Global Alliance for Improved Nutrition - Universal Salt Iodization

The Global Alliance for Improved Nutrition (GAIN)’s Universal Salt Iodization program seeks to prevent serious physical health and mental development problems in children in low- and middle-income countries, by supplementing salt with the crucial nutrient iodine.

If you are interested in co-funding a portfolio of organizations like this one, please see our Global Health and Development Fund.

What problem are they trying to solve?

Iodine is necessary for healthy functioning of the thyroid, which produces vital hormones. These hormones control the rate of many important biological processes, including growth and development, metabolic rates, and even how fast the heart beats.¹ Iodine deficiency disorders arise when the thyroid does not have access to enough iodine. This can cause severe health problems and, particularly in children, developmental issues that severely impair mental function.² Iodine deficiency in pregnant women can also significantly impair both the mental and physical development of their children.³ This can have life-long effects on health and income.⁴

Iodine deficiency is particularly common in the Western Pacific, South-East Asia, and Africa, affecting as many as two billion people globally. Almost 200 million people are “severely” affected.⁵ Poor diets that lack variety are to blame, especially in remote inland areas where no marine foods are eaten.⁶ Vulnerable people who lack the means to adapt their diets are most at risk.⁷

What do they do?

GiveWell reports that GAIN has recently worked on salt iodization in seventeen countries, with Tanzania, Mozambique, Pakistan, Indonesia and Bangladesh accounting for most of their operations.⁸ Salt iodization involves adding iodine, usually in the form of potassium iodate, to salt to increase the amount of iodine in a person’s diet. The nature of GAIN’s involvement in this process varies considerably by location, but frequently includes advocacy, technical assistance, supplying equipment, training government officials and salt producers, and monitoring the processes and outcomes of (often government run) salt iodization schemes.⁹

In Ethiopia, where GiveWell conducted a detailed case study of GAIN’s work, GAIN not only donated potassium iodate to the government for a state run salt iodization program, but also helped the government procure more potassium iodate and develop relationships with salt producers.¹⁰ They also donated crucial iodization equipment and iodine monitoring equipment and trained government staff to use it.¹¹ GAIN also worked with salt producers to improve their iodization practices¹² while supporting a national survey of iodine nutrition.¹³ GAIN claims that its advocacy was instrumental in the passage of Ethiopia’s Universal Salt Iodization law,¹⁴ which passed two years after GAIN began work on salt iodization in the country. They believe that they were responsible for increasing the number of people in Ethiopia receiving iodised salt from 11% to 88%.¹⁵

GAIN has also had a recent notable policy success in Bangladesh, playing a leading role in getting the Iodised Salt Act passed. They helped draft the legislation, convened key actors, and are the sole facilitator of potassium iodide supplies. GAIN believes that if they can increase their annual spending in Bangladesh to help with implementation, they can increase the number of people receiving adequately iodised salt by 60 million.

For further information on Global Alliance for Improved Nutrition’s involvement in salt iodization programs, including a full list of implementation partners and specific interventions/case-studies, see GiveWell’s write-up on GAIN.

Why do we recommend them?

• GiveWell, our research partner in global health and development, thinks GAIN is a highly cost-effective global development organisation, though they do not currently recommend GAIN as a top charity.
• There is strong evidence that salt iodization programs have significant, positive effects on children’s cognitive ability.
• While GAIN works in countries which have seen increases in salt iodization programs, we currently have a limited understanding of their contribution to these changes. This uncertainty has contributed to GiveWell’s rating of GAIN as a standout, rather than top, charity.
• Our interactions with GAIN as well as GiveWell’s experiences suggest that GAIN is a strong, transparent, responsive, and impact-driven organization.

Cost-effectiveness

GiveWell has not closely vetted any data on GAIN's cost-effectiveness and reports that the cost-effectiveness of salt iodization programs can be complicated to calculate.¹⁶ GAIN estimates that it has expanded access to adequately iodized salt for between $0.05 and $0.18 per person in India, Ethiopia, Bangladesh, and the Philippines.¹⁷

Evidence of impact

Is salt iodization effective?

GiveWell states that salt iodization is an effective intervention.¹⁸ Based on the available experimental evidence, they estimate that iodine supplementation of mild-to-moderately deficient children increases their IQ by approximately four points.¹⁹ They also suggest that this effect is likely to be even greater where iodine deficiency is more severe, but there is not yet sufficient evidence to be certain of this.²⁰ Similarly, GiveWell reports that two meta-analyses (Angermayr and Clar 2004 and Taylor et al 2013) identified 6 RCTs evaluating the effect of iodine supplementation of children on their mental function, and generally found significant positive effects.²¹ This increase in mental function is likely to have positive effects on the children’s life outcomes.²²

GiveWell also suggests that salt iodization has a positive impact upon the reduction of congenital iodine deficiency syndrome. They report that high quality reviews from Mahomed and Gulmezoglu 1997 and, more recently, Zhou et al 2013, identify evidence of a reduction in congenital iodine deficiency brought about by iodine supplementation. A quasi-randomised controlled trial, Pharoah, Buttfield and Hetzel 1971, was conducted in an area with severe levels of iodine deficiency and found a large reduction in congenital iodine deficiency syndrome in children born to women receiving iodine supplementation compared to the control group. Moreover, a long term follow up four years later, found that of 412 children born to mothers receiving iodine supplementation, only 7 suffered congenital iodine deficiency syndrome. This was compared to 26 cases out of 406 children in the control group, giving a relative risk of 0.27 (95% CI: 0.12 to 0.60). A further long-term follow up study found that just 3 of 274 children in the iodine supplementation group reported congenital iodine deficiency syndrome, compared to 16 out of 248 in the control group.²³

Do GAIN’s programs improve access to iodized salt?

While there is solid evidence that salt iodization reduces iodine deficiency, GiveWell currently has a limited understanding of GAIN’s contributions to country salt iodization programs. GAIN often operates in partnership with other organisations and it is difficult to know with confidence how impactful their actions in particular were in increasing salt iodization in the countries they work. GiveWell writes that their current best guess is that GAIN’s work was influential in increasing salt iodization in Ethiopia.²⁴ However, they are less certain of this than they are of the impact for their top charities, which they currently rate more highly than they do GAIN. GAIN’s recent success in Bangladesh, as reported by the news²⁵ and described in our conversation with GAIN, increases the probability that they are in fact often instrumental in boosting salt iodisation. The reported declines in salt iodisation in countries such as Vietnam after GAIN had to scale back their operations there due to funding decline in 2016 is also strong evidence for their impact.

Why do we trust this organization?

This charity was assessed by GiveWell, our research partner for global health and development issues. GiveWell is a nonprofit dedicated to finding outstanding giving opportunities and publishing the full details of their analysis to help donors decide where to give. While GAIN is not on GiveWell’s list of top charities, it is a GiveWell standout charity.

Unlike charity evaluators that focus solely on assessing administrative or fundraising costs, GiveWell conducts in-depth research aiming to determine how much good a given program accomplishes, per dollar spent, in terms of lives saved or lives improved. Rather than try to rate as many charities as possible, they focus on the few charities that stand out according to a specific set of criteria, in order to find and confidently recommend high-impact giving opportunities.

What would they do with more funding?

Funding opportunities and room for more funding

GAIN estimates that additional funding of $6.7 million over the next 3 years would enable them to scale-up their salt iodization programs in Tanzania, Indonesia, Pakistan, and Mozambique, as well as creating a significant presence in Bangladesh, Ethiopia and India.²⁶ GAIN is also interested in expanding some of its other salt iodization initiatives, such as iodine proficiency testing schemes, international accreditation for testing schemes, and standards harmonization.²⁷ In addition, more funding is needed to assist national bodies with activities such as iodized salt coverage surveys, supporting national distribution systems for potassium iodate, and (given regulators’ resource constraints and the challenges posed by COVID-19) innovating methods for monitoring iodization compliance remotely.²⁸

What are the major open questions?

GiveWell suggests that, because GAIN’s activities vary between countries and are often undertaken alongside non-profit, governmental, or business partners, their precise impact upon salt iodization is very difficult to calculate.²⁹ Cost-effectiveness estimates are necessarily rough, due to differences between contexts, and it is unclear whether all of GAIN’s interventions are similarly impactful, or precisely how future funding will be used.

There are, moreover, some questions regarding the potential negative impacts of salt iodization. According to GiveWell, it is theoretically possible that an excess in iodine caused by salt iodization could result in similar mental impairment to iodine deficiency.³⁰ However, GiveWell has not found evidence to document this, and the levels of iodine present in most countries are not high enough to meet the probable threshold for these negative impacts.³¹

Message from the organization

“Since 2002, GAIN has supported the roll-out fortification in approximately 30 low and middle-income countries as an approach to help decrease malnutrition. This support has helped to build, improve and sustain national large-scale food fortification (LSFF) programmes. We have invested over USD 200 million in fortification through grants and technical assistance. As a result of these efforts, 14 countries have now mandated LSFF, and an estimated one billion individuals have sustained access to these fortified foods.”³²

More resources

GiveWell write up on GAIN’s Universal Salt Iodization GiveWell review of the evidence for salt iodization GAIN’s website

Notes

1. "Your thyroid is a butterfly-shaped gland in your neck, just above your collarbone. It is one of your endocrine glands, which make hormones. Thyroid hormones control the rate of many activities in your body. These include how fast you burn calories and how fast your heart beats. All of these activities are your body's metabolism." Meadline. (2021). Hyperthyroidism. Meadlineplus.gov. Retrieved 4 March 2021. From https://medlineplus.gov/hypothyroidism.html ↩

2. “Iodine deficiency is the main cause of potentially preventable mental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world.” Angermayr, L. and Clar, C. (2004). “Iodine supplementation for preventing iodine deficiency disorders in children.” in Cochrane Database Syst Rev. 2004;(2). ↩

3. Zhou, S., Anderson, A., Gibson, R., and Makrides, M. (2013). Effect of iodine supplementation in pregnancy on child developmentand other clinical outcomes: a systematic review of randomizedcontrolled trials. AGCN. ↩

4. Agueyo, V., Scott, S., and Ross, J. (2006). Sierra Leone – investing in nutrition to reduce poverty: a call for action. Cambridge: Cambridge University Press.https://www.cambridge.org/core/journals/public-health-nutrition/article/sierra-leone-investing-in-nutrition-to-reduce-poverty-a-call-for-action/99E67DAC608078A77B438635F8E3B371. ↩

5. Vos, T, et al. (2012). “Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010” in Lancet 380(9859). ↩

6. World Health Organization. (2013). Iodine deficiency. Who.int. Retrieved 4 March 2021. From https://www.who.int/data/nutrition/nlis/info/iodine-deficiency. ↩

7. Bai, Y., Naumove, E., and Masters, W. (2020). “Seasonality of diet costs reveals food system performance in East Africa” in Science Advantages 6(49). ↩

8. GiveWell. (2017). Global Alliance for Improved Nutrition (GAIN) - Universal Salt Iodization (USI). givewell.org. Retrieved 4 March 2021. From https://www.givewell.org/charities/GAIN#What_do_they_do. ↩

9. Ibid. ↩

10. GAIN. (2012). Design and Implementation of a Revolving Fund System for the Supply and Delivery of Potassium Iodate in Ethiopia. Global Alliance for Improved Nutrition. ↩

11. GiveWell's non-verbatim summary of conversations with Alem Abay and Greg Garrett, July 8-11, 2015. ↩

12. Ibid. ↩

13. “Ethiopia's 2014 National Micronutrient Survey cost about $1.8 million. GAIN contributed about $100,000 for the measurement of indicators of iodine nutrition. The Ethiopian Public Health Institute conducted the survey after getting comments on its plan for the survey from all partners including GAIN.” Ibid. ↩

14. GAIN. (2015). Achieving Health Impact in Ethiopia through Salt Iodization: Progress to Date and GAIN’s Role. Global Alliance for Improved Nutrition. ↩

15. FP video call with GAIN on June 14, 2022. ↩

16. “The cost-effectiveness of a salt iodization program depends on salt intake, the iodine content in salt once it reaches consumers (poor storage, for instance, can result in iodine loss), and the prevalence of iodine deficiency before implementation of the program.” GiveWell. (2017). Global Alliance for Improved Nutrition (GAIN)) - Universal Salt Iodization (USI): What do you get for your dollar?. Givewell.org. Retrieved 4 March 2021. From https://www.givewell.org/charities/GAIN#What_do_you_get_for_your_dollar ↩

17. Ibid. ↩

18. GiveWell. (2014). Salt Iodization. Givewell.org. Retrieved 4 March 2021. ↩

19. “We would guess that iodine supplementation of mild-to-moderately deficient children increases their IQ by somewhere around 4 points on average.” Ibid. ↩

20. Ibid. ↩

21. GiveWell. Analysis of studies on the effects of iodine supplementation of children on their mental function. ↩

22. There is overwhelming evidence from a wide variety of experimental and observational studies that IQ has an independent effect on a wide range of life outcomes (an experimental study, for example, might randomly assign subjects to tasks with varying demands on cognition and then examine the differences in performance between low IQ and high IQ groups on the different tasks). Some researchers have tried to think of variables confounded with IQ that would explain different life outcomes, but there is always variation in outcomes that can only be explained by IQ differences. IQ is also mostly stable throughout one's life; possible confounders then have to both predict life outcomes and remain relatively stable throughout one's life.” GiveWell's non-verbatim summary of a conversation with James Flynn, Emeritus Professor of Political Studies and Psychology, University of Otago, New Zealand, October 17, 2014, Pg. 2 ↩

23. Analysis 01.03, Mahomed and Gulmezoglu 1997, Pg. 8 "This paper presents the final follow-up results on the children born between 1966 and 1972. The children were last examined in 1982 when they were aged between 10 and 16 years." Pharoah and Connolly 1987, Pg. 68 ↩

24. “Overall, we would guess that GAIN's activities played a role in the increase in access to iodized salt in Ethiopia, but we do not yet have confidence about the extent of GAIN's impact.” GiveWell. (2017). Global Alliance for Improved Nutrition (GAIN)) - Universal Salt Iodization (USI). Givewell.org. Retrieved 4 March 2021. From https://www.givewell.org/charities/GAIN ↩

25. New Food Magazine. “A Milestone Achievement to Protect Our Future with Salt.” Accessed April 30, 2022. ↩

26. Founders Pledge video call with GAIN on June 14, 2022. ↩

27. Ibid. ↩

28. Ibid. ↩

29. “We have found it challenging to fully understand GAIN's impact on USI programs. Because GAIN's activities vary across countries, we have attempted to focus on a small number of countries to start. The first two countries we focused on were Ethiopia and India. In both cases, we were unable to verify GAIN's contribution to improvements in the countries' iodization systems and, for Ethiopia, GAIN provided some information on key details that we found to be inaccurate when we visited salt mills in the country, which indicates to us that it would likely be very difficult to confidently understand GAIN's impact.” GiveWell. (2017). Global Alliance for Improved Nutrition (GAIN)) - Universal Salt Iodization (USI). Givewell.org. Retrieved 4 March 2021. From https://www.givewell.org/charities/GAIN ↩

30. “Salt iodization programs may result in excessive iodine intake, which could plausibly cause impairments in mental function analogous to those caused by iodine deficiency.” GiveWell. (2014). Salt Iodization. Givewell.org. Retrieved 4 March 2021. From https://www.givewell.org/international/technical/programs/salt-iodization ↩

31. Andersson, M., Karumbanathan, V, and Zimmermann, M. (2012). “Global Iodine Status in 2011 and Trends over the Past Decade” in The Journal of Nutrition. ↩

32. GAIN. (2021). Large-Scale Food Fortification. Gainhealth.org. Retrieved 4 March 2021. ↩