Global Strategy to Prevent and Control Iodine Deficiency Disorders
Scurvy in Refugee Camps
Priorities in Nutrition Research
Unesco Nutrition Projects in Three Regions
FAO Nutrition Country Profiles
Iodine deficiency is generally associated with its most visible manifestation, goitre, an enlargement of the thyroid once regarded as a problem with few implications for general health. Recent field investigations have revealed, however, a broad spectrum of “iodine deficiency disorders” (or IDD) - mental and physiological effects which include stillbirths, congenital abnormalities and increased infant deaths. Concerned over estimates that some 800 million people in developing countries are at risk from these disorders, the ACC decided in October 1985 to accept the SCN proposal that priority attention should be given to prevention and control measures. In response, UN agencies, governments and NGO’s have been asked to join and support a new ten-year programme aimed at eliminating cretinism and reducing goitre rates in vulnerable populations to below 10 percent before the turn of the century.
The programme, drawn up by WHO at SCN’s request, was endorsed by the Sub-Committee at its annual session in March 1987. In presenting the programme’s global strategy, WHO said iodine deficiency disorders were found mainly in areas where people consumed foods grown locally in soil depleted of its natural iodine content. IDD are most common in mountainous areas: the entire Andean chain is a major endemic region. More than 80 percent of the estimated 190 million people affected by goitre and cretinism are believed to live in Asia, with at least 40 million in Southeast Asia suffering mental and physical impairment. The disorder is also pronounced in at least 13 African countries. WHO said the spectrum of disorders ranged from abortion, stillbirth, increased infant and perinatal mortality, neurological cretinism to goitre and impaired mental functioning in adolescents and adults. However, undisputed evidence showed that IDD could be successfully and inexpensively prevented and controlled. Because the greatest risk from iodine deficiency was during brain development, the highest priority targets for preventive action were women of reproductive age, infants and school-age children.
Prevention and Control
Iodine supplementation has been shown to prevent goitre. The main approaches are the use of iodized salt and oil, fortification of foods, water and condiments, and distribution of iodine tablets. A single oral dose of iodized oil, for example, can correct severe iodine deficiency for three to five years, while an injection costing between $0.25 and $0.45 is believed to provide even longer protection. Salt iodization is less costly and carries less danger of toxicity than mass dose programmes, but also depends on efficient local level administration and, often, strong public education campaigns. In India, prevalence of goitre among those consuming fortified salt declined from 3 8 percent to 15 percent within five years, and fell to 3 percent after a decade. Researchers in Bolivia found that an iodized oil programme markedly reduced goitre after only two years and improved intellectual performance. In Central Java, Indonesia, large-scale injection campaigns are credited with having eliminated cretinism in new-born children.
The proposed ten-year programme will attempt to apply already extensive knowledge of IDD prevention through national prevention and control programmes supported technically and financially by the UN system and government and non-governmental bilateral agencies. While it will emphasize public health aspects of prevention, including the integration of national efforts into existing health system infrastructures, the programme will seek the active participation of such people as salt producers and traders, food processors and water distribution authorities. The programme’s two main categories of activity are, first, situation assessment, motivation of authorities, development of action plans, training of personnel, public education, and development of educational materials; and, second, the provision of supplies (e.g. iodinated oil and potassium iodate), equipment and funding. WHO estimates the first group of activities to cost about $ 11 million a year during the first four years of the programme; the cost of salt iodization programmes and, on a smaller scale, iodine injections covering 800 million people is tentatively put at $42 million a year.
Iodine-deficiency: the woman on the left is adult.
Programme Implementation
The SCN has formed an IDD Working Group with the task of monitoring the prevalence and severity of the deficiency, helping to mobilize international funding, and facilitating the launch of control programmes and monitoring their progress. The Working Group, which will report annually to the SCN, is linked to the International Council for the Control of Iodine Deficiency Disorders (ICCIDD), set up at a meeting in Kathmandu in March 1986. The council is composed of international experts, with representation from UNICEF, WHO and the World Bank, and is funded by UNICEF and Australia. In March 1987, the ICCIDD, UNICEF and WHO sponsored in Yaounde a Regional Seminar on Control of IDD in Africa attended by representatives from several African countries. After examining evidence that less was known about the extent of IDD in Africa than in any other major region, participants decided to set up a Task Force on IDD to be divided into three sub-regional groups.
UNHCR says new means are needed to combat outbreaks of scurvy among tens of thousands of refugees in camps in the Horn of Africa. Scurvy has been reported in certain refuge camps in Somalia and Sudan for the past four years, with statistics collected by the UNHCR-supported Refugee Health Unit showing prevalences as high as 44 percent of the sampled camp population.
“The cause is obvious: a lack of vitamin C in the diet,” UNHCR reports. “Refugees have been dependent on a food donation ration (primarily cereals), and fresh vegetables are not accessible in remote areas where camps are often located. In addition, many refugees were previously nomadic and their vitamin C needs were met by camel’s milk. Now they have few animals and little grazing land near camps.” A rapid transition from animal-based sources of the vitamin to vegetables is called for but does not occur easily.
Vitamin C, Kitchen Gardens
As an immediate intervention, UNHCR organized the mass distribution of vitamin C tablets. It has also purchased small amounts of fruit for the refugees, although procurement and timely delivery have not always been easy. “The possibility for donors to fortify either wheat flour or dried skim milk with ascorbic acid is under investigation,” UNHCR says. “A fortified cereal blend has already been tested, but the survival rate of vitamin C after cooking appears to be approximately 10 percent of the original content.”
Kitchen gardens are being encouraged. However, while 30 grams of sprouted pulses per refugee daily would provide sufficient amounts of vitamin C to prevent scurvy, this change in dietary habit would take time, UNHCR believes. Meanwhile, the refugees continue to face a serious and widespread nutritional problem demanding immediate intervention.
The SCN is working to build a consensus among UN agencies and bilateral donors on priority areas for future nutrition research. As a first step, the Sub-Committee is circulating to member agencies for comment a report containing a proposed framework for identifying research priorities along with suggested research topics in major areas of concern. Once the report has been finalized, the SCN hopes to foster research on priority topics by bringing together scientists, funders and potential users of research findings.
The report, drafted by an ad hoc working group which met in Washington DC in December 1986, focussed on research priorities relevant to the improvement of national policies and programmes affecting nutrition status in developing countries. The framework proposed by the working group accommodates, therefore, not only conventional biological research on the efficacy of nutrition measures but also operational research on the effectiveness of different solutions and the efficiency of implementation. The working group then applied the draft framework to the most pressing problems - micronutrient deficiencies and proteinenergy malnutrition (PEM) - to produce a series of suggested priority research topics.
New Strategies
Following a review of the report by the Advisory Group on Nutrition, the SCN decided at its annual session in Washington DC in February 1987 that a second phase should consider needs for research into emerging problems that might be foreseen in the next few decades. These include nutritional imbalance leading to obesity, strokes, arteriosclerosis and certain cancers. The SCN will commission background papers to help identify new strategies of intervention and pinpoint those suitable for further research.
This work on establishing research priorities was encouraged by representatives of the U.K. Government (ODA) during a meeting with SCN representatives in London in May 1987. ODA has expressed interest in facilitating one or more meetings, involving policymakers, research institute directors and funders, to discuss the report.
UNESCO has launched or is preparing for implementation-education and social communications projects designed to improve nutrition among poor communities in the Caribbean, East Africa and Southeast Asia.
CIDA/Canada and France are financing a UNESCO social communications nutrition project in five francophone West African countries. The projects - in Burkina Faso, Cote d’Ivoire, Niger, Senegal and Togo - will use communications media to promote nutrition education addressing the priority nutrition problems of women and young children. A similar project is being launched with PAHO for anglophone Caribbean countries.
A four-day policy level round table was held in Barbados in November 1987 to discuss priorities. Meanwhile, UNESCO’s International Programme for the Development of Communications has launched in the ASEAN countries a nutrition education project aimed at mobilizing community-based women’s organizations for nutrition improvement activities. A training workshop was held for selected women’s leaders in Manila in September 1987 to impart knowledge and skills needed to design and implement small-scale information, education and communication (IEC) nutrition projects in rural areas. As a follow-up to this training, five rural IEC projects will be carried out in the ASEAN countries.
Home Economics
Another UNESCO project, for human resources development including nutrition, in Eastern Africa is receiving funding from the Federal Republic of Germany. The project, based at Kenyatta University, Nairobi, aims to promote and strengthen the university’s Home Economics Department and to expand, improve and regionalize training for community-level workers in Ethiopia, Somalia, Tanzania and Uganda. Finally, Norway has agreed to fund a major UNESCO nutrition education project which will help the government of Guyana develop a domestic market for locally-grown foods and encouraging their consumption by low-income women and children. The new project will undertake market research studies to identify suitable strategies for local food production, distribution and promotion.
The Food Policy and Nutrition Division of FAO receives frequent requests for information on the food and nutrition situation of different countries. In 1985 the decision was made to undertake the preparation and routine updating of nutrition country profiles for all developing countries. The profiles will be updated regularly to ensure the availability of recent information.
The profiles provide a valuable tool for national, sectoral and project level planning and for identifying nutritionally disadvantaged areas within countries. Where possible, the profiles highlight major development issues and problems such as demographic changes, access to services, literacy levels, land productivity and agro-ecological zones.
In 1986, approaches were made to national and subregional institutes, covering a total of 88 countries. So far, 49 responses have been received. In addition, all institutions who have responded have agreed to continue to supply new information as it becomes available. For further information, please contact Ms. Suraiya Ismail, ESN, Room C246, FAO, Rome, Italy.
