Engaging Health Officials in the Philippines: Application of a Bottleneck Analysis Tool to Improve Health and Nutrition Program Implementation at the Local Government Level.

Objectives: For children in the Philippines, malnutrition remains a challenge, especially for the youngest and most vulnerable children. An innovative systems analysis tool with local government officials has been developed that uses existing data on IYCF practices and engages local public health workers to identify bottlenecks in service delivery and targeted interventions to improve effective coverage. Methods: A bottleneck analysis tool was developed based on the Tanahashi model. The tool requires the development of a determinants matrix and key indicators to reveal bottlenecks in key components of IYCF programs. The tool helps assess the current status of program delivery and engages local government officials and nutrition experts to identify bottlenecks and propose solutions. Results: The analysis revealed several critical bottlenecks to IYCF program implementation across LGUs in the Philippines. For example, there was a large discrepancy in mother's awareness and knowledge of breastfeeding. These localities proposed culturally appropriate breastfeeding campaigns in their localities or creating targeting educational materials. Conclusions: The results of this initiative demonstrate the utility of targeted bottleneck analysis at a local level to engage and empower local government officials and stakeholders to assess data and identify interventions in a timely manner for improving key IYCF programs in their communities. By creating a collaborative environment, an open discussion regarding data usage, analysis of available data, and positive program improvements can be achieved.

Monitoring salt Iodization in Indonesia: the Need to Account for Iodine from Household and Food Industry Salt.

Objectives: Universal iodization of all edible salt (USI), including household and food industry salt, is the most cost-effective intervention to improve dietary iodine intake. The main metric to track USI programs is the proportion of households consuming adequately iodized salt. However, this does not capture salt consumed from processed foods, such as instant noodles, which are widely consumed in Indonesia. Analyze the association between iodine in household salt, consumption of instant noodles and iodine status, while accounting for the level of iodine in local water, as a possible confounder. Methods: We are currently undertaking analysis of data from the 2013 Indonesia National Health Survey (Riskedas) which included estimates of iodine in household salt, frequency of instant noodle consumption, iodine in local water sources and iodine status. Results: We will have results ready for presentation at the MN Forum. It is expected that estimates of iodine in household salt and the consumption of instant noodles will predict iodine status better than from household salt alone, and suggest that iodized salt is used in most instant noodle production. Conclusions: It was feasible to collect data on the consumption of instant noodles as part of a large nationally representative survey in Indonesia, which enables the analysis of presumed iodine intake from multiple sources. Information from this survey can be used to optimize the salt iodization level in Indonesia and provide important lessons on tools, methods and interpretation that can lead to improved salt iodization program guidance.

Complementary Interventions for Preventing and Controlling Iodine Deficiencies in Pregnant Women, Infants, and Young Children.

Objectives: Inadequate dietary iodine is the main cause of preventable brain damage, posing a serious threat to intellectual development and productivity throughout the world. Salt iodization is the primary strategy for preventing and eliminating iodine deficiencies, and 76% of households worldwide have access to adequately iodized salt. In several settings, new interventions provide iodine containing products for vulnerable groups - pregnant and lactating women, infants (0-5 months), and young children (6-23 months). However, the extent to which these ‘complementary interventions' meet the iodine requirements of these groups has not been investigated. We therefore examined these interventions to understand whether they meet vulnerable groups' needs. We also estimated the number of recipients reached. Methods: We reviewed literature, household surveys, and guidelines to assess whether salt iodization can meet vulnerable groups' iodine requirements. Then, complementary interventions used in public health contexts were mapped, their iodine contribution estimated, and the number of recipients reached calculated. Results: Our analysis suggests that salt iodization may meet the requirements of pregnant and lactating women, but possibly not all infants and young children. There is great variability in objectives, delivery methods, and iodine contribution of complementary interventions. The coverage of various complementary interventions ranges from 0 to 13% of the vulnerable population groups. Conclusions: There is a need for careful coordination to ensure appropriate amounts of iodine are delivered to recipients. Failing to do so can result in the delivery of too little or too much iodine, which can have negative health consequences.

Refinements to Assessment of Iodine Nutrition.

Objectives: The main target groups of iodine programs are pregnant women (PW) and nonpregnant women of reproductive age (NPW), yet surveys frequently focus on school age children (SAC). It is unclear whether median urinary iodine concentration (mUIC) in SAC can be used as a surrogate for PW and NPW. It is also unclear what range of iodine intake is adequate in SAC. The objectives of this research were to: 1) Compare mUIC values in SAC with those in PW and NPW; and 2) determine if the current mUIC range for SAC is appropriate by assessing thyroglobulin (Tg), a functional biomarker of iodine status. Methods: 1) The Iodine Task Force (ITF) reviewed surveys where mUIC in SAC, PW, and NPW were available and compared iodine status across groups; and 2) for determining the adequate range of mUIC in SAC, the ITF analyzed and interpreted a multicenter study. Results: 1) When SAC had adequate or above adequate iodine status, PW were inadequate in 47% of the surveys. 2) In SAC, the two current WHO/UNICEF/ICCIDD mUIC categories for classification of iodine nutrition as "adequate" and "above adequate" could be combined into a single "adequate" range based on Tg results showing no negative effect on the thyroid at the current "above adequate" range. Conclusions: A number of refinements to the current global recommendations in assessing iodine status were identified, including the importance of including PW and/or NPW in population-based assessments, and reconsideration of current mUIC criteria for the classification of optimal iodine nutrition in SAC.