SUPPORTING SALT PRODUCERS TOWARDS

OPTIMAL IODISATION OF HOUSEHOLD SALT IN

SOUTH AFRICA
Dr Pieter Jooste, Nutritional Intervention Research Unit, Medical Research Council, PO Box 19070,
Tygerberg 7505, Cape Town, South Africa; Tel.: (021) 938-0370, e-mail: pieter.jooste@mrc.ac.za
Ms Maude de Hoop, Directorate Nutrition, Department of Health, Private Bag X 828, Pretoria 0001, South Africa;
Tel.: (012) 312-0042, e-mail: DeHoopM@health.gov.za
Mr Andries Pretorius, Directorate Food Control, Department of Health, Private Bag X 828, Pretoria 0001,
South Africa; Tel.: (012) 312-0159, e-mail: PretoA@health.gov.za
Mrs Joan Matji, UNICEF, PO Box 4884, Pretoria 0001, South Africa; Tel.: (012) 338-5255,
e-mail: jmatji@unicef.org

Salt producers represent an indispensable, key 90%. In the three northern provinces coverage
group of role players in the provision of was below 50%, and as low as 39% in the
sufficiently iodised salt in any country. A Limpopo Province. One of the possible reasons
continuous supply of adequately iodised salt is for this is the under-iodisation of salt at the
necessary for sustainable optimal iodine nutrition production site.
in any population that has experienced iodine With the introduction of mandatory iodisation
deficiency in the past, as has South Africa and in 1995, an important public health responsibility
many other countries in the region. was placed on the shoulders of the salt
Globally and nationally, optimal iodine producers. They are indispensable towards
nutrition has been recognised as critical to achieving the international goal of 90% of
ensure normal mental development and households using adequately iodised salt, and
functioning of children and adults. Other benefits averting grave consequences such as brain
of optimal iodine nutrition include prevention of damage and other IDD in children and adults.
iodine-deficiency disorders (IDD) such as goitres, They can increase the accuracy of salt iodisation
hypothyroidism, reproductive failure, cretinism and reduce the variation observed in iodine
and childhood mortality. concentrations in retail and household salt. The
From a public health perspective, health salt producers should be seen as the primary
authorities are therefore obliged to implement role players implementing the salt regulation.
preventive and control measures to eliminate All countries that have implemented a
iodine deficiency. To achieve this goal, national iodisation programme should also have
iodised salt has proved to be the most a functional monitoring system in place. In some
successful public health intervention in many countries the iodisation programme (even
countries. mandatory iodisation) has failed because of the
lack of such a functional monitoring system.
What is the situation in South Africa? Monitoring the iodine concentration of salt is
Direct and indirect evidence of continued iodine seen as one of the cornerstones determining the
deficiency and endemic goitre in South Africa - sustainability of successful iodisation. Monitoring
despite optional iodisation of salt - justified the of the iodine concentration at the production
introduction of mandatory iodisation of table salt sites, as well as at the retail and household
at an elevated iodine concentration of 40 to 60 levels, should be performed regularly and should
ppm at the end of 1995. This legislation applies be an integral part of a national iodisation
to salt for human consumption (not to agricultural programme.
salt for animal use). Since the mandatory regulations on salt
Favourable effects of mandatory iodisation on iodisation came into effect, the DoH and the
the iodine status of children were observed after MRC have conducted external monitoring of the
No. 4 September 2002

1 year, but cases of goitre took longer to iodine concentration of retailer salt.4 Annual Retail
1
recover. A national IDD survey conducted by the Salt Surveys conducted by environmental health
South African Institute for Medical Research in practitioners have shown an increase in the
1998 on behalf of the Department of Health iodine concentration of salt at retail level. The
(DoH) reported national and provincial median 2001/2002 Retail Salt Survey showed that 77,6%
urinary iodine concentrations in the ‘iodine of salt contained more than 15 ppm.
replete’ range, a major improvement in iodine The MRC conducted a national survey of the
status compared to earlier studies.2 However, iodine content of household salt in 1998.3
evidence of iodine deficiency was found in 16% UNICEF also commissioned the MRC on behalf
of 179 schools visited during the national survey, of the DoH to assess iodine concentrations and
and high goitre rates (although the goitres were internal monitoring procedures at production
small) in all of the 49 schools assessed for level.5 In brief, the results indicated that of the 74
thyroid size. salt companies registered with the Department of
Other studies indicate that the international Minerals and Energy, 12 producers, some
goal of 90% of households using adequately representing groups of salt companies, are
iodised salt has not been achieved in South currently iodising salt for human consumption.
Africa. A national survey of the iodine content of The overall distribution of iodine
household salt recently showed that 62,4% of concentration in salt samples obtained from
households use adequately iodised salt,3 these producers and analysed by the titration
considerably short of the international goal of method showed that 31% of salt complied
with the legal requirement of 40 to 60 (2001) on Assessment of the Iodine keep a watchful eye on new entrants to the
ppm, and 58% of salt contained more Deficiency Disorders and Monitoring their iodising industry to ensure appropriate
than 30 ppm of iodine, but 35% of the Elimination; and other relevant material that registration and follow-up.
samples contained less than 20 ppm at may become available.
the production site. 8 Laboratory methodology: Scientific
4 Remedial action to improve the salt problems and opportunities identified
Recommendations and follow-up actions iodisation process: Remedial action is during the study need to be pursued, e.g.
Follow-up actions and recommendations required to motivate and encourage those establishing the correct analytical method
were formulated to help those salt salt producers responsible for the for analysing iodine in salt produced in an
producers requiring assistance to produce substantial proportion of under-iodised salt, environment with high alkalinity,
adequately iodised salt, and to strengthen to rectify their iodisation process. standardising analytical methodology, and
and sustain the successful production of Consideration should be given to the investigating the potentiometric method of
those producers who were iodising salt possibility of appointing a consultant to analysing iodine in salt.
sufficiently: advise salt producers who need support to
improve their existing iodisation process or In conclusion, credit is due to the dedicated
1 Up-to-date register of salt producers to start iodising salt. Particular attention salt producers who produce salt complying
iodising table salt: Interaction with the salt needs to be focused on problem areas in with the legal requirement, who are
producers during the investigation of iodine the iodising industry, i.e. some of the informed about the prevention and control
concentrations in salt at production level, medium, potentially significant and of IDD, and whose efficient internal quality
and the feedback of results, laid the peripheral salt producers. control procedures are instrumental in
foundation for continued liaison with the producing sufficiently iodised salt. Their
salt producers. The register of South 5 Improving internal quality control: contribution towards the remarkable
African salt producers involved in iodising Since shortcomings existed in the internal progress in eliminating iodine deficiency in
salt created during this investigation needs quality control of many salt producers, they South Africa needs to be acknowledged,
to be regularly updated to maintain a record should be encouraged to implement a and they should be encouraged to sustain
of producers who should share in relevant comprehensive internal quality control the production of adequately iodised salt.
information on IDD control as it becomes system. Producers not yet using the However, a substantial percentage of
available. titration method for internal monitoring producers’ salt is still under-iodised,
should be supported in establishing small and shortcomings exist in the
2 Establishing linkages: The industry-based laboratories for routine perceptions and knowledge of IDD, as
Directorates of Nutrition and of Food monitoring of the iodine content of salt well as in the internal quality control
Control of the National DoH, UNICEF and using the titration or equivalent method. procedures of some salt producers. The
the Nutritional Intervention Research Unit Standardised analytical methodology actions outlined above will assist and
of the MRC recently established the South should be made available to all salt support all salt producers towards
African Iodine Deficiency Disorders producers, including those already applying optimal iodisation of household salt,
Network to ensure co-ordination of IDD the titration method. which is critical for achieving the
activities and a flow of related information international goal of 90% of households
among all role players involved. Ideally 6 Follow-up evaluation and using adequately iodised salt.
other role players involved in monitoring: It is proposed that a follow-up
implementation, monitoring and evaluation study evaluating the intervention effects of References
of the national salt iodisation programme the IEC programme as well as of the 1. Jooste PL, Weight MJ, Lombard CJ.
(e.g. representatives of the salt industry) interaction with salt producers should be Short-term effectiveness of mandatory
also need to join the Network. This Network conducted in the next year. In this way the iodization of table salt, at an elevated
will also act as a link between international intervention effect of the baseline study, the iodine concentration, on the iodine and
health agencies and South African salt feedback and the IEC material on goitre status of schoolchildren with
producers. The common objectives should perceptions and knowledge of IDD and on endemic goitre. Am J Clin Nutr 2000;
be to improve knowledge regarding the the iodine concentration of their salt will be 71: 75-80.
control of IDD, to assist the salt producers evaluated. It is extremely important that 2. Immelman R, Towindo T, Kalk WJ,
to improve the accuracy of iodisation and external monitoring of the iodine Paiker J, Makuraj S, Naicker J, Omar S.
reduce the variation in iodine concentration concentration of iodised salt at the Report of the South African Institute for
in salt, and to increase the national and production sites be continued on a regular Medical Research on the Iodine
provincial percentage of households using basis - preferably twice to three times Deficiency Disorder Survey of Primary
adequately iodised salt to at least 90%. annually, but not less than once annually. School Learners for the Department of
Health, South Africa. South African
3 Introducing an information, 7 Training environmental health Institute for Medical Research, 2000.
education, and communication (IEC) practitioners: In a series of three training 3. Jooste PL, Weight MJ, Lombard CJ.
programme: An IEC programme to inform sessions conducted in 2001, the DoH, Iodine concentration in household salt
and educate salt producers about the UNICEF and the MRC collaboratively in South Africa. Bulletin of the World
prevention and control of IDD, emphasising trained more than 100 environmental health Health Organization 2001; 79: 534-540.
the salt producers’ role, was structured to practitioners from all 9 provinces in the 4. Jooste PL, Weight PL, Locatelli-Rossi
build on the momentum created by country on the background, motivation, L, Lombard CJ. Impact after 1 year of
interaction with the salt producers. The implementation and monitoring of the compulsory iodisation on the iodine
following IDD material will be mailed to the national salt iodisation programme. The content of table salt at the retailer level
salt producers at various intervals as part of core group of these environmental health in South Africa. Int J Food Sci Nutr
a co-ordinated IEC strategy: A summary practitioners serving the local authorities 1999; 50: 7-12.
report of the present salt producers’ study; where the salt producers are located need 5. Jooste PL. Iodine Deficiency Disorders:
the IDD booklet, pamphlet and poster to be linked in a register to the respective South African salt producers’ practices
produced by the Directorate Nutrition of the local and provincial health authorities and and perceptions. Tygerberg: Nutritional
DoH and UNICEF; user-friendly summaries to the respective salt producers in their Intervention Research Unit, Medical
of published research data; the recently areas, to enhance mutual collaboration with Research Council, Technical Report,
revised World Health Organization manual the Network. They should also be alerted to ISBN: 1-919809-11-2, August 2001.