Achieving universal salt iodisation in the Philippines through health policy and promotion
by Julius Alejandre (Bangor University)
Micronutrient deficiency has been a major public health concern especially in developing countries. This form of malnutrition does not just affect individuals and population groups, but also, a country as a whole – specifically in terms of human productivity and contribution to economic development. Deficiency in micronutrient has been attributed to a spectrum of clinical manifestations. The most common, and are still prevalent, are night-blindness, deaf-mutism, low brain development, cleft-lip palate, cretinism, goitre, stillbirth, frequent miscarriage, among others. These clinical conditions affect the capacity of individuals to become productive, attend school, and acquire a decent job.
While there is a huge number of micronutrients where people can experience inadequacy, the most common and affects a large proportion of global population is identified as having low concentration of iron, vitamin A, and iodine. Deficiency in these three micronutrients is evident in most developing countries, and can be seen among infants, young or school children, pregnant, and lactating women.
Iodine deficiency for instance, is a classic example of micronutrient deficiency that causes clinical disorders to vulnerable population groups. Iodine deficiency disorders, also known as IDD refer to a spectrum of consequences as a result of severe iodine deficiency. Having insufficient iodine concentration in the body may cause stillbirth, miscarriage, and may result to pregnant women giving birth to low birthweight babies. If babies are born from mother who are iodine deficient, these infants may suffer from congenital anomalies such as deaf-mutism, squint, cretinism, and mental retardation. IDD is a global public health problem, and many countries have been planning and implementing nutrition-specific programs to combat this public health issue.
With the disturbing increase in the goitre incidence rates in the Philippines in 1993, the National Salt Iodisation Programme was launched in the “Ending Hidden Hunger” Conference by former President Fidel V. Ramos. This programme has been an integral part of the efforts to combat micronutrient deficiencies in the country. Two years after, a legislation entitled Republic Act 8172 or an “An Act Promoting Salt Iodisation Nationwide and for Related Purposes” was passed with the hope to institutionalised the implementation of the salt iodisation programme. In essence, the law provides mandatory iodisation of locally produced and imported salt for human and animal consumption including salt in processed foods and in food establishments1. In 1998, results of the National Nutrition Survey conducted by the Food and Nutrition Research Institute of the Department of Science and Technology indicated mild iodine deficiency among school children having urinary iodine concentration (UIC) of 71 mcg/L, while the proportion of the said population having <50 mcg/L of UIC was noted to be high at 35.8%2.
(Left image) When tested by a rapid test kit with iodine solution, an adequately-iodised salt turns to deep purple. This change in color qualitatively indicates presence of iodine. Household salt must contain at least 15 parts per million (ppm) of iodine.
With the passage of the salt iodisation law, the National Salt Iodisation Programme was strengthened and leaned towards the achievement of universal salt iodisation. It focused mainly on providing technical assistance to salt manufacturers, implementing health promotion and campaigns on iodised salt, and regulation and monitoring of salt with iodine. The Philippines’ salt iodisation was among the first in Southeast Asia and has become the model of other salt iodisation programmes implemented by its neighbouring countries. Its major contribution in eradicating iodine deficiency among school children was noted in 2003 when nutrition survey indicated a 201 mcg/L of UIC (adequate iodine concentration is at 100 mcg/L of UIC). This favourable iodine concentration among school children has been maintained over the years as reflected in the succeeding nutrition surveys in 2008 (132 mcg/L) and in 2013 (168 mcg/L)2. But while there have been significant improvements in the iodine nutriture of school children, pregnant and lactating women are still experiencing insufficient iodine nutrition. In addition, iodine content in iodised salt available in the Philippine market is still below the standards set by regulatory authorities (iodine in salt should be at 30-70 parts per million). In the recent nutrition survey conducted in 2013, only 25.7% or 5.2 million households only have access to adequately-iodised salt, or iodised salt produced following the recommended iodine content. Concerns on converting knowledge to health behaviour on adequately-iodised salt among consumers also add up to the deepening problem on iodine deficiency and salt iodisation. Consumers have relatively high awareness on iodised salt but this knowledge is not translated further to favourable health behaviour. For instance, consumers are still not practising proper storage and use of iodised salt in cooking as well as in packaging of iodised salt sold in the market. This health behaviour is important to retain the iodine added in salt considering the volatility of the micronutrient.
(Left image) One of the salt plants found in the Philippines. The country is known for producing sea salt which undergo solar evaporation.
Considering a multi-sectoral approach and by appreciating the participation of local government units and local line agencies and development partners, the Philippines continues its war against iodine deficiency and inadequately-iodised salt. The layering concerns on poor regulation and low awareness among consumers have been a tug-of-war among stakeholders as to which should be prioritised – regulation vs promotion or awareness campaigns. Theoretically, health promotion is not the key intervention when it comes to mandatory food fortification, regulation and monitoring of authorised agencies should be the main component of activities to make sure that all salt being sold in the market has adequate iodine.
But with unfavourable health behaviour of consumers towards the use of adequately-iodised salt and in the hope of increasing the demand for such, the Philippines launched a campaign dubbed as “Saktong iodine sa asin!” or adequate iodine in salt. The campaign used the power of a quality seal which is awarded to salt products with adequate iodine content. The diamond or the crystal seal can be seen in salt packaging of adequately-iodised salt which aims to aide consumers to identify adequately-iodised salt in public markets, supermarkets, and grocery stores.
(Above image) The “Saktong iodine sa asin!” or adequately-iodised salt quality seal which can be found in salt packs which salt contains 30-70 parts per million of iodine. This seal helps consumers identify if salt sold in the market has adequate iodine.
1 Republic Act 8172 (1995). An Act Promoting Salt Iodization Nationwide. Manila: Philippines
2 Food and Nutrition Research Institute (2013). 8th National Nutrition Survey – Iodine defiency disorders among school age children. Taguig: Philippines