Salt iodization in Europe and Central Asia Region (ECAR) countries has a long history. Universal salt iodization (USI) strategies were reintroduced in ECAR countries in the mid-1990s and gained strong momentum during the 2000–2009 decade: by the end of 2009, access to adequately iodized salt by the population in ECAR had risen to 55% — a quantum leap improvement compared to a previous decade but still short of the operational target of 90%. The objective of this review was to document the USI achievements and challenges in the 18 ECAR countries during the decade of 2010-2020 and developed recommendations for actions to maintain the USI. The review was conducted by analysis of information obtained from a variety of sources, including communication with UNICEF country offices, IGN National Coordinators as well as online resources and publications available publicly. Based on available information, countries of the ECAR fall into 3 groups. Group 1. USI at scale: 11 countries (Armenia, Azerbaijan, Bosnia and Herzegovina, Kosovo, North Macedonia, Montenegro, Serbia, Turkmenistan, Kazakhstan, Kyrgyzstan and Georgia) successfully sustained the adequate iodine status achieved earlier. This group should focus on USI maintenance ensuring that the USI target of uninterrupted universal use of iodized salt in households and food/bakery industry is included into relevant national programs, along with the salt reduction targets. Group 2. USI at scale but risk of slippage: 3 countries (Albania, Moldova and Kyrgyzstan) sustained the adequate iodine status of population but their household use of adequately iodized salt remains low and the use of iodized salt in processed foods — patchy, with weak regulatory monitoring and enforcement systems in place putting sustainability at risk. Recommendations for these countries are to secure strong regulatory monitoring and enforcement of the national iodized salt standards to ensure consistent and high (>90%) use of iodized salt at household level as well as in production in key salt-containing industrially processed staple foods (especially, bread). Group 3. USI — more efforts needed: in 4 countries (Russia, Tajikistan, Ukraine and Uzbekistan), the population and, specifically, most vulnerable groups continued to suffer from inadequate iodine status. This group of countries will need to enhance and expand their existing USI effort by better engaging with salt producers and private sector and identifying resources for improved regulatory monitoring. Adoption of USI legislation is paramount to reaching high iodized salt coverage and optimum iodine nutrition in Russia and Ukraine.

The data and information in the present review confirm that USI strategy is successfully sustained in the majority of countries in the ECAR. The experiences in this region add to the growing evidence that USI is effective in alleviating iodine deficiency in the population and support the view that global success can be achieved by ensuring that food-grade salt iodization becomes the norm in the salt industry and society.