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13 March 2013

Eat less salt but make sure it contains iodine!

Salt has been used for thousands of years to flavor & preserve food BUT reliance on fast food, biscuits and tinned goods, with their hidden salt content, has created for us a high salt diet and with it an alarming rise in cardiovascular disease.

SaltshakercreditPHILandamandamillls_smallercroppedReducing our salt intake, by working with food industry and educating the public (World Salt Awareness Week), should counter this disease epidemic.  BUT take this too far, and could an old disease re-emerge? I speak of iodine deficiency in the diet, which can cause abortion, stillbirth, goiters, mental retardation & birth defects: iodized salt solved it. [For the latest research on iodine deficiency and salt iodisation, see the March issue of Global Health Knowledge Base]

WHO recommend universal salt iodization for developing countries as a simple, safe and cost-effective measure to address iodine deficiency, and many developed countries follow this too.

People afraid of salt so a disease re-emerges or is unaddressed?

If we ever needed a reminder of the importance of iodized salt & public attitudes to health, you only had to read “salt rumors add to health crisis in pakistan” (Washington Post).

 Image: Amanda Mills, USDA


Iodine is a trace element (a micronutrient) found in seawater and soil: sources of iodine are therefore plants grown in iodine-rich soil, milk, fish or plants from the   sea. Insufficient iodine in the diet can cause spontaneous abortion, stillbirth, goiters (enlarged thyroid gland in the neck), mental retardation, birth defects and other developmental problems.

The key facts reported in the Post article are that:

  1. nearly half of Pakistan's population of 200 million suffers from some form of iodine deficiency
  2. In 1995, government officials launched a maternal health initiative using a slide show on Pakistani TV to promote better nutrition: unfortunately, they showed a slide promoting iodine (lack of it causing birth defects & abortion), just before the final slide which credited the initiative to the government's department of primary health and family planning.  This juxtaposition was a communication mistake. Today as many as 30% of Pakistanis still won't use “mixed salt” (iodized salt) because they link it to infertility.
  3. Some Pakistan NGOs have resorted to stealth iodization, providing subsidies to salt factory owners who add the micronutrient during production. “It is sold in bulk, unbranded,­ it is open-bag salt, and consumers will not know if it contains iodine,” said Muhammad Yasin with the Micronutrient Initiative. “They get the health benefit even if they don’t know it.”

Our Global Health board member & HIFA2015 moderator Neil Pakenham-Walsh, asks: “Is it justifiable for an NGO to promote iodisation of salt without the knowledge of citizens?

Another HIFA2015 member, Henry Ko,  suggested an alternative strategy for Pakistan:  promote the use of traditional local salt (from sea water evaporation or salt mining) which keeps higher levels of iodine & other trace elements.  His suggestion stemmed from reading the book “Salted: A manifesto on the world’s most essential mineral, with recipes” and you can read more from him on this subject at: Health-giving properties of artisanal salt

What exactly are these trace elements found in traditional salts which might be good for us? I searched Global Health database using (de: salt and de: trace elements), which yielded 386 records. I found that natural sea salts can have 60-80 trace elements in them…not all good for you, mind, but including many of the essential trace elements (i.e. chromium, manganese, iron, nickel, copper, zinc) as well, of course, as Iodine. There was also current research to increase levels of iodine in root vegetables such as carrots as an alternative to USI.

AS in all things, the solution to this food-related crisis is education and moderation (in consumption). It applies to Pakistan and to me, mother of two girls writing in the UK, for here we rely on milk as a good source of iodine and we don’t have statutory USI. In 2011, a BBC article Worrying levels of iodine deficiency in the UK highlighted the results of a study which identified 2/3 of teenage girls studied (750 total, 9 centres) had iodine deficiency…possibly linked to a shift away from drinking milk & enjoying milky cereals at breakfast.

If you add into this shift in eating habits, the worldwide push to decrease salt intake to prevent cardiovascular disease, then we have a new challenge to addressing iodine deficiency in both developing and developed countries. We cannot afford to be complacent: solving a new problem could allow an old one to remerge.

Related References:
Food reformulation: the challenges to the food industry.
Buttriss, J. L. Proceedings of the Nutrition Society, 2013, 72, 1, 61-69, 31 ref.

Projected effect of dietary salt reductions on future cardiovascular disease.
Bibbins-Domingo, K. et al. New England Journal of Medicine, 2010, 362, 7, 590-599, 42 ref.

A dietary risk assessment for indigenous consumption of natural salt deposits in the Darhad Valley, Northern Mongolia.
Barber, L. M. et al. Human and Ecological Risk Assessment, 2009, 15, 5, 907-922, 28 ref.

And a bit of history from Global Health Archive:

Decrease in deafmutism in Switzerland as a result of goitre prophylaxis with iodised salt.
WESPI, H. J.; Schweizerische Medizinische Wochenschrift, 1945, 75, pp 625-629

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