Seven deadly sins in confronting endemic iodine deficiency, and how to avoid them

Iodine deficiency is a problem for almost all countries of the world. Goiter is its most obvious consequence, but others do more damage, particularly effects on the developing brain. In 1990, most countries and international agencies pledged the virtual elimination of iodine deficiency by the year 2000. The technology for the assessment and implementation is sufficient to attain this goal, but translating its potential into success requires careful planning. This article reviews seven major errors that frequently occur in iodine supplementation programs and offers suggestions for their avoidance. They are 1) unreliable assessment of iodine deficiency: the best indicators are urinary iodine concentration, thyroid size (preferably by ultrasound), blood spot thyroglobulin levels, and neonatal TSH determinations; the best group for surveys is schoolchildren; 2) poor iodine supplementation plan: iodized salt is the preferred supplement; its effective application frequently requires extensive changes in salt production and marketing, and poor handling of these changes will endanger the iodization program; other measures include iodized oil, iodized water, and iodine drops; all are occasionally useful, but the long range solution should generally be iodized salt; 3) exclusion of relevant stake-holders: the program should include not only health authorities but other arms of the government as well (education, commerce, agriculture, and standards), the salt industry, health professionals, and the iodine-deficient community itself; 4) inadequate education: an understanding of the effects of iodine deficiency and the means for its correction is essential at all levels, from government to affected population; 5) insufficient monitoring: the best instruments are urinary iodine levels, iodized salt use, and thyroid size, measured in representative groups at regular intervals with public reporting of results; 6) inattention to cost: the expense of iodization must be recognized and apportioned fairly; and 7) nonsustainability: for permanent success, an iodization program must be fair to all relevant parties and accompanied by a regular system of appropriate monitoring. Only with careful avoidance of these seven "deadly sins" can the goal of sustainable elimination of iodine deficiency be achieved.