Salt iodisation and public health campaigns to eradicate iodine deficiency disorders in Armenia

Iodine Status of Infants and Toddlers under 2 Years of Age and Its Association with Feeding Behaviors and Maternal Iodine Status in Shanghai: A Quantile Regression Analysis

It is crucial to provide adequate iodine nutrition to infants and toddlers for proper thyroid function and subsequent brain development. Infants are particularly vulnerable to iodine deficiency during the transition from a milk-based diet (breast milk and/or infant formula) to solid food. This study examines the current iodine levels of children during their first two years of life and investigates the association between these levels and feeding behaviors and the iodine status of their mothers in Shanghai, a city located in eastern China. A hospital-based cohort study was conducted to enroll mother-child pairs, where the child is aged 6-23 months, who visited community health service centers in the 16 districts of Shanghai, China. Data on socio-demographic factors and feeding behavior data were collected from the participants. The urinary iodine concentration (UIC) in both the young children and their mothers were analyzed. A total of 2282 mother-child pairs were included in this analysis. The median (p25-p75) UIC for lactating women, weaning women, and children were 121.3 μg/L (68.1-206.4 μg/L), 123.4 μg/L (58.4-227.2 μg/L), and 152.1 μg/L (75.8-268.3 μg/L), respectively. The UIC in children was found to be higher than that in their mothers (p < 0.001). Children who consumed less than 500 mL per day of formula milk in the last week had lower UICs compared with those who consumed 500 mL per day or more (p = 0.026). Furthermore, the children's UIC was positively correlated with the maternal UIC (rs = 0.285, p < 0.001). Multiple quantile regression analysis revealed a statistically significant positive association between maternal UIC and children's UIC between the 0.1 and 0.9 quantiles (all p < 0.001). We found that the iodine status of infants and toddlers, as well as of mothers, was sufficient. However, a large minority of children and mothers may be at risk of iodine deficiency. Furthermore, no associations between children's UIC and feeding behaviors were observed. Moreover, there was a positive correlation between the UIC of young children and their mothers.

Cancer incidence among Armenians in California

INTRODUCTION

California is home to the largest population of Armenians in the United States. The historical categorization of Armenians as 'White' or 'Some Other Race' in population databases has likely masked cancer incidence patterns in this population. This is the first study considering cancer incidence among Armenians in California.

METHODS

We used the Armenian Surname List and birthplace information in the California Cancer Registry to identify Armenians with cancer diagnosed during 1988-2019. We calculated proportional incidence ratios (PIR) among Armenians compared with non-Hispanic Whites (NHWs). As an exploratory analysis, we calculated incidence rate ratios (IRR) during 2006-2015 using Armenian population denominators from the American Community Survey (ACS). We selected PIR as our primary method given uncertainty regarding the use of ACS population estimates for rate calculations.

RESULTS

There were 27,212 cancer diagnoses among Armenians in California, 13,754 among males and 13,458 among females. Armenian males had notably higher proportions of stomach (PIR = 2.39), thyroid (PIR = 1.45), and tobacco-related cancers including bladder (PIR = 1.53), colorectal (PIR = 1.29), and lung (PIR = 1.16) cancers. Higher proportional incidence of cancers including stomach (PIR = 3.24), thyroid (PIR = 1.47), and colorectal (PIR = 1.29) were observed among Armenian females. Exploratory IRR analyses showed higher stomach (IRR = 1.78), bladder (IRR = 1.13), and colorectal (IRR = 1.12) cancers among Armenian males and higher stomach (IRR = 2.54) cancer among Armenian females.

CONCLUSION

We observed higher stomach, colorectal and thyroid cancer incidence among males and females, and tobacco-related cancers among males. Further research is needed to refine Armenian population estimates and understand and address risk factors associated with specific cancers among Armenians in California.

A scoping review of research on policies to address child undernutrition in the Millennium Development Goals era

OBJECTIVE

The breadth of research on the impact of nutrition-specific policies to address child undernutrition is not well documented. This review maps the evidence base and identifies gaps on such policies.

DESIGN

We systematically searched Medline, Embase, PAIS Index for public policy, Scopus and Web of Science databases to identify eligible studies. Key study characteristics, including research design, type of policy, time span of policy before impact assessment, child age at outcome assessment and types of outcomes assessed, were abstracted in duplicate.

SETTING

Low-, middle- and high-income countries.

PARTICIPANTS

Studies were eligible for inclusion if they aimed to assess the impact of population-level nutrition-specific policies on undernutrition among children under 10 years of age.

RESULTS

Of the 5646 abstracts screened, eighty-three studies were included. A range of policies to address child undernutrition were evaluated; the majority were related to micronutrient fortification. Most studies were observational, reported on mandatory regional or sub-national polices, were conducted in high-income countries and evaluated policies within 1 year of implementation. A narrow set of health outcomes were evaluated, most commonly iodine deficiency disorders and neural tube defects.

CONCLUSIONS

Nutrition policies were commonly associated with improved child nutritional status and health. However, this evidence is primarily based on limited settings and on a limited number of outcomes. Further research is needed to assess the longer-term impact of a broader range of nutrition policies on child health, particularly in low- and middle-income countries.

A STRATIFIED CROSS-SECTIONAL CLUSTER MODEL SURVEY OF IODINE NUTRITION IN ARMENIA AFTER A DECADE OF UNIVERSAL SALT IODIZATION

Objective: Iodine is a necessary nutrient for the synthesis of thyroid hormones and essential in human development. Being naturally deficient in iodine, Armenia launched a national universal salt iodization (USI) strategy in 2004. Although high rates of goiter continued to be reported, iodine status has not been studied since 2005. Therefore, this study sought to assess the current situation of population iodine nutrition in Armenia. Methods: We used a selective cross-sectional model to recruit three groups: school-age children (SAC), pregnant women (PW), and nonpregnant women of reproductive age (WRA) from each province. We collected casual urine and table salt samples from each participant, which were analyzed for iodine concentration. A repeat urine sample was collected in a subset of participants to adjust the results for within-person variation in iodine concentration. Group-wise urinary iodine concentrations (UICs) were compared with international reference criteria for iodine status. Results: Urine samples were collected from 1,125 participants from 13 different towns in Armenia; a total of 1,078 participants were included in the final analysis: 361 SAC (mean age, 10.5 years, 46.6% female), 356 PW (mean age, 26.1 years), and 361 WRA (mean age, 35.5 years). Population and geographically weighted median UIC were: SAC, 242 μg/L ([25th percentile] 203 to [75th percentile] 289 μg/L); PW, 226 μg/L (209 to 247 μg/L); WRA, 311 μg/L (244 to 371 μg/L). A total of 1,041 table salt samples were sufficient for laboratory analysis: 973 (93.4%) of the salt iodine measurements were within the national standard range of 40 ± 15 mg/kg. Conclusion: The results of household salt sampling indicated a successful USI strategy. While the present study did not achieve a truly representative sample of Armenia's population, the UIC results support the conclusion that iodine deficiency has not recurred and is not an underlying factor for any remaining high goiter prevalence in Armenia. Abbreviations: PW = pregnant women; SAC = school-age children; SI = salt iodine; UIC = urinary iodine concentration; USI = universal salt iodization; WHO = World Health Organization; WRA = women of reproductive age.

Constituent analysis of iodine intake in Armenia

OBJECTIVE

We sought to assess the universal salt iodization (USI) strategy in Armenia by characterizing dietary iodine intake from naturally occurring iodine, salt-derived iodine in processed foods and salt-derived iodine in household-prepared foods.

DESIGN

Using a cross-sectional cluster survey model, we collected urine samples which were analysed for iodine and sodium concentrations (UIC and UNaC) and household salt samples which were analysed for iodine concentration (SI). SI and UNaC data were used as explanatory variables in multiple linear regression analyses with UIC as dependent variable, and the regression parameters were used to estimate the iodine intake sources attributable to native iodine and iodine from salt in processed foods and household salt.

SETTING

Armenia is naturally iodine deficient; in 2004, the government mandated a USI strategy.

SUBJECTS

We recruited school-age children (SAC), pregnant women (PW) and non-pregnant women of reproductive age (WRA).

RESULTS

From thirteen sites covering all provinces, sufficient urine and table salt samples were obtained from 312 SAC, 311 PW and 332 WRA. Findings revealed significant differences between groups: contribution of native iodine ranged from 81% in PW to 46% in SAC, while household salt-derived iodine contributed from 19% in SAC to 1% in PW.

CONCLUSIONS

Differences between groups may reflect differences in diet. In all groups, household and processed food salt constituted a significant part of total iodine intake, highlighting the success and importance of USI in ensuring iodine sufficiency. There appears to be leeway to reduce salt intake without adversely affecting the iodine status of the population in Armenia.

Neonatal thyrotropin (TSH) screening as a tool for monitoring iodine nutrition in Armenia

BACKGROUND

Neonatal thyrotropin (TSH) is influenced not only by the infant's own thyroid function, but also by maternal thyroid status, and can thus provide a general index of thyroid health in the community.

METHODS

In 2012, the Republic of Armenia implemented a program of universal neonatal hypothyroidism screening by means of measuring the serum TSH level. The Arabkir Medical Center in Yerevan, Armenia, has maintained records of neonatal TSH screening data comprising nearly 100% of all births in Armenia from 2012 through 2016. We analyzed these data to determine the frequency of neonatal TSH levels higher than the cut point of 5 mIU/L, indicative of sufficient iodine nutrition status, and to detect any time dependence over years or regional variation.

RESULTS

A total of 127,177 records from 2012 to 2016 were included. The geographic distribution of neonatal TSH records was reflective of the population of Armenia; the national percentage of records over 5 mIU/L ranged from a high of 2.88% in 2012 to a low of 1.71% in 2016. Minimal regional variation was noted, from a 2012-2016 cumulative high of 2.93% of records over 5 mIU/L in Shirak province to a low of 0.95% in the Vayots Dzor province.

CONCLUSIONS

From all years and from all regions, values were consistently and uniformly below the cut point of 5 mIU/L. These results show no evidence of iodine deficiency in Armenia, and suggest that neonatal TSH may be a useful tool for monitoring iodine nutrition in Armenia.

To estimate the effect of relationship of salt iodine level and prevalence of goiter among women of reproductive age group (15-49 years)

The present study is a Cross-Sectional Study and was conducted in Post-graduate department of Community Medicine, Govt. Medical College, Srinagar between Feb. 2012 and Jan. 2013. The sample size of 1,041 was estimated. The study was conducted to estimate the effect of relationship of salt iodine level and prevalence of goiter among women of reproductive age group in two districts of Kashmir valley, district Srinagar and district Ganderbal, which were selected randomly. A frame of the blocks and villages in the two districts and their population was formed. From each district 10% of the blocks were selected using simple random sampling. From each block, 5% of the villages were selected using simple random sampling. A door to door survey was conducted in the selected villages and all the women in the reproductive age group (15-49 years) identified and examined clinically for goiter after taking informed consent. Salt samples (one teaspoonful) from every household were taken and assessed for iodine content on spot and the iodine content of salt was assessed qualitatively by spot testing kits. The results of the present study have indicated that iodine deficiency continues to be a health problem. Almost the whole population consumes powdered salt but the storage and cooking practices diminish the iodine content of salt and results in decreased intake. Thus the need of the hour is to make people aware about proper storage and cooking practices. Women in the reproductive age group especially need to be made aware about the importance of consumption of adequately iodized salt because of the wide range of ill effects of iodine deficiency on the developing fetus and the growing child. In addition monitoring of iodine content of salt at distributor level should be done.

The Swiss iodized salt program provides adequate iodine for school children and pregnant women, but weaning infants not receiving iodine-containing complementary foods as well as their mothers are iodine deficient

BACKGROUND

If children and pregnant women in the population are iodine sufficient, it is generally assumed infants are also sufficient. But weaning infants may be at risk of iodine deficiency because iodized salt contributes little dietary iodine during this period. To fill this gap, iodine fortification of infant formula milk (IFM) and complementary foods (CF) is likely important.

OBJECTIVES

The objective of the study was to first confirm that Swiss school children and pregnant women remain iodine sufficient and then to assess iodine status in infancy and the relative contribution of breast milk and IFM/CF to their iodine intakes.

METHODS

We measured urinary iodine concentrations (UIC) in national cross-sectional samples of: 1) pregnant women (n=648); 2) school children (n=916); 3) infants at three time points: at 3-4 d after birth and at 6 and 12 months (n=875); and 4) breast-feeding mothers (n=507). We measured breast milk iodine concentrations in the mothers, assessed iodine sources in infant diets, and analyzed iodine content of commercial IFM/CFs (n=22) and salt samples from the school children's households (n=266).

RESULTS

Median (m) UICs in pregnant women (162 μg/liter) and school children (120 μg/liter) were sufficient, and 80% of the household salt was adequately iodized (≥15 ppm). However, mUICs in infants not receiving IFM/CF were not sufficient: 1) mUIC in breast-fed infants (82 μg/liter) was lower than in non-breast-fed infants (105 μg/liter) (P<0.001) and 2) mUIC in breast-fed weaning infants not receiving IFM/CF (70 μg/liter) was lower than infants receiving IFM (109 μg/liter) (P<0.01). mUIC was low in lactating mothers (67 μg/liter) and median breast milk iodine concentration was 49 μg/kg.

CONCLUSIONS

In countries in which iodized salt programs supply sufficient iodine to older children and pregnant women, weaning infants, particularly those not receiving iodine-containing IFM, may be at risk of inadequate iodine intakes.

Power from below: enabling communities to ensure the provision of iodated salt in Kyrgyzstan

BACKGROUND

In Kyrgyzstan, as in many countries around the world, progress in universal salt iodization has been slow because of difficulties in enforcing existing national regulations.

OBJECTIVE

To study the effects of community testing of the iodine content of salt in households, at local retailers, and at wholesale markets on the percentage of households using iodized salt in Naryn Oblast, a region of Kyrgyzstan.

METHODS

In response to a stated community priority to address iodine deficiency in Naryn Oblast, volunteers from village health committees and personnel of Primary Health Care units living in the communities were trained in testing salt using test kits. A phased introduction of two testing components was conducted in 2002-2003 in two areas with a combined population of 160,000. The two components included testing of salt for iodine content by community members in as many households as possible (Component 1) and testing of retail salt for iodate content by community members and by retailers at wholesale markets (Component 2). Results from these two components provided the data for this study.

RESULTS

For Component 1, salt testing reached 65% of households; coverage of iodized salt increased from 87.6% to 96.8% within 5 to 7 months (averages of the two areas; p < .001), mostly owing to a great decrease in the variation among settlements. For Component 2, in area 1, the percentage of households using iodated salt increased from 71.0% to 90.3% within 5 to 7 months, whereas the percentage of households using iodinated salt decreased from 18.6% to 5.6%. In area 2, the percentage of households using iodated salt increased from 65.2% to 76.2% within 5 to 7 months, with no change in the percentage of households using iodinated salt (21.7% and 20.8%). The differences between areas I and 2 are highly significant (p < .001). At 18 to 21 months, the percentage of households using iodated salt was 97.5% in area 1 and 90.2% in area 2. The intervention cost around U.S. dollars 1500.

CONCLUSIONS

Testing salt in a large percentage of households is an effective, low-cost approach to increasing the percentage of households using iodized salt to satisfactory levels in a very short time. Empowering community members to check salt at retailers and retailers to check salt at wholesale markets with test kits for iodated salt can rapidly ensure almost exclusive consumption of iodated salt in households.