Universal Iodization Business or Health? Lecturer Popescu Cristian George, PhD. University of Bucharest, Faculty of Administration and Business

Transcription

1 Universal Iodization Business or Health? Lecturer Popescu Cristian George, PhD University of Bucharest, Faculty of Administration and Business Lecturer Ion Raluca Andreea, PhD Bucharest University of Economic Studies, Faculty of Agro-food and Environmental Economics Abstract The paper analysis the effects of the decision of adding iodine to salt, from both economical and health approaches. The research questions are: Has the introduction of iodine to salt the effects of decreasing the number of people suffering of hypothyroidism?; Is this decision underpinned economically, or the costs are higher than the estimated results?; Are there any other effects of iodine consumption in excess to people? In order to answer these questions, statistical data, medical reports and results of other studies in the field of health care have been analysed. The outcomes of the research show that the number of sick people to iodine deficiency (hypothyroidism) remained constant, the number of sick people with iodine in excess (hyperthyroidism) doubled, and the new cases of thyroid cancer had an exponential growth. Considering the alarming growth of people affected by iodine, the practical alternative, applied in all developed countries, is to put on the market iodized salt, but not in an exclusivist and compulsory manner. Keywords: salt iodization, hypothyroidism, hyperthyroidism, thyroid cancer Introduction 34 P a g e

2 This paper investigates the effects of the decision of adding iodine to salt in order to prevent iodine deficiency disorders, trying to answer the question whether, based on statistical data, salt iodization prevents disorders or not. Sometimes it is difficult to produce evidence for or against certain decisions on the introduction, amendment or repeal of laws of health. This is because the arguments of specialists physicians with reputation in public health area would be more important than any economic arguments and not only. Rightly, we might think these views, but statistical data and economic reality contradict them. Since 2002 the Romanian society is facing a major medical problem, which shows how health law was thought on a very important segment based on daily diet. It speaks about salt, which is a basic food for people. Thus, if people consume slowly some food (every few days, weeks), salt and water people consume daily. The importance of such food is high, because it is used in all meals. We use to tell stories to children about how important this food is (Salt in food); explaining why salt is a basic food for each of us. In Romania, the problems started in 2002, when Governmental Decision no. 568/2002 regarding universal iodization of salt for human consumption, animal feed and food industry has been approved. This regulation contains a definition never met before: universal iodization. This action is singular, made in world premiere. These are some statements of the regulation: Iodized salt must contain 20±5 mg iodine/kg of salt, respectively 34±8.5 mg potassium iodated/kg of salt, or 26±6.5 mg potassium iodine/kg salt. Delivery to producers or importers of iodized salt for human consumption, animal feed and food industry, with a content of iodine under the level established is penalised with a fine of million lei. Trading iodized salt with a content of iodine under the level established, as a result of economic agents failure to comply with the conditions of transport, storage and trade established by the producer, is penalised with a fine of million lei. 35 P a g e

3 Apparently, everything seems to be fine, but a deeper analysis reveals even more serious problems. The literature in the field speaks about the level of iodine that one could intake. As Harrison 1 argues in his book Principles of Internal Medicine, the reference work in the field that students are supposed to learn to pass the admission to their specializations, in the past, the intake of 0.2 mg/day of iodine has been considered normal. Today, the research of other authors 2 reveals that the intake has increased to 0.5 mg/day and, in some areas, to 1 mg/day, because of: - the fact that iodine is present in food; - the use of iodine in preparing medication and vitamins; - the use of iodine as antiseptic agent; - the use of iodine as contrast agent in some investigations. The Governmental Decision no. 568/2002 introduced the requirement of adding iodine to salt for human consumption, animal feed and food industry, to prevent iodine deficiency disorders. According to medical studies 3 in the field, iodine deficiency is manifested by hypothyroidism. As the medical studies 4 recover, there are other categories of diseases that manifest as excess iodine and for which the iodine is a real problem: hyperthyroidism, iodine allergies, and some cases of thyroid cancer. The objective of this paper is to identify the effects of salt iodization upon human health, considering the results of previous research in medical fields and statistical data regarding the number of hypothyroidism, hyperthyroidism and thyroid cancer, before and after the governmental decision of adding iodine to salt. Further more, the costs paid by the Romanian state for sustaining the care of people suffering of thyroid cancer are estimated. 1 Harrison, Principiile Medicinii Interne, Teora, 1999, pag Chirila, P. coord, Iodarea universală a sarii atentat la sanatatea publica, Puncte Cardinale, no. 9/141, Sibiu, Chirila, P. coord, Iodarea universală a sarii atentat la sanatatea publica, Puncte Cardinale, no. 9/141, Sibiu, Medical studies that express the effects of excessive iodine consumption 36 P a g e

4 Materials and Method Statistical data regarding hypothyroidism and hyperthyroidism diseases have been analysed to have a detailed picture of the situations before and after the decision of adding iodine to salt. In Table 1, the newly declared cases of hypothyroidism and hyperthyroidism are presented. The data refer to the period , that was supposed to be the reference period for underpinning the decision of adding iodine to salt. Table 1 Number of hypothyroidism and hyperthyroidism cases declared in the period Year Cases of pothyroidism Cases of yperthyroidism Source: National Institute of Statistics, Institute of Medical Statistics of Ministry of Health 37 P a g e

5 The cases of hypothyroidism and hyperthyroidism have increased with an average growth of 11.21% and, respectively, 7.66%, in the period , that is the reference period for the decision of adding iodine to salt. The indexes of the cases of hypothyroidism and hyperthyroidism reported to 100,000 inhabitants are 13.95, respectively 38.12, in In Table 2, the newly declared cases of hypothyroidism and hyperthyroidism for the period are presented. Table 2 Number of hypothyroidism and hyperthyroidism cases declared in the period Year Cases of pothyroidism Cases of yperthyroidism Source: National Institute of Statistics, Institute of Medical Statistics of Ministry of Health 38 P a g e

6 Starting with 2003, the moment when iodine had been added to salt, to present, the trend of cases of hypothyroidism has been constant, with an average spore of -1.05%, but the number of hyperthyroidism cases have increased in arithmetic progression (doubling in the same period of time). The most interesting and significant statistic refers to cases of thyroid cancer declared in medical reports of family physicians and presented in Table 3. Table 3 New cases of thyroid cancer declared by physicians in the period Year New cases of hyroid cancer Source: medical reports 39 P a g e

7 The trend of cases of thyroid cancer has been constant from 2002 to After 2006, the number of thyroid cancer has becoming more, and, in the last three years, it increased geometrically. It is interesting to mention that this growing trend of cases of thyroid cancer corresponds to the Governmental Decision no.1904/2006 of increasing the level of iodine added to salt. Until 2006, the salt must contain 20±5 mg iodine/kg of salt, respectively 34±8.5 mg potassium iodated / kg of salt, or 26±6.5 mg potassium iodine / kg of salt. After 2006, as new regulation said 5, the salt must contain 30 mg iodine/kg of salt, respectively 50.6 mg potassium iodated / kg of salt or 39.2 potassium iodine/kg of salt. The growth of the level of iodine is 50% for both iodine and potassium iodated or potassium iodine. Another interesting outcome of the statistical analysis consists in the fact that, from the moment when the regulation of 2002 regarding the universal iodization has been introduced and until 2006: - the number of cases of hypothyroidism has been almost constant, representing about 0.3% of Romanian population (insignificant share); - the number of cases of hyperthyroidism has increased up to ¼ from the level they used to have in 2002 (when the regulation was introduced); - the number of cases of thyroid cancer increased with 70%. Based on these statistics, contrary to the purpose of the regulation introduced in 2002, in 2006 the government decides to increase the level of iodine added to salt. The effects of this decision appeared immediately: the cases of hyperthyroidism and thyroid cancer increased geometrically, which indicates that the mistakes made in the field of health care have serious consequences directly upon human health and, indirectly, on health budget. Results and Discussions The analysis of statistical data of cases of hyperthyroidism, hypothyroidism and thyroid cancer show the significant negative effects of the decision of introducing iodine to salt. 5 Governmental Decision no. 1904/2006 regarding changes of Governmental Decision no. 568/2002 regarding universal iodization of salt for human consumption, animal feed and food industry 40 P a g e

8 The literature in medical field reveals the consequences of universal iodization of salt upon human health 6 : - Hyperthyroidism induced to euthyroid people; - Growth of the cases of thyroid cancer 7. As shows the results of a study conducted in Tasmania, the number of cases of thyroid cancer increased three times to people over 49 years old 8 ; - Increase of thyroid volume, from 4.8 ml to 8.6 ml, as results from a research published in European Journal 2000, by Ana de Premawardhana LD 9 ; - Growth of urinary iodine from 105 to 152 microg/l 7 - Increase of Tg Ab from 14.3% at 11 years, to 69.7% at 16 years (p>0.03) 7 - Diseases of eye sight through direct toxicity upon retina (epithelial retinal pigment), as demonstrated by Singalavanija A.et.all using electroretinographs 10 ; - Constant growth of autoimmune Basedow 11 ; - Hypothyroidism induced by iodine 9 ; - Hashimoto thyroidism 9 ; - Increased incidence of papillary thyroid cancers 9 ; - Research conducted by D. A. Koutras from Department of Clinical Therapeutics, University of Athena, show that food iodization could have the following effects upon thyroid 9 : participation in thyroid hormones: the author argues this claim based on the results of three studies from England (12 iodized"), (1984, 1985), Spain (1994) and Zaire (1996). In all these cases, the growth of hyperthyroidism cases was correlated to compensatory iodization of food. 6 Chirila, P. coord, Iodarea universală a sarii atentat la sanatatea publica, Puncte Cardinale, no. 9/141, Sibiu, Drug Saf 2000 Feb 22(2): Journal Clinica. Endocrinologie. Metabolism, 1973, 37(6): European Endocrinology. Metabolism, 2000, Aug, 143(2): Retina 200; 20(4): Annales d Endocrinologie (Paris)1996, 57: P a g e

9 Multinodular goitre was detected in iodized goitre areas by Miller (1967), Studer (1978), and Ramelli (1982) in their research. in TSH; Decrease in thyroid volume, noticed despite the increase in thyroid hormone and decrease Anti-thyroid: iodization inhibits its own activity, but on short term due to its feed back; It influences the number and type of thyroid cancer. Haroch&Williams, after an iodization in Salta (Argentina) noticed that the number of papillary cancer doubled, the number of undifferentiated follicular and medullar cancers remained the same, and the total number of cancers increased. The main relief of the authors is that papillary cancer can be curable; The appearance of the phenomenon "thyroid cell necrosis", which is a form of adjustment out of control, to block the production in excess of thyroid hormone; Increase of autoimmune thyroid conflict: D.A. Kontras conducted a prophylaxis with iodine in a Greek village. Before the administration of iodine, none of the subjects used to have thyroid auto antibodies. After a few months, 50% of the subjects had antithyroidglobulin or antimicrosomal auto antibodies. In Eastern Germany, where universal iodization has been made, there have been found large shares of auto antibodies than in Western Germany, where iodization has not been made. As results from the study mentioned before, the lymphocytes infiltrates increased from 8% that used to be before iodization, to 25% after it. D.A. Kontras mentioned the study of Laurberg (1991) that demonstrates a significant influence of Graves disease in Iceland, where iodization is made, compared to Denmark, where iodization is not so abusive; Increase of sub clinical hypothyroidism to iodized scholars (detected through MUI and TAA), of no autoimmune origin; 12 The patients who develop transitory hypothyroidism because of salt iodization must be watched long time because they may develop permanent primary hypothyroidism Chinese Medical Journal 81(8): 453-6, 2001, Apr Thyroid 11(5): , 2001, May. 42 P a g e

10 Economic assessment of the situation payable costs The active substances used in the process of adding iodine to salt are potassium iodated (KIO 3 ) and potassium iodide (KI), the first being the most important. In Romania, economical analysis of the costs of salt iodization has been made based on studies in the field 14, in Some conclusions can be drawn from these studies and others 15 : 1. Potassium iodated (KIO 3 ) represents the main raw material for salt iodization worldwide. Its price was between USD/kg, with an increasing trend; 2. The main world producers and exporters are Chile with 55% of the world trade with iodine and Japan with 33%. The main importers are United States of America, European countries (through Belgium), China and India; 3. Of the total of 31,000 t that represent the global market for iodine, world trade accounts for 70%, and 4% are used for salt iodization (1240 t of iodine); 4. Romania has a domestic production of 2.5 million tons of salt. In order to add iodine to salt under the limits decided through Governmental Decision no.1904/2006, tons of potassium iodated should be used yearly, wich accounts for 8 billion USD on the market. This is the lowest price that salt mining companies should pay, if they would import directly from the producers countries. But, in the situation in which a company or a small group of companies import the potassium iodated taking advantage of their privileged position in a monopole market, the price of the raw material is higher. Thereby, producers pay higher prices for potassium iodated, leading to higher prices for salt to the final consumer. Romanian state pays lot of money for new cases of thyroid cancer, particularly for patients in the terminal phase, because they benefit of all free of charge treatments for cancer which are discounted through health programs. Thus, for each sick person, the average costs are about 15,000 Euros 16 during the treatments and, when they cannot be helped any more, the society spends about 300 lei/day for 14 Iodine Market Situation, Briefing Note for Universal Salt Iodization Program Stakeholders Prepared by GAIN, MI and UNICEF, September 13, Monitorizarea și inspecția nivelului de iod din sarea iodata pentru consumul uman, Ministerul Sanatatii, Institutul de Sanatate Publica din Bucuresti, As results from the study Cancerul, prioritate absoluta dezvoltarea unui sistem real de servicii sociale, AM-POR, cod smis P a g e

11 patient care (palliative care). A simple calculation reveals that, if the patient died because of thyroid cancer, supposing he would have al least 30 days of living after entering the irreversible phase, the state would pay, on average, 20,000 Euros. It means that, for 2010, the Government spent about 3.3 billion Euros for those 166 new cases of thyroid cancer (who died in 2009) 17. Moreover, the difference of 336 persons suffering of thyroid cancer in 2009 who survived more than one year determine more money spent for their care. In total, we estimate the state expenses for patients of thyroid cancer to 8.4 million Euros, in Conclusions 1. Considering the shares of sick people in total population, in a sanitary approach, the introduction of universal iodization of salt is not justified because of the small cases of sick people to iodine deficiency (hypothyroidism) and large number of people for whom iodine represents a real danger (hyperthyroidism). 2. Considering statistical data, following a period of four years after the introduction of the regulation regarding universal iodization of salt, the new cases of sick people to iodine deficiency increased, on average, with 2-3% per year (the cases did not decrease, as expected), the number of sick people for whom iodine is a real threat significantly increased in four years with about 20% per year, and, finally, the number of people suffering of thyroid cancer increased with 70%. 3. Nevertheless statistical data, in 2006 the Romanian Government decided to increase with 50% the quantity of iodine added to salt, so the effect rapidly emerged. 4. Considering statistical data from the period , after the decision of increasing with 50% the quantity of iodine added to salt, the negative effects appeared: the number of sick people to iodine deficiency remained constant, the number of sick people with iodine in excess doubled, and the new cases of thyroid cancer in 2006 had an exponential growth. 5. Romania is the only country in the world that decided to introduce compulsory the iodine in salt for human health (and in salt used as raw material for bread industry). 17 Medical reports on deaths due to thyroid cancer, National Institute of Statistic of Romania 44 P a g e

12 6. It is unusual to expose the whole population of a country to such a risk only because of a small number of people suffering of hypothyroidism (0.5% of total population), considering the alarming growth of people affected by iodine. 7. The practical alternative, applied in all developed countries, is to put on the market iodized salt, but not in an exclusivist and compulsory manner. References Chirila, P. coord, Iodarea universală a sarii atentat la sanatatea publica, Puncte Cardinale, no. 9/141, Sibiu, Harrison, Principiile Medicinii Interne, Teora, 1999, pag Journal Clinica. Endocrinologie. Metabolism, 1973, 37(6): Drug Saf 2000 Feb 22(2): European Endocrinology. Metabolism, 2000, Aug, 143(2): Retina 200; 20(4): Annales d Endocrinologie (Paris)1996, 57: Chinese Medical Journal 81(8): 453-6, 2001, Apr. 25. Thyroid 11(5): , 2001, May. Iodine Market Situation, Briefing Note for Universal Salt Iodization Program Stakeholders Prepared by GAIN, MI and UNICEF, September 13, Cancerul, prioritate absoluta dezvoltarea unui sistem real de servicii sociale, AM-POR, cod smis Monitorizarea și inspecția nivelului de iod din sarea iodata pentru consumul uman, Ministerul Sanatatii, Institutul de Sanatate Publica din Bucuresti, Medical reports on deaths due to thyroid cancer, National Institute of Statistic of Romania. Governmental Decision no. 568/2002 regarding universal iodization of salt for human consumption, animal feed and food industry. Governmental Decision no. 1904/2006 regarding changes of Governmental Decision no. 568/2002 regarding universal iodization of salt for human consumption, animal feed and food industry. 45 P a g e