Assessment of adequately iodised salt consumption in Telangana state, India

INTRODUCTION

Iodine deficiency is one of most important causes of preventable mental impairment around the world; inadequate thyroid hormone production of iodine also causes many other adverse effects on growth and development.¹ Many of these adverse outcomes, collectively referred to as iodine deficiency disorders, result from the effects of iodine deficiency on fetal brain development during early pregnancy.² Iodine deficiency can be effectively and inexpensively prevented by iodizing all salt for human and animal consumption (known as) universal salt iodization (USI).^3,4

India’s national government began efforts to promote the consumption of iodized salt in the 1960s.^5,6 Under the National iodine deficiency disorders control program (NIDDCP), there is a policy of universal salt iodization under which the entire population of the country is to receive iodized salt with a minimum of 15 ppm of iodine. However, the Government of Andhra Pradesh had implemented a partial ban on sale of non-iodized salt for edible purposes in iodine endemic districts only.⁷

Prior to the division of Andhra Pradesh according to NFHS 3, the coverage of adequately iodized salt in the state was 46.9%, inadequately iodized salt 35.7% and non-iodized salt 17.4%.⁸ To further expand the coverage of adequately iodized salt, researchers and policy makers have recommended that governments reinforce quality assurance/control systems and routinely monitor household coverage of adequately iodized salt to identify socioeconomic groups and geographic locations where salt iodization can be improved.⁹

With this background, an attempt was made to estimate the consumption of adequately-iodized salt at the household level in Telangana state, find out the socio demographic factors that influence the access to iodized salt at the household level.

METHODS

Secondary data published in the District Level Household and Facility Survey-4 (DLHS-4) is analyzed.¹⁰ The data from these surveys have been useful in setting the benchmarks and examining the progress the country has made after the implementation of universal salt iodization (UIP) programme. In addition, the evidence generated by these surveys has also been useful for the monitoring and evaluation of ongoing programmes and planning of suitable strategies by the central and state governments.

The Ministry of Health and Family Welfare, Government of India, initiated the process of conducting DLHS-4 during 2012-2013 and has designated the International Institute for Population Sciences (IIPS) as the nodal agency to carry out the survey. DLHS-4 is a nationwide survey covering 640 districts from 36 States and Union Territories of India. DLHS-4 is a district level survey and a multi-stage stratified design adopted for selection of representative sample of each district in Telangana. Rural and urban areas of a district are considered as natural strata. Fieldwork in Telangana was conducted during June 2013 to February 2014, a total of 13,927 households of Telangana were tested for iodine in their salt.¹⁰

Salt used in the household is the most common vehicle for iodine fortification to prevent the public health concerns of iodine deficiency disorders. The compound used for fortification of salt is potassium iodate (KIO3). According to the World Health Organization, a country’s salt iodization program is considered to be on a good track to eliminate iodine deficiency when 90 percent of households use iodized salt. The 2012-13 DLHS-4 made an effort to assess household iodized salt consumption by testing iodine contents in the salt being used by the household.

Statistical analysis was done using Microsoft Office Excel 2007. The statistical tests used were proportions with 95% confidence interval (CI) and Chi-square test. P<0.05 was considered to be statistically significant.

RESULTS

Telangana is one of the southern states which performed badly during NFHS 4. Overall, 56 percent of the households were using cooking salt which was iodized at the recommended level of 15 ppm or more. Only 17.6 percent of the households used salt that was not iodized at all and 23.7 percent used salt that was iodized inadequately (<15 ppm) (Figure 1).

The use of adequately iodized salt was high in Adilabad, Mahbubnagar, Karimnagar, Hyderabad, Nalgonda and Rangareddy districts compared to the districts Warangal, Nizamabad, Medak, and Khammam where use of iodized salt was low as compared to the Telangana average. It ranges from a maximum in Adilabad (65%) to the minimum in Khammam (42%) (Figure 2).

Around 60.8 percent of households in urban areas used salt with 15 ppm or more iodine content compared with 51.9 percent of households in rural areas though the difference was not significant. Except for the age 30-44yrs in other socio-demographic variables like education, religion and caste the difference in adequately iodized salt was insignificant (Table 1).

DISCUSSION

Availability and consumption of adequately iodized salt must be granted for sustainable elimination of IDD. According to WHO and International Council for Control of Iodine Deficiency Disorders (ICCIDD) standard, elimination of IDD will be possible if more than 90% of the households consume adequately iodized salt.

In India as per the Coverage Evaluation Survey 2009, 91 per cent of households had access to iodized salt, of whom 71 per cent consumed adequately iodized salt.¹¹ Another 9 per cent consumed salt with no iodine. There are wide rural and urban variations in household coverage of adequately iodized salt (83.2% in urban areas vs. 66.1% in rural areas). The similar differences were reported by other studies in India and in other countries.^12-16 But according to NFHS-4 report, the Telangana state coverage adequately iodized salt is only 55.7% and there is not wide variation in urban and rural areas. We found almost an equal proportion of salt being adequately iodized at the households. The difference was insignificant in relation to education, religion and caste. Studies in West Bengal reported that the religion and caste of households was related to the consumption of iodized salt.¹⁷

The coverage of adequately iodized salt in Telangana is suboptimal. Increasing consumer awareness and demand for adequately iodized salt has been proven to be one of the most effective interventions to promote USI globally. The Behaviour Change Communication (BCC) activities need to be upscaled and intensified.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. WHO. Micronutrient deficiencies. Available at http://www.who.int/nutrition/topics/idd/en/. Accessed on 22 May 2018.
2. 2. Delange F. Iodine deficiency as a cause of brain damage. Postgrad Med J. 2001;77(906):217–20.
3. 3. WHO. Iodine and health. Eliminating iodine deficiency disorders safely through salt iodization: a statement by the World Health Organization. Geneva, World Health Organization; 1994. Available at http://whqlibdoc.who.int/hq/1994/WHO_NUT_94.4.pdf. Accessed on 22 May 2018.
4. 4. UNICEF, WHO. World Summit for Children- Mid-Decade Goal: Iodine Deficiency Disorders [Internet]. Geneva (Switzerland): UNICEF-WHO Joint Committee on Health Policy; 1994 [cited 2017 Mar 21]. Report No. JCHPSS/94/2.7.
5. 5. Ministry of Health & Family Welfare. Revised Policy Guidelines On National Iodine Deficiency Disorders Control Programme. New Dehli: Directorate General of Health Services, Government of India New Delhi; 2006.
6. 6. Pandav CS. Evolution of iodine deficiency disorders control program in India: a journey of 5,000 years. Indian J Public Heal. 2013;57:126–32.
7. 7. Tiwari BK, Kundu AK, Bansal RD. National iodine deficiency disorders control programe in India. Indian J Pub Health. 1995;39:51-6.
8. 8. Summary Report Iodized Salt Coverage Study 2010 Conducted Across Eight States in India. Available at https://www.nutritionintl.org/content/user_files/2011/06/india-salt-coverage-report-2010.pdf. Accessed on 23 May 2018.
9. 9. Rohner F, Zimmermann M, Jooste P, Pandav C, Caldwell K, Raghavan R, et al. Biomarkers of nutrition for development—iodine review. J Nutr. 2014;144:1322–42.
10. 10. International Institute for Population Sciences. District Level Household and Facility Survey-4; State Fact Sheet Telangana (2012-13). Mumbai: International Institute for Population Sciences (Deemed University); 2014.
11. 11. UNICEF. Coverage Evaluation Survey 2009, All India Report. Ministry of Health and Family Welfare, Government of India, New Delhi; 2010.
12. 12. Das DK, Chakrabarty I, Biswas AB, Sarkar GN, Shrivastava P, Sen S. Iodine deficiency disorders among school children of Dakshin Dinajpur district, West Bengal. Indian J Public Health. 2005;49:68–72.
13. 13. Das DK, Chakraborty I, Biswas AB, Saha I, Mazumder P, Saha S. Goitre prevalence, urinary iodine and salt iodisation level in a district of West Bengal, India. J Am Coll Nutr 2008;27:401–5.
14. 14. International Institute for Population Sciences. National family health survey (NFHS-3), 2005–06: India. V. 2. Mumbai: International Institute for Population Sciences. 2007: 295–8.
15. 15. Jooste PL, Weight MJ, Lombard CJ. Iodine concentration in household salt in South Africa. Bull World Health Organ. 2001;79:534–40.
16. 16. Virtual elimination of iodine deficiency disorders in Bolivia. Rev Panam Salud Publica. 1997;2:215–9.
17. 17. Sen TK, Das DK, Biswas AB, Chakrabarty I, Mukhopadhyay S, et al. Limited access to iodized salt among the poor and disadvantaged in North 24 Parganas district of West Bengal, India. J Health Popul Nutr. 2010;28:369–74.