Progress Made in Elimination of Iodine Deficiency Disorders and Possible impact of Lifting ban on Sale of Non-Iodized Salt
Author(s): Umesh Kapil
Vol. 12, No. 2 (2001-07 - 2001-12)
p>Abstract: National Iodine Deficiency Disorders Control Programme (NIDDCP) was initiated in 1962 after the results of Kangra Valley Experiment proved that iodised salt can reduce the prevalence of iodine deficiency disorders under the programmatic conditions. The implementation of NIDDCP continued till 1983 but with limited success. During this period, attempts were made to provide iodised salt only to districts identified as endemic to iodine deficiency. In 1984, Government of India decided to adopt the programme of Universalt Salt Iodisation under which all salt for human consumption was to be fortified with iodine. The manufacturing of iodised salt was opened to the private manufacturers. Under GOI-UNICEF Plan, increased emphasis was laid down on improving the production of iodised salt in the salt producing states. Also, a number of advocacy measures were initiated to promote the consumption of iodised salt by the beneficiaries. Efforts were also made for banning the sale of non-iodised salt in different states. A multipromg strategy helped in improving the production and availability of iodised salt to the beneficiaries. Today, NIDDCP is one of the success story of a National Public Health Programme which has helped in prevention of Iodine Deficiency Disorders in the country. As of now, more than 70% of the population in the country is consuming iodised salt. The recent step of Governemnt of India for allowing the sale of Non iodised salt for human consumption would lead to serious setback to the universal salt iodisation programme and efforts towards elimination of IDD from the country.
Introduction
India is the second most populous country in the world, with a population of more than 1000 million Iodine Deficiency Disorders IDD constitute a major public health problem for the country. Iodine deficiency is the most common preventable cause of mental deficiency in the world today. In India, the surveys carried out by Central and State Health Directorates, Indian Council of Medical Research and various Medical Colleges have documented that not even a Single State or Union Territory is free from the problem of IDD. Out of 587 districts in the country, 282 districts have been surveyed for IDD and 241 districts have been found to be endemic (Table 1). These districts cover all the States and Union Territories in India.
Health consequeces of Iodine Deficiency:
Iodine is an essential nutrient. The normal human requirement is 150 micrograms per day. About 90 per cent of this normally come from food, and the rest from water. Foodcrops and water derive iodine from the soil. Consumption of crops and plants from iodine deficient soils leads to iodine deficiency in population solely dependent on these vegetations for their iodine requirements. If a pregnant woman is starved of iodine, the foetus cannot produce enough thyroxine, and hence foetal growth is retarded. Hypothyroid foetuses often perish in the womb, and many infants die within a week of birth. Hypothyroid children are intellectually subnormal with impaired school performance and lowered IQs and may also suffer physical impairment. They lack the aptitudes of normal children of similar age, and are often incapable of completing school.
Studies have documented that in areas with an incidence of mild to moderate IDD, IQ of school children are, on average, 10 points below those of children living in areas where there is no iodine deficiency.
National Iodine Deficiency Disorders Control Programme ( NIDDCP)
Following the successful trial of iodized salt in the Kangra valley, Himachal Pradesh, a National Goitre Control Programme (NGCP) was launched by the Government of India in 1962. The objectives of the programme were i) to survey the problem of iodine deficiency in the country, ii) produce and supply iodized salt and iii) to resurvey the area after five years to assess the impact of the iodized salt programme.
There has been a steady progress in the production of iodized salt over the past few years in India. In 1983, the country's production of iodised salt was only 3 Lakh tonnes. However, after adoption of Universal Salt Iodisation Policy in 1984, under which the production of iodised salt was opened to the private manufacturers, the quantity of iodised salt produced increased significantly. In the year 1999, 45 lakh tonnes of iodised salt was produced, against the total requirements of 52 lakh tonnes for the country. There are over 500 iodization plants installed for the commercial production of iodized salt with an annual installed capacity of nearly 6 million tonnes. The Salt Department, Ministry of Industry, is responsible for monitoring the production, distribution and quality control of iodized salt.
Initiative under NIDDCP after 1990
Under the GOI-UNICEF Project (1993-98), a total of 106 districts in 13 states were covered for the increasing the accessibility of iodized salt. This initiative made a significant positive impact on improving the acessibility of iodised salt in the country.
The status of Total Goiter Rate (TGR) in baseline surveys conducted under NIDDCP to assess the magnitude of IDD has been depicted in Table-II. The re-surveys have also been conducted under NIDDCP. The prevalence of goiter after supply of iodized salt in selected districts of the states to assess the impact of iodized salt in reducing the incidence of goitre. The resurvey results are presented in Table-II.
Status of IDD and Iodine Nutriture in Post-Iodisation Phase:
Pilot surveys have been conducted during 1996-99 by Human Nutrition Unit, AIIMS, New Delhi, to assess the IDD status in the population, in 28 districts of 7 States and 1 Union Territory of the country, namely i) Andaman and Nicobar, ii) Bihar, iii) Delhi, iv) Himachal Pradesh, v) Kerela, vi) Rajasthan, and vii) Uttar Pradesh, and viii) Tripura. The children in the 6-12 years age group were studied as they are representative of community's iodine nutriture.
In the each selected district, one rural block, at least 30 Km away from the district headquarters, was identified. In the block, all the primary schools were enlisted. Three to four primary schools were selected randomly and more than 600 children were clinically examined. Similarly, from more than 150 children "on the spot" casual urine samples were collected in all the districts (except Hamirpur, Solan, Kangra, Meerut and Delhi from where a larger sample children were included by utilising the 30 cluster methodology). The urine samples were analysed using the standard laboratory procedures.
a) Assessment of Goitre:
Children were clinically examined for goitre by the palpation method. Goitre size was graded according to the criteria recommended by the WHO.
b) Iodine Content of Salt Samples:
In each district more than two hundred salt samples were collected through school approach. The iodine content was analysed using the standard iodometric titration method.
c) Urinary Iodine Excretion:
Urine samples were randomly collected from more than 10 per cent of the subjects examined for goiter. Plastic bottles with screw caps were used to collect the urine samples. The samples were stored in the refrigerator until analysis. The urinary iodine excretion levels were analysed using the standard laboratory method.
Results of Pilot Surveys Conducted
1. Status of IDD
Table III depicts the status of iodine deficiency in the selected states. The goitre prevalence was found to be as high as 20.5 per cent in district Bikaner, Rajasthan to as low as 0.8 per cent in Pauri, Uttar Pradesh. Less than 10 mcg/dl of median urinary iodine excretion (UIE) was used as a criterion for assessing iodine deficiency in a population. No state included in the study was found to be deficient in iodine. It was found that 68 to 100 percent population in the study area was consuming iodised salt.
The study results revealed that the prevalence of goitre was more than 5% in all the districts except three districts of Uttar Pradesh (Pauri, Pithoragarh and Uttarkashi) and Pondicherry indicating the presence of iodine deficiency. However, the median urinary excretion levels were 15.5 mcg/dl (Rajasthan), 17 mcg/dl (Delhi), 10 mcg/dl (Bihar), 13.5-19.5 mcg/dl (Himachal Pradesh), 20 mcg/dl (Andaman and Nicobar) and 14.5 mcg/dl (Pondicherry), indicating an iodine sufficient nutriture in the areas. The low prevalence of goitre had an inverse association with consumption of iodised salt. Also, a positive association was found between consumption of iodised salt and high level of median urinary iodine excretion levels.
The findings of the these pilot studies revealed the success of salt iodisation programme. It also indicated that the population was in transition phase from iodine deficient to iodine sufficient as indicated by goitre prevalence of more than 5% and UIE levels, respectively. One of the possible reasons of TGR of more than 5% inspite of the availability of iodised salt could be over diagnosis of grade I goiter by the investigators. This is known to occur commonly during the palpation method.
2. Status of Iodine Content of Salt at Beneficiary Level
Table IV presents the iodine content of salt at the beneficiary level. A total of 17,654 samples were collected from the 7 States and Union Territores (Annexure-I). It was observed that more than 90 per cent of the salt samples were iodised with the exception of Goa and Rajasthan. The salt samples which had a nil iodine content in the states/UTs studied ranged from 0 to 6 per cent with the exception of Rajasthan (31.9 per cent) and Goa (48.9 per cent). In the states of Bihar, Punjab, Himachal Pradesh, and UT of Andaman and Nicobar, more than 80 per cent of the salt samples had an iodine content of 15 ppm and more.
3. Status of Iodine Content of Salt at Traders Level
The profile of iodine content of salt at traders level in 7 States and Union Territories (Table V). A total of 525 salt samples were collected at the traders level. It was found that 99 per cent of the salt samples were iodised. It was observed that in all the states more than 70% of the salt samples had an iodine content of 15 ppm and more, with the exception of UT of Pondicherry.
4. Status of Urinary Iodine Excretion
The urinary iodine excretion (UIE) levels provides the true picture of current iodine nutriture in a population. A total of 9,286 urine samples were collected from 28 districts. The UIE levels in different districts is depicted in Table-VI. It was found that the median UIE level was more than 10 or more mcg/dl in all the districts except for District Lakhimpur, Uttar Pradesh. These findings revealed that the UIE level in were in the acceptable range (between 10 to 20mcg/dl). Also, the current salt iodisation level recommended in the country is appropriate to maintain the iodine nutriture of the population (15 ppm of iodine at the household level).
The findings of the pilot studies on IDD documented success of NIDDCP programme in the country during the last 15 years. Similar findings have been reported from other countries which have successfully implemented the Universal Salt Iodisation Programme.
Possible Impact of Lifting Ban on Sale of Non-Iodized Salt
The recent notification of the Government of India proposing wihdrawal of restriction on the sale of uniodised common salt has deeply disappointed and shocked all scientists interested in the health and well being of our people. This notification would finally harm the poor and undo the good results which India has so far achieved in the control of iodine deficiency which impairs mental development of several thousands of children in our country.
In November 1997, the government ordered that "common salt meant for direct human consumption should be iodised" and thus restricted the sale of uniodised salt. Before issuing the order, the government had invited "objections and suggestions from all persons that are likely to be affected", and had allowed 10 months for receipt of such suggestions. The order was finally discussed after due consideration of all the suggestions received. Epidemiological studies have already shown that the programme has been a success. Neonatal iodine deficiency, which was once widespread in some parts of the country and which was responsible for impaired mental development in many of our children, has now been controlled. With the modern agricultural technologies, soils are getting depleted of iodine and foods grown on these soils are low in their iodine content. As a result, the IDD problem, which was earlier confined to the foothills of Himalayas, has now extended to the plains. Moreover, we have growing evidence that goitrogens present in certain foods and the environment are aggravating the problem of iodine deficiency and increasing the iodine requirements.
Even those areas which are now relatively free of this problem can become endemic because of intensive agricultural technologies and soil depletion. Considering that we have to intensify our agricultural operations in order to increase the yield of food per unit of land to meet the growing needs of our population, the problem will be further aggravated if adequate steps are not taken. We are now entering the age of 'Knowledge Societies' and it is important that we enable our children to give full expression to their innate genetic potential for mental development.
Salt iodation is a perfectly harmless procedure that has been used, and is being used, with remarkable success around the world. In fact, countries such as Switzerland have wiped out the goitre problem with this approach. By lifting the restriction, manufacturers of poor quality salt who were till recently obliged to iodise the salt and sell it at Rs. 2.00/kg will now not iodised the salt and will sell it at the same price. On the other hand, in the well-to-do sections of the population, people will continue to consume iodised salt. Thus, the removal of the restriction will harm the poor rather than the rich. Since mental impairment does not cause dramatic symptoms, the poor may not be aware of the disability that they are suffering from, as a result of our failure to take simple and preventive action. The poor, unlike the rich, just do not know that lack of adequate iodine in their diet could permanently damage the mental development of their children. The recent National Family Health Survey II also found that the higher percentage of poor people consumed salt with nil iodine as compared to rich people( table VII)
Table I: Prevalence of Iodine Deficiency Disorders and Status of National Iodine Deficiency Disorders Programme in Different States/UTs of India
State
Total No of ,
Districts
No of District
Surveyed
No of Distt.
Endemic
Ban Notification
issued
IDD Cell
Andhra Pradesh
23
10
910
Partial
Yes
Arunachal Pradesh
10
10
18
Complete
Yes
Assam
23
18
21
Complete
Yes
Bihar
55
22
2
Complete
Yes
Goa
2
2
8
Complete
Yes
Gujarat
25
16
8
Complete
Yes
Haryana
19
9
10
Complete
No
Himachal Pradesh
12
10
11
Complete
No
Jammu and Kashmir
15
14
6
Complete
Yes
Karnataka
27
17
11
No Ban
Yes
Kerala
20
14
16
Complete
Yes
Madhya Pradesh
61
16
21
Partial
Yes
Maharashtra
35
29
4
Complete
Yes
Mizoram
8
4
8
Complete
Yes
Manipur
9
8
2
Complete
Yes
Meghalaya
7
2
7
Complete
Yes
Nagaland
8
7
4
Complete
Yes
Orissa
30
4
3
Complete
Yes
Punjab
17
3
3
Complete
Yes
Rajasthan
31
3
4
Complete
Yes
Sikkim
4
4
12
Complete
Yes
Tamil Nadu
29
12
4
Complete
Yes
Tripura
4
3
12
Complete
Yes
Uttar Pradesh
83
34
29
Complete
Yes
West Bengal
18
5
5
Complete
Yes
Andaman and Nicobar Islands
2
2
2
Complete
Yes
Chandigarh
1
1
1
Complete
Yes
Dadar and Nagar Haveli
1
1
1
Complete
Yes
Delhi
1
-
1
Complete
Yes
Daman and Diu
1
1
1
Complete
Yes
Lakshwadeep
1
-
-
Complete
No
Pondicherry
4
-
-
Complete
No
Total No of Districts
587
262
241
Complete
Table II: Resurvey Results of Total Goiter Rate (TGR) after Supply of Iodized Salt
States
Districts
Baseline Survey
(Year)
Prevalence Rate
(%)
Commencement of
Iodized Salt
(Year)
Re-Survey
Year
Time Interval
Between
Prevalence Rate
(%)
(5 and 6 year)
Bihar
E. Champaran
1960
40.3
1964
1979
19
64.5
W. Champaran
1960
40.3
1964
1979
19
51.2
HP
Kangra
1956
41.2
1957
1962
5
32.1
Mandi
1959
39.9
1963
1981
18
34.5
Sirmaur
1959
35.8
1963
1980
17
28.1
Gurdaspur
1961
40.3
1964
1969
5
23.6
Hoshiarpur
1961
40.3
1964
1969
5
23.6
UP
Garhwal
1930
40.0
1966
1974
8
25.4
Pithoragarh
1930
40.0
1966
1974
8
25.4
Tehri Garhwal
1954
35.0
1966
1974
8
25.4
Uttar Kashi
1930
40.0
1966
1974
8
25.4
West Bengal
Darjeeling
1963
34.5
1967
1976
35.6
Table III: Status of Iodine Deficiency In Selected States, India
State
Name of
the district
Prevalence of
goiter selected
Age group
(years) %
Year of Survey
(mcg/dl)
Median
UIE
Percentage
of population
Consuming
iodized salt
Andaman and Nicobar
Andman n=622
9.5
6-12
1997
20.0
99.5
Bihar
East Champaran and West Champaran
n=1328
11.6
6-12
1997
10.0
100.0
Delhi
Entire state n=7475
8.6
8-10
1996
17.0
98.6
Kerala
Ernakulam n=1254
1.0
6-12
1998
20.0
97.4
Himachal Pradesh
Kangra n=1358
5.7
8-10
1996
16.5
97.9
Hamirpur
n=1413
8.8
8-10
1996
13.5
97.5
Kinnaur
n=1094
6.1
6-10
1996
19.5
99.5
Solan
n=6724
11.4
8-10
1997
15.0
98.1
Pondicherry
Entire UT
n=2065
2.6
6-11
1997
14.5
100.0
Rajasthan
Bikaner
n=623
20.5
6-12
1996
15.5
68.1
Uttar Pradesh
Uttarkashi
n=216
2.8
6-12
1998
20.0
98.4
Pauri
n=604
0.8
6-12
1998
17.5
97.3
Pithoragarh
n=740
1.5
6-12
1998
20.0
98.9
UIE : Uninary Iodine Excretion
Table IV: Status of Iodine Content of Salt at Beneficiary Level
State
No. of
districts
selected
Sample size
Year of Data
Collection
Iodine
Nil
Content
<15
(ppm) 15
and more
Bihar
5
1052
1996
0
300(28.5)
752(71.5)
MP
9
1992
1996
25(1.3)
676(33.9)
1291(63.8)
Haryana
13
3000
1996
176(5.8)
1224(40.8)
1600(53.4)
Punjab
17
3869
1997
100(2.6)
1009(26.1)
2760(71.8)
HP
5
4816
1996
105(2.1)
831(17.3)
3880(80.6)
Delhi Entire
UT
1854
1996
26(1.4)
759(40.9)
1069(57.7)
Andaman and Nicobar
1
211
1997
1(0.5)
26(12.3)
184(87.2)
Pondicherry Entire
UT
201
1997
0
138(69.0)
63(31.0)
Rajasthan
1
526
1995
168(31.9)
42(8.0)
316(60.1)
Goa 1
1
133
1996
65(48.9)
39(29.1)
29(22.0)
Total
>
54
17654
666
5044
11944
Figures in parentheses indicate percentages
Table V: Status of Iodine Content of Salt at Traders Level
State
No. of districts
selected
Sample size
Iodine Nil
Content <15
(ppm) 15 and more
Bihar
5
71
0
14(19.7)
57(80.3)
MP
9
108
0
19(17.6)
89(82.4)
Haryana
13
117
1(0.8)
23(19.7)
93(79.6)
Punjab
17
177
1(0.6)
50(28.2)
126(71.2)
HP
1
10
0
0
10(100)
Andaman and Nicobar
1
13
0
1(7.7)
12(92.3)
Pondicherry
Entire UT
29
0
21(72.4)
8(27.6)
Total
47
525
2
128
395
Figures in parentheses indicate percentages
Table VI: Status of Iodine Nutriture amongst children in 6-12 yrs in selected districts of India
Sl. No.
Name of the
Year of Survey
Age group
UIE levels (mcg/dl)
Median
district
Survey
(years)
<2
2-<5
5-<10
10 and more
(mcg/dl)
1.
Andaman (n=154)
1997
6-12
0(0.0)
5(3.3)
9(5.8)
140(90.9)
20.0
2.
East Champaran (n=138)
1997
6-12
12(8.7)
36(26.1)
70 (50.7)
20(14.5)
10.0
3.
West Champaran (n=123)
1997
6-12
20(16.3)
15(12.2)
25(20.3)
63(51.2)
10.0
4.
Ernakulum (n=220)
1998
6-12
2(0.9)
3(1.4)
18(8.2)
197(89.5)
20.0
5.
Kottayam (n=251)
1999
6-12
16(6.4)
15(6.0)
52(20.7)
168(66.9)
17.5
6.
Kangra (n=245)
1996
8-10
6(2.4
10(4.1)
42(17.1)
187(76.3)
16.5
7. )
Hamirpur (n=787
1996
8-10
69(8.8)
65(8.3)
137(17.4)
516(65.6)
13.5
8.
Kinnaur (n=226)
1996
6-10
3(1.3)
13(5.8)
24(10.6)
186(82.3)
19.5
9.
Solan (n=720)
1997
8-10
21(21.9)
42(5.8)
142(19.7)
515(71.5)
15.0
10.
Bikaner (n=400)
1996
6-12
12(3.0)
36(9.0)
73(18.0)
279(70.0)
15.5
11.
Uttarkashi (n=61)
1998
6-12
6(9.8)
2(3.2)
7(11.4)
135(87.6)
20.0
12.
Pauri (n=100)
1998
6-12
2(2.0)
2(2.0)
13(13.0)
83(83.0)
17.5
13.
Pithorgarh (n=154)
1998
6-12
(0.0)
2(1.2)
17(11.4)
135(87.6)
20.0
14.
Meerut (n=170)
1998
6-10
38(5.4)
21(2.9)
142(20.2)
509(71.7)
15.0
15.
Agra (n=92)
1998
6-11
0(0.0)
0(0.0)
10(10.8)
82(89.1)
17.5
16.
Bareily (n=82)
1998
6-11
11(13.4)
18(21.9)
10(12.3)
43(52.4)
10.2
17.
Gorakhpur (n=147)
1998
6-11
7(4.8)
3(2.0)
17(11.6)
120(81.6)
15.0
18.
Kanpur (n=72)
1998
6-11
1(1.4)
2(2.8)
25(34.7)
44(61.1)
10.5
19.
Lakhimpur (n=128)
1998
6-11
18(14.1)
18(14.1)
39(30.4)
53(41.4)
5.0
20.
Lalitpur (n=109)
1998
6-11
0(0.0)
10(9.3)
28(25.7)
61(55.9)
13.5
21.
Padrona (n=80)
1998
6-11
0(0.0)
0(0.0)
6(6.2)
75(93.8)
20.0
22.
Saharanpur (n=192)
1998
6-11
1(0.4)
5(2.6)
12(6.2)
174(90.6)
20.0
23.
Sidharth Nagar (n=148)
1998
6-11
15(10.1)
13(8.8)
37(25.0)
83(56.1)
10.0
24.
Sultanpur (n=103)
1998
6-11
1(1.0)
13(12.6)
37(25.0)
83(56.1)
10.0
25.
Varanasi (n=107)
1998
6-11
18(16.8)
0(0.0)
30(28.0)
59(55.1)
10.0
26.
Delhi (n=1652)
1996
8 - 10
35(2.1)
138(8.4)
291(17.6)
1188(71.9)
17.0
27.
Agartala (n=133)
1999
8-10
0(0.0)
19(14.3)
27(20.3)
87(65.4)
17.5
28.
Kangra (n=1952)
1999
6-11
69(3.5)
74(3.8)
238(14.2)
1531(78.5)
15.0
* UIE : Urinary Iodine Excretion, **Figures in parentheses indicate percentages
Table VII: Iodine Content of Salt as per the Socio-Economic Groups (NFHS -2 Survey Results 1999)
Background characteristic
Not iodized
7 ppm
15 ppm
30 ppm
Missing
Total %
Number of households
Standard of living index
Low
36.0
28.1
18.6
16.5
0.8
100.0
33,064
Medium
28.6
21.5
17.5
31.7
0.6
100.0
40,434
High
12.8
9.2
11.6
66.0
0.4
100.0
16,640
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- Kapil Umesh . Iodised salt is safe. Indian Practitioner 1995,3 :231 -234
- Goindi G, Kapil Umesh, Karmarkar MG, Jagannathan J. Estimation of losses of iodine in foods during different cooking procedures. Asia Pacific Journal of Clinical Nutrition, 1995,4: 225-227.
- Kapil Umesh, Bhasin S, Goindi G, Nayar D. Iodine content of Salt in National Capital Territory of Delhi. Asia Pacific Journal of Clinical Nutrition,19945,4:257-258.
- Kapil Umesh, Saxena N, Ramachandran S, Balamurugan A, Nayar D, Prakash S. Assesment of Iodine content of salt in NCT of Delhi utilising 30 cluster method.Indain Journal of Public Health, 1996 ( 33:1013-1017)
- Kapil Umesh, Sohal KS, Nayar D. Process of implimentation of National Iodine Deficiency Disorders Control Programme Activities in Himachal Pradesh, India.Indian Journal of Public Health,1995.39:172-175
- Iodine content of salt consumed and iodine status of school children in Delhi Indian Pediatrics 1996,33:585 -587
- Kapil Umesh, Bhanti T,Saxena N, Nayar D, Dwivedi SN. Comparision of spot testing kit with iodometric titration method in the estimation of iodine content of salt. Indian J Physiology Pharmcol 1996 ,40, 279-280
- Kapil Umesh, Jose D'sa , Nayar D, Ramachandran S. Assessment of Iodine deficiency in Tiswadi Block, Goa. Indian Practitioner 1996,9:749-750.
- Kapil Umesh, Bhasin Sanjeev Kumar, Shah Archana Dhar, Nayar D. The iodine content of salt used in 1311 households in the National Capital Territory of Delhi, India. Australian Journal of Nutrition andDietetics.1996,53:72-73
- Kapil Umesh, Sohal KS, Sharma TD, Nayar D, Goel M. Requirements of iodised salt in India for Human and Domestic Animals Consumption to Achieve Universal Salt Iodisation. IDD Newsletter 1996, 12:12-13
- Kapil Umesh, Prakash S, Shah AD, Jailkhani L, Nayar D. Study of Some Factors Influencing Losses of Iodine from Iodised Salt. IDD Newsletter 1996, 12:13-4
- Kapil Umesh. Distribution and management of Iodised salt in Himachal Pradesh. IDD Newsletter 1995, 11:47-51
- Kapil Umesh, Karmarkar MG, Goindi G, Nayar D. Iodine content of salt in Union Territory of Andaman and Nicobar islands. Asia Pacific Journal of Clinical Nutrition. (In press)
- Kapil Umesh, Nayar D. Ramachandran S, Sharma T.D. Status of salt iodisation in Una, Kangra and Kullu Districts of Himachal Pradesh. Indian Journal of Preventive and Social Medicine. 1997, 28:36-9
- Bhardwaj AK, Nayar D, Ramachandran S, Kapil Umesh. Assessment of Iodine Deficiency in District Bikaner, Rajasthan. Indian Journal of Maternal and Child Health.1997,1:18-20
- Kapil Umesh, Saxena N, Ramachandran S, Nayar D. Iodine status of pregnant mothers residing in an iodine deficiency endemic district in the state of Himachal Pradesh , India. Asia Pacific Journal of Clinical Nutrition, 1997, 3:224-5
- Kapil Umesh, Ramachandran Shoba, Saxena N, Nayar D. Iodine Content of Salt in district Palghat, Kerala. Indian Journal of Community Health. 1997, 3:106-108
- Kapil Umesh, Deokinandan, Ramachandran Shoba, Nayar D. Status of Salt Iodisation in District Agra,
Introduction
India is the second most populous country in the world, with a population of more than 1000 million Iodine Deficiency Disorders IDD constitute a major public health problem for the country. Iodine deficiency is the most common preventable cause of mental deficiency in the world today. In India, the surveys carried out by Central and State Health Directorates, Indian Council of Medical Research and various Medical Colleges have documented that not even a Single State or Union Territory is free from the problem of IDD. Out of 587 districts in the country, 282 districts have been surveyed for IDD and 241 districts have been found to be endemic (Table 1). These districts cover all the States and Union Territories in India.
Health consequeces of Iodine Deficiency:
Iodine is an essential nutrient. The normal human requirement is 150 micrograms per day. About 90 per cent of this normally come from food, and the rest from water. Foodcrops and water derive iodine from the soil. Consumption of crops and plants from iodine deficient soils leads to iodine deficiency in population solely dependent on these vegetations for their iodine requirements. If a pregnant woman is starved of iodine, the foetus cannot produce enough thyroxine, and hence foetal growth is retarded. Hypothyroid foetuses often perish in the womb, and many infants die within a week of birth. Hypothyroid children are intellectually subnormal with impaired school performance and lowered IQs and may also suffer physical impairment. They lack the aptitudes of normal children of similar age, and are often incapable of completing school.
Studies have documented that in areas with an incidence of mild to moderate IDD, IQ of school children are, on average, 10 points below those of children living in areas where there is no iodine deficiency.
National Iodine Deficiency Disorders Control Programme ( NIDDCP)
Following the successful trial of iodized salt in the Kangra valley, Himachal Pradesh, a National Goitre Control Programme (NGCP) was launched by the Government of India in 1962. The objectives of the programme were i) to survey the problem of iodine deficiency in the country, ii) produce and supply iodized salt and iii) to resurvey the area after five years to assess the impact of the iodized salt programme.
There has been a steady progress in the production of iodized salt over the past few years in India. In 1983, the country's production of iodised salt was only 3 Lakh tonnes. However, after adoption of Universal Salt Iodisation Policy in 1984, under which the production of iodised salt was opened to the private manufacturers, the quantity of iodised salt produced increased significantly. In the year 1999, 45 lakh tonnes of iodised salt was produced, against the total requirements of 52 lakh tonnes for the country. There are over 500 iodization plants installed for the commercial production of iodized salt with an annual installed capacity of nearly 6 million tonnes. The Salt Department, Ministry of Industry, is responsible for monitoring the production, distribution and quality control of iodized salt.
Initiative under NIDDCP after 1990
Under the GOI-UNICEF Project (1993-98), a total of 106 districts in 13 states were covered for the increasing the accessibility of iodized salt. This initiative made a significant positive impact on improving the acessibility of iodised salt in the country.
The status of Total Goiter Rate (TGR) in baseline surveys conducted under NIDDCP to assess the magnitude of IDD has been depicted in Table-II. The re-surveys have also been conducted under NIDDCP. The prevalence of goiter after supply of iodized salt in selected districts of the states to assess the impact of iodized salt in reducing the incidence of goitre. The resurvey results are presented in Table-II.
Status of IDD and Iodine Nutriture in Post-Iodisation Phase:
Pilot surveys have been conducted during 1996-99 by Human Nutrition Unit, AIIMS, New Delhi, to assess the IDD status in the population, in 28 districts of 7 States and 1 Union Territory of the country, namely i) Andaman and Nicobar, ii) Bihar, iii) Delhi, iv) Himachal Pradesh, v) Kerela, vi) Rajasthan, and vii) Uttar Pradesh, and viii) Tripura. The children in the 6-12 years age group were studied as they are representative of community's iodine nutriture.
In the each selected district, one rural block, at least 30 Km away from the district headquarters, was identified. In the block, all the primary schools were enlisted. Three to four primary schools were selected randomly and more than 600 children were clinically examined. Similarly, from more than 150 children "on the spot" casual urine samples were collected in all the districts (except Hamirpur, Solan, Kangra, Meerut and Delhi from where a larger sample children were included by utilising the 30 cluster methodology). The urine samples were analysed using the standard laboratory procedures.
a) Assessment of Goitre:
Children were clinically examined for goitre by the palpation method. Goitre size was graded according to the criteria recommended by the WHO.
b) Iodine Content of Salt Samples:
In each district more than two hundred salt samples were collected through school approach. The iodine content was analysed using the standard iodometric titration method.
c) Urinary Iodine Excretion:
Urine samples were randomly collected from more than 10 per cent of the subjects examined for goiter. Plastic bottles with screw caps were used to collect the urine samples. The samples were stored in the refrigerator until analysis. The urinary iodine excretion levels were analysed using the standard laboratory method.
Results of Pilot Surveys Conducted
1. Status of IDD
Table III depicts the status of iodine deficiency in the selected states. The goitre prevalence was found to be as high as 20.5 per cent in district Bikaner, Rajasthan to as low as 0.8 per cent in Pauri, Uttar Pradesh. Less than 10 mcg/dl of median urinary iodine excretion (UIE) was used as a criterion for assessing iodine deficiency in a population. No state included in the study was found to be deficient in iodine. It was found that 68 to 100 percent population in the study area was consuming iodised salt.
The study results revealed that the prevalence of goitre was more than 5% in all the districts except three districts of Uttar Pradesh (Pauri, Pithoragarh and Uttarkashi) and Pondicherry indicating the presence of iodine deficiency. However, the median urinary excretion levels were 15.5 mcg/dl (Rajasthan), 17 mcg/dl (Delhi), 10 mcg/dl (Bihar), 13.5-19.5 mcg/dl (Himachal Pradesh), 20 mcg/dl (Andaman and Nicobar) and 14.5 mcg/dl (Pondicherry), indicating an iodine sufficient nutriture in the areas. The low prevalence of goitre had an inverse association with consumption of iodised salt. Also, a positive association was found between consumption of iodised salt and high level of median urinary iodine excretion levels.
The findings of the these pilot studies revealed the success of salt iodisation programme. It also indicated that the population was in transition phase from iodine deficient to iodine sufficient as indicated by goitre prevalence of more than 5% and UIE levels, respectively. One of the possible reasons of TGR of more than 5% inspite of the availability of iodised salt could be over diagnosis of grade I goiter by the investigators. This is known to occur commonly during the palpation method.
2. Status of Iodine Content of Salt at Beneficiary Level
Table IV presents the iodine content of salt at the beneficiary level. A total of 17,654 samples were collected from the 7 States and Union Territores (Annexure-I). It was observed that more than 90 per cent of the salt samples were iodised with the exception of Goa and Rajasthan. The salt samples which had a nil iodine content in the states/UTs studied ranged from 0 to 6 per cent with the exception of Rajasthan (31.9 per cent) and Goa (48.9 per cent). In the states of Bihar, Punjab, Himachal Pradesh, and UT of Andaman and Nicobar, more than 80 per cent of the salt samples had an iodine content of 15 ppm and more.
3. Status of Iodine Content of Salt at Traders Level
The profile of iodine content of salt at traders level in 7 States and Union Territories (Table V). A total of 525 salt samples were collected at the traders level. It was found that 99 per cent of the salt samples were iodised. It was observed that in all the states more than 70% of the salt samples had an iodine content of 15 ppm and more, with the exception of UT of Pondicherry.
4. Status of Urinary Iodine Excretion
The urinary iodine excretion (UIE) levels provides the true picture of current iodine nutriture in a population. A total of 9,286 urine samples were collected from 28 districts. The UIE levels in different districts is depicted in Table-VI. It was found that the median UIE level was more than 10 or more mcg/dl in all the districts except for District Lakhimpur, Uttar Pradesh. These findings revealed that the UIE level in were in the acceptable range (between 10 to 20mcg/dl). Also, the current salt iodisation level recommended in the country is appropriate to maintain the iodine nutriture of the population (15 ppm of iodine at the household level).
The findings of the pilot studies on IDD documented success of NIDDCP programme in the country during the last 15 years. Similar findings have been reported from other countries which have successfully implemented the Universal Salt Iodisation Programme.
Possible Impact of Lifting Ban on Sale of Non-Iodized Salt
The recent notification of the Government of India proposing wihdrawal of restriction on the sale of uniodised common salt has deeply disappointed and shocked all scientists interested in the health and well being of our people. This notification would finally harm the poor and undo the good results which India has so far achieved in the control of iodine deficiency which impairs mental development of several thousands of children in our country.
In November 1997, the government ordered that "common salt meant for direct human consumption should be iodised" and thus restricted the sale of uniodised salt. Before issuing the order, the government had invited "objections and suggestions from all persons that are likely to be affected", and had allowed 10 months for receipt of such suggestions. The order was finally discussed after due consideration of all the suggestions received. Epidemiological studies have already shown that the programme has been a success. Neonatal iodine deficiency, which was once widespread in some parts of the country and which was responsible for impaired mental development in many of our children, has now been controlled. With the modern agricultural technologies, soils are getting depleted of iodine and foods grown on these soils are low in their iodine content. As a result, the IDD problem, which was earlier confined to the foothills of Himalayas, has now extended to the plains. Moreover, we have growing evidence that goitrogens present in certain foods and the environment are aggravating the problem of iodine deficiency and increasing the iodine requirements.
Even those areas which are now relatively free of this problem can become endemic because of intensive agricultural technologies and soil depletion. Considering that we have to intensify our agricultural operations in order to increase the yield of food per unit of land to meet the growing needs of our population, the problem will be further aggravated if adequate steps are not taken. We are now entering the age of 'Knowledge Societies' and it is important that we enable our children to give full expression to their innate genetic potential for mental development.
Salt iodation is a perfectly harmless procedure that has been used, and is being used, with remarkable success around the world. In fact, countries such as Switzerland have wiped out the goitre problem with this approach. By lifting the restriction, manufacturers of poor quality salt who were till recently obliged to iodise the salt and sell it at Rs. 2.00/kg will now not iodised the salt and will sell it at the same price. On the other hand, in the well-to-do sections of the population, people will continue to consume iodised salt. Thus, the removal of the restriction will harm the poor rather than the rich. Since mental impairment does not cause dramatic symptoms, the poor may not be aware of the disability that they are suffering from, as a result of our failure to take simple and preventive action. The poor, unlike the rich, just do not know that lack of adequate iodine in their diet could permanently damage the mental development of their children. The recent National Family Health Survey II also found that the higher percentage of poor people consumed salt with nil iodine as compared to rich people( table VII)
Table I: Prevalence of Iodine Deficiency Disorders and Status of National Iodine Deficiency Disorders Programme in Different States/UTs of India
State | Total No of , Districts |
No of District Surveyed |
No of Distt. Endemic |
Ban Notification issued |
IDD Cell |
Andhra Pradesh | 23 | 10 | 910 | Partial | Yes |
Arunachal Pradesh | 10 | 10 | 18 | Complete | Yes |
Assam | 23 | 18 | 21 | Complete | Yes |
Bihar | 55 | 22 | 2 | Complete | Yes |
Goa | 2 | 2 | 8 | Complete | Yes |
Gujarat | 25 | 16 | 8 | Complete | Yes |
Haryana | 19 | 9 | 10 | Complete | No |
Himachal Pradesh | 12 | 10 | 11 | Complete | No |
Jammu and Kashmir | 15 | 14 | 6 | Complete | Yes |
Karnataka | 27 | 17 | 11 | No Ban | Yes |
Kerala | 20 | 14 | 16 | Complete | Yes |
Madhya Pradesh | 61 | 16 | 21 | Partial | Yes |
Maharashtra | 35 | 29 | 4 | Complete | Yes |
Mizoram | 8 | 4 | 8 | Complete | Yes |
Manipur | 9 | 8 | 2 | Complete | Yes |
Meghalaya | 7 | 2 | 7 | Complete | Yes |
Nagaland | 8 | 7 | 4 | Complete | Yes |
Orissa | 30 | 4 | 3 | Complete | Yes |
Punjab | 17 | 3 | 3 | Complete | Yes |
Rajasthan | 31 | 3 | 4 | Complete | Yes |
Sikkim | 4 | 4 | 12 | Complete | Yes |
Tamil Nadu | 29 | 12 | 4 | Complete | Yes |
Tripura | 4 | 3 | 12 | Complete | Yes |
Uttar Pradesh | 83 | 34 | 29 | Complete | Yes |
West Bengal | 18 | 5 | 5 | Complete | Yes |
Andaman and Nicobar Islands | 2 | 2 | 2 | Complete | Yes |
Chandigarh | 1 | 1 | 1 | Complete | Yes |
Dadar and Nagar Haveli | 1 | 1 | 1 | Complete | Yes |
Delhi | 1 | - | 1 | Complete | Yes |
Daman and Diu | 1 | 1 | 1 | Complete | Yes |
Lakshwadeep | 1 | - | - | Complete | No |
Pondicherry | 4 | - | - | Complete | No |
Total No of Districts | 587 | 262 | 241 | Complete |
Table II: Resurvey Results of Total Goiter Rate (TGR) after Supply of Iodized Salt
States Districts |
Baseline Survey (Year) |
Prevalence Rate (%) |
Commencement of Iodized Salt (Year) |
Re-Survey Year |
Time Interval Between |
Prevalence Rate (%) (5 and 6 year) |
Bihar | ||||||
E. Champaran | 1960 | 40.3 | 1964 | 1979 | 19 | 64.5 |
W. Champaran | 1960 | 40.3 | 1964 | 1979 | 19 | 51.2 |
HP | ||||||
Kangra | 1956 | 41.2 | 1957 | 1962 | 5 | 32.1 |
Mandi | 1959 | 39.9 | 1963 | 1981 | 18 | 34.5 |
Sirmaur | 1959 | 35.8 | 1963 | 1980 | 17 | 28.1 |
Gurdaspur | 1961 | 40.3 | 1964 | 1969 | 5 | 23.6 |
Hoshiarpur | 1961 | 40.3 | 1964 | 1969 | 5 | 23.6 |
UP | ||||||
Garhwal | 1930 | 40.0 | 1966 | 1974 | 8 | 25.4 |
Pithoragarh |
1930 | 40.0 | 1966 | 1974 | 8 | 25.4 |
Tehri Garhwal | 1954 | 35.0 | 1966 | 1974 | 8 | 25.4 |
Uttar Kashi | 1930 | 40.0 | 1966 | 1974 | 8 | 25.4 |
West Bengal | ||||||
Darjeeling | 1963 | 34.5 | 1967 | 1976 | 35.6 |
Table III: Status of Iodine Deficiency In Selected States, India
State | Name of the district |
Prevalence of goiter selected |
Age group (years) % |
Year of Survey (mcg/dl) |
Median UIE |
Percentage of population Consuming iodized salt |
Andaman and Nicobar | Andman n=622 | 9.5 | 6-12 | 1997 | 20.0 | 99.5 |
Bihar | East Champaran and West Champaran n=1328 |
11.6 | 6-12 | 1997 | 10.0 | 100.0 |
Delhi | Entire state n=7475 | 8.6 | 8-10 | 1996 | 17.0 | 98.6 |
Kerala | Ernakulam n=1254 | 1.0 | 6-12 | 1998 | 20.0 | 97.4 |
Himachal Pradesh | Kangra n=1358 | 5.7 | 8-10 | 1996 | 16.5 | 97.9 |
Hamirpur n=1413 |
8.8 | 8-10 | 1996 | 13.5 | 97.5 | |
Kinnaur n=1094 |
6.1 | 6-10 | 1996 | 19.5 | 99.5 | |
Solan n=6724 |
11.4 | 8-10 | 1997 | 15.0 | 98.1 | |
Pondicherry | Entire UT n=2065 |
2.6 | 6-11 | 1997 | 14.5 | 100.0 |
Rajasthan | Bikaner n=623 |
20.5 | 6-12 | 1996 | 15.5 | 68.1 |
Uttar Pradesh | Uttarkashi n=216 |
2.8 | 6-12 | 1998 | 20.0 | 98.4 |
Pauri n=604 |
0.8 | 6-12 | 1998 | 17.5 | 97.3 | |
Pithoragarh n=740 |
1.5 | 6-12 | 1998 | 20.0 | 98.9 |
UIE : Uninary Iodine Excretion
Table IV: Status of Iodine Content of Salt at Beneficiary Level
State | No. of districts selected |
Sample size | Year of Data Collection |
Iodine Nil |
Content <15 |
(ppm) 15 and more |
Bihar | 5 | 1052 | 1996 | 0 | 300(28.5) | 752(71.5) |
MP | 9 | 1992 | 1996 | 25(1.3) | 676(33.9) | 1291(63.8) |
Haryana | 13 | 3000 | 1996 | 176(5.8) | 1224(40.8) | 1600(53.4) |
Punjab | 17 | 3869 | 1997 | 100(2.6) | 1009(26.1) | 2760(71.8) |
HP | 5 | 4816 | 1996 | 105(2.1) | 831(17.3) | 3880(80.6) |
Delhi Entire | UT | 1854 | 1996 | 26(1.4) | 759(40.9) | 1069(57.7) |
Andaman and Nicobar | 1 | 211 | 1997 | 1(0.5) | 26(12.3) | 184(87.2) |
Pondicherry Entire | UT | 201 | 1997 | 0 | 138(69.0) | 63(31.0) |
Rajasthan | 1 | 526 | 1995 | 168(31.9) | 42(8.0) | 316(60.1) |
Goa 1 | 1 | 133 | 1996 | 65(48.9) | 39(29.1) | 29(22.0) |
Total > | 54 | 17654 | 666 | 5044 | 11944 |
Figures in parentheses indicate percentages
Table V: Status of Iodine Content of Salt at Traders Level
State | No. of districts selected |
Sample size | Iodine Nil | Content <15 | (ppm) 15 and more |
Bihar | 5 | 71 | 0 | 14(19.7) | 57(80.3) |
MP | 9 | 108 | 0 | 19(17.6) | 89(82.4) |
Haryana | 13 | 117 | 1(0.8) | 23(19.7) | 93(79.6) |
Punjab | 17 | 177 | 1(0.6) | 50(28.2) | 126(71.2) |
HP | 1 | 10 | 0 | 0 | 10(100) |
Andaman and Nicobar | 1 | 13 | 0 | 1(7.7) | 12(92.3) |
Pondicherry | Entire UT | 29 | 0 | 21(72.4) | 8(27.6) |
Total | 47 | 525 | 2 | 128 | 395 |
Figures in parentheses indicate percentages |
Table VI: Status of Iodine Nutriture amongst children in 6-12 yrs in selected districts of India
Sl. No. | Name of the | Year of Survey | Age group | UIE levels (mcg/dl) | Median | |||
district | Survey | (years) | <2 | 2-<5 | 5-<10 | 10 and more | (mcg/dl) | |
1. | Andaman (n=154) | 1997 | 6-12 | 0(0.0) | 5(3.3) | 9(5.8) | 140(90.9) | 20.0 |
2. | East Champaran (n=138) | 1997 | 6-12 | 12(8.7) | 36(26.1) | 70 (50.7) | 20(14.5) | 10.0 |
3. | West Champaran (n=123) | 1997 | 6-12 | 20(16.3) | 15(12.2) | 25(20.3) | 63(51.2) | 10.0 |
4. | Ernakulum (n=220) | 1998 | 6-12 | 2(0.9) | 3(1.4) | 18(8.2) | 197(89.5) | 20.0 |
5. | Kottayam (n=251) | 1999 | 6-12 | 16(6.4) | 15(6.0) | 52(20.7) | 168(66.9) | 17.5 |
6. | Kangra (n=245) | 1996 | 8-10 | 6(2.4 | 10(4.1) | 42(17.1) | 187(76.3) | 16.5 |
7. ) | Hamirpur (n=787 | 1996 | 8-10 | 69(8.8) | 65(8.3) | 137(17.4) | 516(65.6) | 13.5 |
8. | Kinnaur (n=226) | 1996 | 6-10 | 3(1.3) | 13(5.8) | 24(10.6) | 186(82.3) | 19.5 |
9. | Solan (n=720) | 1997 | 8-10 | 21(21.9) | 42(5.8) | 142(19.7) | 515(71.5) | 15.0 |
10. | Bikaner (n=400) | 1996 | 6-12 | 12(3.0) | 36(9.0) | 73(18.0) | 279(70.0) | 15.5 |
11. | Uttarkashi (n=61) | 1998 | 6-12 | 6(9.8) | 2(3.2) | 7(11.4) | 135(87.6) | 20.0 |
12. | Pauri (n=100) | 1998 | 6-12 | 2(2.0) | 2(2.0) | 13(13.0) | 83(83.0) | 17.5 |
13. | Pithorgarh (n=154) | 1998 | 6-12 | (0.0) | 2(1.2) | 17(11.4) | 135(87.6) | 20.0 |
14. | Meerut (n=170) | 1998 | 6-10 | 38(5.4) | 21(2.9) | 142(20.2) | 509(71.7) | 15.0 |
15. | Agra (n=92) | 1998 | 6-11 | 0(0.0) | 0(0.0) | 10(10.8) | 82(89.1) | 17.5 |
16. | Bareily (n=82) | 1998 | 6-11 | 11(13.4) | 18(21.9) | 10(12.3) | 43(52.4) | 10.2 |
17. | Gorakhpur (n=147) | 1998 | 6-11 | 7(4.8) | 3(2.0) | 17(11.6) | 120(81.6) | 15.0 |
18. | Kanpur (n=72) | 1998 | 6-11 | 1(1.4) | 2(2.8) | 25(34.7) | 44(61.1) | 10.5 |
19. | Lakhimpur (n=128) | 1998 | 6-11 | 18(14.1) | 18(14.1) | 39(30.4) | 53(41.4) | 5.0 |
20. | Lalitpur (n=109) | 1998 | 6-11 | 0(0.0) | 10(9.3) | 28(25.7) | 61(55.9) | 13.5 |
21. | Padrona (n=80) | 1998 | 6-11 | 0(0.0) | 0(0.0) | 6(6.2) | 75(93.8) | 20.0 |
22. | Saharanpur (n=192) | 1998 | 6-11 | 1(0.4) | 5(2.6) | 12(6.2) | 174(90.6) | 20.0 |
23. | Sidharth Nagar (n=148) | 1998 | 6-11 | 15(10.1) | 13(8.8) | 37(25.0) | 83(56.1) | 10.0 |
24. | Sultanpur (n=103) | 1998 | 6-11 | 1(1.0) | 13(12.6) | 37(25.0) | 83(56.1) | 10.0 |
25. | Varanasi (n=107) | 1998 | 6-11 | 18(16.8) | 0(0.0) | 30(28.0) | 59(55.1) | 10.0 |
26. | Delhi (n=1652) | 1996 | 8 - 10 | 35(2.1) | 138(8.4) | 291(17.6) | 1188(71.9) | 17.0 |
27. | Agartala (n=133) | 1999 | 8-10 | 0(0.0) | 19(14.3) | 27(20.3) | 87(65.4) | 17.5 |
28. | Kangra (n=1952) | 1999 | 6-11 | 69(3.5) | 74(3.8) | 238(14.2) | 1531(78.5) | 15.0 |
* UIE : Urinary Iodine Excretion, **Figures in parentheses indicate percentages |
Table VII: Iodine Content of Salt as per the Socio-Economic Groups (NFHS -2 Survey Results 1999)
Background characteristic | Not iodized | 7 ppm | 15 ppm | 30 ppm | Missing | Total % | Number of households |
Standard of living index | |||||||
Low | 36.0 | 28.1 | 18.6 | 16.5 | 0.8 | 100.0 | 33,064 |
Medium | 28.6 | 21.5 | 17.5 | 31.7 | 0.6 | 100.0 | 40,434 |
High | 12.8 | 9.2 | 11.6 | 66.0 | 0.4 | 100.0 | 16,640 |
References
- Indicators for assessing Iodine Deficiency Disorders and their control through salt iodization. WHO- UNICEF-ICCIDD. World Health Organisation, Geneva 1994, pp 12-16.
- Policy Guidelines on National Iodine Deficiency Disorders Control Programme. Nutrition and IDD cell. Directorate of Health Services. Ministry of Health and Family Welfare, Government of India, New Delhi 1997, pp 2-5.
- Sundaresan S. Progress achieved in universal salt iodisation programme in India in : Proceeding of symposium on Elimination of IDD through Universal Access to Iodised Salt. Eds. Prakash R, Sunderesan S, Kapil Umesh, Shivansh Computers and Publications, New Delhi 1998 : pp 28-42.
- Kapil Umesh, Saxena N, Ramachandran S, Balamurugan A, Nayar D, Prakash S. Assessment of Iodine Deficiency Disorders rural areas of Delhi. Indian Pediatrics 1996,.33 1093-1017
- Kapil Umesh, Nayar D, Singh C, Saxena N. Monitoring the implementation of universal iodisation of salt programme through school approach in the state of Haryana, India. Indian Journal of Maternal and Child Health.1996;7:69-72
- Kapil Umesh, Nayar D, Goindi G. Utility of Spot Testing Kit in the quantitative estimation of Iodine Content in Salt. Indian Pediatrics 1994;31:1433 - 35
- Kapil Umesh, Nayar D. Iodised salt and its iodine content in Himachal Pradesh, India. Journal of Health and Population Perspectives and Issues, 1994,17: 42 - 57
- Kapil Umesh . Iodised salt is safe. Indian Practitioner 1995,3 :231 -234
- Goindi G, Kapil Umesh, Karmarkar MG, Jagannathan J. Estimation of losses of iodine in foods during different cooking procedures. Asia Pacific Journal of Clinical Nutrition, 1995,4: 225-227.
- Kapil Umesh, Bhasin S, Goindi G, Nayar D. Iodine content of Salt in National Capital Territory of Delhi. Asia Pacific Journal of Clinical Nutrition,19945,4:257-258.
- Kapil Umesh, Saxena N, Ramachandran S, Balamurugan A, Nayar D, Prakash S. Assesment of Iodine content of salt in NCT of Delhi utilising 30 cluster method.Indain Journal of Public Health, 1996 ( 33:1013-1017)
- Kapil Umesh, Sohal KS, Nayar D. Process of implimentation of National Iodine Deficiency Disorders Control Programme Activities in Himachal Pradesh, India.Indian Journal of Public Health,1995.39:172-175
- Iodine content of salt consumed and iodine status of school children in Delhi Indian Pediatrics 1996,33:585 -587
- Kapil Umesh, Bhanti T,Saxena N, Nayar D, Dwivedi SN. Comparision of spot testing kit with iodometric titration method in the estimation of iodine content of salt. Indian J Physiology Pharmcol 1996 ,40, 279-280
- Kapil Umesh, Jose D'sa , Nayar D, Ramachandran S. Assessment of Iodine deficiency in Tiswadi Block, Goa. Indian Practitioner 1996,9:749-750.
- Kapil Umesh, Bhasin Sanjeev Kumar, Shah Archana Dhar, Nayar D. The iodine content of salt used in 1311 households in the National Capital Territory of Delhi, India. Australian Journal of Nutrition andDietetics.1996,53:72-73
- Kapil Umesh, Sohal KS, Sharma TD, Nayar D, Goel M. Requirements of iodised salt in India for Human and Domestic Animals Consumption to Achieve Universal Salt Iodisation. IDD Newsletter 1996, 12:12-13
- Kapil Umesh, Prakash S, Shah AD, Jailkhani L, Nayar D. Study of Some Factors Influencing Losses of Iodine from Iodised Salt. IDD Newsletter 1996, 12:13-4
- Kapil Umesh. Distribution and management of Iodised salt in Himachal Pradesh. IDD Newsletter 1995, 11:47-51
- Kapil Umesh, Karmarkar MG, Goindi G, Nayar D. Iodine content of salt in Union Territory of Andaman and Nicobar islands. Asia Pacific Journal of Clinical Nutrition. (In press)
- Kapil Umesh, Nayar D. Ramachandran S, Sharma T.D. Status of salt iodisation in Una, Kangra and Kullu Districts of Himachal Pradesh. Indian Journal of Preventive and Social Medicine. 1997, 28:36-9
- Bhardwaj AK, Nayar D, Ramachandran S, Kapil Umesh. Assessment of Iodine Deficiency in District Bikaner, Rajasthan. Indian Journal of Maternal and Child Health.1997,1:18-20
- Kapil Umesh, Saxena N, Ramachandran S, Nayar D. Iodine status of pregnant mothers residing in an iodine deficiency endemic district in the state of Himachal Pradesh , India. Asia Pacific Journal of Clinical Nutrition, 1997, 3:224-5
- Kapil Umesh, Ramachandran Shoba, Saxena N, Nayar D. Iodine Content of Salt in district Palghat, Kerala. Indian Journal of Community Health. 1997, 3:106-108
- Kapil Umesh, Deokinandan, Ramachandran Shoba, Nayar D. Status of Salt Iodisation in District Agra,