Household Knowledge of Iodized Salt and Iodine Content of Dietary Salt in Morocco Further 25 Years of Universal Salt Iodization: A National Cross-Sectional Study

Background: At the global level, iodine deficiency (ID) has been significantly reduced since the widespread implementation of salt iodization programs; nevertheless, numerous populations worldwide remain at risk of insufficient iodine intake. In Morocco, the Universal Salt Iodization (USI) strategy was formally adopted in 1995 as a national public health measure to address this nutritional challenge. However, to date, no comprehensive national study has been conducted to evaluate the impact of this strategy on iodine adequacy at the household level.

Aims: This cross-sectional study aims to assess the iodine content of dietary salts at the household level in Morocco on a national scale.

Methods: A national cross-sectional study was conducted in 2019 among Moroccan households (n = 1963). Dietary salt samples were systematically collected from surveyed households to estimate household coverage of adequately iodized salt and to evaluate consumer awareness of iodization labelling. Iodine content analysis was performed employing the standardized iodometric titration method.

Results: At the national level, the majority of households predominantly consumed packaged salt (89%), whilst bulk salt accounted for only 8.1% of total consumption. Packaged salt was significantly more prevalent in urban areas (93.3%), whereas bulk salt was more frequently consumed in rural areas (14%) (p < 0.05). Consistently, the majority of surveyed households (71%) were unaware of the "iodized salt" designation on product labelling. The median iodine content of salt samples collected from the 1,963 households was 7.40 ppm (CI: 7.4 - 8.0), indicating that only 7.5% (95% CI: 6.4 - 8.7) of the surveyed population consumed adequately iodized salt (15 – 40 ppm). Furthermore, 65.6% (95% CI: 63.5 – 67.7) consumed inadequately iodized salt (5 – 14.9 ppm); 25.7% (95% CI: 23.8 – 27.6) consumed non-iodized salt (< 5 ppm); and 1.2% (95% CI: 0.8 – 1.8) consumed over-iodized salt (> 40 ppm).

Conclusion: Household coverage of adequately iodized salt remains critically low in Morocco, 25 years following the adoption of the USI strategy, underscoring the limited effectiveness of current program implementation. These findings highlight the urgent to reinforce and comprehensively revise the national salt iodization strategy through enhanced regulatory oversight, strengthened supply chain monitoring, improved consumer awareness campaigns, and targeted interventions in rural and nutritionally vulnerable populations, in order to fulfil the public health objectives of sustainable iodine deficiency elimination