The Importance of Research:

Putting Pakistan on the Nutritional Map

Nilofer Fatimi Safdar, PhD Director Nutritional Science Program

School of Public Health, DUHS, Pakistan

President, PNDS

What is Research?

Work that adds to scientist's knowledge of how things happen

Pursuing knowledge through scientific discovery

Using a scientific method to an investigation / inquiry

It’s the cornerstone to any health care discipline

Advantages of Doing Research

Enhancement in knowledge, skills,

& competency

Develops critical thinking

Improves ability to conduct subsequent well-designed studies

Support professional growth of members

Reflects in the standards of professional practice

Becomes an advocacy of your profession

Areas of Nutrition Research Conducted

in Pakistan

Nutrition Surveys

Under nutrition among reproductive women & children

Breast & complementary feeding in children

Macronutrient deficiencies (PCM)

Micronutrient deficiencies (Iodine, Vitamin A & iron)

Risk factors & determinants of malnutrition

Factors underlying the lack of improvement

in nutrition indicators

Nutrition Surveys in Pakistan

Nutritional Survey of West Pakistan, 1965

Micronutrient Survey Pakistan, 1976-77

National Nutrition Survey Pakistan, 1985-87

National Health Survey of Pakistan (NHSP),1990-94

National Nutrition Survey Pakistan, 2001-2002

National Nutrition Survey Pakistan, 2011

Purpose of Nutrition Surveys in Pakistan

Estimate the nutrition problem / benchmark for the

future

Identify population groups at risk

Assess food security & their impact on nutritional

status

Identify the need for nutrition interventions

To help establish or expand existing

surveillance

Survey Team Members

Economist

Social Scientists

Research & Survey experts

Medical doctors/ Physicians

Pediatrician

Results of National Surveys

Results of National Surveys

Malnutrition recognized as a major public health problem

High numbers to substantiate the extent of malnutrition

Meetings & workshops are organized to plan strategies for

reducing malnutrition

Policies and intervention programs are promoted

Reports are compiled

Nutrition gets into the agenda of academia /researchers

Donors gets activated

What next?

Yet malnutrition prevails

Successive governments have not recognized the importance &

impact of nutrition in the health & development of the people

None of the surveys have resulted in a national intervention

program aimed at addressing the root causes of malnutrition

NGOs mostly take over public health nutrition concerns

NGOs in Pakistan

National

HANDS

HOPE

International

Asia Foundation

UNICEF

Micronutrient Initiatives (MI)

Care

WHO

Key Areas of Nutritional Intervention in

Pakistan

Child & Maternal under nutrition

Micronutrient deficiencies

Breast & complementary feedings

Infant and young Child feeding programs

Nutrition Programs in Pakistan

Fortification of edible oil with vitamin A & D (1965)

Supplementary feeding of vulnerable groups (1976)

Rural Child Survival Project (1987)

Nutrition Support Program Sind (1989-90)

Lactation Management Program of baby friendly hospitals (1992)

Iodine Deficiency Disorder National Program (1994)

Nutrition Programs in Pakistan

School Nutrition Program (1998)

Mass Vitamin A supplementation (1999)

Bait-ul-mal Food Support program (2000/2002)

National Wheat Fortification with iron & folate (2005)

Universal salt iodization (2006)

Lady Health Workers to provide nutrition education as part of

family planning program (2010)

Outcome of Nutrition Surveys &

Programs in Pakistan

Minimal public awareness at a national level on the

importance of nutrition in the social and economic

development of the society

Nutrition remains the key element missing from the

widely discredited Social Action Program

Few initiatives that addresses food & nutrition research

with qualified people in the public health nutrition issues

What could be the Reasons?

Failure of the Govt, those who undertake surveys, &

those who implement? Collective Failure

Focus is mainly on assessing indicators

Less or nil on identifying causal factors

Lack of qualitative aspect of malnutrition with dietary

factors

Absence of an expert nutritionist in the survey &

intervention team

Tawana Pakistan Project (TPP): 2002-05

Intersectoral project

29 districts

4,000 primary schools

Focused on girls (5-12 yrs) nutritional status

Paid attention to fundamental drivers of malnutrition

Participatory approach

Field experts

Culturally appropriate, low cost & local food,

Nutrition education supplemented the program

Delivery mechanism to maximize program efficiency

Badruddin SH, et al. (2008). Asia Pac J Clin Nutr 17 Suppl 1, 357-360

Tawana Pakistan Project- Results

Increased ability of women to plan nutritionally

balanced meals from 4.7 % to 34.4%

Overall malnutrition rate decreased

wasting by 45%

underweight by 22%

stunting by 6%

Increased school enrollments

Improved dietary knowledge in the communities

Tawana Pakistan Project- Why was it

stopped?

Intersecterol projects

Lack of commitment from the Govt

Prevented siphoning away of funds

Self interest of higher officials

Globalization- commodity push

Pakistani Journals Publishing Nutrition

Research

Journal of Pakistan Medical Association

Journal of College of Physicians and Surgeons Pakistan

Pakistan Journal of Public Health

Pakistan Journal of Medical Sciences

Journal of Ayub Medical College

Pakistan Journal of Biological Sciences

Nurture (Home Economics Journal)

Published Nutrition Research in

Pakistan (2001-2010)

Year National

Journals

International

journals

nutrition

expert among

the authors

others

(Pediatricians,

Physicians,

economist, health

experts)

2001 4 3 3 4

2002 3 7 3 7

2003 5 6 1 10

2004 5 12 2 15

2005 3 8 none 11

2006 1 4 1 4

2007 5 1 none 6

2008 8 9 4 13

2009 5 9 1 13

2010 9 4 none 13

Nutrition Research in Pakistan

(1965-2003) Major area-Therapeutic Nutrition

Search Engine-medline database, pakmedinet & nutrition gate

Number- 99 research

Major topics- Diarrhea, diabetes and cancer

Authors- Pediatrician, Physicians, Food Scientist

Institutes-AKU, JPMC

Journal - JPMA.

Tahir,S (2003) M.ScThesis; College of Home Economics, Karachi

Who are mostly the stake holders in

nutrition related research?

Experts in various sciences other than nutrition

Many of these professionals lack education, training &

expertise in food & nutrition

Net impact negligible in terms of nutrition awareness or

improvement in nutritional situation in the population

You are supposedly the spokesperson in promoting the

relationship between good health and diet

COBRA –Trial (2004-2007)

Dietary information using FFQ

Physical activity assessment using IPQ

Intervention in the form of Home Health Nutrition Education,

counseling & reinforcement

Expertise involved for Diet & Nutrition Component of COBRA

study were qualified people in their respective areas

Papers published to evaluate the efficacy of this program

Jafar TH, et al. (2010) BMJ ; 340, 2641.

Dietitians/ Nutritionist Million

Population

0 50 100 150 200 250 300 350 400

Pakistan

Hong Kong

Thailand

Philippines

Malaysia

Indonesia

Singapore

Taiwan

Korea

Japan

Asia

Slide Courtesy: AFDA 2006

Where do we mostly work?

Health Care Facility

Community Health

Agency

Institution Foodservice

Establishment

Educational Institutes

Business Company

Consultant,

Private Practice

Others

Slide Courtesy: AFDA 2006

Nutrition Research Gaps Among Us

Lack of leadership role & responsibility in food and nutrition

research

Hesitant to play a participatory role in nutrition research

Lack of research ability to conduct well-designed studies

Lack of research undertaken to address the impact of

nutrition related behaviors, attitudes or cultural practices on

nutritional status

Unable to disseminate sound scientific information on food

& nutrition to other health professionals

Schiller et al. J Am Diet Assoc. 1988;88 (9):1070-1075

Research Activities & Interests of Dietetic

Educators

Factors that influence research involvement /publications among dietetics/nutrition professionals

Postal questionnaire survey in USA

Factors inhibiting research

Education

Lack of Training in Research Skills

Lack of Funds

Lack of Administrative Support

Poorly Defined Job Description

Factors promoting

Analytical thinking

Good computer skills

Degree???

Whelan et al. J Acad Nutr Diet. 2012;112:1021-1028

Factors that Influence Research

Involvement among Nutrition Professionals

Qualitative Study, semi structured interviews with 13 nutrition faculty members in UK universities

Themes emerged

Institution/ department (size and structure, research Philosophy)

Activities (faculty roles, time, funds, training, teaching)

The Influence of self / individuals

Overcoming barriers to research involvement is essential for the development of the individual, the discipline & the community

The Road Forward ……

Visibility

Raise your visibility and impact among those who matters

the most

Identify weaknesses & Competencies

Commitment to education, learning, training as a

researcher

Vision

Multi task & prioritize to handle the task

Be Assertive

Learn to handle criticism, but be positive

Future Directions

A national vision needed to guide priorities & to sustain

momentum

Invest in training of qualified nutrition experts in research &

development

Boost the morale of nutrition experts & develop research

culture

Conduct validity studies for diet assessment techniques

Conduct studies of nutrients & disease outcome

Qualitative research

What PNDS can do to Help you…….

Spark a stronger research effort

Organize workshops, seminars, courses & training for

conducting research studies

Promote research culture through professional advocacy

Help you translate your work into scientific nutritional

concerns & public health issues in Pakistan

Expand your role as a researcher in the health-care

environment through the society’s platform

Generate funds to assist researcher

Symposium Outcomes

Platform to present your research

work

Opportunity to enhance key

concepts in good quality nutrition

research

Help seasoned researcher and

nutrition research novice

Offers opportunities for a fresh

perspective and innovation in food,

nutrition & dietetics

‘Research is at the heart of everything we do.

We need a rigorous knowledge base in order

to make sound clinical decisions and give

credible nutrition advice’. Dr Susan C. Finn, AND, Foundation Chair for Research Endowment Fund, 2004

‘Nutrition has historically received just a

tiny sliver of the pie when it comes to aid

money. But that is slowly changing’.

Dr Zulfiqar A. Bhutta, Director of Research for Global Child Health, Toronto

Global Health Report, published on 23rd June’, 2013

Possess Passion for Your Profession

Never lose your Zest and Curiosity !