2004: Varsha, PhD, RD



PARTNERSHIPS IN ACTION: MEDICAL-NUTRITION SYNERGISM FOR CLINICAL NUTRITION/DIETETIC PRACTICE AND NUTRITION EDUCATION IN THE INDIAN SUBCONTINENT

This essay is an attempt to account decisive events/anecdotes that have impacted, shaped the career of the applicant spanning 22 years (1982 to 2004). It summarizes how effective tackling of the varied demands of nutritional interventions that she confronted, be it at clinical, community or commercial level, during this period has stood her in good stead to direct, guide and impact development of practices in India. Also recounted herein is the building up of confidence and experience that is being reflected as a positive influence on the development of sound practice in the neighboring country Sri Lanka, a part of the Indian Subcontinent and yet distinctly diverse.


Background

In India, the terms dietetics and dietitian have been domesticated since the career in dietetics began with the introduction of graduate programs in home sciences. To add to its greater degree of domesticity was the fact that the study of home science was purely a female prerogative. The baccalaureate degree in home science was encouraged because the family felt that the girl was educated without her domesticity being adversely affected, especially in the marriage market. The enterprising among the graduates of home science decided to convert their academic qualification into a specialization in the allied-health specialist category, and thus the profession of dietitian was generated. Their ambit of interaction, however, was limited to the hospital kitchen, thus retaining the domestic character of the dietitian. This identification is best described by the following phrases: glorified cook, a sedentary clerk, calculating and maintaining calories and the weight of the food or nutrient; and maintaining and formulating unappetizing recipes for the helpless, hapless patient.

This myth needed to be exploded. Therefore, to convert nutrition from sheer art of feeding the body at all stages of life to the science that feeds the body in health and disease, in the 1980s, a branch of study was segregated and specifically designated as "Nutrition and Dietetics." But the progression was arrested because the centers offering this training were the home science colleges that were exclusively for women and they had no access to hospitals or medical universities to back their teaching and learning programs.

Although nursing and nutrition are derived from the same root word nutricus, nutrition has not received the exalted status that nursing has in the medical scenario. Despite the added glamour and dietitians calling themselves clinical nutritionists, the work environment did not undergo any change whatsoever.

The nutrition world was changing at a pace much faster than the situation at the home front, and the access to the academic knowledge was limited. This curtailed the advancement of the dietitian in becoming a true and strong link between the community and the clinical and commercial aspects of nutrition. It has been realized that the clinical nutritionist is a vital link between the physician and the patient. The clinical nutritionists or dietitians had understood that they were required to maintain data relevant to the anergic metabolic profile, play a very scientifically dynamic role at the bedside of the patient and be an active member of the team treating the patient. However, the lack of exposure to the hospital-based patient environment inspired no confidence in effecting the change.

The urgent need to promote medical nutrition synergism for effective patient management and dietetic practice increasingly perceived as medical schools and practitioners have moved away from nutrition/diet prescriptions. HM Sinclair declares, "Medicine arose from dietetics and Pythogoreans including Hippocrates used diet as the main line of therapy and drugs only when diet failed." Despite the applicant having established a stronghold in the private medical university the resistance to referring patient to the nutrition support team/practitioner is still the order of the day even in her setup. Theoretical prescriptions still rule the roost and without medical-nutrition synergism, evidence-based practice in nutrition will forever remain a distant illusive dream.


Personal Awareness

The applicant's foray into developing "THE MEDICAL - NUTRITION SYNERGISM" was influenced by a statement of her department HOD, at MS University of Baroda, when completing her master's degree, "Doctors and dietitians shall make perfect marriage partners for the initiation, sustenance and growth of dietetic practice in India." A prophetic statement indeed as the applicant's marriage to a doctor sealed the future path and the journey thus began. This established link was further strengthened by acquisition of the interdisciplinary [doctorate] degree in Foods and Nutrition-Medicine, Faculty of Science, University of Madras, through the Asia's oldest Medical Institution, Madras Medical College, in 1989. The [doctorate] dissertation was highly commended by Prof. J.M. Tanner, Institute of Child Health, London UK.


Partnerships in Action — Indian Context

The Clinical Nutrition Practice Partnership — the applicant was initiated into this partnership under the tutelage of medical-school teacher, Dr. Dante Mathuranayagam, Hon. Physician to President of India, Dr. V.V. Giri at Madras Medical College, in 1982. Certificate course in Clinical Nutrition at Leeds University, UK and training under Dr. Mitch Kaminski, Jr. at Chicago in 1989 gives credence to the applicant's claim for forging such a partnership.

This partnership bloomed into a success story when in 1992, for the first time, a private medical university accorded recognition to the lacuna and supported the applicant's efforts to correct it. Not only was this an act of acknowledging the need for a clinical nutritionist to be identified as a trained professional in the area of nutrition, it was also an exercise in defining the role. The nutrition professional was the one who focuses on diet therapy, incorporating normal and modified prescription, planning and instructing while encouraging individualized dietary compliance in both health and disease the medical university established the Department of Nutrition and Dietetics. Re-christened as Department of Clinical Nutrition, 1995, a job specification was delineated on the premise that the knowledge of clinical nutrition must be used to:

  1. Help assess the severity of malnutrition.
  2. Plan optimal nutritional therapeutic programs.
  3. Assess the balance of macronutrients.
  4. Monitor the progress of intensive nutritional support.
In addition, the Department of Clinical Nutrition, placed under College of Allied Health Sciences of this private medical university, initiated and implemented a one-year postgraduate diploma course in clinical nutrition that gives practical bedside training. Its course content has been inspired by certified nutrition support dietitian syllabus of American Society of Parenteral and Enteral Nutrition (ASPEN).

In 1997, the applicant was encouraged by the vice-chancellor of the medical university to compile a publication as guide for physicians to promote medical nutrition therapy. Released by Dr. Philomina Reddy, former vice-chancellor of Women's University (Tirupati), the publication received overwhelming response through media marketing and was well received by public, too, though compiled for physicians!

The applicant further expanded the horizon by establishing links with the Nutritional Science Education and Research Foundation (NSERF, Syracuse, N.Y., United States) and created the first regional training center in nutrition support systems. This collaboration conducted two training programs in 1999 and 2000 for hospital teams consisting of physicians, clinical nutritionists, nurses and pharmacists.

Since, October 2002 and till date, the applicant is engaged in blazoning new practice path in pediatric nutrition. Her pioneering effort in establishing Pediatric Clinical Nutrition Support Service at a major private 200 bed pediatric hospital in Chennai is one amongst the very many firsts in her career.

April 2004, marks the crowning moment of this partnership endeavors with the invitation to the applicant by Dr. C. Gopalan (father of nutrition in India and presently Founder, Nutrition Foundation of India), to present "Nutrition In The Medical Curriculum: A Nutritionist Perspective," A Nutrition Foundation of India workshop, in collaboration with Indian Council of Medical Research, Medical Council of India, National Academy of Medical Sciences and Directorate General of Health Services.

The applicant, an exception amidst a bevy of medical professionals and academic stalwarts, past and present, in the field of medicine, drawn from the prestigious institutions listed above is a culmination of a decade-long relentless and sincere effort to socially market nutrition services to medical fraternity. An exercise ably aided by the applicant being academically positioned in a private medical university (Associate Professor and Head, Department of Clinical Nutrition, Sri Ramachandra Medical College and Research Institute, Deemed University). Invitations as faculty/guest speaker propounding medical nutrition therapy as mainstay of patient-care has been a routine exercise for over the years at most of the local/regional/national congress/conferences/workshops/seminars of the various specialties of medicine/surgery.

The applicant's practice has not only come of age and matured with respect to medical fraternity recognition, but it has fructified on the nutritional fraternity front, too. The testimony of this has been the applicant being internationally supported/recipient of a listed few below:
  1. British Council Scholarship for Leeds University Course in Clinical Nutrition; Leeds, United Kingdom; 1989.
  2. Cilag Scholarship for 6th International Congress in Nutrition and Metabolism in Renal Disease; Harrogate, United Kingdom; 1991. Presented paper [en]titled "Risk of mortality associated with commonly measured variables indicative of malnutrition in hemodialysis (HD) patients (Pts)."
  3. Prof. Oreopaulis Best Paper Certificate and Cash Award for paper [en]titled "Nutrition Support in CAPD: Principles vs. Practice" and received at the First Conference of Peritoneal Dialysis Society of India; Bangalore; 1997.
  4. Scholarship recipient, 9th International Congress in Nutrition and Metabolism in Renal Disease; Vienna, Austria; 1998. "Nutritional practices for Indian ESRD patients" and "Energy metabolism in renal transplant patients — the Indian Experience."
  5. Social Marketing Concept in Nutrition Education, financially supported as invited Indian faculty, 3rd Asian Congress of Dietetics; Kuala Lumpur, Malaysia; 2002.
  6. Indian Representative on the International Confederation of Dietetic Associations; contributed actively at the Delegate Workshops at Edinburgh, Scotland (2000) and Chicago, [IL] United States (2004).
  7. Privileged and honored to be invited at the interaction "Indian Perspective of Nutritional Management in Pre-Renal Non-Dialysis Status — Application of Guidelines for Chronic Renal Disease in the Care of a Patient in the Outpatient Setting in India," at the XIV International Congress of Dietetics. Session Title "Evidence-Based Medicine: How does it apply to Nutrition;" Presiding Officer, Esther F. Myers, Ph.D., R.D., F.A.D.A., Director, Scientific Affairs and Research, American Dietetic Association; and Co-Speakers Naomi Trostler, Ph.D., R.D. (Israel), Chris Biesemeier, M.S., R.D., I.D.N., F.A.D.A. (USA), and Laura Stewart, B.Sc., B.A. (Hons), S.R.D. (Scotland).
The Commercial Nutrition Partnership — expertise acquisition began through exposure to industry (local pharmaceutical company claiming to be pioneers in zinc therapy in Indian context) sponsored nutrition research protocol on iron-zinc formulation in urban and rural population in 1982.

Deep insights into the working mechanisms of the local/regional, national/multinational nutraceutical/pharmaceuticals and food industry was facilitated by the applicant's unique position as program coordinator and subsequently Secretary, Indian Society of Parenteral and Enteral Nutrition (ISPEN). Professional ethics and code of practice generally preclude any direct or official interaction between the industry and the professional. The applicant's social marketing model evolved in collaboration with Smithkline Beecham for nutrition education to community and her presentation titled "Social Marketing Concept in Nutrition Education" at the 3rd Asian Congress of Dietetics, Kuala Lumpur, 18 to 21 August 2002, were zenith in the applicant's endeavors to promote nutritional health awareness.

The Community Nutrition Partnership — initiated as a one-to-one interaction and as a part of dietetic counseling initially, the major mass scale exposure to this aspect was in 1987 to 1988, through a highly acclaimed non-government organization (NGO) working within and beyond the city limits of Chennai, as its project coordinator. The project SCOVA (Standing Committee on Voluntary Agencies), was a pilot study titled "Integrated Family Nutrition and Workers Training Scheme," granted to Sree Seva Mandir (Temple for Service to Women), Chennai and Ministry of Health and Family Welfare, Government of India. This project exposed the applicant to the most significant aspect of India and as stated by the Father of Nation, Mahatma Gandhi, "Ninety percent of Indian population resides in its villages," the rural community in technical parlance. In 1993, the project findings were presented and abstracted in the proceedings of the XV International Congress of Nutrition, Adelaide, Australia "Integrated family nutrition and workers training scheme — A Pilot Study," Abstract #19. It also presented a rare opportunity to the applicant to interact extensively with government and banking functionaries and be a delegate converted to resource person at NABARD Workshop on marketing strategies for NGO generated small scale/cottage industry products.

In January 1988, the ultimate accolade for this partnership was being placed on the editorial board of the Workshop Manual on National Health Policy. The Workshop participation itself was a prestigious event as it was under the aegis of Tamilnadu Voluntary Health Association of India (TNVHA), a secular non-profit association of voluntary hospitals, dispensaries, health and community development centers, registered in 1970.


Partnerships in Action — Sri Lankan Context

The Clinical Nutrition Practice Partnership:
  • The College of Anesthesiologists of Sri Lanka initiated the first ever act of bestowing recognition to Clinical Nutrition. At the pre-congress workshop on January 25, 2002, the applicant extensively covered "Recent Advances in Clinical Nutrition" — malnutrition, significance of nutrition support and Nutritional assessment criteria in hospitalized patients, enteral nutrition highlights and nutrition support in critically-ill patients. The Sri Lanka Medical Association (SLMA) Auditorium, Wijerama House, Colombo 7, witnessed a full capacity participation for six hours at a stretch, endorsing the rising status of medical nutrition therapy amongst the physicians.
  • Navaloka Hospital, Colombo, a major private sector hospital, arranged an interaction with their staff physicians on "Significance of Nutrition Support in Hospitalized Patients," 26 January 2002.
  • Government General Hospital, Kandy, Sri Lanka, organized "ICU — Nutrition Grand Rounds," 29 January 2002.
  • Mr. Alex Stewart, Australian physiotherapist and coaching team personnel for the cricket board of Sri Lanka and the minister for sports council of Sri Lanka, initiated dialogue on nutrition supplements and support to Sri Lankan athletes and national cricket team.
  • Since the dietitian workforce was yet to be created, Navaloka Hospital, Colombo, deemed it appropriate that the nursing school and nursing staff be updated. Hence "Nutrition Support Principles for Nurses" session was organized on 30 January 2002 by their lone dietitian who had earlier trained under the applicant at Chennai.
  • The College of Physicians of Sri Lanka invited the applicant to address and update them on the burning issue of evidence-based medicine. The applicant delivered a lecture on "Evidence-Based Medicine and Nutrition" on 21 May 2004, SLMA Auditorium.
  • The College of Surgeons of Sri Lanka invited the applicant to address and update including their aspiring PG students on "Application of Nutrition in Surgery" on 21 May 2004, at their Colombo Headquarters.
  • Sports Council of Sri Lanka invited the applicant to address a large gathering on "Nutrition for Athletes," June 7, 2004 at SLMA Auditorium. A rare combination of senior and leading academia ranging from professors of physiology, rheumatology, sports medicine, etc., to field force in the gyms and nutrition students participated in this interaction, emphasizing the gaining popularity of sports nutrition.
  1. The Commercial Nutrition Partnership
    Novartis Nutrition, Switzerland's Sri Lanka arm, has been relentlessly supporting the cause of nutrition principles and education and dietetic practice — a true example of social marketing tool for partnership in action between the multinationals and professionals.
  2. The Community Nutrition Partnership
    "Nutrition Principles for Health" — executives and heads of departments and specially invited members of public session, were given an insight on the diet dimension to their health as a commitment of a private sector hospital by Navaloka Hospital, Colombo, Sri Lanka, 30 January 2002.
  3. Daily News
    Established in 1918 and the quality English Daily with the largest circulation trusted by readers in Sri Lanka, interacted with the applicant to highlight nutrition and health to the Sri Lankan public through their column "Health Watch." The applicant was the chief guest to choose winners of the Medical Crossword Competition, sponsored by Novartis Nutrition.
The applicant has been instrumental in supporting the kindled awareness and the outcome has been tremendously encouraging. Besides, the interactions listed above, it has been heartening that two major policy level decisions and third major breakthrough have resulted this year as delineated below.
  1. The Wayamba University of Sri Lanka, Department of Nutrition and Community Resources Management (NCRM) has established "Nutrition Society of Wayamba University." The applicant has offered unstinted support and has urged them to consider formation of the Dietitians of Sri Lanka or upgrade their existing nutrition society to Nutrition Society of Sri Lanka, and consider working towards getting recognition at the Asian Federation of Dietetic Associations during its Manila, Philippines meet in 2006 and later at the ICDA Japan 2008 meet.
  2. The Government of Sri Lanka has officially created TWO posts for dietitians in National Hospital, Colombo.
  3. The applicant has been invited to present to the President Elect, Medical Council of Sri Lanka, a proposal similar to the one presented to the Indian counterpart beginning of this year as elaborated under the Indian section of this essay.

Summary

This essay summarizes (detailing beyond the scope of this write-up) the applicant's career growth, the scope of the applicant's practice and influences on clinical nutrition/dietetic practice and nutrition education in India. One swallow may not make a summer, but it is every drop of water that makes an ocean, and the efforts of the applicant therefore in Sri Lanka vindicates her beliefs. That her maiden attempt in India is on the verge of being duplicated, replicated and catalyze the much-needed change in the scenario of nutritional care, not only in Indian hospitals but also in Sri Lanka, emboldens her to dream on. She proposes to venture in attempting implementation of a similar exercise in Bangladesh and Nepal, and establishing a workable networking link also with inclusion of Pakistan in the years to come under the geographical compulsion of being the Indian Subcontinent.

"Trinity of Nutritional Challenges in Life — Community nutrition, Clinical nutrition and Commercial nutrition," that one has to constantly encounter right from conception to birth and until death, in health and in disease. The essay applicant developed and strongly subscribes to this premise and hence endeavors that her dietetic education and practice should encompass all the three aspects. Her insatiable quest for adventure and the newer vision to incorporate these three nutritional challenges from the Social Marketing Concept and on a corporate angle, has her set on exploring expedition as the CEO, Vaajini NutriHealth Pvt. Ltd.

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