When Health Ministry public health chief and associate director-general Prof. Itamar Grotto has been asked why it does not require the vital element iodine to be added to all salt when most countries do so, his reply was that it was “unnecessary and the need unproven,”
However, a first-ever national survey led by Hebrew University researchers has found a high burden of iodine deficiency in 62% of school-age children and 85% of pregnant women. The new research found that the shortage of iodine poses a “high risk of maternal and fetal hypothyroidism and impaired neurological development of the fetus in Israel.” Finally, after decades of delay, the ministry partially supported the research effort, along with the European Union’s Horizon 2020 research and innovation program.
The researchers -- who included colleagues at Maccabi Healthcare Services, Barzilai University Medical Center in Ashkelon and ETH Zurich in Switzerland, with support of the non-profit, non-governmental Iodine Global Network -- declared iodine deficiency will require government funding and legislation and a government-regulated program of salt or food iodization.
The International Child Development Steering Group has identified iodine deficiency as a key global risk factor for impaired child development, and the World Health Organization (WHO) recommends routine monitoring of population-based data on urinary iodine every five years as a means of sustainable elimination of the deficiency.
Enough iodine intake is essential for thyroid function and human health throughout life. Even mild iodine deficiency might prevent children from attaining their full intellectual potential, and mild to moderate deficiency has been linked with decreased cognitive performance. Iodine deficiency in utero and in early childhood impairs brain development, and severe iodine deficiency causes cretinism (physical malformation, dwarfism and mental retardation) and goiter (the enlargement of the thyroid gland).
According to the researchers, the high burden of iodine insufficiency in Israel is a serious public health and clinical concern. By comparison to data from other countries with a similar extent of deficiency, these data suggest that there is a high risk of maternal and fetal hypothyroidism and impaired neurological development of the fetus in Israel. By extrapolation, given the rate of insufficiency in Israeli pregnant women, nearly all pregnant women and their children may be at risk, implying that the majority of the population could be unlikely to realize its full intellectual potential.
“The immediate implication of our findings is that we need to improve the public’s intake of iodine,” said Prof. Aron Troen, principal investigator at the nutrition and brain health laboratory at the School of Nutrition Science at HU’s Robert H. Smith Faculty of Agriculture, Food and Environment. “It seems that as in most other countries, Israel’s food supply and our collective dietary habits do not ensure iodine sufficiency. Thus eliminating iodine deficiency and achieving optimal iodine status in Israel’s population will require a sustainable, government-regulated program of salt or food iodization. The costs are small and the benefits substantial and have been proven in over 160 countries around the world where this is done.
The research findings were presented at the 46th Annual Meeting of the Israel Endocrine Society, which took place last week in Ramat Gan.
A committee set up some time ago and headed by its nutrition department head, Prof. Ronit Endevelt, is due to make recommendations soon.
Prof. Ted Tulchinsky, emeritus professor from HU-Hadassah Braun School of Public Health and Community Medicine and current head of the School of Health Sciences at Ashkelon College, has for 20 years been demanding that the ministry introduce iodine into salt. “:Iodine deficiency is a serious public health issue known internationally for a century, including in Israel since the 1950s, for its serious effects on newborns as well as children and adults. This has led the World Health Organization to recommend mandatory fortification of salt with iodine which is safe, costs next to nothing and has been adopted by many countries,” he told The Jerusalem Post.
“Canada, for example, has mandated salt fortification since 1979. My congratulations to Prof Troen and colleagues who presented it to the Endevelt Committee, which is expected to issue its recommendations soon. I hope that this will include adoption of the Canadian model of food fortification, including salt with iodine, milk with vitamin D and flour with vitamin B group, iron, and folic acid, the latter to prevent birth defects. The Canadian model has been recommended by several committees appointed by the ministry since 1996, including Healthy Israel 2020 whose report was endorsed by the Israeli government several years ago.”
Until now, “isolated but persistent calls to address this issue have not translated to action, perhaps due to lack of awareness, or the unfounded but widespread belief that Israel’s proximity to the sea likely prevents ID, leading to a corresponding lack of political will,” the HU-led team of researchers said.
However, the researchers noted that in the absence of a universal salt iodization program, and in light of the heavy national reliance on iodine-depleted desalinated seawater as drinking and irrigating water, the study’s results point to a major national public health problem..
Yet, thanks to Health Ministry policy, Israel has long been “among the few countries in the world that have never performed a national iodine survey and does not provide iodine prophylaxis by requiring it in salt, even though some of its population has suffered from the deficiency in the past. The ministry also lacks current data on the incidence and prevalence of thyroid disease,” the researchers said.
No comment was available from the ministry by press time.
The nationally representative data about iodine status in the population was collected last year at the Maccabi central lab from urine samples from 1,023 school-age children and 1,074 pregnant women, representing all regions and major sectors in Israel (Arab and Jewish secular and religious). The median urinary iodine concentration among Israel’s pregnant women was only 61 micrograms iodine/liter and for school-age children, the median was only 83 micrograms/liter. This, the researchers said, suggested that the iodine status in Israel is amongst the lowest in the world.
Iodine adequacy is defined by the WHO as a population median of 150 to 249 micrograms/liter for pregnant women and 100 to 199 micrograms/liter for school-age children. Virtually no differences were seen between different ethnicities and regions of the country suggesting that low iodine status is widespread and universal throughout the country.
According to the researchers, a universal salt iodization and monitoring program should be urgently initiated. Dr. Jonathan Arbelle, lead co-investigator from Maccabi Healthcare Services, who presented the findings at the meeting, called upon the Israel Endocrine Society to develop guidelines for clinical practitioners who care for pregnant and lactating women. “Caregivers should recommend adequate iodine intake during pregnancy and lactation, and a randomized clinical trial of risk and benefit for correction of mild-moderate iodine deficiency during pregnancy must be considered,” Arbelle
“A healthful diet is a foundation of a prosperous nation. The public has a right, and government has both a moral obligation and clear-cut social and economic incentive to ensure that the nation’s food supply supports the public’s health, well-being and productivity,” said Troen.
As a result of the iodine deficiency, the average IQ of Israeli children over the past 50 years has been four to five points lower than it would have been, Troen said.
Yaniv Ovadia, the doctoral student and registered dietitian who performed the study, said, “Individuals can improve their iodine status through increased consumption of iodine-rich foods such as milk, dairy and salt water fish. They can also replace regular table salt with iodized salt." However, only a small fraction of the salt sold in Israel is iodized, and it is sold at a much higher price than regular salt, although it does not need to be. The World Health Organization and Iodine Global Network encourage mandatory, universal salt iodization, including the all discretionary household salt. However, some countries have effectively been able to increase their iodine intakes through the use of iodized salt in processed foods, including bread and condiments, and this may be considered in Israel. “Government action is needed to ensure that everyone has access to iodized salt, added Troen.
The findings also highlight the critical need for routine public health surveillance, not only of iodine, but also of other nutritional and environmental exposures that determine the Israeli population’s collective health, they said.
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