|Year : 2015 | Volume
| Issue : 1 | Page : 27-31
Food safety: Who's who
Ranabir Pal, Neeti Rustagi
Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
|Date of Web Publication||5-Dec-2014|
Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan
Source of Support: None, Conflict of Interest: None
Healthy lifestyle has fashionably accommodated so-called high-quality eating practice among the great majority of masses. It has been believed by the practitioners of medicine since civilization time immemorial, usually than not, that healthy intake of foods is key elements of disease prevention and health promotion. In the epoch of millions of innovations and protocol supported clinical practice guidelines, transparent steps and ethical approaches have been initiated as the mainstay of health care delivery. As a natural expectation, every patient and their caregivers expect the advice on diet as a hidden agenda from their health care providers. Holistic dietary practice guideline and training module on diet and food safety are needed for all levels of health care providers for the optimum care in health and disease to the last man on the road.
Keywords: Diet, health care providers, nutrition
|How to cite this article:|
Pal R, Rustagi N. Food safety: Who's who
. J Med Nutr Nutraceut 2015;4:27-31
| Prologue|| |
In prehistoric times, our ancestors were challenged to survive with all the adversaries. They were hard-pressed to consume what they could have collected from the "Mother Earth". Later, on the path-breaking invention of cultivation has gifted our civilization with the concept of growing expected quality and quantity of foodstuffs for the hundreds of millions. With the downstream effects of uncountable developments and discoveries could have brought us to the urbane society.
From our age-old mission and vision of confronting the food scarcity, our thought processes have been slowly shifted food safety. Our mind-sets are focused on the turfs of supremacy and portion of one food item over another to keep us in health. Further, currently agri-economic researches on food products have gone a long way down the lane in terms of addition and or deletion of food values.
In the new millennium, nutrition has been metamorphosed to the main concern for the theme of lifestyle which has been correlated with as many diseases the medical literature can encompass. In the lifestyle-related questions of "How and Why" in improving the nutrition-related behavior and subsequent health outcomes, the demand on health care providers of all levels is forced by the stakeholders to afford optimum care of day to day questions of nutrition in health and disease. From the bottom of our heart, we need to nurture professionalism along with the soft skills for the benefits of the health care seekers to provide holistic care plus interlinked advice on food safety, diet and nutrition.
| A Journey Toward an Unknown Truth|| |
My painful soul-searching on this precise zone of service to the mankind at large is haunting me for last three decades since when I became a medical specialist in the mid-80's. I had to agree with countless of my colleagues in our country and abroad to reach an unauthenticated consensus that advice on diet and nutrition is needed from the billionaire to the pauper. Yet, can we reach any conclusion that health care providers are not competent to deliver advice on diet as well as nutrition? As per the age old medical curriculum in India all the medical graduates are supposed to know these topics at their undergraduate levels. On the contrary, can we reach any conclusion that there happens to be any phenomenon of "disuse atrophy" of the cognitive domain on nutrition when medical graduate do not put this knowledge into practice? Probably this may be a reason that the health care providers are "busy bee". They are engrossed with "Koch's postulate" and "magic bullet" in their honeycomb. So they are left with the affective domain of "hidden curriculum" when they learn from their role models during their growing years that "treat the disease" not try to "treat the person." Most probably this may have the root of that leads to the phenomenon. It has now become "hidden truth" or "open secret" that there is a rampant apathy of all levels of health care providers on the issue of dietary advice. The medical specialists including public health specialists have done very little if not anything for the development of the down to earth concepts of protocol-based tailor-made dietary advices in health and disease for the millions of masses flocking around them day in and day out.
| Situational Analysis|| |
Let us think of the dilemma in an incredibly no-nonsense approach. There is no doubt that in the jungle we prefer to appreciate "leopards" for their "thin yet energetic" figures compared to globular figures of "elephants". Yet in the civilized world, a good proportion of the population confidently accepts plump figure and physique as a welcome vision and mission in their life. Whom to blame in this difficult to reach the area! It is all the mindset built upon our age old concept of health equated to the weight gain and disease with weight loss. On one side of the hard to believe truth is that diet and nutrition have become a no-man's land on the part of health care providers. On the other side of the coin, we are helpless to see people are going away with the philosophy of "Go as you like" on what to eat and what not.
In the published information zone, researchers have tried to delineate probable risk factors of stakeholders receive or not tailor-made guidance on diet from their health care providers. In a Canadian study, in the middle of the last decade attempted to find patient behavior or others were somehow related to be given counseling regarding diet at every encounter with their physician. By and large, one-third of the respondents regularly expected dietary advice from their primary care physicians. Yet the persons with good health were not as much of inattention from their caregivers. Male counterparts between third and fifth decades of their life with more chronic illnesses, and better relationship with their health care providers reportedly received special consideration on dietary advices. 
Target the heart, mind will follow
"AAP RUCHISE KHANA, POR RUCHISE PORNA" this common phrase in India literally means "keep preference in your diet, dress as per social norm." In the argument boiling down to the idea of "healthy food" we, the health care providers, fail to sustain any "scientific dietary practice guidelines" as an appendix to "clinical practice guidelines." Poor diet is a key risk factor contributing to a large portion of the world's disease burden. There has been a significant change in the dietary habits and the physical activity levels worldwide, as a result of the industrialization, urbanization, economic development, and the food market globalization.  Further, exodus and relocation is one of the causes of nutrition-related noncommunicable diseases with emerging as a significant problem of overweight and obesity posing threat to the civilization to more or less equivalent to under-nutrition particularly in urban areas and in womenfolk. 
| If you Cannot Convince Anyone, Try to Confuse them|| |
Incidentally or accidentally in absence of consistent community-based translational research work, the prescription on diet and nutrition varies from heaven to hell. Protagonists of one school of thought publicly declare that egg is a "villain" and the killer of civilization, when others declare egg to the most nutritious balanced as well as cost-effective basic food in the world. Some confusing comments also float in the market-"take only white" or "take only the yolk". Otherwise, more complicated comments are there - "poultry eggs are less nutritious than domestically bred hens" or "duck eggs are better than hen eggs" or "boiled egg are worse than poach." I am yet to get informed of any published multicentric study where scientists in the world compared composition of samples of all the varieties of all species of fertilized and unfertilized eggs or studied their effects on the human body on robust samples.
Similar observation also holds good for the age old debate on the drinking of alcohol. We know that alcohols are produced in our normal human physiology within our body. Further, alcohol has been produced since time immemorial indigenously by persons at every corner of the world with their traditional methods making alcohol intake as the "most acceptable social addiction" as a global phenomenon. Yet we shall not hesitate to propagate the scientific information to all that drinking have association with cognitive decline and worsening of comorbidities, including hypertension, stroke, and osteoporosis. Further, no amount of alcohol is safe when it comes as a risk factor for cancer. But who will bell the cat! 
| Sensitize the Stakeholders|| |
Till the other day, all healthcare requirements of the citizens were managed by the health care providers of different shades who all feel comfortable as their friend philosopher and guide available at their doorsteps. Traditionally from womb to tomb, they were sincere to diagnose the problem at their courtyard. Even when the cases were referred to more experienced and any other specialized person, the doctors followed-up the cases without any prejudice as to who has finally solved the problem. We all have experienced in our younger times how they cared us from the bottom of their heart at odd hours not looking back at their personal comfort. Specialization of medicine and its branches has become a cult to produce experts who know more and more about lesser zones. The general physicians have become an endangered species and moving toward probable extinction.
Graduation in medicine in India has become a metaphor that is not regarded as a qualification to be "People's Doctor". A mad rush has spread like a volcano with the specialization for every organ. In the future, we may visualize specialists for every tissue, every cell, and even every RNA or DNA of the human body. We are losing the vision that we are supposed to treat a person not their organs. Diet and nutrition are basically a concept of health promotion with a wide-ranging outlook even in the absence of any health problem. This topic never deals with well-being any organ or system of the body. Hence, health care providers are confused - not interested in learning and practice this nonglamorous field - "everybody's responsibility has become nobody's responsibility." History move spirally. In recent times, the role of primary care physicians has been rejuvenated in the developed countries in womb of ideas from Alma Atta with special training modules with or without downstream degrees. We have to unite our voice that they should also be trained in diet and nutrition for the wholesome care with their extensive comprehension of health and disease in the ground situations. 
To the horizon of my knowledge, till date the competent authorities in the decision-making bodies are yet to introduce medical specialization and super-specialization on nutrition in our country. We spend valuable resources on research to find out hundreds of methods to reduce body weight including bariatric surgery. Yet we are missing the motivation to go back to basics that once the absolute number of lipocytes has increased hundred folds, probably nothing can be done to the human physiology to revert all problems back. What we need is a multipronged approach of behavior change communication in primordial prevention. We have to move against the tide to counsel a great majority of the people help motivated and changed mindset on the scientific role of nutrition in figure, as well as physique. In a study conducted at Saudi Arabia, the lack of training, poor administrative support, and time constraints among others were identified by the researchers as barriers in managing overweight and obesity. 
In the above heartbreaking scenario, nutrition has become an orphan in the era of path-breaking inventions and protocol-based intervention plans. We are taking steps toward transparent and ethical approaches in the patient care except nutritional advices. On the other hand, we have to sincerely introspect on the noncognitive, as well as nonscholastic skills as well as competencies of the health care providers at different levels of health care of the masses at large. This is the only way to help everyone to think and organize the priority of all the stakeholders in a manner that optimum health care reaches to the last man on the road. The same problem is also probably unsolved dilemma in developed countries such as USA and Canada. The Canadian Task Force on Preventive Health Care and the United States Preventive Services Task Force, are yet to get acceptable substantiation to advocate counseling of adults with good dietary advice in primary care settings to end up in good dietary practices with reference to good-quality primary health care. In the extensive global searches of the author, course and curriculum in the global scenario are sparse with the exception of the North American medical specialties entitled "dietetics" deals with food and nutrition. 
Half century ago, Martin Luther King Jr. expressed his views in a speech to the Medical Committee for Human Rights, 1966 that "Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane" that is valid even today. We have to internalize that a skewed development happened in the field of research and spread of information on diet and nutrition. As a downstream effect, people at large have become "pathologically a confused mass of protoplasm" as to whither way to move-traditional belief or spectrum of suggestions from different levels of different thinkers in different streams of medicine. Awareness is an important weapon to promote salutogenesis and prevent pathogenesis than any resource-based protocol of intervention. Public health need well-oiled machinery to percolate clean yet clear newly acquired as well as existing knowledge to the last man in the disadvantaged populations as a basic human right. 
World Health Organization delineates "universal health coverage" as "ensuring that all people have access to needed promotive, preventive, curative, and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services" that encompasses information needs of citizens, as well as health care providers, to establish their "right to health" to receive promotive, preventive, curative, and rehabilitative health services according to need. 
In the era of impressive investments to fight AIDS, tuberculosis, malaria and immunization, we are need sincere global attempt to universal spreading of already acquired health information that are relevant, reliable knowledge of best practices. We hope for the wisdom of the governments to ensure free access to the information to protect in health and disease and to stop misinformation divergent from scientific evidence. Diet and nutrition are probably one of the best examples where misinformation is at the peak in absence of any concerted efforts not only from the health care providers but also from the health professional bodies in the absence of any transparent policy from the governments.  Protagonists of health have lamented that mothers, primary health workers, and rural district hospital workers are not better informed than they were a decade ago. 
| Nutrition: An Orphan in the Medical Arena|| |
We need to revert this paradigm to put doctors as the leader to say best possible yet simple advice on diet and nutrition to be active with an optimum weight in health and disease [Table 1].
|Table 1: The entire range of basic food to be consumed in health-no food is complete on earth |
Click here to view
On the other hand, a better wholesome lifestyle modifications pay more dividend than absolute attention to diet and nutrition in health. Even in the interventions of diseases this hold true. The task becomes uphill to motivate people against the advertisements floated in the media targeted to the younger generations with increase in the screen times. We have to help people believe the philosophy to the core of their that "life is a marathon, not a sprint" in health or living with a disease even with long term illnesses with natural foods a rainbow concept of diet with all colors of foods in their plates every day. 
| An Unbiased World|| |
Nutritional suggestions are imperative means to for behavior change communication in health promotion. Primary care providers have to participate in innovative and premeditated responsibility in facilitating nutritional guidance to their patients religiously as an activity embedded in care in health and disease on a daily basis. It has long been accepted by community health care providers and researchers that people at large should have free access to reliable, relevant, and implementable health-care to reach the Millennium Development Goals. 
A basic framework of training and reinforced re-training is unavoidable in this complicated scenario where primary health care providers are posed to the problem daily that can strongly influence patient behaviors conceptually and contextually. American College of Preventive Medicine recommends that "primary care providers incorporate behavioral interventions such as related to physical activity and poor diet into their practice based on evidence of strong epidemiological linkages between lifestyle factors and health outcomes." With a focus on nutrition, and other factors influencing lifestyle discussions at the health care real life scenario, to assess the contextual factors related to the time spent on lifestyle discussions the researchers noted that not much work has been conducted on this issue to frame any hypotheses. 
Nutritional counseling assesses health needs of the diets as an ongoing process preferably by the Physicians as most trusted friend with an attempt to help maintain the dietary changes. Researchers have noted that the physicians lack this in their regular clinical practice which needs urgent attention to optimize the outcomes of health care. A study conducted in Chhattisgarh state in India explored nutritional counseling practices and attitudes of physicians working at district hospitals where majority articulated their eagerness to undertake supplementary training in nutrition. In a rising problem of nutrition-related chronic diseases in India, it is crucial that health care providers should be skilled satisfactorily so as to advice their patients optimally. 
In the absence of nutritional counseling by the health care providers at every encounter, nutrition-related noncommunicable diseases are on the rise with rising trends in the mortality and the morbidity.  At the crossroads of development jumps in different countries including India, there has been a gross change in a civilized world to the several changes in food habits including consumption of more prepared or semi-prepared foods with questionable quality and quantity of ingredients. Multiple sources of the health- and nutrition-related information misleads and confuse the people unnecessarily and influence the dietary behavior. 
For a diet, recommendations for populations and individuals should include the following [Table 2]:
|Table 2: Achieve energy balance with a healthy weight and energetic life |
Click here to view
In the search of a paradigm shift, World Health Organization has projected the ideation that in nutritional care should be an integral part of patient cares. Reports of international and national experts and reviews of the current scientific evidence recommend goals for nutrient intake in order to prevent chronic diseases. We have to sincerely initiate discussion on diet and nutrition at every intersection of health care delivery from primary care to quaternary care levels. Further, with the age old proverb "charity begins at home" we have to practice "safe food" concept as idol for common people to prolong our dialogue transparently to start a discourse on food safety that does not mean only discussion on food intoxicants and adulteration. Whatsoever we recommend, need to be incorporated in national policies and clinical practice guidelines, taking into account the local situation in the gamut of economy, culture, tradition, and availability. Improving dietary habits is a societal, not just an individual problem that demands a population-based, multisectoral, multi-disciplinary, and culturally relevant approach to exploit all opportunities for nutrition education. 
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[Table 1], [Table 2]