodine per kg salt, while both KI and KIO3 are permitted. Since there are no natural deposits of salt, all the salt requirements in Serbia are imported. Two firms dominate the national salt supply situation, namely ‘Interkomerc’ a general food and household goods trading company located in Belgrade and ‘So Product’ a salt processing and packing company 30km outside of Belgrade. The variety of salt brands in the market shows active competition among the salt suppliers. So Product imports the basic salt mostly from Israel, Belarus, Austria and Ukraine. The firm has a number of modern iodization and packaging lines, with an internal quality assurance system based on quantitative salt iodine analysis on a regular 2-hour basis. Interkomerc imports iodized salt mostly from Solana Tuzla (Bosnia-Herzegovina), but also from other sources in Romania, Greece and Ukraine. Studies of school-age children during 1998-2000 by the National Institute of Public Health in Belgrade showed a median urinary iodine (UI) concentration of 158 μg/L and a decrease in goiter prevalence to 2.35% (2). Adequately iodized salt was being used in 73% of the households in 2000 (3). These findings confirmed the massive improvement in iodine nutrition that occurred during the preceding half a century. The goal of eliminating IDD is only truly successful when the USI strategy endures. During September-December 2007, the Institute of Public Health of Serbia (IPHS), with financial and technical support of UNICEF, carried out a national iodine survey of the supply and consumption of iodized salt in relation to the iodine status of the population (children and pregnant women), using the standard design of 30 clusters (primary schools), selected proportionate to population size. The IPHS laboratory participates successfully in EQUIP, and internal quality control demonstrated a precision of ±5% for the urinary iodine assay. Both iodized salt and iodine supplements are important sources of iodine for pregnant women in Serbia Dragana Jovic and Tanja Knezevic Institute of Public Health of Serbia; Frits van der Haar Global Public Nutrition Solutions, LLC; Alexandra Jovic UNICEF Belgrade IDD NEWSLETTER AUGUST 2010 SERBIA 3 No differences were found in the iodine content of the 950 salt samples obtained from school children and the 347 salt samples from pregnant women (results combined in Figure 1). Notably, all the household salt samples obtained in the survey were iodized. The median salt iodine content was 13.9mg/kg; 32% of the salt samples had ≥15mg/kg, and 76% fell within the range of 12–18mg iodine/ kg mandated by Serbian law. The median UI in school children was 195 μg/L; 9% of the children had UI<100 μg/L, the UI was 100-199 μg/L in 42%, and the UI was ≥200 μg/L in 48% of the children. By ultrasound, elevated thyroid volume was found in only 3% of children (4). The UI data of the children were converted to iodine consumption estimates with the formula of the US Institute of Medicine (5). The median iodine consumption in children was 185 μg/d. Children in urban areas (median 192 μg/d) had higher iodine intake than in rural areas (171 μg/d), and the intake was higher in boys (192 μg/d) than in girls (175 μg/d). As expected, the iodine consumption of the children increased with age (Figure 2). When compared to the recommended dietary allowance, the children in Serbia were consuming a diet that typically provided 158% of their RDA, with an increase from ±125% of the RDA at 6-8 y to ±190% of the RDA at 12-14 y of age. The median UI in pregnant women (Figure 3) was 158 μg/L. The UI was <150 μg/L in 45% of the women, 32% had a UI in the range 150-249 μg/L and UI ≥500 μg/L was found in 5%. Physicians in Serbia often recommend dietary supplements to pregnant women and in this survey, 34% of women reported using an iodine supplement. The UI concentration in pregnant women who used a supplement (median 195 μg/L) was significantly higher than those who reported not using a dietary supplement (146 μg/L). Notably, the median UI in the women not supplementing was just below the range of sufficient UI concentration recommended by WHO/UNICEF/ICCIDD (Figure 4). There was no relationship between the iodine levels in household salt and the UI concentrations in either the school children or the pregnant women (nonsupplement users). The UI levels in the pregnant women not using a dietary supplement (median 146 μg/L) were much lower than those in the school children (195 μg/L), even though the iodine content in the salt from their households did not differ, thus suggesting different dietary practices between these groups. Figure 1: Histogram of the iodine content in household salt, Serbia, 2007