Learning that iodine deficiency is the single most important preventable cause of brain damage among children, Amany Abdel-Moneim
asks just how prevalent the condition is in Egypt
Recent studies indicate that some 1.5 billion people, roughly a third of the earth's population, live in areas defined as suffering from iodine deficiency. The consequences of this all but invisible condition, collectively known as iodine deficiency disorders (IDD), include irreversible mental retardation, goitre, reproductive failure and increased child mortality.
And thankfully all it takes to prevent it is sufficient iodine intake. So dietary specialists told participants in a three-day workshop assessing salt iodisation processes in Egypt. Held by the Ministry of Health and Population (MOHP) in collaboration with UNICEF Egypt, the workshop was aimed at ending the scourge of (IDD) among Egyptian children. "Eliminating iodine deficiency," said UNICEF Egypt's Erma Manoncourt, "is recognised as among the most achievable of the goals that the 1990 World Summit for Children (WSC) set, to improve and protect children's lives." Yet Esmat Mansour, head of the Integrated Health Care and Nursing department of MOHP, pointed out that, while positive steps are underway, more effort is required in controlling the quality of iodised salt and monitoring its consumption, especially in high-risk parts of the country: "In the New Valley governorate, one of the hardest hit regions, early efforts focussed on iodised oil injections," an immediate measure. "The IDD control programme moved onto salt iodisation. And thankfully, sample urinary iodine levels now pass the sufficiency cut-off point."
Hossam Ashour, consultant paediatrician and neonatologist at Al-Galaa Teaching Hospital, elaborated further: "The main manifestations of iodine deficiency are goitre, irreversible mental retardation, increased rates of foetal wastage, stillbirths, and infant deaths." Severe mental and neurological impairment occurs among infants born to mothers who are seriously iodine deficient, he added. While its effects on a brain in the process of development form the most alarming risks, goitre is significant in that it can lead to a variety of serious conditions resulting from altered thyroid functions: "Diagnosis of IDD should be made before the age of six months by hormonal analysis. About four years ago, a national project was launched under the auspices of Mrs Suzanne Mubarak -- to run an obligatory neonatal screening tests in the first week of life through a small drop of blood from the baby's heal. Positive results receive early treatment to pre-empt irreversible damage, and parents' contacts are filed to this end."
Unlike nutrients like iron, calcium or the vitamins, iodine does not occur naturally in specific foods; rather, it is present in the soil and can only be ingested through foods grown in soil. Iodine deficiency results from an uneven distribution of iodine on the earth's crust. So explained UNICEF Egypt's Health and Nutrition Project Officer Magdi El-Sanadi: "The condition results mainly from geological, not social or economic circumstances. It cannot be eliminated by changing dietary habits or eating specific foods. The corrective procedure must be achieved by supplying iodine from an external source -- either by periodic supplementation of deficient populations with iodised oil capsules or other preparations, or by fortifying a commonly eaten food with iodine."
Mansour explained that MOHP has played a vital role in providing much needed iodised potassium since 1995. The department of Food Inspection is also monitoring the specifications of the locally iodised salt.
According to nutritionist Nagwa Abdel-Wahab, iodine deficiency is less strongly correlated with food insecurity than protein and energy malnutrition or iron-deficiency anaemia. It is a hidden hunger that impairs the brain development of children during the first three months of pregnancy. "However, the range of functional consequences of iodine deficiency is broader for women than for men, since it affects both mothers and infants. In addition to a broader range of functional consequences, the prevalence of goitre appears to be significantly higher among females than males in virtually all studies..." Since the mid-1990s, universal salt iodisation (USI) has been recognised as the most cost-effective, sustainable and safe strategy to ensure sufficient consumption of iodine by everyone, since the substance in question is consumed all across the board of a given community. Salt consumption per person, Abdel-Wahab went on to indicate, could be anywhere between 5-20 grammes a day; if the amount of iodine is fixed at 30-100 microgrammes per gramme of salt -- a figure that takes into account iodine losses during transportation and storage -- the minimum health requirement of 15-200 microgrammes per day is covered.
With average household consumption increasing from 56 per cent in 2000 to 79 per cent in 2003 -- according to the Interim Demographic Health Survey -- Egypt has made such good progress that it is "on the verge of eliminating IDD", in the words of El-Sanadi. UNICEF has supported the reimbursable procurement of iodated potassium to assist the major salt producing plants in Alexandria, Port-Said, North Sinai and Fayoum, he said. In addition, it has provided MOHP with salt testing kits to help monitor salt iodisation levels in factories, shops and the household level.
But meeting the demands of salt producers is arguably necessary for sustainable IDD elimination in Egypt. "Salt should be packaged in waterproof bags or containers and labelled with the name and address of the producer as well as the date of manufacture to enable monitoring," said Mohamed Ali Hussein, the production manager of one of the largest state-supported companies, producing some 300,000 tonnes of iodised salt per year. Hussein complained of producers who replicate the company's label, selling locally produced, non-iodised salt at a cheaper price. Six large companies producing iodised salt cover 80 per cent of the market, but the remaining 20 per cent remains a major problem. Hussein also revealed that in Damietta, Beheira, Kafr Al-Sheikh as well as parts of Sinai, "contaminated ponds of stagnant water and raw sewerage canals are used by people to produce salt" -- all the relevant authorities, including the Ministry of Environment, he said, should join forces to either clean these ponds, turning them into fish farms, or simply fill them in.
"Once the effective iodisation of salt is established as a permanent measure," El-Sanadi concluded, "iodine deficiency is eliminated and its recurrence prevented as every individual gets his daily iodine needs." Within one year of iodised salt containing the required concentration of iodine becoming widely available and consumed in a given community, there will be no incidence of mental retardation in that community and goitres, in primary school children and young adults, will have shrunk and started to disappear altogether. The Global Network for Sustained Elimination of Iodine Deficiency, founded in 2002, is an alliance of major organisations currently chaired by UNICEF. They, too, Manoncourt added, share a commitment to helping countries reach the goal of sustained