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urrent Perspective From the Pastn the occasion ofNutrition’s 20th anniversary we recognize eaf Nutrition’s five editorial offices in the different geographireas of the globe by offering the Journal’s Regional Editorspportunity to publish a collection of peer-reviewed manuscccepted by their office. We began with the Latin-American o

n the February 2004 issue. In subsequent issues in 2004 theegional Editors will publish accepted papers and commemanating from their offices preceded by an introductory edito

On this occasion we should like to thank all our friends whour authors, reviewers, readers, subscribers, libraries, and so

or their active participation in this endeavor.

Michael M. Meguid, MD, PhDProfessor of Surgery and Neuroscience

Editor-in-Chief, Nutrition

doi:10.1016/j.nut.2004.01.01

arginal Micronutrients: Iodinensufficiency in Subcontinentaliets—Cultural, Biological, andumanitarian Implications

he typical Pakistani diet contains an inadequate intake of iohis is the substantiated claim made by Akhter et al.1 in this issuef Nutrition. Using neutron activation analyses applied totaples of the Pakistani diet of the relatively more homogenopulation of their sample of the subcontinent’s quarter oflobal population, they determined that the Pakistani diet haseighed in their micronutrient balances and been foanting—by a lot. The mean intake is one fourth (according toS Food and Nutrition Board) or one fifth (according to

nternational Commission of Radiologic Protection BoICRPB]) of world standards. Their chart of national dietary iodankings shows Pakistan at the bottom of the developed woist, with even Sudan coming in at double the Pakistani rate. W

ight such a significant micronutrient shortfall mean for the puealth of so large a population?

The Indian subcontinent is one of the regions known to tho study geographic medicine as an endemia for iodineiency disease (IDD). Pakistani IDD is prevalent, more promilong the Himalayan north of the country, and patchy inraphic distribution of clustered cases of hypothyroidism.

Overt hypothyroidism may represent only the superficiallinically recognizable manifestation of a much larger problemarginal IDD. Hypothyroidism represents a serious biologic

cit in human growth and potential that is distributed worldwut seems highest in incidence in the developing world. Whic

hese twin problems—IDD in nutritional inadequacy and unevelopment in whole populations in the grip of povert

orrespondence to: Glenn W. Geelhoed, MD, MPH, DTMH, MPACS, Department of Surgery, George Washington University Meenter, Office of the Dean, Ross Hall, 2300 I Street, NW, Washington

0037, USA. E-mail: msdgwg@gwumc.edu

utrition 20:334–335, 2004Elsevier Inc., 2004. Printed in the United States. All rights reserved.

r

s

represents the “chicken” and which the antecedent “egg”question that has been raised for other parts of the world.2

Serious disease as recognized in the adult as goiter or in thmore tragic non-starters in development in childhood as cretmay be two overt manifestations of a very much larger epidemIDD-based underdevelopment of foregone human grpotential—physical, mental, and cultural. The desperation ofited energies fully invested in bare subsistence is a characteri“plagues of poverty,” with at least one associated potentialcause—IDD—that might be amenable to eradication. Thisattractive hypothesis and one certainly endorsed by organizdevoted to IDD control3 as one fixable factor in the matrixpoverty and failure to thrive by whole populations plagued bylack of a simple, cheap, and available element.

On the grounds of this micronutrient insufficiency, this reon the woefully inadequate iodine intake measured in this saPakistani population might be a call to action as part of a huitarian development program.

A second concern, by no means free of political and straoverlay, is the safety of whole populations at risk in a wbristling with nuclear options by militarily capable, potentiabelligerent nationalistic armies or terrorist minorities. Withouadequate intake of the stable iodine isotope, the human thgland and other tissues in the body would have high avidity fouptake of carcinogenic radioactive iodine isotopes producednuclear fuel or explosion byproducts.4

Regretfully, for the dangerous world we live in during an ernuclear capabilities and the threat of their use against wpopulations, this strategic examination of the Pakistani diet mbe motivated more by an intent to ameliorate such inhumthreats than by the humanitarian urge to enhance human dement potential.

The market basket method of collection and samplingPakistani diet was further stratified for economic and cullevels in the Pakistani population. In the “land of the pu(Pakistan), a safe assumption is made to exclude severalitems, but also some spices and fish are also eliminated, wunsupported assumption that these elements represent“small fraction of whole diet.” In the biologic concentrationseafood products that magnify the iodine intake of otherminimally enriched food, I recall an aberration caused b“small fraction” element in the South African diet stemming frthe use ofroibos (red bush) Afrikaner tea. The only readavailable organic fertilizer to be used routinely forroiboscultivation turned out to be kelp harvested from coastal seawwhich turned out to be a significant iodine enhancement ootherwise iodine-deficient South African diet. Whether sseafood magnifiers in the biologic amplification of the iodcontent in the food chain, even dried fish transported intointerior and used, like the spices, principally as condiment,have given an incremental boost to iodine intake over the atedly low values in the foodstuffs measured cannot be kngiven the exclusion of seafood products from analysis. It maccount for the discordance of the very low intake of micronutiodine and the higher, but not orders of magnitude higincreases in IDD patterned for Pakistan. Such hypotheminimal enhancement, however, would not be sufficientradioprotection.

Going up the socioeconomic food chain may have assadequate (or overabundant) macrocalories, but still did notmuster in iodine adequacy. The wealthiest social classes maydoubled the iodine intake of the poorest but still came in at ha

ICRPB recommendation.

0899-9007/04/$30.00